Chapter 7 Fundys : Caring in Nursing Practice

Watson's Transpersonal Caring

-According to Jean Watson, caring is a central focus of nursing, and it is integral to maintain the ethical and philosophical roots of the profession -Patients and their families expect a high quality of human interaction from nurses; they need conversations with their nurses and caregivers that are meaningful and address their needs -The transpersonal caring theory rejects the disease orientation to health care and places care before cure (Watson, 2008). A nurse who focuses on transpersonal caring looks for deeper sources of inner healing to protect, enhance, and preserve a person's dignity, humanity, wholeness, and inner harmony.

Relieving Symptoms and Suffering

-Performing caring nursing actions that give a patient comfort, dignity, respect, and peace -Providing necessary comfort and support measures to the family or significant others -Creating a physical patient care environment that soothes and heals the mind, body, and spirit -Comforting through a listening, nonjudgmental, caring presence

Spiritual Caring

-Spiritual health is achieved when a person can find a balance between his life values, goals, and belief symptoms and those of others. -Spirituality offers a sense of intrapersonal, interpersonal, and transpersonal connectedness.

Box 7.4 Nurse Caring Behaviors as Perceived by Families

.Providing honest, clear, and accurate information • Listening to patient and family concerns, complaints, and fears • Assisting family with implementing advance directives • Advocating for patient's care preferences and end-of-life decisions • Involving family in care and teaching the family how to keep the relative physically comfortable • Informing the patient and family about the types of nursing services and the people who may enter the personal care area • Providing comfort (e.g., offering warm blanket, rubbing a patient's back) • Reading patient passages from religious texts, favorite book, cards, or mail • Assuring the patient that nursing services will be available • Helping patients do as much for themselves as possible

Allowing for existential-phenomenological-spiritual forces

Allow spiritual forces to provide a better understanding of yourself and your patient.

Caring in Nursing Practice

As you deal with health and illness in your practice, you grow in your ability to care and develop caring behaviors. Caring is one of those human behaviors that we can give and receive. Recognize the importance of self-care. Use caring behaviors to reach out to your colleagues and care for them as well.

Family Care

Caring for an individual includes a person's family. Nurses should help family members be active participants. Learn familial roles.

Touch (Caring)

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

Caring is

Central to nursing practice.

Instilling faith-hope Provide a connection with the patient that offers purpose and direction when trying to find the meaning of an illness.

Cultivating a sensitivity to one's self and to others Learn to accept yourself and others for their full potential. A caring nurse matures into becoming a self-actualized nurse.

Being with- Being emotionally present to the other Being there Conveying ability Sharing feelings Not burdening

Doing for- Doing for the other as one would do for self if it were at all possible Comforting Anticipating Performing skillfully Protecting Preserving dignity

Box 7.2 EBP: Enhancing Caring

Enhancing Caring PICOT Question: Do carative practices of nurses affect patient satisfaction among hospitalized and long-term care adult patients? Evidence summary Researchers identify a strong, positive relationship between nurse caring behaviors and patient satisfaction. Patients feel that their care is individualized when nurses listen to their stories and concerns, and as a result they report greater satisfaction (Brewer and Watson, 2015). While the promotion of caring, compassionate, supportive, and therapeutic environments increases patient satisfaction, these factors also increase nurses' job satisfaction (Nightingale et al., 2018). Evidence shows that patient and family caregiver satisfaction improves when nurses demonstrate caring behaviors when including patients' specific requests into their care or communicating the reasons why these requests cannot be met immediately (Wyant et al., 2017). Caring nursing practices also help to improve patients' functional status, self-efficacy, coping, and self-care (Su et al., 2020; Ortiz, 2018). Finally, patient-centered care models emphasize that caring interventions promote patient advocacy and predict patient satisfaction (Compton et al., 2018). Application to nursing practice • Use the caring practices of listening, presence, and connectedness to partner with a patient and family through their illness. Use these practices with humility, love, kindness, and compassion (Nightingale et al., 2018). • Ask patients whether they have questions about their illness, treatment, or home care needs (Compton et al., 2018). • Knowing the patient enables you to partner with a patient and family caregiver to obtain vital health care information; understand the patient's health care priorities, expectations, and fears; explore the meaning of the illness; and when necessary help with end-of-life decision making (Murali, 2020; Compton et al., 2018). • Being with and doing for a patient are components of presence, whether it is a dedicated one-on-one physical interaction or quietly sitting with a patient (Mohammadipour et al., 2017). Presence often helps elicit important health care information from a patient and reduces patient fear and anxiety. • Caring nursing practices benefit nursing and nursing staff by reducing workplace stress and increasing job satisfaction (Wei et al., 2019; Nightingale et al., 2018).

Bix 7.1 Watsons 10 Carative Factors

Forming a human-altruistic value system Use loving kindness to extend yourself. Use self-disclosure appropriately to promote a therapeutic alliance with your patient (e.g., share a personal experience in common with your patient such as a child-rearing experience, an illness, or an experience with a parent who needs assistance).

Task oriented touch

Involves the personal contact required when performing nursing procedures

Swanson's Theory of Caring - 5 processes

Knowing- Striving to understand an event as it has meaning in the life of the other Avoiding assumptions Centering on the one cared for Assessing thoroughly Seeking clues to clarify the event Engaging the self or both

Enabling- Facilitating the other's passage through life transitions (e.g., birth, death) and unfamiliar events Informing/explaining Supporting/allowing Focusing Generating alternatives Validating/giving feedback

Maintaining belief- Sustaining faith in the other's capacity to get through an event or transition and face a future with meaning Believing in/holding in esteem Maintaining a hope-filled attitude Offering realistic optimism "Going the distanc

Providing for a supportive, protective, and/or corrective mental, physical, societal, and spiritual environment Create a healing environment at all levels, physical and nonphysical. This promotes wholeness, beauty, comfort, dignity, and peace.

Meeting human needs Intentionally help patients meet basic needs with a caring consciousness.

Box 7.3 Factors and Items Constituting the Caring Assessment Tool

Mutual problem solving • Help me understand how I am thinking. • Ask me how I think treatment is going. • Help me explore alternative ways of dealing. • Ask me what I know. • Help me figure out questions to ask. Attentive reassurance • Are available. • Seem interested. • Support sense of hope. • Help me believe in self. • Anticipate my needs. Human respect • Listen to me. • Accept me. • Treat me kindly. • Respect me. • Pay attention to me. Encouraging manner • Support my beliefs. • Encourage me to ask questions. • Help me to see some good. • Encourage me to go on. • Help me deal with bad feelings. Appreciation of unique meanings • Are concerned with how I view things. • Know what is important to me. • Acknowledge my inner feelings. • Show respect for things having meaning. Healing environment • Check up on me. • Pay attention to me when I am talking. • Make me feel comfortable. • Respect my privacy. • Treat my body carefully. Affiliation needs • Are responsive to my family. • Talk openly with my family. • Allow my family to be involved. Basic human needs • Make sure I get food. • Help me with routine needs for sleep. • Help me feel less worried.

Listening

Necessary for meaningful interactions with patients. True listening leads to knowing and responding to what really matters to a patient and family. To listen effectively you need to silence yourself and listen with an open mind. Through active listening you begin to truly know your patients and what is important to them.

Box 7.1 Cultural Aspects of Care

Nurse Caring Behaviors Caring includes knowing your patient's cultural values and beliefs; respecting privacy, diversity, and individual needs; and interacting and listening to the patient and family (Colman, 2019). Having a sense of what it is like to live in a patient's world is critical. To provide culturally sensitive patient-centered care, you must understand and respect the impact of a patient's cultural beliefs and values on health condition, treatments, and self-care habits. Implications for patient-centered care • Collect a culturally based nursing history by letting patients tell their stories and listening to them (Chapter 9). • Know and clarify a patient's beliefs, attitudes, and cultural practices regarding health care, caring practices, and end-of-life-care (Zolnierek, 2014; Colman, 2019). • Determine whether a member of a patient's family or cultural group is the best resource to guide the use of caring practices, such as providing presence or touching (Merritt et al., 2019; Marion et al., 2017). • Encourage the patient and the family caregiver, if appropriate, to share the perspective of the personal impact of the patient's illness/trauma (Mohammadipour et al., 2017). • Know the patient's cultural practices (such as touching, family involvement) or beliefs that impact the uncertainty related to diagnoses, treatments, and outcomes of care (Markey et al., 2018).

Box 7.1 Cultural Aspects of Care: Nursing Caring Behaviors

Nurse Caring Behaviors Caring includes knowing your patient's cultural values and beliefs; respecting privacy, diversity, and individual needs; and interacting and listening to the patient and family (Colman, 2019). Having a sense of what it is like to live in a patient's world is critical. To provide culturally sensitive patient-centered care, you must understand and respect the impact of a patient's cultural beliefs and values on health condition, treatments, and self-care habits. Implications for patient-centered care • Collect a culturally based nursing history by letting patients tell their stories and listening to them (Chapter 9). • Know and clarify a patient's beliefs, attitudes, and cultural practices regarding health care, caring practices, and end-of-life-care (Zolnierek, 2014; Colman, 2019). • Determine whether a member of a patient's family or cultural group is the best resource to guide the use of caring practices, such as providing presence or touching (Merritt et al., 2019; Marion et al., 2017). • Encourage the patient and the family caregiver, if appropriate, to share the perspective of the personal impact of the patient's illness/trauma (Mohammadipour et al., 2017). • Know the patient's cultural practices (such as touching, family involvement) or beliefs that impact the uncertainty related to diagnoses, treatments, and outcomes of care (Markey et al., 2018).

Summary of Theoretical Views

Nursing caring theories have common themes. Caring is highly relational. Caring theories are valuable when assessing patient perceptions of being cared for in a multicultural environment. Enabling is an aspect of caring. Knowing the context of a patient's illness helps you choose and individualize interventions that will actually help the patient.

Developing a helping, trusting, human caring relationship Learn to develop and sustain helping, trusting, authentic caring relationships through effective communication with your patients.

Promoting and expressing positive and negative feelings Support and accept your patients' feelings. In connecting with your patients, you show a willingness to take risks in sharing in the relationship.

Using creative problem-solving, caring processes Apply critical thinking in the nursing process to systematically make sound clinical judgments.

Promoting transpersonal teaching-learning Learn together while educating the patient to acquire self-care skills. The patient assumes responsibility for learning.

Protective Touch

Protective touch is a form of touch that protects a nurse and/or patient. A patient views it either positively or negatively. The most obvious form of protective touch is in preventing an accident (e.g., holding and bracing a patient to avoid a fall). Protective touch can also protect a nurse emotionally.

Providing Presence

Providing presence is a person-to-person encounter conveying a closeness and sense of caring. Presence involves "being there" and "being with." Nursing presence is the connectedness between a nurse and a patient. Establishing presence strengthens your ability to provide effective patient-centered care.

Table 7.3 Comparison of Research Studies Exploring Nurse Behaviors

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The Challenges of Caring

Task-oriented models and institutional demands Technology Cost-cutting measures Stressors that place nurses at risk for burn out and compassion fatigue - If health care is to make a positive difference in patients' lives, health care must become more holistic and humanistic.

What is the Caring Assessment Tool ?

The Caring Assessment Tool (CAT) was developed to measure caring from a patient's perspective (Duffy et al., 2007). This tool and other caring assessments help you, as a beginning professional, to appreciate the types of behaviors that patients in the hospital identify as caring

Knowing the Patient

The core of clinical decision making and patient-centered care Two elements that facilitate knowing are continuity of care and clinical expertise. Factors of knowing include: ØTime ØContinuity of care ØTeamwork of the nursing staff ØTrust Experience

Leininger's Culture Care Theory

Theory of cultural care diversity and universality Integrates patients' cultural traditions, values and beliefs into care plans Middle-range theory

When do patients become active in the care of plan ?

When patients sense that health care providers are sensitive, sympathetic, compassionate, and interested in them as people, they usually become active partners in the plan of care.

Patients Perspective of Caring

You need to understand patients' perceptions of caring and the association between these perceptions and their satisfaction of care

Non-contact touch

eye contact

Caring is a universal phenomenon influencing the ways in which people think, feel, and behave in relation to one another

•Caring and compassion interventions need to be taught and practiced early in nursing education and emphasized in all clinical practice settings

What does caring improve ?

•Caring improves a nurse's ability to know a patient, recognize a patient's problems, and find and implement individualized solutions

Ethic of Care

•The nurse is the patient's advocate, helps solves ethical dilemmas by attending to relationships and giving priority to each patient's unique personhood Caring is an interaction of mutual respect and trust. The term "ethic" refers to the ideals of right and wrong behavior. An ethic of care is concerned with relationships between people and with a nurse's character and attitude toward others.

Productivity efficiency

•can interfere with nurses' capacity to be caring, compassionate professionals; can threaten nurses' opportunities to establish therapeutic relationships and interpersonal connections with patients and family caregivers

Spirituality offers a sense of connectedness

•intrapersonally (connected with oneself) •interpersonally (connected with others and the environment) •transpersonally (connected with the unseen, God, or a higher power)