Janice M. Morse

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RESEARCH USING PRAGMATIC UTILITY

                Researchers who disagree about facts will often use concepts in different ways, rightly so. After all concepts are not designed to “fit” the facts as researchers see them … if vagueness and ambiguity cannot be avoided, they must be brought out into the open whenever that is possible, to prevent necessary confusion.

—Wim J. van der Steen (1993, p. 11)

Pragmatic utility is a meta-analytic and interpretative technique for eliciting the complex meanings within concepts. This means two things. First, because it is a meta-analytic technique, it uses a large amount of data. By this I mean a quantity of good professional theoretical and research articles, and because many people have used the concept that you are studying, it must fit the criteria for partially mature or mature. Second, because it uses interpretative methods of inquiry, it provides new insights, new perspective, and new understanding of the concept(s) being explored. In other words, it is an activity worth doing, as it provides understanding and insights that moves the field along—which is what research is all about.

Other authors say it is hard; they say that when doing pragmatic utility it is difficult to follow from instructions available (Weaver & Mitcham, 2008). I hope the additional information in this book corrects that shortcoming. Others whisper that the process is exhausting, but finishing is exhilarating. And others complain that it gives them a headache. Nothing comes easy. At graduate school you are paying to learn to think.

EXAMPLE I: CONCEPT CLARIFICATION INSIDE A CONCEPT: THE CONCEPTUALIZATIONS OF CARING AND CARING AS A CONCEPT¹

The problem, in 1990, was that the concept of caring was elusive and confusing. Beyond the obvious dual definitions of caring as an action (to care for) and caring as an affect (a feeling of endearment), there was no consensus in nursing regarding a definition of caring, nor the components of care, nor the process or the outcomes of caring.² There was no discussion, debate, or even comment in the literature on the lack of clarity or differences in perspectives between authors. For instance, care, caring, and nursing care were used interchangeably. Although care or caring may specify the actions performed, as “to take care of” or to exhibit concern, as in “to care about,” these differences in meaning were ignored. Morse and her colleagues argued that if caring was to be retained as the “essence of nursing” and if research was to advance as a caring profession, then caring as a concept must be clarified and the strengths and limitations of the conceptualizations identified (Morse, Bottorff, Neander, & Solberg, 1991; Morse, Solberg, Neander, Bottorff, & Johnson, 1990). The purpose of this research therefore, was in the area of concept clarification, using the method of pragmatic utility.

Literature as Data

The major nurse theorists and researchers who had authored articles on caring were identified, and their literature carefully read and coded. Major references included in the analysis are listed in Box 18.1.

Definitions of caring were delineated and analyzed. Content analysis of 25 of these definitions revealed five different perspectives on the nature of caring, not according to the major focus of the theory, but rather according to the basis from which the perspective was derived. When caring was not explicitly defined, theoretic perspectives were identified and classified from examination of research approaches and their underlying assumptions. For example, Stevenson (1990) reviewed the quantitative literature and sampled all nursing articles that used care in the title, thus implying that care is inherent in all nursing procedures. On the other hand, Aamodt (1994) explored care from the patient’s perspective, implying that care is a concept that is reflected in nursing behaviors and is recognizable by the patient. When the conceptualization of caring was described as a process, the explicit or implied linkages are shown on arrows (see Figure 18.1). For example, Forrest (1989) and Fanslow (1987) view caring as an affect, do not consider outcomes, and therefore their perspective remains within the affect category. These categories are not intended as rigid or inflexible sales, nor is any value judgment intended as to the appropriateness or inappropriateness of the derivations of the conceptualizations. They are merely identified to clarify aspects inherent in the complexity of the literature rather than to imply causal relationships.

The five categories of caring identified were caring as a human trait, caring as a moral imperative or ideal, caring as an affect, caring as an interpersonal relationship, and caring as a therapeutic intervention. In addition to these, two outcomes that were identified were: caring as the subject of experience of the patient and caring as a physical response. In each case, the decision to classify a different definition was based on the theorist’s epistemological perspective. If the theorist viewed caring as a process and described the means and outcome of caring, or the changing nature of the caring relationship, then pathways linked these categories (as shown in Figure 18.1). For example, Leininger (1978, 1981a, 1981b, 1984a, 1984b, 1988, 1995, 2002) reiterates that humans are caring beings and that caring is a universal trait vital to human survival; therefore, this definition was categorized with those who purported that caring is a human trait. The examples of care constructs identified by Leininger are behavioral attributes representative of caring; consequently her definition of caring extends from the human-trait category to “the direct (or indirect) nutrient and skillful activities related to the assisting people” (1984a, p. 4) or the therapeutic intervention category. (For further illustration of this analysis, see Morse, Bottorff, Neander, & Solberg, 1991, pp. 120–121).

Caring as a Human Trait

From this perspective, caring is an innate human trait, the “human mode of being.” Although all humans have the potential to care, this ability is not uniform. Roach (1987) suggests that one’s own experience of being cared for and expressing caring influences one’s ability to care. The nurse’s educational experience professionalizes this caring to the acquisition of knowledge and skills. Despite this assertion that one’s ability to care is influenced by life experiences, being cared for, and expressing caring, this relationship has yet to be examined by exploring the early experiences of nurses. Leininger (1995) states that diverse expressions, meanings, and modalities of caring are culturally derived. Attributes of professional caring, such as Roach’s (1987) dimensions of compassion, competence, confidence, conscience, and commitment, or Leininger’s (1984a) 55 curative constructs, are derived from or have their locus in caring. According to these definitions, the human trait of caring is the motivator of nursing actions.

Caring as a Moral Imperative or Ideal

Authors who considered caring as a moral imperative considered caring to be a “fundamental value” or a moral ideal in nursing. For example, Gadow (1985) and Watson (1985, 1988a) suggest that the substantive base of nursing is preserving the dignity of patients. From this perspective, caring is not manifest as a “set of identifiable behaviors” (Fry, 1989, p. 48), images, or traits evident in the caring nurse (e.g., sympathy, tenderness, or support; Gadow, 1985), nor does it encompass all that nurses do. Rather, caring is the adherence to the commitment of maintaining the individual’s dignity or integrity. In contrast to Gadow’s realistic and attainable view or praxis, Watson suggested that caring actions revealed in the nurse–patient relationship are merely “approximations of caring” (Watson, 1985, p. 34).

In agreement with the theorists who adhere to the human-trait perspective, theorists who describe caring as a moral imperative concur that caring provides the basis for all nursing actions. Thus, the environment in which nurses work must facilitate and support caring. Paradoxically, nurses are caught in a dilemma created by a mandate to care in a society that does not value caring (Reverby, 1987). Nurses are expected to care for others as a duty (i.e., to be altruistic), yet without professional autonomy (i.e., they are unable to exercise their right to control their own practice). Fry (1989) notes that if, as a profession, nursing holds caring as a moral ideal, and present working conditions increasingly limit the opportunity to care (for instance, unsafe staffing conditions persist), then the survival of the profession remains in question.

Caring as an Affect

Authors who define caring as an affect emphasize that the nature of caring extends from emotional involvement with or an empathetic feeling for the patient experience (Bevis, 1981; Forrest, 1989; Fanslow, 1987; Gendron, 1988; McFarlane, 1976). For example, McFarlane (1976) states that caring “signifies a feeling of concern, of interest, of oversight with a view to protection.” Bevis (1981) considers caring to be a feeling of dedication, a feeling that motivates nursing actions. It is a response that is primarily based on increasing intimacy between the nurse and the patient, and this, in turn, enhances mutual self-actualization. Self-actualization consists of four developmental stages: attachment, assiduity, intimacy, and confirmation. The nurse is moved to act selfishly without immediate gratification or the expectation of material reward.

Caring as It Is Manifest in the Nurse–Patient Relationship

Authors who write from this perspective believe the interaction between the nurse and the patient expresses and defines caring. Caring encompasses both the feeling and behaviors occurring within the relationship (Horner, 1998). For example, the relationship (i.e., the feeling) and the content (i.e., the behavior) of caring include such specific aspects as “showing concern” and “health teaching,” touch, being there, and technical competence (Knowlden, 1988). Alternatively, these may be manifest in the supportive relationships nurses have with their patients (Gardner & Wheeler, 1981).

Caring as a Therapeutic Intervention

By defining specific nursing interventions or therapeutics as caring (Stevenson, 1990) or by describing conditions as necessary for caring actions (Gaut, 1986), these theorists have linked caring more directly than others with the work of nurses. Caring actions may be specific, such as attentive listening, patient teaching, patient advocacy, touch, “being there,” and technical competence (Brown, 1986; Larson, 1984; Wolf, 1986) or caring may include all nursing actions (e.g., all nursing procedures for interventions; Stevenson, 1990) that enable or assist patients (Mayer, 1986). Emphasis is placed on the necessity for adequate knowledge and skill as a basis for these caring actions as well as on the congruence between nursing actions and the patient’s perception of need.

Outcomes of Care and Caring

Rather than studying the concept of care and caring, some researchers have examined the concept of care by exploring patient physiological or psychological outcomes. This perspective is primarily used by those researchers who focus on quality assurance and use physiological outcomes as indicators of care (e.g., injuries from patient falls). For example, these outcomes may be the level of care determined by using selected statistical indices, such as morbidity and mortality statistics, length of stay in hospital, or the number of patient incident reports, thus removing the indicators of care to the group level. Alternatively, researchers and auditors may use physical examination to observe for the absence of indicators of poor care, such as skin conditions (pressure ulcers and abrasions), poor muscle tone, or even the patient’s state of hygiene, to ensure that an individual patient has been cared for. The patient’s subjective responses to care are also a part of these quality assurance programs.

COMPARING THE CONCEPTUALIZATIONS AND THEORIES OF CARE

The next phase was to explore the implications of these diverse conceptualizations of caring for nursing practice and examine the commonalties, strengths, and weaknesses of each perspective. This is conducted by sorting all the caring articles into the five definitions of caring (identified in the previous stage), and comparing and contrasting articles in each perspective by asking analytic questions.

The analytic questions regarding the focus of care are:

Analytic Questions Regarding Authors’ Perspective of Care

As stated, the analytic questions that are asked at this stage are crucial for the validity and significance of the study. But where do these questions come from?

Analytic questions are created by extensive reading of the literature and “reading between the lines,” and by reading interpretatively behind the text. In this study, we identified the following:

Preparing a Matrix

Next, on a large sheet of paper (4 foot by 6 foot),³ we made a large grid. The analytic questions related to the different types of care were placed on the top row of the chart. The authors’ name and date of the publication were placed on the left hand row. We prepared a matrix by drawing the rows and columns on the paper, and filled in the matrix by answering the analytic questions from the perspective of each author.

As the analysis proceeded, additional characteristics emerged and raised questions that further illustrated the diversity of conceptualization of caring among theorists. These characteristics included the uniqueness of caring in nursing, the constant or varying nature of the caring capacity of nurses, whether caring may be reduced to behavioral tasks, and whether the outcome of caring influences or affects the nurse, the patient, or both. These results are presented in Table 18.1.

Is Caring Unique to Nursing?

This question is critical if caring is to attain and/or retain a central position in the development of nursing theory. Surprisingly, there is disagreement among nurse theorists regarding the uniqueness of caring in nursing. Although some agree that caring is unique in nursing, several theorists (Benner & Wrubel, 1989; Bevis, 1981; Fry, 1989; Horner, 1998) do not consider caring to be unique in nursing. For example, Benner and Wrubel (1989) state, “Caring practices are lived out in this culture primarily in parenting, child care, nursing, education, counseling and various forms of community life” (p. 408). Others, including Bevis (1981), Fry (1989), and Horner (1998), emphasize the universality of caring as opposed to attempting to identify the unique characteristics of caring in nursing.

Does the Caring Intent of Nursing Vary?

This question considers whether caring is a constant and unchanging motivator within the nurse regardless of characteristics of the patient. Again, several theorists agree that the intent to care changes according to the patient’s characteristics or other variables. This position has received some support from Kahn and Steeves’s (1988) study of the meaning of the caring relationship for nurses. Although the majority of the informants (who were nurses) believed that caring should be an unconditional aspect of nursing, they provided many examples that indicated that caring depended upon “having enough time, getting along with each other and not having too many other demands” (p. 213). Examples in this study showed that nurses found it easier to care for patients whom they liked. The authors stated “nurses indicated that those patients who made it easier for them to do the caring activities, to engage in praxis, more readily elicited caring” (p. 214). Nurses have also reported that patients use strategies, including giving manipulative gifts and using behaviors, such as making themselves “no trouble,” so that nurses will be more willing to care for them during their illness (Morse, 1991b). Watson (1988b) advocates that whereas caring at the “surface level” may vary in relation to situational factors, caring in nursing at the moral and philosophical level “is underpinned by a moral stance that goes beyond the like or dislike of a patient … to touch the human center of the person” (p. 218). Thus, from this perspective, caring is held as a moral ideal in nursing; then the forms of caring may vary due to external constraints, such as the amount of time the nurse and patient have together, while the caring intent remains constant.

Can Caring Be Reduced to Behavioral Tasks?

If caring is to be considered measurable and intervention studies and evaluation research developed, this question is critical. Theorists who view caring as a moral ideal unanimously agree that caring is not reflected in a set of techniques but provide the stance from which one intervenes as a nurse, thereby influencing judgments, decision making, and action. Brody (1988) states, “It is not just the competent performance of technical skills that evokes the image of caring, but the compassionate attitudes and feelings of the nurses toward the patient as they perform their tasks that is the essence of caring” (p. 92). With the exception of McFarlane (1976), theorists who view caring as an affect do not consider the behavioral tasks of nurses as characteristic of caring: “Caring involvement and interaction incorporates on the part of the nurse a preference for ‘being with’ rather than ‘doing to’ a patient” (Forrest, 1989, p. 818). Not surprisingly, all the theorists who were included in the therapeutic intervention category considered caring as specific nursing actions. These actions were both indicators of caring and evidence that caring had taken place. Some of these theorists were quite specific in the delineation of caring tasks (Brown, 1986; Orem, 1985), whereas others used a more global approach (Leininger, 1981a, 1988; Swanson-Kauffman, 1988).⁴

Does the Outcome of the Caring Affect the Patient, the Nurse, or Both?

With the exception of the theorists who view caring as a therapeutic intervention, there was no clear pattern in the caring outcomes for either the nurse or the patient. Nurse outcomes that were identified included personal enrichment (Benner & Wrubel, 1989), increased understanding, emotional capacity, sense of personal worth (Griffin, 1983), and increased emotional burdens (Forrest, 1989). When mutual outcomes are discussed these theorists indicate that both the nurse and patient experience self-actualization (Bevis, 1981), enhanced subjectivity (Gadow, 1985), or increased spirituality (as reflected by Watson, 1988a). Watson states: “In a transpersonal caring relationship a spiritual union occurs between the two persons where both are capable of transcending self, time, space and the life history of each other” (p. 66). On the other hand, theorists who describe the outcomes of caring in terms of patient responses include enhanced health, well-being, comfort, self-integration, and patient satisfaction. For these theorists, the goal of caring would be to affect a desirable outcome in the patient. That outcome could be in terms of a subjective experience on the part of the patient or some actual physical response that could be measured. For example, Gaut (1986) operationalizes her conceptualization of caring with an example; that is, ensuring a patient recovering from surgery is adequately hydrated. The different qualities of power associated with caring are emphasized by Benner (1984). Some qualities—the transformative, integrative, advocacy, and healing qualities of the power of caring—have a direct bearing on patient outcomes. For instance, nurses who cared for patients with prolonged and permanent disabilities have been instrumental in “assessing the importance of helping the patient to continue with normal activities to minimize the isolation, loss of meaning and inactivity … [and nurses have] offered the option of reintegration by providing the patients and families with new possibilities in the midst of deprivation and loss” (p. 211). On the other hand, the power of creative problem solving associated with caring provides effective care and indirectly influences patient outcomes. The power of caring has not been recognized fully by nurses who see their caring role as a source of their powerlessness; yet, as argued by Benner (1984), any definition of power for nursing must include the power that resides in caring.

DISCUSSION ON CARING AS A CONCEPT

If caring is the “essence of nursing,” then the issue of which theoretical perspective of caring is most descriptive of this essence is vital. Given the present diversity in the conceptualizations of caring, all of the attempts to delineate caring may have some application to the central paradigm of nursing. Presently, the concept is poorly developed, and as a result it may not be comprehensive enough to encompass all the components of caring that are necessary to guide clinical practice. There remains a loose link between many definitions of caring and patient outcomes. In particular, the previously unspoken controversy concerning whether caring may be reduced to behavioral tasks and the underdeveloped links to specific patient outcomes form the Achilles heel of caring theory. If the relevance of caring to practice and to the patient cannot be clearly explicated, or if it is claimed that caring cannot be reduced to behavioral tasks, nursing will no longer be a practice discipline. Either the central core of nursing will need to be reformulated or the gap between theory and practice will be widened to insurmountable proportions.⁵

This analysis of caring was conducted two decades ago. At this time it is considered still to be significant, and is still cited—even though some of the caring theorists included in this analysis have gone on to develop their theory further, some in new directions, others to clarify or to expand their original perspectives. Others have not written anything further, and still others have appeared on the horizon—a new cadre of nurse theorists. Nevertheless, the purpose here was to illustrate the power of pragmatic utility and to illustrate the backstage cognitive processes used in making decisions regarding the categories developed, so that others may also use the technique.

EXAMPLE II: CONCEPT CLARIFICATION: ACCOUNTING FOR STRATEGIES OF EMPATHETIC COMFORTING⁶

At this point we became interested in empathy as a strategy for expressing caring and providing comfort. Of course, empathy is a scientific concept and therapeutic strategy. It has been carefully defined, yet when we examined the major literature using pragmatic utility, we found four components: moral, cognitive, emotive, and behavioral (see Table 18.2). Each component was based on slightly different assumptions, and used slightly differently.

However, we were not content. We felt, as clinicians, this analysis did not provide us with anything very surprising. Although empathy was extremely helpful in the psychiatric settings in nursing (where nurses had the opportunity to counsel patients), in the “regular medical-surgical settings,” with the exceptions of emotive empathy, other “empathetic responses” were used on a day-to-day basis. But these other concepts that were linked to empathy as empathetic responses were considered with varying degrees of “therapeutic-ness.” For instance, compassion is considered therapeutic, but sympathy and pity are not considered therapeutic, and their use is even actively discouraged.

Patient Engagement

Underlying our analysis was the concept of engagement, or the identification of the caregiver with the sufferer’s experience (see Gadow, 1980, 1984, 1989). Removed from the experience of suffering, the caregiver is not usually consciously aware of his or her own body. However, observing a patient suffering causes distress in the nurse and, consequently, awareness of his or her own body. Thus, the nurse was engaged with the patient’s experience of suffering so that the patient’s suffering is embodied by the nurse and suffering becomes a shared experience.

Nurses cannot physically escape from the patient’s experience of suffering, yet they are in the position of being responsible for alleviating the suffering. Some methods of alleviating the suffering are not usually in the direct control of the nursing profession (e.g., the prescribing of adequate analgesics), and some are controlled by the profession (e.g., in the skill of nursing arts, such as positioning, the use of touch, the use of appropriate verbal responses, etc.); and in other cases, the nurse is powerless to alleviate the suffering because the pain is so severe and nothing can alleviate the distress. The patient is forced to endure the agony, and the nurse is forced to witness and, therefore, to share in the experience.

Observing such suffering does not leave the nurse unaffected: A patient’s suffering is sensed and experienced by the nurse and evokes an emotive insight (EI) that, in turn, evokes expressions of verbal comfort (e.g., sympathy, pity, compassion, commiseration, consolation, or reflexive reassurance). However, the constant exposure to patient suffering emotionally drains the nurse; consequently, the experience of shared suffering must be controlled by the nurse, (a) so the nurse may leave the distressed patient and move on and care for other patients and (b) so the nurse can limit his or her involvement with the patient’s suffering and avoid becoming emotionally drained and exhausted.

Human responses that are reflexive, first-level, sufferer-focused responses are responses that are triggered by the emotional insight of the caregiver. These responses are culturally conditioned rather than learned, almost reflexive or automatic, and are naturally comforting to the sufferer. We asked: What are these lay “empathetic concepts” that are used clinically, but not taught? Our list was

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