The theory of nursing as caring: A model for transforming practice
Marguerite J. Purnell
Savina O. Schoenhofer
Anne Boykin
“The nature of relationships is transformed through caring”
(Boykin & Schoenhofer, 2001a, p. 4).
Credentials and background of the theorists
Anne boykin
Anne Boykin grew up in Kaukauna, Wisconsin, the eldest of six children. She began her career in nursing in 1966, graduating from Alverno College in Milwaukee, Wisconsin. She received her master’s degree from Emory University in Atlanta, Georgia, and her doctorate degree from Vanderbilt University in Nashville, Tennessee. Dr. Boykin is married to Steve Staudenmeyer, and they have four children. Anne Boykin retired in fall 2011 and is Professor Emeritus of the Christine E. Lynn College of Nursing at Florida Atlantic University. She has relocated to Asheville, North Carolina, where she enjoys being surrounded by mountains and lakes.
Dr. Boykin is currently the Director of the college’s new Anne Boykin Institute for the Advancement of Caring in Nursing. Boykin has a longstanding commitment to the advancement of knowledge in the discipline, especially regarding the phenomenon of caring. Positions she has held in the International Association for Human Caring include president elect (1990 to 1993), president (1993 to 1996), and member of the nominating committee (1997 to 1999). As immediate past president, she served as coeditor of the journal, International Association for Human Caring, from 1996 to 1999.
Boykin’s scholarly work is centered on caring as the grounding for nursing. This is evidenced in her book (coauthored with Schoenhofer), Nursing as Caring: A Model for Transforming Practice(1993, 2001a), and her book, Living a Caring-Based Program (1994b). The latter book illustrates how caring grounds the development of a nursing program by creating the environment for study through evaluation. In addition to these books, Dr. Boykin is editor of Power, Politics and Public Policy: A Matter of Caring (1995) and coeditor (along with Gaut) of Caring as Healing: Renewal Through Hope (1994). She has written numerous book chapters and articles and serves as a consultant locally, regionally, nationally, and internationally on the topic of caring.
Savina o. schoenhofer
Savina Schoenhofer was born the second child and eldest daughter in a family of nine children and spent her formative years on the family cattle ranch in Kansas. She is named for her maternal grandfather, who was a classical musician in Kansas City, Missouri. She has a daughter, Carrie, and a granddaughter, Emma.
During the 1960s, Schoenhofer spent 3 years in the Amazon region of Brazil, working as a volunteer in community development. Her initial nursing degree was completed at Wichita State University, where she also earned graduate degrees in nursing, psychology, and counseling. She completed a PhD in educational foundations and administration at Kansas State University in 1983. In 1990, Schoenhofer co-founded Nightingale Songs, an early venue for communicating the beauty of nursing in poetry and prose. An early study made it apparent to Schoenhofer that caring was the service that patients overwhelmingly recognized. In addition to her work on caring, including co-authorship with Boykin of Nursing as Caring: A Model for Transforming Practice (1993, 2001a), Schoenhofer has written numerous articles on nursing values, primary care, nursing education, support, touch, and mentoring.
Schoenhofer’s career in nursing has been influenced significantly by three colleagues: Lt. Col. Ann Ashjian (Ret.), whose community nursing practice in Brazil presented an inspiring model of nursing; Marilyn E. Parker, PhD, a faculty colleague who mentored her in the idea of nursing as a discipline, the academic role of higher education, and the world of nursing theories and theorists; and Anne Boykin, PhD, who introduced her to caring as a substantive field of study in nursing.
Dr. Schoenhofer serves on the Ethics Advisory Committee at the University of Mississippi Medical Center, where she consults and advises on questions of ethics in clinical situations that arise in practice and health care ethics education in clinical and education settings. She is Professor of Nursing at University of Mississippi Medical Center School of Nursing in Jackson and Adjunct Professor at the Florida Atlantic University College of Nursing, Boca Raton. Dr. Schoenhofer is committed to the study of nursing as caring.
Theoretical sources
The Theory of Nursing as Caring was borne out of the early curriculum development work at Florida Atlantic University College of Nursing. Anne Boykin and Savina Schoenhofer were among the faculty group revising the caring-based curriculum. When the revised curriculum was instituted, each recognized the importance and human necessity of continuing to develop ideas toward a comprehensive conceptual framework that expressed the meaning and purpose of nursing as a discipline and as a profession. The point of departure from traditional thought was the acceptance that caring is the end rather than the means of nursing, and the intention of nursing rather than merely its instrument. This work led Boykin and Schoenhofer to conceptualize the focus of nursing as “nurturing persons living caring and growing in caring” (Boykin & Schoenhofer, 1993, p. 22).
Further work to identify foundational assumptions about nursing clarified the idea of the nursing situation as a shared lived experience in which the “caring between” (Boykin & Schoenhofer, 1993, p. 26) enhances personhood. Personhood is illuminated as living grounded in caring. The clarified notions of nursing situation and focus of nursing bring to life the meaning of the assumptions underlying the theory and permit the practical understanding of nursing as both a discipline and a profession. As critique and refinement of the theory and study of nursing situations progressed, the notion of nursing as being primarily concerned with health was seen as limiting. Boykin and Schoenhofer now propose that nursing is concerned with the broad spectrum of human living.
Three bodies of work significantly influenced the initial development of the theory. Paterson and Zderad’s (1988) existential phenomenological theory of humanistic nursing, viewed by Boykin and Schoenhofer as the historical antecedent of Nursing as Caring, was the source for such germinal ideas as “the between,” “call for nursing,” “nursing response,” and “personhood,” and it served as substantive and structural bases for their conceptualization of nursing as caring. Roach’s (1987, 2002) thesis that caring is the human mode of being finds its natural expression and domain in the assumptions of the theory. Her “6 C’s”—commitment, confidence, conscience, competence, compassion, and comportment—contribute to a language of caring (Roach, 2002). Mayeroff’s (1971) work, On Caring, provided rich, elemental language facilitating recognition and description of the practical meaning of living caring in the ordinariness of life. Mayeroff’s (1971) major ingredients of caring—knowing, alternating rhythms, patience, honesty, trust, humility, hope, and courage—describe the wellspring of human living. In the Theory of Nursing as Caring, these concepts are essential for understanding living as caring, and for coming to appreciate their unique expression in the reciprocal relationship of the nurse and the nursed.
Boykin and Schoenhofer’s conception of nursing as a discipline was influenced directly by Phenix (1964), King and Brownell (1976), and Orem (1979), and as a profession by Flexner’s (1910) ideas. In addition to the work of these thinkers, Boykin and Schoenhofer are longstanding members of the community of nursing scholars whose study focuses on caring. Their collegial association and mutual support also undoubtedly influenced the work.
Nascent forms of the Theory of Nursing as Caring were first published in 1990 and 1991, with the first complete exposition of the theory presented at a theory conference in 1992 (Boykin & Schoenhofer, 1990, 1991; Schoenhofer & Boykin, 1993). These expositions were followed by Nursing as Caring: A Model for Transforming Practice, published in 1993 (Boykin & Schoenhofer, 1993) and re-released with an epilogue in 2001 (Boykin & Schoenhofer, 2001a). Gaut points out in Boykin and Schoenhofer (2001a) that the theory is an excellent example of growth by intension, or gradual illumination, characterized by “the development of an extant bibliography, categorization of caring conceptualizations, and the further development of human care/caring theories” (p. xii).
Use of empirical evidence
The assumptions of Nursing as Caring ground the practice of nursing in knowing, enhancing, and illuminating the caring between the nurse and the one nursed. As such, rather than providing empirical variables from which hypotheses and testable predictions are made, the theory of nursing as caring qualitatively transforms practice. In the theory, persons are unique and unpredictable in the moment and therefore cannot and should not be manipulated or objectified as testable, researchable variables. Ellis believed that theories should reveal the knowledge that nurses must, and should, spend time pursuing (Algase & Whall, 1993). The Theory of Nursing as Caring reveals the essentiality of recognizing caring between the nurse and the one nursed as substantive knowledge that nurses must pursue. From this perspective, the outcomes of nursing care reflect the valuing of person in ways that communicate “value added” richness of the nursing experience (Boykin, Schoenhofer, Smith, et al., 2003, p. 225). Characteristics of personhood are essential to the theory, such as unity, wholeness, awareness, and intention. In Nursing as Caring, outcomes of nursing are articulated in terms that are subjective and descriptive, rather than objective and predictive (Boykin & Schoenhofer, 1997).
Major assumptions
Fundamental beliefs about what it means to be human undergird the Theory of Nursing as Caring. Boykin and Schoenhofer (2001a) address six major assumptions that reflect a set of values to provide a basis for understanding and explicating the meaning of nursing.
Person
One: Persons are caring by virtue of their humanness
The belief that persons are caring by virtue of their humanness sets forth the ontological and ethical bases on which the theory is grounded. Being a person means living caring, through which being and possibilities are known to the fullest. Each person throughout his or her life grows in the capacity to express caring. The assumption that all persons are caring does not require that each act of a person be caring, but it does require the acceptance that “fundamentally, potentially, and actually, each person is caring” (Boykin & Schoenhofer, 2001a, p. 2). Through entering, experiencing, and appreciating the life-world of other, the nature of being human is more fully understood. From the perspective of Nursing as Caring, the understanding of person as caring “centers on valuing and celebrating human wholeness, the human person as living and growing in caring, and active personal engagement with others” (Boykin & Schoenhofer, 2001a, p. 5).
Two: Persons are whole and complete in the moment
Respect for the person is communicated by the notion of person as whole or complete in the moment. Being complete in the moment signifies that there is no insufficiency, no brokenness, and no absence of something. Wholeness, or the fullness of being, is forever present. The view of the person as caring and complete is intentional, offering a unifying lens for being present with the other that prevents segmenting into parts such as mind, body, and spirit. Through this lens, the person is at all times whole, with no insufficiency, brokenness, or absence of something. The idea of wholeness does not preclude the idea of complexity of being. Instead, from the perspective of Nursing as Caring, to encounter a person as less than whole fails to truly encounter the person.
Three: Persons live caring, moment to moment
Caring is a lifetime process that is lived moment to moment and is constantly unfolding. In the rhythm of life experiences, we continually develop expressions of ourselves as caring persons. Actualization of the potential to express caring varies in the moment. As competency in caring is developed through life, we come to understand what it means to be a caring person, to live caring, and to nurture each other as caring. This awareness of self as a caring person brings forth to consciousness the valuing of caring and becomes the moral imperative, directing the “oughts” of actions with the persistent question, “How ought I act as caring person?” (Boykin & Schoenhofer, 2001a, p. 4).
Health
Four: Personhood is living life grounded in caring
Personhood is a process of living caring and growing in caring: It is being authentic, demonstrating congruence between beliefs and behaviors, and living out the meaning of one’s life. Personhood acknowledges the potential for unfolding caring possibilities moment to moment. From the perspective of Nursing as Caring, personhood is the universal human call. This implies that the fullness of being human is expressed in living caring uniquely day to day and is enhanced through participation in caring relationships (Boykin & Schoenhofer, 2001a).
Environment
Five: Personhood is enhanced through participating in nurturing relationships with caring others
As a process, personhood acknowledges the potential of persons to live caring and is enhanced through participation in nurturing relationships with caring others. The nature of relationships is transformed through caring. Caring is living in the context of relational responsibilities and possibilities, and it acknowledges the importance of knowing person as person. “Through knowing self as caring person, I am able to be authentic to self, freeing me to truly be with others” (Boykin & Schoenhofer, 2001a, p. 4).
Nursing
Six: Nursing is both a discipline and a profession
Nursing is an “exquisitely interwoven” (Boykin & Schoenhofer, 2001a, p. 6) unity of aspects of the discipline and profession of nursing. As a discipline, nursing is a way of knowing, being, valuing, and living in the world, and is envisaged as a unity of knowledge within a larger unity. The discipline of nursing attends to the discovery, creation, development, and refinement of knowledge needed for the practice of nursing. The profession of nursing attends to the application of that knowledge in response to human needs.
Nursing as caring focuses on the knowledge needed for plenary understanding of what it means to be human and the distinctive methods needed to verify this knowledge. As a human science, knowing nursing means knowing in the realms of personal, empirical, ethical, and aesthetic all at once (Carper, 1978; Phenix, 1964). These patterns of knowing provide an organizing framework for asking epistemological questions of caring in nursing.
Theoretical assertions
The broad philosophical framework of the theory assures its congruence in a variety of nursing situations. As a general theory, Nursing as Caring is appropriate for various nursing roles, such as individual practice, group or institutional practice, and a variety of practice venues such as acute care, long-term care, nursing administration, and nursing education.
The fundamental assumptions of Nursing as Caring underpin the assertions and concepts of the theory. They are as follows: (1) To be human is to be caring, and (2) the purpose of the discipline and profession is to come to know persons and nurture them as persons living caring and growing in caring. These assumptions give rise to the concept of respect for persons as caring individuals and respect for what matters to them. The notion of respect grounds and characterizes relationships and is the starting place for all nursing caring activities.
Dance of caring persons
The Dance of Caring Persons is a visual representation of the theoretical assertion that lived caring between the nurse and the nursed expresses underlying relationships (Figure 19–1). The egalitarian spirit of caring respect characterizes each participant in the dance of caring persons, where the contributions of each dancer, including the one nursed, are honored.
Dancers enter the nursing situation, visualized as a circle of caring that provides organizing purpose and integrated functioning (Boykin, Schoenhofer, Smith, et al., 2003). Dancers move freely; some dancers touch, some dance alone, but all dance in relation to each other and to the circle. Each dancer brings special gifts as the nursing situation evolves. Some dancers may hear different notes and a different rhythm, but all harmonize in the unity of the dance and the oneness of the circle. Personal knowing of self and other is integral to the connectedness of persons in the dance, in which the nature of relating in the circle is grounded in valuing and respecting person (Boykin & Schoenhofer, 2001a). All in the nursing situation, including the nurse and the nursed, sustain the dance, being energized and resonating with the music of caring.
Outcomes of nursing care
Outcomes of nursing care are conceptualized from values experienced in the nursing relationship, and in normative documentation, these outcomes are unacknowledged. Boykin and Schoenhofer (1997) note that it is the responsibility of the courageous advanced practice nurse to “go beyond what is currently accepted in delimiting and languaging the value expressed by persons who participate in nursing situations” (p. 63).
Logical form
The theory is presented in logical form grounded in nursing as a discipline of knowledge and a profession, and in general assumptions related to persons as caring in nursing. The theory is a broad-based, general theory of nursing rendered in everyday language. Mayeroff’s (1971) work, On Caring, and Roach’s (1987) “5 C’s” provided language that illuminated the practical meaning of caring in nursing situations.
Key concepts of caring, nursing, intention, nursing situation, direct invitation, call for nursing as caring, caring between, and nursing response are described as general assumptions, and interrelated meanings are illustrated in the model of the dance of caring persons. The direct invitation, introduced in the 2001 edition of Nursing as Caring: A Model for Transforming Practice, is an elaboration of the nursing situation and further clarifies the role of the nurse in initiating and sustaining caring responses. Story as a method for knowing focuses on nursing situations as the locus for nursing knowledge as a fluid and logical extension of the framework.
Acceptance by the nursing community
Practice
Nursing is a way of living caring in the world and is revealed in personal patterns of caring. Foundations for practice of the Theory of Nursing as Caring become illumined when the nurse comes to know self as caring person “in ever deepening and broadening dimensions” (Boykin & Schoenhofer, 2001a, p. 23). Practicing nursing within this framework requires the acknowledgment that knowing self as caring matters and is integral to knowing others as caring. This is especially important in light of practice environments that depersonalize and support the notion of the nurse as an instrument and a means to an end. Rather than nursing practice focused on activities, the lens for practice becomes the intention to know and nurture the person as caring. Often, realization of the self as caring person does not occur until the nurse articulates and shares the story of the caring transpiring in the nursing situation. When reflecting upon their caring, nurses describe “Aha!” moments, signal realizations of self as always having been caring, and rediscover freedom in caring possibilities within the nursing situation: “freedom to be, freedom to choose, and freedom to unfold” (Boykin & Schoenhofer, 2001a, p. 23). Honoring caring values in explicit ways reaffirms the substance of nursing and refreshes the caring intention of the nurse. Through the sharing of story, new possibilities arise for living nursing as caring.
Nursing service administration
In living Nursing as Caring, the nursing administrator makes decisions through a lens in which activities are infused with a concern for shaping a transformative culture that embodies the fundamental values expressed within nursing as caring. All activities of the nursing administrator must be connected to the direct work of nursing and be “ultimately directed to the person(s) being nursed” (Boykin & Schoenhofer, 2001a, p. 33). These activities include creating, maintaining, and supporting an environment open to hearing calls for nursing and to providing nurturing responses.
Boykin and Schoenhofer (2001a) point out that contrary to the perception of nurse administrators being removed from the direct care of the nursed, they are able to directly or indirectly enter the world of the nursed, respond uniquely, and assist the nurse in securing resources to nurture persons as they live and grow in caring. The nursing administrator is also able to enter the world of the nursed indirectly, through the stories of colleagues in other roles. Other activities of the nursing administrator within the interdisciplinary environment of the organization include facilitating understanding and clarity of the focus of nursing and informing other members of the interdisciplinary health care team of the unique contributions of nurses. Sharing the depth of nursing with others through nursing situations illuminates meanings and allows for fluid reciprocity among colleagues.
The work of the nurse administrator must also reflect the uniqueness of the discipline so that nursing is being reflected, portraying respect for persons as caring and extending through mission statements, goals, objectives, standards of practice, policies, and procedures (Boykin & Schoenhofer, 2001a). The following story was related by Nancy Hilton, MSN, RN, Chief Nursing Officer, at a Florida hospital. This nurse administrator, practicing from the perspective of Nursing as Caring, reflects the complexity and intentional caring expressed in living caring uniquely and courageously:
We are intentionally refocusing our culture from a traditional bureaucratic one to a person-centered, caring-based values organization. In 2007, our Nursing Councils at St. Lucie Medical Center selected the Theory of Nursing as Caring as the theoretical model to guide our nursing practice. As a Nursing Administrator, I pondered how I could intentionally ground our hospital environment, and the practice of the nurses within its walls, in a perspective of caring. I made a deliberate commitment to deepen our knowledge and awareness by allocating time for all of us to participate in dialogues focused on knowing ourselves as caring persons.
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
