Caring in Nursing Practice

Caring Is Primary

Benner offers nurses a rich, holistic understanding of nursing practice and caring through the interpretation of expert nurses’ stories. After listening to nurses’ stories and analyzing their meaning, she described the essence of excellent nursing practice, which is caring. The stories revealed the nurses’ behaviors and decisions that expressed caring. Caring means that persons, events, projects, and things matter to people (Benner and Wrubel, 1989; Benner et al., 2010). It is a word for being connected.

Caring determines what matters to a person. It underlies a wide range of interactions, from parental love to friendship, from caring for one’s work to caring for one’s pet, to caring for and about one’s patients. Benner and Wrubel (1989) note: “Caring creates possibility.” Personal concern for another person, an event, or thing provides motivation and direction for people to care. Caring as a professional framework has practical implications for transforming nursing practice (Drenkard, 2008). Through caring, nurses help patients recover in the face of illness, give meaning to their illness, and maintain or reestablish connection. Understanding how to provide humanistic caring and compassion begins early in nursing education and continues to mature through experiential practice (Gallagher-Lepak and Kubsch, 2009).

Patients are not all the same. Each person brings a unique background of experiences, values, and cultural perspectives to a health care encounter. Caring is always specific and relational for each nurse-patient encounter. As nurses acquire more experience, they typically learn that caring helps them to focus on the patients for whom they care. Caring facilitates a nurse’s ability to know a patient, allowing the nurse to recognize a patient’s problems and find and implement individualized solutions.

Leininger’s Transcultural Caring

From a transcultural perspective, Madeleine Leininger (1991) describes the concept of care as the essence and central, unifying, and dominant domain that distinguishes nursing from other health disciplines (see Chapter 4). Care is an essential human need, necessary for the health and survival of all individuals. Care, unlike cure, helps an individual or group improve a human condition. Acts of caring refer to nurturing and skillful activities, processes, and decisions to assist people in ways that are empathetic, compassionate, and supportive. An act of caring depends on the needs, problems, and values of the patient. Leininger’s studies of numerous cultures around the world found that care helps protect, develop, nurture, and provide survival to people. It is needed for people of all cultures to recover from illness and to maintain healthy life practices.

Leininger (1991) stresses the importance of nurses’ understanding cultural caring behaviors. Even though human caring is a universal phenomenon, the expressions, processes, and patterns of caring vary among cultures (Box 7-1). Caring is very personal; thus its expression differs for each patient. For caring to be effective, nurses need to learn culturally specific behaviors and words that reflect human caring in different cultures to identify and meet the needs of all patients (see Chapter 9).

Watson’s Transpersonal Caring

Patients and their families expect a high quality of human interaction from nurses. Unfortunately many conversations between patients and their nurses are very brief and disconnected. Watson’s theory of caring is a holistic model for nursing that suggests that a conscious intention to care promotes healing and wholeness (Watson, 2005, 2010). The theory integrates the human caring processes with healing environments, incorporating the life-generating and life-receiving processes of human caring and healing for nurses and their patients (Watson, 2006). The theory describes a consciousness that allows nurses to raise new questions about what it means to be a nurse, to be ill, and to be caring and healing. The transpersonal caring theory rejects the disease orientation to health care and places care before cure (Watson, 1996, 2008). The practitioner looks beyond the patient’s disease and its treatment by conventional means. Instead, transpersonal caring looks for deeper sources of inner healing to protect, enhance, and preserve a person’s dignity, humanity, wholeness, and inner harmony (see also Chapter 4).

In Watson’s view caring becomes almost spiritual. It preserves human dignity in the technological, cure-dominated health care system (Watson, 2006). The emphasis is on the nurse-patient relationship. The focus is on the people behind the patient and nurse and the caring relationship (Table 7-1). A nurse communicates caring-healing to the patient through the consciousness of the nurse. This takes place during a single caring moment between nurse and patient. A connection forms between the one cared for and the one caring. The model is transformative because the relationship influences both the nurse and the patient for better or for worse (Watson, 2006, 2010). Caring-healing consciousness promotes healing. Application of Watson’s caring model in practice enhances nurses’ caring practices (Box 7-2).

Swanson’s Theory of Caring

Kristen Swanson (1991) studied patients and professional caregivers in an effort to develop a theory of caring for nursing practice. This middle-range theory of caring was developed from three perinatal studies that interviewed women who miscarried, parents and health care professionals in a newborn intensive care unit, and socially at-risk mothers who received long-term public health intervention. All groups were in a perinatal (before, during, or after the birth of a child) setting or context and experienced the phenomenon of caring. Researchers asked each group questions regarding how they experienced or expressed caring in their situations (Swanson, 1999a, 1999b). After analyzing the stories and descriptions of the three groups, Swanson developed a theory of caring. The theory describes caring as consisting of five categories or processes (Table 7-2). Swanson (1991) defines caring as a nurturing way of relating to a valued other toward whom one feels a personal sense of commitment and responsibility. This theory supports the claim that caring is a central nursing phenomenon but not necessarily unique to nursing practice.

Swanson’s work (1991) provides direction for how to develop useful and effective caring strategies. Each of the caring processes has definitions and subdimensions that serve as the basis for nursing interventions. Nursing care and caring are crucial in making positive differences in patients’ health and well-being outcomes (Swanson, 1999a). Thus research findings develop and refine the theory and continue to guide clinical nursing practice (Andershed and Olsson, 2009). For example, Swanson (1999b) tested the effects of caring-based counseling on women’s emotional well-being in the first year after miscarrying. Caring-based counseling was significant in reducing women’s depression and anger, particularly for women in the first 4 months following miscarriage.

Summary of Theoretical Views

Nursing caring theories have common themes. Duffy, Hoskins, and Seifert (2007) identify these commonalities as human interaction or communication, mutuality, appreciating the uniqueness of individuals, and improving the welfare of patients and their families. Caring is highly relational. The nurse and the patient enter into a relationship that is much more than one person simply “doing tasks for” another. There is a mutual give-and-take that develops as nurse and patient begin to know and care for one another (Hudacek, 2008; Sumner, 2010). Caring theories are valuable when assessing patient perceptions of being cared for in a multicultural environment (Suliman et al., 2009). Frank (1998) described a personal situation when he was suffering from cancer: “What I wanted when I was ill was a mutual relationship of persons who were also clinician and patient.” It was important for Frank to be seen as one of two fellow human beings, not the dependent patient being cared for by the expert technical clinician.

Caring seems highly invisible at times when a nurse and patient enter a relationship of respect, concern, and support. The nurse’s empathy and compassion become a natural part of every patient encounter. However, when caring is absent, it becomes very obvious. For example, if the nurse shows disinterest or chooses to avoid a patient’s request for help, his or her inaction quickly conveys an uncaring attitude. Benner and Wrubel (1989) relate the story of a clinical nurse specialist who learned from a patient what caring is all about: “I felt that I was teaching him a lot, but actually he taught me. One day he said to me (probably after I had delivered some well-meaning technical information about his disease), ‘You’re doing an OK job, but I can tell that every time you walk in that door you’re walking out.’ ” In this nurse’s story the patient perceived that the nurse was simply going through the motions of teaching and showed little caring toward the patient. Patients quickly know when nurses fail to relate to them.

As you practice caring, your patient will sense your commitment and willingness to enter into a relationship that allows you to understand the patient’s experience of illness. In a study of oncology patients, one patient described a nurse’s caring as “putting the heart in it” and “having an investment” that makes “patients feel that you are with them” (Radwin, 2000). Thus the nurse becomes a coach and partner rather than a detached provider of care.

One aspect of caring is enabling, when a nurse and patient work together to identify alternatives in approaches to care and resources. Consider a nurse working with a patient recently diagnosed with diabetes mellitus who must learn how to administer daily insulin injections. The nurse enables the patient by providing instruction in a manner that allows the patient to successfully adapt diabetes management strategies such as self-medication, exercise, and diet to his own lifestyle.

Another common theme of caring is to understand the context of a person’s life and illness. It is difficult to show caring for another individual without gaining an understanding of who the person is and his or her perception of the illness. Exploring the following questions with your patients helps you understand their perceptions of illness: How was your illness first recognized? How do you feel about the illness? How does your illness affect your daily life practices? Knowing the context of a patient’s illness helps you choose and individualize interventions that will actually help the patient. This approach is more successful than simply selecting interventions on the basis of your patient’s symptoms or disease process.

Providing Presence

Providing presence is a person-to-person encounter conveying a closeness and sense of caring. Fredriksson (1999) explains that presence involves “being there” and “being with.” “Being there” is not only a physical presence; it also includes communication and understanding. Presence is an interpersonal process that is characterized by sensitivity, holism, intimacy, vulnerability, and adaptation to unique circumstances. It results in improved mental well-being for nurses and patients and improved physical well-being in patients (Finfgeld-Connett, 2006). The interpersonal relationship of “being there” depends on the fact that a nurse is attentive to the patient. Presence can be translated into an actual caring art that affects the healing and well-being of both the nurse and patient. It is often used in conjunction with other nursing interventions such as establishing the nurse-patient relationship, providing comfort measures, providing patient education, and listening. The outcomes of nursing presence include alleviating suffering, decreasing a sense of isolation and vulnerability, and personal growth (Zyblock, 2010). This type of presence is something the nurse offers to the patient in achieving patient care goals.

Nursing requires being present with patients at a moment of crisis or need (Zyblock, 2010). “Being with” is also interpersonal. The nurse gives himself or herself, which means being available and at a patient’s disposal. If patients accept the nurse, they will invite him or her to see, share, and touch their vulnerability and suffering. One’s human presence never leaves one unaffected (Watson, 2008). The nurse then enters the patient’s world. In this presence the patient is able to put words to feelings and understand himself or herself in a way that leads to identifying solutions, seeing new directions, and making choices.

When a nurse establishes presence, eye contact, body language, voice tone, listening, and a positive and encouraging attitude act together to create openness and understanding. The message conveyed is that the other’s experience matters to the one caring (Swanson, 1991). Establishing presence enhances the nurse’s ability to learn from the patient. This strengthens the nurse’s ability to provide adequate and appropriate nursing care.

It is especially important to establish presence and caring when patients are experiencing stressful events or situations. Awaiting a physician’s report of test results, preparing for an unfamiliar procedure, and planning for a return home after serious illness are just a few examples of events in the course of a person’s illness that can create unpredictability and dependency on care providers. The nurse’s presence and caring help to calm anxiety and fear related to stressful situations (Finfgeld-Connett, 2008a, 2008b). Giving reassurance and thorough explanations about a procedure, remaining at the patient’s side, and coaching the patient through the experience all convey a presence that is invaluable to the patient’s well-being.

Touch

Patients face situations that are embarrassing, frightening, and painful. Whatever the feeling or symptom, patients look to nurses to provide comfort. The use of touch is one comforting approach that reaches out to patients to communicate concern and support. Touch is relational and leads to a connection between nurse and patient. It involves contact and noncontact touch. Contact touch involves obvious skin-to-skin contact, whereas noncontact touch refers to eye contact. It is difficult to separate the two. Both in turn are described within three categories: task-oriented touch, caring touch, and protective touch (Fredriksson, 1999).

Nurses use task-oriented touch when performing a task or procedure. The skillful and gentle performance of a nursing procedure conveys security and a sense of competence. An expert nurse learns that any procedure is more effective when administered carefully and in consideration of any patient concern. For example, if a patient is anxious about having a procedure such as the insertion of a nasogastric tube, the nurse offers comfort through a full explanation of the procedure and what the patient will feel. Then the nurse performs the procedure safely, skillfully, and successfully. This is done as the nurse prepares the supplies, positions the patient, and gently manipulates and inserts the nasogastric tube. Throughout a procedure the nurse talks quietly with the patient to provide reassurance and support.

Caring touch is a form of nonverbal communication, which successfully influences a patient’s comfort and security, enhances self-esteem, increases confidence of the caregivers, and improves mental well-being (Osterman et al, 2010). You express this in the way you hold a patient’s hand, give a back massage, gently position a patient, or participate in a conversation. When using a caring touch, you connect with the patient physically and emotionally (Zyblock, 2010).

Protective touch is a form of touch that protects the nurse and/or patient (Fredriksson, 1999). The patient views it either positively or negatively. The most obvious form of protective touch is preventing an accident (e.g., holding and bracing the patient to avoid a fall). Protective touch is also a kind of touch that protects the nurse emotionally. A nurse withdraws or distances herself or himself from a patient when he or she is unable to tolerate suffering or needs to escape from a situation that is causing tension. When used in this way, protective touch elicits negative feelings in a patient (Fredriksson, 1999).

Because touch conveys many messages, use it with discretion. Touch itself is a concern when crossing cultural boundaries of either the patient or the nurse (Benner et al., 2010; Benner, 2004). The patient generally permits task-orientated touch because most individuals give nurses and physicians a license to enter their personal space to provide care (see Box 7-1, p. 80). Know and understand if patients accept touch and how they interpret your intentions.

Listening

Caring involves an interpersonal interaction that is much more than two persons simply talking back and forth (Bunkers, 2010). Listening is a critical component of nursing care and is necessary for meaningful interactions with patients (Shipley, 2010). It is a planned and deliberate act in which the listener is present and engages the patient in a nonjudgmental and accepting manner. It includes “taking in” what a patient says and interpreting and understanding what the patient is saying and then giving back that understanding to the patient (Shipley, 2010). Listening to the meaning of what a patient says helps create a mutual relationship. True listening leads to truly knowing and responding to what really matters to the patient and family.

When an individual becomes ill, he or she usually has a story to tell about the meaning of the illness. Any critical or chronic illness affects all of a patient’s life choices and decisions, sometimes the individual’s identity. Being able to tell that story helps the patient break the distress of illness. Thus a story needs a listener. Frank (1998) described his own feelings during his experience with cancer: “I needed a [health care professional’s] gift of listening in order to make my suffering a relationship between us, instead of an iron cage around me.” He needed to be able to express what he needed when he was ill. The personal concerns that are part of a patient’s illness story determine what is at stake for the patient. Caring through listening enables the nurse to be a participant in the patient’s life.

To listen effectively you need to silence yourself and listen with openness (Fredriksson, 1999). Fredriksson describes silencing one’s mouth and also the mind. It is important to remain intentionally silent and concentrate on what the patient has to say. Give patients your full, focused attention as they tell their stories.

When an ill person chooses to tell his or her story, it involves reaching out to another human being. Telling the story implies a relationship that develops only if the clinician exchanges his or her stories as well. Frank (1998) argues that professionals do not routinely take seriously their own need to be known as part of a clinical relationship. Yet, unless the professional acknowledges this need, there is no reciprocal relationship, only an interaction. There is pressure on the clinician to know as much as possible about the patient, but it isolates the clinician from the patient. By contrast, in knowing and being known, each supports the other (Frank, 1998).

Through active listening you begin to truly know your patients and what is important to them (Bernick, 2004). Learning to listen to a patient is sometimes difficult. It is easy to become distracted by tasks at hand, colleagues shouting instructions, or other patients waiting to have their needs met. However, the time you take to listen effectively is worthwhile, in both the information gained and the strengthening of the nurse-patient relationship. Listening involves paying attention to the individual’s words and tone of voice and entering his or her frame of reference (see Chapter 24). By observing the expressions and body language of the patient, you find cues to help the patient explore ways to achieve greater peace.

Knowing the Patient

One of the five caring processes described by Swanson (1991) is knowing the patient. Knowing the patient comprises both the nurse’s understanding of a specific patient and his or her subsequent selection of interventions (Radwin, 2000). It is essential when providing patient-centered care. Two elements that facilitate knowing are continuity of care and clinical expertise. When patient care is fragmented, knowing the patient declines, and patient-centered care is compromised (Crocker and Scholes, 2009).

Knowing develops over time as a nurse learns the clinical conditions within a specialty and the behaviors and physiological responses of patients. Intimate knowing helps the nurse respond to what really matters to the patient. To know a patient means that the nurse avoids assumptions, focuses on the patient, and engages in a caring relationship with the patient that reveals information and cues that facilitate critical thinking and clinical judgments (see Chapter 15). Knowing the patient is at the core of the clinical decision-making process.

Factors that contribute to knowing the patient include time, continuity of care, team work of the nursing staff, trust, and experience. Barriers to knowing the patient are often related to the organizational structure of the organization and economic constraints. Organizational changes often result in decreasing the amount of time that registered nurses are able to spend with their patients, which in turn affects the nurse-patient relationships. Decreased length of stay also reduces the interactions’ between nurses and their patients (Crocker and Scholes 2009; MacDonald, 2008).

Consequences of not knowing the patient are many. In the acute care setting, not knowing the patient contributes to risk for falls and actual falls (Rush et al., 2008). Patients and their families don’t understand the complexities of treatment and their participation in care (MacDonald, 2008). Finally, patients do not adequately understand their discharge guidelines and may administer their home medications or treatments incorrectly. By establishing a caring relationship, the understanding that develops helps the nurse to better know the patient as a unique individual and choose the most appropriate and efficacious nursing therapies (Hobbs, 2009).

The caring relationships that a nurse develops over time, coupled with the nurse’s growing knowledge and experience, provide a rich source of meaning when changes in a patient’s clinical status occur. Expert nurses develop the ability to detect changes in patients’ conditions almost effortlessly (Benner et al., 2010). Clinical decision making, perhaps the most important responsibility of the professional nurse, involves various aspects of knowing the patient: responses to therapies, routines and habits, coping resources, physical capacities and endurance, and body typology and characteristics. Experienced nurses know additional facts about their patients such as their experiences, behaviors, feelings, and perceptions (Benner et al., 2010; MacDonald, 2008). When you make clinical decisions accurately in the context of knowing a patient well, improved patient outcomes result. When a nurse bases care on knowing a patient, the patient perceives care as personalized, comforting, supportive, and healing.

The most important thing for a beginning nurse to recognize is that knowing a patient is more than simply gathering data about the patient’s clinical signs and condition. Success in knowing the patient lies in the relationship you establish. To know a patient is to enter into a caring, social process, which results in a nurse-patient relationship whereby the patient comes to feel known by the nurse (Bunkers, 2010; MacDonald, 2008).

Spiritual Caring

Spiritual health occurs when a person finds a balance between his or her own life values, goals, and belief systems and those of others (see Chapter 35). Research shows a link between spirit, mind, and body. An individual’s beliefs and expectations have effects on the person’s physical well-being.

Establishing a caring relationship with a patient involves interconnectedness between the nurse and the patient. This interconnectedness is why Watson (2008, 2009, 2010) describes the caring relationship in a spiritual sense. Spirituality offers a sense of connectedness: intrapersonally (connected with oneself), interpersonally (connected with others and the environment), and transpersonally (connected with the unseen, God, or a higher power). In a caring relationship the patient and the nurse come to know one another so both move toward a healing relationship by (Watson, 2008):

Relieving Pain and Suffering

Relieving pain and suffering is more than giving pain medications, repositioning the patient, or cleaning a wound. The relief of pain and suffering encompasses caring nursing actions that give a patient comfort, dignity, respect, and peace. Ensuring that the patient care environment is clean and pleasant and includes personal items makes the physical environment a place that soothes and heals the mind, body, and spirit (Gallagher-Lepak and Kubsch, 2009).

Through skillful and accurate assessment of a patient’s level and type of pain you are able to design patient-centered care to improve the patient’s level of comfort. There are multiple interventions for pain relief, but knowing about the patient and the meaning of his or her pain guides your care (see Chapter 43). Often conveying a quiet caring presence, touching a patient, or listening helps you to assess and understand the meaning of your patient’s pain or discomfort. The caring presence helps you and your patient design goals for pain relief.

Human suffering is multifaceted, affecting a patient physically, emotionally, socially, and spiritually. It also affects the patient’s family and friends. You may find yourself working with a young family whose newborn baby has multiple developmental challenges. Their emotional suffering encompasses anger, guilt, fear, or grief. You cannot fix it, but you can provide comfort through a listening, nonjudgmental caring presence. Patients and their families are comforted by a caring listener (Hudacek, 2008).

Family Care

People live in their worlds in an involved way. Each person experiences life through relationships with others. Thus caring for an individual cannot occur in isolation from that person’s family. As a nurse it is important to know the family almost as thoroughly as you know a patient (Fig. 7-2). The family is an important resource. Success with nursing interventions often depends on their willingness to share information about the patient, their acceptance and understanding of therapies, whether the interventions fit with their daily practices, and whether they support and deliver the therapies recommended.

Families of patients with cancer perceived many nurse caring behaviors to be most helpful (Box 7-3). It is critical that the nurse ensures the patient’s well-being and helps the family members to be active participants. Although specific to families of patients with cancer, these behaviors offer useful guidelines for developing a caring relationship with all families. Begin a relationship by learning who makes up the patient’s family and what their roles are in the patient’s life. Showing the family that you care for and are concerned about the patient creates an openness that then enables a relationship to form with the family. Caring for the family takes into consideration the context of the patient’s illness and the stress it imposes on all members (see Chapter 10).

• Caring is the heart of a nurse’s ability to work with people in a respectful and therapeutic way.

• Caring is specific and relational for each nurse-patient encounter.

• For caring to achieve cure, nurses need to learn the culturally specific behaviors and words that reflect human caring in different cultures.

• Because illness is the human experience of loss or dysfunction, any treatment or intervention given without consideration of its meaning to the individual is likely to be worthless.

• Caring involves a mutual give and take that develops as nurse and patient begin to know and care for one another.

• It is difficult to show caring to individuals without gaining an understanding of who they are and their perception of their illness.

• Presence involves a person-to-person encounter that conveys closeness and a sense of caring that involves “being there” and “being with” patients.

• Research shows that touch, both contact and noncontact, includes task-orientated touch, caring touch, and protective touch.

• The skillful and gentle performance of a nursing procedure conveys security and a sense of competence in the nurse.

• Listening is not only “taking in” what a patient says; it also includes interpreting and understanding what the patient is saying and giving back that understanding.

• Knowing the patient is at the core of the process that nurses use to make clinical decisions.

Clinical Application Questions

Review Questions

American Nurses Association. http://www.nursingworld.org/naf, 2002, [Accessed May 9, 2008].

American Organization of Nurse Executives. Guiding principles for patient care delivery toolkit. http://www.aone.org, 2005. [Accessed July 3, 2011].

Bernick, L. Caring for older adults: practice guided by Watson’s care-healing model. Nurs Sci Q. 2004;17(2):128.

Benner, P. Relational ethics of comfort, touch, solace-endangered arts. Am J Critical Care. 2004;13(4):346.

Benner, P, Wrubel, J. The primacy of caring: stress and coping in health and illness. Menlo Park, Calif: Addison Wesley; 1989.

Benner, P, et al. Educating nurses: a call for radical transformation. Stanford, Calif: Carnegie Foundation for the Advancement of Teaching; 2010.

Bunkers, SS. The power and possibility in listening. Nurs Sci Quarterly. 2010;23(1):22.

Crocker, C, Scholes, J. The importance of knowing the patient in weaning from mechanical ventilation. Nurs Crit Care. 2009;14(6):289.

Drenkard, KN. Integrating human caring science into a professional nursing practice model. Crit Care Nurs Clin North Am. 2008;20:403.

Frank, AW. Just listening: narrative and deep illness. Fam Syst Health. 1998;16(3):197.

Galanti, GA. Caring for patients from different cultures, ed 4. Philadelphia: University of Pennsylvania Press; 2008.

Gallagher-Lepak, S, Kubsch, S. Transpersonal caring: a nursing practice guideline. Holisitic Nurs Pract. 2009;23(3):171.

Leininger, MM, Culture care diversity and universality: a theory of nursing. Pub No 15-2402. New York: National League for Nursing Press; 1991.

MacDonald, M. Technology and its effect on knowing the patient: a clinical issue analysis. Clin Nurse Spec. 2008;22(3):149.

Shipley, SD. Listening a: a concept analysis. Nurs Forum. 2010;45(2):125.

Swanson, K. What is known about caring in nursing science. In: Hinshaw AS, et al, eds. Handbook of clinical nursing research. Sherman Oaks, Calif: Sage Publications, 1999.

Watson, J. Caring science as sacred science. Philadelphia: FA Davis; 2005.

Watson, J. Caring theory as an ethical guide to administrative and clinical practices. Nurs Adm Q. 2006;30(1):8.

Watson, J. The philosophy and science of caring. Boulder: University Press of Colorado; 2008.

Watson, J. Caring science and human caring theory: transforming personal and professional practices of nursing and health care. J Health Human Services Admin. 2009;31(4):466.

Watson, J. Caring science and the next decade of holistic healing: transforming self and system from the inside out. Am Holistic Nurses Assoc. 2010;30(2):14.

Zyblock, DM. Nursing presence in contemporary nursing practice. Nurs Forum. 2010;45(2):120.

Andershed, B, Olsson, K. Review of research related to Kristen Swanson’s middle-range theory of caring. Scand J Caring Sci. 2009;23:598.

Brown, CL, et al. Caring in action: the patient care facilitator role. Int J Human Caring. 2005;9(3):51.

Duffy, JR, Hoskins, L, Seifert, RF. Dimensions of caring: psychometric evaluation of the caring assessment tool. Adv Nurs Sci. 2007;30(3):235.

Finfgeld-Connett, D. Meta-synthesis of caring in nursing. J Clin Nurs. 2006;17:196.

Finfgeld-Connett, D. Qualitative convergence of three nursing concepts: art of nursing, presence, and caring. J Adv Nurs. 2008;63(5):527.

Finfgeld-Connett, D. Qualitative comparison and synthesis of nursing presence and caring. Intl J Nurs Terminol Classifications. 2008;19(3):111.

Fredriksson, L. Modes of relating in a caring conversation: a research synthesis on presence, touch, and listening. J Adv Nurs. 1999;30(5):1167.

Hobbs, JL. A dimensional analysis of patient-centered care. Nurs Res. 2009;58(1):52.

Hudacek, SS. Dimensions of caring: a qualitative analysis of nurses’ stories. J Nurs Educ. 2008;47(3):124.

Osterman, PLC, et al. An exploratory study of nurses’ presence in daily care on an oncology unit. Nurs Forum. 2010;45(3):197.

Radwin, L. Oncology patients’ perceptions of quality nursing care. Res Nurs Health. 2000;23(3):179.

Rush, KL, et al. Patient falls: acute care nurses’ experiences. J Clin Nurs. 2008;18:357.

Suliman, WA, et al. Applying Watson’s nursing theory to assess patient perceptions of being cared for in a multicultural environment. J Nurs Res. 2009;17(4):293.

Sumner, J. A critical lens on the instrumentation of caring in nursing theory. Adv Nurs Sci. 2010;33(1):E17.

Swanson, KM. Empirical development of a middle-range theory of caring. Nurs Res. 1991;40(3):161.

Swanson, KM. Effects of caring, measurement, and time on miscarriage impact and women’s well being. Nurs Res. 1999;48(6):288.

Watson, J, Foster, R. The Attending Nurse Caring Model: integrating theory, evidence and advanced caring-healing therapeutics for transforming professional practice. J Clin Nurs. 2003;12:360.