A Theory of Caring

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					 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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