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Caring Theories

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Christina Baker

on 4 April 2013

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Transcript of Caring Theories

Caring Theories Boykin & Schoenhofer CARING THEORIES Middle Range Caring Theories
* these also happen to be newer! Joanne Duffy-Quality Caring
Marilyn Anne Ray-Theory of Bureaucratic Caring Dr. Ann Boykin, R.N.,Ph.D.


BSN Alverno College (1966)
•Master Degree Emory University (1972)
•Doctorate of Nursing Vanderbilt University (1981)


Dean and Professor of Christine E. Lynn College of Nursing
Director of Christine E. Lynn Center for Caring•President Elect in the International Association for Human Caring 1990-1996
International Association of Human Caring nominating committee (1997-1999)
Co-editor of the journal International Association for Human Caring (1996-1999)

Scholarly Work

Co-author of Nursing as Caring: A model for Transforming Practice (1993, 2001)
Author Living a Caring-Based Program (1994)
Editor of Power, Politics and Public Policy: A Matter of Caring (1995)
Co-editor of Caring as Healing: Renewal Through Hope (1994)

(Alligood & Tomey, 2010) Joanne Duffy
PhD,RN, CCRN Quality Caring
Model Biography Nursing Education:
St. Joseph’s Hospital School of Nursing –Providence, RI
BSN-Salve Regina College, Newport, RI
Masters & PhD-Catholic University of America in Washington, DC. Professional:
Fellow of the American Academy of Nursing
Magnet Hospital appraiser
International consultant
Awarded First Annual Health Care Research Award-National Institute of Health Care management Employment:
Endowed Professor of Research and Evidence-based Practice at University of West Virginia
Professor at the Indiana University School of Nursing & Coordinator of the Nursing Leadership and Health Systems Program
Associate Nursing position: George Washington University Medical Center & Georgetown University Medical Center
Developed the Cardiovascular Center for Outcomes Analysis
Administrator of the Transplant center at INOVA Fairfax hospital, Virginia
(Parker & Smith, 2010) and from:
http://nursing.hsc.wvu.edu/Research/Research-Faculty/DuffyJoanne Purpose: Guide professional practice.

Describe the conceptual-theoretical –empirical linkages between quality of care and human caring.

Propose a research agenda that would provide evidence of the value of nursing (Duffy & Hoskins, 2003).

Revised in 2009 to adapt to new global health care system that includes "systems thinking based on knowledge, multiple and often times competing connections and one that values relationships as the basis for actions and decision-making" (Duffy, 2009, p.192). (Duffy, J., 2009) Four Relationships Necessary for Quality Caring Four Main Concepts: Humans in relationship –Humans are multidimensional beings with various characteristics that make them unique. Human characteristics and differences influences human interactions and nursing interventions.

Relationship-centered professional encounters –Independent relationship between the nurse and patient/family and the collaborative relationship that nurses establish with members of the healthcare team.

Feeling cared for—Positive emotion that signifies to patients and families that they matter.

Self-caring --Human phenomenon that is stimulated by caring relationships . Comes about over time with caring connections. It equals quality because it is dynamic and enhances an individual’s well-being.(Parker & Smith, 2010, pp. 404-405) Assumptions Humans are multidimensional beings capable of growth and change.

Humans exist in relationship to themselves, others, communities or groups, and nature.

Humans evolve over time and in space.

Humans are inherently worthy.

Caring is embedded in the daily work of nursing.

Caring is a tangible concept that can be measured.

Caring relationship benefits both the one caring and the one being care for.

Caring relationships benefits society.

Caring is done “in relationship.”

Feeling “cared for” is a positive emotion.(Parker & Smith, 2010, p. 405) Propositions Human caring capacity can be developed.

Caring relationships are composed of discrete factors.

Caring relationships require intent, choice, specialized knowledge and skills, and time.

Engagement in communities through caring relationships between patients and nurses influence feeling “cared for.”

Independent caring relationships between patients and nurses influence feeling “cared for.”

Collaborative caring relationships among nurses and members of the healthcare team influence feeling “cared for.”

Feeling “cared for” is an antecedent to self-advancing systems.

Self-advancement is a nonlinear, complex process that merges over time and in space.

Self-advancing systems are naturally self-caring or self-healing.

Relationships characterized as caring contribute to individual, group, and system self-advancement ( Duffy, 2009). Critical Reflection How clear is the theory? Semantic Clarity & Consistency:
Duffy uses specific and general traits to define caring and relationships.
The Quality-Caring concept’s definitions are consistent with the common meanings of the terms within nursing. How general is the theory? Application to Practice Research Study Example Strengths & Limitations Edited from:(InsideSWA, 2010).http://youtu.be/yxCeiyQVxXw, Marla Salmon is Dean of the University of Washington School of Nursing Dr. Savina O. Schoenhofer, R.N., Ph.D


Undergraduate and graduate degrees in nursing, psychology and counseling Wichita State University
PhD in education foundations and administration Kansas State University 1983


Professor of Graduate Nursing at Cora S. Balmat School of Nursing Alcorn State University
Professor at University of Mississippi School of Nursing

Scholarly Work

Co-founder of Nightingale Songs 1990
Co-author Nursing as Caring: A Model for Transforming Practice (1993, 2001)

(Alligood & Tomey, 2010) Retrieved on March 18, 2013 from http://www.nurses.info/nursing_theory_person_boykin_schoenhofer.htm The most basic premise of the theory is that all humans are caring persons, that to be human is to be called to live one's innate caring nature. Developing the full potential of expressing caring is an ideal and for practical purposes, is a life long process.
The theory is grounded in several key assumptions:
•persons are caring by virtue of their humaness
•persons live their caring moment to moment
•persons are whole or complete in the moment
•personhood is living life grounded in caring
•personhood is enhanced through participating in nurturing relationships with caring others
•nursing is both a discipline and a profession Retrieved on March 18 from http://www.slideshare.net/kai_hikari/presentation1-8624181 Application in the clinical setting
Smiling of the nurses to their patients.
Talking politely to patients.
Speaking quietly at night especially those who are in the night shift.
Approaching their patients with heart whelming smiles even though they are already haggard and tired. Paterson & Zderad
Humanistic Nursing Theory Dr. Loretta Zderad, R.N., Ph.D


Nursing diploma graduate from St. Bernards’ Hospital School of Nursing
Masters of Science in Nursing Education Loyola UniversityPhD from Georgetown University with dissertation on empathy (1968)


Served on the faculty of the State University of New York at Stonybrook
Nursologist at the Veterans Administration, Northport NY (1971-1978)
Retired in 1985 as the Associate Chief of Nursing Ed at the Northport Administration Medical Center

Scholarly Work

Articulated the Humanistic Nursing Theory (1971)
Co-author Project Gutenberg eBook, Humanistic Nursing (2008)

(Parker & Smith, 2010)
(Paterson J.G., Zderad L.T. Humanistic Nursing Theory, retrieved on March 23, 2013 from http://www.scribd.com/doc/36299173/Handout) Dr. Josephine Paterson,R.N., Ph.D


Nursing diploma graduate of Lenox Hill Hospital at St. John’s University
Master’s degree from John Hopkins University School of Hygiene and Public Health
Doctorate of Nursing Science with dissertation in comfort from Boston University (1969)


Faculty member Catholic University (1959-1964)
Nursologist at the Veterans Administration, Northport NY (1971-1978)
Retired 1985 as a clinical Nurse Specialist at the Northport Veterans Administration Medical Center

Scholarly Work

Articulated the Humanistic Nursing Theory (1971)
Co-author Project Gutenberg eBook, Humanistic Nursing (2008)

(Humanistic Nursing by Paterson, Josephine G. Retrieved on March 23, 2013 from http://www.scribd.com/doc/36299173/Handout) Application to the Clinical Setting
Encourages reflection, reflection being a learned process that can help enhance the experience of the nurse and prepare them for similar situations in the clinical environment.
The ability to be with and travel with the patient in the routine of living is often overlooked, but is an essential part of the professional life of a nurse.
Understanding the professional differences between other medical staff and allied health professionals, respect the difference and accept responsibility for challenges of nursing. Retrieved on March 18, 2013 from http://www.slideshare.net/kai_hikari/presentation1-8624181 Highlights of the Theory
In the humanistic nursing theory the components identified as human are the patient, which is the person, family, community or humanity, and the nurse
The nurse has the ability to struggle with another through “peak experiences related to health and suffering in which the participants are and become in accordance with their human potential.”(Parker & Smith, 2010, p.339)
Nurse responds to signal or call for a health related concern and metaphorically goes through life with that person, thus coming into “being” with the patient.
Nurses and patients have their own “gestalts” representing all that the human being is which includes the past and present, hopes, dreams and fears; a concept of wholeness Grand Caring Theories Using the Quality-Caring Model to Organize Patient Care Delivery ( Duffy, Baldwin, & Mastorovich, 2007) A 352 bed hospital and a school of nursing collaborated to design a professional infrastructure based on the Quality-Caring model’s proposition “relationships characterized by caring contribute to positive patient, nurse, and system outcomes (J. R. Duffy & Hoskins, 2003, p. 84).
Lunchtime leadership workshops delved into the model to improve knowledge and stimulate discussion.
A 32 hour educational program was implemented to staff for them to learn the principles of the Quality-Caring model.
Guiding principles were set by the group about the specific aspects of the delivery system. This system was organized around 5 components
After 3 months, patient satisfaction rose 2.71%,patient's reports of pain decreased 33%, nurse vacancy rates decreased 18.55%, and overall nurse satisfaction rose 20%. (J. R. Duffy, Baldwin, & Mastorovich, 2007) Improving Outcomes for Older Adults with Heart Failure (J. R. Duffy, Hoskins, & Dudley-Brown, 2010) RCT study with 2 groups of 32 heart failure patients- those receiving usual home visits versus those receiving the intervention. Quality-Caring Model was used to design an intervention by home health nurses who would communicate via telephone and in-home visits with HF patients.
The telephone script focused on symptom recognition and reporting, education, and emotional support for the patient. The nurse completed an evaluation after each telephone call. If possible the same nurse was assigned during the episode of care so that a caring patient-nurse relationship could be cultivated and sustained.Results-Intervention patients reported more satisfaction with home care services at the end of 60 days(M=55.27, SD=5.55) compared with the control group patients (M=51.44, SD=6.630). Duffy's 2009 revised Quality-Caring theory is a middle-range theory as it draws on other's works (Parker & Smith, 2010).
It has parsimony as it is conceptually simple but allows for a broad range of empiric experiences (Chinn & Kramer, 2008). Some believe that relationships are not tangible phenomena that can be measured (McCrae, 2012).

Besides nursing judgement, knowledge, and skills being needed to develop a caring relationship, time is also an important factor and yet that can be limited in many nursing caring situations. Limitations: Strengths: The ability to measure and link nursing interventions with nursing-sensitive outcomes such as nurse caring and improved health outcomes for patients.

The QCM gives nurse educators values-based methods with meaningful evaluation techniques to help students learn caring (Parker & Smith, 2010).

Quality caring, theory-guided, evidence based professional practice is holistic and profoundly impacts the patient outcomes (Parker & Smith, 2010).

By developing tools such as the caring assessment tool (CAT) that assesses the patient’s perceptions of the nurses caring- then nurses are able to be evaluated on the quality of their interventions (J. R. Duffy, Hoskins, & Seifert, 2007). Caring Factors The specific knowledge and skills necessary for caring relationships Mutual problem-solving
Attentive reassurance
Human respect
Encouraging manner
Appreciation of unique meaning
Healing environment
Affiliation needs
Basic human needs
( Duffy, Hoskins, & Seifert, 2007) Marilyn Anne (Dee) Ray Theory of Bureaucratic Caring Structural Clarity & Consistency:
The diagrams are clear and self-explanatory.
Duffy's revised Quality-Caring Model diagram clearly and simply shows the link between caring relationships and quality care (Parker & Smith, 2010). Born in 1938 in Ontario, Canada (Alligood & Tomey, 2010).
Professor Emeritus at Florida Atlantic University, The Christine E. Lynn College of Nursing
BS and MS in nursing from University of Colorado
MA in cultural anthropology from McMaster University in Hamilton, Canada
PhD in transcultural nursing from the University of Utah – Certified Transcultural Nurse
Served with the US Air Force Reserve Nurse Corps for 30 years
Various faculty positions and positions on journal review boards Purpose: To represent the dialectical relationships of the spiritual-ethical caring, present in nursing, in relation to the bureaucratic structures present in complex healthcare organizations, including physical, educational, political, economic, technological, legal, and social-cultural.
(Alligood & Tomey, 2010) Biography "Research has revolved around cultural, technological, political, economic issues related to caring in complex organizations.” (Parker & Smith, 2010,p. 472) Concepts Caring – complex, transcultural, relational process

Spiritual Ethical Caring – how decision making for the good of other should occur

Educational – formal and informal sharing of information

Physical – physical state of being, biological and mental patterns

Social Cultural – social and cultural factors, relationships, interactions, and structures

Legal – responsibility, accountability, rules, policies and principles that guide behavior

Technological – non human resources

Economic – factors such as money, budget, insurance, financial limitations and guidelines

Political – power and political factors within the administration
(Alligood & Tomey, 2010) Assumptions Nursing is “holistic, relational, spiritual, and ethical caring that seeks the good of self and others in complex community, organizational, and bureaucratic cultures.” (p. 121)

Person is “a spiritual and cultural being… created by God, the Mystery of Being, and the engage co-creatively in human organizational and transcultural relationships to find meaning and value.” (p.121)

Health includes mind, body, soul, and structures (ethnicity, family, political, economic, legal, and technological) and experiences of caring.

Environment is “a complex, spiritual, ethical, ecological, and cultural phenomena … embodies knowledge and conscience about the beauty of life forms and symbolic systems or patterns of meaning.” (p. 122)

(Alligood & Tomey, 2010) Ray’s Theory of Bureaucratic Caring
Structure and Relationships “Person, nursing, environment, and health are integrated into the structure… The theory implies a dialectical relationship (thesis, antithesis, synthesis) between human (person and nurse), the dimension of spiritual-ethical caring, and the structural (nursing, environment) dimensions of the bureaucracy or organizational culture (technological, economic, political, legal, and social).”
(Alligood & Tomey, 2010, p. 122) (Alligood & Tomey, 2010, p. 121) Critical Reflection How clear is the theory? Semantic clarity: structures and concepts are clearly defined
Semantic consistency: definitions are used consistently in practice in accordance with original definitions; however some clarification is needed for terms between model revisions
Structural clarity and Structural consistency: visual representation of structure including multi-directional arrows adds to the organization, understanding and consistency in use of the model (Alligood & Tomey, 2010) How simple is the theory? Ray simplified a very complex and dynamic environment into 8 main concepts and one visual structure (Alligood & Tomey, 2010) How general is the theory? Ray’s theory addresses the nature of caring of nursing in a holistic view with general concepts that are applicable to a large variety of situations in healthcare organizations. The interconnectedness of the concepts allows for a flexible interpretation of situations and environments (Alligood & Tomey, 2010). Critical Reflection How accessible is the theory? Empirical precision is high due to the theory being based in grounded theory with revisions resulting from research (Alligood & Tomey, 2010). How important is the theory? The theory is relevant to the current healthcare environment in which nurses provide caring at the same time while interacting with a variety of environmental influences, as described by the model.
The theory is usable in research, education, and practice (Alligood & Tomey, 2010).
It can be argued that the theory is applicable as a middle range theory, a grounded theory, a grand theory, or a holographic theory (Parker & Smith, 2010). Strengths and Limitations Strengths: Captures a complex, dynamic environment
Incorporates new science: complexity theory, chaos theory and interconnectedness
Relational caring is central to theory
Provides direction Humanistic and empirical base
Reflects a paradoxical reality Limitations Considered idealistic
Provides the vision without the method to deal with the conflicting influences
Needs further research as a theoretical guide as various theoretical levels (Chinn & Kramer, 2008) How simple is the theory? Critical Reflection How accessible is the theory? How important is the theory? Grand Theory Nursing as Caring click picture above here to play Madeleine Leininger Comparison of Caring Theories References Alligood, M & Tomey, A, (2010). Nursing Theorist and Their Work. Jean Watson: Watson's Philosophy and Theory of Transpersonal Care; Madeleine M. Leininger: Culture Care Theory of Diversity and Universality. Maryland Heights, Missouri. Mosby Elsevier.

Andrews, M., Backstrand, J., Boyle, J., Campinha-Bacote, J., Davidhizar, R., Doutrich, D., & ... Zoucha, R. (2010). Chapter3: Theoretical Basis for Transcultural Care. Journal Of Transcultural Nursing, 21(4), 53S-136s. doi:http://dx.doi.org.hsl-

Andrews, M & Boyle, J. Transcultural Concepts in Nursing Care. (2008). Philadelphia, PA. Theoretical Foundations of
Transcultural Nursing. (pp.3-14). Lippincot Williams & Wilkins.

Boykin & Schoenhofer.(1993).Nursing as caring: A model for transforming practice. National league for Nursing Press, NY.

Boykin & Schoenhofer. Retrieved on March 18, 2013 from http://www.nurses.info/nursing_theory_person_boykin_schoenhofer.htm

Chinn, P. & Kramer, M. (2008). Integrated theory and knowledge development in nursing (7th ed.) St. Louisv: Mosby. Chapter 8: Description and critical reflection of empiric theory, pp. 219-249.

Duffy, J. (2009). Quality caring in nursing: Applying theory to clinical practice, education, leadership. New York: Springer.

Duffy, J. R., & Brewer, B. B. (2011). Feasibility of a multi-institution collaborative to improve patient-nurse relationship quality. J Nurs Adm, 41(2), 78-83. doi: 10.1097/NNA.0b013e318205946300005110-201102000-00007 [pii]

Duffy, J. R., Hoskins, L., & Seifert, R. F. (2007). Dimensions of caring: Psychometric evaluation of the caring assessment tool. ANS Adv Nurs Sci, 30(3), 235-245. doi: 10.1097/01.ANS.0000286622.84763.a900012272-200707000-00005 [pii]

Duffy, J. R., & Hoskins, L. M. (2003). The quality-caring model: Blending dual paradigms. ANS Adv Nurs Sci, 26(1), 77-88.

Duffy, J. R., Hoskins, L. M., & Dudley-Brown, S. (2010). Improving outcomes for older adults with heart failure: A randomized trial using a theory-guided nursing intervention. J Nurs Care Qual, 25(1), 56-64. doi: 10.1097/NCQ.0b013e3181ad0fbd

InsideSWSA. (2010, August 31). Nurse: a world of care [Video file]. Retrieved from http://youtu.be/yxCeiyQVxXw. "A caring moment involves an action and choice by both the nurse and other" (Watson, 2010, p.358). Revised Quality-Caring Model

First the theory was presented as a grounded theory based on a variety of areas of qualitative research:

Ethnographic: description of hospital culture
Phenomenologic: the meaning of caring
Grounded theory method: conceptualization of categories, structures, and processes of caring in a complex organization
Differential Caring: based on a variety of meanings of diversity and caring provided by patients in hospital
Complex systems: meanings of bureaucracy
(Parker & Smith, 2010)

Ray revised the theory in 2001 with an increased interconnected view of caring, incorporating complexity theory and chaos theory. She changed the theory to a holographic theory, emphasizing how every structure is a part of the whole and the whole is a part of every structure.

She continues to develop instruments and psychometric tests/tools to improve the model. She has most recently been working with Dr. Marian Turkel in the area of complex caring relational theory, organizational transformation and ethical decision making (Alligood & Tomey, 2010). Development There are four concepts of the theory which keeps it to a minimum but their interrelationships make it more complex. Duffy's concepts (such as "feeling care for ") are linked to the empiric indicators (such as attentive reassurance), that can be used to assess the phenomena (caring relationship) that the Quality-Caring theory describes. Quality caring is linked to nursing-sensitive patient outcomes, improving existing caring instruments, caring based interventional research, educational caring, and cost-benefit analysis.

Quality caring focuses time “in relationship” with the patient versus the disease or task, which generates a meaningful, practice that is the basis for joy. The Quality Caring model benefits patients, nurses, the profession, and the health care system.

The Quality Caring Model offers a way to relate to and engage with other health care providers and the community. Through measurement of the caring relationships consequences are assessed which provides an evaluation design for improvement of services.
(Parker & Smith, p.409). Jean Watson Theory of
Human Care PhD, RN, AHN-BC,FAAN Biography Purpose Education:
Lewis Gal School of nursing, 1961
Bachelor of nursing, 1964
Master of psych-mental health
nursing, 1966
doctorate in Educational
psychology and counseling,1973 Professional
Chair in Caring Science at UC Denver,
College of nursing
Founder of Center for Human Caring
at UC HSC School of Nursing
Member of American Academy of nursing
President of National League for Nursing
Director of Watson Caring Science Institute Awards andHonors :
International Kellogg Fellowship, Australia
Fulbright Research Award, Sweden
Distinguished Professor of nursing, UC School of nursing
Six honorary doctoral degrees
Honorary Lifetime certificate as Holistic nurse, NLN
Author /co-author of over 14 books
(Parker & Smith, 2010) Establish a caring relationship with patients
Treat patients as holistic beings (body, mind and spirit)
Display unconditional acceptance
Treat patients with a positive regard
Display unconditional acceptance
Treat patients with a positive regard
Promote health through knowledge and intervention
Spend uninterrupted time with patients: “caring moments” Elements Carative Factors
Transpersonal caring relationship
Caring occasion/Caring moment References Continued McCrae, N. (2012). Whither nursing models? The value of nursing theory in the context of evidence-based practice and multidisciplinary health care. J Adv Nurs, 68(1), 222-229. doi: 10.1111/j.1365-2648.2011.05821.x

McCance, T. V., McKenna, H. P., & Boore, J. R. (1999). Caring: Theoretical perspectives of relevance to nursing. J Adv Nurs, 30(6), 1388-1395. doi: jan1214 [pii]

Mode of Nursing Actions. (2010). MADELEINE LEININGER Cultural Diversity in Nursing Practice. Retrieved on March 20, 2013 from http://n207groupf.blogspot.com/feeds/posts/default

Parker, M. E., & Smith, M. C. (2010). Nursing theories and nursing practice (3rd ed.). Philadelphia: F.A. Davis Co.

Paterson & Zderad. Retrieved on March 18, 2013 from http://www.slideshare.net/kai_hikari/presentation1-8624181

Sitzman, K & Eichelberger, L. (2010). Understanding the Work of Nurse Theorists: A Creative Beginning. Mandeleine Leininger’s Culture Care: Diversity and Universality Theory. Sudbury, MA. Jones and Bartlett Publishers.

Sredl, D. & Peng, N.H. (2010) CEO - CNE relationships: building an evidence-base of chief nursing executive replacement costs. International Journal of Medical Sciences, 7(3), p.160-168.

Watson, J. (1985). Nursing: Human Science and Human Care - A Theory of Nursing. National League of Nursing Press, New York.

Watson, J. (2010). Jean watson's theory of human caring. In M. E. Parker & M. C. Smith (Eds.), Nursing theories and nursing practice (pp. 358-367). Philadelphia: F.A. Davis Co. Carative Factors Transpersonal Caring relationship 1. Humanistic-altruistic system of value

2. Faith-Hope

3. Sensitivity to self and others

4. Helping-trusting, human care relationship

5. Expressing positive and negative feelings.

6. Creative problem-solving caring process

7. Transpersonal teaching-learning

8. Supportive, protective, and/or corrective mental, physical, societal and spiritual environment

9. Human needs assistant

10. Existential-phenomenological-spiritual forces Practice of loving-kindness and equanimity within the context of caring consciousness.

Being authentically present and enabling and sustaining the deep belief system and subjective life-world of self and one-being-cared for.

Cultivation of one’s own spiritual practices and transpersonal self going beyond the ego self.

Developing and sustaining a helping trusting authentic caring relationship.

Being present to, and supportive of, the expression of positive and negative feelings as a connection with deeper spirit and self and the one-being-cared for.

Creative use of self and all ways of knowing as part of the caring process, to engage in the artistry of caring-healing practices.

Engaging in genuine teaching-learning experience that attends to unity of being and meaning, attempting to stay within other’s frame of reference.

Creating healing environment at all levels (physical and nonphysical, subtle environment of energy and consciousness, where by wholeness, beauty, comfort, dignity, and peace are potentiated).

Assisting with basic needs, with an intentional caring consciousness, administering human care essentials.

Opening and attending to spiritual-mysterious and existential dimensions of one’s own life-death; soul care for self and the on-being-cared for Caritas Process A special kind of human care that depends on:
- The nurse’s moral commitment in protecting and enhancing human dignity as well as the deeper self
- The nurse’s caring consciousness communicated to preserve and honor the embodied spirit, therefore not reducing the person to a moral status of an object
- The nurse’s connection and having the potential to heal since experience, perception, and intentional connection are taking place

Describes how the nurse goes beyond the objective assessment to show concern toward the person’s subjective/deeper meaning of their healthcare situation.

Involves mutuality between the two individuals involved (Parker & Smith, 2010). Caring Occation/Caring Moment “The moment (focal point in space and time) when the nurse and another person come together in such a way that an occasion for human caring is created” (Watson, 1988b, 1999).
Both the nurse and one being cared for can be influenced by the caring moment
Example of caring moment: entering the patient’s room, shaking the patient’s hand, making eye contact with the patient, explaining a procedure, making the patient’s environment more comfortable (Parker & Smith, 2010) Practice: Attending Nursing Caring Model (ANCM), a unique pilot project in a Denver children's hospital, is concerned with the nursing care model. The mission of ANCMis to have a continuous caring relationship with children in pain and their family.
Administration/Leadership: Watson's theory calls for administrative practices and business models to embrace caring, even in a healthcare environment of increased acuity levels of hospitalized individuals, short hospital stays, increasing complexity of technology, and rising expectations in the "task" of nursing.
Education: Watson's writings focus on educating graduate nursing students and providing them with ontological, ethical, and epistemological bases for their praxis, along with research directions.
Research: Watson acknowledges that combination qualitative-quantitative inquiry may be useful to the development of nursing as a human science and art. Smith (2004) published a review of 40 research studies that specifically used Watson's theory. (Parker and Smith, 2010) (Alligood & Tomey, 2010, pp.97) Application of Watson's Theory educator, author, theorist, administrator,
researcher, consultant, public speaker Biography Education:
Diploma in Nursing, 1945
Bachelor in biological science, 1950
Master in psychiatric nursing, 1954
Doctorate in anthropology, 1964
First professional nurse with graduate preparation in nursing to hold a PhD in cultural and social anthropology Professional:
Professor Emeritus of Nursing, Wayne State University College of Nursing
Adjunct Clinical Professor at University of Nebraska College of Nursing
Fellow of the American Academy of Nursing
Distinguished Fellow of the Royal College of Nursing (Australia)
Visiting scholar and lecturer at 85 universities
Visiting professor at numerous foreign universities Awards:
Prestigious President’s Award for Excellence in Teaching
The Board of Governors’ Distinguished Faculty Award
The Gershenson’s Research Fellowship Award
Presented with the Women in Science Award from California State UniversityH
Honored as a Living Legend by the American Academy of Nursing
Honorary degrees from several universities
(Parker & Smith, 2010) Major and unique features Culture Care Diversity
and Universality Theory The theory which was launched in the mid-1950s remains one of the oldest theories in the field of nursing.
It is the only theory that focused unambiguously on the close interrelationships of culture and care on a person's well-being, health, illness, and death.
Culture Care theory is the only theory that focused on comparative culture care.
Being the most holistic and multidimensional theory, it discovered specific and multifaceted culturally based care meanings and practices.
It is the first nursing theory to focus on discovering global cultural care diversities/differences and care universalities/commonalties.
With a method called ethnonursing, it is the first nursing theory with a distinctively designed research method to fit the theory.
In order to deliver culturally congruent care, the theory has both abstract and practical features in addition to three action modes
It is the first nursing theory that focused on generic (emic) and professional (etic) culture care, social structure factors, worldview-related data, and ethnohistory in various environmental contexts.
(Sitzman & Eichelberger, 2010) Overview Orientational Definition Critical analysis CARE - is to render/ help others with the present or incoming needs to facilitate improvement in either human health conditions or even facing death.

CARING - service, or an act of rendering/ giving care.

CULTURE - is the people’s various ways of adaptation in their everyday life.

CULTURAL CARE - is an individual's, group or community's different adaptation or learning, acquired and being used to improve and face their everyday way of life, sickness, health and even facing death.

CULTURAL CARE DIVERSITY - is the people’s own understanding in delivering care that are recognized within or in other circle of community.

CULTURAL CARE UNIVERSALITY - simple/ ordinary care with almost the same perception or concepts that are seen in many cultures.

NURSING - is one branch in health profession that is directed to client in scope of care.

WORLD VIEW - is how the people perceived the world or universe in making their personal understanding of what life is all about.

CULTURAL & SOCIAL STRUCTURAL DIMENSION - the people/ person's activity in daily living and the influences of their culture, traditions, beliefs, how their political views helps, education and even new technologies, primitive history that affects cultural responses of people within cultural context.

HEALTH - is a condition of an individual that is culturally recognized and given importance.

CULTURAL CARE PRESERVATION & MAINTENANCE - rendering care and giving importance to peoples' culture, belief and respecting their values and practices regarding health care status and scope of health care understanding.

CULTURAL ACCOMODATION & NEGOTIATION - offering other alternative ways of rendering health care that is acceptable to people and community for a better result that is shared by the health care provider and health care receiver. Motivation:
Desire to discover unknown or little known knowledge about cultures and their core values, beliefs, and needs. (Parker & Smith, 2010)

Purpose and goal:
To discover and elucidate diverse and universal culturally based care factors that influence an individual's or group's health, well-being, illness, or death is the principal purpose of the theory.
Its goal is to use research findings to provide culturally congruent, competent, safe, and meaningful care to clients of different or similar cultures. The three modes for congruent care, decisions, and actions proposed in the theory are expected to lead to wellness, prevent illness or to face death. (Andrews et al. 2010)

Increased numbers of global migrations
Signs of cultural stresses and conflict
Cultural indication
Signs of unsatisfied care
Signs of misdiagnosis and mistreatment of client from different culture
Signs that health personnel becoming frustrated in caring cultural strangers
Very few health personnel of different cultures caring for clients
Nurses beginning to work in foreign countires. (Parker & Smith, 2010) Major criticisms:
Ambiguous terminology and lacks clarity in describing key concepts
Failure to recognize the relationship between knowledge and power and their inattention to the complexities associated with prejudice, discrimination, and racism.
Failure to recognize the power relationships that exist between groups.
By creating lists of the culture care values, meanings, and action modes of each of the cultures it generalizes research which fosters stereotyping and fails to consider the variations within cultures.

(Andrews & Boyle, 2008) Strengths:
Leininger’s Transcultural Nursing Theory or Culture Care Diversity and Universality focused on the concept of culture in providing nursing care to our patients. It aids the nurse to be culture sensitive. Nurses should be conscious on different culture that necessitates them to respond to the needs of the patient who has different cultural values.
Compared to other theories which primarily focus on people, health, environment and nursing, for Leininger the highlight is on care as the core of nursing. However the assumption of it is based from culture data. For her, in order to fathom care, we should also understand the concept of culture.
(Andrews & Boyle, 2008) Sunrise model Claims:

“The meaning of caring is highly differential, depending on its structures…”

“Caring is bureaucratic, as well as spiritual/ethical…”

“Caring is the primordial construct and consciousness of nursing”
(Alligood & Tomey, 2010, p.122-123) (Parker & Smith, 2010; Alligood & Tomey, 2010) Application to Practice Research Examples OUTLINE There are numerous intriguing caring theories, so we have chosen 2 Middle Range Theories to review in depth: There are 4 Grand Theories that must be mentioned in a review of caring theories. Therefore, we have provided a quick overview of each of these theories: To conclude, we have provided a comparison of the theories! Enjoy! 1. Duffy's Quality Caring Model
2. Ray's Theory of Bureaucratic Caring 1. Leininger's Culture Care Diversity and Universality
2. Paterson & Zderad Humanistic Nursing Theory
3. Watson's Theory of Human Caring
4. Boykin & Schoenhofer Nursing as Human Caring Major theoretical tenets:
Worldview and social structure factors
Professional and genetic care
Three modalities
- Preservation or maintenance
- Accommodation or negotiation
- Restructuring or repatterning
(Parker & Smith, 2010)

Theory Assumption:
Care is essential for human growth, development, survial, and facing death
Care is essential to curing and healing
The forms and processes of human care vary among all cultures
Every culture has generic care, and most also have professional care practice
Culture care values and beliefs are embedded in religious, kinship, social, political, economic, and historical demensions and in language and environmental contexts
Therapeutic nursing care can occur only when culture care values, expressions, and practices are known and use to provide human care
Difference between caregiver and care receiver expectations need to be understood
Culturally congruent, specific, or universal care modes are essential to the health
Nursing is essentially a transcultural care profession and discipline (Duffy, J., 2009) (Chinn &Kramer, 2008). (Chinn & Kramer, 2008) RN, PhD "A correction health service administrator at Telfair State Prison in Georgia described how Ray's Theory applies to nursing in a correctional healthcare setting.

Nurses in corrections have the responsibility of caring for a very complex special population. They must understand the culture, see prisoners as human beings, and have the ability to communicate, educate, and rehabilitate this population in the area of healthcare. Their effectiveness results from incorporating sociocultural, physical, educational, legal, and ethical dimensions of caring theory into daily practice.

In the economic and political areas of the correctional system, nurses struggle with the same issues as nurses in a hospital system, such as decreasing healthcare costs while providing quality care. Economic strategies include conducting health services at the facility level as opposed to transporting patients to a hospital."

(Alligood & Tomey, 2010, p. 123-124)
"Caring within the organizational culture was the focus of the study. It describes the substantive theory of Differential Caring and the formal Theory of Bureaucratic Caring. With caring at the center of the model, the study included ethical, spiritual-religious, economic, technological-physiological, legal, political, and educational-social structures." (Alligood & Tomey, 2010, p. 127) The exploratory mixed-method descriptive pilot study focused on professional relationships, ethnic diversity and the financial impact of turnover for nurse executives. The study used Ray's Theory of Bureaucratic Caring, later modified in the Theory of Relational Complexity by Turkel, as a framework for viewing the relationships among nurse leadership while considering concepts of caring and economic variables. The results identified cohesive factors that may contribute to reduced turnover; also identified a lack of ethnic diversity and the impact of nurse executive turnover rates on an organization's financial health and quality of care. A correctional healthcare facility The Theory of Bureaucratic Caring for Nursing Practice in the Organizational Culture
By: Marilyn Ray (1989)
Published in: Nursing Administration Quarterly 13(2), 31-42. CEO - CNE Relationships: Building an Evidence-Base of Chief Nursing Executive Replacement Costs
By: Darlene Sredl and Niang-Huei Peng (2010)
Published in: International Journal of Medical Sciences, 7(3), p.160-168 (Mode of Nursing Actions, 2010) Duffy and Ray differ from the Grand theories as they present a more immediate relationship to practice and research (Parker & Smith, 2010). Duffy was the first to present tools to evaluate caring and nursing outcomes and Ray focused on the economic value of caring in organizations.
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