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Nursing Science Quarterly

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Review of Research Related to Watson's Theory of Caring

Marlaine Smith Nurs Sci Q 2004 17: 13 DOI: 10.1177/0894318403260545

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Review of Research Related to Watson’s Theory of Caring

Marlaine Smith, RN; PhD; HNC; FAAN

Professor and Associate Dean for Academic Affairs, University of Colorado, Health Sciences Center, Denver, Colorado

Forty retrievable studies are reviewed, covering the period of 1988 to 2003, that were based on Watson’s theory of caring. The author provides an overview of the studies, identifies measurement instruments developed, critiques the body of work, and offers suggestions for future research.

Jean Watson’s theory of human caring was introduced to the nursing community in 1979 with Nursing: The Philoso- phy and Science of Caring. Since then she has published two other books (Watson, 1985, 1999) and numerous chapters and journal articles elaborating her philosophical and theoret- ical ideas. Informed by this body of work researchers sought to test the theory, expand elements of the theory, develop measurement tools, and evaluate practice models based on the theory. The purpose of this column is to review the body of research related to Watson’s theory of transpersonal caring. A comprehensive summary and an analysis of the research will be presented including strengths, weaknesses, and suggested directions for the future. Two reviews of the caring literature have been published. Swanson (1999) summarized and categorized the research re- lated to caring in nursing science and Sherwood (1997) com- pleted a meta-synthesis of the qualitative research on caring. These reviews addressed all research on caring and included studies from different theoretical perspectives and atheoreti- cal work on caring in nursing. This review is different in that it is focused only on research that has been identified explicitly as related to Watson’s theory.

Process of the Review

This review was approached by first identifying the body of research related to Watson’s theory. PubMed and CINAHL databases were searched by entering Watson’s theory of car- ing and research as key terms. Next, comprehensive bibliog- raphies, for example, the bibliography from Fawcett’s (2000) chapter on Watson’s theory and the comprehensive bibliogra- phy on Jean Watson’s web page, were explored. These lists were scanned for articles that suggested empirical research, defined as any systematic inquiry in which researchers col- lected or generated data from human subjects to answer re- search questions. Any research identified by authors as aligned with Watson’s theory was included. Examples of this

Nursing Science Quarterly, Vol. 17 No. 1, January 2004, 13-25 DOI: 10.1177/0894318403260545 © 2004 Sage Publications

alignment could be references to Watson in the theoretical framework, development of the research instrument using con- structs from the theory, or testing of a practice model based on the theory. There were over 50 doctoral dissertations and master’s theses identified in this search; however, these were not included in the review. Each relevant article was acquired, read, and analyzed according to categories in Table 1.

Overview of Studies

Forty studies were reviewed. These studies are summa- rized in Table 1 by purpose, design, participants, process for data collection/generation, and findings. The first study appeared in the literature in 1988, and the most recent study was published in 2003. The years of publication show a sus- tained trajectory of research. Three studies were published in the late 1980s, indicating an understandable gap between Watson’s original theoretical work and the beginning devel- opment of empirical work based on the theory. Thirty-two studies were published in the 1990s, with at least one pub- lished each year. Since 2000, five studies and Watson’s (2000) text on measuring outcomes of caring have been pub- lished. This body of work appears as chapters in 5 books and 22 different journals, including the highest quality research journals in nursing. Seven of the studies were completed by researchers in four countries other than the United States, confirming the international appeal of Watson’s theory. Di- verse designs and methods have been used to answer the research questions including phenomenology, quantitative descriptive surveys, and quasi-experimental designs using standardized scales and physiological measurement.

Categories of Research

An analysis of the published studies revealed four major categories of research related to Watson’s theory. These are:

(a) The nature of nurse caring; (b) nurse caring behaviors as perceived by clients and nurses; (c) human experiences and

Keywords: caring, nursing research, Watson’s theory

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Nursing Science Quarterly, 17:1, January 2004

caring needs; and (d) evaluating outcomes of caring in nurs- ing practice and education. Each will be discussed. The nature of nurse caring was investigated in nine studies. Swedish researchers Jensen, Back-Petterson, and Segesten (1993, 1996) conducted two of these studies. Findings from these studies closely correspond to Watson’s theoretical de- scription of the actual caring occasion. In a case study, Beauchamp (1993) identified themes of dignity, love, secu- rity, presence, respect, and sensitivity that closely corre- sponded to Watson’s descriptions of the essences of caring. Two studies (Clayton, 1989; Miller, Haber, & Byrne, 1992) investigated caring from patients’ and nurses’ perspectives. Swanson (1991) developed a middle-range theory of caring informed by Watson’s grand theory. Her theory was derived from three studies (Swanson-Kauffman, 1986; Swanson, 1990) on women who miscarried, caregivers in the NICU, and at-risk mothers. Finally, Wolf, Giardino, Osborne, and Ambrose (1994) identified dimensions of nurse caring through factor analysis of the Caring Behaviors Inventory. The second area of research related to Watson’s theory is nurse caring behaviors as perceived by clients or nurses. Fourteen studies clustered in this area. Cronin and Harrison’s (1988) landmark study of nurse caring behaviors as perceived by patients following a myocardial infarction became a tem- plate for others. Their Caring Behaviors Assessment Scale, based on the carative factors, was used in its original or modi- fied form in 7 of these 14 studies (Baldursdottir & Jonsdottir, 2002; Cronin & Harrison, 1988; Huggins, Gandy, & Kohut, 1993; Marini, 1999; Mullins, 1996; Parsons, Kee, & Gray, 1993; Schultz, Bridgham, Smith, & Higgins, 1998). Other studies used another instrument or interview (Lemmer, 1991; McNamara, 1995; Nyberg, 1990; Rosenthal, 1992; Ryan, 1992; Smith & Sullivan, 1997). This body of inquiry included participants from a variety of acute care settings. Items that were rated highly as nurse caring behaviors by recipients of care across studies were: knowing what they are doing, know- ing when it is necessary to call the doctor, knowing how to give shots and intravenous therapy, knowing how to handle equipment, knowing how to handle life-threatening changes, giving treatments and medications on time, and providing good physical care. Nurses who were surveyed seemed to take the items related to competence and technical activities more for granted, in that they rated nurse caring behaviors such as viewing the patient as unique, being with the patient, listening to the patient, laughing and crying with the patient, honoring the dignity of the person, and touching as the most important caring behaviors. This seems to suggest that nurses do not include competence with medical and technical skills in the realm of nurse caring behaviors as recipients of care do, especially those in life-threatening situations. Human experiences and caring needs is the third area of research related to Watson’s theory. Seven studies were in this category and included lived experiences of growing up with cystic fibrosis (Tracy, 1997), living in a nursing home (Running, 1997), a caring occasion for depressed women

(Mullaney, 2000), living with adult polycystic kidney disease (Martin, 1991), the caring needs of caregivers of newly dis- abled adults (Weeks, 1995), people with rheumatoid arthritis (Nyman & Lutzen, 1999), and spouses caring for their dying loved one (Andershed & Ternestedt, 1999). In all but one of these studies researchers sought descriptions of experiences and needs through interviews, and themes were constructed from the qualitative data. Because each study is so different, it is difficult to identify commonalities. Themes are: the recog- nition of the importance of subjective experience and under- standing the other through listening to their stories; a focus on the inherent wholeness of the person, rather than the label of disease or disability; and the search for meaning in the un- certainty of these experiences. The final area of research related to Watson’s theory is evaluating caring practices or curricula. There were 11 stud- ies in this area. Six (Leenerts, Koehler, & Neil, 1996; Neil & Schroeder, 1993; Schroeder, 1993a, 1993b; Schroeder & Maeve, 1992; Smith, 1997) evaluated the Denver Nursing Project in Human Caring including the nursing care partner- ship model, a care management model based on Watson’s theory. The evaluation revealed that nurses appreciated the model because it was growth-producing and challenging, facilitated teaching and learning, and enhanced ability to sup- port each other and coordinate care. Nursing documentation changed, referring more consistently to carative factors. Sur- veys showed that nurse care partnerships were viewed as sup- portive and helpful by the clients. Focus group interviews revealed endorsements related to caring behaviors, support groups/peer support, treatments, the non-clinical environ- ment and education/information. Two evaluation studies were reviewed. In an evaluation of a curriculum for practicing nurses based on Watson’s theory, nurses reported being more intentionally present in brief encounters and expressed sat- isfaction that skills were enhanced (Updike, Cleveland, & Nyberg, 2000). An evaluation of a caring curriculum using a newly-developed Caring Efficacy Scale (Coates, 1997) re- vealed significant correlations between graduates’ ratings of caring efficacy and preceptor’s ratings of competence, and alumni ratings of caring efficacy and clinical competence. This suggests the integration of caring and competence in nursing practice. Three studies examined the relationship be- tween caring practices and outcomes. Duffy (1992) found a positive relationship between nurse caring and patient satis- faction. In a Watson study of health-related outcomes, Smith, Kemp, Hemphill, and Vojir (2002) examined the effect of massage and nurse interaction on pain, symptom distress, sleep quality, and anxiety for patients with cancer. Massage was framed as an ontological competency or nursing art-act. Anxiety improved for those in both groups supporting the theory that nursing presence in any form may lessen anxiety. The decrease in pain and symptom distress could be attrib- uted to massage. In the second study, patients with hyperten- sion who were treated by nurses practicing from a Watson theory-based practice model had a significant decrease in sys-

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Research Issues

15

tolic and diastolic blood pressure and greater general well- being (Erci et al., 2003). While the study design is flawed because of the lack of a control group, it is an important turn in the research related to Watson’s theory. Both of these studies attempt to link healing outcomes with caring.

Measurement Instruments

Watson’s (2002) text describes measurement issues in car- ing science and the existing instruments that measure caring. Five of those measurement tools are based on Watson’s the- ory. These were: (a) the Caring Behavior Inventory and re- vised Caring Behavior Inventory (Wolf et al., 1994); (b) the Caring Behavior Assessment Tool (Cronin & Harrison, 1988); (c) the Nyberg Caring Attribute Scale (Nyberg, 1990); (d) the Caring Assessment Tool (Duffy, 1992); and (e) the Caring Efficacy Scale (Coates, 1997). For details see Watson

(2002).

Strengths, Weaknesses, and Directions for Future Research

Through this analysis strengths, weaknesses, and direc- tions for future research related to Watson’s theory have been identified. One notable strength is the sustained level of work with the theory since the late 1980s until now. Another is the level of international interest in research related to Watson’s theory. Together, these confirm the pragmatic value of the theory, that is, its ability to spawn avenues of inquiry, its pro- vocative value in generating widespread interest, and its transcultural appeal. The diversity of the designs and methods used to answer research questions is another strength. The on- tological and epistemological foundations of the theory allow for a research tradition that encompasses a variety of ap- proaches to inquiry. The phenomena that have been studied are varied; most focus on the caring relationship. The qualita- tive work describing the experience of caring has produced empirical support for Watson’s theoretical ideas. In addition, the development of Swanson’s middle-range theory confirms the evolution of the theory through empirical work. There has been an ongoing and in-depth pattern of inquiry into the per- ceptions of caring behaviors by varied recipients of care; this research has yielded rather consistent findings that can in- form practice. In these studies care recipients and nurses have been asked to rate the most important nurse caring behaviors. The incongruence between their perceptions may be ex- plained through the dialectic of medico-technological com- petence and the transpersonal dimensions of caring. Incom- petent practice cannot be perceived as caring in any situation. On the other hand, the highest levels of medico-technological competence do not necessarily reflect transpersonal caring. It is important to note that these studies do not say that care re- cipients accept a lack of caring. It only asks them to prioritize caring behaviors. In life threatening situations, behaviors viewed as sustaining life surface as most important. Nurses, however, assume the importance of competence, and describe

something more and different as caring. Caring is a way of being in which the nurse attends to the person in those ways necessary to support health, healing, and quality of life. In some situations this calls for a high degree of technical skills; in others it may not. So technological competence is inte- grated into caring in some nursing roles. Another strength of this research is the recent focus on the relationship between caring and healing through evaluation of theory-guided prac- tice models and the ontological competencies of Watson’s theory. These studies will be part of the next generation of research stemming from Watson’s most recent theoretical work. In tandem, Watson’s (2002) book on the fit of mea- surement with the theory, including a compendium of in- struments that measure caring is a great contribution to caring science in general, and her own theory in particular. There are several weaknesses in this body of research. First, the research is lagging behind Watson’s most recent theoretical work. This is expected; however, it can create some confusion. Watson’s theory has evolved significantly, and inquiry related to her early work on the carative factors was in process as her theoretical thinking moved toward a more unitary-transformative worldview. Another weakness is that many of the published studies have weak theoretical- empirical linkages, that is, the relationship of the findings to the theory are not explicit. In this way the findings are less able to extend, expand, or modify theoretical assertions. The qualitative studies on lived experiences are so heterogeneous that it is difficult to discern the connection to Watson’s theory. Qualitative work expanding an understanding of relational phenomena and their connection to healing would be more relevant to Watson’s theory. The future of research within Watson’s theory is very promising. International interest in her theory is growing; several theory-guided practice models have been developed and are being evaluated; and there is growing interest in the phenomenon of caring-healing relationships. A recent paper (Quinn, Smith, Ritenbaugh, Swanson, & Watson, 2003) con- tained a summary of research guidelines for assessing the impact of the caring-healing relationship in nursing. These guidelines can be applied to future research related to Watson’s theory. Important research questions are yet to be answered, for example,

What are the particular qualities of relationship that facilitate healing? What part does intentionality and energy play in the caring-healing relationship? What are appropriate indicators of healing, particularly healing that doesn’t include curing, and what are appropriate measures of these indicators? (Quinn et al., 2003, p. 2A)

What difference do caring relationships make in the lives of those we care for? What are the qualities of environments and communities that are considered to be caring? Other guide- lines developed in this paper may guide future research. “Re- search methods need to reflect the nature of the caring- healing relationship” (Quinn et al., 2003, p. 6A). With this principle in mind both members of the relationship should

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Nursing Science Quarterly, 17:1, January 2004

participate in studies of the meaning or impact of the relation- ship. “Multiple ways of knowing are required to explore the full range of multidimensional questions raised about the healing relationship” (Quinn et al., 2003, p. 7A). A model of research that integrates multiple perspectives and ways of knowing is a preferred epistemological model for studying the caring-healing relationship.

Watson’s theory of transpersonal caring and the empirical work related to it have made a significant and lasting impact on nursing science. Future research is promising in address- ing important questions about the relationship of caring, health, and healing. Researchers are encouraged to build on the strengths of the past and address the current gaps as they chart a path toward greater understanding of caring.

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(continued)

Three main categories: To know, to be, and to do. Spouses were:1) seekers of knowl- edge through their loved one, the staff, and others; 2) present to their loved one and in his or her world; acting as the con- tact person for their loved one. Findings were consistent with caring relationships in Watson’s theory, that is, presence, hu- manistic-altruistic systems of values, and assisting patients to meet basic human needs while preserving dignity and wholeness. Most important nurse caring behaviors were: know what they are doing; know when it is necessary to call the doctor; know how to give shots; IVs, etc.; and know how to handle equipment. The subscale human needs assistance was ranked highest. Themes of dignity, love, security, presence, respect, and sensitivity emerged as themes. Four recurring themes were identified by nurses and patients: 1) heightened sensi- tivity to their feelings before and after the caring interaction; 2) existence of a relationship; 3) environ -helping-trusting ment that was supportive, protective, and permissive; 4) appreciation of existential predicament and need to find meaning. needed protection and independ -Elders ence, to share life events, and to know how they were doing daily. There were significant correlations between graduates’ ratings of caring efficacy and competence. There were no sig -clinical nificant correlations between graduates’ ratings of caring efficacy and preceptors’ ratings of competence and graduates’ and ratings of competence. Em -preceptors’ ployer and alumni ratings of competence significantly related and alumni rat -are ings of their own caring and clinical competence are significantly related.

Findings

Observations in care settings; 15 interviews and 23 informal conversations during final period of life and 1-3 months following death

Caring Behaviors Assessment Tool. Surveys mailed 2 weeks post discharge from ED.

Students and alumni received the Caring Efficacy Scale and preceptors of students and employers of alumni received the Clinical Evaluation Tool which assesses caring competence.

Continuing interviews with per- son and others significant to his life. Elders described an experience with a nurse that stood out as “peak” or “highlight” expe -a rience. Met 4-6 times.

Form of and Processes for Collecting or Generating Data

Table 1 Studies Related to Watson’s Theory of Human Caring

programs and 63 pre -ence ceptors of students and 113 employers of nursing alumni completed the long or short form of the Caring Efficacy Scale.

bachelor of science, nursing and master of sci -doctorate,

Four elder-nurse dyads. The elders were over 65 and residents of a nursing home.

patients in the ED; non- probability convenience sample; 62% response rate

6 spouses of persons with grave, incurable cancer of colon, liver, or bile duct

students, 119 alumni of

One person with HIV/AIDS and those involved in his lifeworld

Participants (population and number)

people who had been

110

182

of evaluation of educa -Part tional effectiveness for program accreditation; quantitative survey; correlational analysis

Descriptive qualitative sin- gle case study

Qualitative descriptive us- ing Glaser and Strauss’s constant comparative method of data analysis

Quantitative descriptive

Design and Methods

Grounded theory and phenomenological interviews

survey

To understand the phenomenon of caring and how a dissonant situation evolved into one of harmony. To investigate the phenomenon of transpersonal caring interactions between individuals and nurses; and to de -elderly the caring needs of the institu -termine tionalized elderly.

To identify and categorize family members’ involvement in the care of a dying rela- tive and to examine findings in light of Watson’s and Swanson’s theories.

lidity of the self-report and supervisors’ version of the Caring Efficacy Scale.

To determine the initial reliability and va -Coates

To identify which nurse caring behaviors are perceived by patients in an emer- gency department (ED) as important indicators of caring.

Aims or Research Question(s)

Ternestedt (1999)

Jonsdottir (2002)

Author(s) and Year of Publication

Beauchamp (1993)

Baldursdottir &

Clayton (1989)

(1997)

Andershed &

17

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Patients assigned the highest percentages of “must be present” to the following: know how to handle sudden, life threatening changes; know what they are doing; know how to give shots, start IVs, know how to give treatments, tests or meds; know how to handle equipment; and know when to call the doctor to see you. green thumb nurse has three character -The istics: competence, compassion, and courage. Caring moment equals mutual attention, harmony, trust, and time stopping. Four main characteristics of an excellent nurse emerged: competence, compassion, courage, and concordance. Nursing care partnerships reduced healthcare costs. Savings in potential hospital costs were estimated at

Nursing actions related to presence, compe- tence, physical care, monitoring, teach- ing and kindness were top-rated. Positive relationship between nurse caring and patient satisfaction (r = .46, p < .001); no relationship between nurse car- ing and perceived health, length of stay, and costs. There were statistically significant differ- ences between pre and posttest mean scores of general well-being, physical symptoms and activity, medical interac- tion, and systolic and diastolic blood pressure.

Findings

$1,590,384.

Interviews using an open-ended question and the Caring Be- haviors Assessment tool Patients completed Caring As- sessment Tool, Patient Satis- faction visual analogue scale, Sickness Impact Profile, and Medicus Classification Tool Nurses educated in a theory- guided practice model based on Watson’s theory visited patients and their families once a week in their homes for three months. Blood pres- sure and quality of life were outcomes. Interviews within 30 days of discharge; Modified Caring Behavior Assessment Scale; satisfaction with care; and evaluation of their medical condition

Nurses were asked to describe characteristics of caring and to describe a car -nurses ing moment.

Qualitative surveys, interviews

described characteris -Women tics of an excellent nurse.

Form of and Processes for Collecting or Generating Data

women who had breast can -10 cer surgery and treatment

86 patients with a medical/sur-

75 clients at a nurse-managed center for those with HIV/ AIDS

patients with hypertension in four healthcare units in Turkey

transitional care units who had myocardial infarctions

nurses identified by their as having a spe -managers cial talent in caring for people.

gical diagnosis, randomly selected

288 ambulatory patients in the ED; 81 pa -treated were seeking emer -tients gent care, 99 urgent care, and 108 non-urgent care.

Participants (population and number)

hospitalized patients in

Table 1 (continued)

52

22

16

Quantitative and qualitative descriptive

Descriptive correlational

Quantitative descriptive

One group pre-test and post-test quasi- experimental design

Design and Methods

Qualitative descriptive

Qualitative descriptive

exploratory

exploratory

Descriptive

To identify which behaviors performed by department nurses were per -emergency ceived by patients as important indicators of caring.

To describe essential characteristics of an excellent nurse as perceived by women with breast cancer. To identify and describe clients’ perceptions of care at the Denver Nursing Project in Caring; and to explore cost-effec -Human tiveness of the nursing care partnership model.

To determine the effectiveness of a nurse’s caring relationship according to Watson’s caring model on the blood pressure and the quality of life of patients with hypertension.

To identify nursing behaviors perceived as indicators of caring by patients who have had a myocardial infarction. To measure the relationships between nurse caring behaviors and patient satisfaction, health status, length of stay and nursing care costs.

To identify and describe the characteristics of green-thumb nurses and of caring situations.

Aims or Research Question(s)

Author(s) and Year of Publication

Huggins, Gandy, & Kohut (1993)

Cronin & Harrison

Jensen, Back- Pettersson, & Segesten (1996) Leenerts, Koehler, & Neil (1996)

Segesten (1993)

Erci et al. (2003)

Pettersson, &

Jensen, Back-

Duffy (1992)

(1988)

18

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(continued)

Two major categories of caring by nurses and physicians were: Taking care of and caring for and about. Taking care of in- cluded activities that were designed to meet physiological and safety needs and subcategories were providing expert care and providing information. Caring for or about included those activities demon- strating a sensitivity to and an empathic awareness of the emotional pain of be- reavement and a desire to help them through it. The highest indicator of nurse caring fo- cused on the nurses’ technical competen- cies or instrumental activities. Humanis- tic caring or expressive activities was the second most important indicator of care and included being treated as an individ- ual; with respect; keeping family in- formed of progress; and not giving up on a person when difficult. Four major themes were: knowledge about APKD; attitudes toward APKD; attitudes toward genetic testing; and family plan- ning decisions. These were related to Watson’ s theory. Themes related to caring practices and be- haviors during the preoperative, intraoperative, and postoperative phases identified. Themes included: view -were patients as unique human beings; be -ing ing with patients; using touch. Themes were: holistic understanding, humanness, pres -connectedness/shared ence, anticipating and monitoring needs, beyond the mechanical. An exhaus -and description of the caring nurse-pa -tive tient interaction was developed. themes were: feeling understood; feel -Five ing like there was a way out, regaining an empathetic perspective toward self and other; expressing negative feelings that enable self-acceptance; feeling better and to engage in effective problem-solv -able and health lifeways. Themes were re -ing lated to carative factors.

Therapists’ notes of the clients’ verbalizations and behavioral responses.

Participants completed the Car- ing Behavior Assessment.

Response to: “Tell me about a nurse-patient interac -caring tion you have experienced or in which you provided caring.”

Participants were interviewed using a general interview guide. Interviews were taped and transcribed.

30-60 minute interviews using open-ended questions

Interviews using a semi-struc- tured guide

92 people with adult polycystic kidney disease

15 patients and 16 nurses from 3 adult medical-surgical units

28 participants who were cou- ples who had experienced a third trimester stillbirth or a neonatal death. The loss oc- curred no earlier than 3 weeks and no later than within 14 months of the interview.

21 residents of long-term care or assisted living facilities

women diagnosed with de -11 pression who met with a therapist over a 6 month period.

Five nurses who worked in a perioperative setting.

Qualitative descriptive ex- ploratory with grounded theory methods

Phenomenological (Spiegelberg’s method)

Phenomenological study

Quantitative descriptive

Qualitative descriptive

Qualitative descriptive

To identify which behaviors performed by nursing staff were important indicators of caring as perceived by older adults resid- ing in institutional settings.

understand the lived experience of a car -To ing nurse-patient interaction from the perspective of nurses and hospitalized patients.

What do bereaved parents perceive as ex- pressions of caring by nurses and physi- cians during perinatal bereavement?

To describe the essential structure of the lived experience of depressed women enter therapy and experience Wat -who son’s actual caring occasion within the transpersonal caring relationship.

To understand the experiences of persons with adult polycystic kidney disease (APKD).

To determine how caring is practiced in perioperative nursing.

McNamara (1995)

Mullaney (2000)

Miller, Haber, & Byrne (1992)

Lemmer (1991)

Marini (1999)

Martin (1991)

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The highest rated items were: treat me as an individual, know what they’re doing, know how to give shots, IVs, etc., make me feel someone is there if I need them, treat me with respect, know when it’s necessary to call the doctor, know how to handle equipment, do what they say they’ll do; accept me the way I am, ac- cept my feelings without judgment and give treatments and medications on time. Clients endorsements of the Center were re- lated to: caring behaviors, support groups/peer support, treatments, non- clinical environment, and education/in- formation. Areas for improvement were suggested. Economics and providing human care are interrelated forces. Nurses value and un- derstand human care as paying tribute to the dignity of the person, laughing and crying with patients, reaching out human to human, unconditional positive regard, dealing with the whole person, and being concerned with the betterment of the other. Themes were: seeking help, searching for and uncertainty, and fear of be -meaning ing disappointed.

responses to interview item asking par -Top ticipants to identify nursing behaviors perceived as caring were: reassuring presence, verbal reassurance, attention to physical comfort, teamwork, provision of

ior Assessment were: know what they are

condition closely, make me feel someone

responses to the Caring Behav -frequent

there if I need them, do what they say

doing, be kind, considerate, treat me as

they will do, and answer my questions

relaxed, quiet atmosphere. The most

an individual, reassure me, check my

Findings

clearly.

is

a

Interviews during acupuncture using a conversation guide based on Watson’s carative factors. Interview item and a revised Caring Behavior Assessment

Participants completed the Car- ing Behaviors Assessment

Eight focus group sessions and videotaped interviews with clients and significant others

Questionnaires and interviews of nurse executives; Nyberg Caring Assessment Scale used.

Form of and Processes for Collecting or Generating Data

135 nurses who were randomly selected from 7 hospitals; 7 nurse executives

6 women diagnosed with RA

adults who had outpatient surgery

46 adults with a diagnosis of AIDS or HIV

clients of the Center and their significant others

Participants (population and number)

Table 1 (continued)

19

51

Qualitative descriptive eval- uation study

Quantitative and qualitative descriptive

Quantitative descriptive

Design and Methods

Qualitative descriptive

Descriptive survey

To evaluate client experiences at the Denver Nursing Project in Human Caring

To identify the caring needs specific to the human experience of having rheumatoid (RA) and undergoing acupunc -arthritis ture treatment. To identify perioperative nurse behaviors perceived as caring by selected surgical patients, and to determine if any were perceived as more important than others.

To identify nurse caring behaviors desired by patients with AIDS or HIV.

To explore nurses’ reactions to the eco- nomic changes in the hospital environment.

Aims or Research Question(s)

Author(s) and Year of Publication

Neil & Schroeder

Nyman & Lutzen

Parsons, Kee, & Gray (1993)

Mullins (1996)

Nyberg (1990)

(1999)

(1993)

20

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(continued)

Patients perceived the following as the most important nurse caring behaviors: knows how to give shots and IVs and how to manage the equipment; gives treatments and medications on time; knows when to call the physician; tells the patient, in un- derstandable language what is important to know about disease and treatment; gives good physical care. Nurses per- ceived the following as the most impor- tant nurse caring behaviors: listens to the patient, knows when to call the physi- cian, allows patient to express feelings, gives good physical care, touches when patient needs comforting. Glimpses of experiences were presented as findings. The researcher and participants identified the most significant pieces of their stories. The most helpful nursing behaviors identi- fied by caregivers were a mixture of pa- tient physical and psychosocial needs and caregiver psychosocial needs. The top priorities were: listen to the patient, provide patient with necessary emer- gency measures, assure caregiver that nursing services were available 24/7, an- swer patient questions and talk to the pa- tient to reduce fears. Similarly hospice nurses identified most helpful nursing behaviors as a mixture of physical, psychosocial (patient), and psychosocial (caregiver). Researcher concluded that the Center saved more that $700,000 in 1991 and over $1 million in 1992.

Q-sort method; 60 nursing be- haviors were sorted from least to most helpful and catego- rized as physical, patient psychosocial, and caregiver psychosocial needs.

Larson’s nurse caring behaviors (CARE-Q) were rank-ordered by the Q-sort method.

analysis based on estima -Cost tion of prevented hospital stays, shortened length of stay, delivery of medical treatment in the center and care at home. Pa -supportive tients completed quantitative and qualitative descriptive surveys.

Interviews or visits over a 7 month period (at least 5 visits).

patients in 1991; 340 pa -240 in 1992 for cost analy -tients sis; 30 clients completed survey and 31 com -1992 pleted 1993 survey.

6 residents of a nursing home

30 coronary care patients and 30 coronary care nurses

20 caregivers of hospice pa- tients during the bereave- ment period and 5 hospice nurses

Qualitative descriptive (visit as method)

studies based on pa -Cost tient data and evaluation research from three studies.

Quantitative descriptive

Quantitative descriptive

To examine and describe the experience of living in a nursing home.

To determine those nursing behaviors per- ceived as most helpful and least helpful by primary caregivers and by hospice nurses in a home-care hospice setting.

present analyses of the cost-effective -To of care at the Denver Nursing Pro -ness ject in Human Caring.

To examine the relationship of patient- perceived and nurse-perceived caring behaviors.

Schroeder (1993a,

Rosenthal (1992)

Running (1997)

Ryan (1992)

1993b)

21

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Four major themes were: seeing the unique -Focus

ness and wholeness of the person-family; coming home; discovering a personal path for healing; and feeling the energy of love and compassion.

Nurses in focus groups found NCP to be growth producing and challenging, knowledge was more easily transferred, and nurses were better able to support each other and coordinate services. 75% of the charts contained narrative interview notes; 40% of the charts referred to Wat- son’s carative factors. The survey showed that the NCP was viewed as supportive and helpful; 90% agreed that it helped them to better negotiate the system and 92% agreed that a NCP helped them to understand their plan of treatment. They most liked “having an advocate,” “the ability to translate what is happening,” and “using nursing help rather than hos- pital facilities,” “emotional support, hon- esty and a caring attitude.” The highest valued caring behaviors were:

when to call doctor, trust with re -know spect, know what they are doing, answer clearly and treat me as an indi -questions These were a combination of hu -vidual. man needs, humanistic, and teaching learning. Mean scores for pain, symptom distress, and anxiety improved from baseline for those who received therapeutic massage; only anxiety improved from baseline for participants in the comparison group. Statistically significant interactions were found for pain, symptom distress, and sleep.

Findings

20 patients received therapeutic and 21 received ther -massage apeutic nurse presence (three times in a one week period). Scales completed at baseline and at one week.

Focus groups, random chart re- view of narrative documenta- tion, and an evaluation sur- vey, nurse and client stories of their experiences in the nursing care partnership pro- gram (NCP)

Caring Behavior Assessment completed between the 7th and 9th day of the inpatient stay for antepartum patients and at discharge for postpartum patients

Form of and Processes for Collecting or Generating Data

group

Number of nurses in focus groups was not provided; re- view of 20 randomly se- lected records; 29 patients in the NCP returned surveys

patients admitted to the on -41 cology unit for radiation or chemotherapy

42 antepartum and short-stay postpartum patients

descriptive Five people who use the ser -Qualitative vices of the Caring Center

Participants (population and number)

Table 1 (continued)

Quasi-experimental; two group pre-post test design

Quantitative descriptive

Design and Methods

Qualitative descriptive

survey

To describe the experiences of clients of the Nursing Project in Human Car -Denver ing, a nurse-managed center based on Watson’s theory.

examine the effects of therapeutic mas -To sage on perception of pain, subjective quality, symptom distress, and anx -sleep iety in patients hospitalized for treatment of cancer.

To describe and compare the similarities differences in the perception of car -and ing behaviors between antepartum and short-stay postpartum patients.

To present the results of evaluation of the care partnership relationship.

Aims or Research Question(s)

Schultz, Bridgham, Smith, & Higgins

Schroeder & Maeve

Author(s) and Year of Publication

Hemphill, &

Vojir (2002)

Smith, Kemp,

Smith (1997)

(1998)

(1992)

22

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Patient rankings of the most important car- ing behaviors were: puts patient first, knows how to give shots, start IVs and manage equipment, gives good physical care, knows when to call physician, and is honest. Nurse rankings of the most im- portant caring behaviors were: listens to patient, gives a quick response to pa- tient’s call, knows when to call physi- cian, knows how to give shots, start IVs and manage equipment, and gives good physical care. Five themes of caring were: knowing, being with, doing for, enabling, and maintain- ing belief. Sub-processes were developed. Three overall themes were: being different, “don’t call me terminal”, and will power and faith. Findings were the evaluation of the mod- ules by the participants. Two case studies illustrated the use of massage, acupres- sure and relaxation. “nurses expressed that their presence with the children and families changed toward becoming more intentionally present during the brief en- counters that were possible. They espe- cially expressed satisfaction that their skills were enhanced with specific mo- dalities and that this supported their view of themselves as healers” (p. 108). top rated educational wants were: nor -The the daily routine, ensure that as -malize sistance is available, evaluate the strengths and capabilities of the disabled adult, supervise or carry out prescribed and anticipate needs for fu -treatments, ture assistance. Five dimensions were: respectful deference the other; assurance of human pres -to positive connectedness; profes -ence; sional knowledge and skill; and attention to other’s experience

Nyberg Caring Assessment Scale and the Organizational Context Survey; pre and post implementation focus groups; written evaluations completed by nurse participants; a cur- riculum was offered to nurses over a 6 month period; onsite support was provided; docu- mentation in notes, end of shift reports, and acuity reports Educational Wants of Family Caregivers of Disabled Adults Questionnaire

Care-Q instrument was com- pleted by participants from one nursing unit.

Caring Behaviors Inventory

Interviews and participant observations

Interviews

14 nursing home residents and 15 registered nurses

Study I: 20 women who mis- carried; Study II: 19 care- givers in the NICU; Study III: 8 at-risk mothers 10 adults who were diagnosed with cystic fibrosis at birth or in early infancy 25 nurses on the hematology- oncology unit

278 nurses and 263 patients and former patients

descriptive 83 prospective family care -Quantitative givers of newly disabled adults

Exploratory factor analysis with varimax rotation

Quasi-experimental design (pre-post); quantitative and qualitative methods

Quantitative descriptive

Phenomenological

Phenomenological

To develop and test a curriculum focused on complementary healing modalities (CHMs) and to evaluate the effectiveness of the program toward expanding profes- sional nurses’ knowledge and clinical skills in caring-healing concepts and practices and increasing nurses’ satisfac- tion with expanded clinical practice; inte- grating CHMs into the care of children hospitalized on the hematology-oncology and improving organizational sup -unit; port for CHMs.

To identify the caring behaviors that profes- sional nurses and nursing home patients perceived to be most important in feeling cared for.

To describe the lived experience of growing up with cystic fibrosis.

To describe the dimensions of nurse caring.

family caregivers of newly dis -spective abled adults anticipating discharge to home from rehabilitation.

To describe the educational wants of pro -Weeks

To describe the findings of three studies leading to development of a middle- range theory of caring.

Updike, Cleveland, & Nyberg (2000)

Ambrose (1994)

Smith & Sullivan

Swanson (1991)

Wolf, Giardino,

Osborne, &

(1995)

Tracy (1997)

(1997)

23

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24

Nursing Science Quarterly, 17:1, January 2004

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