Contributor – Leodoro J. Labrague, RN, DM, PhD, CNE
June 2026

Author – Leodoro J. Labrague

Year First Published – 2026

Major Concepts

• Care Climb: Represents the developmental progression of caring behaviors throughout a nurse’s professional journey.
• Systemic Ceiling: Structural and organizational barriers that constrain the expression of higher levels of caring, particularly Holistic Caring and Empowerment Caring.
• De-escalation and Maturation Loop: Process on how nurses recover from periods of caring regression and re-engage in higher levels of caring practice.
• Regression Loop: The process by which nurses temporarily move to lower stages of caring development in response to significant stressors or resource depletion.
• Trapdoor Effect: The triggering mechanism that causes caring regression when demands exceed an individual’s emotional, psychological, or professional capacity.

Typology

The Caring Evolution Theory is mid-range theory because it explains and predicts the developmental processes through which caring grows, regresses, and recovers among nurses across professional practice.

Brief Description

The Caring Evolution Theory explains how caring develops, fluctuates, and matures throughout a nurse’s professional journey. Grounded in caring science, developmental theory, and systems perspectives, the theory views caring not as a fixed personal trait but as a dynamic competency shaped by experience, reflection, professional growth, and organizational influences.

Assumptions
The theory is based on three assumptions:
1. Caring is developmental—it evolves through experience, learning, and professional growth.
2. Caring development is dynamic and non-linear—nurses may progress, remain stable, or temporarily regress depending on personal and professional circumstances.
3. Organizational systems influence caring expression—supportive environments facilitate caring development, whereas systemic barriers may constrain it.

The Care Climb
The central framework of the theory is the ‘Care Climb’, which represents the developmental progression of caring from basic task-oriented practice to transformative, patient-centered care. The Care Climb consists of five stages:

1. Foundational Caring – represents the most basic expression of caring. Nurses focus on patient safety, competence, task completion, and adherence to professional standards. Caring is demonstrated through responsible and safe clinical practice.
2. Attentive Caring – extends beyond task completion and involves purposeful presence, active listening, and sensitivity to patients’ emotional and psychosocial needs. Nurses become more aware of verbal and nonverbal cues and begin forming meaningful therapeutic relationships.
3. Responsive Caring – reflects the ability to tailor care to individual patient needs, preferences, and circumstances. Nurses use empathy, clinical judgment, and situational awareness to adapt interventions and communication strategies.
4. Holistic Caring – recognizes patients as multidimensional beings influenced by physical, psychological, social, cultural, and spiritual factors. Care extends beyond symptom management to address the broader context of the patient’s life and well-being.
5. Empowerment Caring – represents the highest level of caring development. Nurses function as advocates, educators, and collaborators who promote patient autonomy, self-efficacy, shared decision-making, and long-term self-management. Caring becomes transformative and supports human flourishing.

Progression through these stages is cumulative, with each level building upon the competencies and caring capacities developed in earlier stages.

The Systemic Ceiling
A unique contribution of the theory is the concept of the ‘Systemic Ceiling’, which refers to organizational barriers that limit nurses’ ability to consistently practice advanced forms of caring. Factors such as staffing shortages, heavy workloads, documentation demands, productivity pressures, and restrictive workplace structures may constrain the expression of Holistic and Empowerment Caring. The ‘Systemic Ceiling’ emphasizes that caring is not solely an individual responsibility but is influenced by the healthcare environment.

The Regression Loop and Trapdoor Effect
Unlike traditional developmental models that assume continuous growth, the Caring Evolution Theory recognizes that caring may temporarily decline during periods of adversity. This process is known as the ‘Regression Loop’. The mechanism that triggers regression is called the ‘Trapdoor Effect’, which occurs when stressors such as burnout, compassion fatigue, moral distress, workplace violence, traumatic clinical experiences, or persistent workload pressures overwhelm a nurse’s available emotional and professional resources. During these periods, nurses may retreat to more basic forms of caring focused primarily on safety and task completion. Regression is not viewed as failure but as an adaptive response to challenging circumstances.

The De-escalation and Maturation Loop
The ‘De-escalation and Maturation Loop’ explains how nurses recover from caring regression and continue their developmental progression. Recovery may be facilitated through reflective practice, mentorship, clinical supervision, peer support, professional development, supportive leadership, and organizational wellness initiatives. Importantly, recovery is not simply a return to a previous level of functioning. Nurses often emerge from adversity with greater self-awareness, resilience, and deeper caring maturity. Thus, the ‘De-escalation and Maturation Loop’ represents both recovery and transformation, reinforcing the theory’s view that caring development is a lifelong and evolving process.

Primary Sources

Labrague, L. J. (2026). The Caring Evolution Theory: Understanding how nurses’ caring behaviors grow and evolve. Journal of Professional Nursing, 65, 205-211. https://www.sciencedirect.com/science/article/abs/pii/S8755722326000876
Labrague, L. J. (under review). Exploring the evolution of caring in nursing practice: A qualitative study of caring growth, regression, and recovery. Manuscript submitted for publication.

About Leodoro J. Labrague

Dr. Leodoro J. Labrague is an associate professor at Fran and Earl Ziegler College of Nursing, University of Oklahoma. He has extensive teaching experience across the Philippines, the Middle East, and the United States, spanning undergraduate, graduate, and doctoral programs. Dr. Labrague’s program of research focuses on caring science, health systems, and fall prevention.