The authors gratefully acknowledge past and present faculty and students at the College of Nursing at Florida Atlantic University whose sharing through dialogue has contributed to the evolution of ideas over the past 12 years. We are particularly grateful to the faculty for taking the risks necessary to advance a program of study grounded in the discipline with caring as the focal point. Through supporting each other as colleagues, we were able to suspend our traditional pasts in order to study and teach the discipline with a new lens.
We also are indebted to students and colleagues whose questions, stories, and expressions of nursing fostered clarity in our understanding of the ontology of nursing. A special thank you goes to the following colleagues whose stories are re-presented in this book: Gayle Maxwell, Daniel Little, Sheila Carr, Patricia Kronk, Lorraine Wheeler, and Michele Stobie.
To the many scholars in the discipline whose works reflect a commitment to the development of nursing knowledge related to caring in nursing, and especially to the members of the International Association of Human Caring, we thank you. We extend a special thanks to Marilyn Parker and Terri Touhy for their unending devotion and commitment to nursing and for the blessing of their friendship.
We acknowledge Shawn Pennell who designed the image of the dance of caring persons described in this book. Sally Barhydt of the National League for Nursing offered understanding and thoughtful input in the early stages of this process and we thank her for her invaluable support. Thanks also to Allan Graubard of the League for his recognition of the meaning of our work, and for his careful attention in seeing this manuscript through to publication.
We would like to recognize all persons we have been privileged to nurse. Through the experience and study of these nursing situations, the knowledge of the discipline unfolds.
Last, we extend gratitude to our families for living caring with us and supporting our many professional endeavors.
In this chapter we present the fundamental ideas related to person as caring and nursing as a discipline and profession that serves as the perspectival grounding for the theory Nursing as Caring. We intend to offer our perspective of these ideas as influenced by the works of various scholars so that the grounding for Nursing as Caring will be understood. We do not intend to offer a novel perspective of the notion of person, or a new generic understanding of caring or of discipline and profession, but to communicate some of the ideas basic to Nursing as Caring.
Major assumptions underlying Nursing as Caring include:* persons are caring by virtue of their humanness* persons are caring, moment to moment* persons are whole or complete in the moment* personhood is a process of living grounded in caring* personhood is enhanced through participating in nurturingrelationships with caring others* nursing is both a discipline and a profession
Throughout this book the basic premise presides: all persons are caring. Caring is an essential feature and expression of being human. The belief that all persons, by virtue of their humanness, are caring establishes the ontological and ethical ground on which this theory is built. Persons as caring is a value which underlies each of the major concepts of Nursing as Caring and is an essential idea for understanding this theory and its implications. Being a person means living caring, and it is through caring that our "being" and all possibilities are known to the fullest. Elaboration on the meaning of this perspective will provide a necessary backdrop for understanding ideas in subsequent chapters.
Caring is a process. Each person, throughout his or her life, grows in the capacity to express caring. Said another way, each person grows in his or her competency to express self as caring person. Because of our belief that each person is caring and grows in caring throughout life, we will not focus on behaviors considered noncaring in this book. Our assumption that all persons are caring does not require that every act of a person necessarily be caring. There are many experiences of life that teach us that not every act of a person is caring. These acts are obviously not expressions of self as caring person and may well be labeled noncaring. Developing the fullest potential for expressing caring is an ideal. Notwithstanding the abstract context of this ideal, it is knowing the person as living caring and growing in caring that is central to our effort in this book. Therefore, even though an act or acts may be interpreted as noncaring, the person remains caring.
While this assumption does not require that every act be understood as an expression of caring, the assumption that all persons are caring does require an acceptance that fundamentally, potentially, and actually each person is caring. Although persons are innately caring, actualization of the potential to express caring varies in the moment and develops over time. Thus, caring is lived moment to moment and is constantly unfolding. The development of competency in caring occurs over a lifetime. Throughout life we come to understand what it means to be a caring person, to Live caring, and to nurture each other as caring.
Roach and Mayeroff provide some explanation as to what caring involves. Roach in her works (1984, 1987, 1992) has asserted that caring is the "human mode of being" (1992, p. ix). As such, it entails the capacity to care, the calling forth of this ability in ourselves and others, responding to something or someone that matters and finally actualizing the ability to care (192, p. 47). Since caring is a characteristic of being human, it cannot be attributed as a manifestation of any single discipline. These beliefs have directly influenced our assumption that all persons are caring. Mayeroff, a philosopher, in his 1971 book On Caring, discusses caring as an end in itself, an ideal, and not merely a means to some future end. Within the context of caring as process, Roach (1992, 1984) says that caring entails the human capacity to care, the calling forth of this ability in ourselves and others, the responsivity to something or someone that matters, and the actualizing of the power to care. Even though our human nature is to be caring, the full expression of this varies with the lived experience of being human. The process of bringing forth this capability can be nurtured through concern and respect for person as person.
Mayeroff suggests that caring "is not to be confused with such meanings as wishing well, liking, comforting, and maintaining . . . it is not an isolated feeling or a momentary relationship" (p. 1). He describes caring as helping the other grow. In relationships lived through caring, changes in the one who cares and the one cared for are evident. Mayeroff tells us how caring provides meaning and order: In the context of a man's life, caring has a way of ordering his other values and activities around it. When this advising is comprehensive, because of the inclusiveness of his caring, there is a basic stability in his life; he is "in place" in the world instead of being out of place, or merely drifting on endlessly seeking his place. Through caring for certain others, by serving them through caring a man lives the meaning of his own life. In the sense in which a man can ever be said to be at home in the world, he is at home not through dominating, or explaining, or appreciating, but through caring and being cared for (1971, p. 2).
Mayeroff expressed ideas about the meaning of being a caring person when he referred to trust as "being entrusted with the care of another" (p. 7). He spoke of both "being with" the other (p. 43) and "being for" (p. 42) the other, experiencing the other as an extension of self and at the same time "something separate from me that I respect in its own right" (p. 2). To be a caring person means to "live the meaning of my own life" (p. 72), having a sense of stability and basic certainty that allows an openness and accessibility, experiencing belonging, living congruence between beliefs and behavior, and expressing a clarity of values that enables living a simplified rather than a cluttered life.
Watson, a nursing theorist and philosopher, offers insight into caring. In her theory of Human Care, she examines caring as an intersubjective human process expressing respect for the mystery of being-in-the-world, reflected in the three spheres of mind-body-soul. Human care transactions based on reciprocity allow for a unique and authentic quality of presence in the world of the other. In a related vein, Parse (1981) defines the ontology of caring as "risking being with someone toward a moment of joy." Through being with another, connectedness occurs and moments of joy are experienced by both.
If the ontological basis for being is that all persons are caring and that by our humanness caring is, then I accept that I am a caring person. This belief that all persons are caring, however, entails a commitment to know self and other as caring person. According to Trigg (1973), commitment "presupposes certain beliefs and also involves a personal dedication to the actions implied by them" (p. 44). Mayeroff (1971) speaks of this dedication as devotion and states "devotion is essential to caring .. . when devotion breaks down, caring breaks down" (p. 8). Mayeroff also states that "obligations that derive from devotion are a constituent element in caring" (p. 9). Moral obligations arise from our commitments; therefore, when I make a commitment to caring as a way of being, I have become morally obligated. The quality of the moral commitment is a measure of being "in place" in the world. Gadow (1980) asserts that caring represents the moral ideal of nursing wherein the human dignity of the patient and nurse is recognized and enhanced.
As individuals we are continually in the process of developing expressions of ourselves as caring persons. The flow of life experiences provides ongoing opportunities for knowing self as caring person. As we learn to live fully each of these experiences, it becomes easier to allow self and others the space and time to develop innate caring capabilities and authentic being. The awareness of self as caring person calls to consciousness the belief that caring, is lived by each person moment to moment and directs the "oughts" of actions. When decisions are made from this perspective, the emerging question consistently is, "How ought I act as caring person?"
How one is with others is influenced by the degree of authentic awareness of self as caring person. Caring for self as person requires experiencing self as other and yet being one with self, valuing self as special and unique, and having the courage, humility, and trust to honestly know self. It takes courage to let go of the present so that it may be transcended and new meaning be discovered. Letting go, of course, implies a freeing of oneself from present constraints so that we may see and be in new ways. One who cares is genuinely humble in being ready and willing to know more about self and others. Such humility involves the realization that learning is continuous and the recognition that each experience is unique. As my commitment to persons as caring moves into the future, I must choose again and again to ratify it or not. This commitment remains binding and choices are made based on devotion to this commitment.
Personhood is the process of living grounded in caring. Personhood implies living out who we are, demonstrating congruence between beliefs and behaviors, and living the meaning of one's life. As a process, personhood acknowledges the person as having continuous potential for further tapping the current of caring. Therefore, as person we are constantly living caring and unfolding possibilities for self as caring person in each moment. Personhood is being authentic, being who I am as caring person in the moment. This process is enhanced through participation in nurturing relationships with others.
The nature of relationships is transformed through caring. All relations between and among persons carry with them mutual expectations. Caring is living in the context of relational responsibilities. A relationship experienced through caring holds at its heart the importance of person-as-person. Being in the world also mandates participating in human relationships that require re-sponsibility—responsibility to self and other. To the extent that these relationships are shaped through caring, they are consistent with the obligations entailed in relational responsibility, and the "person-al" (person-to-person) relationships. When being with self and others is approached from a desire to know person as living caring, the human potential for actualizing caring directs the moment.
All relationships are opportunities to draw forth caring possibilities, opportunities to reinforce the beauty of person-as-person. Through knowing self as caring person, I am able to be authentic to self and with others. I am able to see from the inside what others see from the outside. Feelings, attitudes, and actions lived in the moment are matched by an inner genuine awareness. The more I am open to knowing and appreciating self and trying to understand the world of other, the greater the awareness of our interconnectedness as caring persons. Knowing of self frees one to truly be with other. How does one come to know self as caring person? Mayeroff's (1971) caring ingredients are useful conceptual tools when one is struggling to know self and other as caring. These ingredients include: honesty, courage, hope, knowing (both knowing about and knowing directly), trust, humility, and alternating rhythm. The idea of a hologram serves as a way of understanding self and other. Pri-bram (1985) offers us an interesting view on relationships in his discussion of hologram. He states that the uniqueness of a hologram is such that if a part (of the hologram) is broken, any part of it is capable of reconstructing the total image (p. 133). Using this idea, if the lens for "being" in relationships is holographic, then the beauty of the person will be retained. Through entering, experiencing, and appreciating the world of other, the nature of being human is ore fully understood. The notion of person as whole or complete expresses an important value. As such, the respect for the total person—all that is in the moment—is communicated. Therefore, from a holographic perspective, it is impossible to focus on a part of a person without seeing the whole person reflected in the part. The wholeness (the fullness of being) is forever present. Perhaps in some context, the word part is incongruent with this notion that there is only wholeness. The term aspect, or dimension, may be a useful substitute.
The view of person as caring and complete is also intentional; it offers a lens for a way of being with another that prevents the segmenting of that other into component parts (e.g., mind, body, spirit). Here, valuing and respecting each person's beauty, worth, and uniqueness is lived as one seeks to understand fully the meaning of values, choices, and priority systems through which values are expressed. The inherent value that persons reflect and to which they respond is the wholeness of persons. The person is at all times whole. The idea of wholeness does not negate an appreciation of the complexity of being. However, from the perspective of the theory Nursing as Caring, to encounter person as less than whole involves a failure to encounter person. Un-il our view is such that it includes the whole as complete person and not just a part, we can not fully know the person. Gadow's (1984) contrasting paradigms, empathic and philanthropic, are relevant to this understanding. The philanthropic paradigm enables a relationship in which dignity is bestowed as a "gift from one who is whole to one who is not" (p. 68). Philanthropy marks the person as other than one like me. Gadow's empathic paradigm, on the other hand, "breaches objectivity" (p. 67) and expresses participating in the experience of another. In the empathic paradigm, the subjectivity of the other is "assumed to be as whole and valid as that of the caregiver" (p. 68). These paradigm descriptions facilitate our knowing how we are with others. Is the attitude expressed through nursing one of person as part or person as whole? How do these perspectives direct nursing practice?
Our understanding of person as caring centers on valuing and celebrating human wholeness, the human person as living and growing in caring, and active personal engagement with others. This perspective of what it means to be human is the foundation for understanding nursing as a human endeavor, a person-to-person service, a human social institution, and a human science.
Our view enables the development of nursing as a discipline of constant discovery and new knowing.
Like disciplines, professions have unique characteristics, as defined by Flexner. Flexner (1919) initially identified as the most basic characteristic of a profession that it addresses a unique and urgent social need through techniques derived from a tested knowledge base. Professions have their historical roots in those human services that people provided for each other within existing social institutions (e.g., tribe, family, or community). Thus, each profession, including nursing, has its origins in everyday human situations and the everyday contributions people make to the welfare of others. Flexner's founding conditions for the designation profession are reiterated in the American Nursing Association's 1980 Social Policy Statement, in which the idea of a social contract is addressed.
Nursing: A Social Policy Statement was intended to provide nurses with a fresh perspective on practice while providing society with a view of nursing for the 1980s. The overall intent of this document was to call to consciousness the linkages between the profession and society. While the Social Policy Statement is considered by many (see, for example, Rodgers, 1991; Packard & Polifroni, 1991; Allen, 1987; White, 1984) to be outdated, we find the concept of the social contract to be useful when studying the relationship of nurse to nursed. As the foundation for professions, the social contract, while understood to be an "hypothetical ideal" (Silva, 1983, p. 150), is also an expression of a people recognizing (1) the presence of a basic need and (2) the existence of greater knowledge and skill available to meet that need than can be readily exercised by each member of the society. Society at large then calls for commitment by a segment of society to the acquisition and use of this knowledge and skill for the good of all. Social goods are promised in return for this commitment.
Today, the profession of nursing is moving from a social contract relationship toward a covenantal relationship between the nurse and nursed. While the social contract implies an impersonal, legalistic stance, the covenantal relationship emphasizes personal engagement and ever present freedom to choose commitments. Cooper (1988), for example, discusses her ideas on the relevance of covenantal relationships for nursing ethics. She states "the promissory nature of the covenant is contained in the willingness of individuals to enter a covenental relationship" (p. 51) and it is within this context that obligations arise. As caring persons, we "see" relationship (covenant) and honor the bond between self and other. The ultimate knowledge gained from this perspective is that we are related to one another (and to the universe) and that harmony (brotherhood and sisterhood) is present as we live out caring relationships.
Concepts of discipline and profession have been dismissed by critical theorists as oppressive, anachronistic, and paternalistic (Allen, 1985; Rodgers, 1991). In our study however, as we have explored essential meanings of these concepts, we have found that they express fundamental values congruent with cherished nursing values. Although we can agree with critical theorists that discipline and profession have been misused, perhaps too frequently, as tools of social elitism and oppression, this misuse remains inappropriate because it violates the covenantal nature of discipline and profession.
The discipline of nursing attends to the discovery, creation, structuring, testing, and refinement of knowledge needed for the practice of nursing. Concomitantly, the profession of nursing attends to the use of that knowledge in response to specific human needs. Certainly, the basic values communicated in the concepts of discipline and profession are resonate with fundamental nursing values and contribute to a fuller understanding of nursing as caring. Included among those shared values are commitment to something that matters, sense of persons being connected in oneness; expression of human imagination and creativity, realization of the unity of knowing with possibilities unfolding, and expression of choice and responsibility.
We have deliberately used the term general theory of nursing to characterize our work. The concept of a general theory is particularly useful in the context of levels of theory. Other authors have addressed what they see as three levels of nursing theory: general or grand, mid-range, and practice (Walker & Avant, 1988; Fawcett, 1989; Chinn & Jacobs, 1987: Nursing Development Conference Group, 1979). What we intend by the use of the term general theory is similar to "conceptual framework," "conceptual model," or "paradigm." That is, a general theory is a framework for understanding any and all instances of nursing, and may be used to describe or to project any given situation of nursing. It is a system of values ordered specifically to reflect a philosophy of nursing to guide knowledge generation and to inform practice.
The statement of focus of any general nursing theory offers an explicit expression of the social need that calls for and justifies the professional service of nursing. In addition, the statement of focus expresses the domain of a discipline as well as the intent of the profession, and thus directs the development of the requisite nursing knowledge. Activity to develop and use nursing knowledge has its ethical ground in the idea of the covenantal relationship as expressed in the specific focus of the profession. Fundamental values inherent in the discipline and profession of nursing derive from an understanding of the focus of nursing.
The conception of nursing that we have used in this book views nursing science as a form of human science. Nursing as caring focuses on the knowledge needed to understand the fullness of what it means to be human and on the methods to verify this knowledge. For this reason, we have not accepted the traditional notion of theory which relies on the "received" view of science, and depends on measurement as the ultimate tool for legitimate knowledge development. The human science of nursing requires the use of all ways of knowing.
Carper's (1978) fundamental patterns of knowing in nursing are useful conceptual tools for expanding our view of nursing science as human science here. These patterns provide an organizing framework for asking epistemological questions of caring in nursing. To experience knowing the whole of a nursing situation with caring as the central focus, each of these patterns comes into play. Personal knowing focuses on knowing and encountering self and other intuitively, the empirical pathway addresses the sense, ethical knowing focuses on moral knowing of what "ought to be" in nursing situations, and aesthetic knowing involves the appreciating and creating that integrates all patterns of knowing in relation to a particular situation. Through the richness of the knowledge gleaned, the nurse as artist creates the caring moment (Boykin & Schoenhofer, 1990).
Nursing, as we have come to understand our discipline, is not a normative science that stands outside a situation to evaluate current observations against empirically derived and tested normative standards. Nursing as a human science takes its value from the knowledge created within the shared lived experience of the unique nursing situation. Although empirical facts and norms do play a role in nursing knowledge, we must remember that that role is not one of unmediated application. Knowledge of nursing comes from within the situation. The nurse reaches out into a body of normative information, transforming that information as understanding is created from within the situation. The same can be said for personal and ethical knowing. Each serves as a pathway for transforming knowledge in the creation of aesthetic knowing within the nursing situation. The view we have taken unifies previously dichotomized notions of nursing as science and nursing as art and requires a new understanding of science.
Nursing as caring reflects an appreciation of persons in the fullness of per-sonhood within the context of the nursing situation. This view transcends perspectives adopted in an earlier period of nursing science philosophy. Examples of the earlier view include the notions of basic versus applied science, and metaphysics versus theory. The idea of a basic science of nursing disconnects nursing from its very ground of ethical value. Without a grounding in praxis, the content and activity of nursing science becomes amoral and meaningless. Similarly, this view transcends an earlier view of nursing theory that treated the unitary phenomenon of nursing as being composed of concepts that could be studied independently or as "independent and dependent variables." Nursing as caring resists fragmentation of the unitary phenomenon of our discipline. In subsequent chapters, we will more fully explore implications of this view of nursing as a human science discipline and profession.
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In Chapter 2, we will present the general theory of Nursing as Caring. Here, the unique focus of nursing is posited as nurturing persons living caring and growing in caring. While we will discuss the meaning of that statement of focus in general terms, we will also describe specific concepts inherent in this focus in the context of the general theory.
If you recall, in Chapter 1 we discussed the several major assumptions that ground the theory of Nursing as Caring:
* Persons are caring by virtue of their humanness* Persons are whole or complete in the moment* Persons live caring, moment to moment* Personhood is a process of living grounded in caring* Personhood is enhanced through participating in nurturingrelationships with caring others* Nursing is both a discipline and profession
In this and succeeding chapters, we will develop the nursing implications of these assumptions.
All persons are caring. This is the fundamental view that grounds the focus of nursing as a discipline and a profession. The unique perspective offered by the theory of Nursing as Caring builds on that view by recognizing personhood as a process of living grounded in caring. This is meant to imply that the fullness of being human is expressed as one lives caring uniquely day to day. The process of living grounded in caring is enhanced through participation in nurturing relationships with caring others, particularly in nursing relationships.
Within the theoretical perspective given herein, a further major assumption appears: persons are viewed as already complete and continuously growing in completeness, fully caring and unfolding caring possibilities moment-to-moment. Such a view assumes that caring is being lived by each of us, moment to moment. Expressions of self as caring person are complete in the moment as caring possibilities unfold; thus, notwithstanding other life contingencies, one continues to grow in caring competency, in fully expressing self as caring person. To say that one is fully caring in the moment also involves a recognition of the uniqueness of person with each moment presenting new possibilities to know self as caring person. The notion of "in the moment" reflects the
idea that competency in knowing self as caring and as living caring grows throughout life. Being complete in the moment also signifies something more: there is no insufficiency, no brokenness, or absence of something. As a result, nursing activities are not directed toward healing in the sense of making whole; from our perspective, wholeness is present and unfolding. There is no lack, failure, or inadequacy which is to be corrected through nursing—persons are whole, complete, and caring.
The theory of Nursing as Caring, then, is based on an understanding that the focus of nursing, both as a discipline and as a profession, involves the nurturing of persons living caring and growing in caring. In this statement of focus, we recognize the unique human need to which nursing is the response as a desire to be recognized as caring person and to be supported in caring.
This focus also requires that the nurse know the person seeking nursing as caring person and that the nursing action be directed toward nurturing the nursed in their living caring and growing in caring. We will briefly discuss this theory in general terms here and more fully illuminate it in subsequent chapters on nursing practice (Chapter 4), education (Chapter 5), and scholarship (Chapter 6). We will address administration of nursing services and of nursing education programs in Chapters 4 and 5, respectively.
Nurturing persons living caring and growing in caring at first glance appears broad and abstract. In some ways, the focus is broad in that it applies to nursing situations in a wide variety of practical settings. On the other hand, it takes on specific and practical meaning in the context of individual nursing situations as the nurse attempts to know the nursed as caring person and focuses on nurturing that person as he or she lives and grows in caring.
When approaching a situation from this perspective, we understand each person as fundamentally caring, living caring in his or her everyday life. Forms of expressing one's unique ways of living caring are limited only by the imagination. Recognizing unique personal ways of living caring also requires an ethical commitment and knowledge of caring. In our everyday lives, failures to express caring are readily recognized. The ability to articulate instances of noncaring does not seem to take any particular skill. When nursing is called for, however, it is necessary that nurses have the commitment, knowledge, and skill to discover the individual unique caring person to be nursed. For example, the nurse may encounter one who may be described as despairing. Relating to that person as helpless recalls Gadow's (1984) characterization of the philanthropic paradigm which assumes "sufficiency and independence on one side and needy dependence on the other" (p. 68). The relationship grounded in nursing as caring would enable the nurse to connect with the hope that underlies an expression of despair or hopelessness. Personal expressions such as despair, or fear, or anger, for example, are neither ignored nor discounted. Rather, they are understood as the caring value which is in some way present. An honest expression of fear or anger, for example, is also an expression of vulnerability, which expresses courage and humility. We reiterate that our approach is grounded in the fundamental assumption that all persons are caring and the commitment which arises from this basic value position.
It is this understanding of person as caring that directs professional nursing decision making and action from the point of view of our Nursing as Caring theory. The nurse enters into the world of the other person with the intention of knowing the other as caring person. It is in knowing the other in their "living caring and growing in caring" that calls for nursing are heard. Of equal importance is our coming to know how the other is living caring in the situation and expressing aspirations for growing in caring. The call for nursing is a call for acknowledgement and affirmation of the person living caring in specific ways in this immediate situation. The call for nursing says "know me as caring person now and affirm me." The call for nursing evokes specific caring responses to sustain and enhance the other as they live caring and grow in caring in the situation of concern. This caring nurturance is what we call the nursing response.
The nursing situation is a key concept in the theory of Nursing as Caring. Thus, we understand nursing situation as a shared lived experience in which the caring between nurse and nursed enhances personhood. The nursing situation is the locus of all that is known and done in nursing. It is in this context that nursing lives. The content and structure of nursing knowledge are known through the study of the nursing situation. The content of nursing knowledge is generated, developed, conserved, and known through the lived experience of the nursing situation. Nursing situation as a construct is constituted in the mind of the nurse when the nurse conceptualizes or prepares to conceptualize a call for nursing. In other words, when a nurse engages in any situation from a nursing focus, a nursing situation is constituted.
In the Scandinavian countries, for instance, all the helping disciplines are called caring sciences. Professions such as medicine, social work, clinical psychology, and pastoral counseling have a caring function; however, caring per se is not their focus. Rather, the focus of each of these professions addresses particular forms of caring or caring in particular ranges of life situations. In nursing situations, the nurse focuses on nurturing person as they live and grow in caring. While caring is not unique to nursing, it is uniquely expressed in nursing. The uniqueness of caring in nursing lies in the intention expressed by the statement of focus. As an expression of nursing, caring is the intentional and authentic presence of the nurse with another who is recognized as person living caring and growing in caring. Here, the nurse endeavors to come to know the other as caring person and seeks to understand how that person might be supported, sustained, and strengthened in kis or her unique process of living caring and growing in caring. Again, each person in interaction in the nursing situation is known as caring. Each person grows in caring through interconnectedness with other.
Calls for nursing are calls for nurturance through personal expressions of caring, and originate within persons who are living caring in their lives and hold dreams and aspirations of growing in caring. Again, the nurse responds to the call of the caring person, not to some determination of an absence of caring. The contributions of each person in the nursing situation are also directed toward a common purpose, the nurturance of the person in living and growing in caring.
In responding to the nursing call, the nurse brings an expert (expert in the sense of deliberately developed) knowledge of what it means to be human, to be caring, as a fully developed commitment to recognizing and nurturing caring in all situations. The nurse enters the other's world in order to know the person as caring. The nurse comes to know how caring is being lived in the moment, discovering unfolding possibilities for growing in caring. This knowing clarifies the nurse's understanding of the call and guides the nursing response. In this context, the general knowledge the nurse brings to the situation is transformed through an understanding of the uniqueness of that particular situation.
Every nursing situation is a lived experience involving at least two unique persons. Therefore, each nursing situation differs from any other. The reciprocal nature of the lived experience of the nursing situation requires a personal investment of both caring persons. The initial focus is on knowing persons as caring, both nurse and nursed. The process for knowing self and other as caring involves a constant and mutual unfolding. In order to know the other, the nurse must be willing to risk entering the other's world. For his or her part, other person must be willing to allow the nurse to enter his or her world this to happen, the acceptance of trust and strength of courage needed, person in the nursing situation can be awe-inspiring.
It is through the openness and willingness in the nursing situation that presence with other occurs. Presence develops as the nurse is willing to risk entering the world of the other and as the other invites the nurse into a special, intimate space. The encountering of the nurse and the nursed gives rise to a phenomenon we call caring between, within which personhood is nurtured. The nurse as caring person is fully present and gives the other time and space to grow. Through presence and intentionality, the nurse is able to know the other in his or her living and growing in caring. This personal knowing enables the nurse to respond to the unique call for nurturing personhood. Of course, responses to nursing calls are as varied as the calls themselves. All truly nursing responses are expressions of caring and are directed toward nurturing persons as they live and grow in the caring in the situation.
In the situation, the nurse draws on personal, empirical, and ethical knowing to bring to life the artistry of nursing. When the nurse, as artist, creates a unique approach to care based on the dreams and goals of the one cared for, the moment comes alive with possibilities. Through the aesthetic, the nurse is free to know and express the beauty of the caring moment (Boykin & Schoenhofer, 1991). This full engagement within the nursing situation allows the nurse to truly experience nursing as caring, and to share that experience with the one nursed.
In Chapter 1, we noted that each profession arose from some everyday service given by one person or another. Nursing has long been associated with the idea of mothering, when mothering is understood as nurturing the personhood of another. The ideal mother (and father) recognizes the child as caring person, perfect in the moment and unfolding possibilities for becoming. The parent acknowledges and affirms the child as caring person and provides the caring environment that nurtures the child in living and growing in caring. The origins of nursing may well be found in the intimacy of parental caring. The roles of both parent and nurse permit and at times even expect that one be involved in the intimacy of the daily life of another. The parent is present in all situations to care for the child. Ideally, parents know the child as eminently worthwhile and caring, despite all the limitations and human frailties. As we recognized in Chapter 1, professions arise from the special needs of everyday situations, and nursing has perhaps emerged in relation to a type of caring that is synonymous with parenthood and friendship. The professional nurse, schooled in the discipline of nursing, brings expert knowledge of human caring to the nursing situation.
In the early years of nursing model development, nursing scholars endeavored to articulate their discipline using the perspective of another discipline, for example, medicine, sociology, or psychology. One example of this endeavor is the Roy Adaptation Model, in which scientific assumptions reflect von Bertalanffy's general systems theory and Helson's adaptation level theory (Roy and Andrews, 1991, p. 5). Parson's theory of Social System Analysis is reflected in Johnson's Behavioral System Model for Nursing and Orem's Self-Care Deficit Theory of Nursing (Meleis, 1985). A second trend involved declaring that the uniqueness of nursing was in the way in which it integrated and applied concepts from other disciplines. The emphasis in the 1960s on nursing model development came as an effort to articulate and structure the substance of nursing knowledge. This work was needed to enhance nursing education, previously based on rules of practice, and to provide a foundation for an emerging interest in nursing research. Nursing scholars engaged in model development as an expression of their commitment to the advancement of nursing as a discipline and profession, and we applaud their contributions. It is our view, however, that these early models, grounded in other disciplines, do not directly address the essence of nursing. The development of Nursing as Caring has benefited from these earlier efforts as well as from the work of more recent scholarship that posits caring as the central construct and essence (Leininger, 1988), and the moral ideal of Nursing (Watson, 1985).
The perspective of nursing presented here is notably different from most conceptual models and general theories in the field. The most radical difference becomes apparent in the form of the call for nursing. Most extant nursing theories, modeled after medicine and other professional fields, present the formal occasion for nursing as problem, need, or deficit (e.g., Self-Care)
Deficit Theory [Orem, 1985], Adaptation Nursing [Roy and Andrews, 1991], Behavioral System Model [Johnson, 1980], and [Neuman, 1989.] Such theories then explain how nursing acts to right the wrong, meet the need, or eliminate or ameliorate the deficit.
The theory of Nursing as Caring proceeds from a frame of reference based on interconnectedness and collegiality rather than on esoteric knowledge, technical expertise, and disempowering hierarchies. In contrast, our emerging theory of nursing is based on an egalitarian model of helping that bears witness to and celebrates the human person in the fullness of his or her being, rather than on some less-than-whole condition of being.