CHAPTER IV. -- IMPLICATIONS FOR PRACTICE AND NURSING SERVICE ADMINISTRATION

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.

HONESTY

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.

CONNECTEDNESS

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.

Heating--HIV + Your wounds weeped Purulent with the discharge of our Pain and fear. They tried to hide, only to reappear. The treatment gentle, slow A warm, loving balm to your soul. Your stomach was fed the comfort Food of your youth And your lips drank in deeply all You knew and understood. The memories sweetened each moment You stood, face to face with terror of What might be mistook. All inside shifted as slowly it came, A gradual awakening; embracing of pain As you conquered your demons A lightness appeared To stay forever and Abolish all fears. (Wheeler, 1990)

NURSING SERVICE ADMINISTRATION

Many of the nursing situations described in this book have taken place in hospital settings, where the nursing service is a shared responsibility of many nurses in a range of functional roles. Nurses in such settings generally nurse many persons intensively and simultaneously and share direct nursing responsibility with one or two other nurses. How can nurses in institutional practice settings be supported so that calls for nursing can be heard and nursing responses made? What is the role of the nurse administrator in supporting the practice of nurses?

It is important to understand clearly the difference between the practice of administration which happens to be delivered by nurses and the practice of nursing administration. Tead (1951) defines administration as "the comprehensive effort to direct, guide, and integrate associated human strivings which are focused toward some specific ends or aims" (p. 3). For example, goals of administration could be business, governmental, education, or nursing. In this definition, it is evident that the focus must be made clear. It is not adequate to have an understanding of administration as a role which is focused in functions such as interpersonal, informational, and decisional. Such a perspective ignores the value of persons and the ministering responsibilities inherent in the role. The administrator must connect his or her work to the direct work of nursing.

Nursing administration by name suggests a groundedness in the discipline. The role of the nursing administrator could indeed be questioned if the focus of the administrative practice is not nursing. There is the assumption that the administration of nursing is practiced from a particular conception of nursing in which the focus or goal of nursing is clear. What the nursing administrator says and does as nurse must reflect the uniqueness of the discipline so that nursing's unique contributions are assured. Nursing administrators must also be able to articulate the unique contributions of nursing to other members of the interdisciplinary health care team.

The relationship of the nurse administrator's role to direct care is implicit in this perspective. The nursing administrator describes him or herself as directly involved in the care of persons. All activities of the nursing administrator are ultimately directed to the person(s) being nursed. It is essential that this direct connection to the goal of nursing be made and that persons assuming nursing administration positions be able to articulate their unique role contributions to nursing care. Without this clarity of focus, one may be engaged in the practice of administration but not nursing administration.

From the viewpoint of nursing as caring, the nurse administrator makes decisions through a lens in which the focus of nursing is nurturing persons as they live caring and grow in caring. All activities in the practice of nursing administration are grounded in a concern for creating, maintaining, and supporting an environment in which calls for nursing are heard and nurturing responses are given. From this point of view, the expectation arises that nursing administrators participate in shaping a culture that evolves from the values articulated within nursing as caring.

Although often perceived to be "removed" from the direct care of the nursed, the nursing administrator is intimately involved in multiple nursing situations simultaneously, hearing calls for nursing and participating in responses to these calls. As calls for nursing are known, one of the unique responses of the nursing administrator is to directly or indirectly enter the world of the nursed, understand special calls when they occur, and assist in securing the resources needed by the nurse to nurture persons as they live and grow in caring. All nursing activities should be approached with this goal in mind. Here, the nurse administrator reflects on the obligations inherent in the role in relation to the nursed. The presiding moral basis for determining right action is the belief that all persons are caring. Frequently, the nurse administrator may enter the world of the nursed through the stories of colleagues who are assuming other roles such as nurse manager. Policy formulation and implementation allow for the consideration of unique situations. The nursing administrator assists others within the organization to understand the focus of nursing and to secure the resources necessary to achieve the goals of nursing. When the focus of nursing can be clearly articulated, nursing's contribution to the whole will be understood, If the focus of practice is clouded, however, this becomes an insurmountable task. Recognition of nursing's value is contingent upon the ability of nurses to articulate their contribution. Traditionally, systems define contribution through patient outcomes and other total quality measures. Future articulation of nursing and its contributions would emanate from the values and assumptions offered in the Nursing as Caring theory.

Sharing nursing situations with others is one way to promote the knowing of nursing. It also is a way for other members of the organization to see how their roles contribute to the well-being of the nursed. The following is a nursing situation, re-presented as the poem "Last Rights," that cries out for nursing administration, that is, nursing support for nursing.

Last Rights

Tight faced, they found and cornered her at work As quick as hammers pounding down a wall of words came hard and nailed that little quirk of honest so fast she held the rail.

"Who were you to say he was a dying man, though he lay white, his lifethread thin. How were you to know the speed his flying heart would race away from bone and shin.

He was hopeless, yes, beneath that tent of filmy gauze, but who were you to say his fate was hinged in prayer-our magic spent. Who knows, he might have lived another day.

"He held my hands, asked the truth," she said. Then turned away to smooth the empty bed.

--Yelland-Marino (1993)

The nurse administrator can nurture the living in caring and growing in caring of the person in this story by creating ways to support the nurse at the bedside in order that the call for hope of being known and supported as caring person, not object, can occur. What are some of the strategies that the nurse administrator could engage in which would reflect the nursing focus?

Because budget determination is such a prominent matter for nurse administrators, we will begin there. Budget decisions should be directed from the perspective of what I ought to do as nurse administrator that would have the greatest effect on nurturing persons being cared for in their living and growing in caring. One aspect of budget essential to this story is time--time for the nurse to focus on knowing self and other colleagues. As Paterson & Zderad (1988) state, for nursing practice to be humanistic, awareness of self and others is essential. The budget should include time allocations for staff to participate in dialogues focused on knowing self as caring person in order that calls, such as the one in the previous story, can be heard. The notion of dialogue is central to transforming ways of being with others in organizations. Bohm (1992) refers to dialogue as creating "a flow of meaning in the whole group, out of which will emerge some new understanding, something creative" (p. 16). Persons engaged in dialogue are focused on trying to understand situations as perceived through another's eyes in order that new possibilities may be recognized. Through the allocation of time, nursing staff come to better know self and other. Shared meanings emerge which become the "glue or cement that holds people and societies together" (p. 16). These opportunities for knowing self assist the nurse to achieve, as Tournier (1957) would put it, a reciprocity of consciousness with other.

Through the opportunity to better know self as caring person, the nurse will learn to intentionally and authentically enter nursing situations focused on knowing and supporting the nursed as they live caring and grow in caring. Time for reflection and collegial dialogue is necessary to maintain this nursing lens in a period of increasing responsibility. Such time allocation communicates the commitment of the nurse administrator to enhance the growth of the nurse in the discipline of nursing.

To propose that the budgeting of time is one of the most essential tasks of a nursing administrator may seem outrageously naïve in a time when organizations seem to be interested only in bottom-line figures. Ironically, however, the time allocation strategy offered here supports the goal of cost containment. Studies have shown that caring behaviors of nurses (Duffy, 1991) and nursing staff attitudes (Cassarea et al., 1986) are directly related to patient satisfaction. Benner and Wrubel (1989) also found that caring is integral to expert practice. As a result, and from the standpoint of quality of care as revenue producing, this strategy of allowing time for dialogue and reflection has merit.

From the viewpoint of the Nursing as Caring theory, the nurse administrators' beliefs about person would require that new ways of being with the nursed are created and supported. The nursing administrator models a way of being with others that portrays respect for person as caring. Through modeling, others grow in their competency to know and express caring. Of course creating and sustaining environments that nurture and value the practice and study of nursing remains the challenge facing nurses caught in the maze of various organizational structures. Systems tend to perpetuate existing ways of being even though their members may repeatedly question the legitimacy of actions flowing from these structures. It is our belief that nursing can create a culture that values caring within systems and organizations. Systems and organizations can be reshaped and transformed through living out the assumptions and values inherent within nursing as caring.

Assumptions on which Nursing as Caring is built serve as stabilizers for the organization. These assumptions directly influence the climate of the organization and serve as the organizational pillars. The climate of organizations is determined by beliefs and values of persons within it. An organization grounded in the assumptions of person as described in