Contributed by Jennifer Stephens
Nursology.net Advisory Team

Nursing theorists seem to be clear about what the discipline is aiming for. Jean Watson describes caring as nursing’s moral ideal, Kristin Swanson defines it as a nurturing way of relating to a valued other, and Boykin and Schoenhofer hold that every person is caring by virtue of being human and that nursing exists to nurture people living and growing in caring. Despite their differences, these theories share a core conviction: the individual is unique and autonomous, and caring is part of nursing’s ontology, meaning it is what nursing is, not just what nurses do. In my own experience, and in conversations with fellow nurses, the clinical world does not always look like this. My friends and I have long been calling the gap “KARING,” a parody of caring in which the gestures are performed but the care is absent, or in which nurses who want to care are not allowed the time to do so.

The research suggests this is more than cynicism. Arlie Hochschild’s (1979) work on emotional labor describes how workers are expected to display feelings that their working conditions leave no room to feel, which is close to what we mean by feigned caring. Beatrice Kalisch and Kyung Hung Lee (2010) studied missed nursing care and found that comforting, talking with patients, and education are among the first things to be dropped when workloads rise. Andrew Andrew Jameton (2017) developed the concept of moral distress which describes what follows when nurses know the caring action but cannot take it. Seen this way, KARING is often not a failure of individual character. It is what happens when a frantically task-focused environment treats caring as optional.

The business model of healthcare adds irony. Joanne Duffy’s Quality-Caring Model (2018) argues that caring relationships improve outcomes such as patient satisfaction, self-care, and health status, which makes caring defensible in financial terms. That argument is practical, but it also means caring must justify itself in the same metrics that tend to crowd it out. When caring is valued only if it can be measured and billed for by organizations, caring itself risks being reduced to scripts, rounding checklists, and satisfaction-score phrases. A theory that treats caring as ontological sits uneasily with a healthcare system that treats it as an objective tool.

Public health raises a different question. If every caring theory begins with the uniqueness and autonomy of the individual, how does that scale to populations where the unit of concern is the community, and resources are allocated by need and evidence? Madeleine Leininger’s Culture Care Diversity and Universality offers one bridge by asking nurses to attend to social structure, worldview, and community as well as the individual. Boykin and Schoenhofer offer another way in which public health could aim to support the conditions in which people and communities can express and sustain their own caring. Still, population-level work must often put equity and efficiency ahead of the individual relationship, and that tension is philosophical as well as practical.

Caring oftentimes received peripheral treatment as our society grows more and more technologically focused. Theories of caring give nurses a vocabulary for what is being lost and provide a standard against which to measure the deficiencies. If caring is the essence of nursing, then protecting the time, staffing, and moral space to practice caring is not a luxury but rather a professional obligation. And yet the allopathic healthcare system we have built collectively over the last 100 years lacks space and incentive to allow nurses to care. The conclusion I take from these theories around caring and human existence is not whether individual nurses care, but whether the systems we work in will let that caring be realized. Until then, KARING might be the best any nurse can realistically achieve.

References

Duffy, J. R. (2018). Quality caring in nursing and health systems : implications for clinicians, educators, and leaders (Third edition.). Springer Publishing Company.

Hochschild, A. R. (1979). Emotion work, feeling rules, and social structure. The American Journal of Sociology, 85(3), 551–575. https://doi.org/10.1086/227049

Jameton, A. (2017). What Moral Distress in Nursing History Could Suggest about the Future of Health Care. AMA Journal of Ethics, 19(6), 617–628. https://doi.org/10.1001/journalofethics.2017.19.6.mhst1-1706

Kalisch, B. J., & Lee, K. H. (2010). The impact of teamwork on missed nursing care. Nursing Outlook, 58(5), 233–241. https://doi.org/10.1016/j.outlook.2010.06.004

Swanson, K. (1991). Empirical development of a middle range theory of caring. Nursing Research, 40(3), 161–165.

About Jennifer Stephens

Dr. Jennifer Stephens is Nursology.net assistant site manager with Peggy Chinn. Jennifer is a long-time professional historian and does lectures and research on the history of nursing in the American West. Jennifer grew up on a ranch outside of Cheyenne (Wyoming) and lived away for a few decades in Oregon, Washington, and British Columbia (Canada). She received her PhD from the University of British Columbia in 2018, having worked with Dr. Sally Thorne as her supervisor. Jennifer returned to Wyoming in 2022 and lives on a ranch outside of Cheyenne. She is an associate professor in the Fay W. Whitney School of Nursing at the University of Wyoming. Jennifer is secretary of the Wyoming Nurses Association (WNA) as well as on the Board of Directors for the Wyoming State Oncology Society (WSOS) and the Rural Nurses Organization (RNO). Her program of research is focused on rural oncology, especially around patient experience and survivorship, and she has been exploring the concept of “cancer ghosting” (see cancerghosting.com).