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meaningless. Similarly, this view transcends an earlier view of
nursing theory that treated the unitary phenomenon of nursing as
being composed of concepts that could be studied independently or
as "independent and dependent variables." Nursing as caring resists
fragmentation of the unitary phenomenon of our discipline. In
subsequent chapters, we will more fully explore implications of this
view of nursing as a human science discipline and profession.

REFERENCES
Allen, D.G. (1985). Nursing research and social control: Alternative
models of science that emphasize understanding and emancipation. Image,
17 (2), 59-64.
Allen, D.G. (1987). The social policy statement; A reappraisal. Advances
in Nursing Science, 10 (I), 39-48.
American Nurses Association. (1980). Nursing: A social policy statement.
Kansas City: American Nurses Association.
Aykin, A., & Schoenhofer, S. (1990). Caring in nursing: Analysis of
extant theory. Nursing Science Quarterly, 4, 149-155.
Carper, B. (1978). Fundamental patterns of knowing in nursing. Advances
in Nursing
Science, 1, 13-24.
Chinn, P, & Jacobs, M. (1987). Theory and nursing. St. Louis: Mosby.
Cooper, M.C. (1988). Covenantal relationships: Grounding for the nursing
ethic.
Advances in Nursing Science, 10 (4), 48-59.
Fawcett, T. (1989). Analysis and evaluation of conceptual models of
nursing. Philadelphia:
F.A. Davis.
Flexner, A. (1910). Medical education in the United States and Canada.
New York: Carnegie
Foundation.
Gadow, S. (1980). Existential advocacy: Philosophical foundations of
nursing. In
S. Spicker & Gadow, S., (Eds.), Nursing: Images and Ideals. New
York: Springer, pp. 79-101.
Gadow, S. (1984). Touch and technology: Two paradigms of patient care.
Journal of Reli-gion and Health, 23, 63-69.
King, A., & Brownell J. (1976). The curriculum and the disciplines
of knowledge. Huntington.
NY: Robert E. Krieger Publishing Co.

Mayeroff, M. (1971). On caring. New York: Harper & Row.
Nursing Development Conference Group. (1979). Concept formalization in
nursing: Process and product. Boston: Little, Brown.
Packard, S.A., & Polifroni, E.C. (1991). The dilemma of nursing
science: Current quandaries and lack of direction. Nursing Science
Quarterly, 4 (1), 7-13.
Parse, R. (1981). Caring from a human science perspective. In M.
Leininger (Ed.). Car-ing: An essential human need. Thorofare, NJ: Slack.
(Reissued by Wayne State Uni-versity Press, Detroit, 1988).
Phenix, P. (1964). Realms of meaning. New York: McGraw Hill.
Pribram, K,H. (1971). Languages of the brain: Experimental paradoxes and
principles in neuro-psychology. Englewood Cliffs, NJ: Prentice-Hall.
Roach, S. (1984). Caring: The human mode of being, implications for
nursing. Toronto: Faculty of Nursing, University of Toronto.
Roach, S. (1987). The human act of caring. Ottawa: Canadian Hospital
Association.
Roach, S. (1992 Revised). The human act of caring. Ottawa: Canadian
Hospital Association.
Rodgers, B.L. (1991). Deconstructing the dogma in nursing knowledge and
practice.
Image, 23 (2), 177-81.
Silva, M.C. (1983). The American Nurses' Association position statement
on nursing and social policy: Philosophical and ethical dimensions.
Journal of Advanced
Nursing, 8 (2), 147-151.
Tillich, P. (1952). The courage to be. New Haven: Yale University Press.
Trigg, R. (1973). Reason and commitment. London: Cambridge University
Press.
Walker, L., & Avant, K. (1988). Strategies for theory construction
in nursing. Norwalk, CT:
Appleton & Lange.
Watson, J. (1988; 1985). Nursing: Human science and human care, a theory
of nursing. Nor-walk, CT: Appleton-Century-Crofts.
White, C.M. (1984). A critique of the ANA Social Policy Statement ...
population and environment focused nursing. Nursing Outlook, 32 (6),
328-331.

CHAPTER II. — NURSING AS
CARING
In Chapter 2, we will present the general theory of Nursing as
Caring. Here, the unique focus of nursing is posited as nurturing
persons living caring and growing in caring. While we will discuss the
meaning of that statement of focus in general terms, we will also
describe specific concepts inherent in this focus in the context of the
general theory.
If you recall, in Chapter 1 we discussed the several major
assumptions that ground the theory of Nursing as Caring:
* Persons are caring by virtue of their humanness
* Persons are whole or complete in the moment
* Persons live caring, moment to moment
* Personhood is a process of living grounded in caring
* Personhood is enhanced through participating in nurturing
relationships with caring others
* Nursing is both a discipline and profession
In this and succeeding chapters, we will develop the nursing
implications of these assumptions.
All persons are caring. This is the fundamental view that grounds
the focus of nursing as a discipline and a profession. The unique
perspective offered by the theory of Nursing as Caring builds on that
view by recognizing personhood as a process of living grounded in
caring. This is meant to imply that the fullness of being human is
expressed as one lives caring uniquely day to day. The process of
living grounded in caring is enhanced through participation in
nurturing relationships with caring others, particularly in nursing
relationships.
Within the theoretical perspective given herein, a further major
assumption appears: persons are viewed as already complete and
continuously growing in completeness, fully caring and unfolding

caring possibilities moment-to-moment. Such a view assumes that
caring is being lived by each of us, moment to moment. Expressions
of self as caring person are complete in the moment as caring
possibilities unfold; thus, notwithstanding other life contingencies,
one continues to grow in caring competency, in fully expressing self
as caring person. To say that one is fully caring in the moment also
involves a recognition of the uniqueness of person with each
moment presenting new possibilities to know self as caring person.
The notion of "in the moment" reflects the
idea that competency in knowing self as caring and as living
caring grows throughout life. Being complete in the moment also
signifies something more: there is no insufficiency, no brokenness, or
absence of something. As a result, nursing activities are not directed
toward healing in the sense of making whole; from our perspective,
wholeness is present and unfolding. There is no lack, failure, or
inadequacy which is to be corrected through nursing—persons are
whole, complete, and caring.
The theory of Nursing as Caring, then, is based on an
understanding that the focus of nursing, both as a discipline and as
a profession, involves the nurturing of persons living caring and
growing in caring. In this statement of focus, we recognize the
unique human need to which nursing is the response as a desire to
be recognized as caring person and to be supported in caring.
This focus also requires that the nurse know the person seeking
nursing as caring person and that the nursing action be directed
toward nurturing the nursed in their living caring and growing in
caring. We will briefly discuss this theory in general terms here and
more fully illuminate it in subsequent chapters on nursing practice
(Chapter 4), education (Chapter 5), and scholarship (Chapter 6). We
will address administration of nursing services and of nursing
education programs in Chapters 4 and 5, respectively.
Nurturing persons living caring and growing in caring at first
glance appears broad and abstract. In some ways, the focus is broad
in that it applies to nursing situations in a wide variety of practical
settings. On the other hand, it takes on specific and practical

meaning in the context of individual nursing situations as the nurse
attempts to know the nursed as caring person and focuses on
nurturing that person as he or she lives and grows in caring.
When approaching a situation from this perspective, we
understand each person as fundamentally caring, living caring in his
or her everyday life. Forms of expressing one's unique ways of living
caring are limited only by the imagination. Recognizing unique
personal ways of living caring also requires an ethical commitment
and knowledge of caring. In our everyday lives, failures to express
caring are readily recognized. The ability to articulate instances of
noncaring does not seem to take any particular skill. When nursing is
called for, however, it is necessary that nurses have the commitment,
knowledge, and skill to discover the individual unique caring person
to be nursed. For example, the nurse may encounter one who may
be described as despairing. Relating to that person as helpless
recalls Gadow's (1984) characterization of the philanthropic
paradigm which assumes "sufficiency and independence on one side
and needy dependence on the other" (p. 68). The relationship
grounded in nursing as caring would enable the nurse to connect
with the hope that underlies an expression of despair or
hopelessness. Personal expressions such as despair, or fear, or anger,
for example, are neither ignored nor discounted. Rather, they are
understood as the caring value which is in some way present. An
honest expression of fear or anger, for example, is also an
expression of vulnerability, which expresses courage and humility.
We reiterate that our approach is grounded in the fundamental
assumption that all persons are caring and the commitment which
arises from this basic value position.
It is this understanding of person as caring that directs
professional nursing decision making and action from the point of
view of our Nursing as Caring theory. The nurse enters into the
world of the other person with the intention of knowing the other as
caring person. It is in knowing the other in their "living caring and
growing in caring" that calls for nursing are heard. Of equal
importance is our coming to know how the other is living caring in

the situation and expressing aspirations for growing in caring. The
call for nursing is a call for acknowledgement and affirmation of the
person living caring in specific ways in this immediate situation. The
call for nursing says "know me as caring person now and affirm me."
The call for nursing evokes specific caring responses to sustain and
enhance the other as they live caring and grow in caring in the
situation of concern. This caring nurturance is what we call the
nursing response.
NURSING SITUATION
The nursing situation is a key concept in the theory of Nursing as
Caring. Thus, we understand nursing situation as a shared lived
experience in which the caring between nurse and nursed enhances
personhood. The nursing situation is the locus of all that is known
and done in nursing. It is in this context that nursing lives. The
content and structure of nursing knowledge are known through the
study of the nursing situation. The content of nursing knowledge is
generated, developed, conserved, and known through the lived
experience of the nursing situation. Nursing situation as a construct
is constituted in the mind of the nurse when the nurse
conceptualizes or prepares to conceptualize a call for nursing. In
other words, when a nurse engages in any situation from a nursing
focus, a nursing situation is constituted.
In the Scandinavian countries, for instance, all the helping
disciplines are called caring sciences. Professions such as medicine,
social work, clinical psychology, and pastoral counseling have a
caring function; however, caring per se is not their focus. Rather, the
focus of each of these professions addresses particular forms of
caring or caring in particular ranges of life situations. In nursing
situations, the nurse focuses on nurturing person as they live and
grow in caring. While caring is not unique to nursing, it is uniquely
expressed in nursing. The uniqueness of caring in nursing lies in the
intention expressed by the statement of focus. As an expression of
nursing, caring is the intentional and authentic presence of the nurse

with another who is recognized as person living caring and growing
in caring. Here, the nurse endeavors to come to know the other as
caring person and seeks to understand how that person might be
supported, sustained, and strengthened in kis or her unique process
of living caring and growing in caring. Again, each person in
interaction in the nursing situation is known as caring. Each person
grows in caring through interconnectedness with other.
Calls for nursing are calls for nurturance through personal
expressions of caring, and originate within persons who are living
caring in their lives and hold dreams and aspirations of growing in
caring. Again, the nurse responds to the call of the caring person,
not to some determination of an absence of caring. The
contributions of each person in the nursing situation are also
directed toward a common purpose, the nurturance of the person in
living and growing in caring.
In responding to the nursing call, the nurse brings an expert
(expert in the sense of deliberately developed) knowledge of what it
means to be human, to be caring, as a fully developed commitment
to recognizing and nurturing caring in all situations. The nurse
enters the other's world in order to know the person as caring. The
nurse comes to know how caring is being lived in the moment,
discovering unfolding possibilities for growing in caring. This
knowing clarifies the nurse's understanding of the call and guides
the nursing response. In this context, the general knowledge the
nurse brings to the situation is transformed through an
understanding of the uniqueness of that particular situation.
Every nursing situation is a lived experience involving at least two
unique persons. Therefore, each nursing situation differs from any
other. The reciprocal nature of the lived experience of the nursing
situation requires a personal investment of both caring persons. The
initial focus is on knowing persons as caring, both nurse and nursed.
The process for knowing self and other as caring involves a constant
and mutual unfolding. In order to know the other, the nurse must be
willing to risk entering the other's world. For his or her part, other
person must be willing to allow the nurse to enter his or her world

this to happen, the acceptance of trust and strength of courage
needed, person in the nursing situation can be awe-inspiring.
It is through the openness and willingness in the nursing situation
that presence with other occurs. Presence develops as the nurse is
willing to risk entering the world of the other and as the other invites
the nurse into a special, intimate space. The encountering of the
nurse and the nursed gives rise to a phenomenon we call caring
between, within which personhood is nurtured. The nurse as caring
person is fully present and gives the other time and space to grow.
Through presence and intentionality, the nurse is able to know the
other in his or her living and growing in caring. This personal
knowing enables the nurse to respond to the unique call for
nurturing personhood. Of course, responses to nursing calls are as
varied as the calls themselves. All truly nursing responses are
expressions of caring and are directed toward nurturing persons as
they live and grow in the caring in the situation.
In the situation, the nurse draws on personal, empirical, and
ethical knowing to bring to life the artistry of nursing. When the
nurse, as artist, creates a unique approach to care based on the
dreams and goals of the one cared for, the moment comes alive with
possibilities. Through the aesthetic, the nurse is free to know and
express the beauty of the caring moment (Boykin & Schoenhofer,
1991). This full engagement within the nursing situation allows the
nurse to truly experience nursing as caring, and to share that
experience with the one nursed.
In Chapter 1, we noted that each profession arose from some
everyday service given by one person or another. Nursing has long
been associated with the idea of mothering, when mothering is
understood as nurturing the personhood of another. The ideal
mother (and father) recognizes the child as caring person, perfect in
the moment and unfolding possibilities for becoming. The parent
acknowledges and affirms the child as caring person and provides
the caring environment that nurtures the child in living and growing
in caring. The origins of nursing may well be found in the intimacy of
parental caring. The roles of both parent and nurse permit and at

times even expect that one be involved in the intimacy of the daily
life of another. The parent is present in all situations to care for the
child. Ideally, parents know the child as eminently worthwhile and
caring, despite all the limitations and human frailties. As we
recognized in Chapter 1, professions arise from the special needs of
everyday situations, and nursing has perhaps emerged in relation to
a type of caring that is synonymous with parenthood and friendship.
The professional nurse, schooled in the discipline of nursing, brings
expert knowledge of human caring to the nursing situation.
In the early years of nursing model development, nursing scholars
endeavored to articulate their discipline using the perspective of
another discipline, for example, medicine, sociology, or psychology.
One example of this endeavor is the Roy Adaptation Model, in which
scientific assumptions reflect von Bertalanffy's general systems
theory and Helson's adaptation level theory (Roy and Andrews,
1991, p. 5). Parson's theory of Social System Analysis is reflected in
Johnson's Behavioral System Model for Nursing and Orem's Self-Care
Deficit Theory of Nursing (Meleis, 1985). A second trend involved
declaring that the uniqueness of nursing was in the way in which it
integrated and applied concepts from other disciplines. The
emphasis in the 1960s on nursing model development came as an
effort to articulate and structure the substance of nursing
knowledge. This work was needed to enhance nursing education,
previously based on rules of practice, and to provide a foundation for
an emerging interest in nursing research. Nursing scholars engaged
in model development as an expression of their commitment to the
advancement of nursing as a discipline and profession, and we
applaud their contributions. It is our view, however, that these early
models, grounded in other disciplines, do not directly address the
essence of nursing. The development of Nursing as Caring has
benefited from these earlier efforts as well as from the work of more
recent scholarship that posits caring as the central construct and
essence (Leininger, 1988), and the moral ideal of Nursing (Watson,
1985).

The perspective of nursing presented here is notably different
from most conceptual models and general theories in the field. The
most radical difference becomes apparent in the form of the call for
nursing. Most extant nursing theories, modeled after medicine and
other professional fields, present the formal occasion for nursing as
problem, need, or deficit (e.g., Self-Care)
Deficit Theory [Orem, 1985], Adaptation Nursing [Roy and
Andrews, 1991], Behavioral System Model [Johnson, 1980], and
[Neuman, 1989.] Such theories then explain how nursing acts to
right the wrong, meet the need, or eliminate or ameliorate the
deficit.
The theory of Nursing as Caring proceeds from a frame of
reference based on interconnectedness and collegiality rather than
on esoteric knowledge, technical expertise, and disempowering
hierarchies. In contrast, our emerging theory of nursing is based on
an egalitarian model of helping that bears witness to and celebrates
the human person in the fullness of his or her being, rather than on
some less-than-whole condition of being.

REFERENCES
Boykin, A., & Schoenhofer, S. (1991). Story as link between nursing
practice, ontology, epistemology. Image, 23, 245-248.
Gadow, S. (1984). Touch and technology: Two paradigms of patient care.
Journal of Religion and Health, 23, 63-69.
Johnson, D.E. (1980). The behavioral system model of nursing. In J.
Riehl & C. Roy (Eds.), Conceptual models for nursing practice (2nd
ed.). New York: Appleton-Century-Crofts.
Leininger, M.M. (1988). Leininger's theory of nursing: Cultural care
diversity and universality. Nursing Science Quarterly, 1, 152-160.
Meleis, A. (1985). Theoretical nursing: Development & progress.
Philadelphia: J.B. Lippencott.
Neuman, B. (1989). The Neumans systems model. Norwalk, CT: Appleton
& Lange. Orem, D.E. (1985). Nursing: Concepts of practice (3rd ed.).
New York: McGraw Hill.
Roy, C., & Andrews, H. (1991). The Roy Adaptation Model: The
definitive statement. Norwalk, CT: Appleton & Lange.
Watson, J. (1985). Nursing: Human science and human care. A theory of
nursing. Norwalk, CT: Appleton-Century-Crofts.

CHAPTER III — NURSING
SITUATION AS THE LOCUS OF
NURSING
The concept of nursing situation is central to every aspect of the
theory of Nursing as Caring. We have claimed that all nursing
knowledge resides within the nursing situation (Boykin &
Schoenhofer, 1991). The nursing situation is both the repository of
nursing knowledge and the context for knowing nursing. The nursing
situation is known as shared lived experience in which the caring
between the nurse and the one nursed enhances personhood.
It is to the nursing situation that the nurse brings self as caring
person. It is within the nursing situation that the nurse comes to
know the other as caring person, expressing unique ways of living
and growing in caring. And it is in the nursing situation that the
nurse attends to calls for caring, creating caring responses that
nurture personhood. It is within the nursing situation that the nurse
comes to know nursing, in the fullness of aesthetic knowing.
The nursing situation comes into being when the nurse actualizes
a personal and professional commitment to the belief that all
persons are caring. It should be recognized that a nurse can engage
in many activities in an occupational role that are not necessarily
expressions of nursing. When a nurse practices nursing thoughtfully,
that nurse is guided by his or her conception of nursing. The concept
of nursing formalized in the Nursing as Caring theory is at the very
heart of nursing, extending back into the unrecorded beginnings of
nursing and forward into the future. Acknowledgement of caring as
the core of nursing implies that any nurse practicing nursing
thoughtfully is creating and living nursing situations because,
whether explicit or tacit, the caring intent of nursing is present.

Remember that the nursing situation is a construct held by the
nurse, any interpersonal experience contains the potential to
become a nursing situation. In the formal sense of professional
nursing, the nursing situation develops when one person presents
self in the role of offering the professional service of nursing and the
other presents self in the role of seeking, wanting, or accepting
nursing service.
The nurse intentionally enters the situation for the purpose of
coming to know the other as caring person. The nurse is also
allowing self to be known as caring person. Authentic presence, like
most human capacities, is inherent and can be more fully developed
through intention and deliberate effort. Authentic presence may be
understood simply as one's intentionally being there with another in
the fullness of one's personhood. Caring communicated through
authentic presence is the initiating and sustaining medium of nursing
within the nursing situation.
The nurse, with developed authentic presence and open to
knowing the other as caring, begins to understand the other's call
for nursing. A call for nursing is a call for specific forms of caring
that acknowledge, affirm, and sustain the other as they strive to live
caring uniquely. We must remember as well that calls for nursing
originate within the unique relationship of the nursing situation. As
the situation ensues, the call for nursing clarifies. The nurse comes
to know the one nursed more and more deeply and to understand
more fully the unique meaning of the person's caring ways and
aspirations for growing in caring. It is in this understanding that the
call for nursing is known as a specific situated expression of caring
and a call for explicit caring response.
The nursing response of caring is also uniquely lived within each
nursing situation. In the nursing situation, the call of the nursed is a
personal "reaching out" to a hoped-for other. The nursed calls forth
the nurse's personal caring response. While the range and scope of
human caring expression can and must be studied, the caring
response called forth in each nursing situation is created for that
moment. The nurse responds to each call for nursing in a way that

uniquely represents the fullness (wholeness) of the nurse. How I
might respond to such a call would and should reflect my unique
living of caring as person and nurse. Each response to a particular
nursing situation would be slightly different and would portray the
beauty of the nurse as person.
The nursing situation is a shared lived experience. The nurse joins
in the life process of the person nursed and brings his or her life
process to the relationship as well. In the nursing situation, there is
caring between the participants. Further, the experience of the
caring within the nursing situation enhances personhood, the
process of living grounded in caring. Each of these components of
the construct of the nursing situation raises questions for immediate
and continuing discussion.
How can an unconscious patient be a participant in a nursing
situation? Can "postmortem care" be considered nursing? How can
the nurse know that the other is truly open to nursing—can the
nurse impose self into the world of the other? What about an
unrepentant child rapist or a person responsible for genocide, can
we say that person is caring, and if not, can we nurse them? Does
the nurse have to like the person being nursed? Does the nurse seek
enhancement of personhood in the nursing situation? If so, might
the goals of the nurse be imposed on the one nursed? If the nurse
gains from the nursing situation, isn't that unprofessional?
In part, these legitimate questions raise larger issues about the
uniqueness and scope of nursing as a discipline and professional
service in society. Certainly the study of these questions adds clarity
to the purpose of nursing actions. To nurse, situations in a general
sense are transcended and transformed When they are
conceptualized as nursing situations. From the perspective of the
Nursing as Caring theory, the study of these questions would require
that the nurse transcend social or other situational contexts and live
out a commitment to nurture the person in the nursing situation as
they live and grow in caring.
Persons with altered levels of consciousness, measured on
normative scales developed for medical science purposes, can and

do participate in nursing situations. Nurses committed to knowing
the unconscious as caring person can and do describe their ways of
expressing caring and aspirations for growing in caring. Nurses
speak of the post-anesthesia patient as living hope in their struggle
to emerge from the deadening effects of the anesthesia; as living
honestly in fretful, fearful thrashing. Nurses help these persons
sustain hope and extend honesty through their care. The profoundly
mentally disabled child lives humility moment-to-moment and calls
forth caring responses to validate and nurture that beautiful humility.
Nurses speak of caring for their deceased patients as nursing those
who have gone and are still in some way present. The nurse,
connected in oneness with the one known and nursed, holds hope
for the other as the other's expression of hopefulness lives on in the
consciousness of the nurse. Thus, a sense of connectedness does
not dissipate when physical presence ends, but remains an active
part of the nurse's experience.
Nursing another is a service of caring, communicated through
authentic presence. Nursing another means living out a commitment
to knowing the other as caring person and responding to the caring
other as someone of value (Boykin & Schoenhofer, 1990, 1991). In
its fullest sense, nursing cannot be rendered impersonally, but must
be offered in a spirit of being connected in oneness. "To care for"
seems to require that the caregiver see oneself as caring person
reflected in the other (Watson, 1987). The theoretical perspective of
Nursing as Caring is grounded in the belief that caring is the human
mode of being (Roach, 1984). When a person is judged by social
standards to be deviant and even evil, however, it is difficult to
summon caring. This points to the contribution nursing is called
upon to make in society. When we speak of nursing's contribution
here, we are invoking earlier discussions of discipline and profession.
Each discipline and profession illuminates a special aspect of person
—in effect, what it means to be human. The light that nursing shines
on the world of person is knowledge of person as caring, so that the
particular contribution of nursing is to illuminate the person as
caring, living caring uniquely in situation and growing in caring. In

nursing, practiced within the context of Nursing as Caring, the
person is taken at face value as caring and never needs to prove him
or herself as caring. The nurse, practicing within the context of
Nursing as Caring, is skilled at recognizing and affirming caring in
self and others. Being caring, that is, living one's commitment to this
value "important-in-self" (Roach, 1984), fuels the nurse's growing in
caring and enables the nurse I turn to nurture others in their living
and growing in caring. The values and assumptions of nursing as
caring can assist the nurse to engage fully in nursing situations with
persons in whom caring is difficult to discover.
Nursing knowledge is discovered and tested in the ongoing
nursing situations. Once experienced, nursing situations can be
made available for living anew, with new discovery and testing.
Aesthetic representation of nursing situations brings the lived
experience into the realm of new experience. Thus, the knowledge
of nursing can be made available for further study. Re-presentation
of nursing situations can occur through the medium of nursing
stories, poetry, painting, sculpture, and other art forms
(Schoenhofer, 1989). Aesthetic re-presentation conserves the
epistemic integrity of nursing while permitting full appreciation of the
singularity of any one nursing situation (Boykin & Schoenhofer,
1991). Here, then, is one nurse's story of a shared lived experience
in which the caring between nurse and the one nursed enhanced
personhood. This story is offered as an example of nursing situation,
re-presented as an open text, available for continuing participation
by all who wish to enter into this shared lived experience of nursing.
In fact, we invite the reader to enter into this nursing situation,
which may then be used in classroom or conference settings to
stimulate general or specific inquiry and dialogue.
CONNECTIONS
One night as I listened to the change of shift report, I remember the
strange feeling in the pit of my stomach when the evening nurse reviewed
the lab tests on Tracy P Tall, strawberry-blonde and freckle-faced,
Tracy was struggling with the everyday problems of adolescence and

fighting a losing battle against leukemia. Tracy rarely had visitors.
As I talked with Tracy this night I felt resentment from her toward her
mother, and I experienced a sense of urgency that her mother be with
her. With Tracy's permission I called her mother and told her that Tracy
needed her that night. I learned that she was a single mother with
two other small children, and that she lived several hours from the
hospital. When she arrived at the hospital, distance and silence
prevailed. With encouragement, the mother sat close to Tracy and I sat
on the other side, stroking Tracy's arm. I left the room to make rounds
and upon return found Mrs. P. still sitting on the edge of the bed
fighting to stay awake. I gently asked Tracy if we could lie on the bed
with her. She nodded. The three of us lay there for a period of time and
I then left the room. Later, when I returned, I found Tracy wrapped
in her mothers arms. Her mothers eyes met mine as she whispered "she's
gone." And then, "please don't take her yet." I left the room and closed
the door quietly behind me. It was just after 6 o'clock when I slipped
back into the room just as the early morning light was coming through
the window. "Mrs. P," I reached out and touched her arm. She raised her
tear-streaked face to look at me. "It's time," I said and waited. When
she was ready, I helped her off the bed and held her in my arms for
a few moments. We cried together. "Thank you, nurse," she said as she
looked into my eyes and pressed my hand between hers. Then she turned
and walked away. The tears continued down my cheeks as I followed her to
the door and watched her disappear down the hall.
Gayle Maxwell (1990)
This nursing situation is replete with possibilities for nurses, and
others, to understand nursing as nurturing persons living caring and
growing in caring. A dialogue ensues on the nursing situation that
allows participants an opportunity to experience both resonance and
uniqueness as personal and shared understandings emerge. As the
reader enters into the text, the nursing situation is experienced
anew, now within the presence of two nurses, not one. Though
intentionally entering the situation, the second nurse experiences d
affirms being connected in oneness with both nurse and nursed as
caring lived in the moment.
Gayle entered into Tracy's world that night open to hearing a
special call. Gayle's openness was partly a reflection of her use of
the empirical pathway of knowing, the data given in report, the
comparison of empirical observations against biological,
psychological, developmental, and social norms. Before discussing
our understanding of Gayle's response from the theoretical per-
perspective represented, it might be helpful to compare how the call
for nursing may have been interpreted if approached, for example,

from a psychological framework. If the nurse responded from a
psychological framework, the problem identified would perhaps be
conceptualized as denial on the part of Tracy's mother. It could be
assumed that Tracy's mother was avoiding the reality of the
impending death of her daughter. Here, the nursing goal would be
assist the mother in dealing with her denial by facilitating grieving.
Denial is only one psychological concept that could be applied in this
situation; avoidance, anxiety, and loss are others. When nursing care
is based on a psychological framework, however, the central theme
of care is likely to be deemphasized in favor of a problem-oriented
approach. The perspective offered by a normative discipline requires
a reliance on empirical knowing. Using only the empirical pathway of
knowing, the richness of nursing is lost.
Gayle's personal knowing, her intuition, however, was the pathway
that illuminated the appreciation of this situation and prompted her
acknowledgement of a call. She heard Tracy's call for intimacy,
comfort, and protection of her mother's presence as she (Tracy)
summoned courage and hope for her journey. Gayle intuitively knew
that the specific caring being called forth was the caring of a mother.
Gayle's caring response also took the form of the courageous
acknowledgement of a call for nursing that would be difficult to sub-
stantiate empirically. Beyond telephoning Tracy's mother, Gayle
continued her nursing effort to answer Tracy's call for the presence
of a mother as she supported Mrs. P. living her interconnectedness,
in being with Tracy. Gayle heard Mrs. P.'s calls for knowing, knowing
what to do and knowing that it would be right to do it, for the
courage to be with her daughter in this new difficult passage. Her
response of showing the way reflects hope and humility. The caring
between the nurse and the ones nursed enhanced the personhood
of all three, as each grew in caring ways. It is possible that the
caring between the original participants in the nursing situation and
those of us who are participating through engagement with the text
continues to enhance personhood.

REFERENCES
Boykin, A., & Schoenhofer, S. (1991). Story as link between nursing
practice, ontology, epistemology. Image, 23, 245-248.
Boykin, A., & Schoenhofer, S. (1990). Caring in nursing: Analysis of
extant theory. Nursing Science Quarterly, 4, 149-155.
Maxwell, G. (1990). Connections. Nightingale Songs, 1 (1). P.O. Box
057563, West Palm Beach, FL 33405.
Paterson, J., & Zderad, L. (1988). Humanistic nursing. New York:
National League for Nursing Press.
Roach, S. (1984). Caring: The human mode of being, implications for
nursing. Toronto: Faculty of Nursing, University of Toronto.
(Perspectives in Caring Monograph 1).
Schoenhofer, S. (1989). Love, beauty and truth: Fundamental nursing
values. Journal of Nursing Education, 28 (8), 382-384.
Watson, J. (1987). Nursing on the caring edge; Metaphorical vignettes.
Advances in Nursing Science, 10, 10-18.

CHAPTER IV. — IMPLICATIONS FOR
PRACTICE AND NURSING SERVICE
ADMINISTRATION
Foundations for practice of the Nursing as Caring theory rest on
the nurse coming to know self as caring person in ever deepening
and broadening dimensions. While all nurses may have (or at least,
may have had) a sense of self as caring person, practicing within this
theoretical framework requires a deliberate commitment to
developing this knowledge. In many settings where nurses find
themselves practicing, there is little in the environment to support a
commitment to ongoing development of a sense of self as caring
person. In fact, many practice environments seem to support
knowing self only as instrument, self as technology. When one
perceives of one's "nursing self" as a depersonalized, disembodied
tool, nursing tends to lose its flavor and the devoted commitment to
nursing burns out. So how to sustain and actualize this fundamental
commitment must be a point of serious study for the nurse who
desires to practice nursing as caring.
Mayeroff's (1971) caring ingredients are useful tools to assist the
nurse in developing an ever-present awareness of self as caring
person. Taking note of personal patterns of expressing hope,
honesty, courage, and the other ingredients is a good starting place.
Understanding the meaning of living caring in one's own life is an
important base for practicing nursing as caring. In reflecting on a
particular lived experience of caring, the nurse can seek to
understand the ways in which caring contributed freedom within the
situation—freedom to be, freedom to choose, and freedom to unfold.
Because nursing is a way of living caring in the world, the nurse
can turn his or her attention to personal patterns of nursing as

expressions of caring. As self understanding as caring person
accrues, the nurse sometimes realizes that such self-awareness was
there all along—it was only waiting to be discovered. Because many
nurses were trained to overlook their caring ways instead of
attending to them, nurses may now need something similar to, or
indeed "sensitivity training" itself, to rediscover and reown the
possibilities of self as caring person, possibilities specific to nursing
as a profession and a discipline. This redirection of focus away from
caring may have been related to several historical social movements.
First, of course, is the move toward science, which for nursing meant
that for a period of several decades nursing education seemed to
reject, either partially or totally, the art of nursing in order to
discover a scientific base for practice. Another related process, the
technology movement, led nurses to understand care as a series of
sequential actions designed to accomplish a specifiable end. In this
context, nursing care became synonymous with managing available
technologies. Third, there existed in the history of nursing education
an era(s) in which nurses were taught to treat symptoms patients
expressed, rather than to care for the person. Fourth, maintaining a
professional distance was a hallmark of professionalism. Now, and
rightly so, the tide has turned. A reawakening of knowing self as
caring person becomes paramount so that the profession of nursing
returns caring to the immediacy of the nursing situation.
With personal awareness and reflection, developed knowledge of
caring also arrives through empirical, ethical, and aesthetic modes of
knowing. There is a growing body of literature in nursing that both
attests to that fact and to the process of how nurses communicate
caring in practice (e.g., Riemen, I 986a, 1986b; Knowlden, 1986;
Swanson-Kauffman, 1986a, 1986b; Swanson, 1990; Kahn and
Steeves, 1988). Given the various perspectives offered by the
authors just mentioned, the individual nurse can enhance his or her
ethical self-development as a caring person by cultivating the
practice of weighing the various meanings of caring now extant in
actual practice situations and then by making choices to express
caring creatively. In pursuit of this end, aesthetic knowing often

subsumes and transcends other forms of knowing and thus may
offer the richest mode of knowing caring. Appreciating structure,
form, harmony, and complementarity across a range of situated
caring expressions enhances knowing self and other as caring
persons.
Knowing self as caring enhances knowing of the other as caring.
Knowing other as caring contributes to our discovery of caring self.
Without knowing the other as caring person, there can be no true
nursing. Living a commitment to nursing as caring can be a
tremendous challenge when nurses are asked to care for someone
who makes it difficult to care. In effect, it is impossible to avoid the
issue of "liking" or "disliking" the patient. Is it possible to truly care
for someone if the nurse doesn't like him or her? In this light,
another question arises: How can 1 enter the world of another who
repulses me? Am I expected to pretend that this person (the
patient) has not treated others inhumanely (if that is the case)?
Must I ignore the reality of the other's hatefulness toward me (if
such exists)? These are questions that come from the human heart.
They express legitimate human issues that present themselves
regularly in nursing situations.
The commitment of the nurse practicing nursing as caring is to
nurture persons living caring and growing in caring. Again, this
implies that the nurse come to know the other as caring person in
the moment. "Difficult to care" situations are those that demonstrate
the extent of knowledge and commitment needed to nurse
effectively. An everyday understanding of the meaning of caring is
obviously inadequate when the nurse is presented with someone for
whom it is difficult to care. In these extreme (though not unusual)
situations, a task-oriented, non discipline-based concept of nursing
may be adequate to assure the completion of certain treatment and
surveillance techniques. Still, in our eyes that is an insufficient
response—it certainly is not the nursing we advocate. The theory,
Nursing as Caring, calls upon the nurse to reach deep within a well-
developed knowledge base that has been structured using all
available patterns of knowing, grounded in the obligations inherent

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