Caring is a concept central to nursing theory. Indeed, an esteemed constellation of nurses throughout history, including Nightingale, Watson, Henderson, and Benner, have integrated the concept of care into their theory and praxis. Caring has been considered a foundational element of nursing such that "compassion and therapeutic relationships" are viewed as essential "underpinnings" of nursing (Skillings, 2008). As with most disciplines, the complexities that accompany professional practice in contemporary settings can pose unanticipated challenges. The ethic of caring that is fundamental to nursing endures an onslaught of competing priorities, barriers to compassionate practice, and adaptations inherent to modern healthcare institutions (Skillings, 2008).
Most behaviors that the nursing discipline considers caring are readily recognized, such as "attentive listening, comforting, honest, patient, responsibility, providing information to the patient can make an informed decision, touch, sensitivity, respect, calling the patient by name" (Vance, 2003). Categorically, many nurse practitioners and nurse educators place these behaviors under several headings. For instance, Swanson's caring theory processes are Knowing, Being With, Doing For, and Enabling (Tonges & Ray, 2011). The Swanson Caring Theory framework for patient well-being considers Enabling and Doing For as behaviors indicating professional competence, while Knowing and Being With are considered manifestations of compassion -- and are directed toward Maintaining Belief in the patient (Tonges & Ray, 2011).
Three theories and models of caring that developed in the 1970s continue to influence the curriculum in preparation programs for professional nursing practice: Patricia Brenner's model of Madeleine Leininger's theory of cultural care and Jean Watson's theory of human caring (Leininger, 1991; Watson, 1988).
Watson viewed caring as a science that enfolds caring processes, experiences, and phenomena into a holistic practice characterized by a humanistic orientation. With a worldview of connectedness and unity, Watson located her theory in relational ontology. That is to say that she perceived the being-in-relation orientation as "concentric circles of caring" with interactive capacity (think: ripples in a pond) to impact others and the environment through caring behavior (Watson, 1996).
Leininger's transcultural theory is sometimes referred to as culture care theory since effective and considerate patient care is central to Leininger's conceptualization. Leininger believed that knowledge of patients' cultures equipped nurses to strengthen their commitment to providing care based on the nurse-patient relationship (Leininger, 1991). Through a greater understanding of the influence of cultural beliefs and practices, nurses are inclined to view their patients more holistically rather than only focusing on a set of symptoms or the manifestation of a patient's illness (Leininger, 1991). A foundation in transcultural understanding fosters the ability of nurses to see how their patients' culture and faith helps them to deal with sickness, suffering, and even death (Leininger, 1991). Through a perspective informed by cultural knowledge, non-traditional treatments -- meditation, anointing, and other spiritual therapies -- nursed can more easily appreciate and integrate diverse approaches to caring (Leininger, 1991).
If nurses are to accept the aphorism that "caring is a practice," then resources allocated to the practice of nursing can provide opportunities to strengthen and integrate caring as a substantive element of nursing in contemporary contexts (Skillings, 2008). One purpose of this discussion is to explore how resource use impacts the articulation of caring in nursing practice. Skillings (2008) asserts that the following arenas have the potential to impact a caring footprint in nursing practice: 1) Training, mentoring, and professional development; 2) organizational aspects, such as cultural transformation, interdisciplinary collaboration, and organizational infrastructure; and 3) nursing leadership across all levels of a healthcare institution.
Caring in Professional Development
Benner developed a model of caring that incorporates the acquisition of nursing skills "novice to expert" and that fits well with professional preparation programs, but is especially germane to in-service staff training (Fry, 1983). Brenner's model construction is broad sweeping, including advocacy, healing power, integrative caring, participative and affirmative power, problem solving, and transformative power (Fry, 1983). Brenner's model helped to establish an ethos within the nursing profession that values patients as whole human beings, inclusive of their physical, psychosocial, and spiritual needs (Fry, 1984).
Implicit in Brenner's model is the idea that the skills needed for nursing can be learned through experience and through instruction or mentoring (Fry, 1993). Indeed, Brenner's model communicates a vision of nursing as relational, involving "the nurse's response as a human being, first, and then secondarily, in the nursing role (Brenner, 1984; Fry, 1993). The relational dynamics between a nursing student and a nurse educator -- or between a practicing nurse and a nursing professional development, in-service trainer -- exemplify caring as an evolving and interpersonal process (Fry, 1993). Instructors must demonstrate caring to the learners, as an example of how the nurses should interact with their patients, and a means to enhance communication, an avenue to more productive mentoring, and as a support to the development of emotional intelligence (Fry, 1993; Skillings, 2008).
Caring in the Organization
Tonges & Ray (2011) describe cultural transformation in a healthcare organization by utilizing the Carolina Care Model developed at the University of North Carolina Hospitals. Their article illustrates how the Swanson Caring Theory was effectively operationalized in a healthcare institution thorough application of the Carolina Care Model (Tones & Ray, 2011). The Carolina Care Model is designed to "actualize caring theory, support practices that promote patient satisfaction, and transform cultural norms" (Tones & Ray, 2011). A primary advantage to this approach is that desired patient outcomes are facilitated while the hospital experiences of patients and their families are enhanced (Tones & Ray, 2011).
The Carolina Care Model is solidly grounded in caring theory, which puts forth the idea that the nursing behaviors that demonstrate caring about patients is as important to the well-being of patients as nursing behaviors that utilize clinical best practices in patient care (Tones & Ray, 2011). A true strength of the Carolina Care Model is that it ensures actionable interventions will be systematically incorporated in the actions of nurses, in the caring processes, and in the expectations of patients, families, as well as for the clinical professional staff (Tones & Ray, 2011). Swanson found that caring is impacted at three levels -- patient, nurse, and organization. At the level of the organization, Swanson further identified three dynamics as manifestations of caring in practice: leadership, compensation and rewards, and professional relationships (Tones & Ray, 2011). By ensuring these components are integrated in organizational functions and operations, a healthy and fair work environment is created that fosters the development of committed nurses who are able to build their practice around a solid core of caring (Tones & Ray, 2011).
The North Carolina Hospitals (UNCH) utilizes the Professional Practice Model (PPM), which is also grounded in caring theory (Tones & Ray, 2011). In essence, the Professional Practice Model is a systems approach to establishing and maintaining the conditions that promote and enable caring (Tones & Ray, 2011). The PPM helps to validate the organizational norm of relationship-based nursing practice (Tones & Ray, 2011). One way the PPM is used by the North Carolina Hospitals to sustain focus on caring is through the use of a highly structured behavioral interviewing technique that is used to identify potential new nursing employees who exhibit a strong capacity to care (Tones & Ray, 2011). The commitment to caring practice at the North Carolina Hospitals is deep, and it is exemplified through the institution's emphasis on three types of relationships pivotal to quality healthcare: relationships wit the patient and family, with colleagues, and with self (Tones & Ray, 2011).
The Carolina Care Model includes a set of nursing behaviors that "consistently communicate caring to patients" and that are grounded in the Professional Practice Model and -- because they are considered a standardized nursing behaviors in the North Carolina Hospitals -- are "replicable by nurses in every practice setting" (Tones & Ray, 2011). The key behavioral aspects of Carolina Care are: 1) Multilevel rounding; 2) words and ways that work; 3) relationship and service components; and 4) partnerships with support services (Tones & Ray, 2011). To illustrate what Carolina Care looks like on the floor, it is useful to consider four elements of the relationship and service component: 1) Moment of caring; 2) no passing zone; 3) partnerships with support services; and 4) blameless apology (Tones & Ray, 2011). Moments of caring are designed to increase patients' sense that their emotional needs are being met (Tones & Ray, 2011). A moment of caring can mean that a nurse sits down with a patient on each shift to talk about how they are coping with their illness, and perhaps touching them on the arm or hand to establish a connection (Tones & Ray, 2011). The no passing zone element is a commitment by all nurses that, regardless of assignments on the floor, they will not pass by a patient's call light (Tones & Ray, 2011). Through partnerships with support services, the Carolina Care model ensures that staff who provide services in patients' rooms and environments (food delivery, custodial chores) will initiate conversations with patients…