Watters goes on to quote Marie Marthey, who deems the art of caring the ‘invisible power of nursing’ (2009). This is, it seems, because of the fundamental yet immeasurable positive effect that a nurse’s caring has on the patient. It is invisible, however, because this specific aspect of nursing is rarely discussed or considered in the discussions that surround the healthcare system. The importance of caring in nursing, however, cannot be oversated – it is integral to the very profession. Watters contends that the reality of nursing care “is an interpersonal process between a patient and the nurse in which knowledge must be applied to create a safe, caring environment” (2009). Seeing as the benefits of nursing care are clear, the subsequent question is two fold: first, what challenges must be addressed in nursing care and, second, what can nurses and other healthcare professionals do to address these difficulties? This paper examines three areas in which difficulties to nursing care may arise: the personal, the educational, and the systematic levels. Each of these is looked at in turn, and an attempt to answer each part of the above question is made. Through this examination, it is clear that nursing care has hit a crossroads both in personal practice and in professional standards. Where caring in nursing goes from here will, largely, determine a similar path for the nursing profession as a whole.
Caring at the Personal Level
Given that caring is inherently a personal attitude, choice, and action, it is clear that caring within the nursing profession begins, and must begin, here. The personal aspect of care is the most important part of the practice – as stated above, nursing is in essence a personal relationship between nurse and patience. Therefore, if there is a lack of care on the part of the nurse, there is consequently a lack of professional fulfillment. However, this is not always a choice, per se. Instead, there are often external factors that affect a nurse’s behaviors and actions. Two in particular are discussed here: the level of self-care in a nurse’s environment, and the level of experience a nurse has with the culture of a patient. While these two may not seem directly related, they both bear a great impact on the level of personal care a nurse is able to give a patient.
First, it is almost a foregone conclusion to say that nurses experience a great deal of pressure and stress in their work environment. Cronqvist, Theorell, Burns, & Lutzen (2004) discuss this aspect of care from a unique perspective. In their paper, the authors discuss the findings of a study made of 36 nurses from various intensive care units. The environment for these units are quite similar – “high working pace, advanced technology, budget restrictions, recent reorganization, and shortage of experienced nurses” (2004). This environment therefore served as an ideal situation for examining the importance and effect of nursing care – it was, seemingly, representative of many nurses’ experiences.
The authors’ findings are relevant to applying personal changes in order to ensure proper care – in essence, the research found that there was a lack of balance between personal care and professional obligations. More specifically, “Moral obligations and work responsibilities are assumed to be complementary dimensions in nursing, yet they were found not to be in balance for intensive care nurses” (Cronqvist et al., 2004). In other words, the researchers found a tension in nurses between the desire to care personally for patients and the reality of having to fulfill working expectations and conditions. This is described in terms of Caring For vs. Caring About. Caring About describes a moral action, based on a “personal ability to know what is morally good to do”; in contrast, Caring For is “task-oriented nursing care that is assigned and controlled by others” (Cronqvist et al., 2004). In essence, Caring About is the true ideal of caring within nursing, while Caring For is a necessary byproduct of nursing as a profession. The resulting effect of the tension between these two aspects of nursing is that neither is able to be fully met by nurses.
In answer to this tension, the authors suggest, “there is a need to support nurses in difficult intensive care situations” (Cronqvist et al., 2004). This may seem an obvious conclusion, but it is of paramount importance for individual employers – such as hospitals and intensive care units – to utilize. The first and foremost form that this ought to take is mentoring for nurses. An active attempt to address the tensions between Caring For and Caring About head on will, in the long run, help nurses gain insight into how this tension arises and how it can be answered. The end result, it is hoped, is both better professional practice and personal care.
A second aspect of the personal answer to nursing care has to do with the experience of the nurse. This is best examined in a study made of the cultural self-efficacy of Canadian nursing students (Quine, Hadjistavropoulos, & Alberts, 2012). While this study focused on the “cultural self-efficacy of Canadian nursing students caring for aboriginal patients with diabetes”, the resulting discussion can be applied to a wider view of nursing care.
The authors define cultural self-efficacy as having to do with “how capable one feels functioning in culturally diverse situations” (Quine et al., 2012). The research found the ability for nurses to care for their patients was largely dependant on their experience with them. If a nurse held low intercultural anxiety, high intercultural communication, and high experience with the persons s/he was dealing with, the nurse possessed higher knowledge and skills for how to care for the patient (Quine et al., 2012). Therefore, an important aspect of addressing the personal aspect of nursing care is to ensure that nurses (both professionals and students) have a high level of interaction and comfort with their patient base. While this may, in part, be met by educational standards, it will ultimately depend on the individual. Each of these aspects help to qualify nurses for caring at the personal level.
Caring at the Educational Level
The second level that is paramount for the preservation of patient care in nursing practice is found in nursing education. This is based on one fundamental position that is important to note, “Nursing education plays a central role in the ability to practice effectively” (Sawatzky, Enns, Ashcroft, Davis, & Harder, 2009). This perspective, if not universally held, is at least widespread among healthcare practitioners. The authors quoted above state that “A teaching philosophy is intimately intertwined with one’s philosophy of nursing and the ethic of caring and therefore is fundamental to a caring framework” (Sawatzky et al., 2009). In other words, the goal of nursing education is not only to instill knowledge and skills, but the philosophy and ethic that are so important for the art of caring in the nursing profession. The ethic of caring may not be able to be taught completely, but can at least be supplemented in a nursing education that includes it. As Sawatzky et al. (2009) argue, this means excellence in teaching scholarship (such as quality research on pedagogy), teaching practice (that is, excellence in teachers themselves) and teaching leadership (for example, providing personal mentoring). An emphasis on this type of excellence in nursing education will, in turn, instill the ethic of care in the nursing profession. The long term benefits of highlighting care in education are clear.
A more specific approach to the educational aspect of nursing care is that of values. As Paldanius & Määttä state, “learning about caring and caring in nursing could be improved during nursing education” seeing as “the most essential element in nursing is the sensibility to feel love for one’s neighbor” (2011). Paldanius & Määttä cite the focus of nursing education as being on both discipline and the spirit of nursing – this will prove a fundamental element of nursing education. The authors state that there are primary values that ought to be instilled in nursing education. Their discussion of these values is worth quoting at length:
The primary values, on which caring is based, are the so-called platonic basic values: truth, beauty, and goodness. The value related to reasoning is truth whereas goodness is connected to will. The values should not be limited to concern only a specific area because it is possible to refer to the goodness and beauty of thoughts as well as to the truth of actions. Values structure the action in their own special way, as our special relationships with other people. (Paldanius & Määttä, 2011)
From this conception of values, the authors derive three essential factors of care: internal feeling, professional caring, and the ethics of nursing. Internal feelings, such as empathy, ought to be encouraged in nursing students. In the same way, the professional standards of caring, such as equality and individuality, ought to be taught outright (Paldanius & Määttä). Finally, the ethical standards of nursing (such as the expectations of nursing activities and interaction with patients) ought to be stressed throughout nursing education. An emphasis on these three essential factors of nursing care in education will, in the long run, lead to better nursing practices outside of the educational setting.
Caring at the Structural Level
The final level of healthcare important to the art of care in nursing practice is that of the overarching system, or structure. Nearly every social or professional endeavor relies on the cooperation of structure – whether it be institutional or governmental. The case of nursing care is no exception. Even if nurses have a personal commitment to care and healthcare professionals have an educational mandate to encourage this care, the practice cannot be sustained if it is not supported by the healthcare system. Laurie Gottlieb, the Editor-in-Chief of the Canadian Journal of Nursing Research, released an insightful and challenging editorial in 2004 related directly to the structural changes needed to maintain care in nursing practice. In the letter, Gottlieb highlights the many personal and professional challenges faced by nurses in relation to a failing Canadian system. These highlights are worth quoting at length:
The system under which nurses work has not been as generous, supportive, committed, and loyal to them as nurses have been to it. It is well documented that nurses have shouldered a disproportionate share of the burden wrought by financial cuts, downsizing, and mergers. Nurses have been marginalized, de-professionalized, and demoralized. They have endured abuses and working conditions that few other health professionals have had to face. They have paid dearly with their own health, frozen and lost wages, elimination of jobs, a decimated leadership structure, working conditions that border on the inhumane, loss of status, workplace violence and abuse, shortages, recruitment and retention difficulties – the list goes on. (Gottlieb, 2004).
This laundry list of challenges can only be solved at the structural level. A nurse’s personal commitment to the ethic of caring is simply not enough. Individuals will burn out. The profession’s attempt to instill care into nursing students will not be enough in the long run, if there is no support. In addition to these efforts, steps must be taken by the healthcare system at the institutional and structural level in order to affect a lasting support of nursing’s devotion to care. This may not necessarily mean drastic changes, but it does necessitate an examination of the core of the structure, to ensure that aligns with the nursing ethos of caring.
It is clear that care is an integral part of nursing as a profession and a practice – it is “the glue that brings the patient to us” (Watters, 2009). Care, when properly implemented by a nurse, is exactly what makes nursing such a unique and necessary part of the healthcare system. Therefore, the above levels of care have been briefly examined in order to give a picture of what is needed to continue, or enhance, the practice of caring nursing in the field of healthcare. Personal commitment is not enough. Education is not enough. Structural changes are not enough. Instead, individual nurses, healthcare professionals, and policymakers must work together in order to affect the needed changes and continue the successes. Care in nursing is at a crossroads, and the careful consideration and application of the above research will prove beneficial for both the personal practice and professional standards of nursing.