Definition of caring:

Caring is defined as a nurturing way of relating to a valued other towards whom one feels a personal sense of commitment and responsibility⁷. More specifically, caring is growth and health producing (nurturing) occurs in relationships (relating) to the one cared-for (a valued other); individualized and intimate (personal), with a sense of commitment (passion), accountability and duty (responsibility)¹.Together with this, nurturing is delivered as a set of interrelated processes that evolve from the nurse’s own convictions, knowledge and interaction with a patient⁷. The caring process: being with, doing for, enabling, and maintaining belief, moreover, are grounded in real nursing behaviours^8,9.

Maintaining belief:

An orientation to caring begins with a fundamental belief in persons and their capacity to get through events and transitions and face their future with meaning. Importantly, this conviction is the base or foundation to the practice of nursing care. Besides, whatever health conditions the patient is facing, a nurse believes in her/his the capacity and power to accept or welcome upcoming days with meaning. Such an orientation intensifies his/her commitment to serve humanity in general, and each patient specifically¹.

For this reason, Swanson describes maintaining belief as holding others in esteem, and believing in their ability to achieve their goal.¹⁰ It involves accepting others in high regard and more importantly with a hop-filled attitude. Meanwhile, the nurse also assists them in recapturing a positive outlook towards their experiences. Along with this, a humanistic view, harmonious balance, hope, love, compassion, and spiritual orientation, affix magnificence to the process of maintaining belief.¹¹ The recognition of a person as a spiritual being who has faith in God – a supernatural being, a life force-with a dynamic quest for a transcendent relationship, is central to the concept of maintain belief. This acknowledgement of the uniqueness and individual differences of patients help nurses to respect each and every one of them as the creation of God.^4,12

Knowing:

In knowing, one perceives events according to the meaning they have in the life of the other. It involves a thorough assessment of all the aspects of a patient’s condition and reality, engaging the self or personhood of the nurse as well as the patient, in a caring style of approach.¹ The important nursing behaviours for knowing are: a humanistic view of the other,¹² nurturing, understanding of his/her situation, analysis and interpretation, compassion, empathy, insight, academic cognition and imagination,¹³ assessment and communication skills, respect for individual differences and recognition of the other as a significant being.¹ When the process knowing occurs there develops a bond of empathy and understanding between the care provider and the care recipient.⁷

By being physically and mindfully present, in view of knowing one’s patients, a nurse displays attentiveness, commitment, deeper involvement and going beyond routine.¹⁴ While emphasizing a respectful¹⁵ and non-judgmental attitude¹⁶ towards the uniqueness of persongs,¹² knowledge of clinical practice, well developed skills in assessment, data gathering, clinical reporting, documentation, and communication – both verbal and non – verbal.^17,18 A comprehensive initial assessment is very vital to knowing. They include the assessment of physical psycho-spiritual16 and existential needs, with careful attention to patients’ perceptions, beliefs, values, wishes and family traditions. The course of knowing also includes esteem for demographic differences such as age, gender, marital status, education, and social influences from cultural backgrounds, health care experiences, length of stay, environmental and economic aresources.^12,15-19

Being with:

Being with, as well as being emotionally present conveys to patients the message that they and their experiences are significant to the nurse. Similarly, emotional presence is a technique by which the nurse shares the meanings, feelings and lived experience of the one-cared for. The nurse assures the patients of her readiness and willingness to be in their reality. it’s a side-by-side physical presence of clearly conveying one’s availability. Basically, the message is, “you are not alone, what happens to you matters to us and we are here for you”. Actually, being with, is giving time to the other for authentic presence, attentive listening and reflective responses⁴. Since being with is regarded as personal relationship, emotional adaptability and progressive availability to patients in both joyful and painful experiences, goes further than knowing⁴. Consequently, the impact of being with is measured not only by interpersonal warmth and friendly interaction but also by proficient nursing practice.²⁰ Therefore, nurses are to be interested in authentic presence as well as standard nursing practice. Moreover, sensitive and kind-hearted nursing caregivers through interpersonal compassion place themselves into the shoes of patients to get into their thoughts and feelings¹⁶.

In a nutshell, the qualities of being with include mutual trust²¹, availability, mutual linking, faithfulness, patience and compliance.^13,14 In being emotionally present, a health professional attempts to calm fears through their action of making themselves present to the patients¹⁵. As said above, being with, therefore encapsulates traits like showing interest, concern and commitment²², compassion and empathy, sympathy, honesty, sincerity and sensitivity²⁰. Additionally, other key factors in being with are protective and anticipative behaviour in avoiding harm and danger. Being with also consists of daring, being firm and doing even things that the patient does not like¹⁴.

Doing for:

The real meaning of doing for is found in the definition of nursing: The unique function of a nurse is to assist the individual, sick of well, in the performance of those activities contributing to health or its recovery (or to peaceful death) that s/he would perform unaided it s/he had the necessary strength, will, or knowledge and to do this in such a way as to help her/him gain independence as rapidly as possible²³. In other words, doing for refers to the activities in which a nurse engages with patients for what they would do for themselves if at all it were possible to them. Doing for as seen in the above definition, involves on the part of the nurse, measures that are performed on behalf of a patient’s long term welfare. They include comforting patients, anticipating their needs, performing procedures skilfully, protecting them from harm and ultimately preserving their human dignity¹.

Furthermore, such an approach also encompasses professional competence, professional attitude, professional presentation and caring capacities¹⁵. The features of professional competence take into consideration nurses’ education and training, clinical knowledge, personal qualities, enduring adjustment, learning, skill mix and self confidence.^12-15Professional competency is seen in the capacity for detecting, preventing, listening, anticipating, educating, advocating, monitoring and practicing surveillance which can produce both positive and negative outcomes. Rendering reassurance, support, comfort, acceptance, legitimacy, confidence, healing, reduction of injury and suffering also comprise the various facets of professional competency^.20-23

However, the formal sign posts to professional competency such as technical skills regarding procedures, tests and medication administration, effective management symptoms, minimising toxicity and relief of pain are form the various facets of professional competence.^14-15. The corner stone of a nurse’s professional competency is comfort giving, which includes promptness in response, listening and giving time to speak, using touch, prayer eye contact and verbal reassurance ^{24, 25}.

Enabling:

Enabling is defined as facilitating the other’s passage through life transitions and unfamiliar events⁷. As in the case of doing for, enabling fosters an environment of self-healing^26,
27. Such an enabling process enhances the patient’s capacity to heal, actualize oneself and in particular practice self-care¹¹. Moreover, self-care animated by intrinsic motivation, self determination and competence are the results of empowering¹⁵,¹⁸that means, a nurse by positively altering one’s self concept, knowledge, attitude and skill–level empowers patients in order to facilitate healing. Even more, the external environment such as provision of safety devices, removal of physical, social or emotional threats or obstacles also contribute to the healing process¹.

Here, patients are partners, with knowledge and self management skills¹⁸. The cornerstone of enabling is appropriate communication with patients and their families. This involves regular and frequent contacts with patients, qualified by empathy and sensitivity to family dynamics, cultural and religious beliefs and previous experience, along with the nature of illness²⁷. Communication also embodies providing information¹², explanation about the given care, medications, tests, and the overall condition of the patient¹⁵. Written materials, phone calls, emails, internet use, independent learning with software and counselling could also be encouraged as well in the process of enabling the patients¹⁸. Nursing care, ultimately involve enabling patients to carry out self care. The process of enabling entails training, informing, illuminating, supporting during painful experiences, guiding in issues through helping to generate alternatives, offering advice and authenticating patient reality. With regards to enabling, the objective is patient’s enduring well-being.

Research evidences:

The Carolina Care Model, based on Swanson Caring Theory, developed practices that promote patient care, at the University of North Carolina hospitals. The application of the ‘caring theory’ ensured consistently high standards of nursing performance. This style of giving care improved patients’ and families’ hospital experience and accelerated caring process and outcomes. Multi-level rounds, standardized tours for new patients, action plans that incorporated caring behaviours and model units displayed nursing innovations related to patient care. On the whole, with the implementation of Carolina Care, patient satisfaction steadily increased over 6 years. Areas that showed positive trends included concern for privacy, meeting emotional needs, attention to personal needs and pain control⁵.

Wang and Hsu describe their experience of a case study using Swanson’s Caring Theory in the care of a terminal lung cancer patient, suffering from spiritual distress. They assessed the patient’s relationship with self, others, environment and God, and found him to be distressed. Interventions such as knowing, being with, doing for, enabling and maintaining belief were applied to deal with the patient’s spiritual suffering and spiritual needs. Application of Swanson’s Caring Theory increased the understanding and compassion of nurses to their patients spiritual needs and to provide effective spiritual care²⁸.

The caring model, developed by Kristen Swanson has been incorporated in hospitals and physician practices. It has created a way for nurses to care for each other and themselves. One of the achievements in nursing units of the hospitals that adopted the Swanson’s Theory of Caring was serenity. Standards and metrics were registered into the hospitals’ production system; so too how nurses improved care, efficiency and satisfaction for patients and staffs were also tracked. The application of the theory elevated comfort level of the patients and the nurses as well, next to their safety²⁹.

CONCLUSION:

The structure of caring in ‘Swanson’s Middle Range Caring Theory’ enlightens nursing care givers on the significance of caring. Caring process and its observable and practical criterion are distinguishing humanitarian behaviours which are mandatory in nursing. The highly significant qualities that were highlighted were those of compassion, knowledge, optimism, reflection, concern and commitment, communication skills, focus on the others experience, respect for individual dignity/worth and being present to the other. If this theory could effectively used to guide clinical practice, the nurses can ensure a personal approach to care.

REFERENCES:

1. Kristen M Swanson, Nursing as Informed Caring for the Well-being of Others. IMAGE Journal of Nursing Scholarship; Volume 25, Number 4, Winter-1993,pages 352-357

2. Jean Mellott, et al. Translating Caring Theory into Practice; A Relationship Based Care Experience. Nurse Leader. October 2012(10),5;44-46,49.

3. Pamela Shellner. Relationship-Based Care: A Model for Transforming Practice. Critical Care Nurse February 2007 vol.27 no166.

4. Kalfoss, M and Owe, j.(2015) Empirical Verification of Swanson’s Caring Processes Fond in Nursing Actions; Systematic Review. Open Journal of Nursing,5,976-986.

5. Tonges M, Ray J. Translating caring theory into practice; the Carolina Care Model. The Journal of Nursing Administration, 41.(9), 374-381.

6. Lee, M., Larson, P.J and Holzemer, W.L. (2006) Psychometric Evaluation of the Modified CARE-Q among Chinese Nurses in Taiwan. International Journal for Human Caring, 10,8-13.

7. Swanson-Kauffman, K.M.(1991) Empirical development of a middle range theory f caring. Nursing Research, 40,161-166.

8. Swanson-Kauffman, K M (1986) Caring in the Instance of Unexpected early Pregnancy Loss. Topics in Clinical Nursing, 8,37-46.

9. Swanson, K.M (1990), Providing care in the NICU: Sometimes an act of love Advances in Nursing Sciences, 13910, 60-73.

10. Gail Anderson (2002). Examining the extent to which Swanson’s theory of carling and Carper’s ways of knowing can be identified in midwife –led care. Midwives magazine: October 2002 Craigavon Area Hospital Group Trust, Northen Ireland.

11. Swanson, K.M (2013) Empirical Development of a Middle Range theory of Nursing. In: Smith, M.C., Turkel, M.C and Wold, Z.R.,Eds., Caring in Nursing Classics, An Essential Resource, Springer, new York, 211-221.

12. Rinchen Pelzang. Time to learn: understanding patient-centred care. British Journal of Nursing,2010,Vol19, No 14, 912-917.

13. Lobochuk, M M Concept Analysis of Perspective Taking: meeting Informal Caregiver Needs for Communication Competence and Accurate Perception. Journal of Advanced Nursing, 2006,54:330-341.

14. Finfgeld-Connett d. meta – synthesis of caring in nursing. J Clin Nurs.2008 Jan; 17(2):196-204

15. Wagney D, Bear M. Patient satisfaction with nursing care; a concept analysis within a nursing framework. J Adv Nurs.2009 Mar;65(3):692-701.

16. Huynh T, Alderson M, Thompson m Emotional labour underlying caring: an evolutionary conept analysis. J Adv nurs.2008 Oct;64(2): 195-208.

17. Quirke, S., Coombs, M.and McEldowney, R.(2011) Suboptimal Care of the Acutely Unwell Ward Patient: A Concept Analysis. Journal of Advanced Nursing, 67, 1834-1845.

18. Kawi J.Self-Management Support in chronic illness care: a concept analysis, Res Theory Nurs Pract.2012;26(2):108-25.

19. Sue Coffey. The Nurse-patient Relationship in Cancer Care as a Shared Convenant A Concept analysis. Advances in Nursing Science vol.29, No.4,pp.308-323.

20. Tjale AA,Bruce. A concept analysis of holistic nursing care in paediatric nursing. JCurationis.2007 dec;30(4);45-52.

21. Hudon,C., St-Cyr Tribble, D., Bravo.G and Poitras. M.E (2011) Enablement in Health Care Contest: A Concept Analysis. Journal of Evaluation in Clinical Practice, 17, 143-149.

22. Brilowski, G.A and Wendler, M.C (2005) an evolutionary Concept Analysis of Caring. Journal of Advance Nursing, 50.641-650.

23. Henderson. V (1966). The nature of nursing: A definition and its implications for practice, research, and education New York: Macmillan

24. Dalpezzo, N.K (2009) nursing Care: A Concept analysis. Nursing Forum, 44, 256-264.

25. Stayer, D (2012) Pediatric Palliative Care: A Conceptual Analysis for Pediatric Nursing Practice. Journal of Pediatric Nursing. 27, 350-356

26. Nightingale, F.(1859), Notes on nursing: What it is and what it is not. London: Harrison and Sons

27. Noble, H., Kelly, D., Rawlings-Anderson, K. and Meyer.J (2007) a Concept Analysis of Renal supportive Care: The Changing Would of Nephrology. Journal of advanced Nursing, 59, 644-653.

28. Wang WP, Hsu HT Applying Swanson’s Caring Theory to Manage Spiritual Distress in a Patient with Terminal Lung Cancer. 2014 Aug;61(4):97-102.

29. NURSE.COM. Virginia Mason implements Swanson’s theory of caring on nursing units. December 17^th 2012. Available at https://www.nurse.com.

Received on 13.11.2017 Modified on 01.12.2017

Asian J. Nursing Education and Research. 2018; 8(1):173-177.

DOI: 10.5958/2349-2996.2018.00036.8