CHAPTER V. -- IMPLICATIONS FOR NURSING EDUCATION

In this chapter, we address the implications of our theory for nursing education, including designing, implementing, and administering a program of study. The assumptions that ground Nursing as Caring also ground the practice of nursing education and nursing education administration. The structure and practices of the education program are expressions of the discipline and, therefore, should be explicit reflections of the values and assumptions inherent in the statement of focus of the discipline. From the perspective of Nursing as Caring, all structures and activities should reflect the fundamental assumption that persons are caring by virtue of their humanness. Other assumptions and values reflected in the education program include: knowing the person as whole and complete in the moment and living caring uniquely; understand that personhood is a process of living grounded in caring and is enhanced through participation in nurturing relationships with caring others; and, finally, affirming nursing as a discipline and profession.

The curriculum, the foundation of the education program, asserts the focus and domain of nursing as nurturing persons living caring and growing in caring. All activities of the program of study are directed toward developing, organizing, and communicating nursing knowledge, that is, knowledge of nurturing persons living caring and growing in caring.

The model for organizational design of nursing education is analogous to the dancing circle described earlier. Members of the circle include administrators, faculty, colleagues, students, staff, community, and the nursed. What this circle represents is the commitment of each dancer to understanding and supporting the study of the discipline of nursing. The role of administrator in the circle is more clearly understood when the origin of the word is reflected upon. The term administrator is derived from the Latin ad ministrare, to serve (Guralnik, 1976). This definition connotes the idea of rendering service. Administrators within the circle are by nature of role obligated to ministering, to securing and to providing resources needed by faculty, students, and staff to meet program objectives. Faculty, students, and administrators dance together in the study of nursing. Faculty support an environment that values the uniqueness of each person and sustains each person's unique way of living and growing in caring. This process requires trust, hope, courage, and patience. Because the purpose of nursing education is to study the discipline and practice of nursing, the nursed must be in the circle. The community created is that of persons living caring in the moment, each person valued as special and unique.

We have said in Chapter 1 that the domain of a discipline is that which its members assert. The statement of focus that directs the study of nursing from this theoretical perspective is that of nurturing persons as they live caring and grow in caring. The study of nursing is approached through the use of nursing situations. The knowledge of nursing resides in the nursing situation and is brought to life through study. The nursing situation is a shared lived experience in which the caring between the nurse and the one nursed enhances personhood or the process of living grounded in caring. These situations, like the many cited in earlier chapters, become available for study through the use of story (recounting the situation in ways that convey the essence of the lived experience). These stories create anew the lived experience of caring between the nurse and the nursed, and bring to life the basic values described in Chapter 1.

Story then becomes the method for studying and knowing nursing. Carper's (1978) four patterns of knowing serve as an organizing framework for asking epistemological questions of caring in nursing. Those patterns include personal, ethical, empirical, and aesthetic knowing. Each of these patterns comes into play as one strives to understand the whole of the situation. Personal knowing centers on knowing and encountering self and other, empirical knowing addresses the science of caring in nursing, ethical knowing focuses on what "ought to be" in nursing situations, and aesthetic knowing is the integration and synthesis of all knowing as lived in a particular situation. The poem, "Intensive Care," a representation of a nursing situation, is given here to illustrate the organization of sample content.

INTENSIVE CARE (centered)

Did you see nurse that you can know me-- The part that is me, my mind and soul is in my eyes These tubes that are everywhere-that is not me. The one in my throat is the worse of all-- Now my whole being, the essence of me I must reflect through my hands but they are tied down, movements of my head but did you realize that uncomfortable for me or through my eyes and you do not notice them-- except once today during my bath. You speak to me and look at the tubes-- Don't you know my thoughts are all over my face Don't you realize your thoughts are on your face-- In your touch and your tone of voice. I wrote a request on paper and you said "I'll take care Of it for you" your tone said "Why can't this woman Do anything for herself?" You positioned your hand to count my pulse but I Can't say you touched me-you wouldn't hold my hand that I may touch you. You walked in for the first time today with a grin on your face but your mouth is now tight you grimaced a lot as you bathed me. Don't you see nurse that you can know me--I'm not A chart or tubes of medication, monitors or all the other things you look at so intensely--I'm more than that I'm scared--just look in my eyes. --S. Carr, 1991

Carper's (1978) patterns of knowing offer a framework for organizing the content for studying this nursing situation.

PERSONAL KNOWING

Who are the nurse and nursed as caring persons in the moment? How are the nurse and nursed expressing caring in this moment? What is the meaning of this situation to the nurse and nursed in terms of present realities and future possibilities? What is the meaning of vulnerability and mortality? What is the value of intuition in practice? Empirical Knowing What nursing and related research exists on modes of communication, the meaning of presence in practice, touch, objectification, recovery of cardiac patients, technological caring, understanding the experience of fear and loneliness? What factual knowledge is needed to be competent in this particular situation--e.g. knowledge of monitors, chest tubes, medications, cardiac care, diagnostic data?

ETHICAL KNOWING

If nursing is practiced from the perspective of Nursing as Caring, what obligations are inherent in this situation? How is the nurse demonstrating the value that all persons are caring? Respect for person-as-person? Interconnectedness? What dilemmas are present in this story?

AESTHETIC KNOWING

How is the nursed supported to live dreams of living and growing in caring? How could the nurse transcend the moment to create possibilities within this specific nursing situation? What metaphors might express the meaning of this nursing situation?

Students studying this nursing situation are challenged to know the person as caring, as living caring uniquely in the moment, as having hopes and dreams for growing in caring, and as being whole or complete in the moment. The student is also challenged to know the nurse as caring person in the moment and to project ways of supporting the nurse as caring person.

Through the study of this situation, students and faculty identify a range of calls for nursing as well as nurturing responses. In this process, there is dialogue focused on knowing the nurse and nursed in the story as caring person. We would contribute the following as our knowing of the nursed as caring person. Through her honest expression of "I'm scared--just look in my eyes," we know her as living hope, honesty, and transcending fear through courage.

Calls for nursing might include a call to be known as caring person and a call to have interconnectedness recognized and affirmed. The nurse's response to these calls is individual and evolves from who one is as person and nurse. Therefore, the range of responses is multiple and varied--each reflecting the nurse's informed living of caring in the moment. Each nurturing response is focused on nurturing the person as he or she lives caring and expresses hopes and dreams for growing in caring.

If the nurse is responding to the call of the person for recognition and affirmation of interconnectedness, perhaps the nurse would express hearing this call by being present with the intention of knowing other as caring person. This may be communicated through active patience--giving the other time and space to be known; through touch which communicates respect and interconnectedness; through the nurse sharing who he or she is as caring person in this relationship--perhaps through tears as the resonance of commonality of this experience is known; through music or poetry if a shared love of these has been discovered.

Through dialogue, students and faculty openly engage in the study of nursing. The dialogue encourages and supports students and faculty to freely express who they are as person and nurse living caring through the re-presented story. It provides an opportunity to affirm values of self and discipline and to study how these values may be lived in practice. It is in this dialogue of nursing that faculty communicate their love for nursing. Time is needed for both faculty and students to reflect on the meaning of being a member of this discipline and more specifically, on the meaning of being a member of a discipline focused on nurturing persons as they live and grow in caring. Dialogue facilitates the integration of this understanding and is a key concept in present and future transformations of nursing education. Common engagement in dialogue as nursing stories are shared and studied is the way of being.

The story lived anew provides students the opportunity to participate in a lived experience of nursing and to create new possibilities. Since nursing can only occur through intentionality and authentic presence with the nursed, students and faculty share how they prepare to enter the world of the nursed, and how they come to understand that world. This process requires that students be encouraged to live fully their personhood. To facilitate such living, faculty support an environment in which students are free to choose and to express self in various ways. For example, perhaps the holistic understanding of a nursing situation would be expressed as aesthetic knowing through dance, poetry, music, painting, or the like. We view this process of education as critical to moral education. When students enter nursing situations to know other as living and growing in caring, they are living out the moral obligation that arises from the commitment to know person as caring. Here, then, is an expression of a dynamic view of morality in which caring is always lived in the moment.

In the study of the situation, Intensive Care, brought to the dialogue are personal experiences of being alone, being afraid, and being with someone and not being heard or seen as caring person. This personal knowing fosters human awareness of our connectedness and interdependence. In this context, the nurse does not study the empirics of cardiac pathology to understand a perceived deficit but rather to become competent in drawing forth the knowledge that is specific to knowing this person as whole in the moment. The nurse comes to know the person as living caring and growing in caring, situated within a particular set of circumstances, some of which the nurse knows explicitly. Each student entering the nursing situation will ask, "How can I nurture this person in living and growing in caring in this situation?" Because each nurse may hear calls for caring in many different ways, nursing responses are many and varied. For nursing faculty, openness to multiple possibilities presents a particular challenge and an opportunity to suspend entrenched patterns of teaching nursing.

Faculty and students study nursing together. Faculty join students in a constant search to discover the content and meaning of the discipline. Undoubtedly, this understanding of extant possibilities presents a different view of the role of teacher. Yet, it is a view that engenders the sort of humility essential to nursing for there is always more to know. Although past methods of teaching of nursing may have been comfortably structured through textbooks organized around medical science, faculty are now empowered to question what should be the focus of study in the discipline of nursing. Faculty are encouraged to take risks and let go of the familiar. The perspective that Nursing as Caring conveys--the fullness and richness of nursing--will allow faculty to willingly assume the risks inherent in a new way of guiding the study of nursing.

In teaching Nursing as Caring, faculty assist students to come to know, appreciate, and celebrate self and other as caring person. Mayeroff's On Caring (1971) provides a context for the generic knowing of self as caring. Through dyads or small groups, students share life situations in which they experienced knowing self and other as caring person. Mayeroff's caring ingredients (knowing, alternating rhythm, trust, honesty, hope, courage, humility, patience) also serve as a source for reflection as one asks "who am I as caring person?". As students engage in this exercise, their emerging reflections begin to ground them as they grow in their understanding of person as they live and grow in caring. Students will also draw on the knowledge gleaned in the study of arts and humanities as they attempt to gain a deeper understanding of person. The process of knowing self and other as caring is lifelong. In an educational program grounded in Nursing as Caring, however, the focus on personal knowing (in the study for every nursing situation) provides a deliberate opportunity for greater knowing of self and other as caring person.

Students, as well as faculty, are in a continual search to discover greater meaning of caring as uniquely expressed in nursing; journaling is an approach that facilitates this search. For example, in a special form of journaling, students actively dialogue with authors whose works they are reading and with the ideas expressed in their works. This process enhances the students' understanding of caring in nursing. Over time, students integrate and synthesize many ideas and create new understandings. Examination is another process to facilitate learning. From this theoretical perspective, essay examinations that present nursing situations provide opportunities for students to express their knowledge of nurturing persons living and growing in caring. Aesthetic projects also allow the student the opportunity to communicate understanding of a nursing situation. We would like to share with you a project from a course in which the students were asked to express the beauty of a nursing situation. In this nursing situation, the nurse, Michelle, shared her gifts of therapeutic touch and voice as expressions of caring for David in the moment, drawing on an earlier dialogue in which David told her of his love of meditation and the Ave Maria, she wrote:

AVE MARIA AND THERAPEUTIC TOUCH FOR DAVID

"David, let me know your pain; From fractured leg and heart, Share with me your private hell. Next to one who's far, Far away his own world: Moaning, crying, weak. What's it like to lie beside One who cannot speak?

"Tell me David, what you do To cancel out the sound; Eliminate the smell of dung In which your roommate's found? Who can you complain about? Are you worse off than he? Tied to IV, traction lines You cannot be free.

"David, I can see your pain. Tell me where you are. Tied in bed. Powerless. From loved ones you're apart. I can't move you from this place To take your pain away. But let me lay my hands on you And sing to you today."

Ave Marie, gratia plena Maria, gratia plena. Ave dominus, dominus tecum. Benedicta to in mulieribus. Et benedictus Et benedictus, fructus ventris; Ventris tui, Jesu. Ave Maria

I sang the song he loved and used To meditate and flee, Escape tormenting stimuli. He needed to be freed, To understand why he must bear This trial, this hell, this pain, I sang the tune; I touched with care To give him peace again.

--Stobie, 1991

Expressions of nursing such as this, which was partly sung, beautifully portray the living of caring between the nurse and the nursed and exemplify how caring enhances personhood. Faculty play a vital role in fostering in students the courage to take such risks. Faculty encourage self-affirmation in students, open, nonjudgmental dialogue, living the caring ideal in the classroom and development of the students' moral groundedness in caring (Boykin & Schoenhofer, 1990). Faculty also take the risk of sharing self through their stories of nursing. The sharing of nursing situations is, in essence, a sharing of our innermost core of common identity and forms a type of collegiality among those who are studying the discipline together.

How can faculty be supported to teach nursing in new ways? The administrator of the program fosters a culture in which the study of the discipline from the caring perspective, as presented here, can be achieved freely and fully. All actions of the dean are directed toward creating, maintaining, and supporting this goal. The theoretical assumptions ground the activities of the dean in both internal and external areas of responsibility.

Internally, the administrator, faculty, staff, and students model commitment by creating an environment that fosters the knowing, living, and growing of persons in caring. The dean "ministers" by assuring that faculty, students, and staff are presented ongoing opportunities to know themselves ontologically as caring persons and professionals and to understand how caring orders their lives. Who we are as person influences who we are as student, colleague, nurse, scholar, and administrator. Therefore, attention must be directed to knowing self. Time must be devoted to knowing and experiencing our humanness.

The constant struggle to know self and other as caring person nourishes our knowing of the nursed. Through constant discovery of self, the other is also continually discovered. This culture sensitizes each person to ways of being with other that necessitate that each action reflect respect for person as person. Therefore, when issues are to be addressed, they are addressed openly and fully. Persons are encouraged to bring forth who they are so there is congruence between actions and feelings. Understanding each other's views is essential to the unfolding of this culture. Dialogue assists one to know the other's needs and desires, and to image oneself in the other's place. As such, the dean, faculty, staff, and students become skilled in the use of the caring ingredients, internalized as personally valid ways of expressing caring: knowing, alternating rhythms, trust, hope, courage, honesty, humility, and patience (Mayeroff, 1971).

Of utmost importance in fostering this culture are decisions regarding selection of faculty. Although many prospective faculty have a fairly traditional lens for the study of nursing (that is, the lens of medical science or frameworks borrowed from other disciplines), this actually becomes an insignificant factor in the process of selection. At the heart of choosing new faculty is knowing their passion for and love of nursing. A focus of the interview process is discerning the person's devotion to the discipline. It is our belief that this attitude, this love of nursing, is the music for the dancers in the circle. One way to know if prospective faculty love nursing is to ask them to share a significant story from practice. Having faculty share a story illuminates their conceptualization of the discipline. Many faculty who have not had the opportunity to teach nursing through an articulated nursing lens, can yet communicate nursing clearly through story.

Faculty are supported in their struggles to conceptualize nursing in a new way. Forums in which faculty come together and aesthetically re-present and share their nursing story is one strategy that effectively engages self and other in the knowing of nursing. It is also a wonderful way to orient faculty as to how to use nursing situations to teach nursing. Faculty support each other as colleagues in learning to teach nursing in a new way, in becoming expert in the practice of nursing education, and in living out the basic assumptions of this theory. This need for support holds true not only for faculty-faculty relationships but for all relationships. The comfort of faculty teaching nursing from the perspective of Nursing as Caring is enhanced as the value of knowing other as caring, as living our histories and as having special nursing stories to share is appreciated.

The administrator, faculty, and staff assist in fostering an environment that furthers the development of the students' capacity to care. Competency in caring is a goal of the educational process. Students are continually guided to know self and other as caring person as faculty and administrators model actions that reflect respect for person as person. Each student is known as caring person, as special and unique. Policies allow for consideration of individual situations and diverse possibilities. In this culture, the dean and faculty attempt to know the student as caring person and student of the discipline. The intention of the dean to know students in this way can be evident through invitations for regularly scheduled dialogue in which students share openly their conceptions about nursing. The administrator is truly with students to know them as caring persons and to hear from them their understanding of nursing as caring.

Externally, the dean "ministers" to faculty, students, and staff through securing resources necessary to accomplish program goals. The dean articulates to persons in the academic and broader community their role in the dance of nursing. The role of these persons is to provide resources such as scholarships, faculty development possibilities, learning resources, and research monies. Although this may be a primary responsibility of the dean by nature of the role, all persons in the circle share in this process by virtue of their commitment to nursing.

The administrator brings to the circle a skillful use of the caring ingredients. Alternating rhythms are used to understand and appreciate each person's unique contributions that support the achievement of program goals. For example, the budgetary process is essential to creating an environment that reflects the valuing of nursing. Commitment of the dean to securing resources necessary to accomplish the program goals drives the budget rather than the budget driving the commitment. The administrator's devotion to the discipline and to the basic assumptions of the theory direct all activities. The administrator makes decisions that reflect the basic beliefs of this theory. All decisions would ultimately be made from this standpoint: "What action should I take as administrator which would support the study of nursing as nurturing persons living in caring and growing in caring?"

What we have tried to suggest here is that every aspect of nursing education is grounded in the values and assumptions inherent in this theoretical focus. Thus, not only is the curriculum a direct expression of Nursing as Caring, but all aspects of program are similarly grounded.

REFERENCES

Boykin, A., & Schoenhofer, S. (1990). Caring in nursing: Analysis of extant theory. Nursing Science Quarterly, 4, 149-155. Carper, B. (1978). Fundamental patterns of knowing in nursing. Advances in Nursing Science, 1, 13-24. Carr, S. (1991). Intensive Care. Nightingale Songs, PO. Box 057563, West Palm Beach, FL 33405-7563, 2 (1). Guralnik, D. (1976). Webster's new world dictionary of the American language. 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 for institutional arrangement. American Journal of Education, 97, 215-230. Roble, M. (1991). Ave Maria and Therapeutic Touch for David. Nightingale Songs, P.O. Box 057563, West Palm Beach, FL 33405-7563, 1 (3).