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Review of Research Related to Watson's Theory of Caring

Marlaine Smith
Nurs Sci Q 2004 17: 13
DOI: 10.1177/0894318403260545

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 Review of Research
Related to Watsons Theory of Caring
Marlaine Smith, RN; PhD; HNC; FAAN
Professor and Associate Dean for Academic Affairs,
University of Colorado, Health Sciences Center, Denver, Colorado
Forty retrievable studies are reviewed, covering the period of 1988 to 2003, that were based on Watsons theory of
caring. The author provides an overview of the studies, identifies measurement instruments developed, critiques the
body of work, and offers suggestions for future research.
Jean Watsons theory of human caring was introduced to
the nursing community in 1979 with Nursing: The Philoso-
phy and Science of Caring. Since then she has published two
other books (Watson, 1985, 1999) and numerous chapters
and journal articles elaborating her philosophical and theoret-
ical ideas. Informed by this body of work researchers sought
to test the theory, expand elements of the theory, develop
measurement tools, and evaluate practice models based on
the theory. The purpose of this column is to review the body of
research related to Watsons theory of transpersonal caring. A
comprehensive summary and an analysis of the research will
be presented including strengths, weaknesses, and suggested
directions for the future.
Two reviews of the caring literature have been published.
Swanson (1999) summarized and categorized the research re-
lated to caring in nursing science and Sherwood (1997) com-
pleted a meta-synthesis of the qualitative research on caring.
These reviews addressed all research on caring and included
studies from different theoretical perspectives and atheoreti-
cal work on caring in nursing. This review is different in that it
is focused only on research that has been identified explicitly
as related to Watsons theory.
Process of the Review
This review was approached by first identifying the body
of research related to Watsons theory. PubMed and CINAHL
databases were searched by entering Watsons theory of car-
ing and research as key terms. Next, comprehensive bibliog-
raphies, for example, the bibliography from Fawcetts (2000)
chapter on Watsons theory and the comprehensive bibliogra-
phy on Jean Watsons web page, were explored. These lists
were scanned for articles that suggested empirical research,
defined as any systematic inquiry in which researchers col-
lected or generated data from human subjects to answer re-
search questions. Any research identified by authors as
aligned with Watsons theory was included. Examples of this
Nursing Science Quarterly, Vol. 17 No. 1, January 2004, 13-25
DOI: 10.1177/0894318403260545
2004 Sage Publications
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alignment could be references to Watson in the theoretical
framework, development of the research instrument using con-
structs from the theory, or testing of a practice model based on
the theory. There were over 50 doctoral dissertations and
masters theses identified in this search; however, these were
not included in the review. Each relevant article was acquired,
read, and analyzed according to categories in Table 1.
Overview of Studies
Forty studies were reviewed. These studies are summa-
rized in Table 1 by purpose, design, participants, process
for data collection/generation, and findings. The first study
appeared in the literature in 1988, and the most recent study
was published in 2003. The years of publication show a sus-
tained trajectory of research. Three studies were published in
the late 1980s, indicating an understandable gap between
Watsons original theoretical work and the beginning devel-
opment of empirical work based on the theory. Thirty-two
studies were published in the 1990s, with at least one pub-
lished each year. Since 2000, five studies and Watsons
(2000) text on measuring outcomes of caring have been pub-
lished. This body of work appears as chapters in 5 books and
22 different journals, including the highest quality research
journals in nursing. Seven of the studies were completed by
researchers in four countries other than the United States,
confirming the international appeal of Watsons theory. Di-
verse designs and methods have been used to answer the
research questions including phenomenology, quantitative
descriptive surveys, and quasi-experimental designs using
standardized scales and physiological measurement.
Categories of Research
An analysis of the published studies revealed four major
categories of research related to Watsons theory. These are:
(a) The nature of nurse caring; (b) nurse caring behaviors as
perceived by clients and nurses; (c) human experiences and
Keywords: caring, nursing research, Watsons theory
14 Nursing Science Quarterly, 17:1, January 2004
caring needs; and (d) evaluating outcomes of caring in nurs-
ing practice and education. Each will be discussed.
The nature of nurse caring was investigated in nine studies.
Swedish researchers Jensen, Back-Petterson, and Segesten
(1993, 1996) conducted two of these studies. Findings from
these studies closely correspond to Watsons theoretical de-
scription of the actual caring occasion. In a case study,
Beauchamp (1993) identified themes of dignity, love, secu-
rity, presence, respect, and sensitivity that closely corre-
sponded to Watsons descriptions of the essences of caring.
Two studies (Clayton, 1989; Miller, Haber, & Byrne, 1992)
investigated caring from patients and nurses perspectives.
Swanson (1991) developed a middle-range theory of caring
informed by Watsons grand theory. Her theory was derived
from three studies (Swanson-Kauffman, 1986; Swanson,
1990) on women who miscarried, caregivers in the NICU,
and at-risk mothers. Finally, Wolf, Giardino, Osborne, and
Ambrose (1994) identified dimensions of nurse caring
through factor analysis of the Caring Behaviors Inventory.
The second area of research related to Watsons theory is
nurse caring behaviors as perceived by clients or nurses.
Fourteen studies clustered in this area. Cronin and Harrisons
(1988) landmark study of nurse caring behaviors as perceived
by patients following a myocardial infarction became a tem-
plate for others. Their Caring Behaviors Assessment Scale,
based on the carative factors, was used in its original or modi-
fied form in 7 of these 14 studies (Baldursdottir & Jonsdottir,
2002; Cronin & Harrison, 1988; Huggins, Gandy, & Kohut,
1993; Marini, 1999; Mullins, 1996; Parsons, Kee, & Gray,
1993; Schultz, Bridgham, Smith, & Higgins, 1998). Other
studies used another instrument or interview (Lemmer, 1991;
McNamara, 1995; Nyberg, 1990; Rosenthal, 1992; Ryan,
1992; Smith & Sullivan, 1997). This body of inquiry included
participants from a variety of acute care settings. Items that
were rated highly as nurse caring behaviors by recipients of
care across studies were: knowing what they are doing, know-
ing when it is necessary to call the doctor, knowing how to
give shots and intravenous therapy, knowing how to handle
equipment, knowing how to handle life-threatening changes,
giving treatments and medications on time, and providing
good physical care. Nurses who were surveyed seemed to
take the items related to competence and technical activities
more for granted, in that they rated nurse caring behaviors
such as viewing the patient as unique, being with the patient,
listening to the patient, laughing and crying with the patient,
honoring the dignity of the person, and touching as the most
important caring behaviors. This seems to suggest that nurses
do not include competence with medical and technical skills
in the realm of nurse caring behaviors as recipients of care do,
especially those in life-threatening situations.
Human experiences and caring needs is the third area of
research related to Watsons theory. Seven studies were in
this category and included lived experiences of growing up
with cystic fibrosis (Tracy, 1997), living in a nursing home
(Running, 1997), a caring occasion for depressed women
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(Mullaney, 2000), living with adult polycystic kidney disease
(Martin, 1991), the caring needs of caregivers of newly dis-
abled adults (Weeks, 1995), people with rheumatoid arthritis
(Nyman & Lutzen, 1999), and spouses caring for their dying
loved one (Andershed & Ternestedt, 1999). In all but one of
these studies researchers sought descriptions of experiences
and needs through interviews, and themes were constructed
from the qualitative data. Because each study is so different, it
is difficult to identify commonalities. Themes are: the recog-
nition of the importance of subjective experience and under-
standing the other through listening to their stories; a focus on
the inherent wholeness of the person, rather than the label of
disease or disability; and the search for meaning in the un-
certainty of these experiences.
The final area of research related to Watsons theory is
evaluating caring practices or curricula. There were 11 stud-
ies in this area. Six (Leenerts, Koehler, & Neil, 1996; Neil &
Schroeder, 1993; Schroeder, 1993a, 1993b; Schroeder &
Maeve, 1992; Smith, 1997) evaluated the Denver Nursing
Project in Human Caring including the nursing care partner-
ship model, a care management model based on Watsons
theory. The evaluation revealed that nurses appreciated the
model because it was growth-producing and challenging,
facilitated teaching and learning, and enhanced ability to sup-
port each other and coordinate care. Nursing documentation
changed, referring more consistently to carative factors. Sur-
veys showed that nurse care partnerships were viewed as sup-
portive and helpful by the clients. Focus group interviews
revealed endorsements related to caring behaviors, support
groups/peer support, treatments, the non-clinical environ-
ment and education/information. Two evaluation studies
were reviewed. In an evaluation of a curriculum for practicing
nurses based on Watsons theory, nurses reported being more
intentionally present in brief encounters and expressed sat-
isfaction that skills were enhanced (Updike, Cleveland, &
Nyberg, 2000). An evaluation of a caring curriculum using a
newly-developed Caring Efficacy Scale (Coates, 1997) re-
vealed significant correlations between graduates ratings of
caring efficacy and preceptors ratings of competence, and
alumni ratings of caring efficacy and clinical competence.
This suggests the integration of caring and competence in
nursing practice. Three studies examined the relationship be-
tween caring practices and outcomes. Duffy (1992) found a
positive relationship between nurse caring and patient satis-
faction. In a Watson study of health-related outcomes, Smith,
Kemp, Hemphill, and Vojir (2002) examined the effect of
massage and nurse interaction on pain, symptom distress,
sleep quality, and anxiety for patients with cancer. Massage
was framed as an ontological competency or nursing art-act.
Anxiety improved for those in both groups supporting the
theory that nursing presence in any form may lessen anxiety.
The decrease in pain and symptom distress could be attrib-
uted to massage. In the second study, patients with hyperten-
sion who were treated by nurses practicing from a Watson
theory-based practice model had a significant decrease in sys-

tolic and diastolic blood pressure and greater general well-
being (Erci et al., 2003). While the study design is flawed
because of the lack of a control group, it is an important turn
in the research related to Watsons theory. Both of these
studies attempt to link healing outcomes with caring.
Measurement Instruments
Watsons (2002) text describes measurement issues in car-
ing science and the existing instruments that measure caring.
Five of those measurement tools are based on Watsons the-
ory. These were: (a) the Caring Behavior Inventory and re-
vised Caring Behavior Inventory (Wolf et al., 1994); (b) the
Caring Behavior Assessment Tool (Cronin & Harrison,
1988); (c) the Nyberg Caring Attribute Scale (Nyberg, 1990);
(d) the Caring Assessment Tool (Duffy, 1992); and (e) the
Caring Efficacy Scale (Coates, 1997). For details see Watson
(2002).
Strengths, Weaknesses, and
Directions for Future Research
Through this analysis strengths, weaknesses, and direc-
tions for future research related to Watsons theory have been
identified. One notable strength is the sustained level of work
with the theory since the late 1980s until now. Another is the
level of international interest in research related to Watsons
theory. Together, these confirm the pragmatic value of the
theory, that is, its ability to spawn avenues of inquiry, its pro-
vocative value in generating widespread interest, and its
transcultural appeal. The diversity of the designs and methods
used to answer research questions is another strength. The on-
tological and epistemological foundations of the theory allow
for a research tradition that encompasses a variety of ap-
proaches to inquiry. The phenomena that have been studied
are varied; most focus on the caring relationship. The qualita-
tive work describing the experience of caring has produced
empirical support for Watsons theoretical ideas. In addition,
the development of Swansons middle-range theory confirms
the evolution of the theory through empirical work. There has
been an ongoing and in-depth pattern of inquiry into the per-
ceptions of caring behaviors by varied recipients of care; this
research has yielded rather consistent findings that can in-
form practice. In these studies care recipients and nurses have
been asked to rate the most important nurse caring behaviors.
The incongruence between their perceptions may be ex-
plained through the dialectic of medico-technological com-
petence and the transpersonal dimensions of caring. Incom-
petent practice cannot be perceived as caring in any situation.
On the other hand, the highest levels of medico-technological
competence do not necessarily reflect transpersonal caring. It
is important to note that these studies do not say that care re-
cipients accept a lack of caring. It only asks them to prioritize
caring behaviors. In life threatening situations, behaviors
viewed as sustaining life surface as most important. Nurses,
however, assume the importance of competence, and describe
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Research Issues 15
something more and different as caring. Caring is a way of
being in which the nurse attends to the person in those ways
necessary to support health, healing, and quality of life. In
some situations this calls for a high degree of technical skills;
in others it may not. So technological competence is inte-
grated into caring in some nursing roles. Another strength of
this research is the recent focus on the relationship between
caring and healing through evaluation of theory-guided prac-
tice models and the ontological competencies of Watsons
theory. These studies will be part of the next generation of
research stemming from Watsons most recent theoretical
work. In tandem, Watsons (2002) book on the fit of mea-
surement with the theory, including a compendium of in-
struments that measure caring is a great contribution to caring
science in general, and her own theory in particular.
There are several weaknesses in this body of research.
First, the research is lagging behind Watsons most recent
theoretical work. This is expected; however, it can create
some confusion. Watsons theory has evolved significantly,
and inquiry related to her early work on the carative factors
was in process as her theoretical thinking moved toward a
more unitary-transformative worldview. Another weakness
is that many of the published studies have weak theoretical-
empirical linkages, that is, the relationship of the findings to
the theory are not explicit. In this way the findings are less
able to extend, expand, or modify theoretical assertions. The
qualitative studies on lived experiences are so heterogeneous
that it is difficult to discern the connection to Watsons theory.
Qualitative work expanding an understanding of relational
phenomena and their connection to healing would be more
relevant to Watsons theory.
The future of research within Watsons theory is very
promising. International interest in her theory is growing;
several theory-guided practice models have been developed
and are being evaluated; and there is growing interest in the
phenomenon of caring-healing relationships. A recent paper
(Quinn, Smith, Ritenbaugh, Swanson, & Watson, 2003) con-
tained a summary of research guidelines for assessing the
impact of the caring-healing relationship in nursing. These
guidelines can be applied to future research related to
Watsons theory. Important research questions are yet to be
answered, for example,
What are the particular qualities of relationship that facilitate
healing? What part does intentionality and energy play in the
caring-healing relationship? What are appropriate indicators
of healing, particularly healing that doesnt include curing,
and what are appropriate measures of these indicators?
(Quinn et al., 2003, p. 2A)
What difference do caring relationships make in the lives of
those we care for? What are the qualities of environments and
communities that are considered to be caring? Other guide-
lines developed in this paper may guide future research. Re-
search methods need to reflect the nature of the caring-
healing relationship (Quinn et al., 2003, p. 6A). With this
principle in mind both members of the relationship should
16 Nursing Science Quarterly, 17:1, January 2004

participate in studies of the meaning or impact of the relation-
ship. Multiple ways of knowing are required to explore the
full range of multidimensional questions raised about the
healing relationship (Quinn et al., 2003, p. 7A). A model of
research that integrates multiple perspectives and ways of
knowing is a preferred epistemological model for studying
the caring-healing relationship.
Watsons theory of transpersonal caring and the empirical
work related to it have made a significant and lasting impact
on nursing science. Future research is promising in address-
ing important questions about the relationship of caring,
health, and healing. Researchers are encouraged to build on
the strengths of the past and address the current gaps as they
chart a path toward greater understanding of caring.

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Author(s) and
Year of Publication Aims or Research Question(s)
Andershed & To identify and categorize family members Qualitative descriptive us-
Ternestedt (1999) involvement in the care of a dying rela- ing Glaser and Strausss
tive and to examine findings in light of constant comparative
Watsons and Swansons theories. method of data analysis
Baldursdottir & To identify which nurse caring behaviors
Jonsdottir (2002) are perceived by patients in an emer-
gency department (ED) as important
indicators of caring.
Beauchamp (1993) To understand the phenomenon of caring
and how a dissonant situation evolved
into one of harmony.
Clayton (1989) To investigate the phenomenon of
transpersonal caring interactions between
elderly individuals and nurses; and to de-
termine the caring needs of the institu-
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tionalized elderly.
Coates (1997) To determine the initial reliability and va-
lidity of the self-report and supervisors
version of the Caring Efficacy Scale.
17
Table 1
Studies Related to Watsons Theory of Human Caring
Design and Methods
6 spouses of persons with
Quantitative descriptive
survey
Descriptive qualitative sin-
gle case study
Grounded theory and
phenomenological
interviews
Part of evaluation of educa-
tional effectiveness for
program accreditation;
quantitative survey;
correlational analysis
Participants
(population and number)
Observations in care settings;
grave, incurable cancer of
colon, liver, or bile duct
182 people who had been
patients in the ED; non-
probability convenience
sample; 62% response rate
One person with HIV/AIDS
and those involved in his
lifeworld
Four elder-nurse dyads. The
elders were over 65 and
residents of a nursing home.
110 students, 119 alumni of
bachelor of science, nursing
doctorate, and master of sci-
ence programs and 63 pre-
ceptors of students and 113
employers of nursing alumni
completed the long or short
form of the Caring Efficacy
Scale.
Form of and Processes for
Collecting or Generating Data
Three main categories: To know, to be, and
15 interviews and 23 informal
conversations during final
period of life and 1-3 months
following death
Caring Behaviors Assessment
Tool. Surveys mailed 2 weeks
post discharge from ED.
Continuing interviews with per- Themes of dignity, love, security, presence,
son and others significant to
his life.
Elders described an experience Four recurring themes were identified by
with a nurse that stood out as
a peak or highlight expe- tivity to their feelings before and after
rience. Met 4-6 times.
Students and alumni received
the Caring Efficacy Scale and
preceptors of students and
employers of alumni received
the Clinical Evaluation Tool
which assesses caring
competence.
Findings
to do. Spouses were:1) seekers of knowl-
edge through their loved one, the staff,
and others; 2) present to their loved one
and in his or her world; acting as the con-
tact person for their loved one. Findings
were consistent with caring relationships
in Watsons theory, that is, presence, hu-
manistic-altruistic systems of values, and
assisting patients to meet basic human
needs while preserving dignity and
wholeness.
Most important nurse caring behaviors
were: know what they are doing; know
when it is necessary to call the doctor;
know how to give shots; IVs, etc.; and
know how to handle equipment. The
subscale human needs assistance was
ranked highest.
respect, and sensitivity emerged as
themes.
nurses and patients: 1) heightened sensi-
the caring interaction; 2) existence of a
helping-trusting relationship; 3) environ-
ment that was supportive, protective, and
permissive; 4) appreciation of existential
predicament and need to find meaning.
Elders needed protection and independ-
ence, to share life events, and to know
how they were doing daily.
There were significant correlations between
graduates ratings of caring efficacy and
clinical competence. There were no sig-
nificant correlations between graduates
ratings of caring efficacy and preceptors
ratings of competence and graduates and
preceptors ratings of competence. Em-
ployer and alumni ratings of competence
are significantly related and alumni rat-
ings of their own caring and clinical
competence are significantly related.
(continued)
 18
Table 1 (continued)
Author(s) and Participants Form of and Processes for
Year of Publication Aims or Research Question(s) Design and Methods (population and number) Collecting or Generating Data Findings

Cronin & Harrison To identify nursing behaviors perceived as Quantitative and qualitative 22 hospitalized patients in Interviews using an open-ended Nursing actions related to presence, compe-
(1988) indicators of caring by patients who have descriptive transitional care units who question and the Caring Be- tence, physical care, monitoring, teach-
had a myocardial infarction. had myocardial infarctions haviors Assessment tool ing and kindness were top-rated.
Duffy (1992) To measure the relationships between nurse Descriptive correlational 86 patients with a medical/sur- Patients completed Caring As- Positive relationship between nurse caring
caring behaviors and patient satisfaction, gical diagnosis, randomly sessment Tool, Patient Satis- and patient satisfaction (r = .46, p <
health status, length of stay and nursing selected faction visual analogue scale, .001); no relationship between nurse car-
care costs. Sickness Impact Profile, and ing and perceived health, length of stay,
Medicus Classification Tool and costs.
Erci et al. (2003) To determine the effectiveness of a nurses One group pre-test and 52 patients with hypertension Nurses educated in a theory- There were statistically significant differ-
caring relationship according to Watsons post-test quasi- in four healthcare units in guided practice model based ences between pre and posttest mean
caring model on the blood pressure and experimental design Turkey on Watsons theory visited scores of general well-being, physical
the quality of life of patients with patients and their families symptoms and activity, medical interac-
hypertension. once a week in their homes tion, and systolic and diastolic blood
for three months. Blood pres- pressure.
sure and quality of life were
outcomes.
Huggins, Gandy, & To identify which behaviors performed by Quantitative descriptive 288 ambulatory patients Interviews within 30 days of Patients assigned the highest percentages of
Kohut (1993) emergency department nurses were per- treated in the ED; 81 pa- discharge; Modified Caring must be present to the following: know
ceived by patients as important indicators tients were seeking emer- Behavior Assessment Scale; how to handle sudden, life threatening

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of caring. gent care, 99 urgent care, satisfaction with care; and changes; know what they are doing;
and 108 non-urgent care. evaluation of their medical know how to give shots, start IVs, know
condition how to give treatments, tests or meds;
know how to handle equipment; and
know when to call the doctor to see you.
Jensen, Back- To identify and describe the characteristics Qualitative descriptive 16 nurses identified by their Nurses were asked to describe The green thumb nurse has three character-
Pettersson, & of green-thumb nurses and of caring exploratory managers as having a spe- characteristics of caring istics: competence, compassion, and
Segesten (1993) situations. cial talent in caring for nurses and to describe a car- courage. Caring moment equals mutual
people. ing moment. attention, harmony, trust, and time
stopping.
Jensen, Back- To describe essential characteristics of an Qualitative descriptive 10 women who had breast can- Women described characteris- Four main characteristics of an excellent
Pettersson, & excellent nurse as perceived by women exploratory cer surgery and treatment tics of an excellent nurse. nurse emerged: competence, compassion,
Segesten (1996) with breast cancer. courage, and concordance.
Leenerts, Koehler, To identify and describe clients perceptions Descriptive 75 clients at a nurse-managed Qualitative surveys, interviews Nursing care partnerships reduced
& Neil (1996) of care at the Denver Nursing Project in center for those with HIV/ healthcare costs. Savings in potential
Human Caring; and to explore cost-effec- AIDS hospital costs were estimated at
tiveness of the nursing care partnership $1,590,384.
model.
 Lemmer (1991) What do bereaved parents perceive as ex-
pressions of caring by nurses and physi-
cians during perinatal bereavement?
Marini (1999) To identify which behaviors performed by
nursing staff were important indicators of
caring as perceived by older adults resid-
ing in institutional settings.
Martin (1991) To understand the experiences of persons
with adult polycystic kidney disease
(APKD).
McNamara (1995) To determine how caring is practiced in
perioperative nursing.
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Miller, Haber, & To understand the lived experience of a car- Phenomenological study
Byrne (1992) ing nurse-patient interaction from the
perspective of nurses and hospitalized
patients.
Mullaney (2000) To describe the essential structure of the
lived experience of depressed women
who enter therapy and experience Wat-
sons actual caring occasion within the
transpersonal caring relationship.
19
Qualitative descriptive ex-
ploratory with grounded
theory methods
Quantitative descriptive
Qualitative descriptive
Qualitative descriptive
Phenomenological
(Spiegelbergs method)
28 participants who were cou-
ples who had experienced a
third trimester stillbirth or a
neonatal death. The loss oc-
curred no earlier than 3
weeks and no later than
within 14 months of the
interview.
21 residents of long-term care
or assisted living facilities
92 people with adult polycystic 30-60 minute interviews using
kidney disease
Five nurses who worked in a
perioperative setting.
15 patients and 16 nurses from Response to: Tell me about a
3 adult medical-surgical
units
11 women diagnosed with de-
pression who met with a
therapist over a 6 month
period.
Participants were interviewed
using a general interview
guide. Interviews were taped
and transcribed.
Participants completed the Car-
ing Behavior Assessment.
open-ended questions
Interviews using a semi-struc-
tured guide
caring nurse-patient interac-
tion you have experienced or
in which you provided
caring.
Therapists notes of the clients
verbalizations and behavioral
responses.
Two major categories of caring by nurses
and physicians were: Taking care of and
caring for and about. Taking care of in-
cluded activities that were designed to
meet physiological and safety needs and
subcategories were providing expert care
and providing information. Caring for or
about included those activities demon-
strating a sensitivity to and an empathic
awareness of the emotional pain of be-
reavement and a desire to help them
through it.
The highest indicator of nurse caring fo-
cused on the nurses technical competen-
cies or instrumental activities. Humanis-
tic caring or expressive activities was the
second most important indicator of care
and included being treated as an individ-
ual; with respect; keeping family in-
formed of progress; and not giving up on
a person when difficult.
Four major themes were: knowledge about
APKD; attitudes toward APKD; attitudes
toward genetic testing; and family plan-
ning decisions. These were related to
Watson s theory.
Themes related to caring practices and be-
haviors during the preoperative,
intraoperative, and postoperative phases
were identified. Themes included: view-
ing patients as unique human beings; be-
ing with patients; using touch.
Themes were: holistic understanding,
connectedness/shared humanness, pres-
ence, anticipating and monitoring needs,
and beyond the mechanical. An exhaus-
tive description of the caring nurse-pa-
tient interaction was developed.
Five themes were: feeling understood; feel-
ing like there was a way out, regaining an
empathetic perspective toward self and
other; expressing negative feelings that
enable self-acceptance; feeling better and
able to engage in effective problem-solv-
ing and health lifeways. Themes were re-
lated to carative factors.
(continued)
 20
Author(s) and
Year of Publication Aims or Research Question(s)
Mullins (1996) To identify nurse caring behaviors desired
by patients with AIDS or HIV.
Neil & Schroeder To evaluate client experiences at the Denver Qualitative descriptive eval- 51 clients of the Center and
(1993) Nursing Project in Human Caring
Nyberg (1990) To explore nurses reactions to the eco-
nomic changes in the hospital
environment.
Nyman & Lutzen To identify the caring needs specific to the
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(1999) human experience of having rheumatoid
arthritis (RA) and undergoing acupunc-
ture treatment.
Parsons, Kee, & To identify perioperative nurse behaviors
Gray (1993) perceived as caring by selected surgical
patients, and to determine if any were
perceived as more important than others.
Table 1 (continued)
Design and Methods
Quantitative descriptive
uation study
Descriptive survey
Qualitative descriptive
Quantitative and qualitative
descriptive
Participants
(population and number)
46 adults with a diagnosis of
AIDS or HIV
their significant others
135 nurses who were randomly Questionnaires and interviews
selected from 7 hospitals; 7 of nurse executives; Nyberg
nurse executives
6 women diagnosed with RA
19 adults who had outpatient
surgery
Form of and Processes for
Collecting or Generating Data
Participants completed the Car-
ing Behaviors Assessment
Eight focus group sessions and
videotaped interviews with
clients and significant others
Economics and providing human care are
Caring Assessment Scale
used.
Interviews during acupuncture
using a conversation guide
based on Watsons carative
factors.
Interview item and a revised
Caring Behavior Assessment
Findings
The highest rated items were: treat me as an
individual, know what theyre doing,
know how to give shots, IVs, etc., make
me feel someone is there if I need them,
treat me with respect, know when its
necessary to call the doctor, know how to
handle equipment, do what they say
theyll do; accept me the way I am, ac-
cept my feelings without judgment and
give treatments and medications on time.
Clients endorsements of the Center were re-
lated to: caring behaviors, support
groups/peer support, treatments, non-
clinical environment, and education/in-
formation. Areas for improvement were
suggested.
interrelated forces. Nurses value and un-
derstand human care as paying tribute to
the dignity of the person, laughing and
crying with patients, reaching out human
to human, unconditional positive regard,
dealing with the whole person, and being
concerned with the betterment of the
other.
Themes were: seeking help, searching for
meaning and uncertainty, and fear of be-
ing disappointed.
Top responses to interview item asking par-
ticipants to identify nursing behaviors
perceived as caring were: reassuring
presence, verbal reassurance, attention to
physical comfort, teamwork, provision of
a relaxed, quiet atmosphere. The most
frequent responses to the Caring Behav-
ior Assessment were: know what they are
doing, be kind, considerate, treat me as
an individual, reassure me, check my
condition closely, make me feel someone
is there if I need them, do what they say
they will do, and answer my questions
clearly.
 Rosenthal (1992) To examine the relationship of patient-
perceived and nurse-perceived caring
behaviors.
Running (1997) To examine and describe the experience of
living in a nursing home.
Ryan (1992) To determine those nursing behaviors per-
ceived as most helpful and least helpful
by primary caregivers and by hospice
nurses in a home-care hospice setting.
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Schroeder (1993a, To present analyses of the cost-effective-
1993b) ness of care at the Denver Nursing Pro-
ject in Human Caring.
21
Quantitative descriptive 30 coronary care patients and
30 coronary care nurses
Qualitative descriptive (visit 6 residents of a nursing home Interviews or visits over a 7
as method)
Quantitative descriptive 20 caregivers of hospice pa-
tients during the bereave-
ment period and 5 hospice
nurses
Cost studies based on pa- 240 patients in 1991; 340 pa-
tient data and evaluation tients in 1992 for cost analy-
research from three sis; 30 clients completed
studies. 1992 survey and 31 com-
pleted 1993 survey.
Larsons nurse caring behaviors Patients perceived the following as the most
(CARE-Q) were rank-ordered
by the Q-sort method.
month period (at least 5
visits).
Q-sort method; 60 nursing be-
haviors were sorted from least
to most helpful and catego-
rized as physical, patient
psychosocial, and caregiver
psychosocial needs.
Cost analysis based on estima-
tion of prevented hospital
stays, shortened length of
stay, delivery of medical
treatment in the center and
supportive care at home. Pa-
tients completed quantitative
and qualitative descriptive
surveys.
important nurse caring behaviors: knows
how to give shots and IVs and how to
manage the equipment; gives treatments
and medications on time; knows when to
call the physician; tells the patient, in un-
derstandable language what is important
to know about disease and treatment;
gives good physical care. Nurses per-
ceived the following as the most impor-
tant nurse caring behaviors: listens to the
patient, knows when to call the physi-
cian, allows patient to express feelings,
gives good physical care, touches when
patient needs comforting.
Glimpses of experiences were presented as
findings. The researcher and participants
identified the most significant pieces of
their stories.
The most helpful nursing behaviors identi-
fied by caregivers were a mixture of pa-
tient physical and psychosocial needs
and caregiver psychosocial needs. The
top priorities were: listen to the patient,
provide patient with necessary emer-
gency measures, assure caregiver that
nursing services were available 24/7, an-
swer patient questions and talk to the pa-
tient to reduce fears. Similarly hospice
nurses identified most helpful nursing
behaviors as a mixture of physical,
psychosocial (patient), and psychosocial
(caregiver).
Researcher concluded that the Center saved
more that $700,000 in 1991 and over $1
million in 1992.
(continued)
 22
Table 1 (continued)
Author(s) and Participants Form of and Processes for
Year of Publication Aims or Research Question(s) Design and Methods (population and number) Collecting or Generating Data Findings

Schroeder & Maeve To present the results of evaluation of the Qualitative descriptive Number of nurses in focus Focus groups, random chart re- Nurses in focus groups found NCP to be
(1992) care partnership relationship. groups was not provided; re- view of narrative documenta- growth producing and challenging,
view of 20 randomly se- tion, and an evaluation sur- knowledge was more easily transferred,
lected records; 29 patients in vey, nurse and client stories and nurses were better able to support
the NCP returned surveys of their experiences in the each other and coordinate services. 75%
nursing care partnership pro- of the charts contained narrative interview
gram (NCP) notes; 40% of the charts referred to Wat-
sons carative factors. The survey showed
that the NCP was viewed as supportive
and helpful; 90% agreed that it helped
them to better negotiate the system and
92% agreed that a NCP helped them to
understand their plan of treatment. They
most liked having an advocate, the
ability to translate what is happening,
and using nursing help rather than hos-
pital facilities, emotional support, hon-
esty and a caring attitude.
Schultz, Bridgham, To describe and compare the similarities Quantitative descriptive 42 antepartum and short-stay Caring Behavior Assessment The highest valued caring behaviors were:
Smith, & Higgins and differences in the perception of car- survey postpartum patients completed between the 7th know when to call doctor, trust with re-
(1998) ing behaviors between antepartum and and 9th day of the inpatient spect, know what they are doing, answer

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short-stay postpartum patients. stay for antepartum patients questions clearly and treat me as an indi-
and at discharge for vidual. These were a combination of hu-
postpartum patients man needs, humanistic, and teaching
learning.
Smith, Kemp, To examine the effects of therapeutic mas- Quasi-experimental; two 41 patients admitted to the on- 20 patients received therapeutic Mean scores for pain, symptom distress,
Hemphill, & sage on perception of pain, subjective group pre-post test design cology unit for radiation or massage and 21 received ther- and anxiety improved from baseline for
Vojir (2002) sleep quality, symptom distress, and anx- chemotherapy apeutic nurse presence (three those who received therapeutic massage;
iety in patients hospitalized for treatment times in a one week period). only anxiety improved from baseline for
of cancer. Scales completed at baseline participants in the comparison group.
and at one week. Statistically significant interactions were
found for pain, symptom distress, and
sleep.
Smith (1997) To describe the experiences of clients of the Qualitative descriptive Five people who use the ser- Focus group Four major themes were: seeing the unique-
Denver Nursing Project in Human Car- vices of the Caring Center ness and wholeness of the person-family;
ing, a nurse-managed center based on coming home; discovering a personal
Watsons theory. path for healing; and feeling the energy
of love and compassion.
 Smith & Sullivan To identify the caring behaviors that profes- Quantitative descriptive
(1997) sional nurses and nursing home patients
perceived to be most important in feeling
cared for.
Swanson (1991) To describe the findings of three studies
leading to development of a middle-
range theory of caring.
Tracy (1997) To describe the lived experience of growing Phenomenological
up with cystic fibrosis.
Updike, Cleveland, To develop and test a curriculum focused
& Nyberg (2000) on complementary healing modalities
(CHMs) and to evaluate the effectiveness
of the program toward expanding profes-
sional nurses knowledge and clinical
skills in caring-healing concepts and
practices and increasing nurses satisfac-
tion with expanded clinical practice; inte-
grating CHMs into the care of children
hospitalized on the hematology-oncology
unit; and improving organizational sup-
port for CHMs.
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Weeks (1995) To describe the educational wants of pro-
spective family caregivers of newly dis-
abled adults anticipating discharge to
home from rehabilitation.
Wolf, Giardino, To describe the dimensions of nurse caring. Exploratory factor analysis
Osborne, &
Ambrose (1994)
23
14 nursing home residents and
15 registered nurses
Phenomenological Study I: 20 women who mis-
carried; Study II: 19 care-
givers in the NICU; Study
III: 8 at-risk mothers
10 adults who were diagnosed
with cystic fibrosis at birth
or in early infancy
Quasi-experimental design 25 nurses on the hematology-
(pre-post); quantitative oncology unit
and qualitative methods
Quantitative descriptive 83 prospective family care-
givers of newly disabled
adults
278 nurses and 263 patients
with varimax rotation and former patients
Care-Q instrument was com-
pleted by participants from
one nursing unit.
Interviews and participant
observations
Interviews
Nyberg Caring Assessment
Scale and the Organizational
Context Survey; pre and post
implementation focus groups;
written evaluations completed
by nurse participants; a cur-
riculum was offered to nurses
over a 6 month period; onsite
support was provided; docu-
mentation in notes, end of
shift reports, and acuity
reports
Educational Wants of Family
Caregivers of Disabled
Adults Questionnaire
Caring Behaviors Inventory
Patient rankings of the most important car-
ing behaviors were: puts patient first,
knows how to give shots, start IVs and
manage equipment, gives good physical
care, knows when to call physician, and
is honest. Nurse rankings of the most im-
portant caring behaviors were: listens to
patient, gives a quick response to pa-
tients call, knows when to call physi-
cian, knows how to give shots, start IVs
and manage equipment, and gives good
physical care.
Five themes of caring were: knowing, being
with, doing for, enabling, and maintain-
ing belief. Sub-processes were
developed.
Three overall themes were: being different,
dont call me terminal, and will power
and faith.
Findings were the evaluation of the mod-
ules by the participants. Two case studies
illustrated the use of massage, acupres-
sure and relaxation. nurses expressed
that their presence with the children and
families changed toward becoming more
intentionally present during the brief en-
counters that were possible. They espe-
cially expressed satisfaction that their
skills were enhanced with specific mo-
dalities and that this supported their view
of themselves as healers (p. 108).
The top rated educational wants were: nor-
malize the daily routine, ensure that as-
sistance is available, evaluate the
strengths and capabilities of the disabled
adult, supervise or carry out prescribed
treatments, and anticipate needs for fu-
ture assistance.
Five dimensions were: respectful deference
to the other; assurance of human pres-
ence; positive connectedness; profes-
sional knowledge and skill; and attention
to others experience
24 Nursing Science Quarterly, 17:1, January 2004
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