1. Caring in Nursing Practice
Chapter 7
Caring in Nursing Practice
•Caring is central to nursing practice.
•Caring is the heart of a nurse’s ability to work with people in a respectful and therapeutic way.
•When rendering care, we use technology to diagnose and treat our patients.
•We must never lose sight that the patient is the center of our care.
•We must guard against depending on technological advances to the exclusion of delivering compassionate care.

2. AONE Guiding Principles for Future Care Delivery
•Fig. 7-1 (from text p. 80) presents Guiding Principles for future care delivery from the American Organization of Nurse Executives (AONE) (2005, Accessed July 3, 2011.)
•AONE describes caring and knowledge as the core of nursing, with caring being a key component of what a nurse brings to a patient experience.
•As we go through the chapter, look for ways that these principles align with other perspectives and philosophies of nursing care.

3. Theoretical Views on Caring
A universal phenomenon that influences the way we think, feel, and behave
Florence Nightingale studied caring.
In the 1980s, Patricia Benner and Benner with Judith Wrubel offered another definition of caring.
•Caring is specific and relational for each nurse-patient encounter.
•Florence Nightingale studied caring from the philosophical and ethical point of view.
•In 1984, Patricia Benner, and then in 1989, Benner and Judith Wrubel looked at caring from a more holistic perspective.
•After listening to staff nurses’ stories and analyzing their meaning, Benner described the essence of excellent nursing practice as CARING.
•This is especially important because all patients are different, and each one has his or her own background, values, and cultural perspectives.
•Important to this work, Benner and Wrubel described the relationship between health, illness, and disease.
•It is imperative that nurses listen to their patients and provide the care they need.

4. The Essence of Nursing and Health
Madeleine Leininger studied caring
from a transcultural perspective.
Caring is an essential human need.
Caring helps an individual or group
improve a human condition.
Caring helps to protect, develop,
nurture, and sustain people.
•For caring to achieve cure, nurses need to learn the culturally specific behaviors and words that reflect human caring in different cultures.
[Ask students to discuss why caring is vital to recovery from illness and to maintenance of healthful life practices.]
•Madeleine Leininger (1978) studied caring from a transcultural perspective.
[You might ask: How do the guiding principles for future care delivery from the American Organization of Nurse Executives (AONE) in Fig. 7-1 correspond to Leininger’s perspective? Encourage discussion.]

5. Cultural Aspects of Care
Implications for nursing practice:
Know the patient’s cultural norms for caring practices.
Know the patient’s cultural practices regarding end-of-life care. In some cultures, it is considered insensitive to tell the patient that he or she is dying.
[Box 7-1 (from text p. 80) is presented here and on the next slide.]
•Box 7-1 presents cultural aspects of care and nurse caring behaviors.
•Caring includes knowing the patients’ cultural values and beliefs.
•Although the need for human caring is universal, its application is based on cultural norms.
•As a result, expectations may change across cultures.

6. Cultural Aspects of Care (cont’d)
Implications for nursing practice:
Determine whether a member of the patient’s family or cultural group is the best resource to use for caring practices such as providing presence or touching.
Know the patient’s cultural practices regarding removal of life support.
[Box 7-1 (from text p. 80) continues here.]
•An example of a cultural practice that a nurse might need to be aware of is that 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 gender-congruent caregivers or the patient’s family need to provide caring touch.
•When listening to the patient, some cultures view eye contact as disrespectful.

7. Case Study
Mrs. Levine is an 82-year-old patient diagnosed 2 months ago with lymphoma, a cancer of the lymph tissue. She has been experiencing weakness and fatigue. Over the past 4 weeks, she has lost 8 pounds.
Mrs. Levine had been relatively independent before her diagnosis, playing bridge each week with friends and going to lunch with fellow church members. But now, she has much less energy to do the things she enjoys.
[This Case Study continues throughout this slide presentation. Encourage discussion of the care Mrs. Levine will need, and how her needs relate to the nursing philosophies and perspectives that have been presented in the chapter thus far.]
•What do you see will be the challenges for Mrs. Levine? [Discuss.]

8. Transpersonal Caring Jean Watson’s theory of caring (1988, 1979)
Promotes healing and wholeness
Rejects the disease orientation to health care
Places care before cure
Emphasizes the nurse-patient relationship
•Because illness is the human experience of loss or dysfunction, any treatment or intervention given without consideration of its meaning to the individual is likely to be worthless.
•According to Watson, caring becomes almost spiritual. (See Box 7-2 on text p. 82 for Evidence-Based Practice: Enhanced Caring.)
•Look at Table 7-1 (on text p. 81) for Watson’s 10 curative factors.

9. Swanson’s Theory of Caring
Kristen Swanson (1991)
A composite of three studies in a perinatal unit
Defines caring as a nurturing way of relating to a valued other, toward whom one feels a personal sense of commitment and responsibility
•Caring involves a mutual give and take that develops as nurse and patient begin to know and care for one another.
•Swanson’s theory supports the claim that caring is a central nursing phenomenon that is not unique to nursing.
•Table 7-2 (on text p. 82) presents the five categories or processes:
•Knowing
•Being with
•Doing for
•Enabling
•Maintaining belief
[You might ask: How does Swanson’s theory of caring compare with Leininger’s perspective? With Watson’s? with the guiding principles for future care delivery from the American Organization of Nurse Executives (AONE) from Fig. 7-1? Encourage discussion.]

10. Case Study (cont’d)
Mrs. Levine’s son, Jim, lives only a few miles away and is a consistent resource when she needs transportation to the physician or trips to the grocery store. 
She will begin a research protocol for chemotherapy treatments this week at the oncology clinic.
[You might ask: Based on what we know so far, how important do you think Jim’s relationship and interaction with his mother will be in the weeks to come? Encourage discussion.]

11. Patient’s Perspective of Caring
Patients value the affective dimension of nursing care.
Reassuring presence
Recognizing an individual as unique
Keeping a close and attentive eye
on the situation
•It is difficult to show caring to individuals without gaining an understanding of who they are and their perception of their illness.
•All patients are unique. You need to know who your patients are.
•You will need to understand their culture and ethnicity (more on this in Chapter 9).
•Table 7-3 (on text p. 83) presents comparison research studies exploring nurse caring behaviors as perceived by patients.
•As you begin to learn how to render care to your patients, it will be important to consider how patients perceive caring and what approaches work best when providing care.

12. Ethic of Care
Concerned with the relationship between the patient and the nurse and the attitude of each toward the other
Places the nurse as the patient’s advocate who solves ethical dilemmas by creating a relationship
Gives priority to each patient as a unique being
•When we care for others, we preserve their dignity.
•It is important that nurses practice ethical standards for good conduct, character, and motives.
•Practicing ethics (more on this in Chapter 23) is essential for nursing practice.
•The ethic of care is essential so that professional nurses do not make professional decisions based solely on intellectual or analytical principles.

13. Case Study (cont’d)
Sue is a nurse who has worked in the oncology clinic for over 10 years. She enters the examination room where Mrs. Levine is waiting, introduces herself, and sits down next to her patient. 
Sue states, “Mrs. Levine, I am here to understand your story. I want to listen and learn how I can best help you.” Sue uses eye contact while talking and leans toward Mrs. Levine to establish a physical presence. Mrs. Levine nods, smiles, and begins her story.
[You might ask: How important do you think Sue’s initial meeting and interaction with Mrs. Levine will be as this case unfolds?
And, what clues do we have that Sue is conscious of the importance of this first meeting? Encourage discussion.]

14. Providing Presence Being with Eye contact Body language Tone of voice
Listening
Positive and
encouraging attitude
•Establishing presence will be every important, especially when a patient experiences a stressful event or situation.
•A nurse’s presence helps to calm anxiety and fear. This will be especially important when you explain a procedure to patients and family members.

15. Caring in Nursing Practice
Behaviors include being present, providing a caring touch, and listening.
Caring is a product of culture, values, experiences, and relationships with others.
• Presence involves a person-to-person encounter that conveys closeness and a sense of caring that involves “being there” and “being with” patients.
[You might ask students: Is caring teachable, or is it a way of being? This is a hard question because experts do not agree on this issue.]
•If you did not receive care earlier in life, maybe you will have a hard time caring now.

16. Case Study (cont’d)
Mrs. Levine explains, “I have had a good life. I just don't know what is going to happen. The doctor tells me the cancer is serious. I worry about what is going to happen to me and how it will affect my son, Jim. I do not want to become a burden to him.” 
Sue responds in a calm, soothing tone, “Mrs. Levine, your concerns are very normal. It is important for you to remain as independent as possible. Let’s talk about how we can do that.”
[You might ask: How do you think this initial interaction between Sue and Mrs. Levine is going? Name three things that Sue has said or done in this initial meeting that indicate how her nursing care will be a positive and integral part of Mrs. Levine’s care.]

17. Touch Provides comfort Creates a connection Contact touch
Noncontact touch
Protective touch
Task-oriented touch
•Research shows that touch, both contact and noncontact, includes task-oriented touch, caring touch, and protective touch.
•Contact touch is a form of nonverbal communication that provides comfort and security.
[Ask students what contact touch might involve. Answer: holding a hand or giving a back rub.]
•Noncontact touch refers to eye contact.
•Protective touch is used to protect a patient, for example, to prevent or stop a fall.
•Task-oriented touch is used when performing a procedure or task.

18. Quick Quiz!
1. A female patient has just found a large lump in her breast. The physician needs to perform a breast biopsy. The nurse helps the patient into the proper position and offers support during the biopsy. The nurse is demonstrating A. Enabling. B. Comforting. C. A sense of presence. D. Maintaining belief.
Answer: C [Discuss.]

19. Case Study (cont’d)
Mrs. Levine has consistently relied on her son, Jim, to provide caregiving support by assisting with transportation and being a day-to-day resource. Jim brings his mother to the outpatient oncology clinic for her first chemotherapy infusion.
The total treatment will last for approximately 5 hours. Sue invites Jim to sit in the treatment area with his mother.
[Pose the following to students.]
•As Sue prepares to administer the chemotherapy, identify three ways that she can demonstrate to Jim her caring for Mrs. Levine.

20. Listening Creates trust Opens lines of communication
Creates a mutual relationship
•Listening is not only “taking in” what a patient says; it also includes interpreting and understanding what the patient is saying and giving back that understanding.
•Listening is an art form that must be developed.
•Indicates that you have your patient’s full attention.
•Listening leads to knowing and responding to what really matters to the patient and family.
•Although it can be difficult at times, nurses must strive to practice active listening.
•In Chapter 24, we will take a more in-depth look at the communication process.

21. Knowing the Patient Develops over time
The core process of clinical decision making
Aspects of knowing include:
Responses to therapy, routines, and habits
Coping resources
Physical capacities and endurance
•Knowing the patient is at the core of the process that nurses use to make clinical decisions.
•The skillful and gentle performance of a nursing procedure conveys security and a sense of competence of the nurse. This is one of the five caring processes identified by Swanson.
•It is important to recognize that knowing a patient involves more than simply gathering data regarding your patient’s signs and symptoms.
•Getting to know a patient is the bonding stage. It makes it possible for the relationship to evolve into “working” and “changing” phases so you can help your patients become involved in their own care and ask for and accept help when needed.

22. Case Study (cont’d)
Outside of the treatment room, Jim asks, “How will my mother respond to this chemotherapy? What should we be expecting?”
Based on Swanson's theory of caring, what might be an appropriate response on Sue's part in “maintaining belief”?
•Before we attempt to answer the question in this section of the Case Study, let’s review Swanson’s theory of caring.
•Table 7-2 presents the five categories or processes of Swanson’s theory of caring: Knowing, Being with, Doing for, Enabling, and Maintaining belief.
•The definition of “maintaining belief” is as follows: Sustaining faith in another’s capacity to get through an event or transition and face a future with meaning.
•The subdimensions for maintaining belief include: Believing in/holding in esteem, Maintaining a hope-filled attitude, Offering realistic optimism, and “Going the distance.”
[After reviewing Swanson’s theory, ask for responses to the Case Study question. Encourage student discussion.]

23. Spiritual Care
Spiritual health is achieved when a person can find a balance between his life values, goals, and belief symptoms and those of others.
Spirituality offers a sense of interpersonal and transpersonal connectedness.
•Sometimes you may have a personal problem in dealing with spirituality, which needs to be addressed at the personal level.
•An intrapersonal relationship is when persons are connected to themselves.
•An interpersonal relationship exists when one is connected with others and the environment.
•A transpersonal relationship exists when one is connected with God, an unseen force, or a higher power.
•In Chapter 29, we will further discuss spiritual health.

24. Family Care
A nurse discusses a patient’s health care needs with his family.
•The skillful and gentle performance of a nursing procedure conveys security and a sense of competence in the nurse. (This is Fig. 7-2 from text p. 86.)
•Box 7-3 (on text p. 86) presents nursing care behaviors as perceived by families.
•People experience life through relationships with others.
•Caring does not occur in isolation from a patient’s family. Family is an integral resource.
•When you care for patients, you will also care for their families.
•Families will seek and require information so they feel a part of the care, treatment, and decisions.
•In Chapter 10, we will look at caring for families.

25. Case Study (cont’d)
Three hours into the infusion, Mrs. Levine asks Sue for a glass of water and begins to talk about her pet cat and her desire to return home and be able to visit with one of her bridge partners tomorrow. Sue has another patient down the hall who has an infusion that has been under way for about an hour.
What should Sue do to show her caring for Mrs. Levine?
•Let’s review the key points of this chapter before we formulate a response to the Case Study question.
•Caring is the heart of a nurse’s ability to work with people in a respectful and therapeutic way.
•Caring is specific and relational for each nurse-patient encounter.
•For caring to achieve cure, nurses need to learn culturally specific behaviors and words that reflect human caring in different cultures.
•Because illness is the human experience of loss or dysfunction, any treatment or intervention given without consideration of its meaning to the individual is likely to be worthless.
•Caring involves a mutual give and take that develops as nurse and patient begin to know and care for one another.
•It is difficult to show caring to individuals without gaining an understanding of who they are and what is their perception of their illness.
•Presence involves a person-to-person encounter that conveys closeness and a sense of caring that involves “being there” and “being with” patients.
•Research shows that touch, both contact and noncontact, includes task-oriented touch, caring touch, and protective touch.
•The skillful and gentle performance of a nursing procedure conveys security and a sense of competence of the nurse.
•Listening is not only “taking in” what a patient says; it also includes interpreting and understanding what the patient is saying and giving back that understanding.
•Knowing the patient is at the core of the process that nurses use to make clinical decisions.
[After reviewing the Key Points, ask for responses to the Case Study question. Encourage student discussion.]

26. Quick Quiz!
2. When a nurse enters a patient’s room and says “Good morning” before starting care, the nurse combines nursing tasks and conversation. An important aspect of care for the nurse to remember is the need to A. Establish a relationship. B. Gather assessment data. C. Treat discomforts quickly. D. Assess the patient’s emotional needs.
Answer: D [Discuss.]

27. The Challenge of Caring
Task-Oriented Care
Technology
Improved Nurse-to-Patient Ratios
•When nursing students are asked why they want to become nurses, many students answer that they want to care for others, they want to help people. Many just want to be able to make a difference in their patients’ lives.
•Strategies to overcome challenges:
•Work with a mentor, get involved in a new grad program, improve nurse-to-patient ratios, and learn to increase autonomy.
•Most important, you will need to be committed to caring and willing to establish relationships necessary for personal, competent, compassionate, and meaningful nursing care.