Caring Theory

Swanson’s Middle Range Nursing Theory of Caring By: Shari Semelroth RN, BSN Mennonite College of Nursing Abstract Do we honestly make an effort to improve the environment, care, medical treatment, and interactions with those patients who are suffering a loss? Do we adequately provide the care that they need? These questions are answered in Swanson’s Middle Range Theory of Caring. We examine the five caring processes and their applications to one’s daily nursing routines. Many healthcare organizations have adopted the caring theory as their model of care for their philosophy and principles for nursing.
Caring theory has also been the focus of many research articles that have concluded that caring is a natural part of nursing and it is based on evidence. All healthcare professionals should be able to achieve the concepts into their daily nursing profession. We care for patients, and what we are currently doing we can always switch to improve for more positive interactions. What is caring and why is it essential to nursing? What are the perceptions of caregivers, care receivers, and care observers regarding caring? A nurturing way of relating to a valued other person toward whom one has a personal sense of commitment and responsibility.
Nursing has traditionally been concerned not only with the caring needs of individuals, but also with caring as a value or principle for nursing action. (Swanson, 1991) The underlying structure of the nursing philosophical system or grand theory of nursing as caring is created by the assumptions of the theory and their interrelationships. (Boykin & Schoenhofer, 2001) These assumptions develop the most fundamental belief that all persons are caring by virtue of their humanness, that to be human is to be caring.

A deep understanding of the practical meaning of that foundational assumptions also organize the theory that personhood is living grounded in caring; that caring is lived moment to moment in relationships with caring others, and that nursing as a discipline and profession of caring is orientated not towards diagnosing needs nor compensating for deficiencies, but as its focus, nurturing persons living caring and growing in caring. (Boykin, 2003) Swanson suggests that a universal definition or conceptualization of caring does not exist within and outside of nursing as to the role of caring in personal and professional relationships. Swanson, 1991) Kristen Swanson is a native of Rhode Island, graduated with a bachelor’s degree in nursing from the University of Rhode Island in 1975. She went on to earn her master’s degree from the University of Pennsylvania in 1978 and PhD in nursing from the University of Colorado. Swanson worked as a Registered Nurse at the University of Massachusetts, as she was drawn to that institution because the founding nursing administration clearly articulated a vision for professional nursing practice and actively worked with nurses to apply these ideas while working with clients. Swanson, 1993) As a novice nurse she wanted to become a knowledgeable and technically skillful practitioner with an ultimate goal of teaching these skills to others. She pursued graduate studies. While studying she worked as a clinical instructor on a med surgical unit. Swanson studied psychosocial nursing with an emphasis on exploring the concepts of loss, stress, coping, interpersonal relationships, persons, environment and caring. As a doctoral student, she was able to experience hands on health promotion activity.
She was involved in a cesarean birth support group. One historical meeting for her was on miscarriage. Swanson noticed that the discussion was based by the physician more on the pathophysiology and health problems of miscarriage. The women of the group were interested in discussing their personal experiences with pregnancy loss. (Alligood & Tomey, 2010) From that day forth she decided to learn more about the human experience. Caring and miscarriage became the focus of her doctoral dissertation and her program of research.
She has since then received numerous awards, has taught fellow nursing students, became the Dean at the University of North Carolina at Chapel Hill and Associate Chief Nursing Officer for Academic Affairs at UNC Hospitals. In addition to teaching and administrative responsibilities, she conducts research funded by National Institutes of Nursing Research, publishes, mentors faculty and students and serves as a consultant at national and international levels. Swanson was inducted as a fellow in the American Academy of Nursing and received Distinguished Alumni Award from the University of Rhode Island.
Swanson used various theoretical sources while developing her theory. During her doctoral studies, she was influenced by other nurses and their theories related to caring. She took Dr. Jacqueline Fawcett’s course on the conceptual basis of nursing practice as a master’s prepared nurse, not only made her better at understanding the differences between the goals of nursing and other health disciplines, but also made her realize that caring for others as they go through life transitions of health, illness, healing, and dying was congruent with her personal values. (Swanson 1991)Dr.
Fawcett developed the Language of Nursing and Metatheory; she displayed a distinctive role in caring for others and the importance of altruistic caring for the person’s well-being. (Fawcett, 1989) Dr. Jean Watson was also a mentor during her doctoral studies. Dr. Watson is known for her Theory of Human Caring. Even with the close relationship, they had, neither has ever seen Swanson’s program of research as an application of Watson’s theory of human caring. They do agree that compatibility of finding on caring in their individual programs add creditability to their individual programs of research.
Swanson acknowledges Dr. Kathryn E. Barnard for encouraging her to make the transaction from interpretive to contemporary empiricist paradigm to convey what she learned and postulated about caring through several phenomenological investigations to direct intervention research and hopefully clinical practice with women who had miscarriages. (Alligood &Tomey, 2010) Dr. Barnard is recognized for her Parent Child Interaction Model. She encouraged Swanson to test her theory through randomized controlled trials.
Swanson’s theory of caring is a nursing set of processes that are formed from the nurse’s own principles and his or her interaction with the patient, with five fundamental processes of knowing, being with, doing for, enabling, and maintain belief. Her theory was formed from three descriptive phenomenological studies from perinatal nursing. The five processes that help explain the concept of this theory has subcategories. The theory has four phenomena of concern: nursing, person, health and environment. Theory concepts of nursing are informed caring for the well-being of others. Beatty, 1984) Person in theory concept is unique beings who are becoming and whose wholeness is manifested in thoughts, feelings, and behaviors. Health in theory is related to having meaning filled experience with wholeness. Environment is any situation that is influenced by the client or influences the client. Knowing is the first process of caring. Knowing is striving to understand the meaning of the event in the life of the other, avoiding assumptions, focusing on the person cared for, seeking clues, assessing thoroughly, and engaging both the one caring and the one cared for in the process of knowing. Swanson 1991) The second caring concept, being with emotionally present to the other. It involves simply “being there”, conveying ongoing availability and sharing feelings whether joyful or painful. Monitor so that the one caring does not ultimately burden the one cared for. The third concept is doing for others what would do for the self at all possible, including anticipating needs comforting, performing skillfully and unconditionally, and protecting the one cared for while preserving his or her dignity (Swanson, 1993) Enabling is the fourth concept.
It is facilitating the others passage through life transitions and unfamiliar events by focusing on the event, informing, exploring, supporting, validating feelings, generating alternatives, thinking through, and giving feedback (Swanson, 1991) The final concept is maintaining belief. Sustaining faith in the others capacity to get through an event or transition and face a future with meaning, believing in others capacity and holding him or her in high esteem, maintaining a hope filled attitude, offering realistic optimism, helping to find meaning and standing by the one cared for no matter what the situation is. Swanson, 1993) Her later work introduced “Informed Caring”, aimed to provide structure for relating the five caring processes and describes assumptions about the four main phenomena of concern to nursing. (Swanson, 1998) An assumption of nursing is informed caring for the well-being of others. Providers must be informed and regarding common responses to health concerns. The nurse will increase care given based on her experiences. Included is evidenced based practices, compassion, understanding of other structure of caring, and understanding of the nursing profession.
Along with this assumption, the nurse may be affected by Benner’s Novice to Expert Theory. Persons are defined as unique beings who are in the midst of becoming and whose wholeness is made manifest in thoughts, feelings and behaviors. (Benner, 1984) Each individual experiences are molded by environment. Spiritual endowment connects each being to an external and universal source of goodness, mystery, life creativity, serenity and free will to choose a range of possibilities. Each person does have equal choices.
Nurses are mandated to take on leadership roles in fighting for human rights, equal access to health care and other humanitarian causes. (Hanson, 2004) Health and well-being is a complex process of curing and healing that includes “releasing inner pain, establishing new meaning, restoring integration, and emerging into a sense of renewed wholeness”. (Swanson, 1993) Bonds are created, free expression of spirituality, thoughts, feelings, intelligence and creativity. The well-being of health is negatively affected by actions of individuals upon the other that inhibit expression of wholeness.
Environment is situational. Any context that influences or is influenced by the designated client informed. (Swanson, 1993) Any forces that exert influence upon or are influenced by the patient. (Hanson, 2004) Forces could come from cultural, economic, political, spiritual, social, physiological realms. Any disturbance or change in the environment or realms will affect the wholeness of the other. According to Swanson (1993), the terms environment and person in nursing may be viewed interchangeable, therefore, what is considered an environment in one situation may be considered a client in another situation.
Internal evaluation of the theory consists of clarity, adequacy, consistency logical development, and level of theory development. Clarity of the caring theory is straight forward and easy to interpret. Swanson’s definition of the environments clearly describes her thought process of how the environment and patient are interchangeable. Adequacy adequately addresses each process with thorough descriptions that bring the theory together as a whole. It recognizes nursing values and missions and uses prior theories and research as the basis for its formation.
It is clear descriptions of its process allow it to be easily applied to practice. Consistency within the theory focus, definition and interpretation of relationships remain consistent throughout the description of the theory. Logical development is described as the formation of caring as an interaction process. It acknowledges the processes that affect each level of the interpersonal relationship between client and environment. Swanson included previous research and knowledge of caring, but later individualized her theory with empirical evidence that her processes can be used to form a healing environment.
Level of theory development is displayed of components of a middle range theory including empirical testing applicable to direct practice, based on a specific phenomenon and narrower in scope because it focusses on the five processes of caring and their interaction, rather that focus on both the medical and psychosocial aspects of nursing. (Peterson & Bredow, 2009) External evaluation of the Theory of Caring include, complexity, discrimination, reality convergence, pragmatic, scope, significance, and utility. Complexity is easily understood with the simple definitions of the four concepts and five processes.
Discrimination is not unique to the nursing field. There are many other theories based on caring. The theory does not have a precise boundary as it can be applied to many situations of nursing as well as outside the nursing practice itself. Reality convergences represent the real worlds of nursing and are true. The concepts and processes are described thoroughly enough to be understood by any professional. This allows the theory to be applied to a broad spectrum of human interaction meant to be caring. Pragmatic can be operationalized in real life setting which is seen in Swanson’s empirical testing.
Scope is met by Swanson of a middle range theory by having the processes narrowly described for individual situations however it is broad enough to be applied to caring interactions that range from nursing to other professions. The components can be testes but remain concrete to be repeatedly applied to different practice setting. Significance of the caring theory is truly substantial to the nursing profession. It has recognized and organized key values of caring that will help to provide improved client to nurse interactions.
The theory clearly describes the importance of recognizing the situational environment, and the influence of a nurse’s interactions on the health and potential outcome of a patient. Utility is a clear with definition and descriptions and has allowed Swanson to continue to have her theory tested for further research. Each process stands on its own, but some also help to build and define the others. Knowing, being with, doing for, and enabling work together to have the path filled with meaning will be chosen and thereby meet the goal of maintaining belief. Limitation in theory was to show relationship between five processes.
She recognized the limitations and worked to link all five processes in to Nursing in Informed Caring for well-being of others. Swanson’s theory is congruent with Benner’s theory of Helping Role of Nursing and Watson’s Carative Factors. There is cross validation and rationale for perception. The University of North Carolina hospital has operationalized Swanson’s Caring theory. Swanson’s Theory has led to research based practicing. The initial investigation that launched this program of clinical research was a phenomenological pilot study of five women who had miscarried within fourteen weeks of participating in the study.
The research questions were: “What is the meaning of miscarriage to the woman who has recently experienced it? ” Another study was a phenomenological study of twenty women who had miscarried two specific aims were (a) to describe the human experience of miscarriage and (b) to describe the meaning of caring as perceived by women who had miscarried. This research study shifted the program of research from a qualitative, interpretative approach to a descriptive quantitative design. Kyle, 1995) Swanson was able to develop instruments to assist in the measuring of her results. The Impact Miscarriage Scale was delivered from her research. (Swanson, 1999) The scale was developed in three phases, it was repeated, measures, and randomized. This scale measures significant aspects of suffering from a miscarriage. She developed an Emotional Strength Scale that measures the extent of how individuals view themselves emotionally and the Caring Other Scale which measures the received after miscarriage from one’s significant other and “others”.
The Caring theory postulates that nurses demonstrating they care about it is as crucial to patient well-being for them through clinical activities such as preventing infection and administration medications. ( Bulfin, 2005) ) Implemented the Carolina Care Model is one approach to actualizing caring theory across a healthcare organization by systematically incorporating interventions that link nursing actions, caring processes, and expectations. The professional practice model for the University of North Carolina hospital completed in 2008 grounded in caring theory.
A model was developed into specific caring behaviors and incorporated them in practice. Four key behavioral characteristics of Carolina Care were developed 🙁 1) multilevel rounding, (2) words and ways that work, (3) relationship service components, (4) partnerships with support services. Hourly rounds combine elements of the caring process of being with and doing for. Scripts may have an adverse reaction, so words and ways that work. Suggests key points to include in interaction that frequently occur that are individualized conversations.
These words are linked to enabling. These may be linked to the other caring process, such as being with. A moment of caring is asked to be done with each patient for 3-5 minutes to talk about how they are coping with their illness while touching the patient’s hand or arm. Moments like this exemplify being with, and information the patient shares may contribute to knowing. These links between caring processes and caring behavior suggested are grounded in a culture of maintaining belief. There are many healthcare organizations that use Swanson’s theory as their care model.
Norton Healthcare, University of North Carolina, Children’s Hospital of Michigan, Virginia Mason Medical Center, Hudson Valley Sinai Hospital in Michigan and Meritus Healthcare in Maryland are a few that has adopted this theory into practice. A theory is an explanation and it is said that nothing is as practical as a good theory. Yet there is a persistent gap between nursing theory and practice. Theory guided practice remains and ideal versus a realized goal in most organizations. Swanson’s caring theory may be a notable exception in accelerating progress toward this goal.
Caring theory postulates that nurses demonstrating they care about patients is as important to patient’s well-being as caring for them through clinical activities such as preventing infection and administrating medication. By incorporating interventions that link nursing actions, caring process and expectations is an approach to actualizing caring theory. All areas of nursing should be able to incorporate the theory of caring into their daily routine with no barriers of resistance. My practice is initiated usually as an inpatient status.
Our providers are called to consult any neurological concern that the admitting physician would like evaluated. We see pediatric patients and their families in the emergency room, NICU, PICU, and general pediatric floor. Some of the patients are new to their current health crisis and some are established patients of our service already. Knowing as defined in Swanson’s theory of caring could be implemented during our first initial visit that we center on the patient. We offer a realistic optimism that we will devote our services to properly diagnosing the patient.
Taking a detailed history and searching for clues to why this admission came about and to determine the next step in helping the patient. Staying with the patient during this complicated and stressful initial consult can be related to Swanson’s being with. Nurses can take the time with our patients and explain in depth the diagnosis and testing that may need to be ordered. Many times we will spend hours with our teenage patients explaining the electroencephalogram. This age of patients can be scared of any testing and need to be told the truth on what is going to take place.
Working in a children’s hospital it is a blessing that we have access to child life. These professionals are specifically trained in child development and can help with the education process with our children. We ask for their assistance to educate our patients. Many of times they have pictures or videos to show that can explain in a way a child or teenager may understand, visual and audio sometimes works in our modern technology generation. We encourage questions and let the patient and their families understand there is no burden on asking questions.
Asking questions is the way our patients learn, and we want them to be educated so they are not scared. With our population, the more the patient knows, the easier the testing usually goes. Doing is applied to all our patients. When we have a seizure patient we have an abundance of education. Seizure patients need to be explained the many safety precautions. When they are being discharged from the hospital we are enabling setting up and scheduling follow up appointments at our clinic. Maintaining belief occurs as we are reassuring that if they are in need of anything before they come in to our clinic to please call and we can try to help.
Many schools require a seizure action plan before students can come back in to class. This is why we try to stay in communication with the patients and their families before their follow up as many times they are scheduled out four months from discharge. Our patients are transferred to adult when they reach 18 years of age, and we hear too often that the adult world is not as caring as we were in pediatrics. I do believe that our services are being seen as a caring process. How can we enhance the theory of caring? Can the theory help us with research in the future?
I believe that the theory of caring can be beneficial in care models, research and evidenced based practice. According to Johnson and Webber (2005), a model should capture central themes and theoretical relations in such a way to help guide nurses in their practice. Boykin, Smith, and Aleman (2003) believed that a model would help create a work environment for nurses that support their commitment to nurture and caring. This model would display the important values that nurses have stated to be critical in the practice of nursing. Caring is the foundation of nursing and defines the nurse’s professional identity. Boykin ; Schoenhofer, 2001) A caring-based nursing model, identified that care is an essential value for nurses and that being able to incorporate this value into their practice increases satisfaction of the nurse and the patient. A study by Bulfin (2005), using the care concepts developed by Boykin and Schoenhofer generated a model of care to patients in a large community hospital. In the Bulfin (2005) study, the researcher asked if a visual model would enhance and support caring in nursing practices and, thus, improve the job satisfaction of the nurse and impact the level of patient satisfaction.
Following the implementation of the caring model, patient satisfaction increased and more positive comments were received from the patients and families (Bulfin, 2005). The National Organization of Nurse Practitioner Faculties (NONPF) issued domains and competencies for every NP graduate that included emphasis on the nurse-patient relationship, use of healing modalities, respect of the worth and dignity of the patient, and incorporation of spiritual beliefs into the plan. These competencies describe the core abilities of NP graduates.
NONPF states that these competencies are a “gold standard” to maintain and shape quality graduate NP programs. NONPF’s emphasis on caring qualities in the NP-patient relationship is further evidence that NPs do not practice from a medical perspective but, rather, as facilitators of holism and health with their patients. Theory of caring can be used to better understand how to relate to our patients. Each process slows for a nurse to formulate an intervention to better care for a patient. This is a theory for the future.
Caring defines nursing and is moving to be an evidence-based profession. Swanson’s five caring process are first grounded in the maintenance of a belief in human kind, anchored by knowing another’s reality, conveyed by being with and enacted through doing for and enabling. When time is taken to observe and interpret nurses’ actions, it becomes clear that nursing practice is the result of blended understandings of the empirical, aesthetic, ethical and intuitive aspects of a given clinical situation and a nexus of maintaining belief in, knowing, being with, doing for and enabling the other. Nursing caring…consists of subtle, yet powerful, practices which are often virtually undisclosed to the casual observer, but are essential to the well-being of its recipient”. (Swanson, 1993, p. 357) Swanson gives nurses a platform to base our caring foundation on. As nurse’s gain experiences we build small levels on the foundation. Like building a house, we all start with the basics of the foundation that we learn in nursing school. It is up to us what we do with that foundation.
Every nurse in any clinical setting can use the theory of caring daily. They may not know the five caring process by name, but they are used in every situation, with every patient, by every nurse. References Alligood. M. R. , ; Tomey, A. M. (2010). Nursing theorists and their work. (7th Ed. ). St. Louis: Mosby. Beatty KD. Reflection on caring for a home care client using Kristen M. Swanson’s theory of caring. Int J Hum Caring 2004; 8: 61–64 Benner, P. (1984). From novice to expert. Menlo Park: Addison-Wesley.
Boykin, A. , ; Schoenhofer, S. (2001). Nursing as caring. Sudbury, MA: Jones ; Bartlett. Boykin, A. , Smith, N. , St. Jean, J. , ; Aleman, D. (2003). Transforming practice using a caring-based nursing model. Nursing Administration Quarterly, 27, 223-231. Bulfin, S. (2005). Nursing as caring theory: Living caring in practice. Nursing Science Quarterly, 18, 313-319. Fawcett, J. (1989). Analysis and Evaluation of Conceptual Models of Nursing, 2nd Edn. F. A. Davis, Philadelphia, PA. Hanson MD.
Using data from critical care nurses to validate Swanson’s phenomenological derived middle range caring theory. J Theory Construction Testing 2004; 8: 21–25 Kyle, T. (1995). The concept of caring: A review of the literature. Journal of Advanced Nursing, 21, 506-514. Kavanaugh K, Moro TT, Savage T, Mehendale R. Enacting a theory of caring to recruit and retain vulnerable participants for sensitive research. Res Nurs Health 2006; 29: 244–52. Nightingale, F. (1859). Notes on nursing: What it is and what it is not.
London: Harrison and Sons. Peterson, S. J. , ; Bredow, T. S. (2009). Middle Range of Theories: Application to Nursing Research (3rd ed. ). Philadelphia, PA: Wolters Kluwer, Lippincott Williams ; Wilkins. Schoenhofer, S. , ; Boykin, A. (1998a). The value of caring experienced in nursing. International Journal for Human Caring, 2(4), 9-15. Swanson, K. (1998). Caring made visible. Creative Nursing, 4(4), 8-12. Swanson K. What’s known about caring in nursing: a literary meta-analysis. In: Hinshaw AS, Feetham S, Shavers J, eds. f Clinical Nursing Research; Thousand Oaks, CA: Sage; 1999:31-58. Swanson, K. M. (1991). Empirical development of a middle range theory of caring. Nurse Researcher, 40(3), 161-16 Swanson, K. M. (1993). Nursing as informed caring for the wellbeing of others. Image: Journal of Nursing Scholarship, 25, 352-357 Watson J. Caring theory as ethical guide to administrative and clinical practices. Nurse Adm Q. 2005; 30(1):48-55. Watson, J. (1988). New dimensions of human caring theory. Nursing Science Quarterly, 1(4), 175-181.

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