The concept of caring is intertwined with nursing—some literature even states that caring and nursing are synonymous (Hayes, and Wilkin,)—and has been identified as central to the theory and practice of nurses. For many years, nurse theorists have developed theories of nursing in which caring is positioned as a major foundational element (Leininger, 1984 and Leininger, 1986, Watson, 1985 and Watson and Jackson, 2005). Efforts to theorise caring, and understand it as a concept that is able to be compatible with, and integral to, the practice of nursing, have occupied a lot of energy in nursing for a number of years, and continue to attract the attention of nurse scholars from all over the world (e.g. Finfgeld-Connett, 2008 and Sumner, 2008). The close relationship of nursing and caring is able to be seen in the many definitions and perspectives of nursing that position caring as inherent and central to the nursing role (e.g. Benner, 1984, Leininger, 1984, Sumner, 2008, Swanson, 1993, Watson, 1988 and Watson and Jackson, 2005).

Initially, the concept of caring may appear to be simple and uncomplicated, and indeed, general dictionary definitions of caring define it in simple terms. It is a generic word and one that is widely used in the general lexicon—meaning that it is not ‘owned’ specifically by nursing and nor does it apply only to nurses and nursing. However, when used in relation to nursing, the concept of care cannot be oversimplified. Terms such as nursing care and nurse caring carry certain meanings and understandings. In these contexts, care is a complex, multidimensional concept that is positioned as the characteristic that distinguishes nursing, and sets it apart from other health-related activities (Jackson & Borbasi 2000). Although a caring perspective is not unique to nursing, it is widely accepted that nursing has an essential role to care for the health of individuals, families and communities, and many believe the care given by nurses has the potential to restore health (Benner and Hooper-Kyriakidis, 1999 and Watson,).

In this chapter we introduce caring as a professional concept, and acquaint you with some of the major arguments and viewpoints associated with caring in general and nurse caring in particular. In writing this chapter we have drawn on a substantial body of international literature that reflects some of the major perspectives of nurse caring that have been published over the past 20–30 years. It is necessary to cover literature over this long period in order to develop an appreciation of the longitudinal and international nature of the debates and discussions around caring. Furthermore, you will see that many of the issues remain unresolved, and that this is one debate that will continue into (and likely even beyond) your own nursing careers.

The complexity around such a seemingly uncomplicated and simple concept such as caring can be seen when one considers the plethora of literature devoted to it. Even a cursory database search on caring will generate copious literature on the subject. Try it! Upon examining this literature you will also see that this is a discussion that has spanned generations of scholars and that each generation builds on the work of previous scholars. You will also see it reveals a multitude of definitions, and various positions on the ways that caring can be conceptualised. Several theories of nursing have been developed from the standpoint of defining and describing caring practices. Leininger (1986) believes caring is the essence of nursing, but dismisses the idea of nurses’ care motivated by a sense of duty. Rather, she considers caring as learned because it is an integral part of cultural life. However, factors within various cultures (e.g. gender) may either curtail or facilitate the use of care knowledge by nurses.

Watson (1988), another well-known luminary on the subject, writes of a science (and practice) of caring, and conceptualises caring as the ethical and moral ideal of nursing. In 1990, Rawnsley noted that caring:

If we look at feminist and nurse Falk Rafael’s (1996:3–17) work, she suggested caring could be considered either ‘ordered caring’, ‘assimilated caring’ or ‘empowered caring’ (p 4). Ordered caring she proposed as problematic for nurses because it is about merely following orders; ‘it allows only a severely limited scope of caring, one that is devoid of knowledge, power or ethics’ (Falk Rafael 1996:11). To illustrate this point, she draws on the example of the kindness and gentleness shown by nurses towards psychiatric patients as they were led towards the Nazi gas chambers. Assimilated caring was described as a form of caring in which the feminine construct of caring is grounded in (male) scientific discourses. This appropriation of a male construct is proposed as giving legitimacy to the essentially female activity of caring. Falk Rafael positioned empowered caring as the most desirable and effective form of caring. This form of caring, she asserted, was grounded within a feminist perspective, and involves the use of power, knowledge and ethics. Falk Rafael (1996) proposes the acronym of CARE (credentials, association, research, expertise) to encapsulate the elements of this empowered caring.

Another theorist you may have found through your literature searching proposed holistic caring as a form of nurse caring (Williams 1997). Williams regards this as a global concept with four dimensions that she names physical caring, interpretive caring, spiritual caring and sensitive caring. No doubt known to you, holism is a concept crucial to the effective practice of nursing, and is a term used to describe the nurse’s belief that a ‘patient is a person with social, physical, mental, and spiritual components’ (Williams 1997:61–62). Holism is positioned as central to notions of professional caring, and is so intrinsic to this, it is often taken for granted—viewed as a ‘given’, and therefore often not described or examined in discussions on professional caring. The use of a holistic perspective is said to facilitate an ethos that recognises the uniqueness and value inherent in individuals, and allows for the provision of individualised nursing care. More recently, a theory of ‘nursing as caring’ has been offered by Boykin and Schoenhofer (2001) who consider human beings as a species to be innately caring, and that reaching one’s full potential in terms of caring is a lifelong process.

Through the literature, there is general agreement about the difficulties associated with defining and positioning caring (Bassett, 2002, Paley, 2001 and Sumner, 2008). What is more, it has even been suggested that the task of rescuing the concept of caring from its elusivity is impossible, a situation Paley (2001) attributes to problematic suppositions about the nature of knowledge. Nevertheless, even accounting for the difficulties associated with defining caring, the importance of exploring how nurses have theorised and attempted to understand the elusive nature of a concept so central to their practice cannot be underestimated.

Let’s look at more of the literature. Many nurses consider caring as being primarily a relationship between nurse and others in which experiences are shared. Consider Pearson (1991:199), for example; he describes the broad, global human concept of caring as ‘investing oneself in the experience of another sufficiently enough to become a participant in that person’s experience’. Sullivan and Deane (1994) assert that nurse caring prizes human relationships, and is informed by principles of sharing, sincerity, concern and moderation. Wolf et al (1994:107) propose that nurse caring has several tangible dimensions, including ‘respectful deference to others, assurance of human presence, positive connectedness, professional knowledge and skill, and attentiveness to the other’s experience’.

In addition, caring is understood to have intellectual as well as emotional aspects (Kapborg & Bertero 2003), and in 1992 Pepin suggested two dimensions of caring: love and labour. Love is said to consist of affective (i.e. pertaining to feelings) concepts such as altruism, compassion, emotion, presence, connectedness, nurturance and comfort, and it is this aspect of caring that has dominated the nursing literature (Pepin 1992). Labour refers to the element of care related to toil and service, and encompasses roles, functions, knowledge and tasks. Though Pepin (1992) suggested that this latter dimension of caring has received much less attention in the nursing literature, a number of these issues are discussed in some depth in nursing discourses on topics such as competency and clinical expertise (e.g. Hardy et al 2002). When considering the concepts of emotion and labour it would be remiss not to mention the concept of ‘emotional labour’. This term emanated from sociology and pertains to workers who are required to display emotions that are in keeping with organisational requirements, rather than how the person—the individual nurse—truly feels (Staden, 1998 and Mann,). Research has shown this to be an under-appreciated and stressful aspect of nurses’ caring work (Henderson, 2001 and Mann,).

Upholding the theory that caring is a concept central to the practice of nurses is not only important for the profession, but is also highly significant for the recipients of that care. It makes sense that if nurses are to claim they are caring professionals, they are obliged to find out what nurse caring means to patients, and how nurses can demonstrate care for patients. Somewhat ironically it has been the more recent rise of quality improvement processes that has spearheaded the interest in patients’ views about the care they receive in healthcare settings, and this movement has not been led by nurses, but economists. Another determinant of mounting interest in patients’ satisfaction with care is the fact that patients are no longer ill informed, passive recipients of health services, but increasingly informed and active consumers who expect a certain standard of care and are not afraid to litigate should their expectations not be met.

REFLECTION

• Have you ever been a recipient of a health service?

• What approach/es do you take if the ‘care’ you receive falls short of your expectations?

• What are your expectations of ‘care’?

• Are you able to articulate them?

• If you have experienced being a patient, would you say that your perceptions of what constitutes caring were different from those you hold when you practise as a nurse or nursing student?