The Moral Construct of Caring in Nursing as Communicative Action: Foundational Elements and
Applications
Zane Robinson Wolf, PhD, RN, FAAN, Denise Nagle Bailey, EdD, MEd, MSN, CSN, RN, La Salle University
Abstract
This continuing education article analyzes Sumners theory, the moral construct of caring in
nursing as communicative action. The dissemination of the theory includes the development of
an instrument, its application to nursing administration, and its promise for use in patient care
situations. It serves as a framework for nurses providing direct care to patients to reexamine the
nursepatient relationship.
Keywords: moral construct, caring, nursing
communicative action, theory
Goal: This continuing education article
examines the theory of the moral construct of
caring in nursing as communicative action
proposed by Sumner. It reviews its structures and
progress as a caring theory and facilitates
understanding nursepatient relationships.
Objectives:
1. Explain the roots of the theory of the moral
construct of caring in nursing as
communicative action.
2. Analyze the major concepts forming the
moral construct of caring in nursing as
communicative action theory.
3. Explore the contributions of the moral
construct of caring in nursing as
communicative action theory to caring
theory development.
4. Evaluate interventions for nursing staff
when applying the moral construct of
caring in nursing as communicative action
theory to nurses work environments.
5. Identify strategies for nursing education
programs and programs of nursing
research that facilitate the implementation
of moral construct of caring in nursing as
communicative action theory.
Introduction
The interest of Jane Finlay Sumner, PhD, RN,
APRN, BC in the nursepatient relationship
began early in her career in New Zealand and
has been sustained for decades. Born a Kiwi
(New Zealander), Dr. Sumner has practiced
nursing on three continents, earning a diploma in
nursing from Hutt Hospital School of Nursing,
New Zealand; a BS in nursing from Eastern
College, Pennsylvania; the master of nursing from
Louisiana State University Health Sciences
Center (LSUHSC) School of Nursing; and the
PhD in educational leadership from the University
of New Orleans. Dr. Sumner, PhD, RN, APRN,
BC, ANEF is currently professor emerita of
nursing at LSUHSC School of Nursing in New
Orleans, where she continues to teach virtually
and face to face. She has also resided in the
United Kingdom and has traveled extensively
(Jane Sumner Collection, n.d.). Dr. Sumner
divides her time between New Orleans, LA, and
Vermont.
Dr. Sumner began her clinical practice as a
tutor sister in the Wellington Hospital School of
Nursing Diploma Program, New Zealand. She
held staff nurse positions in London, U.K., and in
the Visiting Nurse Association/Home Health
Service (VNA/HHS) in Norristown, PA. Her
community nursing practice also included hospice
care, and she became director of the Hospice
VNA/HHS in Norristown. Administrative clinical
positions followed, including in Metarie, LA, when
she moved to New Orleans (Jane Sumner
Collection, n.d.).
The practice of community health and hospice
nursing has enriched Dr. Sumners teaching of
public and community health nursing theory and
advanced nursing concepts. In 1993, Dr. Sumner
joined the faculty of the School of Nursing at
LSUHSC. Dr. Sumner has held various
administrative positions in the school and has
taught bachelors, masters, and doctoral nursing
students (Jane Sumner collection, n.d.).
Dr. Sumner is certified in public health/
community health nursing. Her publications
consist of articles, chapters, a book, and a
number of abstracts presented at regional,
national, and international conferences. They
evidence the pursuit, development, and evolution
of a nurse caring theory. Additionally, her
commitment to the explication of bidirectional
nurse caring continues. Dr. Sumner has
supported the mission of the International
Association for Human Caring (IAHC) as a
member and a conference convener and planner
of the 2015 IAHC conference in New Orleans.
Sumners interest in hospice nursing was
revealed in her masters thesis, The Relationship
Between Spiritual Well-Being of the Terminally Ill
Cancer Patient and Perceived Nurse Empathy
(Sumner, 1993). Hospice patients (n 10) with a
diagnosis of terminal cancer completed the
Spiritual Well-Being Scale (Paloutzian & Ellison,
1982) and Perception of Empathy Inventory
(Wheeler, 1988). Sumner noted the importance of
nurses empathy to patients achieving spiritual
well-being, making choices, and finding their way
at the end of life. She assumed that hospice
patients would respond to empathetic nurses.
When discussing nurse empathy, Sumner
suggested that dying patients need caring and
acceptance, and also explored the nursepatient
relationship whereby caring helps patients heal
during caring occasions. Some statements in the
Perception of Empathy Inventory were positively
correlated and statistically significant; for
example, the nurse identified with the patient,
accepted the patient as he/she was, and
comforted the patient. The small sample size
limited acceptance of the findings.
The thesis (Sumner, 1993) included important
citations on nurse caring, Watson (1988) and
Brown (1986), revealing a focus on interpersonal
communication. Additionally, aspects of nurse
empathy were examined, including intrapsychic,
interpersonal, and biological. Empathy was
analyzed as moral empathy (compassion and
concern for the welfare of others), emotive
empathy (ability to subjectively perceive another
persons intrinsic feelings), cognitive empathy
(intellectual ability to understand anothers
perspective), and behavioral empathy (ability to
communicate empathic understanding verbally
and nonverbally; Sumner, 1993).
Theoretical Origins
Foundational Views
Dr. Sumner induced a nurse caring theory. Her
foundational views on the moral construct of
caring in nursing as communicative action theory
(MCCNCAT) (Table 1) follow:
Caring in nursing as bi-direction[al]
communication has long been of interest to
me. I knew that I was getting something very
powerful back from my patients and that as
a nurse I had thoughts and feelings about
what was going on between in the
interaction. This probably grows out of my
hospice nursing, but from my earliest
nursing training I wondered why some
patients got overlooked or ignored on the
ward, was it the fact that they were dying or
were miserable with uncontrolled pain or that
they were so unpleasant the nurses wanted
to spend as little time as possible with those
patients. I have also long known how much I
have received back from my patients, and
they have made me feel so special as a
nurse. I learned that the dialogue is both
verbal and nonverbal and in some ways the
latter may be the most important because it
is frequently unconscious, but also the tasks
and skills of nursing are an integral part of
communication which is flowing both ways.
(Jane Sumner Collection, n.d.)
She further clarified the underpinnings of the
MCCNCAT:
2016, Vol. 20, No. 2 107
The Moral Construct of Caring in Nursing as Communicative Action: Foundational Elements and Applications

Table 1
Terms and Definitions in MCCNCAT
Term Definition Citation
Bidirectional Communication flows two ways, in both directions whereby the needs Sumner (2008x)
of both nurse and patient are met

Personal self, nurse and patient Intrasubjective; includes every aspect of the individual, including Sumner (2001, 2008x, 2010b)
emotion and reason, and physical, spiritual, and social elements Sumner & Fisher (2008)
(forestructures of understanding)
Intersubjective; includes exposure when the personal self interacts

Professional self, nurse Factual or theoretical, practical, and experiential knowledge Sumner (2001, 2010a, 2010b)

Illness self, patient Diagnosis, coping mechanisms, and family supports Sumner (2001)

Considerateness, need of nurse Vulnerability of persons in communication or discourse revealed in Sumner (2001, 2008x, 2010b)
and patient in communication interaction and represented as a need; consideration for self and Sumner & Fisher (2008)
others does not emerge all at once, fully formed, and varies along the
continuum of moral maturity

Fact, for nurse Scientific knowledge underpinning nursing: understanding disease, the Sumner (2001)
bodys response, and the treatment

Fact, for patient Understanding the need to seek nursing service, and the conscious Sumner (2001)
ceding control of the health/illness needs to the nurse

Spirit Introspective or egocentric self and outwardly focused attitude and Sumner (2002)
enthusiasm

Openness Bidirectional interaction that is flexible, changeable, and has constancy Sumner (2002)

Egalitarianism Equality between the two humans in interaction but not necessarily the Sumner (2001, 2002)
specific roles
Fairness; the norm of discourse; achieved through honesty, mutual
sharing, listening, and speaking

Moral development Preconventional maturity: egocentric and obedient to authority, not Sumner (2001, 2010)
identifying others except in reference to the self Sumner & Fisher (2008)
Conventional maturity: includes an awareness of others that is less
circumscribed by a relation to the self and which also asserts an initial,
thinking objectivity that precludes mindless obedience to authority
Postconventional maturity: formed when a participant is able to
participate abstractly or detachedly in an interaction to evaluate ones
own behaviors and hear the other fairly and justly

Discourse, interaction, discursive Range from coercive or strategic to negotiate; either party has Sumner (2001)
interactions opportunity to agree or disagree with course of action and to accept or Sumner & Fisher (2008)
reject the consequences
Discourse is intersubjective

Health care environment Lifeworld of the interaction of patient and nurse Sumner (2001)

Physis Sense of fulfillment, validation, and acknowledgment that patients Sumner (2001)
needs have been met satisfactorily; self-growth, self-blossoming;
justification for action negotiated during triadic dialogue

Triadic dialog The Iit and thou relationship. The dyadic relationship between Bishop & Scudder (1990, p. 152153)
the nurse and the patient in dialogue incorporates the Ithou and
becomes triadic with the it or the care of the patient, including
healing, the patients own treatment, care, and future health

(Table 1 continued)

108 International Journal for Human Caring

 The Moral Construct of Caring in Nursing as Communicative Action: Foundational Elements and Applications
Table 1 (continued)
Terms and Definitions in MCCNCAT
Term
Claim to truth Fact and rational thinking
Claim to truthfulness Intrasubjective self
Claim to rightness Intrasubjective interaction or discourse that occurs between two
participants; the way individuals participate offers the moral dimension
I had imprinted onto me as a very young
student nurse the duty and obligation of
nursing, which I accepted but when I
grasped that all humans are vulnerable in
need of considerateness I could
acknowledge my humanness as a nurse and
my own need for considerateness. Thus
Habermass (1995) theory of Communicative
Action and Moral Consciousness was the
seminal work for me, enabling me to dissect
the nurse into professional self and personal
self and the patient as illness self and
personal self and then what occurs in the
interaction. The nurse and the patient as a
whole could, at last, be offered, and how
emotion and thinking of each could influence
what was going on, in the interaction.
Habermas explained the moral of nursing in
ways which made complete sense to me,
and the critical social theory lens has
enabled me to think about nursing in ways
that I hadnt before. (Jane Sumner
Collection, n.d.)
Critical Social Theory
The history and lens of critical social theory
(CST) made sense to Dr. Sumner as a fit with her
beginning views on a caring theory for nursing.
She appreciated Habermass (1990) perspectives
and concepts. CST as a scientific approach
guided Sumner in examining forces (stressors
and burdens) and constraints inherent in society
(Sumner, 2010b). Sumner discussed three explicit
questions within CST relating to the examination
of false consciousness, identifying existing gaps
and silences, and developing an understanding of
how individuals can respond to restraining,
historical, and mindlessly accepted norms
(Sumner, 2010a, p. E17).
Sumner applied CST to the acute health care
delivery system and explained that the imposition
of norms is traditionally levied by the dominant
group in whose arena such norms are maintained
in concealed domination and subtle oppression
(Sumner, 2010a, p. E19). Used as a method, CST
is useful in establishing a state of reflexive
consciousness, drawing attention to individual
beliefs and values, and also in the broader society
Definition
where the individual is also a participant
(Habermas, as cited in Sumner, 2010a, p. E19).
CST evolved from primarily Marxist-based
scholarship to a broader emphasis on oppression
in general, as well as class oppression. Its goal
was a revision of Marxism, so that subjective
forms of knowledge, including perceptions and
experiences of human beings along with objective
observations, would be valued as science. The
theory has a transformational purpose; it is
directed at social structures and social
relationships, including logical arguments. CST-
based studies include a broad range of methods,
with qualitative studies often represented. One
form of CST emphasizes political action through
education (Friere, 1970). An alternate
representation is CSTs emphasis on
communication (Habermas, 1990).
Habermas (1990) used critical theory when
analyzing social interaction. He induced a theory
of communicative action and moral
consciousness. Habermas discussed human
vulnerability and the need for considerateness
(regard or thoughtfulness for others and their
feelings). According to Habermas, human
discourse or interaction is moral. This is explained
by humans inherent vulnerability during social
interaction; the need for considerateness means
that all discourse or communication is moral
(Sumner, 2002).
Habermas (1990) clarified the meaning of
moral intuitions regarding being both thoughtful
and considerate toward the vulnerability of others;
the nature of this intuition charges people
about how to best behave in instances where
there is the capacity to lessen the extreme
vulnerability of those individuals (Habermas,
1990). Moralities are designed to be harmonious
with the fragile nature of human beings who are
individuated through the process of
socialization. As a result, humans are required to
resolve two tasks at the same time. Habermas
underscored the importance of highlighting the
inviolability of the individual by advancing the
notion of equal respect for individual dignity.
People are entrusted to protect the web of
intersubjective relations of mutual recognition by
which individuals exist as community members
(Habermas, p. 200). These two harmonizing
Citation
Sumner (2001, 2010a, 2010b)
Sumner (2001, 2010a, 2010b)
Sumner (2010a)
qualities directly relate to the principles of
solidarity and justice (Habermas). Sumners
theory took into account these assumptions.
The MCCNCAT is also framed by
Heideggerian phenomenology. Sumner (2002)
used Heidegger (1959) to explain caring in
nursing, chiefly from the vantage of human
experience; individual feelings and perceptions of
self and the world influence human interests.
Human experience includes physical, spiritual,
emotional, and social components that affect
present experience. Furthermore, current
experience is guided by past and future hopes
and expectations (Sumner, 2002). According to
Allen (1995), hermeneutic phenomenology is
essential because nursing practice needs to be
described and explained considering the social
and political conditions under which language is
produced and reproduced (p. 181).
Sumner integrated frameworks of Heidegger
(1962, 2000), Habermas (1995), and Mayeroff
(1971) in order to position the MCCNCAT. Dr.
Sumners (2000) dissertation, Caring in Nursing:
A Critical Theory Study, reveals the strong
influence of CRT on the development of the
MCCNCAT. Her book (Sumner, 2008b) adheres
closely to the dissertation.
Dr. Sumner (2000, 2006) used CST and
applied the methods of triple hermeneutics to
analyze data and build her theory of caring in
nursing. She examined the mindlessly accepted
norms in the interviews of 10 nurses obtained in
her dissertation.
Basic Principles and Concepts of MCCNCAT
MCCNCAT is a bidirectional, multidimensional
nursing caring theory (Table 1). It is a grand
theory (Sumner & Fisher, n.d.) and ethical values
frame it. According to Sumner (2008x), caring in
nursing is a communicative action framed by
respect for all human life. Respect is visible in
verbal and nonverbal discourse or interaction.
Fairness and equity characterize bidirectional
communication (Sumner, 2006). Furthermore,
both the nurse and patient in the relationship have
autonomy, because each has a sense of control
and self-efficacy. Consequently, respect and
concern for human dignity is assumed. Fairness
2016, Vol. 20, No. 2 109
The Moral Construct of Caring in Nursing as Communicative Action: Foundational Elements and Applications

or justice is another value underpinning

interaction (Sumner, 2001). Figure 1
An unstated value of the theory is that of the Caring in Nursing: The Nurse and Patient in a Communicative Relationship
ethical principle of beneficence or compassion,
because nurses enter into the nursepatient
relationship aimed at the well-being of patients
(American Nurses Association, n.d.). The theorys
explicit assumption is based on Heidegger: the
human being is fundamentally characterized by
care; all human needs are met through the
primordial condition of human caring (Heidegger,
as cited in Sumner & Fischer, 2008, p. 10).
The premise of Sumners theory is that
because nursepatient interaction is
communicative, both persons are inherently
exposed and therefore vulnerable, requiring
considerateness (regard or thoughtfulness for
others and their feelings; Sumner, 2008x). The
nursepatient interaction is defined as an
interactive, collaborative, covenantal, social
contract, related to providing solace for the
human condition and which requires reciprocal
accountability and answerability (Sumner,
2010a, p. E22). Caring communicative action is a
nursing intervention; the outcome of caring in
nursing as communicative action is solace or
comfort. The other outcome is physis (self-
blossoming or self-growth), resulting from the
nurse helping the patient to meet his or her needs
satisfactorily (Sumner, 2001). The context of the
relationship is human experience in a distinct
social world (Sumner, 2008x), that of health care
settings.
Sumner (2001) detailed the intrasubjective
world of the patient and the nurse, describing that
the patient and the nurse have intrasubjective
aspects, including emotion and reason, and
physical, spiritual, and social elements that are
forestructures of understanding. They also have
intersubjective aspects, including exposure when
the personal self interacts in discourse (Sumner,
2001). Intersubjective understanding is realized
as nurses and patients interact and accept the
norms and values implicit in the interaction.
Nurses adhere to professional norms and values.
According to Sumner (2001), patients who are
ill may accept the need for professional In contrast, nurses moral development begins at development. She created a concept analysis of
assistance cognitively and emotionally. They the preconventional level with inexperienced caring in nursing. Three constructs were
temporarily cede autonomy to health care nurses. At the conventional level of moral described: sense of self and efficacy, locus of
professionals. Patients come to the nursepatient development, nurses follow norms of practice and control (emotional and cognitive components);
interaction with a normative claim to truthfulness. authority, but begin to see patients as persons. knowledge; and meeting human needs. She
They are more vulnerable because of illness and Postconventional-level nurses function interconnected them with the domains of nurse,
desire the considerateness of others because of autonomously. Nurses, like patients, experience patient, and environment. Sumner noted that
their unmet needs. She further explained their caring in nursing originates out of human
physis or fulfillment.
moral development. Patients moral development experience within a distinct social world (p. 11).
may be at the preconventional level because of See Figure 1 for a depiction of the theory.
their state of illness. They are self-interested. At Concept Analysis and Beginning Instrument Attributes of the concept, caring in nursing,
the conventional level, patients might participate Development were explained. The defining concepts are nurse,
more in the interaction as equal participants. The Sumner (2006) induced a theoretical definition patient, and interaction (Sumner, 2006). A
postconventional level of moral development of caring in nursing after refining her theoretical communicative relationship or interaction
shows patients participating as they negotiate framework of caring in nursing. The theoretical incorporates the attributes of the social contract
and accept the regimen along with its limitations. definition served as a first step to instrument that is caring in nursing; the interaction is

110 International Journal for Human Caring

 The Moral Construct of Caring in Nursing as Communicative Action: Foundational Elements and Applications

revealed in verbal and nonverbal communication Table 2

within negotiated and agreed upon norms. The Caring Survey Constructs, Number of Items, and Rescoring
social contract is collaborated and bidirectional:
Discourse flows from one to the other with each Construct Number of Items Rescoring
in both the first person, I function, and second
person, you function, depending on who is 1. Caring in nursing responsibilities of care 15 1 VS disagree
speaking (p. 12). Considerateness represents
the moral attribute of bidirectional communication. 2 S disagree
Fairness and equity frame bidirectional
3 disagree
communication.
Sumner (2006) described categories to cluster
4 Agree
caring in nursing concepts: relation, time, place
action, substance, quantity, and quality: 5 S agree
 Relation: inherent within communicative

discourse; 6 VS agree
 Time and place: caring in nursing occurs at

any time and place where the nurse and 123456 654321
patient enter into communicative discourse;
 Action: communicative discourse that
2. Caring in nursing practice 28 1 VS/S disagree
establishes the norms of the interaction and
a negotiated plan of action; 2 disagree
 Substance: the nurse and patient cooperate

to meet the requirements of a patients 3 VS/S agree

health or illness;
 Quantity: variable, because of the needs of 123456 333211
the nurse and patient at any one time; and
 Quality: ideal nursing, constant and excellent 3. Caring in nursing caring identity 44 1 VS/S disagree
(p. 16).
She provided a figure to illustrate the 2 Agree
essentials of the theory (Sumner, 2006). See
Figure 1. Her construct definition of caring in 3 S agree
nursing follows:
As an ideal, caring in nursing is 4 VS agree
communicative action, framed by the
unconditional universal ought of respect for 123456 432111
all human life, encompassing the spectrum
of human experience, and is manifest in the 4. Caring nursepatient partnership 29 1 VS disagree
verbal and nonverbal discourse between two
equal and vulnerable human beings. They 2 S disagree
have assumed the roles of nurse and patient
yet each retain ultimate self-efficacy and a 3 Disagree
sense of control. The interaction is an
interactive, collaborative, covenantal, and 4 Agree
social contract related to providing solace for
the human condition which requires 5 VS/S agree
reciprocal accountability and answerability.
123456 554321
As a social contract, caring in nursing has
embedded considerateness for the human
5. Caring in nursing communication mutuality 8 1 VS/S disagree
vulnerability of both nurse and patient. The
norms of the interaction are developed and 2 Agree
are accepted by both. As a communicative
intervention, caring in nursing validates both 3 S agree
individuals as human. Caring in nursing
arises out of the fundamental dimensions of 4 VS agree
human experience within a distinct social
world. (Sumner, 2006, p. 13) 123456 432111
Applications of the Theory (Table 2 continued)
Nursing Practice Environment
Sumner and Townsend-Rocchiccioli (2003)
offered perspectives on the contribution of the
emotional human-to-human connection to nurses

2016, Vol. 20, No. 2 111

The Moral Construct of Caring in Nursing as Communicative Action: Foundational Elements and Applications
Table 2 (continued)
Caring Survey Constructs, Number of Items, and Rescoring
Construct
6. Caring in nursing professionalism
7. Caring in nursing patient focus
Note: VS very strongly; S strongly.
satisfaction with their role in a discussion on why
nurses were leaving the profession. They noted
that nurses entered the profession to help others.
In the context of the efficiency-oriented health
care system, nurses respond to bureaucratic
constraints with frustration, distancing, and
depersonalization. Nurses need for achievement
is met when patients emotional sensibility is
recognized and valued. The tasks and demands
of health care institutions resulted in nurses
personal decisions to end their careers.
Sumner and Townsend-Rocchicciolis (2003)
concern with the discourse of nursepatient
interaction was revealed in the article, as was the
emphasis on nursings need to provide care and
the intrinsic rewards nurses gain through
interaction. The authors explained a strategy of
acute health care settings for reducing the exodus
of nurses; self-governance of the nursing staff,
consistent with changes characteristic of magnet
hospitals (Sumner & Townsend-Rocchiccioli), is
one strategy. They proposed that more attention
needs to be paid to nurses appreciation of the
human relationship between nurses and patients
in their work environments. How nurses value the
nursepatient relationship is important to nurses.
Work environments that foster interaction might
result in nurse retention.
Research: Instrument Development
In order to access an instrument consistent
with MCCNCAT, Sumner and Fisher (n.d.) created
a pilot instrument, using Rasch scaling. The intent
of the development of the Caring Survey was to
create a valid and reliable measure to be applied
112 International Journal for Human Caring
Number of Items Rescoring
10 1 VS/S disagree
2 Agree
3 S agree
4 VS agree
123456 432111
38 1 VS/S disagree
2 Agree
3 S agree
4 VS agree
123456 432111
to clinical practice. Also, the authors planned that
the instrument be used to compare measures
across different populations. The Rasch rating
scale approach was chosen to assist in
constructing qualitatively meaningful, linear,
interval measures from nonlinear, ordinal
observations (Sumner & Fisher, n.d., p. 11).
The original instrument had 185 items.
Demographic items were included. Items focused
on the personal and professional selves of the
nurse and personal and illness selves of the
patient. The authors hypothesized that the
professional self comes before the personal self
of the nurse. A number of items (32) were
projected to be rated as very strongly agree; 12
were expected to be rated strongly agree, agree,
or in any disagree category. For the 93 nurse and
patient items, the higher summed score indicated
higher agreement. Scoring for the very strongly
agree point on the scale 6; the very strongly
disagree response was scored 1.
Three constructs, initially represented as
scales, were included in the instrument: caring
identity, state of nursing practice, and nurse
patient interaction. The sample consisted of
nurses in clinical practice from the United States
(n 32), New Zealand (n 30), and the United
Kingdom (n 12), and attendees at a conference
(n 6). The sample was mostly female. A total of
79 instruments were included in the analysis. One
instrument was discarded. Optimization was
carried out with five-category responses
combined to three-category scoring for the three
interaction scales. Cronbachs alpha coefficient
was over .85 for all scales. Some calibrations
differed with the theory and some agreed with it.
Demographic data were also included: sex, age,
ethnicity, educational preparation, practicing in
same country as educational preparation, years in
nursing practice, area of practice, function/role,
years working in the same facility, and patient
contact.
The instrument was reduced to 172 items.
See Table 2. Seven constructs were then
identified: caring in nursing, responsibilities of
care; caring in nursing, practice; caring in nursing,
caring identity; caring in nursing, patient
partnership; caring in nursing, communicative
mutuality; caring in nursing, professionalism; and
caring in nursing, patient focus. The rating scale
was: 1 very strongly agree; 2 strongly agree;
3 agree; 4 disagree; 5 strongly disagree;
and 6 very strongly disagree. Sumner and
Fisher (n.d.) concluded that the seven scales
were by themselves middle-range theories of the
overall caring construct, and MCCNCA was a
metatheory. Technical skill items in the caring
subscale, related to the professional self, elicited
most agreement. Because preliminary testing of
the instrument generated a small sample size,
additional testing is called for.
Impact of the MCCNCAT
The MCCNCAT differs from some theories of
nurse caring in that it is framed by CST. The
emphasis on bidirectionality in communication,
and that on how the needs of the nurse and
patient are met (Sumner, 2008x), are very explicit
and strong points of the theory. Also, the
description of considerateness and the mutual
vulnerability of the nurse and patient in the
interpersonal relationship helps to clarify the
relationship as a new opportunity to meet another
and to create interaction.
Studies are needed in which the MCCNAT is
used as a theoretical framework for research
conducted in clinical settings with nurses involved
in direct care situations. Not only could
investigators survey the nurses, but Sumner
might consider developing an intervention study
incorporating elements of the theory. The Caring
Survey is still being developed and includes a
large number of items. Further testing will most
likely assist Sumner and Fisher to evaluate
whether item reduction is an option.
Conclusion
Dr. Sumners development of the MCCNAT
represents an important contribution to caring
theory and caring theory development as a
theoretical framework to assist nurses in
understanding nursepatient relationships. Ethical
values (fairness and equity) frame her theory and
position nursing as communicative action
predicated on respect for each individual.
Bidirectionality (Sumner, 2006) of communication
is a critical component of the theory and is
 The Moral Construct of Caring in Nursing as Communicative Action: Foundational Elements and Applications
characterized by autonomy in the nursepatient
relationship, fostering a feeling of self-control and
efficacy in this relationship, and engendering a
concern for human dignity (Sumner, 2001).
References
Allen, D. G. (1995). Hermeneutics: Philosophical
traditions and nursing practice research.
Nursing Science Quarterly, 8, 174182.
American Nurses Association. (n.d.). Short
definitions of ethical principles and theories:
Familiar words, what do they mean? Retrieved
from: http://www.nursingworld.org/
mainmenucategories/ethicsstandards/
resources/ethics-definitions.pdf
Bishop, A. H., & Scudder, J. R. (1990). The
practical, moral, and personal sense of
nursing: A phenomenological philosophy of
practice. Albany, NY: State University of New
York Press.
Brown, L. (1986). The experience of care: Patient
perspectives. Topics in Clinical Nursing, 8,
5662.
Friere, P. (1970). Pedagogy of the oppressed (M.
B. Ramos, Trans.). New York, NY: Seabury.
Habermas, J. (1990). Moral consciousness and
communicative action (C. Lenhardt & S. W.
Nicholsen, Trans.). Cambridge, MA: MIT
Press.
Heidegger, M. (1962). Being and time. (J.
Macquarrie & E. Robinson, Trans.). New York,
NY: Harper & Row.
Heidegger, M. (2000). Introduction to
metaphysics. (R. Polit & G. Fried, trans.). New
Haven: Haven, CT: Yale University Press.
Jane Sumner Collection. (n.d.). Archives of
Caring in Nursing, Christine E. Lynn College of
Nursing, Florida Atlantic University, Boca
Raton, FL.
Mayeroff, M. (1971). On caring. New York, NY:
Harper & Row.
Paloutzian, R. F., & Ellison, C. W. (1982).
Loneliness, spiritual well-being, and the quality
of life. In L. A. Peplau, & D. Perlman (Eds.).
Loneliness: A sourcebook of current theory,
research and therapy (pp. 224236). New
York, NY: Wiley.
Sumner, J. (1993). The relationship between
spiritual well being of the terminally ill cancer
patient and perceived nurse empathy
(Unpublished masters thesis). Louisiana State
University Health Sciences Center School of
Nursing, New Orleans, LA.
Sumner, J. (2000). Caring in nursing: A critical
theory study. UMI, 9970129.
Sumner, J. (2001). Caring in nursing: A different
interpretation. Journal of Advanced Nursing,
35, 926932.
Sumner, J. (2002, July). The spirit of open
egalitarianism: A caring in nursing practice
model. Paper presented at the Royal College
of Nursing and Sigma Theta Tau International
Nursing Research Congress, Brisbane,
Australia. Retrieved from: http://hdl.handle.net/
10755/155776
Sumner, J. (2006). Concept analysis: The moral
construct of caring in nursing as
communicative action. International Journal for
Human Caring, 19(1), 816.
Sumner, J. (2008a). Is caring in nursing an
impossible ideal for todays practicing nurse.
Nursing Administration Quarterly, 32, 92101.
Sumner, J. (2008b). The moral construct of caring
in nursing as communicative action: A theory
for nursing practice. Saarbrucken, Germany:
VDM Verlag Dr. Muller Aktiengesellschaft.
Sumner, J. (2010a). A critical lens on the
instrumentation of caring in nursing theory.
Advances in Nursing Science, 33(1),
E17E26.
Sumner, J. (2010b). Reflection and moral maturity
in a nurses caring practice: A critical
perspective. Nursing Philosophy, 11, 159169.
Sumner, J., & Fisher, W. P. (n.d.). Caring in
nursing theory: An ontologic-epistemic
foundation for instrument development and
testing. Unpublished manuscript.
Sumner, J., & Fisher, W. P. (2008). The moral
construct of caring in nursing as
communicative action: The theory and
practice of a caring science. Advances in
Nursing Science, 31(4), E19E36.
Sumner, J., & Townsend-Rocchiccioli, J. (2003).
Why are nurses leaving nursing? Nursing
Administration Quarterly, 27, 164171.
Watson, J. (1988). Nursing: Human science and
human care. A theory of nursing. New York,
NY: National League for Nursing Press.
Wheeler, K. (1988). Perception of empathy
Inventory. In O. L. Strickland & C. Waltz
(Eds.). Measurement of nursing outcomes:
Vol. 4. Measuring client self-care and coping
skills (pp. 181198). New York, NY: Springer.
Author Note
Zane Robinson Wolf, PhD, RN, FAAN is Dean
Emerita and Professor; Denise Nagle Bailey,
EdD, MEd, MSN, RN, CSN is Director, La Salle
Neighborhood Nursing Center, Independence
Foundation Chair, Nursing Programs, School of
Nursing and Health Sciences, La Salle University,
Philadelphia, PA, USA.
Correspondence concerning this article may
be sent to Dr. Zane Robinson Wolf, La Salle
University, 1900 West Olney Avenue,
Philadelphia, PA 19141. Electronic mail may be
sent via the Internet to wolf@lasalle.edu
2016, Vol. 20, No. 2 113
Copyright of International Journal for Human Caring is the property of International
Association for Human Caring and its content may not be copied or emailed to multiple sites
or posted to a listserv without the copyright holder's express written permission. However,
users may print, download, or email articles for individual use.