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?