Chapter 5 addresses issues and strategies for transforming nursing

education and nursing education administration based on nursing as caring.

Our understanding of nursing as a human science discipline is the central focus of Chapter 6. In this chapter, we discuss the necessity of transforming models of nursing inquiry to facilitate the further development of nursing knowledge in the context of the theory of Nursing as Caring. We also share our commitment to the ongoing development of nursing as caring and directions we wish to take in living that commitment.

It has been our intention to organize and communicate the initial, comprehensive presentation of Nursing as Caring usefully for nurses in practice, as well as those in administrative and academic roles. We have benefited wonderfully from the dialogue resulting from formal and informal opportunities to share this work as it evolved. We look forward to continuing this dialogue. Anne Boykin, PhD, RN Dean and Professor College of Nursing Florida Atlantic University Boca Raton, FL Savina Schoenhofer, PhD Professor of Graduate Nursing Alcorn State University Natchez, MS REFERENCE Mayeroff, M. (1971). On Caring. New York: Harper and Row.

INTRODUCTION

The study of human caring as a unique and essential characteristic of nursing practice has gradually expanded from early definitional, philosophical, and cultural research on the meanings of caring, to the explication of theoretical definitions of caring, conceptual models, proposed taxonomy of caring concepts, a great deal of creative experimentation with research methodologies, and the development of several theories of caring.

In general, one may say that knowledge of caring has grown in two ways, first by extension and, more recently, by intension. Growth by extension consists of a relatively full explanation of a small region which is then carried over into an explanation of adjoining regions. Growth by extension can be associated with the metaphors of building a model or putting together a jigsaw puzzle (Kaplan, 1964, p. 305).

In growth by intension, a partial explanation of a whole region is made more and more adequate and outlines for subsequent theory and observation are clarified. Growth by intension is associated with the metaphor of gradually illuminating a darkened room. A few persons enter the room with their individual lights and are able to slowly perceive what is in that room. As more persons enter the room, it becomes more fully illuminated, and the observed reality is clarified (Kaplan, 1964, p. 305).

Growth by extension is implicit in the early caring definitions, explications, and models. The knowledge about caring was built up piece-by-piece, in the first ten years of study, by a few nurse scholars committed to the study of human care and caring.

Today, some fifteen years later, progress in the study of the caring phenomenon is no longer piecemeal but gradual and on a larger scale, with illumination from the works that have preceded. Growth by intension is evidenced by the development of an extant bibliography, categorization of caring conceptualizations, and the further development of human care/caring theories. Although the concept of caring has not been definitively and exhaustively explored, the understanding of the broad-scale phenomena of human care and caring has become enlarged. A review of the caring literature by Smerke (1989) and an analysis of the nursing research on care and caring by Morse, Bottoroff, Leander, and Solberg (1990) now provides researchers with an interdisciplinary guide to human caring literature and a categorization of five major conceptualizations of caring: (1) a human trait, (2) a moral imperative, (3) an affect, (4) an interpersonal interaction, and (5) an intervention. There is now a body of knowledge about care and caring that can be used to further develop new knowledge through subsequent theory and research.

The Boykin and Schoenhofer work, Nursing as Caring: A Model for Transforming Practice, is an excellent example of growth by intension. Utilizing previous caring research, caring theory, and personal knowledge, the authors have put forth a theory that will not only increase the content of caring knowledge but will also change its form. A new theory adds some knowledge and it transforms what was previously known, clarifying it and giving it new meaning as well as more confirmation. The whole structure of caring knowledge changes with growth, even though it is recognizably similar to what it has been. As one reads this theory, many of the assumptions presented seem familiar, perhaps because the authors realized that caring theory could best be understood in both its historical and immediate context.

The historical context of the systematic study, explication, and theorizing about human care and caring phenomena in nursing began some twenty years ago with the early work of Madeleine Leininger. The first structural stones were laid by a group of nurse researchers who met for the first time in 1978 at a conference convened by Dr. Leininger at the University of Utah in Salt Lake City. Some sixteen enthusiastic participants underscored the need for continued in-depth thinking and for sharing scholarly ideas about the phenomena and nature of caring.

Plans were made to continue with yearly research conferences focused on four major goals:

1. The identification of major philosophical, epistemological, and professional dimensions of caring to advance the body of knowledge that constitutes nursing.

2. Explication of the nature, scope, and functions of caring and its relationship to nursing care.

3. Explication of the major components, processes, and patterns of care or caring in relationship to nursing care from a transcultural perspective.

4. Stimulation of nurse scholars to systematically investigate care and caring and to share their findings with others. These four goals, developed by the members of the Caring Research Conference Group, provided nurse scholars with a direction for caring research that yielded a substantial piece of research-based literature.

The first ten years of the Conference group (1978-1988) witnessed a great deal of diverse and stimulating research. Major philosophical dimensions of caring were explicated in the works of Bevis (1981), Gaut (1984), Ray (1981), Roach (1984), and Watson (1979)

Explication of major components, processes, and patterns of care or caring from a transcultural perspective was first developed in the early work of Aamodt (1978) and Leininger (1978, 1981), to be followed by the works of Baziak-Dugan (1984), Boyle (1984), Guthrie (1981), Wang (1984), and Wenger and Wenger (1988).

Another group of nurse researchers chose to study the concept of care and caring concomitantly with nursing care practices. Brown (1982), Gardner and Wheeler (1981), Knowlden (1985), Larson (1981, 1984), Riemen (1984, 1986), Sherwood (1991), and Wolf (1986) investigated nurse behaviors perceived by patients and nurses as indicators of caring and noncaring in an attempt to further develop the essential structure of a caring interaction.

Watson, Bruckhardt, Brown, Block, and Hester (1979) proposed an alternative health care model for nursing practice and research. After seven years of implementation experience using a clinical practice model with various hospitals, Wesorick (1990) presented a model that supported caring as a practice norm in hospital settings.

Administrative caring within an institutional or organizational culture was the research focus for Nyberg (1989), Ray (1984, 1989), Valentine (1989, 1991), and Wesorick (1990, 1991). Caring within educational settings and in the teacher-learner relationship also received attention by Bevis (1978), Bush (1988), Condon (1986), and MacDonald (1984).

Research methodologies became a focus of study as investigators struggled with how best to study nurse caring phenomena: Boyle (1981), Gaut (1981, 1985), Larson (1981), Leininger (1976), Ray (1985), Riemen (1986), Swanson-Kauffman (1986), Valentine (1988), Watson (1985), and Wenger (1985).

By the 1980s, it became clear that the systematic study of human care and caring as a distinct feature of the profession of nursing had evolved globally. Dunlop (1986), from Australia, asked: "Is a science of caring possible?" Bjrn (1987) described the caring sciences in Denmark, and Eriksson (1987, 1992) began to develop her theories of caring as communion, and caring as health. Kleppe (1987) discussed the background and development of caring research in Norway. Flynn (1988) compared the caring communities of nursing in England and the United States. Halldorsdottir (1989, 1991), from Iceland, developed research on caring and uncaring encounters in nursing practice and in nursing education.

The early endeavors of the first nurse researchers who focused on caring laid out the lines and clarified the observable realities for subsequent research and theorizing. The production of nursing theory is dependent on an intellectual apprehension of the movement between the concrete realities of nursing practice and the abstract world of those assumptions and propositions known as theories (Benoliel, 1977, p. 110). The creation of new knowledge rests on some known assumptions, and Boykin and Schoenhofer's theory builds on the work of three other nurse scholars who have developed theories of caring in nursing, each with a differing apprehension of the realities of human care and caring: Madeline Leininger from an anthropological perspective--one of the first nurse theorists to focus on caring as the essence of nursing practice; Sister M. Simone Roach, who provides a philosophical and theological perspective; and Jean Watson from an existential, philosophical perspective.

The significance of Leininger's Culture-Care Theory (1993) is in the study of human care from a transcultural nursing perspective. This focus has led to new and unique insights about care and the nature of caring and nursing in different cultures, and has developed the knowledge so essential to providing culturally sensitive nursing care throughout the world.

Roach's work, The Human Act of Caring (1984, 1992) is recognized as one of the most substantive, insightful, and sensitive publications on human caring. Her ultimate conclusion after years of study and reflection is: "Caring is the human mode of being."

Watson, in her theory of human care (1985, 1989), addressed the issue of nursing as a humanistic science rather than a formal or biological science. This perspective was an essential paradigm shift for nursing knowledge, but essential for study of the caring phenomena. Within this context, Watson developed a theory of caring in nursing that involves values, a will and a commitment to care, knowledge, caring actions, and consequences. Caring then becomes a moral imperative for practitioners of the profession of nursing.

Boykin and Schoenhofer's theory comes not only from "what is known about caring" but also from their imagination and creative sense of "what could be known." They suggest a context for personal theorizing about caring experiences, trusting that each person will examine the content of those experiences as a sequence of more or less meaningful events--meaningful both in them and in the patterns of their occurrence. The authors put forth a framework for just such reflection, and they challenge practicing nurses to "come to know self as caring person in ever deepening and broadening dimensions."

If science has to do with knowing and that which is known, then theory is about knowledge production. In one sense of the term, theory activity might well be regarded as most important and distinctive for human beings because is stands for the symbolic dimension of experience (Kaplan, 1964, p. 294).

Boykin and Schoenhofer's work invites all nurses to develop nursing knowledge and to theorize from within the nursing situation. The invitation requests a sharing of both content and context of nursing experiences as they are lived in meaningful patterns that have significant bearings on all other patterns. To engage in theorizing means not only to learn by experience, but to learn from experience--that is, to take thought about what is there to be learned (Kaplan, 1964, p. 295).

In the thinking of Alfred North Whitehead (1967), theory functions not to allow prediction but to provide a frame of reference, a pattern through which one can discern particulars of any given situation. Theory in this sense permits attendance or focus by giving form to otherwise unstructured content. The proposed theory, Nursing as Caring: A Model for Transforming Practice, provides the context. The frame of reference through which any nurse engaged in a shared lived experience of caring can not only interpret the experience but also can perceive and symbolically express the patterns of nurse caring. The perception of patterns will give the readers and listeners a "click of meaningfulness," and the explanation will be the discovery of interconnections among patterns. The perception that everything is just where it should be to complete the pattern is what gives us intellectual satisfaction and provides the context or focus for the one aspect of reality that is the essence of nursing-caring.

Delores A. Gaut, PhD, RN Immediate Past President International Association of Human Caring, Inc. Visiting Professor University of Portland School of Nursing Portland, Oregon

REFERENCES

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Condon, E. (1986). Theory derivation: Application to nursing, the caring perspective within professional role development. Journal of Nursing Education, 25 (4), 156159. Dunlop, M. J. (1986). Is a science of caring possible? Journal of Advanced Nursing, 11 (6), 661-670. Eriksson, K. (1987). Vardanaets ide (The idea of caring) Stockholm: Almqvist & Wiksell. Eriksson, K. (1992). The alleviation of suffering-the idea of caring. Scandinavian Journal of Caring Sciences, 6 (2), 119-123. Flynn, B.C. (1988). The caring community: Primary health care and nursing in England and the United States. In M. Leininger (Ed.), Care: Discovery and uses in clinical and community nursing (pp. 29-38). Detroit, MI: Wayne State University Press. Gardner, K., & Wheeler, E. (1981). The meaning of caring in the context of nursing. In M. Leininger (Ed.), Caring: An essential human need (pp. 69-79). Detroit, MI: Wayne State University Press. Gaut, D.A. (1983). Development of a theoretically adequate description of caring. Western journal of Nursing Research, 5 (4), 312-324. Gaut, D.A. (1984). A theoretic description of caring as action. In M. Leininger (Ed.), Care: The essence of nursing and health (pp. 27-44). Detroit, MI: Wayne State University Press. Gaut, D.A. (1985). Philosophical analysis as research method. In M. Leininger (Ed.),

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Larson, P. (1984). Important nurse caring behaviors perceived by patients with cancer. Oncology Nurse Forum, 11 (6), 46-50. Larson, P. (1986). Cancer nurses' perceptions of caring. Cancer Nursing, 9 (2), 86-91. Leininger, M. (1978). Transcultural nursing: Concepts, theories, and practices. New York: Wiley. Leininger, M. (1981). Some philosophical, historical and taxonomic aspects of nursing and caring in American culture. In M. Leininger (Ed.), Caring: An essential human need (pp. 133-143). Detroit, MI: Wayne State University Press. Leininger, M. (1991). Culture care diversity and universality: A theory for nursing. New York: National League for Nursing. MacDonald, M. (1984). Caring: The central construct for an Associate Degree Nursing curriculum. In M. Leininger (Ed.), Care: The essence of nursing and health (pp. 233248). Detroit, MI: Wayne State University Press. Morse, J., Bottoroff, J., Neander, W., & Solberg, S. (1991). Comparative analysis of conceptualizations and theories of caring. Image: The Journal of Nursing Scholarship, 23 (2), 119-126. Nyberg, J. (1989). The element of caring in nursing administration. Nursing Administration Quarterly, 13 (3), 9-16. Ray, M. (1981). A philosophical analysis of caring within nursing. In M. Leininger (Ed.), Caring: An essential human need (pp. 25-36). Detroit, MI: Wayne State University Press. Ray, M. (1984). The development of a classification system of institutional caring. In M. Leininger (Ed.), Care: The essence of nursing and health (pp. 95-112). Detroit, MI: Wayne State University Press. Ray, M. (1989). The theory of bureaucratic caring for nursing practice in the organizational culture. Nursing Administration Quarterly, 13 (2), 31-42. Riemen, D. (1986A). Noncaring and caring in the clinical setting: Patients' descriptions. Topics in Clinical Nursing, 8 (2), 30-36. Riemen, D. (1986B). The essential structure of a caring interaction: Doing phenomenology. In Munhall & Oiler (Eds.), Nursing research: A qualitative perspective (pp. 85108). Norwalk, CT: Appleton-Century-Crofts. Roach, M.S. (1987). The human act of caring: A blueprint for the health professions. Ottawa: The Canadian Hospital Association Press. Roach, M.S. (1992). The human act of caring: A blueprint for the health professions rev. ed.). Ottawa: The Canadian Hospital Association Press. Sherwood, G. (1991). Expressions of nurses' caring: The role of the compassionate healer. In D. Gaut & M. Leininger (Eds.), Caring: The compassionate healer (pp. 79881. New York: National League for Nursing. Smerke, 1. (1989). Interdisciplinary guide to the literature for human caring. New York: National League for Nursing. Swanson-Kauffman, K. (1986). A combined qualitative methodology for nursing research. Advances in Nursing Science, 8 (3), 58-69. Valentine, K. (1988). Advancing care and ethics in health management: An evaluation strategy. In M. Leininger (Ed.), Care: Discovery and uses in clinical community nursing (pp. 151-167). Detroit, MI: Wayne State University Press. Valentine, K. (1989). Caring is more than kindness: Modeling its complexities. Journal of Nursing Administration, 19 (11), 28-34.

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ACKNOWLEDGEMENTS

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.