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Martin Luther King Jr: "I have decided to stick to love… Hate is too great a burden to bear."
Contents
Preface ix
Acknowledgements xi
About the Author xiii
About the Notes On … Series xv
1 Introduction 1
1.1 About This Book 1
2 What Is Caring? 5
2.1 Introduction 5
2.2 Defining Care 5
2.3 Theories of Care 9
2.4 Summary 14
3 Professional Caring 17
3.1 Introduction 17
3.2 Types of Care 18
3.3 Summary 24
4 The Attributes (or Ingredients) of Transformational Care 25
4.1 Introduction 25
4.2 The Seven Cs + 25
4.3 Ingredients/Attributes of Transformational Care 27
4.4 Summary 51
5 Understanding the Context of Care 53
5.1 Introduction 53
5.2 Nurses, Other Health Professionals, and Caring 54
5.3 So, Why Did You Want to become a Nurse or Health Professional? 54
5.4 So, What Is Important to You? 55
5.5 Contributors to the Challenge 56
5.6 Summary 63
6 The Therapeutic Relationship: The Key to Professional Care 65
6.1 Introduction 65
6.2 The Therapeutic Relationship: Defined 65
6.3 Characteristics: What Constitutes a Therapeutic Relationship? 67
6.4 The Zone of Helpfulness 70
6.5 Phases of a Therapeutic Relationship (Building the Bridge) 74
6.6 Summary 76
7 Compassion, Empathy, and Sympathy 79
7.1 Introduction 79
7.2 Compassion 79
7.3 Compassion Fatigue 80
7.4 Compassionate Leadership 81
7.5 Congruent Leadership 84
7.6 Empathy 86
7.7 Sympathy 87
7.8 Summary 89
8 Who Cares? – Self-Care/Self-Compassion – When the Oxygen Masks Fall! 91
8.1 Introduction 91
8.2 Hardwired to Put Others First 92
8.3 Hardwired to Bring Others Down 94
8.4 What Are the Risks of a Lack of Self-Care? 98
8.5 Caring for Self 99
8.6 Definition of Self-Care, Self-Compassion, and Compassionate Care 99
8.7 Strategies for Managing and Promoting Self-Care and Self-Compassion 100
8.8 The Future 105
8.9 Summary 106 References 107 Index 123
Preface
The landscape of healthcare provision across the world has changed in the past few years. An increased dependence on technology, growing financial pressure on the world’s health services, the potential impact of AI, an ongoing shortage of qualified nursing and other health professional staff, the global pandemic, and a host of other regional and local pressures has meant that the act of providing care in the healthcare domain or health service has come under growing pressure. As well, the path towards becoming a nurse or health professional has changed, with unprecedented clinical challenges and changes in the way students learn as greater content is moved to online learning platforms and clinical exposure is diminished. The global pandemic has exposed weaknesses in health services around the world, but it has also emphasised the commitment, care, and courage health professionals have been able to bring to their roles each day and in a multitude of clinical environments.
Today’s nursing and health professional students are tomorrow’s clinical leaders, and now is an excellent opportunity to explore what ‘care’ means for health professionals facing sustained and ongoing clinical challenges. Nurses and other health professionals are expected to employ a solid knowledge base, sound clinical skills, and think critically and to do so with a firm grasp of what it means to ‘care’ and how caring is practiced; however, this too is coming under pressure from the same forces mentioned above. With the additional challenges of burn out, compassion fatigue, bullying and a seeming host of more hostile clinical environments.
This text: Notes On … Caring is written to provide an outline of what it means to ‘care’ from a health professional perspective. Its goal is to help nurses and health professionals understand the concepts and context of care and how effective care provision can or might be used to enhance their practice – to excel as a nurse or health professional and to offer genuinely transformational care.
Acknowledgements
This book would not have been possible without the support of a wide host of people. The team at Wiley-Blackwell including Tom Marriott, Christabel Daniel Raj and Swetha Kodimari have been a source of support and inspiration. My writing colleagues, Clare Bennett, Alison James, and Dominic Roche who have likewise been wonderful in joining with this project and participating with writing contributions and practical advice and feedback.
As well, thank you to my nurse academic colleagues from around the world and particularly from CSU and UNE you know who you are, you were inspirational too in your own way.
About the Author
cert, grad cert hpe
David began his nursing career in the days when nurses wore huge belt buckles and funny hats. He ‘trained’ as a Registered Nurse and Midwife in South Australia and worked through his formative career in several hospitals and clinical environments in Australia. In 1993, he completed a Bachelor of Nursing at Flinders University, Adelaide and, after a number of years of volunteer work in Africa, he moved to the UK and worked as the Coordinator of Children’s Services and as a Nurse Practitioner. He completed a Master of Health Science degree at Birmingham University. For a short time, he worked in Central Australia for Remote Health Services before returning to the UK to complete his nursing doctorate, researching clinical leadership. This resulted in the development of a new values-based leadership theory: Congruent Leadership. He continued to research in the areas of clinical leadership, men in nursing, and the role of the media in nursing while contributing to teaching roles at several Australian Universities. He has recently retired from nursing and is focused on writing poetry and fiction.
DAVID STANLEY nursd, msc hs, ba ng, dip he (nursing), ex-rn, ex-rm, tf, gerontic
About the Notes On … Series
Florence Nightingale wrote two health-focused books, Notes on Nursing and Notes on Hospitals, however this series of short books (inspired by her use of the ‘Notes on’ title) is developed to address a range of nursing and health-specific topics in brief or note form. Each book in the series offers a comprehensive overview of information on a wide range of topics for nurses, midwives, and other health professionals. It is hoped the books will be especially useful for students in a number of health professions, with the books providing key, relevant, concise, information in an accessible way. Notes On… Caring is the first book in the series.
“I thought not caring was a superpower, I was wrong. Caring about stuff (people too) that’s what really matters. Kindness, making other people feel good, that’s the real superpower, and we’ve all got it.”
Ricky Gervais as (Tony) in After Life (2019) Season 3 Episode 6.
1.1 About This Book
Nursing is a dynamic and ever-changing profession and central to the provision of effective healthcare, as are other health-focused professions. In recent years the global shortage of a range of health professionals including nurses, nurse educators, researchers, and academics, and tensions between the professional aspirations of nurses and the growing dominance of financially driven health services may be having a significant impact how care is received and provided. It may be that health services, broken by the growing cost of health service delivery or government ineptitude or corporate greed, has promoted a proliferation of disturbing stories of clinical neglect and patient abuse, the apparent breakdown in professional standards in the face of the recent global pandemic, and unhealthy and unacceptable working conditions, paradoxically in parallel with vocal support for nurses and their role during the COVID-19 pandemic (Royal Commission into Aged Care Quality and Safety 2021). All this has seen the central place of care in nursing and the healthcare industry shift the moral imperative as caring has slipped, as the demands to do more and more, with less and less cripple nurses’ (and other health professionals’) capacity to care, or (perhaps) will, to practice with compassion and empathy.
Sandvik et al. (2021) is of the view that the application of care related theory is ill supported once students graduate and begin their working lives, leading to a care-focused theory-practice gap.
I have been a nurse for over 40 years, and while predominantly involved in clinical nursing and nursing education, I have also supported the design of several nursing curricula. On occasions they have included content related to the philosophy of nursing, models of nursing or nursing’s history and development. All topics that help nursing students grasp the place their profession has in the delivery of healthcare and of the role nurses and nursing has, from an historical and philosophical standpoint. I have also been involved in teaching a range of other health professionals, and although my involvement has dealt predominantly with areas
of their professional development it has sometimes involved education in the areas of professionalism and their role as professional leaders.
With all the health professional education I have been involved in, little of it has focused on ‘care’ or how ‘caring’ is expressed by health professionals and my impression is that this is a topic that is either taken as a given within care-focused professions (such as nursing), or there is little need to explore care or caring as a concept because the concept is thought to be self-evident.
However, discussion of a detailed meaning of ‘care’, or ‘caring’ or the role care has in helping others grow, or heal or in supporting clients, patients, or the people at the heart of nursing care or the health service, is often scant or missing (Miller and Keane 1978). This is an old view, although I believe it remains valid today. I wonder too if, as nursing clambered for professional status, something of the art of nursing, of the heart of nursing was lost, neglected, or dismissed as trivial or tied to the ‘women’s business,’ and the mysticism of nursing’s past and origins.
Fearing that understanding or even discussing care will somehow diminish the advances made by nurses towards professional status, ‘care’ – the thing at the centre of nursing (Watson 1979; Leininger 1991, 2001), has been relegated to a glib cliché as Woodward (1997) claims however I feel ‘care’ is more relevant today, than the emphasis focused on the instrumental element of care, to the detriment of the nursing profession. Care seems to have been relegated to a by-word for nursing that requires no further insight, or it is used as an isolated expression, as if no understanding beyond the obvious were needed. Leininger (one of nursing’s great philosophers) said in 1984, ‘Caring is nursing, and nursing is caring,’ as if no further explanation were needed. Watson (another master nursing philosopher) said in 1979, ‘Caring is the essence of nursing.’ I have to say I agree, but if caring is the essence, why is it that education about care, or discussions of what it means to care, and how care can be recognised, or what benefits there are from care, are sometimes missing from the education and instruction of nurses and other health professionals?
Radsma (1994, p. 444) proposed several questions about caring that I believe remain unanswered. She asked, ‘Is caring presumed to be a given in nursing?’ And ‘Caring can exist without nursing, but can there be nursing without caring?’ Radsma’s (1994) paper reminds us that caring can be seen as an ethic (Kurtz and Wang 1991; Fry 1988), from a scientific perspective (Dunlop 1986; Watson 1979), as the core or essence of nursing (Leininger 1991; Ritchie 1987). It can be viewed from a historical perspective (Reverby 1987), a feminist perspective (Hagell 1989; Condon 1992), in terms of an anthropology bent (Leininger 1991), from a theological standpoint (Roach 1984), from a philosophical perspective (Mayeroff 1990; Benner and Wrubel 1998), and from a psychological standpoint (Watson 1979).
Radsma (1994) and Smith (1990) suggest that in terms of understanding conceptualising and describing ‘care’ and ‘caring’, nursing faces a dilemma, that I believe remains unresolved.
One concern in addressing the concept of ‘care’ from the perspective of the function of nurses is that it may imply that this is all nurses do and as such it is employed by groups (politicians, doctors and some other health professionals or the public) who do not understand what it is that nurses do, who then use ‘caring’ as a tool to reduce the significance of nursing activity and the value of care, down to a simplistic narrative about what nursing is and what nurses do, with this sort of misunderstanding used to diminish the recognition and value of the vital role nurses provide across the health service (Jackson et al. 2021). Nurses make up approximately 60% of the healthcare workforce across the world (WHO 2019, 2020) and as such understanding their contribution to the health service through ‘care’ or ‘carework’ is vital.
This book sets out to redress this oversight and to add a range of perspectives and information so this neglect can be corrected. The book is aimed at undergraduate nurses and other health professionals and maybe of use for a range of practicing nurses and health professionals. It begins with an oversight of definitions and with theories of care explored in Chapter 2; Chapter 3 explores what professional caring might look like, expanding on the concepts of instrumental care, expressive care, and discussing transformational care, as well as the types of caring central to healthcare provision. Chapter 4 considers the attributes of caring required for the provision of transformational care. Chapter 5 outlines the context of professional care and explores what challenges impact on the delivery of care in the health arena. Chapter 6 offers an overview of the therapeutic relationship and why this matters for the provision of professional care, while Chapter 7 defines and elaborates upon three key aspects of care: compassion, empathy, and sympathy, as well as outlining compassion fatigue, compassionate leadership, and congruent leadership. Chapter 8 explores the issues of self-care and self-compassion as well as considering why caring presents several challenges such as the difficulties of bullying and horizontal violence within nursing (in particular) and strategies for fostering greater self-care.
Throughout the book the meaning of care from a nursing and midwifery perspective is outlined, and the component parts of care are expressed from the perspective of the healing and healthcare arts.
Reflective Activity 1:
Before you read on – think about how you practice ‘care’. How do you ‘care’ in your daily professional practice? Who do you care for in your professional practice? (This is not as simple a question as you might think. Did you think of yourself? If not, why not?). Where did you learn to care, or was it something that is innate to you or your professional responsibilities?
2
What Is Caring?
2.1
Introduction
This section of the book considers how caring is defined and how the term ‘care’ can be better understood. It also outlines several theories of caring, explaining each in the hope of laying bare the concept of ‘care’ and ‘caring’. It should be noted that most of the theories presented are now aging although most remain relevant and useful as a base to understand care.
Reflective Activity 2:
Before you read on – think about the word ‘care’. Where do you use it? In what context? With whom (strangers, pets, children, family, friends)? How does the word vary if used at home in your personal life or in a professional context? Do you use the word differently based on context?
Who or what do you care about?
2.2 Defining Care
Mayeroff (1990) suggested that caring in its most significant sense is about helping others grow. He offered the example of a father caring for their child, of an educator caring for their students, of a therapist caring for the emotional growth of their client. Caring, Mayeroff (1990, p. 1) said, ‘is the antithesis of simply using the other person to satisfy our own needs,’ adding that caring should not be confused with liking another, wishing well, comforting, or simply having a passing interest in another. Caring does not involve an isolated feeling or momentary relationship, nor is it simply a matter of wanting to care for someone.
Eslick et al. (2022) suggest that caring means different things to different people and, as such nurses and other health professionals will enact care in different ways
as they interact with a client or patients. Caring involves helping another or others grow and ‘actualize’ themselves. Critically Mayeroff (1990, p. 2) defined care ‘as a way of relating to someone that involves development, in the same way that friendship can only emerge in time through mutual trust and a deepening and qualitative transformation of the relationship.’ However, Mayeroff never mentioned the other central role of caring: to heal. By healing I do not mean to ‘cure’ but healing in the sense that the wellbeing of the other, physically, emotionally, and/or spiritually is enhanced by the relationship and the other, the person being cared for, is supported in a position where they can be ‘well’. This could even mean die well. I recall spending three hours on a quiet surgical ward doing little but holding the hand of a terminally ill man. It was near Christmas and the number of surgical cases was small. Enough for the other nurses to attend to. This gave me space to stay with this man in his final hours. We spoke little, and as the night wore on, I could see he was waning. He was comfortable but passing in and out of consciousness. I said a few kind words, words of reassurance, of comfort and although I wasn’t sure he could hear them, I spoke kindly to him regardless. I also held his hand. I didn’t stroke it, I just held his hand in mine, gently and with purpose. There were no relatives present, there were no others to call. But earlier in his admission he’d expressed a fear of dying alone and as a result I felt privileged to have been the one to be there with him at his end. In effect, all I did was ‘be there’, speak gently and kindly, and hold his hand. Crucially he wasn’t alone, and I was sure he knew this, and this I hoped, gave him comfort. I believe the care I provided was a form of healing.
Virginia Henderson’s (1966, p. 3) definition of nursing best fits the meaning of care that relates to both growth and healing. She wrote:
The unique function of the nurse is to assist the individual, sick or well, in the performance of those activities contributing to health or its recovery (or to peaceful death) that he (sic) would perform unaided if he (sic) had the necessary strength, will knowledge, and to do this in such a way as to help him (sic) gain independence as rapidly as possible.
Henderson’s interpretation of nursing addresses both health and illness, each a feature of healing, and she acknowledges that nursing also involves engagement with people (not just patients or clients) when they are well or ill, and that this engagement may also involve a teaching and advocacy role (with greater focus on growth than healing). Henderson’s theory is considered a, ‘theory of nursing’ and not a ‘theory of care’ Indicating that perhaps nursing is not just caring, and caring is not the core of nursing, as Leininger (1991) suggests (below). By placing the dual features of healing and growth at the centre of what it means to ‘care’ it is possible to reconcile the common themes evident in the many contemporary definitions of nursing, where nursing is considered to be:
● a science ● an art
● person centred
● holistic
● caring
● adaptive
● addressing health promotion
● addressing health maintenance
● addressing health restoration
● a helping profession
Healing (in its broadest sense), and growth are replete within these perspectives of what nursing is and how ‘care’ lies at the heart of what nursing may be. This view is supported by Leininger (1991) who said, ‘caring is nursing, and nursing is caring’ adding that care is the dominant, distinctive, and unifying feature of nursing, with both Leininger (1991) and Watson (1979) declaring that care is the essence of nursing, with each describing ‘theories of care’ to help outline nursing rather than specific ‘theories of nursing’. Others support this perspective with Andersson et al. (2015) and Tang et al. (2019) also suggesting that care is at the heart of nursing practice.
Dictionary definitions of ‘care’:
Care: noun
1. the provision of what is necessary for the health, welfare, maintenance, and protection of someone or something.
‘The care of the elderly.’
2. serious attention or consideration applied to doing something correctly or to avoid damage or risk.
‘He planned his departure with great care.’
Care: verb
1. feel concern or interest; attach importance to something.
The process of protecting someone or something and providing what that person or thing needs. ‘The standard of care at our local hospital is excellent.’
‘Mir’s going to be very weak for a long time after the operation, so she’ll need a lot of care.’
‘Nurseries are responsible for the children in their care.’
Caring is the way in which humans respond to the ill, distressed, and vulnerable in society and it is fundamental to human survival (Watson 1979; Leininger 1991). However, the definitions above only highlight some of what is understood about this most vital of human qualities. When Florence Nightingale died in 1910 her sister Parthenope said of Florence, she was ‘a shocking nurse,’ with ‘little or none of what is called charity’ (Brighton 2004, p. 308).
Charity is a term associated with religious concepts of care. Charity was something the poor and disaffected sought when they looked to the church for care –healthcare, social care, food, or shelter. The term is rarely used in the twenty-first century, but it describes what we would consider ‘care’ to mean today. It may be a surprise to realise that the most famous nurse was regarded as a ‘shocking nurse’ who showed little or no care. Perhaps we should look here at how others describe the concept of care. The following quote is from one of the nurses Patricia Benner interviewed about the meaning of caring in 1984. She describes care as:
a person to person kind of thing, just being with someone, really communicating with people … you talk about empathy or whatever, but somebody is frightened and just sitting down and listening to people, it’s not that you even have to say anything. (Benner 1984)
The American Holistic Nurses Association (AHNA) suggested that holistic nursing includes all nursing practice (care) that has healing the whole person as its goal (Frisch et al. 2000). The AHNA descriptions of holistic nursing also includes the notion that the holistic nurse is an instrument of healing and a facilitator of the healing process (Frisch and Rabinowitsch 2019). Others suggest that to practice holistic nursing the nurse must integrate self-care, self-responsibility, and reflection in their lives (Mariano 2007; Dossey and Keegan 2009). Therefore, the practice of holistic care proceeds from a balance of physical, spiritual, psychological, and social needs with wholeness being dependent upon our relationship to each other, our environment and that which gives our lives meaning. Holistic nursing begins with an open mind and a willingness to explore the potential for personal growth and well-being for others and ourselves.
The National Council of State Boards of Nursing (2006) described care as where the nurse acts in the best interests of the patient and respects their dignity. This means the nurse abstains from gaining personally at the clients’ expense and refrains from inappropriate involvement in the client’s relationships. Others see care as forming the majority of nursing situations, predominantly in relationships that are mutual (Morse 1991). Although, these are usually short-term relationships, while even here, the nurse needs to understand that the patient is also a person. Although as Stein-Parbury (2017, p. 27) states, ‘no single definition could possibly capture the rich and complex nature of the relationship between patients and nurses.’
In 2017, Petrou et al. undertook a study with nursing students to explore their understanding of care. Their study results proposed that nursing students understood care almost as a description of what nurses do. So that care was seen to mean – helping others, meeting other’s health needs, health maintenance, disease prevention and health promotion. As well, respondents saw the provision of psychological and emotional support as keys to providing patient care.
To expand on an understanding of care a number of theories of ‘care’ have been developed and these are considered next.
2.3 Theories of Care
2.3.1
The Theory of Human Caring: Jean Watson
Watson’s Theory of Human Caring was developed between 1975 and 1979 (Watson and Woodward 2010) and it sees caring as the moral ideal and essence of nursing. Watson sees human caring as the core of a nurse’s role in society and that it is a nurse’s moral role to be committed to human care. In developing the theory Watson created what she called ‘carative factors’ that stood in contrast to medical ‘curative factors’ in an effort to position nursing as a ‘unique discipline’ with its own scientific and professional profile.
The major conceptual elements of the theory are based on ten carative factors that evolved into the clinical caritas processes. A focus on transpersonal caring relationships, with caring moments, or caring occasions and caring-healing modalities (Watson and Woodward 2010). The theory suggests that a CaringScience orientation is central or necessary for the survival of nursing as well as humanity and that nursing’s caring-healing core becomes both discipline specific and trans-disciplinary, building on the timeless, ancient, enduring and most noble contributions of nursing realised scientifically, aesthetically and ethically (Watson and Woodward 2010; Sitzman and Watson 2018).
The ten ‘carative factors’ were outlined to describe the ‘core’ of nursing work and were initially used to give structure to the theory. However, as the theory evolved, the term ‘caritas processes’ was proposed, with ‘caritas’ meaning ‘to cherish and appreciate, giving special attention to or loving.’ Placing the core of nursing in a special or precious place. Linking care and love so that love and caring come together to form a new form of deep transpersonal caring. The link is thought to build a relationship between love and caring that supports inner healing for self and others and includes a cosmic connection to the universe. Watson and Woodward (2010, p. 354) suggest that:
…when we include caring and love in our work and in our life we discover and affirm that nursing, like teaching, is more than just a job; it is also a life-giving and life receiving career for a lifetime of growth and learning.
