Boykin, A., & Schoenhofer, S. (1991). Story as link between nursingpractice, ontology, epistemology. Image, 23, 245-248.Gadow, S. (1984). Touch and technology: Two paradigms of patient care.Journal of Religion and Health, 23, 63-69.Johnson, D.E. (1980). The behavioral system model of nursing. In J.Riehl & C. Roy (Eds.), Conceptual models for nursing practice (2nded.). New York: Appleton-Century-Crofts.Leininger, M.M. (1988). Leininger's theory of nursing: Cultural carediversity and universality. Nursing Science Quarterly, 1, 152-160.Meleis, A. (1985). Theoretical nursing: Development & progress.Philadelphia: J.B. Lippencott.Neuman, B. (1989). The Neumans systems model. Norwalk, CT: Appleton& Lange. Orem, D.E. (1985). Nursing: Concepts of practice (3rd ed.).New York: McGraw Hill.Roy, C., & Andrews, H. (1991). The Roy Adaptation Model: Thedefinitive statement. Norwalk, CT: Appleton & Lange.Watson, J. (1985). Nursing: Human science and human care. A theory ofnursing. Norwalk, CT: Appleton-Century-Crofts.
The concept of nursing situation is central to every aspect of the theory of Nursing as Caring. We have claimed that all nursing knowledge resides within the nursing situation (Boykin & Schoenhofer, 1991). The nursing situation is both the repository of nursing knowledge and the context for knowing nursing. The nursing situation is known as shared lived experience in which the caring between the nurse and the one nursed enhances personhood.
It is to the nursing situation that the nurse brings self as caring person. It is within the nursing situation that the nurse comes to know the other as caring person, expressing unique ways of living and growing in caring. And it is in the nursing situation that the nurse attends to calls for caring, creating caring responses that nurture personhood. It is within the nursing situation that the nurse comes to know nursing, in the fullness of aesthetic knowing.
The nursing situation comes into being when the nurse actualizes a personal and professional commitment to the belief that all persons are caring. It should be recognized that a nurse can engage in many activities in an occupational role that are not necessarily expressions of nursing. When a nurse practices nursing thoughtfully, that nurse is guided by his or her conception of nursing. The concept of nursing formalized in the Nursing as Caring theory is at the very heart of nursing, extending back into the unrecorded beginnings of nursing and forward into the future. Acknowledgement of caring as the core of nursing implies that any nurse practicing nursing thoughtfully is creating and living nursing situations because, whether explicit or tacit, the caring intent of nursing is present.
Remember that the nursing situation is a construct held by the nurse, any interpersonal experience contains the potential to become a nursing situation. In the formal sense of professional nursing, the nursing situation develops when one person presents self in the role of offering the professional service of nursing and the other presents self in the role of seeking, wanting, or accepting nursing service.
The nurse intentionally enters the situation for the purpose of coming to know the other as caring person. The nurse is also allowing self to be known as caring person. Authentic presence, like most human capacities, is inherent and can be more fully developed through intention and deliberate effort. Authentic presence may be understood simply as one's intentionally being there with another in the fullness of one's personhood. Caring communicated through authentic presence is the initiating and sustaining medium of nursing within the nursing situation.
The nurse, with developed authentic presence and open to knowing the other as caring, begins to understand the other's call for nursing. A call for nursing is a call for specific forms of caring that acknowledge, affirm, and sustain the other as they strive to live caring uniquely. We must remember as well that calls for nursing originate within the unique relationship of the nursing situation. As the situation ensues, the call for nursing clarifies. The nurse comes to know the one nursed more and more deeply and to understand more fully the unique meaning of the person's caring ways and aspirations for growing in caring. It is in this understanding that the call for nursing is known as a specific situated expression of caring and a call for explicit caring response.
The nursing response of caring is also uniquely lived within each nursing situation. In the nursing situation, the call of the nursed is a personal "reaching out" to a hoped-for other. The nursed calls forth the nurse's personal caring response. While the range and scope of human caring expression can and must be studied, the caring response called forth in each nursing situation is created for that moment. The nurse responds to each call for nursing in a way that uniquely represents the fullness (wholeness) of the nurse. How I might respond to such a call would and should reflect my unique living of caring as person and nurse. Each response to a particular nursing situation would be slightly different and would portray the beauty of the nurse as person.
The nursing situation is a shared lived experience. The nurse joins in the life process of the person nursed and brings his or her life process to the relationship as well. In the nursing situation, there is caring between the participants. Further, the experience of the caring within the nursing situation enhances personhood, the process of living grounded in caring. Each of these components of the construct of the nursing situation raises questions for immediate and continuing discussion.
How can an unconscious patient be a participant in a nursing situation? Can "postmortem care" be considered nursing? How can the nurse know that the other is truly open to nursing—can the nurse impose self into the world of the other? What about an unrepentant child rapist or a person responsible for genocide, can we say that person is caring, and if not, can we nurse them? Does the nurse have to like the person being nursed? Does the nurse seek enhancement of personhood in the nursing situation? If so, might the goals of the nurse be imposed on the one nursed? If the nurse gains from the nursing situation, isn't that unprofessional?
In part, these legitimate questions raise larger issues about the uniqueness and scope of nursing as a discipline and professional service in society. Certainly the study of these questions adds clarity to the purpose of nursing actions. To nurse, situations in a general sense are transcended and transformed When they are conceptualized as nursing situations. From the perspective of the Nursing as Caring theory, the study of these questions would require that the nurse transcend social or other situational contexts and live out a commitment to nurture the person in the nursing situation as they live and grow in caring.
Persons with altered levels of consciousness, measured on normative scales developed for medical science purposes, can and do participate in nursing situations. Nurses committed to knowing the unconscious as caring person can and do describe their ways of expressing caring and aspirations for growing in caring. Nurses speak of the post-anesthesia patient as living hope in their struggle to emerge from the deadening effects of the anesthesia; as living honestly in fretful, fearful thrashing. Nurses help these persons sustain hope and extend honesty through their care. The profoundly mentally disabled child lives humility moment-to-moment and calls forth caring responses to validate and nurture that beautiful humility. Nurses speak of caring for their deceased patients as nursing those who have gone and are still in some way present. The nurse, connected in oneness with the one known and nursed, holds hope for the other as the other's expression of hopefulness lives on in the consciousness of the nurse. Thus, a sense of connectedness does not dissipate when physical presence ends, but remains an active part of the nurse's experience.
Nursing another is a service of caring, communicated through authentic presence. Nursing another means living out a commitment to knowing the other as caring person and responding to the caring other as someone of value (Boykin & Schoenhofer, 1990, 1991). In its fullest sense, nursing cannot be rendered impersonally, but must be offered in a spirit of being connected in oneness. "To care for" seems to require that the caregiver see oneself as caring person reflected in the other (Watson, 1987). The theoretical perspective of Nursing as Caring is grounded in the belief that caring is the human mode of being (Roach, 1984). When a person is judged by social standards to be deviant and even evil, however, it is difficult to summon caring. This points to the contribution nursing is called upon to make in society. When we speak of nursing's contribution here, we are invoking earlier discussions of discipline and profession. Each discipline and profession illuminates a special aspect of person—in effect, what it means to be human. The light that nursing shines on the world of person is knowledge of person as caring, so that the particular contribution of nursing is to illuminate the person as caring, living caring uniquely in situation and growing in caring. In nursing, practiced within the context of Nursing as Caring, the person is taken at face value as caring and never needs to prove him or herself as caring. The nurse, practicing within the context of Nursing as Caring, is skilled at recognizing and affirming caring in self and others. Being caring, that is, living one's commitment to this value "important-in-self" (Roach, 1984), fuels the nurse's growing in caring and enables the nurse I turn to nurture others in their living and growing in caring. The values and assumptions of nursing as caring can assist the nurse to engage fully in nursing situations with persons in whom caring is difficult to discover.
Nursing knowledge is discovered and tested in the ongoing nursing situations. Once experienced, nursing situations can be made available for living anew, with new discovery and testing. Aesthetic representation of nursing situations brings the lived experience into the realm of new experience. Thus, the knowledge of nursing can be made available for further study. Re-presentation of nursing situations can occur through the medium of nursing stories, poetry, painting, sculpture, and other art forms (Schoenhofer, 1989). Aesthetic re-presentation conserves the epistemic integrity of nursing while permitting full appreciation of the singularity of any one nursing situation (Boykin & Schoenhofer, 1991). Here, then, is one nurse's story of a shared lived experience in which the caring between nurse and the one nursed enhanced personhood. This story is offered as an example of nursing situation, re-presented as an open text, available for continuing participation by all who wish to enter into this shared lived experience of nursing. In fact, we invite the reader to enter into this nursing situation, which may then be used in classroom or conference settings to stimulate general or specific inquiry and dialogue.
One night as I listened to the change of shift report, I remember thestrange feeling in the pit of my stomach when the evening nurse reviewedthe lab tests on Tracy P Tall, strawberry-blonde and freckle-faced,Tracy was struggling with the everyday problems of adolescence andfighting a losing battle against leukemia. Tracy rarely had visitors.As I talked with Tracy this night I felt resentment from her toward hermother, and I experienced a sense of urgency that her mother be withher. With Tracy's permission I called her mother and told her that Tracyneeded her that night. I learned that she was a single mother withtwo other small children, and that she lived several hours from thehospital. When she arrived at the hospital, distance and silenceprevailed. With encouragement, the mother sat close to Tracy and I saton the other side, stroking Tracy's arm. I left the room to make roundsand upon return found Mrs. P. still sitting on the edge of the bedfighting to stay awake. I gently asked Tracy if we could lie on the bedwith her. She nodded. The three of us lay there for a period of time andI then left the room. Later, when I returned, I found Tracy wrappedin her mothers arms. Her mothers eyes met mine as she whispered "she'sgone." And then, "please don't take her yet." I left the room and closedthe door quietly behind me. It was just after 6 o'clock when I slippedback into the room just as the early morning light was coming throughthe window. "Mrs. P," I reached out and touched her arm. She raised hertear-streaked face to look at me. "It's time," I said and waited. Whenshe was ready, I helped her off the bed and held her in my arms fora few moments. We cried together. "Thank you, nurse," she said as shelooked into my eyes and pressed my hand between hers. Then she turnedand walked away. The tears continued down my cheeks as I followed her tothe door and watched her disappear down the hall.Gayle Maxwell (1990)
This nursing situation is replete with possibilities for nurses, and others, to understand nursing as nurturing persons living caring and growing in caring. A dialogue ensues on the nursing situation that allows participants an opportunity to experience both resonance and uniqueness as personal and shared understandings emerge. As the reader enters into the text, the nursing situation is experienced anew, now within the presence of two nurses, not one. Though intentionally entering the situation, the second nurse experiences d affirms being connected in oneness with both nurse and nursed as caring lived in the moment.
Gayle entered into Tracy's world that night open to hearing a special call. Gayle's openness was partly a reflection of her use of the empirical pathway of knowing, the data given in report, the comparison of empirical observations against biological, psychological, developmental, and social norms. Before discussing our understanding of Gayle's response from the theoretical per-perspective represented, it might be helpful to compare how the call for nursing may have been interpreted if approached, for example, from a psychological framework. If the nurse responded from a psychological framework, the problem identified would perhaps be conceptualized as denial on the part of Tracy's mother. It could be assumed that Tracy's mother was avoiding the reality of the impending death of her daughter. Here, the nursing goal would be assist the mother in dealing with her denial by facilitating grieving. Denial is only one psychological concept that could be applied in this situation; avoidance, anxiety, and loss are others. When nursing care is based on a psychological framework, however, the central theme of care is likely to be deemphasized in favor of a problem-oriented approach. The perspective offered by a normative discipline requires a reliance on empirical knowing. Using only the empirical pathway of knowing, the richness of nursing is lost.
Gayle's personal knowing, her intuition, however, was the pathway that illuminated the appreciation of this situation and prompted her acknowledgement of a call. She heard Tracy's call for intimacy, comfort, and protection of her mother's presence as she (Tracy) summoned courage and hope for her journey. Gayle intuitively knew that the specific caring being called forth was the caring of a mother. Gayle's caring response also took the form of the courageous acknowledgement of a call for nursing that would be difficult to sub-stantiate empirically. Beyond telephoning Tracy's mother, Gayle continued her nursing effort to answer Tracy's call for the presence of a mother as she supported Mrs. P. living her interconnectedness, in being with Tracy. Gayle heard Mrs. P.'s calls for knowing, knowing what to do and knowing that it would be right to do it, for the courage to be with her daughter in this new difficult passage. Her response of showing the way reflects hope and humility. The caring between the nurse and the ones nursed enhanced the personhood of all three, as each grew in caring ways. It is possible that the caring between the original participants in the nursing situation and those of us who are participating through engagement with the text continues to enhance personhood.
Boykin, A., & Schoenhofer, S. (1991). Story as link between nursingpractice, ontology, epistemology. Image, 23, 245-248.Boykin, A., & Schoenhofer, S. (1990). Caring in nursing: Analysis ofextant theory. Nursing Science Quarterly, 4, 149-155.Maxwell, G. (1990). Connections. Nightingale Songs, 1 (1). P.O. Box057563, West Palm Beach, FL 33405.Paterson, J., & Zderad, L. (1988). Humanistic nursing. New York:National League for Nursing Press.Roach, S. (1984). Caring: The human mode of being, implications fornursing. Toronto: Faculty of Nursing, University of Toronto.(Perspectives in Caring Monograph 1).Schoenhofer, S. (1989). Love, beauty and truth: Fundamental nursingvalues. Journal of Nursing Education, 28 (8), 382-384.Watson, J. (1987). Nursing on the caring edge; Metaphorical vignettes.Advances in Nursing Science, 10, 10-18.
Foundations for practice of the Nursing as Caring theory rest on the nurse coming to know self as caring person in ever deepening and broadening dimensions. While all nurses may have (or at least, may have had) a sense of self as caring person, practicing within this theoretical framework requires a deliberate commitment to developing this knowledge. In many settings where nurses find themselves practicing, there is little in the environment to support a commitment to ongoing development of a sense of self as caring person. In fact, many practice environments seem to support knowing self only as instrument, self as technology. When one perceives of one's "nursing self" as a depersonalized, disembodied tool, nursing tends to lose its flavor and the devoted commitment to nursing burns out. So how to sustain and actualize this fundamental commitment must be a point of serious study for the nurse who desires to practice nursing as caring.
Mayeroff's (1971) caring ingredients are useful tools to assist the nurse in developing an ever-present awareness of self as caring person. Taking note of personal patterns of expressing hope, honesty, courage, and the other ingredients is a good starting place. Understanding the meaning of living caring in one's own life is an important base for practicing nursing as caring. In reflecting on a particular lived experience of caring, the nurse can seek to understand the ways in which caring contributed freedom within the situation—freedom to be, freedom to choose, and freedom to unfold.
Because nursing is a way of living caring in the world, the nurse can turn his or her attention to personal patterns of nursing as expressions of caring. As self understanding as caring person accrues, the nurse sometimes realizes that such self-awareness was there all along—it was only waiting to be discovered. Because many nurses were trained to overlook their caring ways instead of attending to them, nurses may now need something similar to, or indeed "sensitivity training" itself, to rediscover and reown the possibilities of self as caring person, possibilities specific to nursing as a profession and a discipline. This redirection of focus away from caring may have been related to several historical social movements. First, of course, is the move toward science, which for nursing meant that for a period of several decades nursing education seemed to reject, either partially or totally, the art of nursing in order to discover a scientific base for practice. Another related process, the technology movement, led nurses to understand care as a series of sequential actions designed to accomplish a specifiable end. In this context, nursing care became synonymous with managing available technologies. Third, there existed in the history of nursing education an era(s) in which nurses were taught to treat symptoms patients expressed, rather than to care for the person. Fourth, maintaining a professional distance was a hallmark of professionalism. Now, and rightly so, the tide has turned. A reawakening of knowing self as caring person becomes paramount so that the profession of nursing returns caring to the immediacy of the nursing situation.
With personal awareness and reflection, developed knowledge of caring also arrives through empirical, ethical, and aesthetic modes of knowing. There is a growing body of literature in nursing that both attests to that fact and to the process of how nurses communicate caring in practice (e.g., Riemen, I 986a, 1986b; Knowlden, 1986; Swanson-Kauffman, 1986a, 1986b; Swanson, 1990; Kahn and Steeves, 1988). Given the various perspectives offered by the authors just mentioned, the individual nurse can enhance his or her ethical self-development as a caring person by cultivating the practice of weighing the various meanings of caring now extant in actual practice situations and then by making choices to express caring creatively. In pursuit of this end, aesthetic knowing often subsumes and transcends other forms of knowing and thus may offer the richest mode of knowing caring. Appreciating structure, form, harmony, and complementarity across a range of situated caring expressions enhances knowing self and other as caring persons.
Knowing self as caring enhances knowing of the other as caring. Knowing other as caring contributes to our discovery of caring self. Without knowing the other as caring person, there can be no true nursing. Living a commitment to nursing as caring can be a tremendous challenge when nurses are asked to care for someone who makes it difficult to care. In effect, it is impossible to avoid the issue of "liking" or "disliking" the patient. Is it possible to truly care for someone if the nurse doesn't like him or her? In this light, another question arises: How can 1 enter the world of another who repulses me? Am I expected to pretend that this person (the patient) has not treated others inhumanely (if that is the case)? Must I ignore the reality of the other's hatefulness toward me (if such exists)? These are questions that come from the human heart. They express legitimate human issues that present themselves regularly in nursing situations.
The commitment of the nurse practicing nursing as caring is to nurture persons living caring and growing in caring. Again, this implies that the nurse come to know the other as caring person in the moment. "Difficult to care" situations are those that demonstrate the extent of knowledge and commitment needed to nurse effectively. An everyday understanding of the meaning of caring is obviously inadequate when the nurse is presented with someone for whom it is difficult to care. In these extreme (though not unusual) situations, a task-oriented, non discipline-based concept of nursing may be adequate to assure the completion of certain treatment and surveillance techniques. Still, in our eyes that is an insufficient response—it certainly is not the nursing we advocate. The theory, Nursing as Caring, calls upon the nurse to reach deep within a well-developed knowledge base that has been structured using all available patterns of knowing, grounded in the obligations inherent in the commitment to know persons as caring. These patterns of knowing may include intuition, scientifically quantifiable data emerging from research, related knowledge from a variety of disciplines, ethical beliefs, as well as many other types of knowing. All knowledge held by the nurse which may be relevant to understanding the situation at hand is drawn forward and integrated into practice in particular nursing situations. Although the degree of challenge presented from situation to situation varies, the commitment to know self and other as caring persons is steadfast.
Caring expressed in nursing is personal, not abstract. The caring that is nursing cannot be expressed as an impersonal generalized stance of good will, but must be expressed knowledgeably. That is, the caring that is nursing must be a lived experience of caring, communicated intentionally, and in authentic presence through a person-with-person interconnectedness, a sense of oneness with self and other. The nurse is not expected to be super-human, superficial, or naïve. Rather, a genuine openness to caring and a formed intention of knowing the other as caring person are required. In this sense, and referring back to patients with whom an expression of empathy is problematic; liking may be understood as a less personally committed form of caring or loving. In other words, liking is superficial and may not require the devotion needed to know other as caring. When the nurse truly connects with the other, liking the other becomes a moot issue.
Stories nurses tell about their nursing bring to light the sustenance they find in the nursing situation. Lived experiences of practice, recounted to crystallize the essential meaning of nursing, contain the tangible seeds of awareness of self as caring person. However, the nurse may not be fully aware of self as caring person until the nursing story is articulated and shared. When the practicing nurse can begin to describe practice as the personal expression of caring with and for another, possibilities for living nursing as caring emerge.
Here is one nurse's response to the invitation to tell a story that conveys the beauty of nursing. The authentic presence of the nurse in the following nursing situation focuses on honesty as an expression of self as caring person.
As Jason came through the door to RAC, a young black man lying lifelessly on a stretcher of pale green linen, the surgeon came towards me telling me not to tell Jason that his biopsy was positive.
I felt inner terror. A man, less than 18 years old, was going to come close to the "truth" of living today. Yet the terror inside me was really fueled by the becoming moral issue I was going to face soon.
Jason was surely going to ask of the results upon waking from anesthesia. "They always do." Going to sleep unknowing demands waking-to-know. "Honesty."
Honesty as a lived precept of caring requires that I, nurse, must always and ever regard the person nursed from a position of love. I must enter all nursing activity with the sole purpose of using truth, only and ever, to promote the spiritual growth of the person nursed. In this climate of openness to myself and to the other, we can begin to experience freedom from fear.
Jason inevitably opened his eyes only seconds or minutes later—I was so concerned with the surgeon's directive that I lost perception of time. My choice? The surgeon's choice? Jason's choice?
All too soon, before I could decide "how" to act, Jason had arrived at our moment of honesty versus dishonesty.
There were tears in Jason's eyes and as quickly as the endotrachial tube was removed, words came from Jason's essence. "Why me, God?"
I was pre-empted. (That's what happens when I write the script of nursing.)
Instead of dancing around "telling" Jason, I was now only able to "be-with" Jason. To suffer with Jason, to come to compassionate knowing of Jason's subjective reality. "I heard him," Jason choked and sobbed.
I just sat next to his stretcher and held his left hand with my right hand. I softly stroked his shoulder. This intimate hand-in-hand gesture only expressed a small part of the instant connectedness that we were co-experiencing, each alone, each with the other, all at once.
I sat there for more than thirty minutes telling Jason repeatedly to rest, trust God to help him, have strength, courage, and hope.
Having come together, Jason and I, through the darkness of anesthetized sleep to the harsh reality of "wakefulness," we both move on with our lives.
I asked the surgeon of Jason several times, but he couldn't remember Jason.
I will never forget Jason. Jason brought me closer to understanding honesty as caring (Little, 1992).
An explicit realization of nursing as a personal expression of caring can fuel a commitment to growing in caring throughout life. A vivid, articulated sense of self connects with an equally strong and explicit sense of nursing, and a personal commitment to caring in and through nursing is created. Research makes the unequivocal point that those who seek our nursing service identify caring as the sine qua non of nursing [Samaral], 1988; Winland-Brown & Schoenhofer, 1992). Entering these covenantal relationships obligates us to mutually live and grow in caring. What has also become apparent through our practice is that it is increasingly difficult for nurses to conceptualize their service as caring. Many nurses have lost faith in themselves as persons contributing caring in health service delivery situations. Thus, the raison d'être for the professional service career of nursing is lost, and nurses become disheartened.
It is our experience, as illustrated in the previous story, Honesty, that nurses can recapture the spirit of nursing, can rekindle hope for themselves as persons caring through and in nursing. The reader is invited to pause a moment and experience a sense of self as person expressing caring in nursing. You are invited to enter a quiet, contemplative inner space. Allow the attentions and distractions of the moment to recede as you create quietude. Now, bring to life the most beautiful nursing you have ever done. Recall that precious instance that stands out for you as truly nursing. Savor the fullness of that experience. Explore the meaning of this wonderful experience of nursing.
If possible, pause now and tell the story of your finest nursing moment—aloud to another nurse, or in writing to the nurse you are today. Share your story and invite other nurses to share theirs with you.
Now that the moment has been reborn and communicated, it is available as a powerful resource for you. The essence of nursing which connects you to all others in nursing is also to be found here. In that story resides the central meaning of nursing, available now for your inspiration and for your study.
For many nurses, the practice of nursing as caring will require changes in the conceptualization of nursing and nursing practice structures. Certain ideologies and cognitive frameworks that have gained prominence in nursing in the recent past are not fully congruent with the values expressed in the Nursing as Caring theory.
For example, the problem-solving process introduced into nursing by Orlando (1961), known as the Nursing Process, comes from a worldview that is incompatible with that which undergirds nursing as caring. In the 1960s, nurses came to value Orlando's Nursing Process for its role in helping them organize and put to use a growing body of scientific nursing knowledge. Having borrowed the "problematizing" approach to service delivery that was so successful in medical contexts, the Nursing Process also fit with an emerging documentation system known as Problem Oriented Medical Records, which again was adapted from medicine for nursing use. During the late 1970s and through the 1980s, this impetus was further developed in the Nursing Diagnosis movement.
What difficulties exist with the problem-solving process in nursing? More than anything else, this process directs nurses to locate something in the internal or external environment or character of the client that is in need of correction. Gadow (1984) refers to this view as a paradigm of philanthropy. In this demeaning paradigm, "touch is a gift from one who is whole to one who is not" (p. 68). Within the context of Orlando's Nursing Process, such problem solving requires that the nurse find something that needs correction to legitimately offer appropriate care. This focus on correction—and cure—distracts nurses from their primary mission of caring and therefore practice results in objectification, labeling, ritualism, and non-involvement. The context for nursing is lost.
Further, Orlando's Process has resulted in nursing's knowledge base being ever more deeply grounded in disciplines other than nursing. An examination of a list of nursing diagnoses reveals that specific knowledge from disciplines such as medicine, psychology, anthropology, sociology, and epidemiology is what is required to solve the problems to which the diagnoses refer. Rather than leading nurses toward the development of the knowledge of nursing, Orlando's Nursing Process has intensified the concept of nursing as a context-free integrator of other disciplines.
The following story of a nursing situation demonstrates the freedom and creativity that is possible when the nurse takes a focused, unfolding view of the lived world of nursing. What occasioned this nursing relationship was conceptualized in the larger system as providing care for the caregiver, providing support in a family context. Here, home nursing is seen as once again on the ascendancy as nurses discover what is increasingly missing in institutional bureaucratic settings—the opportunity to nurse.
I was with J. tonight, and for the first time I enjoyed "authentic presence" with her. I am not so sure it was because I was less fatigued and more receptive to "what is" in her home, but because J. was clearly "different" tonight. She greeted me with her usual rush of activity and then startled me by asking me to "be with me, please," when she gave her son an injection and changed the injection site on his central venous catheter line. I had met her son before, but had never been invited to his room or the upstairs quarters. We spent a long time in A's room with J. and A. talking, sharing thoughts and feelings about (sister) K., frustrations of J. trying to do it all and still find a little peaceful time for herself, angry outbursts and feelings of shame and sadness, and J's desire to go to Mass on Sunday without feelings of extreme anger and despair because K. cries when J. leaves the house, and ending with J's stated determination to do the impossible task of being all things to all people at all times. The dialogue was really between mother and son, with questions directed toward me but immediately answered by J. and A. The conversation was sparkling with humor and piercing with honesty, and created in mind's eye a rich, colorful mosaic of years of love, beauty, and truth. Tonight I wish I were an artist so I could capture this vision on canvas.
1. asked me to stay with A. while she did a small chore in the kitchen, and I settled in a side chair for whatever might present itself. The I.V. pole in the corner of the room caught my attention and A. offered the name of the drug and its purpose. I honestly did not know that particular drug, and had nothing to offer, so I just nodded my head. A. looked at me, cleared his throat, and proceeded to tell me about a problem he is encountering. I interrupted him and told him that I know nothing about him other than his name and he is J's son, and that J. has not shared anything about him privately with me. He smiled, and then with his head bowed and eyes peering at me, told me that he has AIDS, worries about the stigma, and dreads the stance most health professionals assume when he encounters them as they interpret the name of his disease process. I sat very still and nodded my head. I wanted to acknowledge his pain and show acceptance of him and what appeared to be his need to connect with me. Together we reflected on the wonderfulness of the human spirit, the concept of personhood, and holistic beings with thoughts, feelings, wants, and needs. When A. was ready we ventured down the stairs and found J. sitting quietly in a rocking chair. It seemed she had finished her "task," and I wondered how long she had been sitting alone. I sensed that she had invited me into her private pain, and courageously shared another part of her life with me. I also knew intuitively that she did not want to talk about it.
J. had prepared the piano, and all of them asked me to play for them and expressed disappointment that I did not play the piano during my visit last week. So I played gentle, reflective songs interspersed with light melodic phrases. Requests were offered by each member of the family, and within minutes J. was sitting next to me on the piano bench, singing loudly and punctuating words with feelings and strength and lending incredible meaning to lyrics. "Old Man River," deep, low, rumbling of the piano and purposefully driving tempo was responded to in kind with J. stamping her food with each beat and pounding her knee with each word as she emphatically sang "He just keeps rolling along, he keeps on rolling along." It seemed to be cathartic for her as expressions seemed to come from the center of her being. We applauded ourselves when we finished and J. let me hug her. A. caught my eye and mouthed "thank you for helping my mother to smile." J. was quiet then, and I felt her exhaustion. We agreed that it was time to close the piano for another week, and I left. J. followed me to my car, and left me with "God bless you."
This was an exhausting visit to J's home, yet it was even more energizing because of the multiple caring moments I experienced with J. and her family. I have come to believe that caring moments are unique to each nursing situation and evolve naturally from the mutuality of authentic presence as the fullness of the nurse's personhood blends with the fullness of the other's personhood. Together they transcend the moment. The caring moment is connectedness between nurse and other and both experience moments of joy. (Kronk, 1992)
To characterize this nursing situation with a nursing diagnosis and to portray it as a linear process driven by the diagnosis or problem to be addressed with a pre-envisioned outcome would be to rob the situation of all the beauty of nursing. Because a story of a nursing situation is narrative, there is a temporal structure. However, this structure supports rather than destroys the "lived experience" character of the situation. The story of the nursing situation conveys the "all-at-once" as well as the unfolding. This approach permits us to conceptualize as well as contextualize the knowledge of nursing the story tells. Through story, the meaning for this nurse of knowing herself as caring person, as entering into the world of other(s) with authentic presence, is understood. The nurse knows other as caring person, and in that knowing attends to specific calls for caring with unique expressions of caring responses created in the moment.
The Nursing as Caring theory, grounded in the assumption that all persons are caring, has as its focus a general call to nurture persons as they live caring uniquely and grow as caring persons. The challenge then for nursing is not to discover what is missing, weakened, or needed in another, but to come to know the other as caring person and to nurture that person in situation-specific, creative ways. We no longer understand nursing as a "process," in the sense of a complex sequence of predictable acts resulting in some predetermined desirable end product. Nursing is, we believe, processual, in the sense that it is always unfolding and that it is guided by intention.
Nursing is a professional service offered in social contexts, most often in bureaucratically organized health services. Discussions of health services, overheard in boardrooms and legislative chambers, are languaged in impersonal, aggregate, disembodying, and perhaps more importantly, economic terms. In contrast to the accepted ritualization of such language, nursing has a very important role to play—to bring the human, the personal dimension to health policy planning, and health care delivery systems. Clearly, it is nursing knowledge itself, of human person, of person as caring, that has been missing. While other groups rightly bring in knowledge of efficient operation and financing, nursing's contribution to the dialogue on effective care has the potential to remind all players of the real bottom line, the person being cared for. We must remember that in most industrialized countries health service is viewed as a commodity delivery system, an economic exchange of goods and services. While this is not the only context for nursing, it is the most prevalent context. If nurses choose to participate in existing delivery systems, and most do, then ways must be created that preserve the service of nursing while responding to the appropriate requirements of the system. Ultimately, this would require of nurses that they become skilled in articulating their service as nursing, and connecting that service to the recording and billing systems in use. Although this same goal animated the nursing diagnosis movement of the 1970s, within the terms of that movement, the result was less than fortunate: nursing's effort to emulate the fee-for-service billing practices of medicine failed, and nursing contributions were neither communicated nor reimbursed.
When nurses tell the stories of their nursing situations, however, the service of nursing becomes recognizable. The unique contribution that nurses make, expressed in the focus of nursing, emerges across settings. The difference between a nursing story and a typical nursing case report is striking; the first conveys the nursing care given, the second reports the medical-assisting activities performed by the nurse. We have discovered in our work with nurses that while nursing care is usually given, it is frequently neither acknowledged nor communicated.
The nurse practicing within the caring context described here will most often be interfacing with the health care system in two ways: first, to communicate nursing in ways that can be understood; and second, to articulate nursing service as a unique contribution within the system in such a way that the system itself grows to support nursing.
The concept of profession is involved in the practice of nursing as caring. With the advent of the information and action technologies of the twenty-first century, the present concept of professions as repositories of esoteric knowledge employed by social elites is rapidly becoming outdated. As many nurses will attest, the patient often teaches the nurse about new medical technologies and about the management of them. In this regard, what will it mean, in the next century, to profess nursing? A renewed commitment to professional caring means that nurses would seek connectedness in all collegial relationships as nurses are open to discovering the unfolding meaning of human caring, with persons valued as important in themselves. Therefore, nurses forfeit assuming authoritative stances toward each other, the persons nursed, and other participants in the health care enterprise. More than ever, it will mean that nurses will, in relation with others, live out the value of caring in everyday life. Thus, the organized nursing profession would assume responsibility for developing and sharing knowledge of nurturing persons living caring and growing in caring.
The following story of a nursing situation, told in the form of a poem, exemplifies the reconceptualization called for in the practice of Nursing as Caring. In this situation, the nurse carried out a medically prescribed treatment, not as a form of medicine but as a form of nursing. The nurse communicates a knowing of the other as caring person, living courage and hope in the face of pain and fear. This example illustrates the meaning of knowing as a caring ingredient (Mayeroff, 1971), in the connectedness of the nurse with the patient.
The nurse's knowing both forms the intention to nurse and is formed by the intention to know other as caring person and nurture caring. A more typical recounting of this situation would focus on the specific procedure of the treatment being applied, in terms of the condition of the wound. In this poem, the nurse renders the meaning of nursing.