CHAPTER II. -- NURSING AS CARING

In Chapter 2, we will present the general theory of Nursing as Caring. Here, the unique focus of nursing is posited as nurturing persons living caring and growing in caring. While we will discuss the meaning of that statement of focus in general terms, we will also describe specific concepts inherent in this focus in the context of the general theory.

If you recall, in Chapter 1 we discussed the several major assumptions that ground the theory of Nursing as Caring:

* Persons are caring by virtue of their humanness * Persons are whole or complete in the moment * Persons live caring, moment to moment * Personhood is a process of living grounded in caring * Personhood is enhanced through participating in nurturing relationships with caring others * Nursing is both a discipline and profession

In this and succeeding chapters, we will develop the nursing implications of these assumptions.

All persons are caring. This is the fundamental view that grounds the focus of nursing as a discipline and a profession. The unique perspective offered by the theory of Nursing as Caring builds on that view by recognizing personhood as a process of living grounded in caring. This is meant to imply that the fullness of being human is expressed as one lives caring uniquely day to day. The process of living grounded in caring is enhanced through participation in nurturing relationships with caring others, particularly in nursing relationships.

Within the theoretical perspective given herein, a further major assumption appears: persons are viewed as already complete and continuously growing in completeness, fully caring and unfolding caring possibilities moment-to-moment. Such a view assumes that caring is being lived by each of us, moment to moment. Expressions of self as caring person are complete in the moment as caring possibilities unfold; thus, notwithstanding other life contingencies, one continues to grow in caring competency, in fully expressing self as caring person. To say that one is fully caring in the moment also involves a recognition of the uniqueness of person with each moment presenting new possibilities to know self as caring person. The notion of "in the moment" reflects the

idea that competency in knowing self as caring and as living caring grows throughout life. Being complete in the moment also signifies something more: there is no insufficiency, no brokenness, or absence of something. As a result, nursing activities are not directed toward healing in the sense of making whole; from our perspective, wholeness is present and unfolding. There is no lack, failure, or inadequacy which is to be corrected through nursing--persons are whole, complete, and caring.

The theory of Nursing as Caring, then, is based on an understanding that the focus of nursing, both as a discipline and as a profession, involves the nurturing of persons living caring and growing in caring. In this statement of focus, we recognize the unique human need to which nursing is the response as a desire to be recognized as caring person and to be supported in caring.

This focus also requires that the nurse know the person seeking nursing as caring person and that the nursing action be directed toward nurturing the nursed in their living caring and growing in caring. We will briefly discuss this theory in general terms here and more fully illuminate it in subsequent chapters on nursing practice (Chapter 4), education (Chapter 5), and scholarship (Chapter 6). We will address administration of nursing services and of nursing education programs in Chapters 4 and 5, respectively.

Nurturing persons living caring and growing in caring at first glance appears broad and abstract. In some ways, the focus is broad in that it applies to nursing situations in a wide variety of practical settings. On the other hand, it takes on specific and practical meaning in the context of individual nursing situations as the nurse attempts to know the nursed as caring person and focuses on nurturing that person as he or she lives and grows in caring.

When approaching a situation from this perspective, we understand each person as fundamentally caring, living caring in his or her everyday life. Forms of expressing one's unique ways of living caring are limited only by the imagination. Recognizing unique personal ways of living caring also requires an ethical commitment and knowledge of caring. In our everyday lives, failures to express caring are readily recognized. The ability to articulate instances of noncaring does not seem to take any particular skill. When nursing is called for, however, it is necessary that nurses have the commitment, knowledge, and skill to discover the individual unique caring person to be nursed. For example, the nurse may encounter one who may be described as despairing. Relating to that person as helpless recalls Gadow's (1984) characterization of the philanthropic paradigm which assumes "sufficiency and independence on one side and needy dependence on the other" (p. 68). The relationship grounded in nursing as caring would enable the nurse to connect with the hope that underlies an expression of despair or hopelessness. Personal expressions such as despair, or fear, or anger, for example, are neither ignored nor discounted. Rather, they are understood as the caring value which is in some way present. An honest expression of fear or anger, for example, is also an expression of vulnerability, which expresses courage and humility. We reiterate that our approach is grounded in the fundamental assumption that all persons are caring and the commitment which arises from this basic value position.

It is this understanding of person as caring that directs professional nursing decision making and action from the point of view of our Nursing as Caring theory. The nurse enters into the world of the other person with the intention of knowing the other as caring person. It is in knowing the other in their "living caring and growing in caring" that calls for nursing are heard. Of equal importance is our coming to know how the other is living caring in the situation and expressing aspirations for growing in caring. The call for nursing is a call for acknowledgement and affirmation of the person living caring in specific ways in this immediate situation. The call for nursing says "know me as caring person now and affirm me." The call for nursing evokes specific caring responses to sustain and enhance the other as they live caring and grow in caring in the situation of concern. This caring nurturance is what we call the nursing response.

NURSING SITUATION

The nursing situation is a key concept in the theory of Nursing as Caring. Thus, we understand nursing situation as a shared lived experience in which the caring between nurse and nursed enhances personhood. The nursing situation is the locus of all that is known and done in nursing. It is in this context that nursing lives. The content and structure of nursing knowledge are known through the study of the nursing situation. The content of nursing knowledge is generated, developed, conserved, and known through the lived experience of the nursing situation. Nursing situation as a construct is constituted in the mind of the nurse when the nurse conceptualizes or prepares to conceptualize a call for nursing. In other words, when a nurse engages in any situation from a nursing focus, a nursing situation is constituted.

In the Scandinavian countries, for instance, all the helping disciplines are called caring sciences. Professions such as medicine, social work, clinical psychology, and pastoral counseling have a caring function; however, caring per se is not their focus. Rather, the focus of each of these professions addresses particular forms of caring or caring in particular ranges of life situations. In nursing situations, the nurse focuses on nurturing person as they live and grow in caring. While caring is not unique to nursing, it is uniquely expressed in nursing. The uniqueness of caring in nursing lies in the intention expressed by the statement of focus. As an expression of nursing, caring is the intentional and authentic presence of the nurse with another who is recognized as person living caring and growing in caring. Here, the nurse endeavors to come to know the other as caring person and seeks to understand how that person might be supported, sustained, and strengthened in kis or her unique process of living caring and growing in caring. Again, each person in interaction in the nursing situation is known as caring. Each person grows in caring through interconnectedness with other.

Calls for nursing are calls for nurturance through personal expressions of caring, and originate within persons who are living caring in their lives and hold dreams and aspirations of growing in caring. Again, the nurse responds to the call of the caring person, not to some determination of an absence of caring. The contributions of each person in the nursing situation are also directed toward a common purpose, the nurturance of the person in living and growing in caring.

In responding to the nursing call, the nurse brings an expert (expert in the sense of deliberately developed) knowledge of what it means to be human, to be caring, as a fully developed commitment to recognizing and nurturing caring in all situations. The nurse enters the other's world in order to know the person as caring. The nurse comes to know how caring is being lived in the moment, discovering unfolding possibilities for growing in caring. This knowing clarifies the nurse's understanding of the call and guides the nursing response. In this context, the general knowledge the nurse brings to the situation is transformed through an understanding of the uniqueness of that particular situation.

Every nursing situation is a lived experience involving at least two unique persons. Therefore, each nursing situation differs from any other. The reciprocal nature of the lived experience of the nursing situation requires a personal investment of both caring persons. The initial focus is on knowing persons as caring, both nurse and nursed. The process for knowing self and other as caring involves a constant and mutual unfolding. In order to know the other, the nurse must be willing to risk entering the other's world. For his or her part, other person must be willing to allow the nurse to enter his or her world this to happen, the acceptance of trust and strength of courage needed, person in the nursing situation can be awe-inspiring.

It is through the openness and willingness in the nursing situation that presence with other occurs. Presence develops as the nurse is willing to risk entering the world of the other and as the other invites the nurse into a special, intimate space. The encountering of the nurse and the nursed gives rise to a phenomenon we call caring between, within which personhood is nurtured. The nurse as caring person is fully present and gives the other time and space to grow. Through presence and intentionality, the nurse is able to know the other in his or her living and growing in caring. This personal knowing enables the nurse to respond to the unique call for nurturing personhood. Of course, responses to nursing calls are as varied as the calls themselves. All truly nursing responses are expressions of caring and are directed toward nurturing persons as they live and grow in the caring in the situation.

In the situation, the nurse draws on personal, empirical, and ethical knowing to bring to life the artistry of nursing. When the nurse, as artist, creates a unique approach to care based on the dreams and goals of the one cared for, the moment comes alive with possibilities. Through the aesthetic, the nurse is free to know and express the beauty of the caring moment (Boykin & Schoenhofer, 1991). This full engagement within the nursing situation allows the nurse to truly experience nursing as caring, and to share that experience with the one nursed.

In Chapter 1, we noted that each profession arose from some everyday service given by one person or another. Nursing has long been associated with the idea of mothering, when mothering is understood as nurturing the personhood of another. The ideal mother (and father) recognizes the child as caring person, perfect in the moment and unfolding possibilities for becoming. The parent acknowledges and affirms the child as caring person and provides the caring environment that nurtures the child in living and growing in caring. The origins of nursing may well be found in the intimacy of parental caring. The roles of both parent and nurse permit and at times even expect that one be involved in the intimacy of the daily life of another. The parent is present in all situations to care for the child. Ideally, parents know the child as eminently worthwhile and caring, despite all the limitations and human frailties. As we recognized in Chapter 1, professions arise from the special needs of everyday situations, and nursing has perhaps emerged in relation to a type of caring that is synonymous with parenthood and friendship. The professional nurse, schooled in the discipline of nursing, brings expert knowledge of human caring to the nursing situation.

In the early years of nursing model development, nursing scholars endeavored to articulate their discipline using the perspective of another discipline, for example, medicine, sociology, or psychology. One example of this endeavor is the Roy Adaptation Model, in which scientific assumptions reflect von Bertalanffy's general systems theory and Helson's adaptation level theory (Roy and Andrews, 1991, p. 5). Parson's theory of Social System Analysis is reflected in Johnson's Behavioral System Model for Nursing and Orem's Self-Care Deficit Theory of Nursing (Meleis, 1985). A second trend involved declaring that the uniqueness of nursing was in the way in which it integrated and applied concepts from other disciplines. The emphasis in the 1960s on nursing model development came as an effort to articulate and structure the substance of nursing knowledge. This work was needed to enhance nursing education, previously based on rules of practice, and to provide a foundation for an emerging interest in nursing research. Nursing scholars engaged in model development as an expression of their commitment to the advancement of nursing as a discipline and profession, and we applaud their contributions. It is our view, however, that these early models, grounded in other disciplines, do not directly address the essence of nursing. The development of Nursing as Caring has benefited from these earlier efforts as well as from the work of more recent scholarship that posits caring as the central construct and essence (Leininger, 1988), and the moral ideal of Nursing (Watson, 1985).

The perspective of nursing presented here is notably different from most conceptual models and general theories in the field. The most radical difference becomes apparent in the form of the call for nursing. Most extant nursing theories, modeled after medicine and other professional fields, present the formal occasion for nursing as problem, need, or deficit (e.g., Self-Care)

Deficit Theory [Orem, 1985], Adaptation Nursing [Roy and Andrews, 1991], Behavioral System Model [Johnson, 1980], and [Neuman, 1989.] Such theories then explain how nursing acts to right the wrong, meet the need, or eliminate or ameliorate the deficit.

The theory of Nursing as Caring proceeds from a frame of reference based on interconnectedness and collegiality rather than on esoteric knowledge, technical expertise, and disempowering hierarchies. In contrast, our emerging theory of nursing is based on an egalitarian model of helping that bears witness to and celebrates the human person in the fullness of his or her being, rather than on some less-than-whole condition of being.

REFERENCES

Boykin, A., & Schoenhofer, S. (1991). Story as link between nursing practice, 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 (2nd ed.). New York: Appleton-Century-Crofts. Leininger, M.M. (1988). Leininger's theory of nursing: Cultural care diversity 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: The definitive statement. Norwalk, CT: Appleton & Lange. Watson, J. (1985). Nursing: Human science and human care. A theory of nursing. Norwalk, CT: Appleton-Century-Crofts.