Escolar Documentos
Profissional Documentos
Cultura Documentos
clusions. Of the 68 articles selected, another seven did not Table 2 Chosen definitions for identified attributes of caring (pre-
j any data relevant to the concept and were eliminated, sented in order of appearance in the analysis; Gove 1986)
resulting in. a final total of 61 articles being formally
Relationship: The state or character of being related (po 1916); the
reviewed, wbich equated to a 21-6% inclusion rate. state of being mutuallyor reciprocally interested (p. 1916); to have
meaningful social relationships (Gove 1986, p. 1916)
Action: A deliberative or authorized proceeding; a voluntary act of
Data analysis will that manifests itself externally or that may be completed
internally; a thing done (p. 21)
During the initial analysis, a coding system was created in
Attit1ide: position or bearing as indicating action. feeling or mood;
which data pertaining to the attributes of the concept of the feeling or mood itself; a persistent disposition to act, either
caring, the contextual features of and related/surrogate positively or negatively, toward a person, group, object, situation
concepts were retrieved on individual coding sheets. or value (p. 141)
Each coding sheet was then reviewed for recurrent themes, Acceptance: Act of accepting (p. 11); to treat partially or with
favoritism; to regard as proper, suitable, normal (p. 10)
which were identified as categories. Identification of the
Variability: The quality of be.ing variable or subject to variation
significance (prominence of the concept), use (common (p. 2533}; vary, to malce an especiallyminor or partial change
manner employing the concept; Rodgers & Knafl 2000), in, malee different in some attribute or cllaracteristic (p. 2535).
and application, range and scope of the concept of caring was
the focus of this review. Word labels were then selected that
best illuminated tbe nature of the data. A nursing scholar importance of this relationship has been emphasized by
with expertise in the area of concept analysis and familiar referring to the nurse as a companion on an illness journey
with Rodgers' (2000a) approach also reviewed the raw data [Lindholm & Eriksson 1993, HaUdocsdottir & Hamrin
and word labels Were agreed upon. The articles were then 1997, Pearson et al. 1997).
grouped according to the emerging themes and collapsed into Important characteristics on this caring relationship are
the following synopsis. trust, intimacy, and responsibility (Moccia 1988). Trust and
intimacy were essential in a professional eating relationship.
Nurses attempt to create a trusting relationship characterized
'indings
by openness, sincerity, love, and patience. It is important to
Rodgers (2000b) asserted that 'identification of the attributes be near, and not to abandon the patient (Fitzpatrick 1992,
of the concept represents the primary accomplishment of the Ha111993, Lindholm & Eriksson 1993).
concept analysis' (p. 91) and constitutes a 'rea)' (Rodgers A professional caring relationship places responsibility on
2000a, p. 91) definition of the concept. By using the iterative the person who is providing the care. That person is
processes identified by Rodgers (1989, 200Oa, 2000b), the responsible for actions directed toward the well-being of
findings of the present concept analysis suggested that there the person being cared for. Therefore, it is imperative that the
are five attributes of caring within nursing. These attributes actions of professional carers are knowledgeable and current.
are: relationship, action, attitude, acceptance, and variability. Professional ethical codes provide a framework. for nurses to
Definitions of these attributes are given in Table 2. facilitate decision-making and ensure a high standard of
conduct (Watson 1990a, Fealy 1995, Welch 1999).
Relationship
Action
Relationship has been called the 'foundation of nursing'
(Hartrick 1997, p. 524) and even a 'moral imperative to Action was the second attribute and was a dominant theme in
enter into a relationship with clients of nursing' (Hartman the conceptual analysis. Professional caring almost always
1998, p. 18). This relationship is initiated when one person, includes some action, such as doing for the patient or being
most often the nurse, identifies a need in another and is with the patient (Fealy 1995, Halldorsdortir & Hamrin 1997,
motivated to act (Fealy 1995). This becomes a relationship of Krebs 2001). These actions originate from the carer's
professional nurse eating when the other needs assistance perception of another's needs, and result in motivation to
because of disease, crisis, or inability to engage in self-care act to meet those needs (Fealy 1995).
(Balasco 1990, Schattsneider 1992, Boykin et al. 1994, From (1995), a nurse educator, discusses nursing students'
Fealy 1995). This relationship has also been compared with perception of caring. When asked to describe their percep-
friendship, in that both are relationships that develop from tions of caring, students replied with a spectrum of caring
affection and concern for another (Olsen 1992). The actions. One student wrote, 'I don't grimace or flinch'.
e 2005 Blackwell Publishing Ltd, Journal of Advanced Ntming, 50(6), 641-650 643
---- ~--
G.A. Brilowski and M.C. Wendler
i
Another replied, 'Helping a patient through all of those awful Competence
procedures'. A third noted that a caring nurse 'looks at all the A fourth action related to caring was clinical competence. An
available resources the hospital has for a patient' (From understanding of how human and physical science interacts
1995, p. 330). These responses reflect four important actions: with the humanity of patients and their family members is
nursing care, touch, presence and competence. crucial to good care (Welch 1999, Sanford 2000). Indeed,
Halldorsdottir and Hamrin (1997) assert that: 'Caring
Nursing care without competence is meaningless' (p. 123). As nursing care
Nursing care consists of the actions and interactions between becomes increasingly focused on technology, competence to
a nurse and patient (Fealy 1995), with physical care as a care has an increased urgency, with at times with life-
primary focus (Garbett 1996, Shamansky & Graham 1997, threatening or life-saving consequences. The literature,
Guilo 1998). For example, Hallock (1994) notes: 'It made me however, suggests that competency alone is not considered to
feel good to do little things to try to make him more com- be caring (Locsin 1995, Happ 1996, Thompson 1996).
fortable like giving him a back rub or getting him a new
supper' (p, 88). Danielson (1996), describing her mother's
Attitude
care in a nursing home, states that: 'From bathroom detail to
whirlpool baths, from getting her in and out of chairs, in and The third attribute of caring revealed in the analysis was
out of bed. They dressed her and undressed her, made sure attitude. The literature revealed the importance of the nurse
that her hair was done, and her makeup was perfect' (p. 28). presenting a particular positive attitude in order to be
These examples demonstrate the importance of the provision considered caring. In fact, the concept of caring about
of physical care as a primary focus of caring through nurse represents a particular disposition. or attitude, toward
action. another. Caring is not simply a series of actions, but is also
a way of acting (Fealy 1995}, a comportment, or ontology, of
Touch the nurse. Often it includes a positive approach to people and
Caring touch was identified as a second action of a caring to life (Halldorsdottir & Hamrin 1997, Kearns 1999). Watson
nurse (Clapham 1992, Ebersole 1996, Guilo 1998). It is a (1990b) wrote: 'If caring is to be sustained, those who care
form of non-verbal communication, and is influenced by a must be strong, courageous, and capable of inner love, peace,
nurse's intentionality and a patient's perceptions (Fredriksson and joy both in relation to themselves and others' (p. 64).
1999). Mallory (1988, p. 63), writing of her brother's illness, Dyson (1996) suggests that work style, an expression of
records that: 'Joan wasn't afraid to touch him, to stroke his attitude, is an indicator of caring. HaUdorsdottir and Hamrin
hair, or to hold his hand. She'd say and do things to make (1997) interviewed nine health care recipients and asked
him laugh. Most of all, she made him feel good through small them to develop a description of a caring nurse. The findings
acts of concern, such as making sure the washcloth was identified a caring nurse as attentive, honest, genuine,
warm'. Ufema (1994) adds that: 'the little things really mean involved, a good listener, genuinely concerned about the
the most to everyone involved' (p. 18). patient's welfare, committed, understanding. respectful of
questions and sensitive to the patient's needs. In another
Presence example. Pryds-Jensen et al. (1993} asked 16 nurses to
A third action of the caring nurse was presence. This nurse develop a picture of the caring nurse, and discovered that
uses self as a tool to be totally present (Pryds-jensen such a nurse demonstrates knowledge, practical skills,
et al. 1993, Smith 1999). Being there is not only a physical self-confidence, reflective self-knowledge, and knowledge of
presence, bur also specifically includes a giving of self others. The caring nurse demonstrates empathy, timing based
(Fredriksson 1999). It consists of occupying the same space on intuition, creativity, humour, and possessed the imagina-
with the patient, listening carefully, allowing time to share tion to facilitate the development of a new perspective for
[Pryds-jensen et al. 1993, Fredriksson 1999), and commu- patients. These nurses also demonstrate a love for humans,
nicating to patients and families the nurse's interest in them are deeply concerned, and act on the basis of ethical values
(Stewart-Amidei 1988). Thus, presence is the act of genuinely and attitudes. They approach patients with a positive attitude .
engaging with another (Liehr 1989). As Welter (1989) asks, and are committed, interested, honest, and generous. Caring
'How many nurses have charted at the bedside of a restless or nurses demonstrate courage, acting calmly to control stressful
dying patient ... patting his hand, stroking his forehead, and or threatening situations (Pryds-jensen et al. 1993). These:
speaking a few words to assure him that he is not alone' attributes all illuminate the idea that attitude is an important
(p.45)1 attribute of nurse caring.
J
Nursing theory and concept developmentor analysis An euolutionary concept analysis of caring
~ptance Variability
1_ ~ptance of another as a feilow human being is viewed as Variability was the fifth and final attribute identified through
critical to caring by many (Wurzbach 1990, Benner 1991, this conceptual analysis process and appeared frequently in
Schroeder 1995, Pearson et al. 1997, Smith 1999). The most the included nursing literature. Cameron (1991) states that:
compelling reason chat one cares for another is that the other 'caring is personal, partial, intuitive, particular, contempla-
is a fellow human being worthy of dignity and respect (Fealy tive, subjective and concrete' (p. 206). Caring has been
1995). A nurse is as concerned with a patient's spiritual repeatedly described as fluid, malleable, and changing,
well-being as with their physical and emotional well-being depending on the circumstances, environment, and the people
(Sanford 2000). Boykin et al. (1994) writes involved (Schattsneider 1992. Brown 1993. Fealy 1995,
Warelow 1996, McCance et al. 2001). Variability is also an
Caring is viewed as the intentional and authentic presence of the
aspect of care, and is a fluidity learned through experience.
nurse with another who is recognizedas a person living,caring, and
Therefore, the appearance of caring will change or evolve as a
glowing in caring. It is through undersranding, appreciating, and
nurse becomes more proficient in practice (Benner 1991,
being open to the aesthetic pathway that the fullness of the nursing
Young-Mason 1991).
situation is known. (p. 59)
c[:) 200S Blackwcll Publishing Ltd.JOUJ7fQ/of Advanced Nursing, SO(6), 641~50 645
G.A. Bri[owski and M.c' Wendler
J
I watched a once vibrant woman who had lootthe zest for life when the concept be included. In this review, which spanned
her husband died thrive under the attention and care of the staff at 14 years from the initiation of the keyword 'caring' in
the nursing home (p. 29). CINAHL to 2002, five attributes, antecedents, consequences,
Caring also results in a sense of solidarity, empowerment, and related terms were identified. Descriptions of caring moved
hope, comfort, security, increased self-esteem, increased from simple stories of exquisitely orchestrated episodes of
reality orientation, personal growth, and lessening of fear physical care between a patient and nurse to rigorous research
and anxiety for patients (Francis 1988, Beck 1991, Funk s~udies defining and describing the characteristics of profes-
1992, Pryds-jensen et al. 1993, Owen-Mills 1995, Halldors- sional nurse caring. Of note is the (act that the earlier articles
reviewed often included a dearly-articulated definition of
dottir & Hamrin 1997, Gullo 1998, Fredriksson 1999).
. nursing. Paradoxically, as complexity in the concept developed
Mallory (1988) illustrates this as follows: 'How well Lloyd
knew suffering and how well I know that a nurse's kindness ~ver time, and the resulting need for conceptual understanding
and support can ease it' (p. 63). Caring also influences a Increased, there were actually fewer specific definitions of the
concept and this hindered understanding.
patient's perception of a nurse. The nurse is now viewed
as compassionate, competent, concerned, and respectful
(Halldorsdottir & Hamrin 1997), but not in every case: Exemplar case: William encounters nurse caring
Crigger (1997) notes that enmeshment and exploitation can
An important completing process in evolutionary concept
also occur as a consequence of nurse caring.
analysis is the development of the exemplar case. In Rodgers'
The nurse is also influenced by the caring experience,
approach (Rodgers 1989, 2000a, 2000b), because the coo-
including an increasing ability to tolerate uncertainty and an
cept is seen as evolving over time, there is a focus on the
increasing sense of empowerment and choice (Hartrick
significance, use, and application of the concept within
1997}. Caring renews energy, feeds passion, and increases a
the discipline (Rodgers 1989). This careful case description
nurse's personal and professional satisfaction [Oulton 1997),
of,the concept, if included in the analysis, must come from the
demonstrating reciprocity. Through caring. a nurse is bet-
'real world' (Rodgers 1989, 2000a, 2000b). This 'real world'
ter able to understand the illness experience (Baker &:
case may be illustrated through qualitative research or,
Diekelmann 1994). Caring also provides a nurse with a
because nursing is a practice discipline, may emerge from a
position of strength in the economy because caring is a
specific practice situation. The exemplar case here describes
desired product in health care (Tuck et al. 1998).
the experience of the first author (GB) in a caring situation in
clinical practice, illuminating all the identified attributes and
Related concepts some of the antecedents and consequences.
WiUiam (a pseudonym) was an older man hospitalized
Related concepts are 'concepts that bear some relationship to
after being struck by a falling tree. He suffered massive
the concept of interest but do not seem to share the same set
trauma, his many injuries including multiple intracranial
of attributes' (Rodgers 2000a, p, 92). Concepts related to
hemorrhages, a cervical fracture, and many fractures to the
caring identified in this process included nurturing, compas-
right side of his body. Multiple operations and many weeks in
sion, concern and ministering (Young-Mason 1991, Boykin
the hospital left him with chronic agitation and confusion,
et al. 1994, Crigger 1997, Oulton 1997). All of the related
with occasional aggression. A tracheostomy, placed early in
concepts 'were mentioned only once and were embedded
his hospitalization to assist in mechanical ventilation, later
within a broader discussion of caring, thus demonstrating this
made swallowing impossible. His transfers from the intensive
relatedness.
care unit and seep-down trauma unit, and unsuccessful
transfers to the rehabilitation unit and, later, to a nursing
Discussion borne, resulted in multiple readmissions to the inpatient, step-
down trauma unit. Some time during the first parr of his
Rodgers (1989, 2000a, 2000b) determined that the overall
~.
itI,",
outcome of evolutionary concept analysis is a list of defining
attributes, antecedents, and consequences. A definition is not
offered, as it unduly concretizes a concept, thereby hindering
hospitalization, William also acquired Methicillin-Resistant
Staphylococcus Aureus (MRSA) infection, requiring contact
isolation to prevent organism spread. Because of his multiple
health management problems, including restlessness, non-
U its further development. In addition to the identification of
adherence to isolation requirements and occasional aggres-
attributes, antecedents, consequences, and related concepts,
sion, he became a possible permanent resident of the
Rodgers (2000a) specified that an analysis of the evolution of
. ~
.
inpatient step-down trauma unit. His depression as his WilIiam, who was a patient, and the nurse. The nurse used her
rery slowed also affected his sense of well-being. positive attitude to begin to envision possibility for him, even
Ltlitially, William would frequently wander through the as she accepted him for exactly who he was as a human being.
corridors, ignoring the requirements for isolation. When staff She took action, first by purchasing the puzzles and by
attempted to redirect him, he was often physically aggressive. working alongside Williamj when that was not enougb, she
Restraints were not indicated [and are actively discouraged varied her approach to modify the hospital room further to
by law in the United States of America (USA)), and his nurses make it more comfortable. The nurse took into the situation
became increasingly frustrated as his care and his needs trust, rapport and individual commitment; the positive
absorbed enormous amounts of their time. consequences for William included an increase in self-esteem
Realizing that transfer to another facility was unlikely, a and reality orientation, a decrease in his anxiety as expressed
nurse began to assess measures to improve WiUiam's quality by agitation and, in the end, a final and successful transition
of life. With a positive attitude, she actively created a from the hospital.
relationship, focusing her concern on his quality of life.
Planning a diversional activity that could be shared, she took
Implications for nursing
action and purchased a few puzzles, an engaging activity that
could be done in his isolation room. Thus, she provided Important to concept development is the identification of
variaEnlity based on William's need for social interaction, an further areas of research (Rodgers 2000a), to assist in
expression of relationship. In the beginning. the nurse would determining the soundness of tbe findings of the analysis. In
work alone on the puzzle, providing presence, in short this case, there is an obvious need for additional theory
sections of time, silently offering acceptance of him as a development and research. The articles selected for this
human being worthy of nursing care and concern. Eventually study did not include a single concept analysis. This is
WilIiam began to work along with her. This was enormously important because a more detailed look at the sample
successful, as he spent many hours attempting to complete identified a tendency for authors to discuss caring but not to
the puzzles. As he was more engaged in diversion, the define it. The results of the present analysis may provide
isodes of agitation and aggressiveness subsided. important markers for the development of a defini-
VilIiam's depression became more prominent as the tion through further research. Questions for research
agitation and confusion subsided, for he more clearly include:
understood that he could not leave his room. Further, he • In what way are the core attributes of nurse caring related
could not enjoy the pleasure of eating food because of his to quality outcomes for hospitalized patients?
swallowing difficulty; and communication barriers persisted • What are the origins, or roots, of professional nurse
because of the continued need for the tracheostomy. The caring?
nurse began to note that he spent many hours alone simply • What is the most effective way to teach students how to
lying on his bed. care?
Again, the nurse took action. The family was asked to • Does nurse caring change outcome of hospitalization?
bring to the hospital a few precious belongings, including Length of scay? Complications? Morbidity and mortality?
photographs and a treasured blanket. Although these The findings of tbis Study suggest that caring is a valuable
personal belongings added warmth, they did not alter the aspect of clinical nursing practice. More specifically, the
institutionalized environment of the hospital room. The nurse identified attributes provide specific guidance for nurses, who
further varied the environment with decorations purchased may reflect on their own clinical practices to determine how
for the interior of the room, and, with these William's room caring can be more fully incorporated into their practice. The
was transformed from institutional to cozy and home-like. identified antecedents empower nurses to address personal
During the placement of decorations, he seemed bemused and and environmental factors that promote or hinder nurse
Would respond with a shrug of his shoulders when he was caring. The consequences of caring provide outcome criteria
asked about the change. However, over time, nurses reported for the assessment of caring in practice.
that he would smile when asked about his 'new room'. His The study could provide a practical method of student
mood brightened and his symptoms decreased; approxi- evaluation, through use of the identified attributes.
mately 2 weeks after the room had been altered, WilIiam was Additionally, the attributes, antecedents, consequences,
able successfully to move to a nursing home. related concepts, and the exemplar could facilitate under-
----- This is an exemplar of caring because it demonstrates the standing by nursing students of the core features of nurse
ve attributes described. There was a relationship between caring.
publish in English led to an Anglophone bias. This concept Dyson 1- (1996) Nurses' conceptualizationl; of caring attitudes and
behavion. Journal of It.dvanad Nursi1lg 23(6), 1263-1269.
analysis, then, may give an incomplete picture of the
Ebersole M.E. (1996) Honnonal administration in prostate cancers a
evolution of the state of the concept. caring approach. Urologic Nur.ring 16(1), 23-26.
Fealy G.M. (1995) Professional c;aring: tbt moral dimension. JOtmIlll
of Advanad NtuSing 22(6}, 1135-1140.
Conclusion FitzparnckJ.J. (1992) Caring words. Applied NMrWIg Reuarch 5(1),
1.
During the past 15 years, caring as a concept in nursing has
PhD Fowler MD.M. (1989) When did "do not resuscitate" mean "do
become increasingly important. The purpose of this evolu-
not care"? HtI/Jrland Umg;JounutlofCritical Care 18(4),424-425.
tionary concept analysis was to focus on the significance, we Francis B. (1988) How the Eastet bnnny came to t!H: I.C.U. Nursing
and application of the concept in nursing. The findings 18(3),26.
suggest that the core attributes of caring are relationship, Fredrilcsson L. (1999) Modes of relating in a caring conversaeiore
a research synthesis on presence, touch, and listening. Journal
action, attitude. acceptance, and variability. Factors such as
of Adtlanad NMrsing 30(5), 1167-1176.
trust, rapport, understanding of self and other, and commit-
From M.A. (1995) Nune's notes, Caring, learning, and remember-
ment were identified as antecedents and need to be present for ing. Image: ]mmraJ of Nursing Scholarship 27(4), 330.
cuing to occur. The consequences of caring include an Funk M. (1992) Caring. Imagl!: J0lmJ41 of N"rs;ng Scholarship
increased ability to heal for patients and an increased sense of 24(2),159.
personal and professional satisfaction for nurses. These Garbett R. (1996) Nurse-led clinics! the growth of nurse-led care.
Nl«Sing r_s 92(1), 29.
findings not only add to the body of knowledge but also
Gino C. (1998) Dear colleague: building pink bridges. NursiHg 28(7),
serve as an important impetus for further theory development 10.
and research in nursing.
648 Cl 2005 Blackwell Publishing Ltd. Journal of Adf/anced Nursing, 50(6), 641~50