CHAPTER

7
Caring in Nursing Practice

OBJECTIVES
Discuss the role that caring plays in building the nurse-patient Describe ways to express caring through presence and touch.
relationship. Describe the therapeutic benefit of listening to patients.
Compare and contrast theories on caring. Explain the relationship between knowing a patient and clinical decision
Discuss the evidence that exists about patients perceptions of caring. making.
Explain how an ethic of care influences nurses decision making.

KEY TERMS
Caring, p. 80 Ethic of care, p. 83 Transcultural, p. 80
Comforting, p. 84 Presence, p. 83 Transformative, p. 81

in a caring and compassionate manner, you learn that the thera-

peutic gain in caring makes enormous contributions to the health
http://evolve.elsevier.com/Potter/fundamentals/ and well-being of your patients.
Review Questions Have you ever been ill or experienced a problem requiring
Case Study with Questions health care intervention? Think about that experience. Then con-
Audio Glossary
sider the following two scenarios and select the situation that you
Interactive Learning Activities
Key Term Flashcards
believe most successfully demonstrates a sense of caring.
Content Updates
A nurse enters a patients room, greets the patient warmly while
touching him or her lightly on the shoulder, makes eye contact,

C
aring is central to nursing practice, but it is even more sits down for a few minutes and asks about the patients
important in todays hectic health care environment. The thoughts and concerns, listens to the patients story, looks at the
demands, pressure, and time constraints in the health care intravenous (IV) solution hanging in the room, briefly exam-
environment leave little room for caring practice, which results in ines the patient, and then checks the vital sign summary on the
nurses and other health professionals becoming dissatisfied with bedside computer screen before departing the room.
their jobs and cold and indifferent to patient needs (Watson, 2006, A second nurse enters the patients room, looks at the IV
2009). Increasing use of technological advances for rapid diagnosis solution hanging in the room, checks the vital sign summary
and treatment often causes nurses and other health care providers sheet on the bedside computer screen, and acknowledges the
to perceive the patient relationship as less important. Technological patient but never sits down or touches him or her. The nurse
advances become dangerous without a context of skillful and com- makes eye contact from above while the patient is lying in bed.
passionate care. Despite these challenges, more professional orga- He or she asks a few brief questions about the patients symp-
nizations are stressing the importance of caring in health care. toms and leaves.
Nursings Agenda for the Future (ANA, 2002) states that Nursing is
the pivotal health care profession highly valued for its specialized There is little doubt that the first scenario presents the nurse in
knowledge, skill, and caring in improving the health status of the specific acts of caring. The nurses calm presence, parallel eye
individual, family, and the community. The American Organiza- contact, attention to the patients concerns, and physical closeness
tion of Nurse Executives (AONE, 2005) describes caring and all express a person-centered, comforting approach. In contrast, the
knowledge as the core of nursing, with caring being a key compo- second scenario is task-oriented and expresses a sense of indiffer-
nent of what a nurse brings to a patient experience (Fig. 7-1). ence to patient concerns. Both of these scenarios take approxi-
It is time to value and embrace caring practices and expert mately the same amount of time but leave very different patient
knowledge that are the heart of competent nursing practice (Benner perceptions. It is important to remember that, during times of
and Wrubel, 1989; Benner etal., 2010). When you engage patients illness or when a person seeks the professional guidance of a nurse,

79
80 UNIT 2 Caring Throughout the Life Span

BOX 7-1 CULTURAL ASPECTS OF CARE

Nurse Caring Behaviors
Caring includes knowing a patients cultural values and beliefs (Suliman
The core of nursing etal., 2009). Although the need for human caring is universal, its application
is knowledge is based on cultural norms. As a result, expectations may change across
and caring
cultures. For example, providing time for family presence is often more
valuable to traditional Asian families than a nursing presence. Using
touch to convey caring sometimes crosses cultural norms. Sometimes
Managing Care is
the journey gender-congruent caregivers or the patients family need to provide
user-based
caring touch. When listening to the patient, some cultures view eye contact
as disrespectful.
Patient/
population
Implications for Practice
Relationships
Know the patients cultural norms for caring practices.
of care
presencevirtual Know the patients cultural practices regarding end-of-life care. In some
Knowledge is cultures it is considered insensitive to tell the patient that he or she is
access-based
dying (Suliman etal., 2009).
Knowledge is Determine if a member of the patients family or cultural group is the best
synthesized resource to use for caring practices such as providing presence or touching
(Galanti, 2008).
Know the patients cultural practices regarding the removal of life support
(Galanti, 2008).

FIG. 7-1 AONE guiding principles for future care delivery. (Copy-
right 2005 by the American Organization of Nurse Executives
[AONE]. All rights reserved.)
and maintain or reestablish connection. Understanding how to
provide humanistic caring and compassion begins early in nursing
education and continues to mature through experiential practice
caring is essential in helping the individual reach positive (Gallagher-Lepak and Kubsch, 2009).
outcomes. Patients are not all the same. Each person brings a unique back-
ground of experiences, values, and cultural perspectives to a health
care encounter. Caring is always specific and relational for each
THEORETICAL VIEWS ON CARING
nurse-patient encounter. As nurses acquire more experience, they
Caring is a universal phenomenon influencing the ways in which typically learn that caring helps them to focus on the patients for
people think, feel, and behave in relation to one another. Since whom they care. Caring facilitates a nurses ability to know a
Florence Nightingale, nurses have studied caring from a variety of patient, allowing the nurse to recognize a patients problems and
philosophical and ethical perspectives. A number of nursing schol- find and implement individualized solutions.
ars have developed theories on caring because of its importance to
nursing practice. This chapter does not detail all of the theories of Leiningers Transcultural Caring
caring, but it is designed to help you understand how caring is at From a transcultural perspective, Madeleine Leininger (1991)
the heart of a nurses ability to work with all patients in a respectful describes the concept of care as the essence and central, unifying,
and therapeutic way. and dominant domain that distinguishes nursing from other
health disciplines (see Chapter 4). Care is an essential human need,
Caring Is Primary necessary for the health and survival of all individuals. Care, unlike
Benner offers nurses a rich, holistic understanding of nursing prac- cure, helps an individual or group improve a human condition.
tice and caring through the interpretation of expert nurses stories. Acts of caring refer to nurturing and skillful activities, processes,
After listening to nurses stories and analyzing their meaning, she and decisions to assist people in ways that are empathetic, compas-
described the essence of excellent nursing practice, which is caring. sionate, and supportive. An act of caring depends on the needs,
The stories revealed the nurses behaviors and decisions that problems, and values of the patient. Leiningers studies of numer-
expressed caring. Caring means that persons, events, projects, and ous cultures around the world found that care helps protect,
things matter to people (Benner and Wrubel, 1989; Benner etal., develop, nurture, and provide survival to people. It is needed for
2010). It is a word for being connected. people of all cultures to recover from illness and to maintain
Caring determines what matters to a person. It underlies a wide healthy life practices.
range of interactions, from parental love to friendship, from caring Leininger (1991) stresses the importance of nurses understand-
for ones work to caring for ones pet, to caring for and about ones ing cultural caring behaviors. Even though human caring is a uni-
patients. Benner and Wrubel (1989) note: Caring creates possibil- versal phenomenon, the expressions, processes, and patterns of
ity. Personal concern for another person, an event, or thing pro- caring vary among cultures (Box 7-1). Caring is very personal; thus
vides motivation and direction for people to care. Caring as a its expression differs for each patient. For caring to be effective,
professional framework has practical implications for transform- nurses need to learn culturally specific behaviors and words that
ing nursing practice (Drenkard, 2008). Through caring, nurses help reflect human caring in different cultures to identify and meet the
patients recover in the face of illness, give meaning to their illness, needs of all patients (see Chapter 9).
 CHAPTER 7 Caring in Nursing Practice 81

Watsons Transpersonal Caring

TABLE 7-1 Watsons 10 Carative Factors
Patients and their families expect a high quality of human inter (Watson, 2005, 2008)
action from nurses. Unfortunately many conversations between
patients and their nurses are very brief and disconnected. Watsons CARATIVE FACTOR EXAMPLE IN PRACTICE
theory of caring is a holistic model for nursing that suggests that Forming a human-altruistic Use loving kindness to extend yourself.
a conscious intention to care promotes healing and wholeness value system Use self-disclosure appropriately to
(Watson, 2005, 2010). The theory integrates the human caring promote a therapeutic alliance with your
processes with healing environments, incorporating the life- patient.
generating and life-receiving processes of human caring and
healing for nurses and their patients (Watson, 2006). The theory Instilling faith-hope Provide a connection with the patient that
describes a consciousness that allows nurses to raise new questions offers purpose and direction when trying
about what it means to be a nurse, to be ill, and to be caring and to find the meaning of an illness.
healing. The transpersonal caring theory rejects the disease orien- Cultivating a sensitivity to Learn to accept yourself and others for their
tation to health care and places care before cure (Watson, 1996, ones self and to others full potential. A caring nurse matures into
2008). The practitioner looks beyond the patients disease and its becoming a self-actualized nurse.
treatment by conventional means. Instead, transpersonal caring Developing a helping, Learn to develop and sustain helping,
looks for deeper sources of inner healing to protect, enhance, trusting, human caring trusting, authentic, caring relationships
and preserve a persons dignity, humanity, wholeness, and inner relationship through effective communication with
harmony (see also Chapter 4). your patients.
In Watsons view caring becomes almost spiritual. It preserves
human dignity in the technological, cure-dominated health care Promoting and expressing Support and accept your patients feelings.
system (Watson, 2006). The emphasis is on the nurse-patient rela- positive and negative In connecting with your patients you
tionship. The focus is on the people behind the patient and nurse feelings show a willingness to take risks in
and the caring relationship (Table 7-1). A nurse communicates sharing in the relationship.
caring-healing to the patient through the consciousness of the Using creative problem- Apply the nursing process in systematic,
nurse. This takes place during a single caring moment between solving, caring scientific problem-solving decision making
nurse and patient. A connection forms between the one cared for processes in providing patient-centered care.
and the one caring. The model is transformative because the rela- Promoting transpersonal Learn together while educating the patient
tionship influences both the nurse and the patient for better or for teaching-learning to acquire self-care skills. The patient
worse (Watson, 2006, 2010). Caring-healing consciousness pro- assumes responsibility for learning.
motes healing. Application of Watsons caring model in practice
enhances nurses caring practices (Box 7-2). Providing for a supportive, Create a healing environment at all levels,
protective, and/or physical and nonphysical. This promotes
Swansons Theory of Caring corrective mental, wholeness, beauty, comfort, dignity, and
Kristen Swanson (1991) studied patients and professional caregiv- physical, societal, and peace.
ers in an effort to develop a theory of caring for nursing practice. spiritual environment
This middle-range theory of caring was developed from three peri- Meeting human needs Assist patients with basic needs with an
natal studies that interviewed women who miscarried, parents and intentional care and caring
health care professionals in a newborn intensive care unit, and consciousness.
socially at-risk mothers who received long-term public health Allowing for existential- Allow spiritual forces to provide a better
intervention. All groups were in a perinatal (before, during, or after phenomenological- understanding of yourself and your
the birth of a child) setting or context and experienced the spiritual forces patient.
phenomenon of caring. Researchers asked each group questions
regarding how they experienced or expressed caring in their situa-
tions (Swanson, 1999a, 1999b). After analyzing the stories and
descriptions of the three groups, Swanson developed a theory of
caring. The theory describes caring as consisting of five categories counseling was significant in reducing womens depression and
or processes (Table 7-2). Swanson (1991) defines caring as a nur- anger, particularly for women in the first 4 months following
turing way of relating to a valued other toward whom one feels a miscarriage.
personal sense of commitment and responsibility. This theory sup-
ports the claim that caring is a central nursing phenomenon but Summary of Theoretical Views
not necessarily unique to nursing practice. Nursing caring theories have common themes. Duffy, Hoskins, and
Swansons work (1991) provides direction for how to develop Seifert (2007) identify these commonalities as human interaction
useful and effective caring strategies. Each of the caring processes or communication, mutuality, appreciating the uniqueness of indi-
has definitions and subdimensions that serve as the basis for viduals, and improving the welfare of patients and their families.
nursing interventions. Nursing care and caring are crucial in Caring is highly relational. The nurse and the patient enter into a
making positive differences in patients health and well-being relationship that is much more than one person simply doing
outcomes (Swanson, 1999a). Thus research findings develop and tasks for another. There is a mutual give-and-take that develops
refine the theory and continue to guide clinical nursing practice as nurse and patient begin to know and care for one another
(Andershed and Olsson, 2009). For example, Swanson (1999b) (Hudacek, 2008; Sumner, 2010). Caring theories are valuable when
tested the effects of caring-based counseling on womens emotional assessing patient perceptions of being cared for in a multicultural
well-being in the first year after miscarrying. Caring-based environment (Suliman etal., 2009). Frank (1998) described a
82 UNIT 2 Caring Throughout the Life Span

BOX 7-2 EVIDENCE-BASED PRACTICE TABLE 7-2 Swansons Theory of Caring

Enhancing Caring (Swanson, 1991)

PICO Question: Do patient satisfaction rates among hospitalized adult CARING

patients improve when carative nursing practices are used? PROCESS DEFINITIONS SUBDIMENSIONS
Knowing Striving to understand Avoiding assumptions
Evidence Summary
an event as it has Centering on the one cared for
Patient satisfaction is an important indicator for the quality of health care.
meaning in the life Assessing thoroughly
Caring facilitates healing and improves patient satisfaction with nursing care
of the other Seeking cues
(Rush etal., 2008; Osterman etal., 2010). Researchers integrated human
Engaging the self or both
science caring into a professional practice model in a large health care system.
This model was designed to increase nurses presence and help them know Being with Being emotionally Being there
their patients better. In turn the nurses implemented practice changes. Patient present to the other Conveying ability
satisfaction increased, and patients indicated a willingness to return to the Sharing feelings
health care system in the event hospitalization was needed in the future Not burdening
(Drenkard, 2008). When using carative nursing practices, the interaction Doing for Doing for the other as Comforting
between the nurse and patient is essential and contributes to patient-centered he or she would do Anticipating
care (Hobbs, 2009). for self if it were at Performing skillfully
all possible Protecting
Application to Nursing Practice Preserving dignity
Setting a specific dedicated time to meet one-on-one with a patient
during each nursing shift encourages the patient to be an active partner in Enabling Facilitating the others Informing/explaining
care and helps the nurse understand the patients perception of the need passage through life Supporting/allowing
for caring (Drenkard, 2008). transitions (e.g., Focusing
The use of caring in nursing practice encourages a more holistic approach birth, death) and Generating alternatives
to nursing care. unfamiliar events Validating/giving feedback
As nurses use caring, they get to know their patients and therefore better Maintaining Sustaining faith in the Believing in/holding in esteem
meet their needs (Drenkard, 2008). belief others capacity to Maintaining a hope-filled
The caring model involves a closeness, commitment, and involvement in get through an attitude
the nurse-patient relationship, which contributes to patient-centered care event or transition Offering realistic optimism
(Hobbs, 2009). and face a future Going the distance
with meaning

personal situation when he was suffering from cancer: What I

wanted when I was ill was a mutual relationship of persons who One aspect of caring is enabling, when a nurse and patient work
were also clinician and patient. It was important for Frank to be together to identify alternatives in approaches to care and resources.
seen as one of two fellow human beings, not the dependent patient Consider a nurse working with a patient recently diagnosed with
being cared for by the expert technical clinician. diabetes mellitus who must learn how to administer daily insulin
Caring seems highly invisible at times when a nurse and patient injections. The nurse enables the patient by providing instruction
enter a relationship of respect, concern, and support. The nurses in a manner that allows the patient to successfully adapt diabetes
empathy and compassion become a natural part of every patient management strategies such as self-medication, exercise, and diet
encounter. However, when caring is absent, it becomes very obvious. to his own lifestyle.
For example, if the nurse shows disinterest or chooses to avoid a Another common theme of caring is to understand the context
patients request for help, his or her inaction quickly conveys an of a persons life and illness. It is difficult to show caring for another
uncaring attitude. Benner and Wrubel (1989) relate the story of a individual without gaining an understanding of who the person is
clinical nurse specialist who learned from a patient what caring is and his or her perception of the illness. Exploring the following
all about: I felt that I was teaching him a lot, but actually he taught questions with your patients helps you understand their percep-
me. One day he said to me (probably after I had delivered some tions of illness: How was your illness first recognized? How do you
well-meaning technical information about his disease), Youre feel about the illness? How does your illness affect your daily life
doing an OK job, but I can tell that every time you walk in that practices? Knowing the context of a patients illness helps you
door youre walking out. In this nurses story the patient perceived choose and individualize interventions that will actually help the
that the nurse was simply going through the motions of teaching patient. This approach is more successful than simply selecting
and showed little caring toward the patient. Patients quickly know interventions on the basis of your patients symptoms or disease
when nurses fail to relate to them. process.
As you practice caring, your patient will sense your commitment
and willingness to enter into a relationship that allows you to
PATIENTS PERCEPTIONS OF CARING
understand the patients experience of illness. In a study of oncol-
ogy patients, one patient described a nurses caring as putting the Leiningers, Watsons, and Swansons theories provide an excellent
heart in it and having an investment that makes patients feel beginning to understanding the behaviors and processes that char-
that you are with them (Radwin, 2000). Thus the nurse becomes acterize caring. Researchers explored nursing care behaviors as
a coach and partner rather than a detached provider of care. perceived by patients (Table 7-3). Their findings emphasize what
 CHAPTER 7 Caring in Nursing Practice 83

TABLE 7-3 Comparison of Research Studies Exploring Nurse Caring Behaviors (as Perceived by Patients)
PATIENT FALLS: EXPLORATORY STUDY OF IMPORTANCE OF KNOWING THE
ACUTE CARE NURSES NURSES PRESENCE IN DAILY PATIENT IN WEANING FROM
EXPERIENCES (RUSH CARE ON AN ONCOLOGY UNIT MECHANICAL VENTILATION
ETAL [2008]) (OSTERMAN ETAL [2010)] (CROCKER AND SCHOLES [2009])
Using compassion when identifying Being compassionate and patient is important. Nursing presence contributes to knowing the
risk factors associated with falling Developing patient-nurse trust and patient. Patients indicated that knowing
Using nursing presence to know the responsiveness to patient is critical to the the patient was essential to patient-
patient and identify patient- emergence of full presence. centered care.
centered factors that promote or Maintaining presence is a way to provide Maintaining a balance of continuity of care
impede patient risk of falls emotional support to patients who are and nursing expertise. The inexperienced
Communicating effectively between experiencing overwhelming stressors and nurse was more likely to be away from the
nurses and patient/family decisions. Morning care provides an patient or provide care in a hurried manner.
Incorporating patients and families opportunity for nurses to be present with Creating a trusting relationship between
into the solution their patients. patient and nurse is important.

patients expect from their caregivers and thus provide useful guide- nursing has with its public (Watson, 2010). Caring science provides
lines for your practice. Patients continue to value nurses effective- a disciplinary foundation from which you deliver patient-centered
ness in performing tasks; but clearly patients value the affective care (Watson, 2005, 2008). Chapter 22 explores the importance of
dimension of nursing care. ethics in professional nursing. The term ethics refers to the ideals
The study of patients perceptions is important because health of right and wrong behavior. In any patient encounter a nurse
care is placing greater emphasis on patient satisfaction (see Chapter needs to know what behavior is ethically appropriate. An ethic of
2). Duffy, Hoskins, and Seifert (2007) developed the Caring Assess- care is unique so professional nurses do not make professional
ment Tool (CAT) to measure caring from a patients perspective. decisions based solely on intellectual or analytical principles.
This tool and other caring assessments help you, as a beginning Instead, an ethic of care places caring at the center of decision
professional, to appreciate the type of behaviors that hospitalized making. For example, what resources should be used to care for an
patients identify as caring. When patients sense that health care indigent patient? Is it caring to place a disabled relative in a long-
providers are sensitive, sympathetic, compassionate, and interested term care facility?
in them as people, they usually become active partners in the plan An ethic of care is concerned with relationships between people
of care (Gallagher-Lepak and Kubsch, 2009). Suliman etal. (2009) and with a nurses character and attitude toward others. Nurses
studied the impact of Watsons caring theory as an assessment who function from an ethic of care are sensitive to unequal rela-
framework in a multicultural environment. Patients in the study tionships that lead to an abuse of one persons power over another
indicated that they did not perceive any cultural bias when they intentional or otherwise. In health care settings patients and
perceived nurses to be caring. Radwin (2000) found that oncology families are often on unequal footing with professionals because of
patients associated excellent nursing care with attentiveness, part- the patients illness, lack of information, regression caused by pain
nership, individualization, rapport, and caring. As institutions look and suffering, and unfamiliar circumstances. An ethic of care places
to improve patient satisfaction, creating an environment of caring the nurse as the patients advocate, solving ethical dilemmas by
is a necessary and worthwhile goal. Patient satisfaction with nursing attending to relationships and by giving priority to each patients
care is an important factor in their decision to return to a hospital. unique personhood.
As you begin clinical practice, consider how patients perceive
caring and the best approaches to provide care. Behaviors associ-
CARING IN NURSING PRACTICE
ated with caring offer an excellent starting point. It is also impor-
tant to determine an individual patients perceptions and unique It is impossible to prescribe ways that guarantee whether or when
expectations. Frequently patients and nurses differ in their percep- a nurse becomes a caring professional. Experts disagree as to
tions of caring (Hudacek, 2008). For that reason focus on building whether caring is teachable or more fundamentally a way of being
a relationship that allows you to learn what is important to your in the world. For those who find caring a normal part of their lives,
patients (Gallagher-Lepak and Kubsch, 2009). For example, your it is a product of their culture, values, experiences, and relation-
patient is fearful of having an intravenous catheter inserted, and ships with others. Persons who do not experience care in their lives
you are still a novice at catheter insertion. Instead of giving a often find it difficult to act in caring ways. As you deal with health
lengthy description of the procedure to relieve anxiety, you decide and illness in your practice, you grow in your ability to care. Caring
that the patient will benefit more if you obtain assistance from a behaviors include providing presence, offering a caring touch, and
skilled staff member. Knowing who patients are helps you select listening.
caring approaches that are most appropriate to their needs.
Providing Presence
Providing presence is a person-to-person encounter conveying a
ETHIC OF CARE
closeness and sense of caring. Fredriksson (1999) explains that
Caring is a moral imperative, not a commodity to be bought and presence involves being there and being with. Being there is
sold. Caring for other human beings protects, enhances, and pre- not only a physical presence; it also includes communication and
serves human dignity. It is a professional, ethical covenant that understanding. Presence is an interpersonal process that is
84 UNIT 2 Caring Throughout the Life Span

characterized by sensitivity, holism, intimacy, vulnerability, and of a nasogastric tube, the nurse offers comfort through a full expla-
adaptation to unique circumstances. It results in improved mental nation of the procedure and what the patient will feel. Then the
well-being for nurses and patients and improved physical well- nurse performs the procedure safely, skillfully, and successfully.
being in patients (Finfgeld-Connett, 2006). The interpersonal This is done as the nurse prepares the supplies, positions the
relationship of being there depends on the fact that a nurse is patient, and gently manipulates and inserts the nasogastric tube.
attentive to the patient. Presence can be translated into an actual Throughout a procedure the nurse talks quietly with the patient to
caring art that affects the healing and well-being of both the nurse provide reassurance and support.
and patient. It is often used in conjunction with other nursing Caring touch is a form of nonverbal communication, which
interventions such as establishing the nurse-patient relationship, successfully influences a patients comfort and security, enhances
providing comfort measures, providing patient education, and self-esteem, increases confidence of the caregivers, and improves
listening. The outcomes of nursing presence include alleviating mental well-being (Osterman etal, 2010). You express this in the
suffering, decreasing a sense of isolation and vulnerability, and way you hold a patients hand, give a back massage, gently position
personal growth (Zyblock, 2010). This type of presence is a patient, or participate in a conversation. When using a caring
something the nurse offers to the patient in achieving patient touch, you connect with the patient physically and emotionally
care goals. (Zyblock, 2010).
Nursing requires being present with patients at a moment of Protective touch is a form of touch that protects the nurse and/
crisis or need (Zyblock, 2010). Being with is also interpersonal. or patient (Fredriksson, 1999). The patient views it either positively
The nurse gives himself or herself, which means being available and or negatively. The most obvious form of protective touch is pre-
at a patients disposal. If patients accept the nurse, they will invite venting an accident (e.g., holding and bracing the patient to avoid
him or her to see, share, and touch their vulnerability and suffering. a fall). Protective touch is also a kind of touch that protects the
Ones human presence never leaves one unaffected (Watson, 2008). nurse emotionally. A nurse withdraws or distances herself or
The nurse then enters the patients world. In this presence the himself from a patient when he or she is unable to tolerate suffering
patient is able to put words to feelings and understand himself or or needs to escape from a situation that is causing tension. When
herself in a way that leads to identifying solutions, seeing new used in this way, protective touch elicits negative feelings in a
directions, and making choices. patient (Fredriksson, 1999).
When a nurse establishes presence, eye contact, body language, Because touch conveys many messages, use it with discretion.
voice tone, listening, and a positive and encouraging attitude act Touch itself is a concern when crossing cultural boundaries of
together to create openness and understanding. The message con- either the patient or the nurse (Benner etal., 2010; Benner, 2004).
veyed is that the others experience matters to the one caring The patient generally permits task-orientated touch because most
(Swanson, 1991). Establishing presence enhances the nurses ability individuals give nurses and physicians a license to enter their
to learn from the patient. This strengthens the nurses ability to personal space to provide care (see Box 7-1, p. 80). Know and
provide adequate and appropriate nursing care. understand if patients accept touch and how they interpret your
It is especially important to establish presence and caring when intentions.
patients are experiencing stressful events or situations. Awaiting a
physicians report of test results, preparing for an unfamiliar pro- Listening
cedure, and planning for a return home after serious illness are just Caring involves an interpersonal interaction that is much more
a few examples of events in the course of a persons illness that can than two persons simply talking back and forth (Bunkers, 2010).
create unpredictability and dependency on care providers. The Listening is a critical component of nursing care and is necessary
nurses presence and caring help to calm anxiety and fear related for meaningful interactions with patients (Shipley, 2010). It is a
to stressful situations (Finfgeld-Connett, 2008a, 2008b). Giving planned and deliberate act in which the listener is present and
reassurance and thorough explanations about a procedure, remain- engages the patient in a nonjudgmental and accepting manner. It
ing at the patients side, and coaching the patient through the includes taking in what a patient says and interpreting and under-
experience all convey a presence that is invaluable to the patients standing what the patient is saying and then giving back that
well-being. understanding to the patient (Shipley, 2010). Listening to the
meaning of what a patient says helps create a mutual relationship.
Touch True listening leads to truly knowing and responding to what really
Patients face situations that are embarrassing, frightening, and matters to the patient and family.
painful. Whatever the feeling or symptom, patients look to nurses When an individual becomes ill, he or she usually has a story to
to provide comfort. The use of touch is one comforting approach tell about the meaning of the illness. Any critical or chronic illness
that reaches out to patients to communicate concern and support. affects all of a patients life choices and decisions, sometimes the
Touch is relational and leads to a connection between nurse and individuals identity. Being able to tell that story helps the patient
patient. It involves contact and noncontact touch. Contact touch break the distress of illness. Thus a story needs a listener. Frank
involves obvious skin-to-skin contact, whereas noncontact touch (1998) described his own feelings during his experience with
refers to eye contact. It is difficult to separate the two. Both in turn cancer: I needed a [health care professionals] gift of listening in
are described within three categories: task-oriented touch, caring order to make my suffering a relationship between us, instead of
touch, and protective touch (Fredriksson, 1999). an iron cage around me. He needed to be able to express what he
Nurses use task-oriented touch when performing a task or pro- needed when he was ill. The personal concerns that are part of a
cedure. The skillful and gentle performance of a nursing procedure patients illness story determine what is at stake for the patient.
conveys security and a sense of competence. An expert nurse learns Caring through listening enables the nurse to be a participant in
that any procedure is more effective when administered carefully the patients life.
and in consideration of any patient concern. For example, if a To listen effectively you need to silence yourself and listen with
patient is anxious about having a procedure such as the insertion openness (Fredriksson, 1999). Fredriksson describes silencing ones
 CHAPTER 7 Caring in Nursing Practice 85

mouth and also the mind. It is important to remain intentionally choose the most appropriate and efficacious nursing therapies
silent and concentrate on what the patient has to say. Give patients (Hobbs, 2009).
your full, focused attention as they tell their stories. The caring relationships that a nurse develops over time,
When an ill person chooses to tell his or her story, it involves coupled with the nurses growing knowledge and experience,
reaching out to another human being. Telling the story implies a provide a rich source of meaning when changes in a patients clini-
relationship that develops only if the clinician exchanges his or her cal status occur. Expert nurses develop the ability to detect changes
stories as well. Frank (1998) argues that professionals do not rou- in patients conditions almost effortlessly (Benner etal., 2010).
tinely take seriously their own need to be known as part of a clinical Clinical decision making, perhaps the most important responsibil-
relationship. Yet, unless the professional acknowledges this need, ity of the professional nurse, involves various aspects of knowing
there is no reciprocal relationship, only an interaction. There the patient: responses to therapies, routines and habits, coping
is pressure on the clinician to know as much as possible about resources, physical capacities and endurance, and body typology
the patient, but it isolates the clinician from the patient. By and characteristics. Experienced nurses know additional facts
contrast, in knowing and being known, each supports the other about their patients such as their experiences, behaviors, feelings,
(Frank, 1998). and perceptions (Benner etal., 2010; MacDonald, 2008). When you
Through active listening you begin to truly know your patients make clinical decisions accurately in the context of knowing a
and what is important to them (Bernick, 2004). Learning to listen patient well, improved patient outcomes result. When a nurse bases
to a patient is sometimes difficult. It is easy to become distracted care on knowing a patient, the patient perceives care as personal-
by tasks at hand, colleagues shouting instructions, or other patients ized, comforting, supportive, and healing.
waiting to have their needs met. However, the time you take to The most important thing for a beginning nurse to recognize is
listen effectively is worthwhile, in both the information gained and that knowing a patient is more than simply gathering data about
the strengthening of the nurse-patient relationship. Listening the patients clinical signs and condition. Success in knowing the
involves paying attention to the individuals words and tone of patient lies in the relationship you establish. To know a patient is
voice and entering his or her frame of reference (see Chapter 24). to enter into a caring, social process, which results in a nurse-
By observing the expressions and body language of the patient, you patient relationship whereby the patient comes to feel known by
find cues to help the patient explore ways to achieve greater peace. the nurse (Bunkers, 2010; MacDonald, 2008).

Knowing the Patient Spiritual Caring

One of the five caring processes described by Swanson (1991) is Spiritual health occurs when a person finds a balance between his
knowing the patient. Knowing the patient comprises both the or her own life values, goals, and belief systems and those of others
nurses understanding of a specific patient and his or her subse- (see Chapter 35). Research shows a link between spirit, mind, and
quent selection of interventions (Radwin, 2000). It is essential body. An individuals beliefs and expectations have effects on the
when providing patient-centered care. Two elements that facilitate persons physical well-being.
knowing are continuity of care and clinical expertise. When patient Establishing a caring relationship with a patient involves inter-
care is fragmented, knowing the patient declines, and patient- connectedness between the nurse and the patient. This intercon-
centered care is compromised (Crocker and Scholes, 2009). nectedness is why Watson (2008, 2009, 2010) describes the caring
Knowing develops over time as a nurse learns the clinical condi- relationship in a spiritual sense. Spirituality offers a sense of
tions within a specialty and the behaviors and physiological connectedness: intrapersonally (connected with oneself), inter
responses of patients. Intimate knowing helps the nurse respond personally (connected with others and the environment), and
to what really matters to the patient. To know a patient means that transpersonally (connected with the unseen, God, or a higher
the nurse avoids assumptions, focuses on the patient, and engages power). In a caring relationship the patient and the nurse come to
in a caring relationship with the patient that reveals information know one another so both move toward a healing relationship by
and cues that facilitate critical thinking and clinical judgments (see (Watson, 2008):
Chapter 15). Knowing the patient is at the core of the clinical Mobilizing hope for the patient and the nurse.
decision-making process. Finding an interpretation or understanding of illness, symp-
Factors that contribute to knowing the patient include time, toms, or emotions that is acceptable to the patient.
continuity of care, team work of the nursing staff, trust, and experi- Assisting the patient in using social, emotional, or spiritual
ence. Barriers to knowing the patient are often related to the orga- resources.
nizational structure of the organization and economic constraints. Recognizing that caring relationships connect us human to
Organizational changes often result in decreasing the amount of human, spirit to spirit.
time that registered nurses are able to spend with their patients,
which in turn affects the nurse-patient relationships. Decreased Relieving Pain and Suffering
length of stay also reduces the interactions between nurses and Relieving pain and suffering is more than giving pain medications,
their patients (Crocker and Scholes 2009; MacDonald, 2008). repositioning the patient, or cleaning a wound. The relief of pain
Consequences of not knowing the patient are many. In the acute and suffering encompasses caring nursing actions that give a
care setting, not knowing the patient contributes to risk for falls patient comfort, dignity, respect, and peace. Ensuring that the
and actual falls (Rush etal., 2008). Patients and their families dont patient care environment is clean and pleasant and includes
understand the complexities of treatment and their participation personal items makes the physical environment a place that
in care (MacDonald, 2008). Finally, patients do not adequately soothes and heals the mind, body, and spirit (Gallagher-Lepak and
understand their discharge guidelines and may administer their Kubsch, 2009).
home medications or treatments incorrectly. By establishing Through skillful and accurate assessment of a patients level and
a caring relationship, the understanding that develops helps type of pain you are able to design patient-centered care to improve
the nurse to better know the patient as a unique individual and the patients level of comfort. There are multiple interventions for
86 UNIT 2 Caring Throughout the Life Span

BOX 7-3 NURSE CARING BEHAVIORS AS

PERCEIVED BY FAMILIES
Being honest
Advocating for patients care preferences
Giving clear explanations
Keeping family members informed
Asking permission before doing something to a patient
Providing comfort (e.g., offering warm blanket, rubbing a patients back)
Reading patient passages from religious texts, favorite book, cards, or mail
Providing for and maintaining patient privacy
Assuring the patient that nursing services will be available
Helping patients do as much for themselves as possible
Teaching the family how to keep the relative physically comfortable
FIG. 7-2 Nurse discusses patients health care needs with the
family. Data from Brown CL etal: Caring in action: the patient care facilitator role, Int J
Hum Caring 9(3):51, 2005; Radwin L: Oncology patients perceptions of quality
nursing care, Res Nurs Health 23(3):179, 2000; and Carr T: Mapping the processes
and qualities of spiritual nursing care, Qual Health Res 18(5):686, 2008.
pain relief, but knowing about the patient and the meaning of his
or her pain guides your care (see Chapter 43). Often conveying a
quiet caring presence, touching a patient, or listening helps you to Benner etal., 2010). Caring is a motivating force for people to
assess and understand the meaning of your patients pain or dis- become nurses, and it becomes a source of satisfaction when nurses
comfort. The caring presence helps you and your patient design know that they have made a difference in their patients lives.
goals for pain relief. It is becoming more of a challenge to care in todays health care
Human suffering is multifaceted, affecting a patient physically, system. Being a part of the helping professions is difficult and
emotionally, socially, and spiritually. It also affects the patients demanding. Nurses are torn between the human caring model and
family and friends. You may find yourself working with a young the task-oriented biomedical model and institutional demands that
family whose newborn baby has multiple developmental chal- consume their practice (Watson and Foster, 2003). Nurses have
lenges. Their emotional suffering encompasses anger, guilt, fear, increasingly less time to spend with patients, making it much
or grief. You cannot fix it, but you can provide comfort through a harder to know who they are. A reliance on technology and cost-
listening, nonjudgmental caring presence. Patients and their fami- effective health care strategies and efforts to standardize and refine
lies are comforted by a caring listener (Hudacek, 2008). work processes all undermine the nature of caring. Too often
patients become just a number, with their real needs either over-
Family Care looked or ignored.
People live in their worlds in an involved way. Each person experi- The American Nurses Association (ANA), National League for
ences life through relationships with others. Thus caring for an Nursing (NLN), American Organization of Nurse Executives
individual cannot occur in isolation from that persons family. (AONE), and American Association of Colleges of Nursing (AACN)
As a nurse it is important to know the family almost as thoroughly recommend strategies to reverse the current nursing shortage.
as you know a patient (Fig. 7-2). The family is an important A number of these strategies have potential for creating work
resource. Success with nursing interventions often depends on environments that enable nurses to demonstrate more caring
their willingness to share information about the patient, their behaviors. Environmental factors promote a more artful nursing
acceptance and understanding of therapies, whether the interven- and caring presence that further enhances patient-centered care
tions fit with their daily practices, and whether they support and (Finfgeld-Connett, 2008a; Hobbs, 2009). Strategies include intro-
deliver the therapies recommended. ducing greater flexibility into the work environment structure,
Families of patients with cancer perceived many nurse caring rewarding experienced nurse mentors, improving nurse staffing,
behaviors to be most helpful (Box 7-3). It is critical that the nurse and providing nurses with autonomy over their practice (Brown
ensures the patients well-being and helps the family members to etal., 2005; Watson, 2009).
be active participants. Although specific to families of patients with If health care is to make a positive difference in their lives,
cancer, these behaviors offer useful guidelines for developing a patients cannot be treated like machines or robots. Instead, health
caring relationship with all families. Begin a relationship by learn- care must become more holistic and humanistic. Nurses play an
ing who makes up the patients family and what their roles are in important role in making caring an integral part of health care
the patients life. Showing the family that you care for and are delivery. This begins by making caring a part of the philosophy and
concerned about the patient creates an openness that then enables environment in the workplace. Incorporating caring concepts into
a relationship to form with the family. Caring for the family takes standards of nursing practice establishes the guidelines for profes-
into consideration the context of the patients illness and the stress sional conduct. Finally, during day-to-day practice with patients
it imposes on all members (see Chapter 10). and families, nurses need to be committed to caring and willing
to establish the relationships necessary for personal, competent,
compassionate, and meaningful nursing care. Consistent with the
THE CHALLENGE OF CARING
wisdom and vision of Nightingale, nursing is a lifetime journey of
Assisting individuals during a time of need is the reason many enter caring and healing, seeking to understand and preserve the whole-
nursing. When nurses are able to affirm themselves as caring indi- ness of human existence and to offer compassionate, informed
viduals, their lives achieve a meaning and purpose (Benner, 2004; knowledgeable human caring (Watson, 2009).
 CHAPTER 7 Caring in Nursing Practice 87

b. Why was it important for the patient to share his or her

KEY POINTS
story?
Caring is the heart of a nurses ability to work with people in a c. What did you do that made it easy or difficult for the patient
respectful and therapeutic way. to talk with you? What did you do well? What could you
Caring is specific and relational for each nurse-patient have done better?
encounter. d. Would you rate yourself a good listener? How can you listen
For caring to achieve cure, nurses need to learn the culturally better?
specific behaviors and words that reflect human caring in dif-
ferent cultures. Answers to Clinical Application Questions can be found
Because illness is the human experience of loss or dysfunction, on the Evolve website.
any treatment or intervention given without consideration of
its meaning to the individual is likely to be worthless.
REVIEW QUESTIONS
Caring involves a mutual give and take that develops as nurse
and patient begin to know and care for one another. Are You Ready to Test Your Nursing Knowledge?
It is difficult to show caring to individuals without gaining an 1. A nurse hears a colleague tell a nursing student that she never
understanding of who they are and their perception of their touches a patient unless she is performing a procedure or
illness. doing an assessment. The nurse tells the student that from a
Presence involves a person-to-person encounter that conveys caring perspective:
closeness and a sense of caring that involves being there and 1. She does not touch the patients either.
being with patients. 2. Touch is a type of verbal communication.
Research shows that touch, both contact and noncontact, 3. There is never a problem with using touch.
includes task-orientated touch, caring touch, and protective 4. Touch forms a connection between nurse and patient.
touch. 2. Of the five caring processes described by Swanson, which
The skillful and gentle performance of a nursing procedure describes knowing the patient?
conveys security and a sense of competence in the nurse. 1. Anticipating the patients cultural preferences
Listening is not only taking in what a patient says; it also 2. Determining the patients physician preference
includes interpreting and understanding what the patient is 3. Establishing an understanding of a specific patient
saying and giving back that understanding. 4. Gathering task-oriented information during assessment
Knowing the patient is at the core of the process that nurses use 3. A Muslim woman enters the clinic to have a womans health
to make clinical decisions. examination for the first time. Which nursing behavior applies
Swansons caring process of knowing the patient?
1. Sharing feelings about the importance of having regular
CLINICAL APPLICATION QUESTIONS
womans health examinations
Preparing for Clinical Practice 2. Gaining an understanding of what a womans health exam-
1. Mrs. Lowe is a 52-year-old patient being treated for lymphoma ination means to the patient
(cancer of the lymph nodes) that occurred 6 years after a lung 3. Recognizing that the patient is modest; obtaining gender-
transplant. Mrs. Lowe is discouraged about her current health congruent caregiver
status and has a lot of what she describes as muscle pain. The 4. Explaining the risk factors for cervical cancer
unit where Mrs. Lowe is receiving care has a number of very 4. Helping a new mother through the birthing experience dem-
sick patients and is short staffed. onstrates which of Swansons five caring processes?
a. You enter her room to do a morning assessment and find 1. Knowing
Mrs. Lowe crying. How are you going to use caring practices 2. Enabling
to help her, knowing that your day has just begun and you 3. Doing for
have many nursing interventions to complete? 4. Being with
b. When you listen to Mrs. Lowe, she explains that her muscle 5. A patient is fearful of upcoming surgery and a possible cancer
pain is very bothersome and it was worse when she was diagnosis. He discusses his love for the Bible with his nurse,
alone. Both you and Mrs. Lowe determine that an injection who recommends a favorite Bible verse. Another nurse tells the
for her pain would be beneficial. In what way can you patients nurse that there is no place in nursing for spiritual
show caring in the way you administer the injection to caring. The patients nurse replies:
Mrs. Lowe? 1. Spiritual care should be left to a professional.
c. Mrs. Lowes day is getting better. She seems more comfort- 2. You are correct, religion is a personal decision.
able and is crying less. You find that your day is more 3. Nurses should not force their religious beliefs on patients.
controlled. What else can you do for Mrs. Lowe? 4. Spiritual, mind, and body connections can affect health.
2. During your next clinical practicum, select a patient to talk 6. Which of the following is a strategy for creating work environ-
with for at least 15 to 20 minutes. Ask the patient to tell you ments that enable nurses to demonstrate more caring behav-
about his or her illness. Review the skills of listening in this iors?
chapter and in Chapter 24. Immediately after your discussion, 1. Increasing the working hours of the staff
reflect on the discussion with the patient and determine if you 2. Increasing salary benefits of the staff
have enough information about him or her to answer the 3. Creating a setting that allows flexibility and autonomy for
following questions: staff
a. What do you believe the patient was trying to tell you about 4. Encouraging increased input concerning nursing functions
his or her illness? from physicians
88 UNIT 2 Caring Throughout the Life Span

7. When a nurse helps a patient find the meaning of cancer by 3. Conveys a closeness and a sense of caring.
supporting beliefs about life, this is an example of: 4. Describes being in close contact with a patient.
1. Instilling hope and faith. 13. A nurse enters a patients room, arranges the supplies for a
2. Forming a human-altruistic value system. Foley catheter insertion, and explains the procedure to
3. Cultural caring. the patient. She tells the patient what to expect; just
4. Being with. before inserting the catheter, she tells the patient to relax
8. An example of a nurse caring behavior that families of acutely and that, once the catheter is in place, she will not feel
ill patients perceive as important to patients well-being is: the bladder pressure. The nurse then proceeds to skillfully
1. Making health care decisions for patients. insert the Foley catheter. This is an example of what type of
2. Having family members provide a patients total personal touch?
hygiene. 1. Caring touch
3. Injecting the nurses perceptions about the level of care 2. Protective touch
provided. 3. Task-oriented touch
4. Asking permission before performing a procedure on a 4. Interpersonal touch
patient. 14. A hospice nurse sits at the bedside of a male patient in the final
9. A nurse demonstrates caring by helping family members: stages of cancer. He and his parents made the decision that
1. Become active participants in care. he would move home and they would help him in the final
2. Provide activities of daily living (ADLs). stages of his disease. The family participates in his care,
3. Remove themselves from personal care. but lately the nurse has increased the amount of time she
4. Make health care decisions for the patient. spends with the family. Whenever she enters the room or
10. Listening is not only taking in what a patient says; it also approaches the patient to give care, she touches his shoulder
includes: and tells him that she is present. This is an example of what
1. Incorporating the views of the physician. type of touch?
2. Correcting any errors in the patients understanding. 1. Caring touch
3. Injecting the nurses personal views and statements. 2. Protective touch
4. Interpreting and understanding what the patient means. 3. Task-oriented touch
11. A nurse is caring for an older adult who needs to enter an 4. Interpersonal touch
assisted-living facility following discharge from the hospital. 15. Match the following caring behaviors with their definitions.
Which of the following is an example of listening that displays 1. Knowing a. Sustaining faith in ones
caring? 2. Being with capacity to get through a
1. The nurse encourages the patient to talk about his concerns 3. Doing for situation
while reviewing the computer screen in the room. 4. Maintaining belief b. Striving to understand an
2. The nurse sits at the patients bedside, listens as he relays events meaning for another
his fear of never seeing his home again, and then asks if he person
wants anything to eat. c. Being emotionally there for
3. The nurse listens to the patients story while sitting on the another person
side of the bed and then summarizes the story. d. Providing for another as he or
4. The nurse listens to the patient talk about his fears of not she would do for themselves.
returning home and then tells him to think positively.
12. Presence involves a person-to-person encounter that: 12. 3; 13. 3; 14. 1; 15. 1 b, 2 c, 3 d, 4 a.
1. Enables patients to care for self. Answers: 1. 4; 2. 3; 3. 2; 4. 2; 5. 4; 6. 3; 7. 1; 8. 4; 9. 1; 10. 4; 11. 3;
2. Provides personal care to a patient.

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