A Theory of Caring
Theory Critique and Presentation
Kristen M. Swanson
Empirical Development of a Middle Range Theory
Swanson, K.M. (1991). Empirical Development of a
Middle Range Theory of Caring. Nursing Research,
Nursing as Informed Caring for the Well-Being of
Swanson, K.M. (1993). Nursing as Informed Caring
for the Well-Being of Others. Image, 25(4), 352-357.
• “What are the perceptions of care givers, care
receivers, and care observers regarding caring?”
Previous research had studied other aspects of
Benner & Wrubel (1989)
“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?”
Five Caring Processes:
1. Knowing: Avoiding assumptions, centering on person
cared for, assessing thoroughly, seeking clues, engaging
2. Being With: Being there, conveying ability, sharing
3. Doing For: Comforting, anticipating, performing
skillfully, protecting, preserving dignity
4. Enabling: Informing/explaining,
supporting/allowing, focusing, generating alternatives,
5. Maintaining Belief: believing in, holding in esteem,
maintaining hope-filled attitude, offering realistic
optimism, “going the distance”
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:
2. Health/Well being
Unique and are in the process of developing. Are continually
growing and seeking to connect with others.
Living life connected and engaged
Influences and/or influenced by client
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.
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
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
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
Mother’s support group-“Reality of the fragility of life
profoundly touched me”
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
Evidence for this is Swanson her self’s explanation
along with other scholars (Wojnar, Lo-Biondo-
Unique beings becoming whole (Swanson 1991, Swanson 1993)
Manifest wholeness through behaviors, thoughts, feelings (Ryden 1998, Swanson
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
Forces that exert influence upon or are influenced by the patient (Hanson 2004,
Cultural, economical, political, spiritual, social, psychological, biophysical
realms (Swanson 1993)
Disturbance or change in environment or realms will affect the wholeness of
“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
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
Spirituality as Part of Humanism
Swanson: Life of an individual is affected by a
Brings goodness, mystery, life, creativity, serenity
Takes the form of a soul, higher power, positive energy,
Can be fulfilled by the presence of caregivers providing
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
Individuals – including self & other nurses, families, groups and
“unique beings who are in the midst of becoming and whose
wholeness is made manifest in thoughts, feelings, and behaviors”
Shaped by environment.
When personhood is understood, nurses are mandated to take
on leadership role in the fight for humanitarian causes.
Depending on the situation, either influences, or is influenced
by, the person/client.
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.
Informed caring for the well-being of others.
The convergence of empirical knowledge and personal
knowledge that includes ethics, values, expectations and
- 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
“A nurturing way of relating to a valued other
Occurs in relationships The one
Growth and health producing cared-for
toward whom one feels a
personal sense of commitment and
and intimate Bond, pledge,
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
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
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).
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
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”
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
• 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.
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
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
– Strong correlation between research and practice.
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
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
Enabling: Presence, acceptance, empathic
acknowledgment of feelings
Caring for Peers
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.
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.
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
Swanson is more interested in testing and application in
practice than in further development.
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
can it be learned or is it inherent?
Does it work in settings other than nursing?
Alligood, M.R. & Marriner-Tomey, A. (2006). Nursing Theorists and Their Work. 6th ed. City: Elsevier
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:
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,
Swanson, K.M. (1993). Nursing as informed caring for the well-being of others. Image: The Journal of
Nursing Scholarship, 25(4), 352-357.