REFERENCES
Boykin, A., & Schoenhofer, S. (1991). Story as link between nursing
practice, ontology, epistemology. Image, 23, 245-248.
Boykin, A., & Schoenhofer, S. (1990). Caring in nursing: Analysis of
extant theory. Nursing Science Quarterly, 4, 149-155.
Maxwell, G. (1990). Connections. Nightingale Songs, 1 (1). P.O. Box
057563, West Palm Beach, FL 33405.
Paterson, J., & Zderad, L. (1988). Humanistic nursing. New York:
National League for Nursing Press.
Roach, S. (1984). Caring: The human mode of being, implications for
nursing. Toronto: Faculty of Nursing, University of Toronto.
(Perspectives in Caring Monograph 1).
Schoenhofer, S. (1989). Love, beauty and truth: Fundamental nursing
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Watson, J. (1987). Nursing on the caring edge; Metaphorical vignettes.
Advances in Nursing Science, 10, 10-18.
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.