Do we need to redefine caring? How about re-finding it?A response to Mochan’s Query

In a recent letter to the editor of Nursing Philosophy,Kara Mochan (2008) asks the pertinent question ‘Dowe need to redefine caring?’ (p. 221). Based on herreading of Kirk’s (2007) ‘Beyond Empathy: ClinicalIntimacy in Nursing Practice’, she wonders ‘what thepractical implications of introducing the concept ofintimacy to nursing students and vulnerable patientswould be’ (p. 221). She further inquires ‘what is theunique contribution that a concept model of clinicalintimacy in nursing can provide that better encapsu-lates the caring process then [Swanson’s] Theory ofCaring?’ (p. 221).

This brought to mind an issue that has botheredme for some time now concerning care theory andnursing education. Several years ago I began to noticethat, although the word caring was used a great deal innursing education (in manuals, mission statements,by students, by professors) there seemed to be littleunderstanding, and virtually no appreciation, of it.This is to say that it (the word caring) is frequentlyused outside of its seminal position in care theory.This is, of course, entirely understandable given thecommon usage of the word; however, it appeared tome that it had somehow become synonymous with,being polite, well mannered, courteous and kind.Moreover, it had become a catch-all phrase for pleas-ant behaviour. I noticed, to my chagrin, that nursingstudents were being taught very little about caring asa theory and when they did refer to theory, most ofthem seemed to think that it was invented by JeanWatson, or at any rate that was a product of nursingtheory (rather than an import from psychology andphilosophy).

They had never heard of Carol Gilligan (1982) orNel Noddings (1984), two of the original formulatorsof care theory, and their respective work. They wereunaware of the connection between caring (astheory) and feminism, its controversial relationshipto justice theory, its epistemology, its ethical philoso-phy and so on. Again it appeared to have become

a general means of referring to professionaldemeanour. When I began supervising students inclinical placements, I noticed the same thing in thediscourse of practising nurses. I have even seen itdiscussed as such in the nursing literature, e.g. arecent exchange of papers in the International

Journal of Nursing Studies initiated by Corbin’s(2008) editorial Is caring a lost art in nursing? Noneof the papers (Ehlers, 2008; Griffiths, 2008; Maben,2008; Pajnkihar, 2008) mentions or cites Gilligan,Noddings, the development of care theory (as a reac-tion Kohlberg’s Stages of Moral Development),feminism, the care vs. justice debate and so on.

I recently attempted to remedy this problem byteaching students care theory, or more specificallywhere it came from, again Gilligan’s critique ofKohlberg’s stage theory (often termed the Gilligan-Kohlberg debate, see Sharpe, 1992; Rice, 2001;Jorgensen, 2006) and its conclusion that women areless morally developed than men. Although it wassomewhat difficult for them to grasp, ironically giventhe ubiquity of the word, their eyes were opened soto speak. Finally, a theory had been put to this omni-present word, and a profound and interesting theoryindeed, if problematic. I submit then, that caring, likeCruess & Cruess (1997) suggest of professionalism‘must be taught’ (p. 1674). In other words, there is,again like professionalism (Cruess, 2006), a cognitiveaspect to caring, indeed a theory, principles andpractice. Moreover, simply exposing students toWaston (1985), Swanson (1991), Leininger (1988),Parse (1992), Boykin & Schoenhofer (2001) or anyother nursing theory that situates caring as a centralcomponent, is not enough. Students need to betaught caring as an intellectual and theoreticalmatter, rather than merely a word to use, an abstractconcept to aspire to, or a behavioural outcome.Moreover, if we are going to continue to claimcaring as the/a core of nursing, even implicitly, thenstudents ought to be exposed to the controversy this

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has created. That means, those who support such aposition (Spengel & Kelly, 1992; Bradshaw, 1996),those against it (Allmark, 1995; Barker & Reynolds,1995) and those who find it ridiculous (Paley, 2002).While it is true that caring in nursing is not identicalto the ethics of care, there are important similaritiesindeed, hence some of the objections (to both). Inany case, it seems a better place to start education-ally than ‘introducing the concept of intimacy tonursing students’ (Mochan, 2008, p. 221), althoughthe introduction of intimacy is certainly not some-thing I object to.

As for redefining caring, and it could certainlyuse some redefining, I suggest the work of thepolitical theorist William E. Connolly, or more spe-cifically his concept of critical responsiveness. From apostmodern critique of modernity, coupled with aradical democracy perspective, i.e. an emphasis onidentity/different, Connolly (1999, 1995) developscritical responsiveness as an active means ofresponding to suffering created by difference. Criti-cal responsiveness differs from caring in that itexpects one to not only respond to the other, but aswell this response requires a self-reflection of sorts,and perhaps self-modification where necessary. Ashe puts it:

. . . where tolerance implies benevolence toward others amid

stability of ourselves, critical responsiveness involves active

work on our current identities in order to modify the terms

of relations between us and them . . . For example, as hetero-

sexuals respond to the politics of becoming by which a

previous history of medicalization and demoralization of

homosexuality is reconfigured they are also pressed to

acknowledge for the first time that heterosexuality is not

firmly grounded in the universality of nature, the commands

of a god, or the automatic outcome of normal sensual devel-

opment. (Connolly, 1999, pp. 62–63)

Although critical responsiveness was not developedspecifically for professionals, indeed it is the outcomeof a democratic political theory; it has always been myview that it fits well with the so-called, caring agendaof nursing, while also advocating a politics of differ-ence that, I think, is quite conducive to nursing (boththeory and practice).

Clinton E. BettsAssistant Professor

School of Nursing

Faculty of Health Sciences

McMaster University

Hamilton, Ontario

Canada

E-mail: bettsc@mcmaster.ca

References

Allmark P. (1995) Can there be an ethics of care? Journal ofMedical Ethics, 21(1), 19–24.

Barker P.J. & Reynolds W. (1995) The proper focus ofnursing: a critique of the ‘caring’ ideology. InternationalJournal of Nursing Studies, 32(4), 386–397.

Boykin A. & Schoenhofer S.O. (2001) Nursing as Caring:A Model for Transforming Practice. Jones & BartlettPublishers, Sudbury, MA.

Bradshaw A. (1996). Yes! There is an ethics of care: ananswer for Peter Allmark. Journal of Medical Ethics,22(1), 8–12.

Connolly W. (1995) The Ethos of Pluralization. University ofMinnesota Press, Minneapolis, MN.

Connolly W. (1999) Why I Am not a Secularist. University ofMinnesota Press, Minneapolis, MN.

Corbin J. (2008) Is caring a lost art in nursing? InternationalJournal of Nursing Studies, 45(2), 163–165.

Cruess R.L. (2006) Teaching professionalism: theory, prin-ciples, and practices. Clinical Orthopaedics and RelatedResearch, 449, 177–185.

Cruess S.R. & Cruess R.L. (1997) Professionalism must betaught. British Medical Journal, 315, 1674–1677.

Ehlers V.J. (2008) Is caring a lost art in nursing or is it achanging reality? Commentary on the editorial writtenby Juliet Corbin. International Journal of Nursing Studies,45(5), 802–804.

Gilligan C. (1982) In a Different Voice: Psychological Theoryand Women’s Development. Harvard University Press,Cambridge.

Griffiths P. (2008) The art of losing . . . ? A response to thequestion ‘is caring a lost art?’ International Journal ofNursing Studies, 45(3), 329–332.

Jorgensen G. (2006) Kohlberg and Gilligan: duet or duel?Journal of Moral Education, 35(2), 179–196.

Kirk T.W. (2007) Beyond empathy: clinical intimacy innursing practice. Nursing Philosophy, 8, 233–243.

Leininger M.M. (1988) Leininger’s theory of nursing:cultural care diversity and universality. Nursing ScienceQuarterly, 1, 152–160.

Maben J. (2008) The art of caring: invisible and subordi-nated? A response to Juliet Corbin: ‘Is caring a lost art in

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nursing?’ International Journal of Nursing Studies, 45(3),335–338.

Mochan K. (2008) Do we need to redefine caring? NursingPhilosophy, 9, 221.

Noddings N. (1984) Caring: A Feminine Approach to Ethicsand Moral Education. University of California Press,Berkeley, CA.

Pajnkihar M. (2008) Is caring a lost art in nursing? Interna-tional Journal of Nursing Studies, 45(5), 807–808.

Paley J. (2002) Caring as a slave morality: Nietzscheanthemes in nursing. Journal of Advanced Nursing, 40(1),25–35.

Parse R.R. (1992) Human becoming: Parse’s theory ofnursing. Nursing Science Quarterly, 5, 35–42.

Rice C. (2001) Making moral decisions: comparing two theo-ries. Mental Retardation, 39(2), 155–157.

Sharpe V.A. (1992) Justice and care: the implications ofKohlber-Gilligan debate for medical ethics. TheoreticalMedicine, 13, 295–318.

Spengel A. & Kelly J. (1992) The ethics of care: a basis ofholistic care. Journal of Holistic Nursing, 10(3), 231–239.

Swanson K.M. (1991) Empirical development of a middlerange theory of caring. Nursing Research, 40(3), 161–166.

Waston J. (1985) Nursing: Human Science and Human Care.National League for Nursing, New York.

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