Theory of Caring

Theory of Caring

Danuta M. Wojnar


Kristen M. Swanson, R.N., Ph.D., F.A.A.N., was born on January 13, 1953, in Providence, Rhode Island. She earned her baccalaureate degree (magna cum laude) from the University of Rhode Island College of Nursing in 1975. After graduation, Swanson began her career as a registered nurse at the University of Massachusetts Medical Center in Worcester. She was drawn to that institution because the founding nursing administration clearly articulated a vision for professional nursing practice and actively worked with nurses to apply these ideals while working with clients (Swanson, 2001).

As a novice nurse, more than anything Swanson wanted to become a knowledgeable and technically skillful practitioner with an ultimate goal of teaching these skills to others. Thus, she pursued graduate studies in Adult Health and Illness Nursing Program at the University of Pennsylvania in Philadelphia. After receiving a master’s degree in nursing (1978), Swanson worked for a year as a clinical instructor of medical-surgical nursing at the University of Pennsylvania School of Nursing and subsequently enrolled in the Ph.D. in nursing program at the University of Colorado in Denver, Colorado. There she studied psychosocial nursing with an emphasis on exploring the concepts of loss, stress, coping, interpersonal relationships, person and personhood, environments, and caring.

While a doctoral student, as part of a hands-on experience with a self-selected health promotion activity, Swanson participated in a cesarean birth support group. At one of the meetings, which focused on miscarriage, she observed that while the guest speaker, a physician, focused on pathophysiology and health problems prevalent after miscarriage, women who attended the meeting were more interested in talking about their personal experiences with pregnancy loss. From that day on, Swanson decided to learn more about the human experience and responses to miscarrying. Caring and miscarriage became the focus of her doctoral dissertation and, subsequently, her program of research.

After earning a Ph.D. in nursing science, Swanson received an individually awarded National Research Service postdoctoral fellowship from the National Center for Nursing Research, which she completed under the direction of Dr. Kathryn E. Barnard at the University of Washington in Seattle. Afterward, she joined the faculty at University of Washington School of Nursing, where she continues scholarly work to this day as a professor and chairperson of the Department of Family Child Nursing. In addition to teaching and administrative responsibilities, Swanson conducts research funded by the National Institutes of Health and National Institutes of Nursing Research, publishes, mentors faculty and students, and serves as a consultant at national and international levels. In recognition of the many outstanding contributions to the development of nursing discipline, among other honors, Swanson was inducted as a fellow in the American Academy of Nursing (1991) and received a Distinguished Alumnus Award from the University of Rhode Island (2002).


Swanson has drawn on various theoretical sources while developing her Theory of Caring. She recalls that from the beginning of her nursing career, knowledge obtained from book learning and clinical experience made her acutely aware of the profound difference caring made in the lives of people she served:

In addition, Swanson credits several nursing scholars for the insights that shaped her beliefs about the nursing discipline and influenced her program of research. She acknowledges that taking Dr. Jacqueline Fawcett’s course on the conceptual basis of nursing practice as a master’s-prepared nurse not only made her better understand the differences between the goals of nursing and other health disciplines, but also made her realize that caring for others as they go through life transitions of health, illness, healing, and dying was congruent with her personal values (Swanson, 2001). Hence, Swanson chose Dr. Jean Watson as a mentor during her doctoral studies. She attributes the emphasis on exploring the concept of caring in her doctoral dissertation to Dr. Watson’s influence. However, despite the close working relationship and emphasis on caring in Swanson’s dissertation work, neither Swanson nor Watson has ever seen Swanson’s program of research as application of Watson’s Theory of Human Caring (Watson, 1979, 1988, 1999). Instead, both Swanson and Watson assert that compatibility of findings on caring in their individual programs of research adds credibility to their theoretical assertions (Swanson, 2001). Swanson also acknowledges Dr. Kathryn E. Barnard for encouraging her to make the transition from the interpretive to contemporary empiricist paradigm, to transfer what she learned and postulated about caring through several phenomenological investigations to guide intervention research and, hopefully, clinical practice with women who have miscarried.



Caring is a nurturing way of relating to a valued other toward whom one feels a personal sense of commitment and responsibility (Swanson, 1991).


Swanson formulated her Theory of Caring inductively, as a result of several investigations. For her doctoral dissertation, using descriptive phenomenology, Swanson analyzed data obtained from in-depth interviews with 20 women who had recently miscarried. As a result of this phenomenological investigation, Swanson proposed two models:

The Caring Model, in which Swanson proposed that five basic processes (knowing, being with, doing for, enabling, and maintaining belief) give meaning to acts labeled as caring (Swanson-Kauffman, 1986, 1988a, 1988b), later became the foundation for Swanson’s (1991) middle range Theory of Caring.

While a postdoctoral fellow, Swanson conducted another phenomenological study, which explored what it was like to be a provider of care to vulnerable infants in the neonatal intensive care unit (NICU). As a result of this investigation, Swanson (1990) discovered that the caring processes she identified with women who miscarried were also applicable to mothers, fathers, physicians, and nurses who were responsible for taking care of infants in the NICU. Hence, she decided to retain the wording that described the acts of caring and proposed all-inclusive care in a complex environment embraces balance among caring (for self and the one cared for), attaching (to others and roles), managing responsibilities (assigned by self, others, and society), and avoiding bad outcomes (Swanson, 1990).

In a subsequent phenomenological investigation conducted with socially at-risk mothers, Swanson (1991) explored what it had been like for these mothers to receive an intense, long-term nursing intervention. Swanson recalls that after this study, she was finally able to define caring and further refine the understanding of caring processes. Collectively, phenomenological inquiries with women who miscarried, with caregivers in the NICU, and with socially at-risk mothers provided the basis for expanding the Caring Model into the middle range Theory of Caring (Swanson, 1991, 1993).

Later, Swanson tested her Theory of Caring with women who miscarried in several investigations funded by the National Institutes of Health, National Institutes of Nursing Research, and other funding sources. Swanson’s (1999a, 1999b) intervention research (N = 242) focused on examining the effects of caring-based counseling sessions on the women’s coming to terms with loss and emotional well-being during the first year after miscarrying. Additional aims of the project were to examine the effects of the passage of time on healing during that first year and to develop strategies to monitor caring interventions. This study established that although passing of time had positive effects on women’s healing after miscarriage, caring interventions had a positive impact on decreasing the overall disturbed mood, anger, and level of depression. The second aim of this investigation was to monitor the caring variable and identify whether caring was delivered as intended. To do so, caring was monitored in the following three ways:

The most noteworthy finding of monitoring caring was that, overall, the clients were highly satisfied with caring received during counseling sessions, suggesting that caring was delivered and received as intended.

Swanson’s (1999c) subsequent investigation was a literary meta-analysis on caring. An in-depth review of 130 investigations on caring led Swanson to propose that knowledge about caring may be categorized into five hierarchical domains (levels) and that research conducted in any one domain assumes the presence of all previous domains (Swanson, 1999c). The first domain refers to the persons’ capacities to deliver caring; the second domain refers to individuals’ concerns and commitments that lead to caring actions; the third domain refers to the conditions (nurse, client, organizational) that enhance or diminish likelihood of delivering caring; the fourth domain refers to actions of caring; and the fifth domain refers to the consequences or the intentional and unintentional outcomes of caring for both the client and the provider (Swanson, 1999c). Conducting the literary meta-analysis clarified the meaning of the concept of caring as it is used in nursing discipline and validated transferability of Swanson’s middle range Theory of Caring beyond the perinatal context.

Most recently, Swanson conducted an intervention study funded by the National Institutes of Health called Couples Miscarriage Healing Project. The purposes of this investigation were to better understand the effects of miscarriage on men and women as individuals and as couples, to explore the effects of miscarriage on couple relationships, and to identify best ways of helping men and women heal as individuals and as couples after unexpected pregnancy loss. Study participants (341 heterosexual couples) were randomly assigned to control or one of the following three treatment groups: (1) nurse caring, which entailed attending three counseling sessions with a nurse, (2) self-caring, which involved completing three videos and workbooks, or (3) combined caring, which involved attending one nurse caring session and three videos and workbooks, to determine the most effective way of supporting couples after miscarriage. All interventions were designed and delivered within Swanson’s Theory of Caring framework. Ongoing data analysis has shown that while both genders are affected by early-unexpected pregnancy loss, women experience more pure grief and depression than men. Moreover, Swanson found that caring interventions were effective in facilitating couples’ healing. Currently, articles discussing study findings are being prepared for publication.


In 1993, Swanson further developed her theory of informed caring by making explicit her major assumptions about the four main phenomena of concern to the nursing discipline: nursing, person/client, health, and environment.


Swanson (1991, 1993) defines nursing as informed caring for the well-being of others. She asserts that the nursing discipline is informed by empirical knowledge from nursing and other related disciplines, as well as “ethical, personal and aesthetic knowledge derived from the humanities, clinical experience, and personal and societal values and expectations” (Swanson, 1993, p. 352).


Swanson (1993) defines persons as “unique beings who are in the midst of becoming and whose wholeness is made manifest in thoughts, feelings, and behaviors” (p. 352). She posits that the life experiences of each individual are influenced by a complex interplay of “a genetic heritage, spiritual endowment and the capacity to exercise free will” (Swanson, 1993, p. 352). Hence, persons both shape and are shaped by the environment in which they live.

Swanson (1993) views persons as dynamic, growing, self-reflecting, yearning to be connected with others, and spiritual beings. She suggests the following: “…spiritual endowment connects each being to an eternal and universal source of goodness, mystery, life, creativity, and serenity. The spiritual endowment may be a soul, higher power/Holy Spirit, positive energy, or, simply grace. Free will equates with choice and the capacity to decide how to act when confronted with a range of possibilities” (p. 352). Swanson (1993) noted, however, that limitations set by race, class, gender, or access to care might prevent individuals from exercising free will. Hence, acknowledging free will mandates the nursing discipline to honor individuality and to consider a whole range of possibilities that are acceptable or desirable for those whom nurses attend.

Moreover, Swanson posits that the other, whose personhood nursing discipline serves, refers to families, groups, and societies. Thus, with this understanding of personhood, nurses are mandated to take on leadership roles in fighting for human rights, equal access to health care, and other humanitarian causes. Lastly, when nurses think about the other to whom they direct their caring, they also need to think of self and other nurses and their care as that cared-for other.

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Feb 9, 2017 | Posted by in NURSING | Comments Off on Theory of Caring

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