A Theory of Caring Theory Critique and Presentation Jessica Brandt Kara Rasplica Brita Hanson Hali Saucier Kristi Eilers Kristen M. Swanson Background Empirical Development of a Middle Range Theory of Caring Swanson, K.M. (1991). Empirical Development of a Middle Range Theory of Caring. Nursing Research, 40(3), 161-166. Nursing as Informed Caring for the Well-Being of Others Swanson, K.M. (1993). Nursing as Informed Caring for the Well-Being of Others. Image, 25(4), 352-357. Background • “What are the perceptions of care givers, care receivers, and care observers regarding caring?” Previous research had studied other aspects of caring- Noddings (1984) Benner & Wrubel (1989) Gilligan (1982) Ray (1987) Larson (1984) Watson (1988) Background “Theory of Caring” involved three research studies- Caring and Miscarriage “What are the caring behaviors of others that are identified as helpful by women who have miscarried?” “What constitutes caring in the instance of miscarriage?” Caring in the Newborn Intensive Care Unit “What is it like to be a provider of care in the Newborn Intensive Care Unit (NICU)?” Caring and the Clinical Nursing Models Project “How do recipients of a long-term intensive nursing intervention recall and describe the nurse-patient relationship four years post intervention?” Background Five Caring Processes: 1. Knowing: Avoiding assumptions, centering on person cared for, assessing thoroughly, seeking clues, engaging both 2. Being With: Being there, conveying ability, sharing feelings, not-burdening 3. Doing For: Comforting, anticipating, performing skillfully, protecting, preserving dignity 4. Enabling: Informing/explaining, supporting/allowing, focusing, generating alternatives, validating/feedback 5. Maintaining Belief: believing in, holding in esteem, maintaining hope-filled attitude, offering realistic optimism, “going the distance” Background Later work “Informed Caring” aimed to provide structure for relating the five caring processes and describe assumptions about the four main phenomena of concern to nursing: 1. Persons/Clients 2. Health/Well being 3. Environments 4. Nursing Background Persons/Clients- Unique and are in the process of developing. Are continually growing and seeking to connect with others. Health/Well Being- Living life connected and engaged Environments- Influences and/or influenced by client Nursing- Purpose is both the ANA description of “diagnose and treat human responses to actual or potential health problems” but also greater than this is an integration of science, concern for humanity, and caring. Background Relates the Five Caring Processes as first grounded in the maintenance of a belief in human kind, anchored by knowing another’s reality, conveyed by being with, and enacted through dong for and enabling. Background Dr. Jacqueline Fawcett (Master’s degree studies at University of Pennsylvania, 1978): During this time she notes that she realized that caring for others was very congruent with her values. Dr. Jean Watson (Doctoral degree studies at University of Colorado, 1983): Chose Dr. Watson as her mentor specifically to explore the concept of caring. Dr. Kathryn E. Barnard (Post-Doctoral fellowship at University of Washington, 1985-1987): Helped Swanson to transition from interpretive research to intervention research. Mother’s support group-“Reality of the fragility of life profoundly touched me” Background Development of theory- Empirically derived through phenomenological inquiry and inductive methodology. What this means is that care givers, receivers, and observers were asked about their perceptions of caring, and hypotheses/relationships were then induced. Evidence for this is Swanson her self’s explanation along with other scholars (Wojnar, Lo-Biondo- Wood, Haber). Assumptions Persons/Clients Unique beings becoming whole (Swanson 1991, Swanson 1993) Manifest wholeness through behaviors, thoughts, feelings (Ryden 1998, Swanson 1993) Molded by environment Spiritual endowment: soul, higher power, positive energy, grace (Swanson 1993) Free will to choose from a range of possibilities (Swanson 1993) Each does not have equal choices Environment Forces that exert influence upon or are influenced by the patient (Hanson 2004, Swanson 1993) Cultural, economical, political, spiritual, social, psychological, biophysical realms (Swanson 1993) Disturbance or change in environment or realms will affect the wholeness of the other Assumptions Health/Well-Being “Living in such a state that one feels integrated and engaged with living and dying” (Swanson 1993) Health includes connecting with others and creating lasting human bonds Depends on free expression (Swanson 1991, Swanson 1993) Spirituality, thoughts, feelings, intelligence, creativity, etc. Well-being is negatively affected by actions of individuals upon the other that inhibit expression of wholeness Nursing Affected by Benner’s Novice to Expert (Swanson 1993) Focus on the overall well-being/wholeness of other (Swanson, 1993) Providers must be informed regarding common responses to health problems (Hanson 2004) Past experiences increase care given by nurse Includes evidence-based practices, compassion, understanding of other, structure of caring (Swanson 1991), understanding of nursing profession Swanson & Spiritual Humanism 1. Humans are individuals able to think for themselves 2. Humans make reasoned decisions 3. An understanding of the world is based upon collecting information through the senses 4. Humans are not critical of the source of ideas 5. Human knowledge is not perfect 6. Human values must be placed in the context of current existing human life 7. Ethical decisions are based on human needs/concerns & not the needs of other powers 8. Humans understand that ethical dilemmas are situational & difficult Spirituality as Part of Humanism Swanson: Life of an individual is affected by a spiritual endowment Brings goodness, mystery, life, creativity, serenity Takes the form of a soul, higher power, positive energy, or grace Can be fulfilled by the presence of caregivers providing informed care Humanism: People are to be appreciated as they are as their own beings Are not to be used for purposes of others “Need will be met through the contemplation of beauty, through the support & warmth of the human bond, through heightened & exhilarated moments of joy” (Chuman 1992) Metaparadigm Persons/clients Individuals – including self & other nurses, families, groups and societies. “unique beings who are in the midst of becoming and whose wholeness is made manifest in thoughts, feelings, and behaviors” (Swanson, 1993) Shaped by environment. When personhood is understood, nurses are mandated to take on leadership role in the fight for humanitarian causes. Environments Shape clients. Depending on the situation, either influences, or is influenced by, the person/client. Metaparadigm Health/Well-being Re-establishing well-being is the process of healing and curing that renews wholeness. Wholeness – all facets of being are free to be expressed: spirituality, thoughts, feelings, intelligence, creativity, relatedness, femininity, masculinity, sexuality. Nursing Informed caring for the well-being of others. The convergence of empirical knowledge and personal knowledge that includes ethics, values, expectations and experiences. Major Concepts Caring Presence Environment Knowing Health/Well-being Enabling Nursing client - These concepts are defined theoretically, drawing on previous advances in the nursing literature. - Some of the concepts (like so many concepts in nursing) are in need of further development Caring Defined “A nurturing way of relating to a valued other Occurs in relationships The one Growth and health producing cared-for matters toward whom one feels a personal sense of commitment and Individualized and intimate Bond, pledge, responsibility” or passion Accountability and duty Swanson 1991; 1993 Caring: Concept Analysis Swanson acknowledged the lack of universal definition/conceptualization of caring. Identified inconsistencies and unanswered questions. Definition: “A nurturing way of relating to a valued other toward whom one has a personal sense of commitment and responsibility.” Defining Characteristics: 5 caring processes Antecedents: relate to the 5 caring processes. Ex. In order to know the patient, the nurse must possess knowledge of self (Swanson, 1993). Consequences: Enhanced patient well-being, smoother life transitions (Swanson, 1993) Increased self-esteem, reduced emotional disturbance (Swanson, 1999) Enhanced meaning of nurse’s caring efforts (Ryden, 1998). Propositions Maintaining belief is the foundation of caring Knowing is the anchor that “moors the beliefs” of nurse/nursing to the lived reality of the patient Being with is how the nurse conveys caring Doing For and Enabling are the visible ways in which the nurse enacts caring Categories of caring are not mutually exclusive (Swanson, 1991). Ex. Being with and doing for can occur simultaneously when the nurse takes time to brush the patient’s hair while they talk. Structure of Caring Doing for/Enabling Being with Knowing Maintaining beliefBelief Maintaining Clarity of Theory Theory gives definition to caring: “Caring is a nurturing way of relating to a valued other toward whom one feels a personal sense of commitment and responsibility” (Swanson, 1991) Provides clear definitions to 5 categories of theory. Definitions further refined through 3 studies Theory easily understood and linked to practice. Conclusions mapped out in a logical way. — Pulled from interviews and past research. Congruence of Theory Each process stands on its own but some also help to build and define the others. Being with is the next step after knowing Knowing, being with, doing for, and enabling work together to have the path filled with meaning will be chosen and thereby meet the goal of maintaining belief. • Limitation in theory was to show relationship between all 5 processes. – Swanson recognized this limitation, and later worked to link all 5 processes in Nursing in Informed Caring for the Well-Being of Others. Congruence cont. Swanson’s theory congruent with other’s work to show validity beyond perinatal circumstances. Benner: Helping Role of Nursing Watson: Carative Factors • Cross-validates and gives reasoning for perception Benner & Watson’s nurturing or helpful. Swanson, K.M. (1991). Empirical Development of a Middle Range Theory of Caring. Nursing Research, 40(3), 161-166. Level of Theory Descriptive Theory provides definition of caring and the five essential categories of processes that are proposed to characterized caring. (Swanson, 1991) • Middle Range – Theory developed under the limited scope of perinatal situations. – Strong correlation between research and practice. Nursing Actions Theory can be used to better understand how to relate to patients. Each process allows for a nurse to formulate an intervention to better care for a patient. Using Swanson’s Theory Patients/“the Other” with Dementia Maintaining Belief: Protection of reduction to object status Knowing: Awareness of research about growth & development in later life Being With: Center presence on the other Doing For: Facilitate function even if not efficient for task completion Enabling: Presence, acceptance, empathic acknowledgment of feelings Perinatal Context Education Caring for Peers Testability Does it work beyond the perinatal setting? She tested herself via a literary meta-analysis on caring. Others have tested it as well…and it has held up. Examples: Hanson, M. D. () Using Data from Critical Care Nurses to Validate Swanson’s Phenomenological Derived Middle Range Caring Theory. The Journal of Theory Construction & Testing, 8(1), 21-25. Used to describe how personal life-experiences impact the caring response in critical care nurses. Ryden, M. B. (1998) A theory of caring and dementia. American Journal of Alzheimer’s Disease, 13, 203-207. Explored the caring process in the context of those providing care to those suffering with dementia. Testability Further development… Theory of Informed Caring The care recipient’s capacity to integrate a life event and experience a state of well being is enhanced by receiving caring from a provider who is informed about common human responses to a specific health problem. Swanson is more interested in testing and application in practice than in further development. Future Yes, this is a theory for the future! caring defines nursing nursing is moving to be an evidence-based profession Swanson’s theory created a conceptual framework to: elucidate a vague concept allow a structure from which research could be done and practice can be based there is so much more research that can be done regarding caring… can it be learned or is it inherent? Does it work in settings other than nursing? References Alligood, M.R. & Marriner-Tomey, A. (2006). Nursing Theorists and Their Work. 6th ed. City: Elsevier Health Sciences. Chuman, J. (1992). Humanism and spirituality. Humanism Today, 7, 37-48. Edwords, F. (2008). The humanist philosophy in perspective. Retrieved November 7, 2008, from The American Humanist Association. Website: http://www.americanhumanist.org/humanism/perspective.php. Hanson M.D. (2004). Using data from critical care nurses to validate Swanson’s phenomenological derived middle range caring theory. The Journal of Theory Construction and Testing, 8 (1), 21-25. Jakobson P. (1998). Leader interview. Caring made visible…Kristen M. Swanson. Creative Nursing, 4 (4), 8-11, 16. Ryden, M.B. (1998). A theory of caring and dementia. American Journal of Alzheimer’s Disease and Other Dementias, 13, 203-207. Swanson, K.M. (1999). Effects of caring, measurement, and time on miscarriage impact and women’s well-being. Nursing Research, 48 (6), 288-298. Swanson, K.M. (1991). Empirical development of a middle range theory of caring. Nursing Research, 40(3), 161-166. Swanson, K.M. (1993). Nursing as informed caring for the well-being of others. Image: The Journal of Nursing Scholarship, 25(4), 352-357.
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