PERSPECTIVE OF PERSONS AS CARING
Throughout this book the basic premise presides: all persons are caring. Caring is an essential feature and expression of being human. The belief that all persons, by virtue of their humanness, are caring establishes the ontological and ethical ground on which this theory is built. Persons as caring is a value which underlies each of the major concepts of Nursing as Caring and is an essential idea for understanding this theory and its implications. Being a person means living caring, and it is through caring that our "being" and all possibilities are known to the fullest. Elaboration on the meaning of this perspective will provide a necessary backdrop for understanding ideas in subsequent chapters.
Caring is a process. Each person, throughout his or her life, grows in the capacity to express caring. Said another way, each person grows in his or her competency to express self as caring person. Because of our belief that each person is caring and grows in caring throughout life, we will not focus on behaviors considered noncaring in this book. Our assumption that all persons are caring does not require that every act of a person necessarily be caring. There are many experiences of life that teach us that not every act of a person is caring. These acts are obviously not expressions of self as caring person and may well be labeled noncaring. Developing the fullest potential for expressing caring is an ideal. Notwithstanding the abstract context of this ideal, it is knowing the person as living caring and growing in caring that is central to our effort in this book. Therefore, even though an act or acts may be interpreted as noncaring, the person remains caring.
While this assumption does not require that every act be understood as an expression of caring, the assumption that all persons are caring does require an acceptance that fundamentally, potentially, and actually each person is caring. Although persons are innately caring, actualization of the potential to express caring varies in the moment and develops over time. Thus, caring is lived moment to moment and is constantly unfolding. The development of competency in caring occurs over a lifetime. Throughout life we come to understand what it means to be a caring person, to Live caring, and to nurture each other as caring.
Roach and Mayeroff provide some explanation as to what caring involves. Roach in her works (1984, 1987, 1992) has asserted that caring is the "human mode of being" (1992, p. ix). As such, it entails the capacity to care, the calling forth of this ability in ourselves and others, responding to something or someone that matters and finally actualizing the ability to care (192, p. 47). Since caring is a characteristic of being human, it cannot be attributed as a manifestation of any single discipline. These beliefs have directly influenced our assumption that all persons are caring. Mayeroff, a philosopher, in his 1971 book On Caring, discusses caring as an end in itself, an ideal, and not merely a means to some future end. Within the context of caring as process, Roach (1992, 1984) says that caring entails the human capacity to care, the calling forth of this ability in ourselves and others, the responsivity to something or someone that matters, and the actualizing of the power to care. Even though our human nature is to be caring, the full expression of this varies with the lived experience of being human. The process of bringing forth this capability can be nurtured through concern and respect for person as person.
Mayeroff suggests that caring "is not to be confused with such meanings as wishing well, liking, comforting, and maintaining . . . it is not an isolated feeling or a momentary relationship" (p. 1). He describes caring as helping the other grow. In relationships lived through caring, changes in the one who cares and the one cared for are evident. Mayeroff tells us how caring provides meaning and order: In the context of a man's life, caring has a way of ordering his other values and activities around it. When this advising is comprehensive, because of the inclusiveness of his caring, there is a basic stability in his life; he is "in place" in the world instead of being out of place, or merely drifting on endlessly seeking his place. Through caring for certain others, by serving them through caring a man lives the meaning of his own life. In the sense in which a man can ever be said to be at home in the world, he is at home not through dominating, or explaining, or appreciating, but through caring and being cared for (1971, p. 2).
Mayeroff expressed ideas about the meaning of being a caring person when he referred to trust as "being entrusted with the care of another" (p. 7). He spoke of both "being with" the other (p. 43) and "being for" (p. 42) the other, experiencing the other as an extension of self and at the same time "something separate from me that I respect in its own right" (p. 2). To be a caring person means to "live the meaning of my own life" (p. 72), having a sense of stability and basic certainty that allows an openness and accessibility, experiencing belonging, living congruence between beliefs and behavior, and expressing a clarity of values that enables living a simplified rather than a cluttered life.
Watson, a nursing theorist and philosopher, offers insight into caring. In her theory of Human Care, she examines caring as an intersubjective human process expressing respect for the mystery of being-in-the-world, reflected in the three spheres of mind-body-soul. Human care transactions based on reciprocity allow for a unique and authentic quality of presence in the world of the other. In a related vein, Parse (1981) defines the ontology of caring as "risking being with someone toward a moment of joy." Through being with another, connectedness occurs and moments of joy are experienced by both.
If the ontological basis for being is that all persons are caring and that by our humanness caring is, then I accept that I am a caring person. This belief that all persons are caring, however, entails a commitment to know self and other as caring person. According to Trigg (1973), commitment "presupposes certain beliefs and also involves a personal dedication to the actions implied by them" (p. 44). Mayeroff (1971) speaks of this dedication as devotion and states "devotion is essential to caring .. . when devotion breaks down, caring breaks down" (p. 8). Mayeroff also states that "obligations that derive from devotion are a constituent element in caring" (p. 9). Moral obligations arise from our commitments; therefore, when I make a commitment to caring as a way of being, I have become morally obligated. The quality of the moral commitment is a measure of being "in place" in the world. Gadow (1980) asserts that caring represents the moral ideal of nursing wherein the human dignity of the patient and nurse is recognized and enhanced.
As individuals we are continually in the process of developing expressions of ourselves as caring persons. The flow of life experiences provides ongoing opportunities for knowing self as caring person. As we learn to live fully each of these experiences, it becomes easier to allow self and others the space and time to develop innate caring capabilities and authentic being. The awareness of self as caring person calls to consciousness the belief that caring, is lived by each person moment to moment and directs the "oughts" of actions. When decisions are made from this perspective, the emerging question consistently is, "How ought I act as caring person?"
How one is with others is influenced by the degree of authentic awareness of self as caring person. Caring for self as person requires experiencing self as other and yet being one with self, valuing self as special and unique, and having the courage, humility, and trust to honestly know self. It takes courage to let go of the present so that it may be transcended and new meaning be discovered. Letting go, of course, implies a freeing of oneself from present constraints so that we may see and be in new ways. One who cares is genuinely humble in being ready and willing to know more about self and others. Such humility involves the realization that learning is continuous and the recognition that each experience is unique. As my commitment to persons as caring moves into the future, I must choose again and again to ratify it or not. This commitment remains binding and choices are made based on devotion to this commitment.
Personhood is the process of living grounded in caring. Personhood implies living out who we are, demonstrating congruence between beliefs and behaviors, and living the meaning of one's life. As a process, personhood acknowledges the person as having continuous potential for further tapping the current of caring. Therefore, as person we are constantly living caring and unfolding possibilities for self as caring person in each moment. Personhood is being authentic, being who I am as caring person in the moment. This process is enhanced through participation in nurturing relationships with others.
The nature of relationships is transformed through caring. All relations between and among persons carry with them mutual expectations. Caring is living in the context of relational responsibilities. A relationship experienced through caring holds at its heart the importance of person-as-person. Being in the world also mandates participating in human relationships that require re-sponsibility—responsibility to self and other. To the extent that these relationships are shaped through caring, they are consistent with the obligations entailed in relational responsibility, and the "person-al" (person-to-person) relationships. When being with self and others is approached from a desire to know person as living caring, the human potential for actualizing caring directs the moment.
All relationships are opportunities to draw forth caring possibilities, opportunities to reinforce the beauty of person-as-person. Through knowing self as caring person, I am able to be authentic to self and with others. I am able to see from the inside what others see from the outside. Feelings, attitudes, and actions lived in the moment are matched by an inner genuine awareness. The more I am open to knowing and appreciating self and trying to understand the world of other, the greater the awareness of our interconnectedness as caring persons. Knowing of self frees one to truly be with other. How does one come to know self as caring person? Mayeroff's (1971) caring ingredients are useful conceptual tools when one is struggling to know self and other as caring. These ingredients include: honesty, courage, hope, knowing (both knowing about and knowing directly), trust, humility, and alternating rhythm. The idea of a hologram serves as a way of understanding self and other. Pri-bram (1985) offers us an interesting view on relationships in his discussion of hologram. He states that the uniqueness of a hologram is such that if a part (of the hologram) is broken, any part of it is capable of reconstructing the total image (p. 133). Using this idea, if the lens for "being" in relationships is holographic, then the beauty of the person will be retained. Through entering, experiencing, and appreciating the world of other, the nature of being human is ore fully understood. The notion of person as whole or complete expresses an important value. As such, the respect for the total person—all that is in the moment—is communicated. Therefore, from a holographic perspective, it is impossible to focus on a part of a person without seeing the whole person reflected in the part. The wholeness (the fullness of being) is forever present. Perhaps in some context, the word part is incongruent with this notion that there is only wholeness. The term aspect, or dimension, may be a useful substitute.
The view of person as caring and complete is also intentional; it offers a lens for a way of being with another that prevents the segmenting of that other into component parts (e.g., mind, body, spirit). Here, valuing and respecting each person's beauty, worth, and uniqueness is lived as one seeks to understand fully the meaning of values, choices, and priority systems through which values are expressed. The inherent value that persons reflect and to which they respond is the wholeness of persons. The person is at all times whole. The idea of wholeness does not negate an appreciation of the complexity of being. However, from the perspective of the theory Nursing as Caring, to encounter person as less than whole involves a failure to encounter person. Un-il our view is such that it includes the whole as complete person and not just a part, we can not fully know the person. Gadow's (1984) contrasting paradigms, empathic and philanthropic, are relevant to this understanding. The philanthropic paradigm enables a relationship in which dignity is bestowed as a "gift from one who is whole to one who is not" (p. 68). Philanthropy marks the person as other than one like me. Gadow's empathic paradigm, on the other hand, "breaches objectivity" (p. 67) and expresses participating in the experience of another. In the empathic paradigm, the subjectivity of the other is "assumed to be as whole and valid as that of the caregiver" (p. 68). These paradigm descriptions facilitate our knowing how we are with others. Is the attitude expressed through nursing one of person as part or person as whole? How do these perspectives direct nursing practice?
Our understanding of person as caring centers on valuing and celebrating human wholeness, the human person as living and growing in caring, and active personal engagement with others. This perspective of what it means to be human is the foundation for understanding nursing as a human endeavor, a person-to-person service, a human social institution, and a human science.
Our view enables the development of nursing as a discipline of constant discovery and new knowing.
Like disciplines, professions have unique characteristics, as defined by Flexner. Flexner (1919) initially identified as the most basic characteristic of a profession that it addresses a unique and urgent social need through techniques derived from a tested knowledge base. Professions have their historical roots in those human services that people provided for each other within existing social institutions (e.g., tribe, family, or community). Thus, each profession, including nursing, has its origins in everyday human situations and the everyday contributions people make to the welfare of others. Flexner's founding conditions for the designation profession are reiterated in the American Nursing Association's 1980 Social Policy Statement, in which the idea of a social contract is addressed.
Nursing: A Social Policy Statement was intended to provide nurses with a fresh perspective on practice while providing society with a view of nursing for the 1980s. The overall intent of this document was to call to consciousness the linkages between the profession and society. While the Social Policy Statement is considered by many (see, for example, Rodgers, 1991; Packard & Polifroni, 1991; Allen, 1987; White, 1984) to be outdated, we find the concept of the social contract to be useful when studying the relationship of nurse to nursed. As the foundation for professions, the social contract, while understood to be an "hypothetical ideal" (Silva, 1983, p. 150), is also an expression of a people recognizing (1) the presence of a basic need and (2) the existence of greater knowledge and skill available to meet that need than can be readily exercised by each member of the society. Society at large then calls for commitment by a segment of society to the acquisition and use of this knowledge and skill for the good of all. Social goods are promised in return for this commitment.
Today, the profession of nursing is moving from a social contract relationship toward a covenantal relationship between the nurse and nursed. While the social contract implies an impersonal, legalistic stance, the covenantal relationship emphasizes personal engagement and ever present freedom to choose commitments. Cooper (1988), for example, discusses her ideas on the relevance of covenantal relationships for nursing ethics. She states "the promissory nature of the covenant is contained in the willingness of individuals to enter a covenental relationship" (p. 51) and it is within this context that obligations arise. As caring persons, we "see" relationship (covenant) and honor the bond between self and other. The ultimate knowledge gained from this perspective is that we are related to one another (and to the universe) and that harmony (brotherhood and sisterhood) is present as we live out caring relationships.
Concepts of discipline and profession have been dismissed by critical theorists as oppressive, anachronistic, and paternalistic (Allen, 1985; Rodgers, 1991). In our study however, as we have explored essential meanings of these concepts, we have found that they express fundamental values congruent with cherished nursing values. Although we can agree with critical theorists that discipline and profession have been misused, perhaps too frequently, as tools of social elitism and oppression, this misuse remains inappropriate because it violates the covenantal nature of discipline and profession.
The discipline of nursing attends to the discovery, creation, structuring, testing, and refinement of knowledge needed for the practice of nursing. Concomitantly, the profession of nursing attends to the use of that knowledge in response to specific human needs. Certainly, the basic values communicated in the concepts of discipline and profession are resonate with fundamental nursing values and contribute to a fuller understanding of nursing as caring. Included among those shared values are commitment to something that matters, sense of persons being connected in oneness; expression of human imagination and creativity, realization of the unity of knowing with possibilities unfolding, and expression of choice and responsibility.
We have deliberately used the term general theory of nursing to characterize our work. The concept of a general theory is particularly useful in the context of levels of theory. Other authors have addressed what they see as three levels of nursing theory: general or grand, mid-range, and practice (Walker & Avant, 1988; Fawcett, 1989; Chinn & Jacobs, 1987: Nursing Development Conference Group, 1979). What we intend by the use of the term general theory is similar to "conceptual framework," "conceptual model," or "paradigm." That is, a general theory is a framework for understanding any and all instances of nursing, and may be used to describe or to project any given situation of nursing. It is a system of values ordered specifically to reflect a philosophy of nursing to guide knowledge generation and to inform practice.
The statement of focus of any general nursing theory offers an explicit expression of the social need that calls for and justifies the professional service of nursing. In addition, the statement of focus expresses the domain of a discipline as well as the intent of the profession, and thus directs the development of the requisite nursing knowledge. Activity to develop and use nursing knowledge has its ethical ground in the idea of the covenantal relationship as expressed in the specific focus of the profession. Fundamental values inherent in the discipline and profession of nursing derive from an understanding of the focus of nursing.
The conception of nursing that we have used in this book views nursing science as a form of human science. Nursing as caring focuses on the knowledge needed to understand the fullness of what it means to be human and on the methods to verify this knowledge. For this reason, we have not accepted the traditional notion of theory which relies on the "received" view of science, and depends on measurement as the ultimate tool for legitimate knowledge development. The human science of nursing requires the use of all ways of knowing.
Carper's (1978) fundamental patterns of knowing in nursing are useful conceptual tools for expanding our view of nursing science as human science here. These patterns provide an organizing framework for asking epistemological questions of caring in nursing. To experience knowing the whole of a nursing situation with caring as the central focus, each of these patterns comes into play. Personal knowing focuses on knowing and encountering self and other intuitively, the empirical pathway addresses the sense, ethical knowing focuses on moral knowing of what "ought to be" in nursing situations, and aesthetic knowing involves the appreciating and creating that integrates all patterns of knowing in relation to a particular situation. Through the richness of the knowledge gleaned, the nurse as artist creates the caring moment (Boykin & Schoenhofer, 1990).
Nursing, as we have come to understand our discipline, is not a normative science that stands outside a situation to evaluate current observations against empirically derived and tested normative standards. Nursing as a human science takes its value from the knowledge created within the shared lived experience of the unique nursing situation. Although empirical facts and norms do play a role in nursing knowledge, we must remember that that role is not one of unmediated application. Knowledge of nursing comes from within the situation. The nurse reaches out into a body of normative information, transforming that information as understanding is created from within the situation. The same can be said for personal and ethical knowing. Each serves as a pathway for transforming knowledge in the creation of aesthetic knowing within the nursing situation. The view we have taken unifies previously dichotomized notions of nursing as science and nursing as art and requires a new understanding of science.
Nursing as caring reflects an appreciation of persons in the fullness of per-sonhood within the context of the nursing situation. This view transcends perspectives adopted in an earlier period of nursing science philosophy. Examples of the earlier view include the notions of basic versus applied science, and metaphysics versus theory. The idea of a basic science of nursing disconnects nursing from its very ground of ethical value. Without a grounding in praxis, the content and activity of nursing science becomes amoral and meaningless. Similarly, this view transcends an earlier view of nursing theory that treated the unitary phenomenon of nursing as being composed of concepts that could be studied independently or as "independent and dependent variables." Nursing as caring resists fragmentation of the unitary phenomenon of our discipline. In subsequent chapters, we will more fully explore implications of this view of nursing as a human science discipline and profession.