Analysis on Caring in Nursing Practice

There are five fundamental elements of nursing practice: critical thinking, holism, communication, professionalism, and caring. This paper will discuss the pillar of caring in nursing practice. According to the South University Bachelor of Science Handbook, caring is defined as "encompassing the nurses’ empathy for and connection with the patient as well as the ability to translate the values of altruism, autonomy, human dignity, integrity, and social justice into compassionate, sensitive, appropriate care". Caring is a universal conception that can be considered in terms of feelings, actions, or behaviors in relation to another individual (Potter, 2015). Caring as a nursing concept has been studied from many different theoretical and philosophical perspectives (Potter, 2015). This nursing concept has been explored by so many as caring is at the core of all nursing practice (Potter, 2015).

Madeleine Leininger suggested a transcultural perspective of caring. She stated that care is a necessary human need that is required for the survival of all individuals across all cultures (Potter, 2015). Leininger further stated that the act of caring is dependent on a patient’s needs, problems, and values (Potter, 2015).

Watson offered a transpersonal theory of caring (Potter, 2015). This theory emphasized the human interaction between nurses and patients and their relatives (Potter, 2015). Watson’s transpersonal care theory places the patient’s care well above curing the patient’s disease and treatment (Potter, 2015). Instead, this type of care explores inner healing to "protect, enhance, and preserve" the dignity of the patient (Potter, 2015, p. 519).

Swanson defined caring as "a nurturing way of relating to a valued other, toward whom one feels a personal sense of commitment and responsibility" (Potter, 2015, p. 520). Her theory emphasizes how caring is at the heart of nursing care but not necessarily unique to the practice of nursing (Potter, 2015). Swanson’s caring theory also provides direction for how to develop useful and effective caring strategies (Potter, 2015).

A study in Sweden was conducted to explore the perspectives of registered nurses on the concept of caring through different qualitative ways of understanding the concept of nursing care in practice including: caring as person-centeredness, caring as safeguarding the patient’s interests, and caring as nursing interventions (Andersson, 2015). Under the category of caring as person-centeredness, the nurses described themselves as a tool for caring and conceived caring as "maintaining and strengthening the patient’s sense of dignity and being a person" (Andersson, 2015). The nurses believed that this meant being truly present, readily available, and conveying a sense of comfort (Andersson, 2015). The person’s experiences, feelings, and preferences were considered to be vital aspects of caring (Andersson, 2015). Showing respect for the person’s decisions or opinions, especially when they were in conflict with the opinion of the professionals, was also regarded as being essential to caring (Andersson, 2015).

Under the category of caring as safeguarding the patient’s best interests, the nurses described caring as "protecting patients from unnecessary suffering" (Andersson, 2015). This would be done by questioning whether prescribed examinations and tests were actually in the best interests of the patient (Andersson, 2015). Documenting the care process in the patient’s records was also stated to be a caring action in regards to promoting patient safety (Andersson, 2015). The early evaluation of the patient’s social situation, needs, and desire for additional care following discharge and acting as a liaison between the hospital and the patient by advocating for the patient were also described as caring by the nurses (Andersson, 2015). Showing respect for the patient’s integrity, respecting the patient’s privacy and accepting the extent to which the patient wanted to participate in his or her own care were other examples the nurses gave as a way of caring as safeguarding the patient’s best interests (Andersson, 2015).

In the category of caring as nursing interventions, the nurses believed caring to be vigilant patient observation resulting in care activities that lead to improvement of symptoms and enhanced well-being (Andersson, 2015). The caring interventions included assessing vital signs, observing and interpreting body language, providing food, hydration, good personal hygiene, safety, and pharmacologic and nonpharmacologic interventions (Andersson, 2015). All of these nursing care interventions require vigilance, compassion, and dedication from nurses when providing nursing care in practice (Andersson, 2015).

Upon analysis, the study found the nursing concept of caring as being an act that takes place in collaboration with the patient while focusing on the patient’s best interests through guiding, protecting, supporting and respecting the patient (Andersson, 2015). It was also concluded that caring was found to be giving the patient freedom to choose when he or she wants to be considered a patient and when to be considered a person (Andersson, 2015). By acknowledging the patient’s choice the nurses fulfill duty in upholding their patient’s wishes (Andersson 2015).

In 1980, Dorothy Johnson established a behavioral system model for nursing care which views a patient in terms of the equilibrium of their behavioral system instead of their diagnosis or illness (Alligood, 2013). A patient should be seen as a compilation of behavioral subsystems that combine to form a behavioral system (Alligood, 2013). The focus is specific towards the patient’s behavior, not the individual’s illness and the ultimate goal is achieving a balance of behaviors (Alligood, 2013).

The behavioral model system is organized into seven subsystems of behavior: achievement, affiliative, aggressive, dependence, eliminative, ingestive, and sexual (Alligood, 2013). Nurses using this model in practice often believe that "restorative" should be added as an additional behavior to be addressed (Alligood, 2013, p. 140). Each subsystem has its own structure and function along with a goal based on universal drive, set, choice, and action (Alligood, 2013). These factors contribute to the overall observable activity of an individual (Alligood, 2013). The goal of a subsystem is defined as "the ultimate consequence of behaviors" (Alligood, 2013, p. 140).

This goal is based upon a universal drive which is evidence-based (Alligood, 2013). The goal for each behavioral subsystem is consistent for all individuals in general terms but there can be variations among individuals depending on the goal and drive strength (Alligood, 2013). The second structural concept is set (Alligood, 2013). Set is defined as a "tendency to act in a certain way in a given situation" (Alligood, 2013, p. 140). Once a set is developed, it is relatively stable (Alligood, 2013). Set formation is usually dependent upon societal norms and variables such as culture, family, values, experience, and perseverative sets (Alligood, 2013). In this context, "perseverative sets" refer to the habits an individual maintains and can vary with each person (Alligood, 2013, p. 140). Set plays a major role in concluding what choices an individual makes and predicting what actions he or she may eventually carry out (Alligood, 2013).

Choice is the third structural concept upon which the goal of subsystem is based (Alligood, 2013). Choice refers to the different behaviors a person contemplates in various situations (Alligood, 2013). An individual can have a broad or narrow range of options which can be influenced by age, gender, culture, and socioeconomic status (Alligood, 2013). The final structural concept is action, "the observable behavior of a person" (Alligood, 2013, p. 140). An individual’s actual behavior is limited by their size and abilities (Alligood 2013). When it comes to action, the concern is the efficiency and effectiveness of the behavior in being able to attain the goal (Alligood, 2013).

Each subsystem has not only a structure but also a function synonymous to the physiology of biological systems in the human body (Alligood, 2013). The goal is considered part of the structure, but it can also be a part of the function (Alligood 2013). In order for the eight subsystems to maintain balance and stability, each must have certain "functional requirements" which are provided by the environment (Alligood, 2013, p. 140). These functional requirements consist of protection from unwanted, disturbing stimuli; giving input from the environment to nurture an individual such as providing food and care; encouragement; and stimulation by experiences, events, and behavior to "enhance growth and prevent stagnation" (Alligood, 2013, p. 141).

The behavioral subsystems can maintain equilibrium as long as both internal and external environments are "orderly, organized, and predictable" and the goals are met for each subsystem (Alligood, 2013, p. 141). Imbalance of the behavioral subsystem can occur when a disturbance in the structure, function, or functional regimen (Alligood, 2013). Johnson established four diagnostic classifications of these disturbances: insufficiency, discrepancy, incompatibility, and dominance (Alligood,
2013).

Dorothy Johnson’s Behavioral Model System can be applied to nursing in today’s modern practice, especially in regards to the nursing concept of caring. The goals of nursing include maintaining, restoring, and achieving a sense of equilibrium and stability in the behavioral system (Alligood, 2013). Nurses act as the environment in the behavioral model system as caring actions are carried out to modify the structure or provide alternate means by which the behavioral subsystems fulfill each structure’s functional requirement (Alligood, 2013). Nursing interventions can be used to restore the equilibrium of the behavioral system through care actions directed towards repairing any disturbances in the structural units of the subsystem (Alligood, 2013). These damages to the structural units can occur with the nurse imposing regulatory and control measures to help the patient develop or enhance his or her supply of essential functional requirements (Alligood, 2013). These considerations can be supported by the perspectives and input provided by the registered nurses participating in the aforementioned study conducted by Andersson in 2015. Dorothy Johnson’s behavioral model states that the "environment must supply the functional requirements of protection from unwanted, disturbing stimuli; nurturance through giving input from the environment; encouragement; and stimulation by experiences, events, and behavior that would enhance growth and prevent stagnation" (Alligood 2013, p. 140).

Under the category of caring as person-centeredness, the nurses defined caring as "maintaining and strengthening the patient’s sense of dignity and being a person" (Andersson, 2015). This was carried out through caring actions of not only being present, available, and providing a sense of comfort but also by considering a patient’s experiences, feelings, and preferences, and showing respect for the patient’s decisions as important aspects of caring (Andersson, 2015). These actions are consistent with the function of the environment as they fulfill the functional requirement of "nurturance through giving input from the environment" by providing conditions that support growth and development (Alligood, 2013, p. 140). They also provide "stimulation by experiences, events, and behavior" that gives an individual a positive experience knowing the nurse is present, available, and able to provide comfort and support (Alligood, 2013, p. 140). This requirement is also met by taking the patient’s own experiences, feelings and preferences into consideration, and showing respect allow for enhanced growth. Not receiving these vital aspects which could result in stagnation.

In the category of caring as safeguarding the patient’s interests, the nurses described caring as "protecting patients from unnecessary suffering" (Andersson, 2015). The functional requirements of "protection from unwanted, disturbing stimuli" and "nurturance through giving input from the environment" in Johnson’s behavioral model theory are supplied through this category of caring (Alligood, 2013, p. 140). The examples provided by nurses in the study place emphasis on the nurse’s role as the patient’s advocate. This role provides protection from any orders or opinions that could be brought up in a collaborative setting that may not be in the patient’s best interest. If a patient knows that the nurse will respect his or her integrity it could result in enhanced growth and development as a result of the nurse fulfilling their role as the environment and providing positive conditions for this growth.

The category of caring as nursing interventions was defined as the vigilance of the nurse in the supervision and observation of the patient resulting in the enhanced holistic well-being of the patient (Andersson, 2015). This category of nursing supplies the functional requirement of "nurturance through giving input from the environment" (Alligood, 2013, p. 140). The functional requirement is fulfilled as the nurse acts as the environment in enacting protocols and assessments to enhance the essential functional requirements of the patient. This done through the caring actions of assessments and observation of vital signs, interpretation of body language, application of medical knowledge, and the integration and interpretation of objective and subjective data (Andersson, 2015). Nursing care interventions in terms of this functional requirement do not simply stop at regulatory measures, they can also supply this requirement through providing the essential needs of an individual including: keeping a patient fed, hydrated, clean, calm, safe, being involved in the patient’s own care, and providing both pharmacological and nonpharmacological interventions (Andersson, 2015).

There are various aspects to the nursing concept of caring. This concept has been explored by many nursing theorists in terms of establishing models, theories, research, and application. The concept of caring in the nursing field can viewed from different perspectives including Leininger’s transcultural caring theory, Watson’s transpersonal caring theory and Swanson’s theory of caring. These are only a few of the nursing theorists that have explored caring in nursing practice. Many theoretical perspectives of caring in nursing practice have commonalities: human interaction, mutual problem solving, consideration for the uniqueness of every individual, and efforts to enhance the overall well-being of the individual and their families (Duffy, 2007). One major conclusion that can be made is that caring is highly dependent on the development of a relationship between the nurse and the patient (Potter, 2015). In terms of Dorothy Johnson’s behavioral theory, the supplementation of the patient’s essential functional requirements is highly dependent upon the environment, which is represented by the nurse. A relationship must be established between the nurse and the patient in order for the nurse to provide the required protection, nurturance, encouragement, and provision of conditions to enhance the patient’s growth (Alligood, 2013).

Although Johnson’s behavioral theory is was established in 1980, this theory still has significance in nursing care practice today. Her theory emphasized the importance of balance of behavior in order to prevent illness and the role and responsibility of the environment to supply the essential functional requirement to enhance any structural unit damage that could occur as a result of an ailment (Alligood, 2013). This idea is not unfounded as the sense of equilibrium is important from a physiological standpoint. The human body requires a constant internal environment known as homeostasis and self-regulates and adjusts maintain homeostasis. Instead of emphasizing self-regulation, the behavioral model suggests that the nurse act as the environment to temporarily impose nursing care interventions to help enhance the fulfillment of essential functional required to achieve the overall balance of behaviors (Alligood, 2013). The nursing concept of caring can be found at the heart of Dorothy Johnson’s Behavioral model as the balance of behaviors cannot be achieved without the implementation of the multiple care activities of nursing.

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