First published in 1990: Law Harrison L. (1990) Maintaining the ethic of caring in nursing. Journal of Advanced Nursing 15, 125–127
‘Nurses care’ is a phrase used commonly to describe the essence of nursing practice. I have even seen automobile bumper stickers sporting the slogan. There are disturbing signs, however, that current social and economic forces make it difficult for nurses to maintain an ethic of caring in practice. Gaut (1981) questioned whether caring has become merely ‘a slogan to provide a rallying point for nurses involved in a movement toward professionalism and role identification’. What does the concept ‘caring’ really mean, and what can be done to remove barriers to caring in nursing practice?
Although the terms ‘care’ and ‘caring’ have been used throughout nursing's history, prior to the mid 1970s nurses rarely studied the phenomenon of caring (Leininger 1981). Since that time, however, there have been numerous articles and conferences devoted to the topic. The University of Colorado, USA, even established the Centre for Human Caring in the School of Nursing in 1986 to promote ‘an interdisciplinary approach to the study and teaching of human caring’ (Watson 1988). Caring is a process and an art that requires commitment, knowledge, and continual practice, and encompasses ‘a feeling of dedication to another to the extent that it motivates and energizes action to influence life constructively and positively by increasing intimacy and mutual self-actualization’ (Bevis, 1981). An ethic of caring serves as a universal value that guides nursing practice (Fry 1988).
Leininger (1981) identified 27 different caring constructs including compassion, concern, empathy, love, nurturance, presence, support, and trust. Although caring is a universal phenomenon, its expression is influenced by a variety of factors including culture, values, cost, stress levels, maturational levels, and time (Bevis 1981).
Care has beneficial effects on both the recipient and the giver of care. Caring nursing interventions make cure possible. In contrast, uncaring, impersonal nursing interventions may ‘repair the [patient's] body, but crush the soul’ (Kelly 1988). A major source of burnout is related to ‘nurses not being able to give care in the fullest way desired and to receive positive rewards or recognition for their caring activities and efforts’ (Leininger 1981). In fact, Maslach (1982) defined burnout as the loss of human caring.
Despite the increased emphasis on caring in nursing research and education, however, there is growing concern that today's economic, bureaucratic, and technological environment is limiting nurses’ caring abilities (Ray 1981). Reverby (1987) suggested that the central dilemma facing nursing today is the ‘order to care by a society that refuses to value caring’. Nurses are expected to do more, with fewer resources, and often lack the autonomy and authority to determine how they will provide the care demanded by society.
There are disturbing signs that the public image of nursing reflects a profession that has lost its ethic of caring. Kelly (1988) lamented that consumers of nursing care described nurses as ‘uncaring, cruel, rough, thoughtless, mean, [and] indifferent’. During a recent hospitalization, I also experienced an absence of caring among many of my nurses. Fortunately, however, the ‘uncaring’ of some was compensated by genuine caring of others. The caring nurses shared a number of common characteristics: they took time, although some nurses were caring even when their encounters with me were brief; they listened; they seemed genuinely interested in me as a person; they shared of themselves; and most of them told me their names!
In contrast, the uncaring nurses seemed to have no names (or they shared at most first names with me); and they seemed primarily interested in completing tasks or duties. They did not ask questions about my perceptions or feelings, and did not seem to listen if I voiced questions or concerns. Both groups worked in the same environment and confronted the same stresses related to workload and institutional expectations. What factors account for the differences in these two groups of nurses?
One theory that might explain the differences between the caring and uncaring nurses was proposed by Hutchinson (1984) to describe how nurses ‘create meaning’ and cope with the stresses of work in a neonatal intensive care unit. I believe that Hutchinson's theory could be applied to nurses in all types of work settings. Hutchinson proposed that nurses cope with the stresses of their jobs by creating meaning in three ways: emotionally, technically, and rationally. Nurses create meaning emotionally by investing emotion in the patients and families with whom they work. Such emotional investment requires both attaching to and separating from patients/families.
Nurses create meaning technically by providing sophisticated technical care and deriving satisfaction from involvement in this care. Nurses create meaning rationally by using justification or acceptance in order to ‘make sense’ of their activities or situations. For example, nurses may ‘justify the frequent performance of painful procedures by the belief that they are necessary for the [patient's] survival’ (Hutchinson 1984). Or, they may accept human or technical errors and limitations in order to create meaning rationally.
Hutchinson proposed that nurses must balance the three ways of creating meaning in order to avoid burnout. ‘If a nurse becomes a technician, devoting all energies to learning about new techniques and new equipment, other processes of meaning will remain elusive. The nurse will be capable of giving only technical care, lacking the humanness necessary for relating to (patients) and (families) as well as the ability to make sense of (his/her) work’ (Hutchinson 1984). I believe that nurses must create meaning emotionally and balance the three ways of creating meaning in order to practice caring nursing.
Nursing educational programmes must emphasize and teach caring philosophy and behaviours to students. A recent survey of baccalaureate nursing degree programmes in the United States revealed that 97% of the programmes addressed caring in the curriculum (Slevin & Harter 1987). The extent to which caring is emphasized, however, and the strategies used to help students learn to practice caring nursing, varies widely. We need further research to identify the most effective ways to teach beginning nurses how to balance the three ways of creating meaning described by Hutchinson (1984), and how to incorporate an ethic of caring into their practice. Slevin & Harter (1987) recommended that patients' perceptions of students' caring behaviours be incorporated into the clinical evaluation process. Such a strategy may also be useful in nursing staff development or orientation programmes.
Practising nurses who are aware of the process of creating meaning can be encouraged to develop innovative approaches to balancing the demands of their jobs. One such approach was described recently by a nurse who revealed that she deliberately seeks out at least one emotionally rewarding patient interaction each day in order to find meaning in her work.
In order for nurses to be caring with their patients, they must feel cared for and valued by their colleagues and by the institutions in which they work. Many nurses are plagued by the ‘supernurse syndrome’ in which they have unrealistically high expectations of themselves and their coworkers. Good nurses are expected to be ‘selfless and tireless, and to put everyone elses’ needs first and (their) own needs last’ (Albright 1988). Because of such unrealistic expectations, nurses often fail to care for themselves and for their colleagues. We need to identify ways to support one another and ‘care for the caregivers’ (Albright 1988, Service 1988). One programme to foster mutual support among nurses was implemented recently in a neonatal intensive care unit in which nurses draw names of colleagues for whom they will be a ‘secret buddy’ throughout the year. ‘Secret buddies’ frequently leave notes recognizing jobs well done, or small gifts on special occasions.
Mallison (1988) stressed the need to publicly recognize the thousands of nurses who do care, daily, and ‘not to let ourselves internalize a corrosive self-criticism’. By publicizing exemplary caring in nursing in the media and through personal contacts, each of us can increase the value of caring in our societies, and ultimately make it easier for nurses to maintain an ethic of caring in practice.
Administrators in healthcare organizations can minimize institutional barriers to caring by implementing policies that reflect respect and care for nurse employees. Such policies would involve nurses in decision-making so that nurses could determine how to implement caring nursing. In addition, healthcare administrators could establish programmes that facilitate nurses’ meeting their personal as well as professional responsibilities. Examples include child care services, flexible staffing patterns, and resorting to policies such as mandatory overtime only when absolutely necessary. These strategies cost money, which may be difficult for administrators to justify in today's era of fiscal restraint. We need to include caring behaviours in cost/benefit analyses of healthcare resources. Caring resources such as support, education, and therapeutic communication all have significant economic benefits for healthcare organizations. Such benefits need to be documented and publicized to healthcare administrators and policy planners (Ray 1987).
There is a clear need to build on and expand existing research and theory related to the phenomenon of caring and to identify factors in the healthcare system that will enable nurses to care. Nurse practitioners, administrators, educators, researchers, and theorists must continue to work together to ensure that the ethic of caring remains an essential, unique focus of our profession.