Benner offers nurses a rich, holistic understanding of nursing practice and caring through the interpretation of expert nurses’ stories. After listening to nurses’ stories and analyzing their meaning, she described the essence of excellent nursing practice, which is caring. The stories revealed the nurses’ behaviors and decisions that expressed caring. Caring means that persons, events, projects, and things matter to people (Benner and Wrubel, 1989; Benner et al., 2010). It is a word for being connected.

Caring determines what matters to a person. It underlies a wide range of interactions, from parental love to friendship, from caring for one’s work to caring for one’s pet, to caring for and about one’s patients. Benner and Wrubel (1989) note: “Caring creates possibility.” Personal concern for another person, an event, or thing provides motivation and direction for people to care. Caring as a professional framework has practical implications for transforming nursing practice (Drenkard, 2008). Through caring, nurses help patients recover in the face of illness, give meaning to their illness, 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 (Gallagher-Lepak and Kubsch, 2009).

Patients are not all the same. Each person brings a unique background of experiences, values, and cultural perspectives to a health care encounter. Caring is always specific and relational for each nurse-patient encounter. As nurses acquire more experience, they typically learn that caring helps them to focus on the patients for whom they care. Caring facilitates a nurse’s ability to know a patient, allowing the nurse to recognize a patient’s problems and find and implement individualized solutions.

From a transcultural perspective, Madeleine Leininger (1991) describes the concept of care as the essence and central, unifying, and dominant domain that distinguishes nursing from other health disciplines (see Chapter 4). Care is an essential human need, necessary for the health and survival of all individuals. Care, unlike cure, helps an individual or group improve a human condition. Acts of caring refer to nurturing and skillful activities, processes, and decisions to assist people in ways that are empathetic, compassionate, and supportive. An act of caring depends on the needs, problems, and values of the patient. Leininger’s studies of numerous cultures around the world found that care helps protect, develop, nurture, and provide survival to people. It is needed for people of all cultures to recover from illness and to maintain healthy life practices.

Leininger (1991) stresses the importance of nurses’ understanding cultural caring behaviors. Even though human caring is a universal phenomenon, the expressions, processes, and patterns of caring vary among cultures (Box 7-1). Caring is very personal; thus its expression differs for each patient. For caring to be effective, nurses need to learn culturally specific behaviors and words that reflect human caring in different cultures to identify and meet the needs of all patients (see Chapter 9).

Patients and their families expect a high quality of human interaction from nurses. Unfortunately many conversations between patients and their nurses are very brief and disconnected. Watson’s theory of caring is a holistic model for nursing that suggests that a conscious intention to care promotes healing and wholeness (Watson, 2005, 2010). The theory integrates the human caring processes with healing environments, incorporating the life-generating and life-receiving processes of human caring and healing for nurses and their patients (Watson, 2006). The theory describes a consciousness that allows nurses to raise new questions about what it means to be a nurse, to be ill, and to be caring and healing. The transpersonal caring theory rejects the disease orientation to health care and places care before cure (Watson, 1996, 2008). The practitioner looks beyond the patient’s disease and its treatment by conventional means. Instead, transpersonal caring looks for deeper sources of inner healing to protect, enhance, and preserve a person’s dignity, humanity, wholeness, and inner harmony (see also Chapter 4).

In Watson’s view caring becomes almost spiritual. It preserves human dignity in the technological, cure-dominated health care system (Watson, 2006). The emphasis is on the nurse-patient relationship. The focus is on the people behind the patient and nurse and the caring relationship (Table 7-1). A nurse communicates caring-healing to the patient through the consciousness of the nurse. This takes place during a single caring moment between nurse and patient. A connection forms between the one cared for and the one caring. The model is transformative because the relationship influences both the nurse and the patient for better or for worse (Watson, 2006, 2010). Caring-healing consciousness promotes healing. Application of Watson’s caring model in practice enhances nurses’ caring practices (Box 7-2).

Kristen Swanson (1991) studied patients and professional caregivers in an effort to develop a theory of caring for nursing practice. This middle-range theory of caring was developed from three perinatal studies that interviewed women who miscarried, parents and health care professionals in a newborn intensive care unit, and socially at-risk mothers who received long-term public health intervention. All groups were in a perinatal (before, during, or after the birth of a child) setting or context and experienced the phenomenon of caring. Researchers asked each group questions regarding how they experienced or expressed caring in their situations (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 or processes (Table 7-2). Swanson (1991) defines caring as a nurturing way of relating to a valued other toward whom one feels a personal sense of commitment and responsibility. This theory supports the claim that caring is a central nursing phenomenon but not necessarily unique to nursing practice.

Swanson’s work (1991) provides direction for how to develop useful and effective caring strategies. Each of the caring processes has definitions and subdimensions that serve as the basis for nursing interventions. Nursing care and caring are crucial in making positive differences in patients’ health and well-being outcomes (Swanson, 1999a). Thus research findings develop and refine the theory and continue to guide clinical nursing practice (Andershed and Olsson, 2009). For example, Swanson (1999b) tested the effects of caring-based counseling on women’s emotional well-being in the first year after miscarrying. Caring-based counseling was significant in reducing women’s depression and anger, particularly for women in the first 4 months following miscarriage.

Nursing caring theories have common themes. Duffy, Hoskins, and Seifert (2007) identify these commonalities as human interaction or communication, mutuality, appreciating the uniqueness of individuals, and improving the welfare of patients and their families. Caring is highly relational. The nurse and the patient enter into a relationship that is much more than one person simply “doing tasks for” another. There is a mutual give-and-take that develops as nurse and patient begin to know and care for one another (Hudacek, 2008; Sumner, 2010). Caring theories are valuable when assessing patient perceptions of being cared for in a multicultural environment (Suliman et al., 2009). Frank (1998) described a personal situation when he was suffering from cancer: “What I wanted when I was ill was a mutual relationship of persons who were also clinician and patient.” It was important for Frank to be seen as one of two fellow human beings, not the dependent patient being cared for by the expert technical clinician.

Caring seems highly invisible at times when a nurse and patient enter a relationship of respect, concern, and support. The nurse’s empathy and compassion become a natural part of every patient encounter. However, when caring is absent, it becomes very obvious. For example, if the nurse shows disinterest or chooses to avoid a patient’s request for help, his or her inaction quickly conveys an uncaring attitude. Benner and Wrubel (1989) relate the story of a clinical nurse specialist who learned from a patient what caring is all about: “I felt that I was teaching him a lot, but actually he taught me. One day he said to me (probably after I had delivered some well-meaning technical information about his disease), ‘You’re doing an OK job, but I can tell that every time you walk in that door you’re walking out.’ ” In this nurse’s story the patient perceived that the nurse was simply going through the motions of teaching and showed little caring toward the patient. Patients quickly know when nurses fail to relate to them.

As you practice caring, your patient will sense your commitment and willingness to enter into a relationship that allows you to understand the patient’s experience of illness. In a study of oncology patients, one patient described a nurse’s caring as “putting the heart in it” and “having an investment” that makes “patients feel that you are with them” (Radwin, 2000). Thus the nurse becomes a coach and partner rather than a detached provider of care.

One aspect of caring is enabling, when a nurse and patient work together to identify alternatives in approaches to care and resources. Consider a nurse working with a patient recently diagnosed with diabetes mellitus who must learn how to administer daily insulin injections. The nurse enables the patient by providing instruction in a manner that allows the patient to successfully adapt diabetes management strategies such as self-medication, exercise, and diet to his own lifestyle.

Another common theme of caring is to understand the context of a person’s life and illness. It is difficult to show caring for another individual without gaining an understanding of who the person is and his or her perception of the illness. Exploring the following questions with your patients helps you understand their perceptions of illness: How was your illness first recognized? How do you feel about the illness? How does your illness affect your daily life practices? Knowing the context of a patient’s illness helps you choose and individualize interventions that will actually help the patient. This approach is more successful than simply selecting interventions on the basis of your patient’s symptoms or disease process.