In Chapter 1, personhood was described as a process of living grounded in caring. In an effort to clarify the meaning of "a process" in the context of the theory of Nursing as Caring, we explained that personhood, understood as living grounded in caring, is processual—ongoing, experienced moment to moment, evolutionary, transformative—rather than a generalized sequence of steps or operations. In subsequent publications, personhood was described as "living grounded in caring," eliminating the problematic use of the term "process" entirely (Schoenhofer & Boykin, 1998a; Boykin & Schoenhofer, 2000).
RESEARCH DEVELOPMENT OF THE FOUNDATIONAL CONCEPTS OF PERSON AS CARING AND PERSONHOOD
Nursing as Caring guides nurses to enter into the world of the other and allows them to come to know the nursed as living caring uniquely in situation. In consulting with nurses using Nursing as Caring as their framework for practice, we found that nurses could easily recognize expressions of caring when caring was lived in ways familiar to their own lifeworlds. However, in nursing situations where personal ways of caring were outside the experience of the nurse, there seemed to be difficulties in knowing and thus affirming the nursed as person uniquely living caring in the moment. Without this situated knowing, we saw that nurses tended to lose the focus of recognizing the other as living caring uniquely in the moment, and instead, to concentrate on ways in which persons "were not living caring" and "should grow in caring." This tendency to return to a normative practice framework in difficult times is easily understood as nurses struggle to transcend a familiar paradigm characterized by terms such as "nursing process," "nursing diagnosis," "nursing intervention" and to evolve toward what has been called a simultaneity paradigm (Parse, 1987).
Because knowing the other as caring is the basic act of nursing, it became clear to us that knowledge expansion would be helpful in enhancing nurses' ability to recognize uniquely personal ways their patients live the value of caring. Schoenhofer conducted a series of studies over several years to develop knowledge of personal lived meaning of everyday caring. In one unpublished study, adolescents shared stories of personal caring. Their stories were found to center around the theme of "helping out." Adolescents described everyday caring in terms such as "cheering up someone you love," "helping another get what they need," "work as caring," "caring by physical presence." The stories illustrated situations where caring was expressed as "helping out when you don't really want to, but doing it anyway," "helping without being asked," "filling in where caring is missing." One teenage boy told of caring for a former girlfriend who was angry about their breakup; he made deliberate efforts to remain active as a friend, as a way to help the girl deal with the loss of their romantic relationship. He characterized his caring as "keeping on showing care even though it doesn't seem to change things."
In another similar study, 4th grade students told stories of caring in which they acted as advocates for other children and offered help to others, both adults and children, who were perceived as less fortunate and in need of care (Schoenhofer, Bingham & Hutchins, 1998). Adults, too, have unique and personal ways of living their everyday caring. One father related an example of caring for his young daughter by restricting her activities because of poor school performance, and then engaging in a dialogue with her that resulted in a compromise. The father saw willingness to discipline as an act of caring and felt that his willingness to listen to the child's perspective was also part of his caring (Schoenhofer, Bingham & Hutchins, 1998). Several adults whose parents had become disabled told stories of caring for parents in ways that preserved cherished role relationships. These adults understood that their caring required extra effort to avoid infantalization of the parent but felt that without that extra effort, attention would be given to certain needs but adequate caring would not be given.
Research into everyday caring was conducted in a group discussion format, with persons invited to relate a story that illustrated how they lived their caring in everyday situations. The ease with which these research participants understood what was being asked of them, their willingness to respond and the clarity of the exemplars they shared have the potential to inform nursing practice. When nurse colleagues learned of this research effort, they often expressed doubt that people could and would describe their everyday caring ways. Based on the experience of the researchers and research participants in this series of studies, however, it became clear that persons do understand their unique ways of caring, and do recognize the importance of sharing that understanding.
Nurses committed to practice guided by the tenets of Nursing as Caring can and should incorporate direct invitation as part of their coming to know other as caring person, A number of important benefits are possible with a direct approach to knowing the other as caring. One benefit is that as the nurse raises the issue of caring, patients are helped to understand that caring is of immediate importance to nurses, thus clarifying the service and value of nursing among the health disciplines. A second benefit is that as nurses address caring directly with their patients, nurses themselves gain affirmation of nursing as a caring service and of themselves as persons committed to caring. However, the most immediate benefit of a direct approach to caring is the opening of a line of communication that clearly establishes the "caring between," that space, that relationship within which and through which all that is important in nursing occurs. The patient is given the opportunity to recognize self as caring person and to join in mutual affirmation and celebration with the nurse. Nurses who are reluctant to engage patients in dialogues about caring ways may think the topic is "too intimate." It is true that caring is intimate and personal, but caring is also very visible, just as many of the topics introduced in the nursing situation are personal and intimate and have visible referents. As nurses have the courage to raise the topic of caring, the central importance of caring in human living can become not only recognized but openly and publicly valued.
RESEARCH DEVELOPMENT OF NURSING OUTCOMES-VALUES EXPERIENCED IN THE NURSING SITUATION
Another research thread has focused on the development of an approach to identifying and languaging outcomes of nursing guided by the theory of Nursing as Caring (Boykin & Schoenhofer, 1997; Schoenhofer & Boykin, 1998a, 1998b). Within the context of the theory, the idea of outcomes has been reconceptualized as "values experienced in the nursing situation." Several case studies illuminated a dialogical form of praxis involving nurse, patient and researcher that revealed values experienced by patients and their nurses. Values experienced by families, health care administrators and systems were also uncovered as the caring created in the nursing situation was found to resonate beyond the immediate nurse-patient relationship. This line of research has demonstrated that while traditional economic valuation can be calculated, the value of caring in nursing can and must be more clearly explicated in human terms. For example, one case study of home health nursing found that the economic value of six nursing visits produced a health care cost savings of $5,709, primarily by obviating the necessity of trips to the emergency department of the local hospital. Through this unique research approach, the human value of the six visits was identified and languaged in terms that clearly demonstrate the direct, unmediated worth of nursing care—to the one nursed, the family, the nurse and the larger circle of health care systems. The patient and family gained the important value of confidence through the caring of the home health nurse; with the nurse's commitment to caring, they gained faith in themselves, their ability to deal with new health-related situations as they arose, faith that they wouldn't be left alone, faith that they were known as persons valuable in their own right and worthy of care. This is the value of nursing, the reason nursing exists as a distinguishable social and human service. Nurses can learn to assert the human value of nursing, and in fact, nurses must accept the responsibility for bringing the human value of care to the forefront. Re-establishing the primary position of care in the health care arena depends on nurses speaking out in clearly human terms about the meaning and value of care, using the language of caring knowledgably and without apology.
In May, 2000, Boykin launched a funded study to examine the potential of the theory of Nursing as Caring to enhance the achievement of quality outcomes in acute care settings. This two-year demonstration project and evaluation study involves specifying quality indicators and targeting benchmarks prior to introducing the theory as the nursing practice framework in the acute care division of a community hospital. On-site guidance and consultation in the use of the theory will be available during the course of the project. Post-program evaluation will focus on quality indicators and benchmarks relating to patient and staff satisfaction, family and community support, and cost-benefit care ratios.