Running head: THE ART OF CARING

The Art of Caring By Joan A Kronlein RN October 13, 2012 NUR 450/VL2

THE ART OF CARING

Abstract All nurses know what care and caring are in terms of patient care. The art of caring in nursing is an issue because it cannot be accurately and totally defined and measured, although surveys are able to measure some components. Caring behaviors are based on patient perceptions of what caring behaviors or a caring relationship looks like. Measurement is important for evidencebased practice and for quality and safety issues as they relate to patient satisfaction. Patient satisfaction relates to perceptions of caring behaviors from nursing staff, thus caring behaviors have an impact on patient outcomes. Caring assessment and research for best practice are a part of the American Nurses Associations: Scope and Standards of Practice which impacts the Quality and Safety Education for Nurses (QSEN) competencies.

THE ART OF CARING The Art of Caring The art of caring has been synonymous with nursing in the literature. Many believe caring is what nursing does and is; it defines the essence of nursing itself (American Nurses Association, 2010). Others believe that caring is an umbrella for what nursing does but does not define nursing (Sargent, 2012). This is the issue that surrounds caring in the nursing world. Nurses know that they care for and care about patients, this is not the issue. The issue surrounds defining what it is that nurses uniquely do. Nursing governing bodies have a difficult time describing what nursing does in terms of caring. According to Watson (1999, 2008) in the American Nurses Association (ANA) (2010), Central to nursing is the art of caring, which is represented in the personal relationship that the nurse enters with the patient[but] goes beyond the emotional connections of humans to the

ability to respondand involves spirituality, healing, empathy, mutual respect, and compassion. These intangible aspects foster health [emphasis added] (p. 23). Key to the issue is the word intangible. Intangible implies un-measureable. Because of the shift in nursing and all health care to focus on research and evidence based practice (EBP), nurses must base their practice on what research and evidence says is best (Haas, 2008). Research has shown that caring relationships between patients and nurses give better patient outcomes (Ervin, 2006). To quantify what is best has to involve measuring outcomes, but to measure outcomes the input, or caring, must also be measured. This measurement of caring is, therefore, the issue. Nursing seeks to measure the impact of nursing caring behaviors on perceived patient care satisfaction, and, therefore, quality care compared to nursing non-caring behaviors (PICO question). The following will look at defining care and caring behaviors; theories of caring and

THE ART OF CARING relational care from nursing, medicine, and management perspectives; the environment, particularly the nurse work environment and how caring is impacted; and an analysis of Quality and Safety Education for Nurses (QSEN) related to ANA standards related to implication/inferences for nurses. Caring: What is it? And can it be measured? Caring can have many different meanings in a cultural context. What one individual thinks are caring behaviors, another might not. The same is true for nurses. What a nurse thinks is caring behavior, the patient might not. In a literature review, Patistea and Siamanta (1999) found that patients hold a traditional perception of caring based on tasks, duties, and manual skillsNurses view, on the other, shows a stronger orientation toward the psychosocial and human aspects of caring (p. 308). The authors go on to say the study results presenting caring

as the performance of basic nursing care activities are in accordance with Maslows hierarchy of needs[and] nurses may need to demonstrate their scientific knowledge and technical skill to meet basic needs[prior to] addressing the emotional and affective aspects of caring (p. 308). Prior to caring the patient must be willing to accept caring from the nurse. Also, the nurse must have a work environment that allows the ability to care, a moral ability to be caring, and the maturity to understand life situations (ANA, 2010; Finfgeld-Connett, 2008). Caring is an interpersonal process that is characterized by expert nursing, interpersonal sensitivity and intimate relationships (Finfgeld-Connett, 2008, p. 198). According to Valentine (1989) in Patistea and Siamantas (1999), Caring meanings and behaviors are context specific and suggest that nurse clinicians should determine caring needs and actions in the context of practice (p. 310). Jean Watson as referenced in Jasmine (2009),

THE ART OF CARING describes caring as an attribute or a calling of moral commitment toward protecting human dignity and preserving humanityCaring includes attention to and concern for the patient, individual responsibility for or providing for the patient at some level, and regard for, fondness for, or attachment to the patient (p. 416).

So caring is a moral calling which provides attention, responsibility, attachment and fondness for and towards a patient (Jasmine, 2009) and is specific to a situation (Papastavrou et al., 2012; Patistea & Siamanta, 1999). Leininger (1988) in ANA (2010) states, Care is essential to human growth and survival, and to face death. There can be no curing without caringand it is transcultural (p. 25). At the other end of the debate on caring, Curzer in Warelow, Edward and Vinek (2008) states caring leads to stress, burnout, and job dissatisfactionand healthcare professionals should not care for their patients, rather be benevolent and act in a caring manner (p. 148). This is not the position of the ANA, but a valid point and the opposite end of the spectrum from a true connection with the patient. Warelow, Edwards, & Vinek (2008) summarize caring as a combination of both which fluctuates between caring and non-caring because of patient and nurse diffierences. Care and caring are individual perceptions of each patient in a unique patientnurse relationship. To summarize, care and caring can be seen as providing basic tasks and duties in a competent manner (Patistea & Siamanta,1999), a moral commitment or calling (Jasmine, 2009), can fluctuate between caring and non-caring, can cause or create a relationship or it can be benevolent (Warelow, Edwards, & Vinek, 2008). It is preceded by openness to a caring relationship and nurse maturity (Finfgeld-Connett, 2008). It is not the same for every person or situation (Patistea & Siamanta, 1999).

THE ART OF CARING Can care and caring in totality be measured? Patients measure care everyday by telling people whether or not they felt cared for and equate this with quality (Nursing Standard, 2012). On the other hand, how can something so individual, relational, and time bound be measured to

increase quality outcomes? This author suggests not analyzing caring and what it is, but realizing that we do care and caring to all the degrees listed above which impacts how patients view care which, in turn, impacts patient satisfaction and quality of care perceptions. It is the patients perception that matters. Interdisciplinary Theories on Caring Just as nursing cares for patients to the extent above, care theories are available in other disciplines that align with that of nursing. They are all about relationships between people. In nursing, Jean Watson asserts that caring seeks to connect with, and embrace, the spirit or soul of the other through the processes of caring, healing, and being authentic (Warelow, Edward, and Vinek, 2008, p. 148). Caring is both a value and an excellence (ANA, 2010, p 75). This can be applied to other relationships as well. In palliative medicine, Care is a nebulous concept[and] absorbs a range of rich and complex meanings, designating something that is deeply important and difficult to define (Jannsen, Macleod, and Walker, 2008, p. 389). This aligns with nursing definitions of caring. In medicine, education of caring has been neglected, but is key to helping people who are suffering have quality of life. The authors propose changing how medicine educates students to incorporate human caring. In business management settings, Autry (1991) states Good management is largely a matter of loveOr call it caring because proper management involves caring for people not manipulating them (Introduction). This follows with the theory of Transformational Leadership

THE ART OF CARING which inspires a vision by understanding or caring about what is important to others (YoderWise, 2010). The authors connect caring in different contexts, just as caring for an individual in nursing involves understanding what caring is in the setting, in this case, the healthcare setting. Healthcare Environment It is common knowledge that the healthcare environment is in transition. Hospitals have cut nursing staff or have frozen the hiring of nurses. This has put strains on nurses caring for patients. The health care environment is imperative to maintaining the caring relationship

between the nurse and the patient. This environment impacts patient safety, satisfaction and thus quality of care (Yoder-Wise, 2010). The healthcare environment involves not only staffing ratios (processes), but technology, finances, and attitudes of the organizations (Yoder-Wise, 2010). A root cause analysis defines the multiple sources or systems of breakdown for a poor environment for caring. Root Cause Analysis: Why nurses dont care. The findings in a healthcare (nursing) root cause analysis are safety issues (the finding), which equates to lack of quality care (Ervin, 2006). The lack of quality care and patient dissatisfaction with nursing care can be the result of nurses not having time to care. This results from (perhaps) inadequate staffing; lack of finances; low morale; lack of leadership and lack of investment in nursing; other priorities like being a for-profit organization; and the organizational structure. A nurse may not provide care because of personal qualities of; personal history, inability, lack of training, or psychological barriers. This Root-cause analysis shows some potential reasons that patients perceive an uncaring nurse encounter.

THE ART OF CARING The following are implications and inferences (related to the root-cause analysis within the healthcare environment) for creating care and caring between the nurse and patient. Implications For nurses to provide an environment that allows nurses to care, nurses must become less involved in the tasks of their job and more focused on the complex care needs of their individual patients (Warelow, Edward and Vinek, 2009, p. 151). If nurses are given an

environment that allows them to care, then there will be decreased staff dissatisfaction, increased recruitment, and retention of nursing staff. This environment features adequate healthcare personnel, managers that foster caring relationships with patients, and strong caring leadership (Warelow, Edward, & Vinek, 2009). Technology allows easier and quicker access of information, thus freeing up time for the nurse to interact with the patient in the caring relationship. Technology has the potential to improve the practice environment for nurses, as well as patients and families (Yoder-Wise, 2010, p. 198) and can improve decisions, quality and safety, and decrease costs. (Yoder-Wise, 2010). By creating an environment where nurses can have a caring relationship with patients there will be financial rewards (Warelow, Edward and Vinek, 2010, p. 151). Financial rewards are due to less staff call-ins, and nurse retention. Attitudes of organizations aid in creating an environment for caring. Attitudes of organizations with magnet status have obtained nursing structural empowerment. Magnet organizations create empowerment by having Solid structures and processes developed by influential leadership [that] provide an innovative environment where strong professional practice flourishes and where the mission, vision, and values [(of caring)] come to life to achieve

THE ART OF CARING the outcomes believed to be important for the organization (American Nurses Credentialing Center (ANCC), 2008, p. 5). All nurses need to be competent in basic skills (ANA, 2010) but perhaps in a given setting the patient sees caring as being really great at technical skills, another person would see giving information as a caring behavior (Cossette, Cote, Pepin, Ricard, & DAoust, 2006). The ANA (2010) suggests that this is part of the assessment and planning processes within Standard 1 and 4. QSEN defines patient centered care as recognize[ing] the patient or designee as the source of control and full partner in providing compassionate and coordinated care based on

respect for the patients preferences, values, and needs (patient centered, definition). This aligns with ANA Standards 1, 4, and 5. Knowledge and skills for this QSEN competency have to do with communicating with diverse peoples, and communication skills. Necessary attitudes for this competency are putting oneself in the perspective of the patient and communicating about care needs. The QSEN definition of EBP is to integrate best current evidence with clinical expertise and patient/family preferences and values for delivery of optimal care (EBP, definition). The QSEN competency of EBP aligns with ANA Standards 1 and 4, as well. Knowledge under this area has to do with describing EBP as including components of research evidence, clinical expertise and patient/family values. The QSEN competency of Quality Improvement (QI) states, nurses use data to monitor the outcomes of care processes and use improvement methods to design and test changes to continuously improve the quality and safety of [the] health care system (QI, definition). Knowledge within this competency is to explain the importance of variation and measurement in assessing quality of care (QI, knowledge, para.4). Assessment (part of ANA Standard 1) within this area can be in the form of caring behavior research through the use of specific tools

THE ART OF CARING

10

that measure different aspects of caring. This also follows ANA (2010) Standard 9 which states The registered nurse: participatesin the formulation of evidence based practice through research (p. 51). . One such tool is the Caring Nurse-Patient Interaction Scale (CNPI-Short Scale) which measures humanistic care, relational care, clinical care, and comforting care (Cossette et al., 2006, p. 198). The authors of the CNPI-Short Scale acknowledge that Measuring caringon patient outcomes is a priority,[but] the concept is not entirely empirical (Cossette, et al, 2006, p. 212). The QSEN of safety is impacted by care/caring by understanding the care environment. As the root cause showed, there are environmental factors that affect caring behaviors, but are also safety problems, like decreased staffing due to budget restrictions. According to ANA (2010) Standard 10, The registered nurse: participates in quality improvement. Activities may include: analyzing organizational systems for barriers to quality healthcare consumer outcomes (p. 53). This can be accomplished through a root cause analysis. The root-cause analysis is a retrospective review of an incident [in this case, lack of caring and therefore quality] to identify the sequence of events with the goal of identifying the root causes (Yoder-Wise, 2010, p. 405). The ANA standards above align with the QSEN competencies of patient centered care, evidence-based practice (EBP), and quality improvement and are interrelated within the issue of caring. Thus, this system of organizational care, which incorporates ANA and QSEN competencies, relating to staffing processes (patient centered care, EBP, quality improvement, technology, finances, and attitudes) is the health care environment. This environment affects patient satisfaction and therefore quality of care. This environment needs to be one that

THE ART OF CARING

11

empowers nurses to deliver care and caring. A balance in the care environment to allow for care will increase patient perceived quality and safety of care outcomes. Inferences Within the healthcare environment, the nurse uses her assessment skills to understand what behaviors the individual patient views as caring. The nurse uses surveys to best quantify what caring is and can use this information for evidence based practice regarding care to affect quality and safety outcomes. The nurse can use root-cause analysis to study lack of patient satisfaction to determine why a patient did not perceive quality of care. At the outset of this analysis, the art of caring seemed simple to dissect but in reality it is a debate about what nurses do. Caring is truly an elusive term to define, but every nurse knows what it is and perhaps what it looks like, not that all nurses demonstrate it all the time. The problem is trying to define it to then measure it to put it into the realm of science. The science of nursing says we need to be able to track outcomes based on inputs. Research has shown that caring makes a difference in patient outcomes as evidenced by patient satisfaction which then equates to quality care. This is why some want to quantify it, and to understand what it is. After doing the research, it is not possible to totally quantify it. This is why caring in nursing is termed an art (Jasmine, 2009). The total health care environment impacts a nurses ability to provide care. The health care environment from the top down (administrators and processes, to the individual nurse) has to create the caring environment. Many have tried to come up with a specific set of behaviors that represent caring, but the list is then exhaustive, because again, it is individual to the patient and unique to that short period of time the individual nurse is with that individual patient. Conclusion

THE ART OF CARING

12

Caring is truly a diverse set of behaviors that are specific to a giving situation in a single given time with the patient defining what caring is to them. The analysis describes caring as a whole exhaustive set of variations, but it is known that measurement is important. Even when quantifying caring by the use of the a survey like the CNPI-Short Scale, the authors conclude with a note of caution. If endlessly expanded, this concept of caring in nursing might not survive: it might eventually incorporate almost every possible theoretical combinations of words and expressions that would be impossible to comprehend in clinical practice (Cossette et al., 2006, p. 213). Thus, caring is important to measure (or get close to a measurement), but caring encompasses so many words, actions, and gestures that it is still elusive. Nurses and patients know care and caring. It is important to create an environment that is optimal for caring behaviors and a caring relationship between a nurse and patient.

THE ART OF CARING References

13

American Nurses Association. (2010). Guide to the code of ethics for nurses. Silver Spring, MD: Author. American Nurses Association. (2010). Nursing scope and standards of practice. (2nd ed) Silver Spring, MD: Author. American Nurses Credentialing Center. (2008). A new model for ANCCs magnet recognition program. Retrieved from http://www.nursecredentialing.org/Documents/Magnet/NewModelBrochure.pdf. Autry, J. (1991). Love and Profit: The Art of Caring Leadership. NewYork, NY: Harper Collins. Retrieved from http://books.google.com Beck, C. T. (1999), Quantitative measurement of caring. Journal of Advanced Nursing, 30, 24 32. doi: 10.1046/j.1365-2648.1999.01045.x Cossette, S., Cote, J. K., Pepin, J., Ricard, N., & D'Aoust, L. X. (2006). A dimensional structure of nurse-patient interactions from a caring perspective: refinement of the caring nursepatient interaction scale (CNPI-Short Scale). Journal of Advanced Nursing, 55(2), 198214. doi: 10.1111/j.1365-2648.2006.03895.x Ervin, N. E., (2006). Does patient satisfaction contribute to nursing care quality? Journal of Nursing Administration, 36(3), 126-130. Retrieved from http://0www.ncbi.nlm.nih.gov.libcat.ferris.edu/pubmed/16601514. Finfgeld-Connett, D. (2008), Meta-synthesis of caring in nursing. Journal of Clinical Nursing, 17, 196204. doi: 10.1111/j.1365-2702.2006.01824.x Haas, S. A. (2008). Resourcing evidence-based care in ambulatory care nursing. Nursing Economics, 26.5, 319. Retrieved from http://0-go.galegroup.com.licat.ferris.edu.

THE ART OF CARING

14

Jannsen, A.L., Macleod, R.D. & Walker, S.T. (2008). Recognition, reflection, and role models: critical elements in education about care in medicine. Palliative and Supportive Care, 6, 389-395. Retrieved from http://illiad.ferris.edu/illiad/illiad.dll?Action=10&Form=75&Value=97605 Jasmine, T. (2009). Art, science, or both? Keeping the care in nursing. The Nursing Clinics of North America, 44(4). doi: 10.1016/j.cnur.2009.07.003 Papastavrou, E., Efstathiou, G., Tsangari, H., Suhonen, R., Leino-Kilpi, H., Patiraki, E., Merkouris, A. (2012). A cross-cultural study of the concept of caring through behaviours: patients and nurses perspectives in six different EU countries. Journal of Advanced Nursing, 68, 10261037. doi: 10.1111/j.1365-2648.2011.05807.x Patistea, E. & Siamanta, H. (1999). A literature review of patients compared with nurses perceptions of caring: Implications for practice and research. Journal of Professional Nursing, 15(5). Retrieved from http://0-dx.doi.org.libcat.ferris.edu/10.1016/S87557223(99)80056-8 Quality and Safety Education for Nurses (2012). Quality/safety competencies: Pre-licensure ksas. Retrieved from http://www.qsen.org/ Sargent, A. (2012), Reframing caring as discursive practice: a critical review of conceptual analyses of caring in nursing. Nursing Inquiry, 19, 134143. doi: 10.1111/j.14401800.2011.00559.x Warelow, P., Edward, K. L., & Vinek, J. (2008). Care: What nurses say and what nurses do. Holistic Nurse Practitioner, 22(3), 146-153. Retrieved from http://0www.ncbi.nlm.nih.gov.libcat.ferris.edu/pubmed/18453894