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 from Vanderbilt University in Nashville, Tennessee. South Florida became her home in 1981 and, today, continues to enchant and nourish her love for the natural life. Dr. Boykin is married to Steve Staudenmeyer, and they have four children.

Anne Boykin is dean and professor of the Christine E. Lynn College of Nursing at Florida Atlantic University. She is director of the Christine E. Lynn Center for Caring, which is housed in the College of Nursing. This center was created for the purpose of humanizing care through the integration of teaching, research, and service. A new and exciting initiative is the creation of the Archives of Caring in Nursing. The goals of the Archives are to preserve the papers of caring scholars, invite the study of caring, advance caring as an essential domain of nursing knowledge, and create meaning for the practice of 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.

THEORETICAL SOURCES

The Theory of Nursing as Caring was borne out of the early curriculum development work in the College of Nursing at Florida Atlantic University. 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 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 that facilitated the 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 those 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, Anne Boykin and Savina Schoenhofer are longstanding members of the community of nursing scholars whose study focuses on caring. Their collegial association and mutual support also undoubtedly brought subtle influence to bear on Boykin and Schoenhofer’s 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 the work, 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 notes 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 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 the caring between the nurse and the one nursed as the substantive knowledge that nurses must pursue. From this perspective, outcomes of nursing care reflect the valuing of person in ways that communicate the “value added” richness of the nursing experience (Boykin, Schoenhofer, Smith, St. Jean, & Aleman, 2003, p. 225). Characteristics of personhood essential to the theory, such as unity, wholeness, awareness, and intention, are not consonant with the objective terms of normative science that permeates the language of outcomes. In Nursing as Caring, outcomes 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.

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 an appropriate model 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 all 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 activities.

Dance of Caring Persons

The Dance of Caring Persons is a visual representation of the lived caring between the nurse and the nursed and expresses underlying relationships (Figure 19-1). The concept of a hierarchical ladder is inconsistent with Nursing as Caring. Instead, the egalitarian spirit of caring respect characterizes each participant in the dance of caring persons, in which 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 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.

LOGICAL FORM

The theory is presented in logical form grounded in general assumptions related to persons as caring and in nursing as a discipline of knowledge and a profession. 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.

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 instrument and a means to an end. Rather than nursing practice focused on activities, the lens for practice becomes the intention to know person as caring. Often realization of the self as caring person does not occur until the story of the caring transpiring in the nursing situation is articulated and shared. 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). Reentering moments of caring through articulation of the nursing story allows the nurse to frame outcomes of caring in the language and substance of caring that is meaningful for practice. 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 healthcare 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 it is nursing which 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.

I am able to live caring uniquely as the CNO by ministering to the nurses providing direct patient care. Many nurses were trained to focus on technology and treating symptoms. I give the nurses the freedom to care in their unique way. Our Clinical Nurse Leaders (CNLs) are transforming nursing practice at St. Lucie Medical Center by incorporating the Theory of Nursing as Caring into bedside nursing. Through direct invitation, the CNLs are role modeling how to “hear” calls for nursing, that is, ascertaining in their own unique way “what matters most” to the patient. I have partnered with the CNLs and assisted with dialoguing with the staff. Through my honesty, I have disclosed to the nurses that I don’t have all the answers. As we transform our nursing practice, we live and grow in caring together.

What I do best is utilize the art of storytelling to translate the calls for nursing into the language of the boardroom. Through the use of strategic nursing situations, I connect the administrators directly to the one nursed. While these indirect caregivers yearn for connectedness to the patient, it takes the ingredient of courage on my part to convince the administrators why it is critical to transform an entire healthcare system by intentionally grounding it in a perspective of caring.

We needed a graphic representation of how all disciplines in the hospital relate to the patient. The Dance of Caring Persons was the visual representation of an organizational model that supports a way of being with others that respects, honors, and celebrates each person. I have been willing to conceptualize and chart the course as well as partner with key leaders in creating an environment to embody the true values of caring.

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