Nursing as a caring practice from a phenomenological perspective

Nursing as a caring practice from a phenomenological perspective Elisabeth Spichiger1 PhD, RN, Margaret I. Wallhagen2 PhD, RN, CS, GNP and Patricia Benner3 PhD, RN, FAAN 1

Scientific collaborator, Institute of Nursing Science, University Basel, and Scientific Collaborator, University Hospital Bern, Bern, Switzerland, Professor, Department of Physiological Nursing and Associate Director, John A. Hartford Center of Geriatric Nursing Excellence, School of Nursing, University of California, San Francisco and 3Chairperson and Professor, Thelma Cook Endowed Chair in Ethics and Spirituality, Department of Social and Behavioral Sciences, School of Nursing, University of California, San Francisco, CA, USA

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Scand J Caring Sci; 2005; 19; 303–309 Nursing as a caring practice from a phenomenological perspective Nursing is frequently described as a caring practice. What this concept means may be less clear. This paper considers nursing as a caring practice in three steps. First, the concept of practice based on Taylor’s and MacIntyre’s philosophical definitions of the term is described. Secondly, numerous notions of caring are presented; the call from some nurse researchers for quantification of the concept and why this is problematic is discussed; and an exposition of caring from a phenomenological perspective is provided.

Introduction Nursing is frequently described as a caring practice. However, what a caring practice means may be less clear. There exists no agreed upon definition of caring and controversy surrounds its measurement. The purpose of this paper is threefold: (1) to describe the concept of practice based on comprehensive, philosophical definitions of the term; (2) to present current, differing views of caring and then describe a phenomenological view of the concept and (3) to join the two concepts and illustrate nursing as a public caring practice with examples from an interpretive phenomenological study.

Practices Some general understandings of practice are exemplified by the following definitions of the concept in Webster’s ninth new collegiate dictionary (1): (1a) actual performance or application, (b) a repeated or customary action, (c)

Correspondence to: Elisabeth Spichiger, Institute of Nursing Science, University of Basel, Bernoullistrasse 28, 4056 Basel, Switzerland. E-mail: [email protected]

Finally, the notions of practice and caring are joined, and the concept of a caring practice is presented. Nursing as a public caring practice is illustrated with examples from an interpretive phenomenological study. In conclusion, it is claimed that a phenomenological view of caring combined with a comprehensive definition of practice is well suited to nursing, and allows for a description of nurses’ caring practices from both a nursing and patient perspective. Keywords: caring, practices, caring practices, nursing, phenomenology. Submitted 27 January 2005, Accepted 16 May 2005

the usual way of doing something; (2a) systematic exercise for proficiency, (b) the condition of being proficient through systematic exercise; (3) the continuous exercise of a profession. Thus the common understanding of practice is that it is the performance of customary actions in a proficient manner that requires ongoing performance for its maintenance. Notions of practice that extend beyond this general understanding of the word are found in the definitions of Taylor and MacIntyre.

Taylor’s notion of practices By practice, Taylor (2) meant something extremely vague and general: more or less any stable configuration of shared activity, whose shape is defined by a certain pattern of dos and don’ts, can be a practice for my purpose. The way we discipline our children, greet each other in the street, determine group decisions through voting in elections, and exchange things through markets are all practices. And there are practices at all levels of human social life: family, village, national politics, rituals of religious communities, and so on. (p. 204) This definition includes the key elements from the common view of practice but highlights that such a practice is based in a cultural tradition that is socially constituted in

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both the private and public arena. For example, social groups share common taken for granted meanings and expectations about what it means to be a good or poor parent, teacher or nurse. Furthermore, a practice is constituted by meaningful actions. Moving a piece of wood on a checkered board becomes a meaningful action constituting the practice of playing chess when performed by a chess player (3).

MacIntyre’s notion of practices MacIntyre (4) included the above elements but restricted the concept to activities that meet specific conditions when he defined practice as any coherent and complex form of socially established cooperative human activity through which goods internal to that form of activity are realized in the course of trying to achieve those standards of excellence which are appropriate to, and partially definitive of, that form of activity, with the result that human powers to achieve excellence, and human conceptions of the ends and goods involved, are systematically extended. (p. 187) Giving an example, the author explained that the planting of turnips is a technical activity not yet a practice; farming, however, is one. All practices require technical skills, but a practice is always more than a set of technical skills. A wide range of activities falls under the concept, for instance the arts, sciences, games, or the making and sustaining of family life. MacIntyre (4) distinguished goods external and internal to a practice. By goods external to a practice he meant such goods as prestige, status and money. Engaging in a certain practice is only one of several ways to achieve these external goods (e.g. we can engage in building a house or buy one). Goods external to a practice may be objects of competition with losers and winners. In contrast, goods internal to a practice can only be achieved by engaging in a certain practice. MacIntyre (4) called these goods internal for two reasons: they can only be specified in terms of a certain practice, and they can only be identified and recognized by the experience of participating in this practice. People who lack this experience are not capable of making judgements on the internal goods achieved. Typically, the achievement of goods internal to a practice is an achievement for all people participating in this practice. Only chess players can, for instance, enjoy a challenging game and fully appreciate the analytic skill and strategic imagination needed to play chess. From MacIntyre’s (4) perspective, people entering a practice have to accept the standards of excellence featured within this practice, that is, the best standards achieved so far in this practice. Each practice has a history from which new practitioners have to learn. As he stated:

To enter into a practice is to enter into a relationship not only with its contemporary practitioners, but also with those who have preceded us in the practice, particularly those whose achievements extended the reach of the practice to its present point. (p. 194) In striving to achieve excellence, practitioners have the potential to refine a practice and to work it out in new situations (5). Practices should not be confused with institutions (4). Chess is a practice; the chess club is an institution. Institutions are involved in acquiring and distributing material goods such as money and power. They have to do so to sustain themselves and the practices they bear. Without the support of institutions, practices cannot survive. Practices and institutions – and consequently external goods and goods internal to a practice – are therefore closely related. The ideals and the creativity of a practice and the practitioners’ cooperative care for common goods are always vulnerable to the acquisitiveness and the competitiveness of an institution. In summary, a practice is seen here as a culturally based, shared activity with a tradition. It has standards of excellence, which its practitioners strive to achieve. Practices, thereby, realize internal goods and extend their capacities to achieve these standards while creating the standards themselves. It is argued here that practices, attending in some way to human beings and with practitioners who let these human beings matter to them, are what constitute caring practices.

Caring In this section, numerous notions of caring are presented. Then the call from some nurse researchers for quantification of the concept and why this is problematic is discussed. An exposition of caring from a phenomenological perspective follows.

Conceptualizations of caring Caring is described in a myriad of different ways in the nursing literature. Meleis (6), for whom caring is a component of what defines a nursing perspective, summarized views that contrast with her own. These include: caring as the essence of nursing; caring as equal to the discipline of nursing; caring as the goal, mission, or both of nursing; caring as the moral ideal or central virtue of nursing and caring as the art of nursing. The numerous conceptualizations of caring have been constructed in different ways. Some were developed deductively, such as Watson’s (7) theory of human care. Others were formed inductively and represent different levels of abstraction (8). Examples are Leininger’s (9) grand theory of cultural care diversity and universality that grew out of several ethnographic studies, or Swanson’s

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Nursing as a caring practice (10) middle-range theory of caring, which was empirically developed from three phenomenological studies. Many authors have provided descriptions of the concept based on single studies derived from patients’, families’, nurses’, nursing students’, nursing teachers’ and other health care professionals’ perspectives of caring (11). The concept has been mainly investigated with qualitative methods, including phenomenology, grounded theory, content analysis and ethnography. The few quantitative studies have mostly used caring behaviour inventories with ranking scales. In their review of nursing literature on caring, Morse et al. (12) explored various conceptualizations and identified 35 explicit or implicit definitions of this concept. The authors analysed the definitions and described five related perspectives on the nature of caring: caring as a human trait, a moral imperative or ideal, an affect, an interpersonal relationship, and a therapeutic intervention. Two outcomes of caring were identified as well: patients’ subjective experiences of being cared for and patients’ physical response to caring. Sherwood (13) performed a meta-synthesis of 16 qualitative studies that investigated caring from the client’s perspective. The following four patterns of nurses’ caring emerged from this synthesis: healing interaction (e.g. creating an overall healing milieu), nurses’ knowledge (e.g. making knowledgeable decisions), intentional response (e.g. performing helpful interventions) and therapeutic outcomes (e.g. resolving physical and affective needs). Swanson (11) reviewed approximately 130 data-based, quantitative and qualitative investigations of caring to determine the current state of knowledge about the concept in nursing. These studies were mainly published between 1980 and 1996. She distinguished five levels of discourse when discussing the concept of caring: Level I identified the characteristics of persons with the capacity for caring; level II summarized concerns and commitments by focusing on the beliefs or values undergirding caring actions; level III identified patient-, nurse-, or organizationrelated conditions that enhance or diminish the likelihood of caring transactions; level IV described caring actions, behaviours, or therapeutic interventions and level V focused on positive and negative consequences of caring. For each level, study results were presented in extensive lists with categorized descriptors. According to the author, the five levels of caring knowledge were hierarchical not in order of significance but in order of level of assumption. For example, a study of caring actions assumed that the participants had the capacity and the commitment for caring and that the conditions in place were supportive of caring. The various conceptualizations of caring (6, 12) and the syntheses of knowledge about the concept (11, 13) show that it has been extensively described and explored; the publications demonstrate that many authors consider caring as a relevant concept for nursing. However, the

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numerous definitions and the research findings that include many distinct aspects also illustrate that authors do not share a common view of the concept and that, therefore, researchers need to carefully choose and describe their perspective.

Problems with the quest for the quantification of caring Morse et al. (12), Sherwood (13) and Swanson (11) believed that nursing knowledge on the concept of caring needs further development. The latter two authors also shared a call for quantitative research. Swanson stated this most forcefully: Nurse researchers working in a clinical arena need to expand (some may say constrict) their thinking to consider caring as a commodity that may be measured, rigorously applied, and tested for its effectiveness in promoting healing, recovery, or optimal wellbeing. (p. 55) The request for quantitative research is based on the positivist assumption that caring can be operationalized into measurable features. According to Dunlop (14), this traditional view of science, that is, the view following the natural science model, implies that caring can be described in a set of context-free, measurable variables. However, if stripped of their context, variables delineating caring (e.g. compassion) cannot be defined in measurable terms any better than caring itself. The human sciences are confronted with a fundamental problem when emulating the natural science model because a description of human capacities in terms of context-free features, abstracted from everyday contexts, is impossible (15). Taylor (16) made a similar point when saying that science cannot treat aspects of personhood in exactly the same way it approaches people’s organic being. Swanson’s (11) meta-analysis on caring can serve as an illustrative example here. The author gave an all-embracing overview of the research on the concept. But for the reader, caring easily becomes elusive amidst the extensive lists of abstract categories and descriptors. With the removal of the study context through the process of meta-analysis, the meaning that caring held for a particular population situated in a specific context is lost.

Phronesis vs. techne Swanson’s (11) meta-analysis on caring serves to point out yet another relevant issue related to the call for quantification: the distinction between phronesis and techne. According to Dunne (17), Aristotle made a distinction between practical knowledge or phronesis and productive knowledge or techne. Techne refers to the knowledge of an expert maker, that is, to the universal principles, means and ends underlying the production of something. The producer can provide a rational account of the artefact’s

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production and teach others. The artefact, once produced, can stand on its own, independent of its maker. Phronesis requires and refers to embodied practical knowledge about how to act well. Good action itself is its end. Therefore, phronesis implies excellence and continual learning embedded in a socially organized practice. Embodied agents are engaged in their actions and act in relationships with others. They attune universal knowledge to particular situations, but experience, perceptiveness and understanding the responses of the other have priority over context-free formal knowledge. Actions cannot be separated from the agent or the particular context, and the agents can narrate about but not transform their actions into the kind of universal knowledge that is timeless and a-contextual because essential relational dimensions such as attunement and timing of caring are lost. However, narrative examples of caring can gather up commonly held cultural meanings about what it is to care for and about, and what it is to experience care (18). Once narrated, a particular instance of caring might be considered as a ‘particular universal’ or a paradigm case that illustrates caring (19). In this way, caring becomes accessible in the ways that literature is accessible. In relation to caring, an approach like Swanson’s (11) that breaks down the concept into means and ends, implies a view of caring that is based on techne, with a formulated body of knowledge, which, if applied correctly, will produce the desired outcomes independent of the one caring or receiving care. In contrast, the phenomenological perspective on caring discussed below is rooted in phronesis and, therefore, considers caring as closely tied up with the actors (the one caring and the one cared for).

A phenomenological approach to caring According to Dunlop (14), a science of caring is only possible if one chooses a route that steps away from the natural science method with its quest for universal principles and prediction. She suggested hermeneutic inquiry as an appropriate way to articulate what caring means in a particular context. This approach is exemplified by the hermeneutical studies published by Benner and colleagues that articulate the nature of nurses’ caring (20–23). This understanding of caring is rooted in Kierkegaard’s (24) notions of self-defining relationships, spheres of existence, or lifeworlds structured by self-defining/world-defining concerns, notions that were also described by Heidegger (25). The phenomenon of care. Their lived bodies open persons to particular lifeworlds and make care necessary and possible (26). Care has ontological privilege in that it constitutes our being in the world. Care is ontological (i.e. primary (27)) in that it structures being human, what and how something matters to persons and what they can

encounter (notice) and know. This is captured in Benner and Wrubel’s (28) description: Care means that persons, events, projects, and things matter to people. Caring is essential if the person is to live in a differentiated world where some things really matter, while others are less important or not important at all. ‘Caring’ as a word for being connected and having things matter works well because it fuses thought, feeling, and action – knowing and being. And the term caring is used appropriately to describe a wide range of involvements, from romantic love to parental love to friendship, from caring for one’s garden to caring about one’s work to caring for and about one’s patients. (p. 1) Caring is ontological in three ways (26, 28): (1) it sets up what matters, and therefore also what is stressful, to a person and which possibilities are available for coping. Caring makes the carer vulnerable to experiencing loss and pain, but may also result in joy and fulfilment; (2) caring enables persons to focus on the event or the one cared for. For caring persons in any given situation, certain aspects will show up as relevant, and these will enable them to recognize problems and possible solutions; and (3) caring sets up the ways in which giving help and receiving help are possible. Ontological care does not refer to any particular style of caregiving, rather it relates to the range of connectedness and mattering that human beings can experience in their lifeworlds (26). While caring for others, however, human beings as family members, friends, or professionals always manifest specific styles and contents of caregiving in a particular lifeworld (ontic forms of caregiving). Mothers’ caring for their babies, for example, differs according to specific cultural traditions, and caregiving in rehabilitation is distinct in its goals and style from caregiving in critical care nursing. The ontological forms of care that constitute persons and their lifeworlds, and the particular ontic forms of local caregiving are inter-related (26). Care that is located in specific lifeworlds and cultural traditions of caring typically provided in the home, school, neonatal intensive care unit, long term care settings etc. is ontic, and must be related to the person’s ontological structures of concerns that shape his or her being-in-the-world. In other words, ontic caregiving, in order to be experienced as nurturing and supportive, must be attuned to the person’s ontological concerns or structures of care. And they must be robust enough to assist the person in repairing the particular ontological structures of care in her or his lifeworlds. An illness, for instance, can disrupt a person’s taken-forgranted lifeworld. Therefore, recovery comes not only from the body’s cure, but also from re-integrating the person in his or her particular world (26). Two crucial aspects of caring. Two implicit yet crucial assumptions underlie the above account of caring: the strengthening of qualitative distinctions and the absence of radical freedom of choice. They warrant further discussion.

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Nursing as a caring practice Kierkegaard (29) identified ‘levelling’, his word for nihilism, as the striking problem of the modern age. ‘Our age is essentially one of understanding and reflection, without passion, momentarily bursting into enthusiasm, and shrewdly relapsing into repose’ (p. 33). Here, passion stands for commitment and reflection for thought instead of action. In the modern culture, according to Kierkegaard, detachment had replaced commitments in human relationships (30). In a similar vein, Taylor (31) described how the individualism of self-fulfilment, currently widespread in Western societies, centres on the self and concomitantly shuts out, or is even unaware, of the greater religious, political, or historical issues or concerns that transcend the self. Consequently, life becomes narrowed or flattened. The consequence of this lack of any commitments is a weakening of qualitative distinctions (16). Without a strong commitment, nothing will show up as more or less significant for human beings. Qualitative distinctions can only be maintained by a commitment to certain things or persons. For example, only a person to whom serious literature really matters is able to maintain the distinction between serious and trivial literature (30, 32). Strong commitments that constitute the person’s world and self, will thereby contain the risk of loss and disruption. The vulnerability that follows from strong commitments may cause people to shy away from getting involved as a way of avoiding risk and loss (32, 33). Rubin (34) illustrated how nurses’ inability to become engaged in the caring ends internal to nursing practice makes it difficult if not impossible to make qualitative distinctions because making such distinctions requires engaged reasoning, relationship and context. Contrary to expert nurses exhibiting excellent caring (22), a subsample of 25 nurses in this study, although experienced, could hardly remember particular patients and their specific situations. The nurses’ disengaged stance prevented meaningful distinctions between patients and even between patients’ experiences and their own. Rather, patients were stereotyped. The inability to experience patients as individuals, discovered in this subsample of study participants, hampered adequate care, as when a nurse was acting based on her untested assumptions about the patient’s feelings. Human beings are always situated or immersed in a world that provides background familiarity and meaning (25). As noted above, this opens up possibilities. However, it also means that no human being can create his or her own self completely independent of others. Persons’ identities crucially depend on their dialogical relations with others (31). Caring demonstrates how autonomy is co-created by ontological and ontic structures of care, dialogue and recognition. ‘Human beings dwell in human worlds constituted by care, relying on others and the human lifeworlds that they both constitute and are, in turn, constituted by’ (26: 354).

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The intertwining of self and world is so pervasive that it lies in the taken-for-granted background. Therefore, human beings fail to see, and thus forget, the concerns that daily suspend them in the webs of care that make up their worlds (26). Without networks of care or concern people would not know how to get around in the world or make sensible choices because they would lack the structures and emotionally valenced preferences and desires in which to ground their actions and choices. Taylor (16) underlined that a position of radical freedom of choice is untenable: The subject of radical choice is another avatar of that recurrent figure which our civilization aspires to realize, the disembodied ego, the subject who can objectify all being, including his own, and choose in radical freedom. But this promised total self-possession would in fact be the most total self-loss. (p. 35) Thus, from this phenomenological perspective, caring always involves human beings situated in a meaningful world and connected to other human beings through their significance-giving concerns. Caring actions are determined by this world and by the carers’ commitments.

Caring practices Following the above discussion, caring practices refer to activities of people, activities they get involved in because other persons matter to them. Their commitment and their location in a meaningful world set up the possibilities to engage in a practice, that is, to engage in a culturally based tradition, constituted of meaningful actions. As practitioners, people strive to achieve the practice’s standards of excellence and, thereby, realize goods internal to the practice and extend their capacities to achieve excellence as well as the practice’s standards of excellence. Caring practices can be found in the private as well as the public arena. Parenting is seen as the paradigm case for a private caring practice, whereas nursing is paradigmatic for the public sphere in Western cultures (35). Public caring practices differ in some significant ways from private caring practices. Contrary to private caring practices nursing as a public caring practice is embedded in formal education and is institutionally structured. In addition, the joys and losses involved in public caring affect practitioners to a lesser degree than private caring practices: Caring as a public practice does not have the same burdens as caring in one’s private life since the growth, vulnerability and suffering of the one cared for does not threaten or damage the personal world of the care-giver. (35: 142)

Nursing as a caring practice An articulation of nursing as a caring practice can be found in Benner and her colleagues’ work. These authors described, among other aspects, caring practices of critical care

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nurses they observed and interviewed in a large, twophased interpretive phenomenological study of critical care nursing (20, 22, 23). For instance, several domains of nursing practice were described, including the helping role, the teaching-coaching function, the diagnostic and patient-monitoring function, effective management of rapidly changing situations, and the administration and monitoring of therapeutic interventions and regimens (20). For each domain, practices were articulated through narratives and interpretations that demonstrated nurses’ caring for their patients. The helping role, among other practices, involved establishing a healing relationship, providing comfort measures, being with the patient, and maximizing the patient’s participation in his or her own recovery. A nurse, for example, cared for a concert pianist who had suffered a mild stroke, was very depressed over the weakness in her right hand, and therefore refused to go to physical therapy. The nurse sat down with her patient and listened and talked to her without mentioning physical therapy. She pointed out in detail the day-to-day progress that the patient had made in moving her arm, hand and fingers since admission. While the patient only realized what she had lost, the nurse focused on the capacities she had regained and related them to her ability to play the piano again. After this talk, the patient went to physical therapy. This nurse, truly concerned about her patient, was able to act in a meaningful way that fostered the woman’s recovery. Critical care nurses cared for patients’ families primarily in three ways: they ensured that the family could be with the patient; they provided the family with information and support and they encouraged family involvement in caregiving activities (23). For instance, recognizing families’ fear of approaching a patient after surgery, a nurse would put the siderails down, give the family permission to go close and kiss and hug the patient. In an often busy and turbulent intensive care unit, nurses had to recognize and support the families’ role in care to exhibit caring practices to families (36). These nurses cared creatively and innovatively for families, and balanced family involvement with their efforts to care for and cure the patients. Nurses who, for different reasons, uniquely focused on the patients and the technical aspects of nursing, tended to see families as obstacles and tried to distance families from their usual caregiving roles.

Conclusions Advocated in this paper is a phenomenological view of caring that addresses the ways that ontological concerns structure the person’s lifeworld and how specific ontic caregiving practices must be attuned to the person’s lifeworld, combined with the broader notion of practice as culturally based, shared activity given by Taylor (2) and MacIntyre (4). A caring practice requires phronesis and

cannot be adequately described as definite behaviours, actions, sentiments, outcomes and so forth. Rather, what is perceived as a caring practice depends on the concerns that define the person’s self and world and the caring practices required to restore the person and/or his or her lifeworld. This view of a caring practice is well suited to nursing and allows for a description of nurses’ caring from both nurses’ and patients’ perspective in a variety of contexts.

Author contribution Elisabeth Spichiger conceptualized the article, drafted and revised the manuscript. Margaret I. Wallhagen contributed substantially to the concept of the article, critically revised it for important intellectual content, and approved the final version of the manuscript. Patricia Benner contributed substantially to the concept and content of the article, critically revised it for important intellectual content and approved the final version of the manuscript.

Funding Funding of Elisabeth Spichiger’s studies from the following sources is gratefully acknowledged: The Regents Fellowship, Nursing, of the Graduate Division, University of California San Franscisco; The Non-Resident Tuition Scholarship of the University of California San Francisco; the Bernese Cancer Grant from the Bernese Cancer League; the Inselspital Bern, Switzerland; the Lindenhof Red Cross Nursing Foundation School of Registered Nursing, Bern, Switzerland.

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