Boykin, A., & Schoenhofer, S. (1990). Caring in nursing: Analysis ofextant theory. Nursing Science Quarterly, 4, 149-155.Carper, B. (1978). Fundamental patterns of knowing in nursing. Advancesin Nursing Science, 1, 13-24.Carr, S. (1991). Intensive Care. Nightingale Songs, PO. Box 057563, WestPalm Beach, FL 33405-7563, 2 (1).Guralnik, D. (1976). Webster's new world dictionary of the Americanlanguage. Cleveland: William Collings + World Publishing Co.Mayeroff, M. (1971). On caring. New York: Harper & Row.Nodding, N. (1988). An ethic of caring and its implications forinstitutional arrangement. American Journal of Education, 97, 215-230.Roble, M. (1991). Ave Maria and Therapeutic Touch for David. NightingaleSongs, P.O. Box 057563, West Palm Beach, FL 33405-7563, 1 (3).
In this chapter, we will address our conception of nursing as human science and suggest directions and strategies for further development of the theory of Nursing as Caring. We initially introduced our perspective of nursing as discipline and profession in Chapter 1 and as a grounding context for the theory. As a discipline, nursing is a way of knowing, being, valuing, a way of living humanely, connected in oneness with others, living caring and growing in caring. The unity nursing offers is known in human experience through personal, empirical, ethical, and aesthetic realms.
Science has to do with knowing and that which is known. Philosophers of science are concerned with valid ways of knowing and ways of validating that which is known. Human science is described by scholars in various ways, each emphasizing particular values but all connecting to a common understanding that human science is concerned with knowing the world of human experience. A committed inquiry into human experience seems to call forth certain values related to the meaning of being human. Herein lies the fundamental difference between formal science and human science, as we perceive it. Formal science, that which is practiced in the natural sciences and other sciences that emulate them, is modeled on the structure of mathematics. Mathematics is a highly lawful science that has contributed enormous social benefits over time. However, formal science grounded in mathematics and languaged as calculus is an inappropriate approach to the study of person-as-person. A perspective that addresses the phenomenon of person-as-person is grounded in central values such as caring, freedom, and creativity. Methods to study person must be similarly grounded.
We have come to understand that valid ways of knowing nursing and legitimate warrants for nursing knowledge are discovered from within the study of nursing itself; that is, within the study of the nursing situation. The manner in which certain disciplines are conceptualized, especially those dealing in normative contexts, calls for a dialectical form of sciencing, comparing, and contrasting. However, coming to know nursing is a dialogical process—direct engagement with the "word of nursing." Nursing science must be contextual; the decontextualized methodology of formal science, while essential for certain disciplines, cannot reveal direct knowledge of nursing. Because of the nature of nursing, nursing science must permit intentionality, intimacy, mutuality, and particularity.
Human science has understanding as its goal, with the definite expectation that understanding is in the moment only (Watson, 1988; Van Manen, 1990). In addition, the nature of nursing praxis does not require knowledge for the purpose of control, but for enlightenment, moment-to-moment and reflectively. The nurse seeks knowledge neither to control one's own behavior or that of the nursed. If it were otherwise, the nurse would become his or her own prisoner, and would relate to the other as dominator rather than caring nurse. The concept of the hermeneutic circle informs our understanding of the nature of nursing as a human science. This circle of understanding, really a sphere more than a uni-dimensional circle, is a heuristic device which directs our attention. As attention pauses at any aspect of the nursing situation, we must attend to other aspects and to the whole of the nursing situation to create useful understanding. One hermeneutist has pointed out that the circle brings us further along, not the issue at hand (Droysen, 1988). This distinction points to the human science position that understanding is not constituted through analysis of facts but through dialogue with text and context. That is, what moves within the circle is the seeker, rather than that which is sought, so that many aspects are illuminated in context, and understanding grows. The hermeneutic circle requires that what we note in our inquiry remains contextualized, developing "new and ever new circles" (Boeckh, 1988). This is in contrast to normal science that requires an external referent for objects of study in order to avoid circular thinking. Heidegger (1988), for example, contrasts the vicious circle of normal science (tautology) with the circle of hermeneutic: " . . . in the circle is hidden a positive possibility of the most primordial kind of knowing" (p. 225). We would propose that valid knowing in nursing is that which is known from within the circle.
While the work of several scholars has influenced our understanding (e.g., Gadamer, 1989; Van Manen, 1990; Ray, 1994; Reeder, 1988), Macdonald's (1975) interpretation from the field of humanistic education is especially meaningful. He explains hermeneutic knowing methodologically as "circular rather than linear in that the interpretation of meaning in hermeneutic understanding depends on a reciprocal relation" (p. 286) rather than on a fixed normative reference point. The hermeneutic circle models the idea of reciprocal relation, but Macdonald goes further to call for a self-reflective science that will "transcend problems of monological and hermeneutic meaning" (p. 287). The nature of nursing as expressed in the Nursing as Caring theory is a reciprocal relation, one characterized by its grounding in person as caring, and as persons connected in oneness in caring. Sciencing in nursing from this perspective must go beyond linearity to encompass the dialogic circling involved in the nursing situation. This places the discipline of nursing among the human sciences, and calls for methods of inquiry that assure the circle or dialogue, and further, fully accommodate that which can be known of nursing.
Nursing is properly catalogued as one of the human sciences for many reasons. The most basic reason is that the discipline and the disciplined practice of nursing directly involve persons in the fullness of their humanness. From our perspective, this means person as caring. Person as caring implies person in community, connected in oneness with others and with the universe, person freely choosing the living of values which are expressions of caring. This nursing ontology requires an epistemology consonant with human science values and methods. To know of, through and with nursing necessitates methods and techniques that honor freedom, creativity, and interconnectedness.
In Chapter 4, we asserted that nursing knowledge is created and discovered within and from within the nursing situation. (Nursing situation, you may recall, is understood as a shared lived experience in which the caring between the nurse and the one nursed enhances personhood.) Therefore, because the locus of nursing inquiry is the nursing situation, the systematic study of nursing calls for a new methodology that recognizes that fact.
Certainly, we acknowledge that something useful for nursing can be learned through existing methodologies, from both natural and human science traditions. For example, an experimental design can produce information about the effectiveness of a given clinical technique within a specified range of use (e.g., placement of an oral thermometer). Such information can be important and useful to the work of the nurse and useful to the client of nursing. It tells us nothing, however, of nursing. In fact, the central tenet underlying measurement in normal science directly contradicts the central tenet of human science: created versus creating. Thus, the fullness of the nursing situation is not amenable to study by measurement techniques. Yet, aspects of the nursing situation can be abstracted and studied as variables in relation to other variables. This does not, however, yield knowledge of the nursing situation in its fullest. At best, measurement approaches can call attention to an aspect so that it can be considered within the unfolding.
Phenomenology, on the other hand, offers an example of an orientation and methodology that more closely approximates what is needed in a nursing method of inquiry. Phenomenology is an orientation toward inquiry that may be actualized through any one of a number of generic approaches, but is generally understood as the study of lived experience (e.g., Van Manen, 1990; Oiler, 1986). When the phenomenon conceptualized for study is representative of the nursing situation, nursing may be known. That is, new nursing knowledge may eventuate. New understanding of the meaning of the shared lived experience of caring between nurse and nursed enhancing personhood can be created.
Yet, for the purposes of nursing, phenomenology also has its limits. For example, when phenomena which have been abstracted from a nursing situation are selected for study (that is, when phenomena are taken out of context), results of the inquiry cannot generate knowledge of nursing proper. For example, the understanding that comes in developing a description of the essential structure of what it is like for a nurse to be called to nurse informs us about nurses, but not about nursing directly. Similarly, an exquisite phenomenological description of what it is like for a person to live grieving is helpful in understanding the person. However, it should not be mistaken for knowledge of nursing, but knowledge which illuminates the study of nursing when taken back to the full context of the nursing situation. Further, the various phenomenologies in the literature come from frames of reference that are not nursing (e.g., existential psychology or educational psychology), and thus impose a "silent" borrowed framework when used to study nursing.
Is this drawing too fine a line? And is it really important to press the issue of nursing knowledge versus knowledge of and for nurses? The answers to these questions are probably found in one's concept of nursing as a field of knowledge (discipline) and a human service (profession). It seems that nursing and nurses have suffered significantly over the years with this dilemma. Is it possible to have a sense of self as nurse without a concomitant sense of nursing as a discipline which is more than tacit and to which one is committed? Students of nursing and practitioners alike have abundant opportunities to acquire a sense of self as nurse. Yet why is it that many programs of nursing education (at all levels) do not convey a sense of nursing as a discipline? The answer may lie in those conducting the programs, who have experienced training for practice and education in disciplines other than nursing and without explicit education in the discipline of nursing.
From the perspective of Nursing as Caring, with its grounding in person as caring and nursing as discipline, the distinctions implied in this question of "does it really matter" are of central importance. Nurses in practice, education, and administration continue to address nursing primarily in terms of "what nurses do," (e.g., nursing "interventions") and most nursing research seems to derive from that perspective as well. Without a clearly articulated understanding of the focus of the discipline, it has been extremely difficult to organize and structure nursing knowledge in ways that facilitate the development of the discipline. In this book, we have offered a theory, Nursing as Caring, as one expression of that focus, languaged in terms that communicate the essence of nursing.
Nursing knowledge is knowledge of nurturing persons living caring and growing in caring within shared lived experiences in which the caring between nurse and nursed enhances personhood. Furthering nursing knowledge requires methods that can illuminate the central phenomenon of the discipline. The development of such a methodology is, as we see it, the next major effort to be undertaken in the development of the theory. In this regard, we envision a fully adequate methodology that would include a phenomenological aspect which goes beyond description to a hermeneutical process, within an action research orientation. That is, what seems to be needed is a methodology that would permit the study of nursing meaning as it is being co-created in the lived experience of the nursing situation. Supplemental methods could continue to include traditional phenomenological and hermeneutic work with texts describing particular nursing situations. Nurses who are interested in developing knowledge of techniques or modes of expressing caring would continue to use traditional methods of formal and human science for these kinds of nursing-related questions.
The development of methods of nursing inquiry appropriate to the study of the theory, Nursing as Caring, is in a formative stage. We understand to a considerable extent the limitations of existing modes of inquiry, and have a growing sense of what will be required of a new methodology. Nursing scholars are working to develop methods to illuminate the fullness of nursing. Examples of that work which has encouraged our efforts include that by Parker (1993), Swanson-Kauffman (1986), Parse (1990), and Ray (Wallace, 1992). The work of these scholars demonstrates that the development of nursing ways of inquiry is important and that a search has begun. As we have come to understand the concept of human science, our understanding of nursing has been enriched. Like most of our contemporaries in nursing, we were trained in the often-unarticulated assumptions of natural science. And we have traveled the road familiar to many nursing scholars, the road of expertise in objectification and quantification. Along that road, we began to notice the trivialization of cherished nursing ideas like presence, touch, relationship, knowing, and caring. Resisting the temptation to abandon the journey, we each persevered in a commitment to nursing as something which mattered, something involving intimate, personal, caring relationships. Discovering, inventing, and creating a new methodology is an important dream and we are committed to continuing this aspect of theory development.
Nursing as Caring is a transformational model for all arenas. Nursing practice, nursing service organization, nursing education, and nursing inquiry require a full understanding of nursing as nurturing persons living caring and growing in caring, and these underlying assumptions:
* 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 nurturing relationships with caring others.* Nursing is both a discipline and profession.
With these transformations, the fullness of nursing will be realized and we will grow in our understanding of self and other as caring persons connected in oneness.
Boeckh, P. (1988). Theory of criticism. In K. Mueller-Vollmer (Ed.), Thehermeneutics reader. New York: Continuum.Droysen, J. (1988). The investigation of origins. In K. Mueller-Vollmer(Ed.). The hermeneutics reader. New York: Continuum, pp. 124-126.Gadamer, H. (1989). Truth and method. New York: Crossroad Publishers.Heidegger, M. (1988). Understanding and interpretation. In K. Mueller-Vollmer (Ed.), The hermeneutics reader. New York: Continuum, pp. 221-228.Macdonald, J. (1975). Curriculum and human interests. In W. Pinar,Curriculum theorizing: The reconceptualists. Berkeley: McCutchanPublishers.Oiler, C. (1986). Phenomenology: The method. In P. Munhall & C.Oiler (Eds.), Nursing research: A qualitative perspective. Norwalk, CT:Appleton-Century-Crofts.Parker, M. (1993). Living nursing values in nursing practice. Paperpresented at 7th Annual Conference of the Southern Research Association,Birmingham, AL, February 18,1993.Parse, R. (1990). Parse's research methodology with an illustration ofthe lived experience of hope. Nursing Science Quarterly, 3,9-17.Ray, M.A. (1994). The richness of phenomenology: Philosophic, Theoreticand Methodologic Concerns. In J. Morse (Ed.), Critical issues inqualitative research. A contemporary dialogue. Newbury Park, CA: Sage,Ch. 7.Reeder, F. (1988). Hermeneutics. In B. Sarter (Ed.), Paths to Knowledge.New York: National League for Nursing.Swanson-Kauffman, K. (1986). A combined qualitative methodology fornursing research. Advances in Nursing Science, 8 (3), 58-69.Van Manen, M. (1990). Researching lived experience. London, Ontario:State University of New York Press.Wallace, C. (1992). A conspiracy of caring: The meaning of the client'sexperience of nursing as the promotion of well-being. Unpublishedmaster's thesis, College of Nursing, Florida Atlantic University.Watson, J. (1988). Nursing: Human science and human care. A theory ofnursing. New York: National League for Nursing.
The Theory of Nursing as Caring was initially presented in its entirety at the South Florida Nursing Theories Conference in 1992. The theory was explicated in the original release of Nursing as Caring: A Model for Transforming Practice in 1993 (Boykin & Schoenhofer, 1993). As work has progressed to develop the theory for use in nursing practice, research and education, the underlying assumptions introduced in Chapter 1 have been affirmed as central to the integrity of the theory. This epilogue highlights ongoing development of the theory by its authors and by other nurses. Developmental efforts include clarification of the concept of personhood, expansion of the understanding of enhancing per-sonhood as the general "outcome" of nursing, research innovations, and use of the theory in middle range theory work and in the critical analysis of caring.
In Chapter 1, personhood was described as a process of living grounded in caring. In an effort to clarify the meaning of "a process" in the context of the theory of Nursing as Caring, we explained that personhood, understood as living grounded in caring, is processual—ongoing, experienced moment to moment, evolutionary, transformative—rather than a generalized sequence of steps or operations. In subsequent publications, personhood was described as "living grounded in caring," eliminating the problematic use of the term "process" entirely (Schoenhofer & Boykin, 1998a; Boykin & Schoenhofer, 2000).
Nursing as Caring guides nurses to enter into the world of the other and allows them to come to know the nursed as living caring uniquely in situation. In consulting with nurses using Nursing as Caring as their framework for practice, we found that nurses could easily recognize expressions of caring when caring was lived in ways familiar to their own lifeworlds. However, in nursing situations where personal ways of caring were outside the experience of the nurse, there seemed to be difficulties in knowing and thus affirming the nursed as person uniquely living caring in the moment. Without this situated knowing, we saw that nurses tended to lose the focus of recognizing the other as living caring uniquely in the moment, and instead, to concentrate on ways in which persons "were not living caring" and "should grow in caring." This tendency to return to a normative practice framework in difficult times is easily understood as nurses struggle to transcend a familiar paradigm characterized by terms such as "nursing process," "nursing diagnosis," "nursing intervention" and to evolve toward what has been called a simultaneity paradigm (Parse, 1987).
Because knowing the other as caring is the basic act of nursing, it became clear to us that knowledge expansion would be helpful in enhancing nurses' ability to recognize uniquely personal ways their patients live the value of caring. Schoenhofer conducted a series of studies over several years to develop knowledge of personal lived meaning of everyday caring. In one unpublished study, adolescents shared stories of personal caring. Their stories were found to center around the theme of "helping out." Adolescents described everyday caring in terms such as "cheering up someone you love," "helping another get what they need," "work as caring," "caring by physical presence." The stories illustrated situations where caring was expressed as "helping out when you don't really want to, but doing it anyway," "helping without being asked," "filling in where caring is missing." One teenage boy told of caring for a former girlfriend who was angry about their breakup; he made deliberate efforts to remain active as a friend, as a way to help the girl deal with the loss of their romantic relationship. He characterized his caring as "keeping on showing care even though it doesn't seem to change things."
In another similar study, 4th grade students told stories of caring in which they acted as advocates for other children and offered help to others, both adults and children, who were perceived as less fortunate and in need of care (Schoenhofer, Bingham & Hutchins, 1998). Adults, too, have unique and personal ways of living their everyday caring. One father related an example of caring for his young daughter by restricting her activities because of poor school performance, and then engaging in a dialogue with her that resulted in a compromise. The father saw willingness to discipline as an act of caring and felt that his willingness to listen to the child's perspective was also part of his caring (Schoenhofer, Bingham & Hutchins, 1998). Several adults whose parents had become disabled told stories of caring for parents in ways that preserved cherished role relationships. These adults understood that their caring required extra effort to avoid infantalization of the parent but felt that without that extra effort, attention would be given to certain needs but adequate caring would not be given.
Research into everyday caring was conducted in a group discussion format, with persons invited to relate a story that illustrated how they lived their caring in everyday situations. The ease with which these research participants understood what was being asked of them, their willingness to respond and the clarity of the exemplars they shared have the potential to inform nursing practice. When nurse colleagues learned of this research effort, they often expressed doubt that people could and would describe their everyday caring ways. Based on the experience of the researchers and research participants in this series of studies, however, it became clear that persons do understand their unique ways of caring, and do recognize the importance of sharing that understanding.
Nurses committed to practice guided by the tenets of Nursing as Caring can and should incorporate direct invitation as part of their coming to know other as caring person, A number of important benefits are possible with a direct approach to knowing the other as caring. One benefit is that as the nurse raises the issue of caring, patients are helped to understand that caring is of immediate importance to nurses, thus clarifying the service and value of nursing among the health disciplines. A second benefit is that as nurses address caring directly with their patients, nurses themselves gain affirmation of nursing as a caring service and of themselves as persons committed to caring. However, the most immediate benefit of a direct approach to caring is the opening of a line of communication that clearly establishes the "caring between," that space, that relationship within which and through which all that is important in nursing occurs. The patient is given the opportunity to recognize self as caring person and to join in mutual affirmation and celebration with the nurse. Nurses who are reluctant to engage patients in dialogues about caring ways may think the topic is "too intimate." It is true that caring is intimate and personal, but caring is also very visible, just as many of the topics introduced in the nursing situation are personal and intimate and have visible referents. As nurses have the courage to raise the topic of caring, the central importance of caring in human living can become not only recognized but openly and publicly valued.
Another research thread has focused on the development of an approach to identifying and languaging outcomes of nursing guided by the theory of Nursing as Caring (Boykin & Schoenhofer, 1997; Schoenhofer & Boykin, 1998a, 1998b). Within the context of the theory, the idea of outcomes has been reconceptualized as "values experienced in the nursing situation." Several case studies illuminated a dialogical form of praxis involving nurse, patient and researcher that revealed values experienced by patients and their nurses. Values experienced by families, health care administrators and systems were also uncovered as the caring created in the nursing situation was found to resonate beyond the immediate nurse-patient relationship. This line of research has demonstrated that while traditional economic valuation can be calculated, the value of caring in nursing can and must be more clearly explicated in human terms. For example, one case study of home health nursing found that the economic value of six nursing visits produced a health care cost savings of $5,709, primarily by obviating the necessity of trips to the emergency department of the local hospital. Through this unique research approach, the human value of the six visits was identified and languaged in terms that clearly demonstrate the direct, unmediated worth of nursing care—to the one nursed, the family, the nurse and the larger circle of health care systems. The patient and family gained the important value of confidence through the caring of the home health nurse; with the nurse's commitment to caring, they gained faith in themselves, their ability to deal with new health-related situations as they arose, faith that they wouldn't be left alone, faith that they were known as persons valuable in their own right and worthy of care. This is the value of nursing, the reason nursing exists as a distinguishable social and human service. Nurses can learn to assert the human value of nursing, and in fact, nurses must accept the responsibility for bringing the human value of care to the forefront. Re-establishing the primary position of care in the health care arena depends on nurses speaking out in clearly human terms about the meaning and value of care, using the language of caring knowledgably and without apology.
In May, 2000, Boykin launched a funded study to examine the potential of the theory of Nursing as Caring to enhance the achievement of quality outcomes in acute care settings. This two-year demonstration project and evaluation study involves specifying quality indicators and targeting benchmarks prior to introducing the theory as the nursing practice framework in the acute care division of a community hospital. On-site guidance and consultation in the use of the theory will be available during the course of the project. Post-program evaluation will focus on quality indicators and benchmarks relating to patient and staff satisfaction, family and community support, and cost-benefit care ratios.
A theory that describes or explains a limited range of situations. Locsin (1995) developed a model of the harmonious relation between technology and caring in nursing. Further development of the model led to a theory of technological competence as caring in critical care nursing (Locsin, 1998). The mediating factors between application of technology and caring in nursing are posited as intentionality and authentic presence. The underlying theoretical framework draws on the theory of Nursing as Caring, and particularly the focus of nursing as knowing and thus nurturing the other as caring person. The intention to know the other as caring person is actualized through direct knowing as well as through the medium of technologically produced data. The intention to care, to nurture the other as caring, is expressed in interpersonal ways as well as in technological competence.
Dunphy (1998) drew on aspects of the theory of Nursing as Caring, particularly the idea of knowing the other as caring person, in the development of a model for advanced practice nursing, "the circle of caring." Dunphy was concerned with clarifying the disciplinary identify of advanced practice nursing as nursing. In an effort to transcend perspectives of advanced practice nursing based on the traditional reductionist medical science and nursing process models, processes of care are superimposed on a traditional medical model (Dunphy, 1998). The circle of care "incorporates individual strengths of both nursing and medicine but reformulates them in a new model of care... rooted in the lived experience of the patient" (p. 11). Caring quality indicators suffuse the entire model, and include courage, authentic presence, advocacy, knowing, commitment and patience. Elements formerly termed diagnosis and treatment are termed caring processes in the new model, in an attempt to ground advanced practice in nursing values. The core component of the model, caring processes, focuses on ways of knowing the person as caring and of truly being with the person in advanced practice nursing situations. It is this core that provides the crucial link of caring as the central focus of both traditional nursing and advanced practice nursing.
There is evidence that the theory of Nursing as Caring has entered the mainstream of nursing thought. Nursing as Caring is included in several collected and/or edited works on nursing theories (George, 1995; Parker, 1993; Parker, 2000). In George's (1995) compendium of general nursing theories, Nursing as Caring is described and the structures of nursing process and the metaparadigm concepts of Fawcett are used as a framework for analysis and evaluation. Parker's books, Patterns of Nursing Theories in Practice (1993) and Nursing Theories and Nursing Practice (2000) are collections of original chapters authored by the various nurse theorists and by nurses using the particular theory in practice.
Nursing as Caring is represented in both these books by original chapters authored by the theory's originators (Schoenhofer & Boykin, 1993; Boykin & Schoenhofer, 2000) as well as by chapters written by nurses describing their practice which is guided by the theory (Kearney &Yeager, 1993; Linden, 2000).
Nursing as Caring was one of four caring theories included in a comparative analysis reported by McCance, McKenna and Boore (1999). That analysis was based on a number of factors, including origin, scope and key concepts of the theory, definition of caring, description of nursing, the goal or outcome of nursing from the perspective of the theory, and simplicity of the internal structure. Findings of the analysis were developed in terms of utility of the theory in practice. Smith (1999) analyzed concepts from the literature on caring in nursing in an effort to uncover points of congruence between that literature and the theoretical perspective of the Science of Unitary Human Beings. The theory of Nursing as Caring figured prominently in Smith's concept clarification, contributing to four of the five synthesized constitutive meanings of caring: manifesting intentions, appreciating pattern, attuning to dynamic flow and inviting creative emergence (Smith, 1999).
In Chapter 6, Theory Development and Research, we envisioned an approach that "would include a phenomenological aspect which goes beyond description to an hermeneutical process, within an action research orientation" (Boykin & Schoenhofer, 1993, p. 97). Two research approaches have been developed within the context of studying Nursing as Caring, one focusing on discovering the lived meaning of everyday caring and the second directed toward understanding the value experienced in nursing situations.
There is relatively little literature that deliberately sets out to describe the multitude of ways of human caring. However, most if not all human text does reflect uniquely personal ways of caring, and can profitably be studied for this purpose. In an effort to provide a knowledge base of the variety of human caring ways, one of the authors (Schoenhofer) innovated a group phenomenology approach in which research participants not only generated data in group settings, but also led the synthesis of meaning (Schoenhofer, Bingham, & Hutchins, 1997). The group approach to data generation was chosen for several reasons—one was efficiency, but the primary reason was a belief in the synergistic potential of the group process experience. The group approach to data synthesis was added to the design based on the assumption that persons living the phenomenon being studied and generating the data may be most well qualified to intuit meaning across examples. The series of studies of everyday caring may best be understood as general foundational human science, rather than as nursing science per se. Results of the studies produced knowledge that has potential to enlighten nursing practice, rather than producing direct knowledge of nursing practice.
While initiated for research purposes, the group phenomenology approach became a form of nursing praxis. Early in the project, groups spontaneously shared a sense of pleasure and gratitude for the experience of celebrating themselves and each other as caring persons. This opportunity for reflection was then added as closure for the subsequent groups as it was recognized by the primary researchers that the tenets of Nursing as Caring were being lived: persons were known, acknowledged, affirmed and celebrated as caring; per-sonhood was enhanced as group members recapitulated, clarified and reaffirmed the meaning and value of caring in their lives; caring between nurse (researchers) and nursed in the nursing (research) situation was created and persons were nurtured in their uniquely personal ways of caring.
A second research approach was designed to study values experienced in nursing situations (Schoenhofer & Boykin, 1998a; 1998b). The design of this approach was based on several considerations: 1) the tenet that all that can be known of nursing is known through the nursing situation, the shared lived experience of caring between nurse and nursed; and, 2) the blurred lines between research and practice, between roles of researcher, practitioner and even patient. A mode of inquiry into outcomes of caring in nursing, from the perspective of Nursing as Caring, must necessarily be centered within the nursing situation. In earlier phases of this research, only the nurse participated in the research dialogue (Boykin & Schoenhofer, 1997). While this approach was fruitful, two important qualities were missing: 1) the synergism that brought a wealth of rich data when both nurse and nursed were present; and, 2) the intersubjective confirmation provided by having both the nurse and the nursed as research participants. Once again, the mutuality of the dialogue about the value of caring experienced went beyond simple data production for research purposes. The dialogue itself was an extension of the nursing relationship and the caring between nurse and nursed, with the research nurse now included in the unfolding nursing situation.
This epilogue has been written to bring the reader up to date on the development of the theory of Nursing as Caring. Developmental efforts projected in Chapter 6 are still needed, and efforts in progress hold promise for further development. As the cadre of nurses interested in working within the theory grows, development will accelerate, in both projected and novel directions.
Anne Boykin, PhD, RN Professor and Dean College of Nursing Florida Atlantic University
Boca Raton, Florida
October, 2000
Savina O. Schoenhofer, PhD, RN Professor of Graduate Nursing Alcorn State University
Natchez, Mississippi
Boykin, A., & Schoenhofer, S. 0. (1993). Nursing as caring: A modelfor transforming practice. New York: National League for Nursing Press.Boykin, A., & Schoenhofer, S. 0. (2000). Nursing as caring: Anoverview of a general theory of nursing. In Parker. M. E., Ed., Nursingtheories and nursing practice. Philadelphia: F. A. Davis Co.Boykin, A., & Schoenhofer, S. 0. (1997). Reframing nursing outcomes.Advanced Practice Nursing Quarterly, 1(3), 60-65.Dunphy, L. H. (1998). The circle of caring: A transformative model ofadvanced practice nursing. 20th Research Conference of the InternationalAssociation for Human Caring, Philadelphia, Pa.George, J. B. (1995). Nursing theories: The base for nursing practice.(4th ed.). Norwalk: CT: Appleton & Lange.Kearney, C. & Yeager, V. (1993). Practical Applications of Nursingas Caring theory. In Parker, M. E., Ed. Patterns of nursing theories inpractice. New York: National League for Nursing Press, Ch. 8.Linden, D. (2000). Application of Nursing as Caring in practice. InParker, M. E., Ed., Nursing theories and nursing practice. Philadelphia:F. A. Davis Co., 1993.Locsin, R. C. (1995). Machine technologies and caring in nursing. Image,27, 201-203.Locsin, R. C. (1998). Technological competence as caring in criticalcare nursing. Holistic Nursing Practice, 12(4), 50-56.McCance, T. V., McKenna, H. P., & Boore, J. R. P (1999). Caring:Theoretical perspectives of relevance to nursing. Journal of AdvancedNursing, 30, 1388-1395.Parker, M. E. (Ed.). (2000). Nursing theories and nursing practice.Philadelphia: F. A. Davis Co.Parker, M. E. (Ed.). (1993). Patterns of nursing theories in practice.New York: National League for Nursing.Parse, R. R. (1987). Nursing science: Major paradigms, theories andcritiques. Philadelphia: Saunders.Schoenhofer, S. 0., Bingham, V., & Hutchins, G. C. (1998). Giving ofoneself on an-other's behalf: The phenomenology of everyday caring.International Journal for Human Caring, 2(2), 23-29.Schoenhofer, S. 0., & Boykin, A. (1993). Nursing as Caring: Issuesfor practice. InParker, M. E., (Ed). Patterns of Nursing Theories in Practice. New York:National League for Publications, pp. 83-92.Schoenhofer, S. 0., & Boykin, A. (1998a). The value of caringexperienced in nursing. International Journal for Human Caring, 2(4), 9-15.Schoenhofer, S. 0., & Boykin, A. (1998b). Discovering the value ofnursing in high tech environments: Outcomes revisited. Holistic NursingPractice, 12(4), 31-39.Smith, M. C. (1999). Caring and the Science of Unitary Human Beings.Advances in Nursing Science, 21(4), 14-28.
index-1 (185K)index-2 (201K)index-3 (200K)index-4 (101K)
Anne Boykin,
Savina O. Schoenhofer
Caring is one of the first words that comes to mind when talking about the practice of nursing. Caring is an essential value in the personal and professional lives of nurses. However, the formal recognition of caring in nursing as an area of study is relatively new. Nursing As Caring sets forth a different order of nursing theory.
This new nursing theory is personal, not abstract. The focus of the Nursing As Caring theory is not toward an end product such as health or wellness; it is about a unique way of nurses living caring in the world. This theory provides a view that can be lived in all nursing situations and can be practiced alone or in combination with other theories. This is perhaps the most basic, bedrock, and therefore radical, of nursing theories and is essential to all that is truly nursing.