Abstract The purpose of this paper is to describe nursing as caring as a model for transforming practice. The purpose is achieved through presentation and analysis of nursing situa- tions offered by a staff nurse in an Emergency Services Department and the nurse di- rector of that department. The analysis of these situations of caring betvreen nurse and nursed illuminates the power of theory-based practice focused on enhancing living grounded in caring.

Key Words: Nursing as caring, caring, nursing theory, emergency nursing, transformative

Introduction Theory-based practice has long been

envisioned as a move forward in nursing. Having nursing practice grounded explicitly in theories of the discipline could contribute to two important objectives: coherent, effective patient care and coherence within the practice discipline of nursing as a learned profession. Tbe desire to improve coherence and effectiveness of patient care has led to the call for evidence-based prac- tice in the discipline with evidence-based practice focusing primarily on the use of de- veloped and tested middle-range theory. Arising largely at the impetus of a similar move in medicine, there are currently multi- ple and diverse perspectives of the precise meaning of evidence-based practice in nurs- ing (Banning, 2005). Regardless of the ab- sence of consensus in meaning, interest in evidence-based practice has greatly ex- panded nurses’ awareness of the value of middle-range theory and signals a growing maturity in nursing as a discipline, as a practiced discipline, and as a disciplined practice. However, as the authors of this paper, and others such as Reed (1995)

advocate, the role of grand theory as a trans- formative framework for coherent nursing practice cannot be minimized.

Connections between Middle-Range Theory, Evidence-Based Practice, and

Grand Theory Although the role of grand nursing the-

ory, or as Kikuchi (1997) terms it, nursing philosophical frameworks is not universally accepted and perhaps not universally under- stood, the evidence in the practice literature is mounting that nursing practice is increas- ingly being grounded in an explicit grand nursing theory. Further, the popular use of generic concepts of caring, unrelated to an organized nursing theoretical perspective, has not resulted in the hoped-for transfor- mations. The purpose of this paper is two- fold: (a) to propose that transformation of practice beyond the superficial or cosmetic requires the use of a fully developed con- ceptual system known as a grand nursing theory and (b) to demonstrate the value of the theory of nursing as caring (Boykin & Schoenhofer, 2001a) as a productive fVamework for transforming practice that enhances coherence and effectiveness (Boykin, Bulfin, Baldwin, & Southern, 2004).

Some may ask the question, “Why, when we have emerging middle-range theories of caring for nursing, do we need grand nurs- ing theories focused on caring?” or “Why grand nursing theories, when the clarion call in nursing seems to be for evidence- based practice, reflecting middle-range the- ories, rather than philosophic or grand theories?” Understanding answers to these questions requires, in part, that we address the failure of eclecticism in nursing practice frameworks. Successfully mixing and matching bits and pieces drawn iTom di- verse internally coherent conceptual sys- tems necessitates the disciplined development of a new conceptual system, a new philosophic theory of nursing that inte- grates the bits and pieces into a new harmo- nious whole. Often what we see in practice settings are efforts to create “eclectic” frameworks without doing the work of con- ceptual integration. Those well intentioned efforts are almost always undertaken in a desire to create a model for collective prac- tice that enhances coherence and supports a number of interrelated outcomes of care for patients as well as achievement of interre- lated goals for the nursing service and its larger healthcare system. A review of the nursing and healthcare literature, however, reveals very few enduring successes. Personal communication with colleagues reveals considerable disappointment in re- sults with ad hoc or eclectic frameworks for nursing. This pattern of disappointment seems likely to be repeated as evidence- based practice replaces earlier idealized models like shared governance and continu- ous quality improvement. Why? Because when there is no rigorously worked out grand nursing theory, no overarching sys- tem of clear and justifiable interrelated nursing values and concepts, certain desir- able though perhaps previously unarticu- lated nursing aims slip through the cracks.

Middle-range theory, the kind of theory that is most likely to serve as the immediate basis for evidence-based practice, is con- structed from a particular persp)ective or

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point of view most often, however, that point of view is unarticulated and perhaps even functions out of direct awareness of the theorist. Further, some middle-range theories are congruent with some grand philosophic nursing perspectives and not congruent with others. In order to create a coherent conceptual pattern for nursing practice, middle-range theories need to be selected that are compatible with the over- arching grand nursing theoretical perspec- tive. This coherence is most likely when the associated grand nursing theory is made ex- plicit. Examples of successful middle-range theories about caring in nursing that were developed from within an explicit grand nursing theory are Locsin’s (1995, 1998) technological competence as caring (related to Boykin and Schoenhofer’s nursing as caring) and Swanson’s (1991) middle-range theory of caring (related to Watson’s transpersonal caring).

Having briefly addressed the important role of explicit grand nursing theory as a necessary umbrella for middle-range theory and subsequent coherent evidence-based practice, we will tum now to one particular grand nursing theory, Boykin and Schoenhofer’s (2001a) nursing as caring. We will present a brief overview of the major assumptions and ideas of the theory. The remainder of the paper will focus on a description of creative, coherent, and com- prehensive processes and outcomes of care that emerged from the use of a transforma- tive practice model based on nursing as car- ing (Boykin et al., 2004).

An Overview of the Theory of Nursing as Caring

The underlying structure of the nursing philosophical system or grand theory of nursing as caring is created by the assump- tions of the theory and their interrelation- ships (Boykin & Schoenhofer, 2001a). These assumptions, in summary, begin with the most fundamental idea, that all persons are caring by virtue of their humaruiess, that to be human is to be caring. A deep under-

standing of the practical meaning of that foundational assumption leads to additional assumptions that further structure the the- ory: that personhood is living grounded in caring; that caring is lived moment to mo- ment, in relationship with caring others; and that nursing as a discipline and profession of caring is oriented not towards diagnosing needs nor compensating for deficiencies but has, as its focus, nurturing persons living caring and growing in caring. The concept of nursing situation is a key one for the practical use of the theory. It is posited that all nursing takes place in nursing situa- tions—shared, lived experiences in which the caring between nurse and nursed en- hances personhood. Thus, all nursing is cre- ated in this special relation called caring between. The nurse enters intentionally into the world of the other in order to come to know the other as person living caring uniquely in the moment and expressing per- sonal dreams and aspirations for growing in caring. In this “coming to know,” the nurse offers a direct invitation to the other to ex- press calls for nursing, calls for caring in re- lation to that which matters to the person. The nurse responds to calls with nurturing responses of caring created for the moment. Another key element of nursing as caring is the “dance of caring persons.” This image was created to express the egalitarian nature of nursing, the idea that all who participate in or connect with the nursing situation have a contribution to make to the caring that is being created and expressed. The dance of caring persons illustrates fluid connectedness among persons intentionally engaged in a shared caring enterprise.

Transforming Practice The process of transforming practice

takes time, courage, and a commitment to live nursing. Transformation begins as nurses refocus their lenses for nursing prac- tice. Practice shifts from a normative per- spective, where it is directed by the medical diagnosis and treatment, to an understand- ing that the unique focus of nursing is nur-

ttiring persons living caring and growing in caring. This focus of nursing calls for an un- derstanding of relationships grounded in caring, relationships that value the impor- tance of person-as-person. The essence of nursing is embedded in the nursing situa- tion, the shared lived experience in which the nurse intentionally enters the world of the one nursed to come to know those nursed as caring person and to nurture and support their livhig and growing in caring. The nurse also allows self to be known as caring person, participating in the shared creation of a relationship of mutuality.

The concept of “living and growing in caring” takes on substantive meaning as nurses reflect on their own personal expres- sions of living caring day-to-day. This un- derstanding can be facilitated through the study of Mayeroff’s (1971) caring ingredi- ents: knowing, patience, alternating rhythms, hope, courage, trust, and honesty. Coming to know self as caring enhances the nurse’s ability to know and appreciate unique expressions of caring of those nursed.

The following nursing situation, shared by a nurse whose practice is grounded in the theory of nursing as caring, is offered to ad- vance practical understanding of the prac- tice model based on the transformative theory of nursing as caring:

I went to work as usual, my normal Wednesday morning. I got to work and we were not all that busy, so I was asked to float. I heard an overhead page of a Code Pink. I talked to the charge nurse and she told me an 18- month old was hit by a car and would be here in 15 minutes. The tension of the staff was palpable, as we all knew how especially tragic it is to have such a young patient with a traumatic injury. When the child arrived there was the typical flurry of activity. The child was an adorable blond hair, brown-eyed lit- tle girl. Her left side of her head was boggy and you could see where the tire marks went over her. She had a cdch, two intraosseus IVs, and was being

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resuscitated. I assessed the child with the other nurses and performed my re- sponsibilities to the best of my ability. We gave her numerous medications and placed a chest tube for a pneu- mothorax. You could feel the tensions rise with each failed effort to save this child. I mentioned to the pediatric in- tensivist that the parents should be with her. Several minutes later, the parents were invited to be with their child. When the parents walked in, my heart froze. I realized that I knew the parents of this little girl. I knew that I had to have courage knowing them personally and I needed to be strong, and have hope for this family. When the mother recognized me, she said “Oh, Anne, thank God you are here, please help save our baby!”

I went to the nfiother and hugged her. She and her husband were very sup- portive and patient as they watched us work over their daughter ever so dili- gently. I brought them close to their daughter. The parents, I’ll call them Ellen and James, were both telling the child to fight and live, “You can do it!” they would say. After 30 minutes, the doctor told finally acknowledged, “Her heart is not beating, and she is not breathing on her own.” The mother fell to her knees and cried. All I could do was to comfort her by being with her. The parents were allowed to hold baby Melissa as long as they wanted. I re- mained in the room with the family but I also allowed them space to grieve silently. I was there if they needed me.

Ifl had not studied nursing as car- ing, if we had not developed and been using the practice model based on the theory in the ED, my care would have been different—objectified—I would have responded to the situation focused on the protocols for trauma—I would have seen the baby as a diagnosis and I wouldn’t have been involved person- ally. The theory-based model of care helped me focus on person. Through

the family, I came to know the baby and the family as caring persons and to enter into the whole of the situation with intimacy, honoring persons as car- ing—I felt as though I had truly nursed.

Coining to Know Person as Caring The nurse entered this nursing situation

with the intention of knowing the nursed as caring person in the moment. The question guiding her being in relationship was: who are the persons as caring persons and how can I nurture and sustain them as they live their caring uniquely? This nursing situation demonstrates that in a mutually lived expe- rience of caring between the nurse and nursed, a knowing occurs that enhances personhood. Both nurse and nursed live and grow in caring.

The nurse expressed her caring as she drew on empirical knowledge to care com- petently, “I assessed the child with the other nurses and performed my responsibilities to the best of my ability.”

This nurse understood that participating competently in the use ofthe various life- sustaining technologies was an expression of her caring (Schoenhofer & Boykin, 1998b). This connection between compe- tence and caring was addressed in the nurs- ing as caring practice model, augmented by Locsin’s (1995,1998) middle-range theory of technological competence as an expres- sion of caring. She demonstrated courage and a commitment to the value of person- as-person in suggesting to the intensivist that the parents be allowed to be present as efforts to save their daughter continued. The personal knowing ofthe nurse in realizing that parents and child belonged together and the professional knowing that survival for the child was very tenuous came together so that the nurse was encouraged to risk mak- ing the suggestion. In taking the risk, trust was fostered in this situation and the way was opened for the nurse to intimately enter the world of those nursed. Through the nurse’s way of listening and communicat- ing, a relationship evolved in which both the nurse and family experienced connect-

edness, a sense of oneness. This phenome- non is called the “caring between.” In this very special space created by nurse and par- ents, the nurse was able to know and sup- port the parents living caring and growing in caring. The parents expressed trust in the competence of the staff and the staff mem- bers were able to develop trust in the com- petence of the parents to be present in ways that mattered. Parents and nurse lived active patience in silently participating in the child’s care. In humility, nurse and parents lived, through their actions, in hope that everything humanly possible would be done to save the life of the child.

Calls for Nursing In order for calls for nursing to be heard,

the nurse, as in this situation, must be fully immersed in the nursing situation. The in- tention of this nurse’s presence was in itself a “direct invitation” (Boykin & Schoenhofer, 2001a, p. 59) to know person as caring. It created an openness for per- sonal knowing that allowed the nurse to hear the family’s unique calls for nurturing personhood. Examples of calls for specific forms of caring included the call:

• To support and sustain hope in the mo- ment.

• To be one with the family. • For comfort and support. • For exceptional knowledge of technol-

ogy and competence in technological expressions of caring for the person.

The Nursing Response The nursing response is an expression of

the nurse living caring uniquely and cre- atively in the moment. The response refiects who the nurse is as person and as nurse. In this situation, the nurse responds to the fam- ily’s desire to be recognized and supported in their living of caring. Through living courage and trust the nurse sustained the hope ofthe parents by inviting them to share in this experience with their daughter. She expressed an understanding of the call for connectedness as she lived active

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patience in allowing the family to hold their daughter as long as they wanted and gave them space to grieve silently.

This exemplar illustrates the fullness of nursing when practiced from the theoretical framework of nursing as caring. The process of transformation begins as the nurse comes to know self as caring person. In the nursing situation described above, the nurse had been an active participant in de- signing a practice model unique to the set- ting, a model grounded in nursing as caring. As this understanding of self as caring per- son grows, the way one lives changes as caring becomes the compass for making de- cisions. The heightened awareness of self as caring person allows one to connect with others in a way that honors humanness and celebrates uniqueness. It is this continual growing in knowing self as caring that de- velops the nurse’s skill to know and affum caring in others. It is this understanding that enables the nurse to nurture others as they live their caring and grow in caring ways.

Practice grounded in nursing as caring holds at its heart the importance of person- as-person; person as caring. The focus of nursing is knowing person as caring and nurturing them in their living caring and growing in caring. It calls for the nurse to truly know what matters most to those nursed and to respond with specific expres- sions of caring. Practicing from this frame- work assures the practice of nursing—a practice that is informed by an expertly de- veloped knowledge base of caring.

The Dance of Caring Persons: Creating a Caring Environment

The assumptions of nursing as caring can guide the way of relating—the way of being—at an organizational level. Within the belief that all persons are caring is woven the understanding that cultures are comprised of caring persons. Therefore, persons in systems are called to know self and other as caring and to support living and growing in caring. This perspective is in direct contrast to that which exists in many healthcare systems today. Healthcare

organizational structures typically reflect only bureaucratic values and beliefs. The hierarchical way of relating, a dominant characteristic of bureaucratic organizations, engenders impersonalization, competition, and authoritarianism.

The dance of caring persons (Boykin & Schoenhofer, 2001a) is a model for relating that is based in the assumptions of the the- ory of nursing as caring. It is a dance, repre- sented by an open circle, in which each person brings his or her special gifts that are directed toward the coming to understand that which matters to those seeking care and responding to that understanding. In the dance of caring persons, the dancers are the same individuals who were in the hierarchi- cal structure but are now encouraged in a way of being with each other that conveys respect for and honoring of person-as-person.

In this dance, all dancers are valued, re- spected, and supported in their unique role (e.g., nursing, medicine, respiratory care, dietary, radiology, volunteers, etc.) without the encumbrances of power and authority differentials and positional importance re- stricting their unique contribution to the dance—with the dance being the venue for expressing personal and shared caring (Boykin & Schoenhofer, 2001b). It is as- sumed in this model that each dancer is a caring person and that each discipline is valued. Following are the reflections of a Director of an Emergency Department (ED) on the transformations brought to the ED with the creation of a practice model grounded in the theory of nursing as caring:

In creating and supporting a model of care grounded in nursing as caring, it was essential for me as a nursing leader to understand, embrace, and clearly ar- ticulate, in words and lived experi- ences, the core assumptions of this theory. Modeling in this fashion helped to capture the hearts and hands of nurs- ing service personnel who truly are the front line interface with patients and their significant others.

In the beginning, nursing as caring was so totally unique in its conceptual

foundation that I found myself to be resistant. I realized that I had not come to know myself as caring person. It is crucial the leader first know self as caring person and identify personal ways of living and growing in caring. Through this knowing, one can more easily “see” others (both professionally and personally) as living caring and honoring their unique expressions. Commitment to knowing myself as caring person opened for me the oppor- tunity to know staff as caring persons and to realize how important my role was to nurturing their living and grow- ing in caring. I had to let go and trust staff and not exert my positional au- thority. I had to see myself as one of the performers in the dance of the car- ing persons but not as pre-eminent. Everyone had equal value and con- tributed to the dance we were creating. As I continued to immerse myself more in the theory, I came to see the total practicality and “obviousness” of its tenets. It was then much clearer to me that the implementation of nursing as caring could indeed transform the practice of nursing.

It became my role to create an envi- ronment, or “culture,” that promoted, supported, and sustained caring as the foundation for nursing service. In real- ity, this is the very focus of all nursing (whether it be at the service level or the administrative level) to nurture f»ersons living and growing in caring. In order for this transformation to occur there must be a commitment to intentionally focus on creating this caring-based cul- ture. That is, time and effort must be afforded in a planned fashion in order for change, and then maintenance, of this nature to occur. Individuals must have opportunities to dialogue on nursing as caring. They need support from leadership to make explorations into this new territory—explorations that will expectedly not always be successful in and of themselves, but

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will certainly yield discoveries and learning that will eventually lead to success over time.

The exemplar of the nursing situa- tion you encountered earlier was a di- rect result of the culture change in our department as a result of exploring nursing as caring. In fact, over time, many of the staff today share their nursing situations in staff meetings and through the dialogue we are growing in our understanding of unique expres- sions of living caring in practice.

We have made a number of changes in our departments as a result of our implementing nursing as caring (Boykin et al., 2004). The following questions guide our decisions: “What is the right thing to do, being grounded in the values of nursing as caring?” “What is best for the patient or staff?” The answers to these two very heavy questions do not always provide easy answers, but they do offer a compass to guide us through the maze of possible answers.

Coming Full Circle We introduced this paper by proposing

two reasons why the ideal of nursing prac- tice grounded in caring requires the deliber- ate and consistent use of an explicit nursing theoretical framework. Those reasons are the facilitation of coherent, effective patient care, and coherence within the practice dis- cipline around the idea of nursing as a learned profession. We have presented two stories of nursing and nursing administra- tion practice and discussed these stories in

relation to the transformative value of an explicit nursing theoretical framework, the theory of nursing as caring. Patient care grounded in a practice model based on nurs- ing as caring has been demonstrated to be coherent and effective, enhancing person- hood of all participating in the dance of car- ing persons (Boykin et al., 2004; Boykin, Schoenhofer, Smith, St. Jean, & Aleman, 2003; Schoenhofer & Boykin, 1998a, 1998b) The practice model described by the ED nurse and the ED nurse administrator has been shown to provide clear and consis- tent guidance for creative and personally satisfying coherence. A thoroughly devel- oped ethical, conceptual, and language system, a nursing theoretical framework grounded in caring, is a key element in bringing to fruition an effective, coherent practice model. Nursing as caring is one such framework.

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Boykin, A., Bulfin, S., Baldwin, J., & Southern, S. (2004). Transforming care in the emergency department. Topics in Emergency Medicine, 26(4), 331-336.

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Schoenhofer, S., & Boykin, A. (1998a). The value of caring experienced in nursing. International Journal for Human Caring, 2(4), 9-15.

Schoenhofer, S., & Boykin, A. (1998b). Discovering the value of nursing in high tech environments: Outcomes revisited. Holistic Nursing Practice, 72(4), 31-39.

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Author Note

Anne Boykin, Professor and Dean, Christine E. Lynn College of Nursing, Florida Atlantic University, Boca Raton, Florida; Savina O. Schoenhofer, Professor, Department of Graduate Nursing, Alcorn State University, Natchez, Mississippi; Susan Bulfin, Research Project Director, Christine E. Lynn College of Nursing, Florida Atlantic University, Boca Raton, Florida; John Baldwin, Director of Emergency Services, Boca Raton Community Hospital, Boca Raton, Florida; and Dee McCarthy, Chief Nursing Officer, Boca Raton Community Hospital, Boca Raton, Florida.

Correspondence concerning this article should be addressed to Anne Boykin, Christine E. Lynn College of Nursing, Florida Atlantic University, 777 Glades Road, Boca Raton, Florida, 33431-0991 USA. Electronic mail may be sent via Internet to boykina@fau.edu

The authors gratefully acknowledge the contributions of Ann Mon, RN, Staff Nurse, Emergency Services Department, Boca Raton Community Hospital, Boca Raton, Florida.

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