Running head: ISSUE ANALYSIS ON CARING

Issue Analysis on the Art of Caring and the Professional Nurse

Sueann K. Unger

NURS 450

ISSUE ANALYSIS ON CARING 2

Abstract

Caring behaviors of the professional nurse were evaluated in this paper. Positively correlated

were caring behaviors to patient satisfaction and patient loyalty in emergency departments.

Caring theories of both nursing and non-nursing disciplines were uncovered to show

interdisciplinary and collaborative perspectives and the effect caring behaviors can have on a

patient both physically and emotionally. An assessment of the healthcare environment was

completed to provide a systems framework to discover the quality and safety issues related to the

topic of caring. Implications, inferences and consequences were well covered from a variety of

research materials. Results of this research show that improving caring behaviors in nursing

staff increases patient satisfaction, provides emotional support, improves patient outcomes and is

an expected quality of the professional nurse.

Keywords: care, caring, caring behaviors, compassion, patient centeredness

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Caring and nursing are terms synonymous with the nursing profession, yet are they

always integrated together in our practice? How do we monitor caring? How do we get caring

back into our practice? These are the questions I have found that nurses need to ask of

themselves to deliver care that is both competent and caring. This issue is as widespread and

encompassing as the nursing profession reaches. According to Yoder-Wise (2011), caring is

described as the essence of nursing but must combine with critical thinking and timely and

appropriate action to be therapeutic (p. 446).

According to the American Nurses Association (ANA) Scope of Nursing Practice, “the

art of nursing is based on caring and respect for human dignity. A compassionate approach to

patient care carries a mandate to provide that care competently” (2010, p. 23). Also of

importance from the ANA Scope of Nursing Practice, “Central to the nursing practice is the art

of caring, which is represented in the personal relationship that the nurse enters with the patient”

(2010, p. 23). Nursing is defined as caring and caring definitions invariably use the word

nursing to explain the action of caring.

Researching the subject of caring has led to several results that are found when the caring

aspect is thoroughly integrated into the professional nurses’ practice. Results are seen in

improved patient outcomes, improved patient satisfaction scores and in the development of the

professional nurse’s character and the quality of their interactions. According to Douglas (2010),

many of us understand the professional practice of the nurse that includes the five domains of

scientist, leader, practitioner, educator and transferor of knowledge “but there is another less

spoken of role, the role of supporting other human beings through fear, pain, loss, and the

resulting impact on the patient and caregiver” (p. 416). Douglas (2010), believes that if this

aspect of caring for others and self was made more visible and not as an issue that is in the

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background there could be “structures put into place that support and even prevent potential

negative impacts from this part of the role” (p. 416).

In regard to differing points of view, none have been uncovered in the scope of this

research paper. Nurses are expected to be caring. It is part of the job description whether written

or not. In a study of 74 nursing students who were asked their motivation for entering the

nursing profession, the number one reason given was altruism. Intelligence was

“overwhelmingly acknowledged” as a major factor in nursing competence and over two-thirds

expressed caring as an essential nursing characteristic (Rhodes, Morris, Lazenby, 2011). I

believe nurses entering the profession realize that caring is a prerequisite but putting that

knowledge into practice, offering helps and supporting the nurse in transforming their practice

should be encouraged more by nursing schools and places of employment.

Theory Base

Watson’s Theory of Caring is one of the most well known nursing theories on the subject.

The three major elements include her carative factors, the first of which is that the nurse realizes

the uniqueness of the individual and goes to all extents possible to preserve the patient’s dignity.

The transpersonal caring relationship is the nurse’s caring consciousness and moral commitment

to intentionally connect with the patient. The caring occasion/caring moment of Watson’s theory

is the occasion where nurse and patient interact for caring to occur (Lachman, 2012, p. 112).

Another nursing theory of interest is Halldorsdottir’s Theory of Caring and Uncaring

Behaviors. This nursing theory espouses that caring and uncaring behaviors relate to “the lived

nurse-patient relationship which is characterized by a spiritual connection and bond made of

energy that empowers the patient” (Bailey, 2011, p. 54). The summation of this theory is that

ISSUE ANALYSIS ON CARING 5

“uncaring behaviors threaten the psychoneuroimmunologic capacities of those cared for and the

immune response is positively affected by the nurse-patient relationships as patients experience

caring” (Bailey, 2011, p. 54). Halldorsdottir comes from a nursing background and of particular

interest was her “Five Basic Modes of Being with Another” which shows the spectrum of

differences of life-giving care to life destroying care (Bailey, 2011, p. 58).

Joan Tronto is a professor of political science and women’s studies who studied the work

of Carol Gilligan, another non-nursing theorist who wrote a theory of caring. Tronto’s four

elements of caring include attentiveness to the needs of the patient, the ethical responsibility the

nurse has to care for the patient, competence in the nurse’s duties to the patient and

responsiveness of the nurse to that patient either with actions or lack of actions (Lachman, 2012,

p.113).

The ethics of care theories from these mentioned theorists merge together well from the

interdisciplinary and collaborative perspective. Tronto’s theory coincides with the Code of

Ethics for Nurses which states that all professional nurses have a responsibility to care for

patients under their care (ANA, Code of Ethics for Nurses, 2013). According to the Lachman

(2012) article, “Care ethics stem from the idea that care is basic to human existence and weaves

people into a network of relationships” (p. 114). Personal biases and prejudices must be put

aside to implement Tronto’s theory. A statement on the subject of caring that is particularly

succinct came from the Lachman (2012) article, “Care can be considered simply an ethical task

and thus a burden of one more thing to do, or it can be considered a commitment to attending to

and becoming enthusiastically involved in the patient’s needs” (p. 114). Knowledge of caring

theories and the ethics of care will be for naught if the practicing of caring behaviors is missing

from the nurse’s bedside practice.

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Assessment of the Healthcare Environment

Hospital Consumer Assessment of Healthcare Providers and Systems

Comparative data between hospitals on the patient experience is becoming more

important. The Centers for Medicare and Medicaid Services have a standardized voluntary

measurement to rate the patient’s experience in the hospital setting. This survey is called

Hospital Consumer Assessment of Healthcare Providers and Systems or HCAHPS. Research

has shown that physician and nursing’s interaction with patients have great impact on these

ratings along with likeliness to recommend (Liu, Franz, Allen, Chang, Janowiak, Mayne and

White, 2010, p. 404).

A study of four emergency departments with diverse backgrounds and sizes resulted in

common themes of importance. The first area of importance was prompt attention to needs upon

arrival to the emergency department, and secondly, the area rated least positive in their

emergency department experience was the same, prompt attention to their needs on arrival.

Third in importance was caring behaviors listed as “making sure that the patient is aware of care-

related details, working with a caring touch, and making the treatment procedure clearly

understood by the patient” (Liu et al., 2010, p. 404). Fourthly, there was a significant correlation

on patient wait time to see a caregiver and patient loyalty (Liu et al., 2010, p. 404). This study

supports the significance of the patient experience with caring behaviors from providers and

patient loyalty.

National Database of Nursing Quality Indicators

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The National Database of Nursing Quality Indicators (NDNQI) is a quality measurement

program that provides hospitals with “nursing sensitive indicators that reflect the structure,

process and outcomes of nursing care” (National Database of Nursing Quality Indicators

[NDNQI], 2013, “Our mission,” para 1-2). This allows organizations to compare their unit-

based outcomes with other hospitals. These indicators include satisfaction with nursing care and

allow nurses and nurse managers to make improvements (Yoder-Wise, 2011, p. 447). Nurses are

at the forefront of care for the patient and have 24-hour accountability. Caring behaviors and

competency are the standards to which all nurses are to be held. The NDNQI measurement

system is a unique way for organizations to measure how they compare with other like

organizations.

Institute of Medicine

According to the Agency for Healthcare Research and Quality (AHRQ) the Institute of

Medicine has identified patient centeredness as a core component of quality health care. “Patient

centeredness encompasses qualities of compassion, empathy, and responsiveness to the needs,

values, and expressed preferences of the individual patient” (Agency for Healthcare Research

and Quality [AHRQ], 2011, “Chapter 5. Patient Centeredness,” para 1). This statement very

closely follows the issue of caring behaviors of the professional nurse and the importance the

Institute of Medicine has placed on it. Interdisciplinary partnership between those involved with

the patient ensures that care is patient centered, respecting their needs and preferences and

allowing them the ability to participate in their care.

Quality and Safety Education in Nursing

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Quality and Safety Education in Nursing (QSEN) is a national work between the

American Association of Colleges of Nursing and the Robert Wood Johnson Foundation to

improve the ability of nursing faculty to “effectively develop quality and safety competencies

among graduates of their programs to assure that nursing professionals are provided the

knowledge and tools needed to deliver high quality, safe, effective, and patient-centered care”

(American Association of Colleges of Nursing [AACN], 2013, “About QSEN,” para 1).

One of the competencies listed of the QSEN is that of patient centered care. Their

definition of patient centered care is to “recognize the patient or designee as the source of control

and full partner in providing compassionate and coordinated care based on the patient’s

preferences, values, and needs” (American Association of Colleges of Nursing QSEN Education

Consortium, 2012, p. 10). The importance of patient centered care as a competency is

recognized and integrated into the curriculum by training nursing faculty. Caring provides the

emotional support, values and spiritual context associated with this competency.

Underlying foundational assumptions concerning the subject of caring is that nurses will

always be caring and supportive. Nurses have a highly favorable status rating from the public

with a poll citing “83% of Americans believing nurses’ honesty and ethical standards are high or

very high” (Yoder-Wise, 2011, p. 440). The consumer expects competence and a caring

presence from nursing interactions. With expectations high for the nurse in their ability to

provide compassionate care, more training in self-care for nurses by their organizations and

development of screening tools prior to acceptance into nursing schools would be beneficial to

filter those who lack compassion and the qualities that allow a nurse to be emotionally present.

Inferences/Implications/Consequences

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Development and implementation of ways to improve caring behaviors of nursing staff

are one of the implications from the previously mentioned study of emergency departments.

Caring behaviors and patient loyalty, along with an increase in patient satisfaction scores were

correlated. Developing a plan to increase knowledge of caring behaviors would be of great

benefit to an organization. Care, concern and communication, body language, and initial

greetings were all cited in this study as having the greatest potential for increasing patient

loyalty. Efforts at designing education around these main areas for caregivers would be

beneficial in improving patient satisfaction. Other benefits noted were decreased anxiety when

caregivers displayed caring behaviors consistently. Another implication from enhancing caring

behaviors from this study was increased rapport building between caregivers and patients which

benefits long-term quality improvement and patient-caregiver relationships (Liu et al., 2010, p.

405).

Consequences of decreased time to perform caring behaviors were noted in the article by

Douglas (2010) and that when caring behaviors are absent the patient suffers. The author

wondered about the implications for patients with their course of care, ability to heal and length

of stay with the professional nurse being overburdened with tasks that take them away from the

bedside (Douglas, 2010, p. 416). Implications from this author were that the nursing community

should consider screening “upon entry into education programs, the profession, or on hiring, for

the characteristic of emotional availability and compassion” (Douglas, 2010, p. 417).

A limited study of 74 nursing students on their motivation for entering the nursing

profession and their perceptions on the importance of competence and caring offered

implications for nursing programs. When nurses enter the profession valuing altruism and

making a difference, nursing educational programs should be designed to include courses that

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stimulate these desires. Teaching strategies should be developed to promote competence and

caring in nursing. Also, idealistic perceptions of caring can be translated into motivation for

competence (Rhodes, Morris & Lazenby, 2011). This study showed that caring and compassion

were important attributes realized by nursing students with the outcome of possible nursing

faculty designing programs to enhance the student’s competence, quality and safety of care to

deliver a knowledge base to enhance their altruistic desires.

Lachman (2012) stated that “some individuals suffer from a moral blindness and are not

moved by the suffering of others or it is not as developed in others, for this reason a care

orientation is fundamental to the nurse-patient relationship and the nursing profession itself” (p.

113). Applying the ethics of caring to the nursing practice, Joan Tronto states there is a “pre-

existing moral relationship between people and a nurse should ask themselves how they can meet

their caring responsibility” (Lachman, 2012, p. 113). Inferences from this article can be aimed at

the importance of care being necessary to human development from the care an infant needs and

the patient who is nearing the end of life and the moral commitment nurses have to care for all

patients (Lachman, 2012, p. 114).

Recommendations for Quality and Safety Improvements

American Nurses Association Standards

Implementation competency – “the registered nurse demonstrates caring behaviors toward

healthcare consumers, significant others, and groups of people receiving care” (American Nurses

Association [ANA], 2010, p. 38). Demonstration of caring behaviors by the professional nurse is

a standard that is expected by the healthcare public. In the emergency department (ED) it will

include providing care and comfort to family members as well as to the patient following a

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traumatic incident. Caring behaviors are described as listening, taking time, tone of voice, eye

contact and acknowledgement of family members in this context (Clukey, Hayes, Merrill &

Curtis, 2009, p. 73). The ED study conducted by Liu et al. (2010) revealed the importance of

patients being aware of care-related details that accounted for their perception of caring

providers. This resulted in one hospital setting a 30-minute target time for rounding to update

patients on medical information regarding their care (p. 411).

Communication – “the registered nurse communicates effectively in a variety of formats in all

areas of practice” (ANA, 2010, p. 54). Communicating a healing touch to another person is one

of the varieties of formats that nursing practices. Other forms of communicating caring include a

personal relationship that the nurse enters into with the patient, helping, listening, being fully

present, supporting, empathy, tolerance and others that promote a holistic practice (ANA, 2010,

p. 23). Effectively communicating caring to patients can involve many different actions and

words. Active listening, using facial expression, intonation and eye contact are all ways to

express caring (Leebov, 2008, p. 22). According to Leebov (2008), nurses need to make it clear

that the patient is the focus, expressing genuine regret if the patient is having a negative

experience without taking the blame and express appreciation to the patient (p. 22).

Collaboration – “the registered nurse collaborates with the healthcare consumer, family and

others in the conduct of nursing practice” (ANA, 2010, p. 57). Collaborating with the patient,

family and others involved in patient care is a dynamic process that allows the nurse to apply

competent caring treatment to the patient. Quality care is delivered by the nurse when all

modalities of healthcare are involved in patient care. Patient safety is improved when prompt

attention to call lights can avert a fall. Hourly rounding is a form of collaboration with the

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patient as the nurse explains that staff will be checking on them for any needs every hour and the

nurse portrays a caring attitude.

Quality and Safety Education in Nursing (QSEN) Competencies

Patient centered care integrates patient, family and community preferences and values

and engages them in coordination, communication and education. Physical comfort and

emotional support are important for patient wellness along with showing consideration and

respect for the patient. Care is coordinated and integrated with patient and family considerations.

Safety is addressed by examining barriers such as polypharmacy, medication costs and financial

barriers to obtaining medications (Forneris, S., Crownover, J., Dorsey, L., Leahy, N., Maas, N.,

Wong, L., Zabriskie, A., & Zavertnik, J., 2012, p. 28-29).

Teamwork and collaboration may involve utilizing other individuals or groups who can

help the patient achieve health goals. For the purposes of this paper an example may be of

making available counseling resources or community assistance. Quality improvement may be

an example of teaching during discharge that has been designed for the understanding of the

patient and is particularly helpful to patient discharge outcomes. Evidence-based practice,

explained in easy to understand terms is a way to give reliable information that can be integrated

into the patient’s knowledge base. Informatics can be utilized to access patient data to allow

consistency in care and for safety issues that would include checking medications for interactions

(Forneris et al., 2012).

The importance of caring behaviors and the professional nurse’s practice cannot be

overlooked or considered to be any less of an attribute than another. The caring and competent

nursing professional will always be in great demand by their organization and the patient that

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depends on that care. Nursing is a caring and compassionate profession that communicates

through its skills and interactions a healing touch that can be duplicated by no other.

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