KnowingDoingValuing as Systems of Cocreations: A Germinal Theory on Ethical Caring

Mark Donald C. Renosa, DNS, RN, Research Institute for Tropical Medicine

Abstract caring must be faced to meet the changing

Ethics is one of the major considerations in conducting nursing research. Nurses are engaged in demands on clinical research nursing.
clinical research practice; however, not much is known about the influence of ethics on their The purpose of this study is to explore the
practice. A hermeneutic phenomenological research design was used in the determination of lived experiences and aesthetic expressions of
thematic structures describing ethical caring through in-depth interviews, field notes, and clinical research nurses on ethical caring by
aesthetic expressions. Ten clinical research nurses saturated the data. Results showed that as understanding their dynamic situations to build
clinical research nurses became immersed in a novel nursing praxis, they formed positive and translational constructs and insights. This
negative views about clinical research, human subjects, and ethical caring. These affected their provides an analysis of clinical research nurses
sensitivity towards the radical changes and also their adaptation to the adversities that they ethical caring concepts, focusing on unique
encountered within the milieu. The process that they underwent of rendering ethical care towards salient points and their implications for nursing as
human subjects was explicated in the triphasic concepts of knowingdoingvaluing as systems a discipline and profession to materialize
of cocreations; the germinal theory developed, an integral component of unifying the dichotomy constructs and frameworks for the bases of its
of research and ethical caring. praxis.

Keywords: ethical caring, clinical research,
nursing, caring
Introduction
Clinical research nursing practice is unknown
to most practitioners in the world. Generally, the
role of clinical research nurses is geared towards
production of new treatments or regimens for the
management of past, present, and future
illnesses, paving the way for the improvement of
overall quality of life. Clinical research nurses are
accountable to care for human subjects in
research who are at risk and vulnerable to
adverse events involving biological innovations,
vaccines, and treatments. This situation brings
about several issues in clinical research nursing,
such as questions in relation to caring in nursing
and compliance to the research protocol. Clinical
research nurses are affected by several queries
along this line; in fact, Elliot (2002) even argued
about the serious danger and exploitation of
human subjects on issues governing morality and
care that are dependent solely on research
protocols and standards. One important emphasis
that emerged was the occurrence of numerous
ethical questions on the use of humans as
subjects for clinical research.
Seen in this way, I recollect my experience
serving in clinical research on vaccine production
and supports the belief that this nursing practice
creates a complex scenario of caring bounded by
research protocol. Beyond the idea of clinical
research in utilitarian perspective, the researcher
has been pressed several times to respond to
unwavering ontological and epistemological
queries: How can we express our caring to
human subjects during actual experimentation?
How is ethical caring translated in the clinical
research process? How is ethical caring known
in clinical research nursing? and Are clinical
research nurses equally emphatic in the treatment
of human subjects? On that note, What, then,
is the essence of ethical caring in clinical research
nursing?
A personal communication of one of the
researchers colleagues extends the clamor on
finding authentic caring experience on clinical
research.
There are times when I begin to doubt and
forget that I am still a nurse, vowed to give
care and comfort to the sick. Every time I am
attending to my human subjects, there are
times that I am viewing them as piece[s] of
information I need just to complete the
research protocol. How can I find caring
experience in this kind of nursing practice?
Or should I ask, is there really caring in
human experimentation? (N. Gammad,
personal communication, May 14, 2013)
Notably, there is a dilemma regarding clinical
research nurses caring insight on human
subjects and an emerging consensus that
involvement of nurses has a negative impact on
their caring demeanor that hampers their
professional practice. Nurses, then, withdraw from
their caring selves, which in turn closes the
opportunity for authentic human health
experience (Newman, Sime, & Corcoran-Perry,
1991). Further, the practice becomes more
problematic when the research design is severely
robust because the range of caring is restricted,
unbinding the provision of safe and quality
practice, which leads to the separation of the
dichotomy of research and nursing. This
highlights a clear spectrum of ethical dilemmas
between the dichotomy of research and nursing
as caring.
This, then, may impose a recurrent inquiry on
how to address a wide range of ethical issues on
human experimentation, on how to observe the
ethical guidelines on its practice, and on the
importance of adhering to ethics of caring in towards helping to develop new drugs, treatment
clinical research. One must take a brave step to regimens, and caring pathways for patients in
reflect on the current picture vis-a-vis real-life
experiences of practicing clinical research nurses. meeting the legal requirements as outlined by the
These concerns guided the researcher: amidst
the glamour of evidence-based research, ethical
Review of Literature
The continuing need for nursing science to
personalize care towards varied aspects suggests
the utilization of research to validate, revalidate,
and invalidate ways to remain fluid on its progress
as a discipline and profession (Richardson, 2005).
The thriving developments brought about by
nursing research have faceted a myriad of issues
and concerns in the past and in the present.
Notable and significant changes have occurred
because of the utilization of this evidence-based
approach fueling and supporting contemporary
nursing practice (Brim & Schoonover, 2009;
Cope, 2003; Prior, Wilkinson, & Neville, 2010;
Profetto-McGrath, Negrin, Hugo, & Smith, 2010).
Alongside the development of evidence-based
practice, a new lens in its praxis called clinical
research nursing has flourished and was formally
defined as a specialty practice of nursing in 2010
by the National Institutes of Health (Clinical
Research Nursing, 2010). On that end, it emerges
as a new, multidimensional expanded version of
the nursing science profession.
However, despite the widespread evidence of
clinical research across the globe, there was no
clear definition of the nursing practice until the
National Institute on Health took the lead to
increase awareness and created a certification
process for clinical research (Hastings, 2009). As
vibrantly cited by Gordon (2008), Scottish
Executive (2005) elucidated the difference
between nurse researchers and clinical research
nurses. The former are engaged in developing
their own research questions and so do not
necessarily need to work in a research-oriented
milieu, as long as their purpose is to acquire new
knowledge for patient care or practice provision,
whereas clinical research nurses are moved
general as data collectors and safety experts
International Committee for Harmonisation of
Good Clinical Practice (1996).

60 International Journal for Human Caring


The actual title given to those nurses
practicing in a clinical research can create
confusion as it has different variationsfor
example, clinical trial nurse, study nurse, scientists were so fascinated with the idea of
and research assistantmaking it problematic omnipotence that they tended to disregard the
whether or not to use a title globally (Catania,
2012). With this, a generic title for nurses serving
many principal investigators (or becoming
principal investigators themselves) in producing
biological treatment modalities and caring
pathways and vaccines for quality of life has
emerged and been made known to the public as
clinical research nurse (Grady & Edgerly, 2009; that became known to the public were Nazi
Hastings, 2009; Royal College of Nursing, 1998).
Nevertheless, the clinical research nurse can
assume a principal investigator role in
pharmaceutical clinical research only if a
physician is listed as a subinvestigator (Catania,
2012).
With this, emergence of the model of care has
clarified the nursing care delivery by bringing
foundations of clinical actions but has not
necessarily shed light on on the clinical research
nurses ethical caring dilemmas (International
Association of Clinical Research Nursing, 2010).
The setting of clinical research nursing is well
represented in the nursing literature; however;
there is absent a union of constructs that could be
valuable to contemporary caring and the era of
innovation.
Clinical Research Nurses and Their Ethics of
Practice
Clinical research sparks an excitement in
nurses, as they are to be involved to something
novel and exceptional in the production of
scientific and logical evidence. However, they are
faced with many difficulties regarding the use of
humans to generate knowledge on health and
illness. As cited by Dyal (2001), Charlotte Lewy
(1983) stated that using human beings as
research guinea pigs is an ethical dilemma of
considerable magnitude. Humans are the
resources in generating useful knowledge
constructs in clinical research, and are at risk of
exploitation. In this regard, this may cause fear to
some nurses that science is valued over human
life.
Because of its diverse field, clinical research
cannot be compared to clinical practice in
ethically relevant conduct: it has different goals,
different methods, and different justifications for
risk of individuals. In view of clinical research
facets, many studies have been conducted
deliberately utilizing and experimenting humans
for the conduct of its science from the 17th
century to the present. The grounding of the idea
of utilitarianism as rationale for clinical research
still provokes debate. This point of view still
dominates the current practice of clinical
research, pronouncing that society has an
obligation to participate to experiments for the
KnowingDoingValuing as Systems of Cocreations: A Germinal Theory on Ethical Caring
greater good of future generations, based on the
assumption that the society has equal access to
societal goods (Mill, 2004). At some point
Harmonisation on Good Clinical Practice (1996)
and several accepted ways to conduct clinical
integrity and value of human life. Gaw (2012)
reconstructs an article on Beecher and
Pappworths collaborative articles and books on
contemporary research ethics. These two
prominent people were considered the
whistleblowers in research ethics of the 20th
century. Among the several controversial studies
experiments and the Tuskegee Syphilis Study,
which, in turn, changed the entire history of
research.
Gomes (2010) expounded on his paper that
Nazi experiments were conducted in
concentration camps that included freezing
victims for hypothermia research, testing potable
seawater on gypsies, high-altitude simulation
tests to benefit pilots, and finding cures for war
wounds. There was a global contention that these
experiments abandoned ethics, and they were
considered bad science. The Nuremberg code
became the landmark document following the
Nazi experiments outburst in 1947. It primarily
highlights investigators responsibilities in putting
utmost importance on human subjects rights.
Voluntary consent, the weight of benefits over
risks, and right to withdraw without repercussions
are emphasized (Ghooi, 2011).
Meanwhile, a failure of ethics and racism on a
grand scale described the Tuskegee Syphilis
Study, in which 600 Black men from Alabama
were enrolled; 399 had syphilis, and were
deliberately denied proper treatment for syphilis to
take a fearless historical account of the nature of
the disease (Gamble, 1997; Rusert, 2009; Walker,
2009). The study was supposed to take place for
only 6 months; however, it went on for almost 40
years. Bozeman, Slade, and Hirsch (2009)
considered the study a major ethical calamity, as
it violated the vulnerability of the population
because it focused mainly on the poor and
proposed benefits were not clearly explained.
Although standard treatment for syphilis at that
time was available in the market, study subjects
were deprived of access to penicillin. Following
this event, the Belmont report was released,
highlighting three salient principles: self-
determination, beneficence, and justice among
research subjects (Rice, 2008). On this end,
ethical precept on clinical research was highly
favored.
Notably, alongside the release of the
Nuremberg code and the Belmont report, there
have been evolutions in guidelines released on
clinical research; one of the major transitions
occurring in the clinical research field was the
development in 1964 of the Declaration of
Helsinki, which is considered the cornerstone
document that guides research involving human
subjects (Rid & Schmidt, 2010). It has had
profound influence on the International
research to date. Good clinical practice requires
each clinical research protocol to be examined by
an accredited institutional ethical committee prior
to the start to affirm its scientific proceedings. It
also tackles the thoroughness of record handling
and keeping and the process of informed consent,
besides human subjects safety (Sweatman,
2003). In principle, all governing regulations
released boil down to the protection of human
subjects.
With the shared weight on safety and
efficiency in clinical research, the anxiety imposed
on all scientists, including clinical research
nurses, in assuming a safeguard role in the
context of an evidence-based milieu needs to be
underlined. To put this in perspective, Catania
(2012) explored nurses role in safety reporting,
which includes (a) detection of adverse events,
(b) assessment of adverse events, (c)
documentation and recording of adverse events,
and (d) adverse events reporting, alongside their
usual functions of obtaining informed consent,
determining participant eligibility, gathering
information on serious adverse events, and
monitoring human subjects. Nonetheless, it is
also emphasized that integration and utilization of
nurses knowledge, experience and skills, and
sound ethical principles takes precedence.
Clinical research nurses then becomes an integral
component in protecting the health status of
human subjects and maintaining the integrity of
research data.
Clinical Research Nursing and Its Dilemmas
The submission of clinical research to nursing
expands many hampering dilemmas. Shields and
Pearn (2007) commented on a fundamental
struggle on the science of altruism or
encapsulation of the art of commerce, raising the
call for inducements for voluntary human
subjects. Most are beyond the adversities of
nurses, such as the use of electronic data
capture, subject recruitment, safety, and retention
(Alcabes & Williams, 2002; Kolman et al., 2012).
Hoglund, Helgesson, & Eriksson (2010)
explicated the ethical dilemmas experienced by
Swedish research nurses in their usual daily work.
Twelve respondents mentioned tensions and the
risk of suffering or harm of the patient. It was then
explored that the rising dilemmas were closely
interwoven with the perceived role of being a
nurse, which calls for caring, and being an
assistant in a research endeavor. As such,
respondents perceived themselves as alarming
invisibleslacking the concepts of
belongingness and ethical competence-building
opportunities.
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KnowingDoingValuing as Systems of Cocreations: A Germinal Theory on Ethical Caring
To further explore the ethical constructs, Anna,
Hoglund, Eriksson, & Helgesson (2010) continued
their study focusing on the perception of ethical
guidelines and their role in ethical competence-
building among Swedish physicians and research
nurses. Appallingly, results were espoused as to
the overall impression that the ethical guidelines
in practice were invaluable in competence
building and might limit the decisional stand on
ethical dilemmas. In turn, this might disrupt the
progress of professional research demeanors.
They recommended a paradigm shift on virtues
and characters whereby their professional thought
processes would be connected through the use of
ethical dialogues.
Meanwhile, Wilkes (2005) investigated nurse
researchers views on the appropriateness of
actions when conducting clinical research. Nurses
used myriad frameworks on their decisions,
including their personalmoral values, nursing
competencies, and research rigor. The findings
then stressed the vague impression and
confusion between the dichotomy of nursing and
research roles. This confusion of nurses roles
was also studied and confirmed by Spilsbury et al.
(2006), who focused on the scope and their
potential contribution to clinical research.
Conformingly, nurses faced dilemmas on the
transition to the clinical research role. The study
also revealed heightened challenges associated
with training and management of their critical
roles. On the same note, Fisher & Kalbaugh
(2012) identified how research coordinators
manage role and ethical conflicts within clinical
research. A qualitative study combining
observations was conducted, resulting in the use
of altruism to manage different conflicts the frame of reference in determining clinical
between research and care.
On the other hand, Davis, Hull, Grady,
Wilfond, & Henderson (2002) answered the extent
to which research coordinators shape the ethical
conduct on clinical research and how their
multiple roles affect the protection of subjects.
Focus-group discussion was utilized, gaining
three critical themes signifying the function of
study coordinators, namely (a) patient, (b)
subject, and (c) study advocacies. As this role is
in constant transition, any crucial misbalance on
the triad may cause ethical lapses in the process
of clinical research, cascading to a low rate of
subject participation. This was also concluded in
the study of Ford et al. (2013), looking at potential
solutions to this rising concern. Fifty-seven
African Americans and Latinos were utilized as
respondents, reflecting several barriers to
participation. Characteristics of study processes
involved were highlighted as the topmost concern,
and it was recommended that they be reinforced
by addressing safety concerns and costs
associated with participation. Moreover,
increasing the amount of time spent with the
subjects and building on the sense of altruism
62 International Journal for Human Caring
could be possible motivators for clinical research
participation.
Same motivators were also derived by Kost,
Lee, Yessis, Coller, & Henderson (2011) as they
also assessed the participants perception of the
clinical research experience. Eighty-five
participants and 29 professionals in 12 focus
groups perceived that the experience was highly
valued because of staff relationships, health
gains, new knowledge, and compensation.
Respondents were also satisfied with the
informed consent process, but felt saddened
about nondisclosure of test results and/or
unknown study outcomes. Meanwhile, informed
consent procedure was underscored by Mueller &
Instone (2008) in an ethnographic study providing
insight into how changes in protocol requirements
and patient health status prompted actions and
judgment during the conduct of clinical research.
These governing issues, nevertheless,
encompass a full range of phenomena
encountered by nurses. The inescapably
epistemological and ontological issues progress
on the core merit of evidence. The products of
several erudite inquiries are geared toward a
competency-based strategic approach on clinical
research pathways (Royal College of Nursing,
1998). Such development of competency
rekindled a new hope of optimism among clinical
research nurses, who were agog that there was
still something to be done through concerted
labors. Several scholarly strategies have included
a revisit to curricular structure, research capacity,
extent of knowledge on ethics, laws, drug
development and management, wide arrays of
analytical processes, and outcome evaluation as
pathway to clinical research nurses by essentially
research effectiveness and efficiency.
Nonetheless, there has still been a premeditated
element that is overleapedcaring. It is apparent
that because of the zealous pressure to produce
scientific and logical evidence, the concept of
caring was clearly compromised and conceded as
a burden to clinical research nurses.
In the review of literature, the researcher
found a blank spot on the lived experiences and
aesthetic expressions of clinical research nurses
on ethical caring. This, then, merits a systematic
inquiry, as one may wonder on the relevance of
the insights on this phenomenon to worldwide
clinical research nursing knowledge development.
Thus, it is the researchers interest to fill in this
gap in literature through the collection of
narratives from the participants to explore this
phenomenon.
Theoretical Framework
With the academic and stimulating aspect of
clinical research, utilizing ethical caring as patient-
centered competency focuses on knowing the
person as a whole (Swanson, 1991) and not as
pieces of information or guinea pigs, data from the lived experiences of the
enticing a landscape of discovering new
dimension of authentic human health experience.
It was explicated by Newman, Sime, & Corcoran-
Perry (1991) that the absence of caring in a
certain human health experience is not
considered nursing at all. In this light, the unitary
transformative paradigm of Newman et al. was
utilized as a lens to help translate an essential
component in revealing an in-depth or deeper
context consistent to the evolving world view, thus
submerging oneself in the process of authentic
and creative unfolding of human health
experience. Notwithstanding the unpredictability
of change that may arise from the human
experimentation phenomenon in both the nurse
and the one being nursed, the
interconnectedness of a diverse field on a unified
perspective institutes a sound truth and clear
concepts for meaning constructs. From such a
view, grounding on human science as
philosophical underpinning creates a bridge to
substantial and meaningful expressions of nursing
as caring in a clinical research milieu (Boykin &
Schoenhofer, 2001).
Boykin and Schoenhofer (2001) assume that
nursing takes place within nursing situations. The
clinical research arena professes complex and
dynamic interactions in which the nurse should be
knowledgeable of the authenticity and uniqueness
of experience. Guided by Carpers (1978)
fundamental patterns of knowing in nursing, which
are (a) empirics, (b) aesthetics, (c) personal
knowledge, and (d) ethics, this may then address
the dilemma of viewing the person as a mere
piece of information or human guinea pig. The
idea of knowing the person provides a vivid
bringing together the fundamental patterns yet
appreciating each priceless encounter, creating a
milieu of interconnectedness and sharing in a
lived nursing situation. Nonetheless, it was
highlighted that in the process of knowing the
person, a redirection of dynamism and unfolding
of nursing practice should be the primary focus,
not the product itself (Boykin, Parker, &
Schoenhofer, 1994). Therefore, the theory of
Boykin and Schoenhofers nursing as caring was
utilized as a guiding framework attuned in
responding to nursing situations in fullness and in
harmony with the one being nursed.
Method
This study utilized a hermeneutic
phenomenological approach grounded on
Heideggers philosophy. This approach assumed
that human beings have myriad perspectives,
intrinsic depths, and the ability to create and
shape their own experiences, and that truth was
composed of many realities (de Freitas, 2007;
Wojnar & Swanson, 2007). Thus, the researcher,
being a clinical research nurse, cocreated the

participants. Furthermore, the researcher himself
became the research instrument and directed his
attention to human realities rather than the
concrete realities of objects (Polit & Beck, 2010),
which created a symphony of meanings and
understandings (Wojnar & Swanson, 2007).
Data Collection
Selection of participants was facilitated
through purposive sampling, which included 10
clinical research nurses (age range 2426 years;
7 females and 3 males, respectively) who (a)
were employed at the Research Institute for
Tropical Medicine, Philippines (excluding those on
satellite sites); (b) had 2 years or more clinical
research experiences; (c) were willing to give
informed consent; (d) were knowledgeable in
speaking English or Filipino, as because
qualitative research is primarily concerned with
making meanings out of the data gathered (Polit
& Beck, 2008), a common vocabulary between
the researcher and the participants is essential to
acquire a full understanding of the phenomenon
to be studied; and (e) were willing to share their
experiences through art and narration, which
would come from the interviews to be utilized as
means of collecting data. Ten participants
saturated the data.
The study utilized three procedures for data
gathering:
1. A semistructured interview was utilized that
involved predetermined open-ended
questions that allowed spontaneous, in-
depth responses and richness of content
with approximately 2030-minute or longer
sessions as permitted and as deemed
necessary. The interview was audiotaped
using a high-quality tape recorder. The
researcher translated all recorded
information verbatim after every interview.
The researcher followed the preparation
and transcription protocol and principles
based on McLellan, MacQueen, & Neideg
(2003).
2. Field notes were also utilized during each
encounter that recorded gathered
narrations and nonverbal cues, which were
relevant in the study. Because there is a
danger of either forgetting important
observations or possible manipulation (Polit
& Beck, 2008), notes were then written
down as soon as important information
manifested to preserve the purity and
essence of the information.
3. Finally, the researcher encouraged
participants to explore their experiences
through their own choice of aesthetic
expressions. An emphasis was made that
steps can be employed through many
subtle choices in creation of aesthetic
expression, be it in poetic language,
musical symphony, painting, photograph,
KnowingDoingValuing as Systems of Cocreations: A Germinal Theory on Ethical Caring
caricatures, acrylic paints, in any art, on the
participants appreciation on the concept of
ethical caring in the clinical research
practice. After the completion of the art, the
researcher let the participants express their
thoughts, to give voice to the lived
experiences in an ethically caring
community. Through art, participants
expressed ideas and feelings that they
could not express otherwise.
Data Analysis
This study utilized the methods of van Manen
(1990) for textual features of the qualitative report
and incorporated Diekelmann, Allen, & Tanners
(1989) seven-step method of textual analysis to
help build a meaning-making process and
reflective awareness of the phenomenon being
studied, each of which was based on
Heideggerian philosophy. Narratives were
translated and analyzed. Words, phrases, and
statements that described the lived experiences
of clinical research nurses and those that
appeared to be edifying were identified and
highlighted. This was done using van Manens
(1990) selective reading approach, where
meanings are formulated from the significant
statements. These meanings were isolated, thus
forming themes reflecting Clinical Research
Nurses experiences. This study also adhered to
Lincoln and Gubas (1985) criteria in establishing
rigor, which included credibility, transferability,
dependability, and confirmability.
Following the formation of themes, the highest
level of hermeneutical analysis, which was the
search for constitutive patterns, was conducted.
This involved reading each whole interview again,
which projected the global perspective of the
stories while cascading the linkage between
relational themes that existed in all transcriptions.
In this way, both the researcher and the
participants journeyed to the core of the
phenomenon through constant dialogue. The
researcher enhanced the interpretation through
the use of other relevant text and aesthetic
expressions. At the end, an eidetic insight, which
was rich in description and interpretation, was
used to enmesh varied layers of meaning on the
experiences. In this case, a germinal theory was
constructed.
Ethical Considerations
The clinical research division chief of the
Research Institute for Tropical Medicine approved
this study under an expedited ethical review
procedure. Research protocols and other related
procedures and policies of the institution were
properly observed during the course of data
collection. Participants who met the criteria were
given a brief description of what would happen to
ease initial apprehension and anxiety; they were
informed of the purpose of the study, and
informed consent was obtained. All participants
were informed about study purposes and
procedures, and because the study involved only
collection of information, there were no
anticipated risks for involvement.
Transcripts were destroyed after the data
analysis. A master list of participants names and
code numbers was kept in a locked cabinet in the
event that a participant needed to be contacted
for further information or scheduled for a follow-up
interview. The researcher secured confidentiality
of gathered data by deleting all the transcriptions
and field notes used in the study.
Results
Entering into the deepest-lying meanings of
ethical caring, the participants imparted their
different points of view on their significant lived
experiences and aesthetic expressions on clinical
research nursing. Upon careful observations and
analysis of meanings, three essential themes
emerged: (a) cocreation of knowing, (b)
cocreation of doing, and (c) cocreation of valuing,
with nine subthemes (Table 1). At the end, lived
experiences and aesthetic expressions of clinical
research nurses on ethical caring were described
and interpreted as the knowingdoingvaluing
as systems of cocreations phenomenon.
Theme 1: Cocreation of Knowing
Over the years, nurses gradually moved from
hospitals to clinical research practice and were
tasked with the responsibility of caring for human
subjects, puzzled and unprepared. As clinical
research nurses went into a different and
unrecognized practice of nursing, they
distinguished the importance of using their
education and valued self to guide their actions
within the clinical research setting. Watson &
Smith (2002), as cited by Bailey (2009), distinctly
postulated that as caring professionals, nurses
have to embrace multiple ways of knowing to
understand the conglomeration of arts,
humanities, and clinical sciences, that is, being
becoming, evolvingethical, intuitive, personal,
empirical, aesthetic, and even metaphysical/
spiritual ways of knowing and becoming.
Therefore, the link between clinical research
nursing and ethical caring is through the process
of knowing the personal experience and the
process of acquiring meanings in the whole
clinical research experience.
Art of Unknowing. In every ethical caring act in
clinical research, it can be argued that there
exists a spectrum of unknowing to a virtue of
knowing within the process of cocreation.
Unknowing has been identified by Mulhall (1993),
as cited by Heath (1998) and Zander (2007), as
the fifth pattern of knowing and deeply interrelated
to personal knowing. Unknowing is the nurses
2016, Vol. 20, No. 2 63
KnowingDoingValuing as Systems of Cocreations: A Germinal Theory on Ethical Caring
Table 1
Summary of Ethical Caring Themes
Major Themes
Cocreations of knowing
Cocreations of doing
Cocreations of valuing
awareness of deficient empirical knowledge to
guide their actions, making them eager to learn
how, when, and where theory and research can
be utilized to produce desired results. Meanwhile,
Bonis (2009) expounded that knowing is unique in
each individual because it is rooted in personal
experience.
Participants shared the struggle they
considered essential to their experiencesto be
known and recognized as an existing profession
in nursing while maintaining and finding meanings
in their everyday journey. Being a clinical
research nurse requires the huge responsibility of
making sure that a human subject gets the best
possible level of care, and it also entails the
burden of having to accept the truth of maintaining
nursing amidst experimentation. Most of the
respondents discussed the professional challenge
during their encounters in clinical research of not
being known and unknowing the practice they are
in:
R-003: Honestly, I really dont know that . . .
clinical research nurse work existed. It came
as a surprise, actually!
R-005: Ah . . . like everybody, I really [didnt]
know that a clinical research field in nursing
existed even though this was mentioned in
school, in college, its like you cannot easily
venture on this.
The transcripts clearly expressed participants
feelings of ambiguity and uncertainty during their
first years of clinical research. Participants felt
strangers to the profession they were in because
clinical research nursing was yet to be
strengthened and known. Participants R-007 and
R-002 recounted their limited knowledge of
clinical research:
64 International Journal for Human Caring
Subthemes
 Art of unknowing
 Enhancing nursing theory
 Situated cognition
 Challenges on research process
 Compassionate commitment
 Human subjects safety
 Creative unfolding moment by moment
 Shared humanity
 Appreciating unique nursing encounter
R-007: Usually, our research then was like
knowing how to construct a paper, not
conducting study like this, clinical research, I
never encountered this in college.
R-002: Of course, at first, I really [didnt]
know what it is. I thought it was more on
paper works, basic research that is. What I
[didnt] know was it is vaccine trials, clinical
research on humans!
The reality of working in an environment that
is not a personal parameter creates complex
situations to the point that ones moral courage
will be put to the test. As a result, role transition
and possible role conflict are evident (Spilsbury et
al., 2006). Higgins et al. (2010) even highlighted
that the lack of familiarity of nurses with research
language challenges the practice. This was also
confirmed by Hoglund et al. (2010) in their study
on ethical dilemmas and ethical competence,
which concluded that some research nurses
perceived that they were invisible in the nursing
field.
A challenge facing the clinical research
nursing practice profession is in the promise of
safe and quality care embodied with the core
competencies honed on caring and compassion
to human subjects. Limited knowledge on that
end can hamper the fulfilment of that specific
mission. However, transcripts proved that there
exists a deliberation of ethical appreciation of the
pattern of unknowing that has guided clinical
research nurses ways of knowing and learning
clinical research nursing. Chinn and Kramer
(2011) communicated that ways of knowing lead
to nursing knowledge, rather than knowledge itself
being the basis for knowing nursing. Coming from
all the personal and empirical patterns, together
with the unknowing domain, these are echoed as
the major patterns of knowing and learning.
Although clinical research nurses were aware of
the thought of uncertainty, their openness to
clinical research highlights the clear aspect of
unknowing, which thrusts them to learning.
From the verbatim transcripts, the openness
to new learning and meaning was very
outstanding in participants ethical caring process.
They conveyed:
R-007: Yes, of course we need it. We need
to grow. I am still learning much . . . and
many more, many opportunities for
learnings, learned much and will learn even
more.
R-003: Actually theres many, and maybe
too much and I believe that people never
stop improving and developing once
potential in everyday doings. You need to
find other ways to improve on certain things
or be open-minded in learning new things for
yourself.
Germana (2007) even pointed out that
unknowing reinvests us into the known with a
renewed sincerity of interest and thereby offers
the truth of greater intimacy through further
recognition and discovery (p. 249). Regardless
of the uncertainty, clinical research nurses have
practiced within their scope of work and are
inured to providing care for human subjects as the
very mantra of their profession and their whole
being. Unknowing appears as a dilemma, but
some dilemmas must be lived, and in unknowing
there is a progression of knowing. Such
interdependence that each and every one
undergoes the process of unknowing and
knowing, clinical research nurses can enter into a
shape of confidence and coping practice. It can
be argued, at this point, that through these
viewpoints of both unknowing and knowing lie the
ontological and epistemological foundation of
ethical caring in nursing.
As Zander (2007) expounded: Knowing
connotes that one has a solid base on which to
structure an action or way of being. That base is
knowledge, but in order to gain knowledge one
has to employ a process known as learning (p.
7). Learning is embedded in the struggles and
understanding that clinical research nurses
undergo. It is as complex as the nursing itself, but
profoundly, clinical research nurses battle and
apply their ways of knowing to the unique
particulars and context of clinical research
dynamics. To meet the unique needs of their
situation, clinical research nurses undergo a
dramatic shift of ways of unknowing to knowing
that establishes the depth of their ethical caring.
Enhancing nursing theory. The dynamic interplay
of unknowing and knowing exemplifies the
transformational activity happening in clinical
research nursing environment. Through this
shared unknowing and knowing reflection, the

focus becomes not just on cognition but on
adapting and enhancing the research praxis.
Clinical research nurses become aware of nursing
situations and draw the dimension of learning with
ones working practice. The subtheme became
evident with responses of the participants:
R-009: Sometimes we need to change those
practices we have as nurses. So sometimes
even if we know the things to be done, we
need to consult it first so and so. So there,
we need to live by the protocol. That even if
we knew the right thing but since its not
what protocol is saying, you are not allowed
[to do] it.
Clinical research nurses portrayed the reality
of ethical caring on the norms of our capacity to
accept and enhance the different nursing
situations. Additionally, knowledge in nursing can
be found on nursing situations (Boykin &
Schoenhofer, 2001) and in this case, on clinical
research praxis. What the research praxis needs
more than brilliant minds is flexible clinical
research nurses who can bend to emerging
standards and to various human subjects with
whom they deal every day. Flexibility enhances
nurses ability to be reflective and finds workable
solutions to situations (Gustafsson, Asp, &
Fagerberg, 2008). Clinical research requires a
wider range of reflection through moral courage of
shifting and enhancing the language of nursing
theories. In fact, OCallaghan (2005) strongly
affirmed that reflection allows the person to
understand and translate meanings that contradict
theory and practice. Clinical research nursings
essential ethical care does not change; what
changes is how nursing fulfills its caring role. In
turn, this enables the clinical research nurses to
have heightened awareness of the depth and
intricacies of nursing knowledge.
Participant R-008 expressed through an oil-
pastel artwork that whereas ethical caring is an
abstract, it is also a process, that caring varies in
the moment and develops over time. Through
acquisition of knowledge, experience, and
competence one may continuously grow as an
ethical carer in a research-oriented milieu.
Learning through experience in clinical
research nursing, regardless of the meaning of an
individuals (the nurses) experience, speaks of
applicability. It is an ethical and professional
responsibility of nurses to utilize the knowledge of
their discipline; however, there is a continuous
growth of inquiry in clinical research nursing,
which emphasizes greater attention to the
synthesis of its knowledge development. Clinical
research nurses are able to fully understand the
unique situation and plan interventions within the
therapeutic milieu (Bonis, 2009). Yet they
continue to grapple on how to sustain such
enhancement in day-to-day practice and its
particular contexts. Clinical research nurses put
so much emphasis on the development of ethical
KnowingDoingValuing as Systems of Cocreations: A Germinal Theory on Ethical Caring
caring through the spirit of the art of knowing.
Clinical research nurses may be wounded with
pain over the unrecognized path, but finding the
purpose and realizing the ethical caring and
authentic human health experience shared
eventually triggers the enhancement and
refinement of their nursing knowingmaking it a
research-as-praxis geared on thoughtful reflection
that allows world-transforming acts.
Situated cognition. On a clearer lens, one
element flourished and took the limelight above
the two subthemes, which was their positive view
on the profession that, despite the notable
struggles, still they opt to stay to the ethical caring
side of the research praxis. In this case, situated
cognition was knowing the practice and being
able to aspire for continuous improvement,
supporting Germanas (2007) argument that in
order to gain intimate relationships, one must
grasp order and chase for spontaneous changes.
Clinical research nurses willingness to
unknow and know the clinical research praxis
through experience, learning, and understanding
commences the unfolding of meanings that
establishes the ethical caring domain. Yet, as
more knowledge becomes known, hopes,
appreciation, and changes occur. Mayeroff
(1971), as cited by Schoenhofer (2002),
postulated that hope and commitment are strong
components of caring. This is true with the
participants accounts of a handful promise of
hope that continuously shed meanings on their
whole ethical caring experience.
R-002: Its not expanding today but I believe
its starting to escalate now, my feeling [is
that a] few years from now more expansion
of clinical research nursing will happen.
R-003: If youll think of looking forward, this
investigational product once approved will
have an impact to the future of the children
and many people will receive its benefits.
More so, the prevention of the diseases and
its eradication.
Because of their appreciation of the researchs
meaning, clinical research nurses become fully
engaged in their practice and can suggest an
awakening and innovation of a unique nursing
knowledge (Billay, Myrick, Luhanga, & Younge,
2007). Also, the study of Scott, White, Johnson, &
Roydhouse (2012) suggests that clinical research
nurses should have a broad range of knowledge
and skills relating to clinical research in order to
deeply conduct their roles. Innovation is apparent
in the transcriptions below, as participants
recommended the need to have a solid
foundation on an undergraduate degree in
nursing:
R-006: Since little was known about it, it
creates a problem. Better if there would be a
field, or like training or [a] subject in school.
R-007: Actually, I was thinking that maybe
there should be . . . what do you call that?
Specialization of nurses or [they] should
have a special subject in school. For even
all the nurses would have an idea of being
clinical research nurse[s].
Clinical research praxis and human subjects
are both demanding greater levels of
personalization of the experience and placing
nursing under increasing press As cited by Dyal
ure to cocreate meanings with them. When a
clinical research nurse begins to question the
nursing situation, one should go beyond this
reflectiveexpressive inquiry utilizing a
systematized body of knowledge, the knowing
embodied to potential attributes in empowering
the vulnerable subjects for their fullest potentials
towards cocreation and transformation. This will
then be essential to the ethical caring journey, and
with that, an authentic human health experience
will be expressed and achieved. With this goal,
the knowing domain for clinical research nursing
ethical caring blossoms through the grounding of
the unitarytransformative paradigm. Knowing the
clinical research through the cocreation of
meanings with their personal caring dimension
shapes and sustains the nursing as ethical caring.
Newman et al. (1991) translated it as an essential
component in revealing an in-depth context
consistent to the evolving worldview, thus
submerging oneself in the process of authentic
and creative unfolding of human health
experience. It was an uneasy path for the clinical
research nurses to cocreate meanings with
human subjects, and for the whole clinical
research nursing practice as there was no
existing knowledge to validate and balance their
praxis. Knowing the ideologies of the clinical
research praxis was just a fundamental step to
achieve ethical caring in the profession.
The cocreation of knowing described by the
clinical research nurses was based on meanings
clearly achieved through valued time. Sufficing
the unpredictability of change that may arise from
the clinical research phenomenon of both the
nurse and the one being nursed, the
interconnectedness of diverse fields on a unified
perspective institutes a sound truth and clear
concepts for the model of care.
Theme 2: Cocreation of Doing
Equally important, aside from the cocreation of
knowing through meanings, the participants also
shared their research actions and processes to
achieve the full meaning of the ethical caring
domain in clinical research nursing. One takes the
dramatic shifts on trying to nurture the doing
intentionality of the nursing milieu. Schoenhofer
(2002) depicted intentionality as formed through
structuring meaning: as clinical research nurses
enter into the profession, they are fueled with the
simple intent of commitment that grows and
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KnowingDoingValuing as Systems of Cocreations: A Germinal Theory on Ethical Caring
flourishes in living nursing as ethical caring.
Participants shared their experiences on adapting
to new paradigms in the clinical research arena
and how they managed to take into work
demands that eventually unfolded cocreation of
research innovations and processes.
Challenges to the research process. Clinical
research is a complex activity. Because of its
complexity, clinical research nurses become
vulnerable. Transcripts mentioned the difficulties
clinical research nurses may face in rendering
care to human subjects enclosed in a restricted
research environment. As they continued to know
the research dynamics, they were caught in a
situation that tried their decision-making skills.
Doing clinical research is such an avenue for
clinical research nurses to uphold the knowledge
gained through the ways of knowing. However,
weighing the goals of clinical research over the
human subjects condition becomes problematic
(Fisher & Kalbaugh, 2012). Participants vividly
recounted the care given to human subjects in a
restricted environment:
R-005: Its like, in clinical research, you just
need to do, what [you ought] to do.
R-007: I am so afraid to make [a] mistake, of
course you will be scolded by your superior,
if its not in the protocol then that can be a
deviation.
R-004: So its like youre thinking of the
safety of the patient and you want to do this,
but because the protocol says none, its not
possible.
R-009: Since this is [a] clinical research
setting, you have to follow what the protocol
is telling you . . . Just like that.
It was clearly explicated that clinical research
nurses were faced with ethical dilemmas and
claimed to have protocol-centered nursing care.
Hoglund et al. (2010) clearly discussed that there
exists a tension between clinical research nurses
responsibility towards the research and
responsibility towards the human subject
involved. A conflict of interest between the need
for the study results and doing no harm to human
subjects highlights the ethical dilemma. Further,
they argued that this dilemma is rooted in the
premise of the perceived role conflict of being a
nurse providing the possible best care with that of
being an assistant in the research study.
Matsumoto, Nagamura, Ogami, Yamashita, &
Kamibeppu (2011) also confirmed through their
study on nursing staff involved in oncology clinical
research that the most common difficulty
expressed by respondents is caring for subjects
throughout the entire clinical research process.
They were expected to have a border role;
however, it was identified that nurses had
negative attitudes towards the work because of
the notable unique challenges. Because of the
nature of clinical research protocols, clinical
research nurses were restricted in rendering the
66 International Journal for Human Caring
fullest account of ethical care to human subjects,
making them feel frustrated and disappointed.
Participants recounted:
R-007: At first, its good but sometimes
seems like becoming negative. Sometimes
you have to do this because it is in the
protocol even if its against your will.
R-004: Seems that you are not really
functioning as a nurse, its like what you
want to do would not be possible because
its not written in the protocol.
Participant R-007 even emphasized in her
colored-pastel sketch her experience of being
taken away by research protocol and becoming
cold-blooded in doing the clinical research
process:
R-007: A nurse should be caring.
Sometimes it seems that what Im doing is
not in my heart. Thats it. There are times
that it seems like you have to do it just to
finish the day or to just simply do it . . . well, I
was thinking of several things to be done
after vaccination . . . I was like a robot, just
doing it but with a half heart.
Participant R-007 was weeping the entire
session, describing that clinical research made
her a half human in the beginning. The struggles
to provide the best and valued care come from
finding what is right for human subjects anchored
through the love of nursing. This was supported
by Watson (2003), as she declared that it is our
humanity that both wounds us and heals us, and
those whom we serve; and in the end it is only
love that matters. This is done by maintaining
the symbiosis of caring and research. It was
further strengthened that the development of the
capacity to care and doing the significance of
ethical care will be attained in a particular time,
within a particular frame of reference, and within
the specific context of its defined role of service in
praxis.
Compassionate commitment on research
spectrums. Ethical challenges have important
implications for clinical research nurses daily
practice. It is good to note that clinical research
nurses urge that ways be found to promote ethical
development that goes beyond the research
protocol to a more personalized, person-centered
practice. In response to these challenges, clinical
research nurses were stimulated to reflect
critically and creatively on their work in relation to
human subjects well-being. This can be
confirmed through participant R-005 0 s narration;
she cited an example on how to achieve ethical
caring beyond clinical research protocol:
R-005: Like how to correct the deviation,
how to handle those mistakes, how will you
avoid it and not . . . cause more serious
issue[s] or damage.
Clinical research nursing, therefore, involves a
wider range of understanding on research
processes, commitment, and resilience and much
time beyond the normal working hours to promote
caring while at the same time undertaking the
standard procedures research entails (Higgins et
al., 2010). Commitment was explored by Trigg
(1973), as cited by Boykin and Schoenhofer
(2001), that this presupposes certain beliefs and
also involves a personal dedication to the actions
implied by them. These beliefs and this
dedication were regarded as moral obligations
important in the practice of clinical research
nursing. It was noted that by feeling, knowing, and
believing, nurses may exhibit both theoretical
ethical knowledge and moral action knowledge
(Sarvimaki, 1995, as cited by Cronqvist, Theorell,
Burns, & Lutzen, 2004). By expressing their
awareness and reflection on the research
spectrum, they provided a clear view of balancing
their moral obligations and work responsibilities.
The participants regarded their different roles and
responsibilities as priceless ethical acts anchored
through commitment by maintaining the
ideologies of clinical research experience. They
conveyed:
R-009: You can see sometimes the need to
work more than the required hours . . .
sometimes you have to go on . . . weekends,
holidays because there are deadlines to
meet.
On the other hand, R-003 also shared that in
order to achieve the fullest ethical care to human
subjects, one should take seriously the
documentation process:
R-003: You need to be vigilant in all your
doings, the documentation should be
detailed and should be accurate. Because
we are dealing with lives of people under
research.
As the findings imply, the sagacity of social
accountability was evidently upheld and endowed
with a promising level of ethical demeanor.
Clinical research nurses were empowered to
make a difference, to hold themselves and others
to account, and to decide how their ways of doing
could enhance ethical care. There appeared to be
an underlying assumption here that altruism
towards human subjects on the part of clinical
research nurses is necessary. Jansen (2009)
argued that altruism and clinical research are
exposed to ethical complexities. It was
championed that the mere possibility that
someone did not expose human subjects to risks
or harm justified the practice as caring. However,
altruism was sometimes used in different way, a
negative manner. This is true with the findings of
Fisher and Kalbaugh (2012) in which a context of
selfish altruism was described. Sometimes
clinical research coordinators were shaped
differently by the ethical complexities, as they
tend to create moral pressure on human subjects
just to adhere to research protocolthat the
interest was not focused on human subjects but

on maintaining professional nursing identity.
Giuffra (2013), on the other hand, rebutted that
the nursing was not a military profession that is
programmed to deal with a war. Altruism is the
heart of the storythat the values we live in and
espouse should be reexamined and reshaped.
Henceforth, always putting human subjects safety
above the research protocol makes it mandatory
for ethical caring.
Human subjects safety. Clinical research nursing
to date has not yet fully proven its worth and
dignity to the world. It may not be recognized as
one of the leading advanced practices in nursing;
still, it uniquely provides care to all human
subjects in various settings regardless of creed,
beliefs, or cultural perspectives. Participants
highlighted that maintaining safety is a
supplementary way of rendering ethical caring to
human subjects:
R-008: The root of clinical trial[s] is good
clinical practice, which is geared on human
subjects safety. So it is a must that ethical
caring be based on safety of the patient.
R-007: All patients should be safe. Its
difficult to have mistake[s].
Participants portrayed the need to create an
environment that optimizes the role of clinical
research nurses to engage in value-based
procurement for the human subjects rather than
focusing on research protocol; they could thus
spend time on patient education, prepare for care
coordination, and increase their interaction with
subjects, thus increasing the cocreation of doing
of the nurse and the one being nursed. Participant
R-002 reemphasized:
R-002: By means of safety follow-up, those
surveillance, because here in clinical
research, surveillance sometimes is the
heart, those safety follow-ups, that is the
heart of the work. If they are sick, you need
to ensure theyre safe.
It was clearly raised by Oberle & Allen (2006)
that clinical research nurses are faced with
methodological issues and notions of ethical
precepts within the context of moral obligations.
As perceived, clinical research nurses are taught
to offer therapeutic presence to human subjects;
however, these are not taken into fullest
consideration in the protocol design. The moral
dilemma begins when a nurse is conflicted on
choices between contravening the research
protocol and following the professional obligation
to do good (beneficence) and to do no harm
(nonmaleficence). This could be a very difficult
dilemma for a nurse. It is significant to note, then,
that scientific advancement potentially creates a
moral distress to clinical research nurses.
For these reasons, the doing ethical caring
concept provides a parallel avenue to realign
actions of clinical research nurses necessary to
override some research instances to meet human
KnowingDoingValuing as Systems of Cocreations: A Germinal Theory on Ethical Caring
subjects needs. The concept of doing appears to
provide a potentially useful construct to describe
the attributes clinical research nurses went
through after knowing the ideologies of clinical
research. In that context, cocreations of doing
then is defined herewith as clinical research
nurses ways of innovating and enhancing the
nursing as ethical caring through research
processes. This has to be understood as an
iterative process involving the construction and
deconstruction of experience. This emphasizes
the premise that clinical research nurses should
practice ethical caring as doing in accord with
what they wanted to do for themselves under
research protocol circumstances. The ethical gap
on human subjects will be filled through
competence and skillful innovation of research
processes; in that way, the clinical research
practice will be anticipatory, comforting,
protecting, and preserving (Swanson, 1999, as
cited by Bailey, 2009).
Conversely, Roachs (1984) attributes of
professional caring seemed to address the
evolving trend, synchronizing the concept of
knowing and doing in clinical research. As noted,
they included (a) compassion, (b) competence,
(c) confidence, (d) conscience, (e) commitment,
and (f) comportment as components of
professional practice, and in that way appreciation
of the preciousness of the human subject through
these acts, although bounded by research
protocol, projects a coherent approach in
illuminating phenomenon within a restricted but
coherent milieu. As such, the doing processes go
through systematized facets of meaning and
nursing process development. These then are
translated into more specific and innovated acts
of doing as ethical caring.
The doing process in ethical caring starts with
innovative planning. Having explored the
importance of knowing in ethical caring, clinical
research nurses assume a planning role that
should mirror clinical practice. Before they can
even start extending their ethical caring skills,
clinical research nurses begin as unknowers,
striving to unclothe the domain of clinical research
and eventually extend their knowledge in
trainings, meetings, and review of research
protocol. On that end, clinical research nurses
may find solutions that impede their delivery of
care.
The quality of ethical care that they provide
begins by transforming and making a difference in
themselves as nurses. Upholding the nursing
values of compassion, clinical research nurses
may journey with human subjects in highlighting
the authentic human health experience without
violating the research protocol. Clinical research
nurses then should act as ethical doers in
ensuring and understanding the rights and
responsibilities of human subjects and preventing
them from coercion and misinformation. The
process highlights the inconsistencies between
care and research protocol and prompts the
clinical research nurses to propose changes to
meet human subjects needs. By embedding the
challenges and objectivity of clinical research,
compassionate recruitment as a second facet of
ethical caring as doing may then be expressed.
Clinical research illustrates an ethical breadth
concerning human participation and highlights the
growing awareness of the many factors that can
impact an individual or communitys research
experience. In fact, several studies show the
protection of human subjects continuously to fall
short in clinical research (Iacona & Carling-
Jenkins, 2012; Shepherd & Riley, 2012). In order
to enable clinical research nurses to articulate a
research environment that is comforting, the
monitoring of human subjects should be reshaped
and re-empowered, which is considered the third
facet in doing. Thomas (2004) particularly
stressed that safety in research is imperative
because it is not usually part of the standard care
because participation is highly voluntary. The
nurse must always be aware of the risks involved
and should extend an arm on familiarizing
guidelines and regulations that pertains to human
subjects protection. It is then argued that
because of the complexities of the research
environment, clinical research nurses should
modify their usual nursing actions, aligning to
research protocol to meet the needs of the
institution, the nursing self, and the human
subject.
The sustained commitment to transform the
whole research process enables clinical research
nurses to provide health-promoting interventions
to maintain human subjects health, free from
adverse events and reactions to investigational
products. A key learning is about how to do it in
an ethical waydealing sensitively with human
subjects, engaging in activities for subjects
safety, and staying involved with safety decisions.
These symbolic acts of doing bridge nurses being
and becoming with human subjects, allowing for
goodness and hope in valuing the experience
(Arman & Rehnsfeldt, 2007). The experiences of
clinical research nurses here strengthen the need
to appreciate and recognize the context of the
clinical research praxis.
In this view, a doing responsibility and
inclination towards ethical care will avoid mistrust
issues with human subjects. The parties, nurse
and human subject, will authentically grow in their
clinical research experience if they understand
the value of their humanness. Their value must be
engaged with their role of protecting each other
from pain and danger brought by clinical research
activities. Yarborough (2009) pointed out the
importance of creating a culture of safety and of
developing accountability practices in the
research enterprise to enhance trustworthiness. If
human subjects perceive that they are ethically
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KnowingDoingValuing as Systems of Cocreations: A Germinal Theory on Ethical Caring

Table 2
Reengineered Concepts of Doing Facets in Clinical Research Nursing
Facet Definition
Creative collaboration The nurse and human subject perceive the experience as authentic, leading to cocreation of
processes, the highest facet of doing.

Human subject retention The ability of clinical research nurses to minimize dropouts in human experimentation.

Monitoring human subjects The ability to respond to the need of human subjects.

Compassionate recruitment By merging the compassionate domain with research, clinical research nurses take into account the
vulnerability of human subjects, thus having a sound ethical consideration in enrolling in clinical research.

Innovative planning Clinical research nurses provide a platform of restricted but coherent plans anchored with knowing to
ignite the authentic health experience.

cared for, then minimal human subject dropout
will be experienced and the fourth facet of doing
will be attuned, which is human subject retention.
The reengineered facets of doing (Table 2)
offer a transformative shift in contemporary
nursing practice, particularly focusing on the
newer paradigm that includes the view of the
human subject as a whole person and as a
cocreator in valuing and finding meaning in the
experience. Through the integration of these
forms of reengineered knowledge, clinical
research nurses can expand a unique moral
quandry and can make a meaningful contribution
to the realm of ethics and nursing science in
cocreating authentic human health experience;
creative collaboration will exist on its end.
Theme 3: Cocreation of Valuing
Ranheim (2009) explicated that all caring
meanings are intertwined, interrelated, and
inseparable and that they exist in dynamic
movement. Our being affects caring and caring
affects our being. A synthesis can be drawn then
that there is a clear correlation of knowing to
doing and of doing to valuing, and that they can
all move in the same direction. Given the clear
ethical obligation, nursing as valuing should be
thoroughly integrated in clinical research
practice. The cocreations of knowing, doing, and
valuing may lead to the development of a
responsive ethical caring culture in the clinical
research field.
When reflecting upon their experiences, the
respondents related knowing and doing in their
caring activities. The meanings, innovations, and
processes gained through experiential
knowledge enabled them to create an inner
space of freedom in which they could choose to
provide ethically right decisions and even
respond effectively to the needs of human
subjects treating them as whole and complete.
To further allow such grounding and to translate
the real impact of knowing and doing in the
practice, valuing must be sensitive enough to
bridge the gap of research and nursing and be
explored on its unique ethical constructs.
Creative unfolding moment by moment. It was
found out that clinical research nurses are
genuinely concerned about the extension of their
ethical caring hands, and that they want to
address the existing conditions that hamper their
delivery of ethical care. It was proved that
whenever nurses choose to practice the
profession, whether its in academe, hospitals,
community health facilities, or specialized
research settings isnt what matters mostits the
identity they build. Boykin and Schoenhofer
(2001) expressed that caring is lived moment to
moment and is continuously unfolding. This is
factual to clinical research nursing as the
development of ethical caring occurs and
develops over time. Developing the fullest
potential for the expression of self as caring
person is dominant in this field of nursing practice.
It was further confirmed as an interesting and
somewhat fundamental liberation of ethical care in
clinical research:
R-009: So, technically, as a nurse, what I am
doing, since the protocol was saying that we
are allowed to advise. There. So I think,
through advice, we can render caring to our
patients even if they are our subjects.
R-010: Ahh . . . when I am calling then to
ask if they are feeling good every 2 weeks, if
they are experiencing any sickness and I am
also asking if what happened to them. So
thats [it].
It was highlighted through participants
narratives that as nurses by soul, they still
managed to find priceless moments of connection
with human subjects through their valuable caring
values. Participants shared their little ways of
rendering nursing care despite the stringent
research protocol:
R-002: You are following them up through
phone calls, you are conducting health
teaching to them, like I felt that health
teachings is the best way caring is being
delivered.
This only proved that regardless of struggles
that clinical research nurses faced in the clinical
research field, still they could wholeheartedly
look for caring values to achieve the
transmission of authentic human health
experience to human subjects. The nurses
choice to say yes to the gift of nurturing and
enhancing personhood for herself and for human
subjects proves its roots in nursing as caring
(Schoenhofer, 2002). Clinical research nurses
are continuously upgrading their skills, which
focus not only on clinical knowledge but on the
level of extending ethical care to human
subjects. The preparation set forth opens new
doors for these clinical research nurses to
contribute innovations. Little by little, this act of
caring creates a scenario where one can
experience nursing as caring, intentional and
authentic, in a highly controlled environment
(Boykin and Schoenhofer, 2001).
Creative unfolding is really happening and
caring moments are inherent and embodied
through clinical research nurses intentionality. A
shared intentionality is cocreated within the
human subjects as clinical research nurses enter
into their lives and come to know them as caring
persons in that way, growing and living in nursing
as caring unfolds (Boykin & Schoenhofer, 2001).
These then reflect that being part and parcel of
building a culture of safe and service excellence
in human subject care is now one of the highest
priority domains that should looked into.
Shared humanity. Fagerstrom (2006), as cited by
Rundqvist, Sivonen, & Delmar (2011), discussed
that nurses are confronted with the dilemma of
deciding to be good or bad because of the
several ethical issues that arises in the

68 International Journal for Human Caring

 KnowingDoingValuing as Systems of Cocreations: A Germinal Theory on Ethical Caring

Aesthetic Expression 1 R-005: Probably if you look at it, the protocol

is not really telling you . . . to only obey me.
R-008: Growing Inside
Seems like you have to find ways on how to
be a nurse in a clinical research because in
the first place you are a nurse.
R-003: Patient care is always the first.
R-001: It does not mean that because this is
a clinical research, like you can harm them,
that shouldnt be. The reason why we have
research is to improve our care with our
patients.
Participants clearly related the context of
being a nurse by heart. As it is greatly affected by
personal experience and culture, it is apparent
that people have their own interpretation and
personal view of the meaning of caring. Clinical
research nurses, in turn, found a way of becoming
ethical carers by safeguarding the rights and
value of each human subject enrolled in the
clinical research. Participants conveyed:
R-006: So once that they tell us that they
wanted to withdraw their consent, maybe
thats the time we need to stop, that we need
. . . to explain further, like so and so. That is
where caring is . . . valuing their decisions.
As such, it can be argued that clinical
research nurses position on wholeness during
the entire clinical research process is just a
profession. The sustainability of caring precepts reframing their utmost potentials that could fraction of totality of the ethical caring force or the
remains a challenge in clinical research. This is complement a right balance between the cocreation. It was clearly espoused by participant
rooted in the descriptions of nurses with which dichotomy of research and caring. Participants R-006 in her aesthetic expression that ethical
nurses are bombarded that are based only on narrated: caring involves humanistic and spiritual
their role functions as helpers or agents of help,
not on their humanity (Taylor, 1992). In
agreement, Watson (2003) explicated that the Aesthetic Expression 2
crisis lies in nurses failure in finding meanings R-007: Half Human, Half Robot
for the nature of our being human. As nurses,
our tasks of nursing, health, and healing are
woven into our intention of shared humanity.
The need to reexamine clinical research
nurses own meaning of nursing, during this time
of despair and unfortunate events, will sustain the
cultivation of healing environment for self and
others. Roach (1984) considered that the desire
to care is humanmanifesting the human mode
of caring, hence explicating that caring is not
unique in nursing or even to the caring
professions. It is primarily a characteristic of
human beings, in that alone embodying the
qualities of the helping discipline. The utmost and
fullest human sacredness allows clinical research
nurses to engage in a compassionate clinical
research merging and fulfilling choices to care
beyond research barriers; on that, a new space, a
new moment arises with and within our
relationship to nursing, self, and others into a
deeper level.
Within its complex and restricted protocol-
centered arena, respondents cited different
holistic approaches to address the need for

2016, Vol. 20, No. 2 69

KnowingDoingValuing as Systems of Cocreations: A Germinal Theory on Ethical Caring
Aesthetic Expression 3
R-006: Its in the Heart
dimensions within an array of love and
compassion. A participant declared,
Love of humanity holds our practice. Our
love makes us alive. There is sacredness in
love, because when we are loving we know
that we are alive. Then, if we [know] that we
are loving, we can share our piece of self to
vulnerable persons, willing to be cared and
loved. In turn, we can hold of our practice as
caring.
With these stronghold narrations, the clinical
research nursing profession itself continues to
evolve through the scholarly inquiry that facilitates
building of evidence-based practice to ascertain
that the goals of the practice of nursing are
aligned within the needs of the patients and the
community at large.
Appreciating unique nursing encounters.
Through these clinical research nurses
transcriptions, it can be argued at this point that
caring really hurts. Clinical research nurses may
be wounded with uncertain profession and stress
within their restricted environments, but somehow
along the journey they find light amidst unknowing
and knowing. Caring really begins when we face
the hurt in its full force and then grow through it
with all the strength of our soul. Mayeroff (1972)
expounded, as cited by Ranheim, Karner, and
Bertero (2011), that it involves the process of
relating to someone that nurtures development.
For every reward of learning and growing, some
degree of pain is always the price. Clinical
70 International Journal for Human Caring
research nurses realize their capacity and power
to care, and understand their intentionality and
being there for the human subjects (Roach,
1984). Clinical research nurses not only stand to
exemplify what is expected from them and the
outcome of the deliverance of care in all levels of
ethical care but also acquire the process of
transformation of thoughts. As a result of these
profound experiences, participants realized that
Aesthetic Expression 4
R-001: Puzzling Research and Care
they found fulfillment in their chosen field of
nursing.
R-006: For me, my heart is here. I mean, I
am happy here in clinical research. I am
learning so much. Every day I am learning
new things.
Caring in the clinical research nursing
profession is expected to take place every time a
nurse-to-human subject contact is made as part
of our sworn duty to society. The caring attitude
exhibited by the nurse from the initial encounter
will determine the milieu of the entire nurse-to-
human subject relationship. Caring helps nurses
to become more sensitive and more awake to life.
It invites gifts of humility and faith. Watson (2003)
explicated that caring is the moral ideal of nursing
whereby the end is protection, enhancement, and
preservation of human dignity. It opens clinical
research nurses hearts to the profound
complexities of truth, beauty, divinity, and grace.
Thus, caring is the essence of nursing (Schwerin,
2004).
Participant R-001 utilized watercolor painting
in describing her journey in clinical research,
mentioning that ethical caring is the one important
element to balance the conflict on research
protocol and the struggle to administer care to
human subjects. She mentioned that her
eagerness to learn and unlearn the clinical
research process and some acts of modification
help her to portray the practice as ethical caring.
Participant R-001 recounted:
Moment by moment lifes preciousness is
fulfilled through connecting puzzles. Puzzles
are realities. Realities make us humans
caring, comforting, adapting, and loving.
Nurses hold of the ideologies of being human
provides answers to questions of absence of
 KnowingDoingValuing as Systems of Cocreations: A Germinal Theory on Ethical Caring

Aesthetic Expression 5 research. Changing the perception and notion of

R-003: All Known human experimentation may take some time, but
clinical research nurses have taken the leap of faith
to cause an inevitable effect to the entire profession
(Figure 1).
Tarlier (2004) explored the moral and ethical
foundations of nursing, that is, the personal moral
sense that is within the nurse and the one being
nursed. The responsive relationship should be
bounded with respect, trust, and mutuality to
facilitate ethical bases of nursing and as a
reflection of ethical nursing knowledge. It is
therefore imperative that clinical research nurses
render care considering with utmost magnitude
the moral and spiritual obligations of personal
actions integrating varied constructs on nursing
care, such as legal, economic, educational,
technological, and physical culture.
Appreciating the value of the profession and
maintaining ones control to humanity aligns the
objectives and philosophies of what nursing is all
about. Through this, all clinical research nurses
who are entering the discipline will be more
adaptive, responsive, accountable, and
responsible to their bestowed functions.

General Discussion
In this light, the process that clinical research
nurses undergo as they take on the challenge of
rendering ethical care towards human subjects in
caring in the practice. Understanding oneself as a a restricted research environment may be
human being may influence how people described and interpreted through this emerging
germinal theory (Figure 1). These connecting
understand, grow, and nurture in the world
(Boykin & Schoenhofer, 2001). The art depicted
Aesthetic Expression 6
that knowing the value of clinical research and
taking hold of nurses humanity creates a diffusion R-004: Be the Change
of research and care. As a result, ethical caring
emerges.
Meanwhile, participant R-003 explicated,
through the medium of colored pastels, that
ethical caring was based on the concept of
knowing all the guidelines and standard operating
procedures of the research protocol. Clinical
research nurses may struggle in finding the best
avenue to render care to human subjects; still, the
participant perceived that rendering ethical care
may be successfully achieved if one may continue
to fill in those gaps of knowledge in clinical
research. The participant clearly espoused that a
clinical research nurse may render
unquestionable ethical care if one is competent
enough and values taking the road less traveled
(Carper, 1978).
Further, participant R-004 supported ethical
caring through becoming the change agent the
society needs. It was clearly explained, through
colored pastels, that clinical research nurses
really work hard to fill those caring gaps in clinical

2016, Vol. 20, No. 2 71

KnowingDoingValuing as Systems of Cocreations: A Germinal Theory on Ethical Caring
Figure 1
KnowingDoingValuing as Systems of Cocreations
puzzles implicate that integration of meanings,
innovations and processes, and values through
the process of cocreations of experiences of the
nurse and the one being nursed will achieve
ethical caring, on its end, in an authentic human
health experience.
As clinical research nurses strive to attain the
fullest meanings of their experience, one may
achieve the knowing domain, which explicates the
deepest understanding on their purpose within the
context of human experimentation. This
encompasses the process of shedding light on
the unrecognized and maintaining ones integrity
translated to appreciation of the nursing
profession. By taking of guard on the meanings
perceived, clinical research nurses brought
together the doing domain on the field, innovating
ways to better render care within a stringent
protocol even if one may face hurdles along the
way. Processes were then carefully framed and
re-empowered by essentially bringing together the
fundamental precepts in the clinical research
process. As their experiences progressed, clinical
research nurses took on a deeper domain, which
is valuing. Nurses journeyed with the human
subjects through the gift of humanity. Values were
raised on a personal degree within the strands of
professional precept.
With the triphasic concepts of knowingdoing
valuing, system of cocreations were guardedly
established. The building of cocreation rudiments
focuses on enhancing authentic human health
experience by involving the human subjects in
establishment of value and meaning. On this
72 International Journal for Human Caring
premise, the human subjects become an active
partner for the cocreation of future value, rather
than just a passive recipient of research
experiments whereas obliterating the clinical
research nurses notion on human subjects as
mere information or guinea pigs. This through stringent research protocols focused on
mutual relationship affects both the nurse and the
one being nursed, reshaping their ways of
thinking, interacting, and innovating. Cocreation
creates a highly promising and more holistic
approach to value creation. Its benefits can cut
both ways. Whereas human subjects benefit from
greater personalization and value as a result of
cocreation processes, the motivation of clinical
research nurses is about building authentic
human health experience by turning doubts from
human subjects into valuing for their professional
growth.
Considering and borrowing profoundly from
notable nursing theorists, the following
assumptions were carefully framed:
1. All persons are caring.
2. Our task of nursing is woven into our
intention of shared humanity.
3. Knowing and valuing the person as a
whole and not as mere information or
guinea pigs will create and consider the
human experimentation experience as
nursing.
4. Ethical caring is lived moment by moment
in clinical research situation, and
continuously unfolding through time.
5. Intentionality and love are ethical caring
constructs.
6. Unknowing and knowing are fundamental
domains of ethical caring.
7. Symbolic acts of doing bridges nurses
being and becoming to human subjects
allowing for goodness and hope in valuing
the experience as nursing.
8. Integrating the reengineered concepts of
knowing, doing and valuing allows the
appreciation of human experimentation as
ethical caring.
9. Cocreation will enable creativity, and
potentially enable for both the nurse and
the one being nursed development of
meaning, innovations, processes, and
caring moments for ethical caring in
clinical research.
10. Ethical caring is the moral ideal of nursing
whereby the end is protection,
enhancement, and preservation of human
dignity.
Having thought of Boykin and Schoenhofers
(2001) assumptions that nursing takes place within
different nursing situations, the clinical research
arena professes complex and dynamic interactions
in which the nurse should be knowledgeable of the
authenticity and uniqueness of experience. And in
that perspective, the combination of knowing,
doing, and valuing as ethical caring constructs
provides expositions to equate and appreciate the
unique nursing encounter as ethical caring. It
simply denotes that the nursing phenomenon
explored herewith was a human transformational
activity of both the nurse and the one being nursed
knowing the person as a whole and not as a mere
piece of information or guinea pig, fostered with
compassionate valuing to myriad positive doings as
essential ingredients to cocreate value, meaning,
innovation and processes for quality of life.
While this model emerges, we must
understand that every individual is whole and
complete in the duration of the experimentation
and is unique in his or her perspective of health,
and must be treated in accord to his or her being
human to arrive at a quality of life achieved
through a worthwhile recuperation and authentic
human health experience. This beats our purpose
of creating a frame of mind of what nursing really
is, and what it is geared at.
In the radiance of the wide range of desiderata
relevant to nursing science, this theory is
germane to the track of a reflectiveexpressive
clinical research nursing practice that would not
just help develop the knowing and valuing but
also integrate the capacity to attend to this call, to
be able to extend the implementation of research
protocols through doing in nursing. Through the
understanding of persons experiences, we would
be able to expand our nursing arms for the
comprehensive nursing care research
management. Knowingdoingvaluing in clinical
research nursing is an integral component of

unifying the dichotomy of research and ethical
caring. The practical significance of this
foundation is aligned to the nursing profession,
practice, and discipline.
Ethical Caring Defined
Building a culture of ethical caring does not
happen overnight; rather, it entails the tedious
progression from knowing to doing to valuing. The
harmony derived from the integrated review of
literature, individual interviews, and aesthetic
expressions suggested the following definition of
ethical caring:
These are voluntary actions of being and
becoming which are deeply woven into our
intention of love, compassion and shared
humanity. It is focused on matters of
obligation or what ought to be done arising
from our moral and integral constructs of
knowing, doing and valuing. Ethical caring is
continuously and creatively unfolding
through cocreation of meanings,
innovations, processes, and values with and
within our environment, the nurse and the
one being nursed.
Ethical caring takes place when a clinical
research nurse speaks through an open heart full
of compassion and authentic intentionality. Then,
it transcends through its continuous and creative
unfolding of experiences to touch the human
subjects open heart. It happens to us with our
fundamental patterns of knowing nursing
situations (Boykin & Schoenhofer, 2001). Gilligan
(1982) stated, as cited by Puka (1990) and
Lachman (2012), that ethics of care directs us to
the needs of establishing relationship, such as
responding, paying attention, and listening with
oneself and others and coping more than moral
development through a feeling of connectedness.
It is primarily contextual and psychological and
deeply upholds ones liberation. Receiving forms
of analgesia from ethical caring cocreations can
give the most wonderful piece of nursing as
caring from the nurses own voice. The end result
will become evident when we feel the heavy
energies exit our bodies and whats left is the
everlasting glow of optimism. Relating and
responding to its release is the best way to feel
the ethical caring touch. As clinical research
nurses pursue achievement of a soul in
accordance with virtue, they become more
inclined to provide quality nursing care and be an
advocate for what is true and what is just, and
more importantly, offer themselves to a more
caring world.
Conclusion
In line with this advancement in nursing,
developing nurses ethical caring behaviors is
paramount to strengthening their capacity to
exemplify what is expected from them and the
outcome of their care in the restricted research
KnowingDoingValuing as Systems of Cocreations: A Germinal Theory on Ethical Caring
protocol-driven environment. Because the
demands in human research are changing, the
nursing profession should also learn to strategize
how it can align its objectives and philosophies to
meet such demands and needs of individuals,
family, and community and in a macro context.
Through knowingdoingvaluing as systems
of cocreations, all clinical research nurses who
are entering the discipline will be more adaptive,
responsive, accountable, and responsible to their
bestowed functions as culled from international
guidelines and standards in the practice of
nursing, raising a new generation anchored on
ethical caring culture.
The ontological and epistemological approach
in this paper makes a novel contribution to the
ethical caring concept in clinical research nursing.
While this model of ethical care emerges, we
must understand that every individual is whole
and complete in the duration of the human
experimentation and is unique in his perspective
of health, and must be treated in accord to his
being human to arrive at a quality of life in an
authentic human health experience. This beat our
purpose of creating a frame of mind of what
nursing really is, and what it is geared at.
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Author Note
Mark Donald C. Renosa, DNS, RN, is Science
Research Specialist II, Research Institute for
Tropical Medicine, Muntinlupa City, Philippines.
The author would like to express his deepest
gratitude to St. Paul University Philippines, Dr.
Josephine Lorica, Dr. Elizabeth Baua, Dr. Oscar
Turingan, and Dr. Rozzano Locsin for their support,
guidance, and advice throughout the research
project, as well as their painstaking effort in
proofreading the drafts, which was greatly
appreciated. The author is also grateful for
Kassandra Gaerlan and Byron Webb Romero, who
provided valuable assistance in data collection.
The author does not have any conflicting
interest and did not receive any sponsorship for the
completion of this research project.
Correspondence concerning this article may be
addressed to Dr. Mark Donald C. Renosa, Science
Research Specialist II, Research Institute for
Tropical Medicine, Philippines Filinvest Corporate
City, Alabang, Muntinlupa City, National Capital
Region, 1718, Philippines. Electronic mail may be
sent via the Internet to drmarkdonaldrn@gmail.com
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