The Community as Client: A Critical Caring Exemplar

Dorothea Fox-Jakob

I first heard of Dorothea Fox Jakob when I began public health nursing practice, mid-way through my nursing career.  She was well known in public health nursing circles for her strong advocacy efforts, particularly in relation to influencing public policy changes that would help to address the adverse effects poverty had on human health, and particularly that of children.  That work had earned her a letter of thanks from none other than the nursing theorist, Virginia Henderson!  (See November 20, 2013 post “An Introduction to the Canadian Nursing Theories Perspective“)

Now retired, Dorothea is sorting through her many papers and came upon one she had been invited to give at a local NANDA group meeting in Massachusetts. The request was prompted by her speaking out passionately at a national NANDA meeting on the need for the group to consider nursing diagnoses for communities-as-clients, not only for individuals. The paper, “We Look Like Giants” (click to download), represents a case study of an aspect of the work of a team of 3 public health nurses  with young mothers in a district of Toronto in which she practiced.

The educational background of the PHN team is not specified, except that one was a mental health nurse specialist, one a generalist. I know from dialogue with Dorothea, that she was the 3rd nurse and had attended NYU where she earned a Masters of Public Health Nursing, a degree that prepared her as a public health clinical nurse specialist. NYU, known for its strong emphasis on nursing theory, would also have given her a strong nursing theoretical foundation for her work. The attached paper, however, does not identify a specific nursing theoretical framework that informed the PHN team’s practice.

W hen I read “We look like Giants”, I was struck by how it demonstrated Critical Caring in action.  Although the paper was written 15 years before I articulated the theory, I have previously referred to it as a “descriptive theory”, i.e., it was my effort to articulate the practice of expert public health nurses within a coherent nursing theoretical framework, initially as I observed it in practice (Falk-Rafael, 2005), and then through research (Falk-Rafael & Betker, 2012a; Falk-Rafael & Betker, 2012b) and most recently through further reflection (Falk-Rafael, 2020).

Critical caring is rooted in the writings and example of Nightingale, Watson’s  human caring science, and feminist critical social theories. It is conceptualized  as a way of being (in relation), knowing (embracing multiple ways of knowing), and choosing (ethics). It identifies 7 carative health promoting processes (CHPPs).

In our conversations, Dorothea emphasized that the focus of the 3-public health nurses who undertook this process was in supporting a neighbourhood  drop-in centre by helping it meet the needs of young mothers in the area. And, certainly the “client” in the example may be conceptualized in this way, Client” could also refer to the larger community the drop-in centre served, or the group of Moms who attended the group sessions that the nurses facilitated. Because the paper provides more information about the nurses’ relationship with the group of Moms, I will focus on them as the “community as client” for the purpose of this blog..

CHPP I involves the preparation of self. In addition to Dorothea’s education and nursing experience, she  identifies her own experience as a mother in preparing her for the her work with the group. In addition, she identifies engaging in “soul-searching” and values clarification at the outset.

CHPP II involves developing and maintaining a helping-trusting relationship. Evidence of a respectful, non judgemental, and an authentic way of being present is evident throughout Dorothea’s narrative. Evidence of mutuality in goal-setting and evaluation methods is also described – the mothers identified the issues they wanted to rap (or talk) about and the nurses defined the temporal boundaries (1 ½ hours/week for 10 weeks) and committed to be there. The paper has many examples of inclusiveness and acceptance – sporadic attendees were as welcome as regular attendees, the presence of small children and/or babies was not only accommodated but efforts were made to “spell off” mothers with babies. Self-disclosure and human touch were also identified and contributed to the relationship-building.

Dorothea’s story describes the reflexive approach of the nurse-facilitators in identifying, planning, responding to health goals, as well as in evaluation (CHPP III – using a systematic, reflexive approach). For example, topics were added as new issues were raised. Likewise, some evidence of transpersonal teaching-learning (CHPP IV – engaging in transpersonal teaching-learning) may be seen and/or inferred as group members shared their experiences in managing situations other group members were experiencing. It is clear in the example that the nurse facilitators created a safe environment in which the women could share their experiences comfortably (CHPP V – providing, creating and/or maintaining supportive and sustainable environments).

CHPP VI refers to meeting needs and building capacity. The narrative identifies meeting needs for nourishment and  child-care during the meetings, in addition to attending to the needs for social interaction and improved self-image. As participants were encouraged to call each other between meetings, it is reasonable to assume that their capacity to care for each other may have improved. On another level, the nurses’ efforts also met a need and strengthened the capacity of the drop-in centre to support young mothers in the surrounding community.

CHPP VII refers to being open to various ways of making meaning in which those for whom we care engage. Whereas the narrative does not specifically address this process, group members’ identification of the instillation of hope as one of the outcomes of the group sessions may be an aspect of this carative process.

The focus of Dorothea’s paper was to give an example of public health nursing work with a community- as-client to a group of nurses involved with NANDA at a local level. Although the explicit nursing knowledge that informed the practice of the PHN team is not specified in her paper, retrospectively the congruence of their nursing care for this community  with a nursing theoretical approach is clear. The paper identifies at least one positive outcome, in that the drop-in centre was able to remain viable for at least the next several years . The story’s title, “We Look Like Giants”, an observation of one of the mothers in the group, suggests, perhaps, that  an enhanced self-image of the participating Moms was another.


Falk-Rafael, A. (2005). Advancing nursing theory through theory-guided practice: the emergence of a critical caring perspective. ANS. Advances in Nursing Science, 28(1), 38–49. DOI 10.1097/00012272-200501000-00005

Falk-Rafael, A. (2020). Adeline Falk-Rafael’s Critical Caring Theory. In M. C. Smith (Ed.), Nursing Theories and Nursing Practice (5th ed) (pp. 509–521). FA Davis.

Falk-Rafael, A., & Betker, C. (2012a). Witnessing Social Injustice Downstream and Advocating for Health Equity Upstream: “The Trombone Slide” of Nursing. ANS. Advances in Nursing Science, 35(2), 98. DOI 10.1097/ANS.0b013e31824fe70f.

Falk-Rafael, A., & Betker, C. (2012b). The primacy of relationships: a study of public health nursing practice from a critical caring perspective. Advances in Nursing Science, 35(4), 315–332. DOI 10.1097/ANS.0b013e318271d127.

3 thoughts on “The Community as Client: A Critical Caring Exemplar

  1. Dr. Falk-Rafael, first and foremost, as a fan of your work (especially for your critical feminist perspective, and as it applies to the work I am doing in population health), thank you for your post. I love Nursology, because it lets novices (like me) interact with scholars (like yourself) without delay or downtime (instant gratification, so to speak, which is widely known to be appealing to the Millennial and Post-Millennial generations!). If I ever end up teaching nursing theory, I will undoubtedly be using Nursology as part of routine assignments – getting students involved in the theory culture!

    While reading your post, I got to thinking about not only the theory-practice gap (which we discussed a bit last week), but the theory-research gap. The thought struck me: Wait! THIS is a theory that fits in well not only with the emancipatory paradigm to which I ascribe, but, Wow! This is a theory that makes total sense with the movement toward community based participatory research methods and, arguably, even pragmatic clinical trials — both in which community stake-holders are intimately involved in the research process, which is occurring in real-time and outside the sterility of a “lab.”

  2. Shannon, thank you so much for your kind words and insights into the possibility of using the theory in participatory action research! I must confess, I hadn’t thought of that!

  3. Dorotha Fox Jakob asked me to post this comment to provide context for Adeline Falk-Rafael’s blog. In an email to me following publication of Adeline’s blog, Dorothea wrote:

    My clinical paper, “We Look Like Giants,” was given in May of 1990. At the time the 236 nurses employed by the Department of Public Health of the City of Toronto had been in the process of outlining their values and beliefs since 1987 in the effort of creating their own conceptual framework facilitated by the Nursing Theory Workgroup of which I was a member.

    As a result, definitions of nurse, person, health and environment were presented back to staff in 1988 and in another series of workshops developed assumptions for the four elements, once again presented back to staff in June of 1990. Furthermore, a department-specific conceptual framework emerged entitled “Creating Our Own Conceptual Framework” facilitated by the Nursing Theory Workgroup. The framework was revised in November 1991 continuing the concept/process of making a quilt, the metaparadigm framework, from the 1800 words, phrases and sentences of values and beliefs articulated by staff in workshops.

    So, you see that the staff [thought] that “most conceptual frameworks for nursing practice give insufficient attention to the relationship between health and culture…Recognition of the dilemma led nurses…to clarify their own professional values and beliefs…a department-specific conceptual framework begins to emerge…our effort to provide an “experiential account of the truth” of the “domain of experience” of being a PHN in Toronto”.

    At the time of writing “We Look Like Giants” we PHNs in the city of Toronto were seeking common ground from our practices. It was awesome.

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