caring is a hot topic in nursing literature these days.

There are stories and affirmations of caring, tales and accusations of lack of caring, theories of caring, research studies, two journals and an International

seems when you start looking at it, caring is an elusive concept to nail down. Take a look at nursing literature, and youll find different interpretations of caring. Some of this comes from pulling the concept apart to understand it.Analyzing any concept is like the story of the five blind men describing an elephant. Each one was feeling the same elephant but experienced it quite differently. Like most everything else in life, worldview plays a huge part in determining what you think caring is.What I believe about reality, right and wrong, our origins, what happens when we die, or what truth is, greatly impacts what I understand caring to be. If I believe all there is to life is the physical world, what we experience through the five senses, then my idea of caring may tend to be more hands-on, focusing on the hereandnow.This doesnt mean Im not a caring nurse, but how I put caring into practice is going to come from what I think is important. If I believe a universal life force sustains and somehow connects all things,my ideas of caring will probably incorporate aspects of life force and take how I connect to others into

Association of Human Caring. Caring seems to be taking center stage. Nursing has always been defined by four overarching concepts (i.e., our metaparadigm): nursing is what we do; person is the focus of what we do (i.e., who we do it to); health is the goal of nursing; and environment is the context in which we nurse.The core of all nursing theories is examining and elucidating these four concepts to explain and guide nursing. But nursing is now also being defined as caring. Caring has become the fifth metaparadigm concept. Why point this out? For starters, this is a good thing. Nurses have long known our provision of a caring relationship that facilitates health and healing is an essential feature of nursing.1 Identifying, delineating and understanding caring explains what we do, what is unique about nursing, and guides us as we seek to care. But an interesting problem has arisen. While every nurse knows what caring is, it

consideration. Despite the impact our worldview has

on how we think, authors rarely state their underlying worldview in discussions of caring (at least in those Ive read).Assumptions, tenets and principles are offered, but views of reality, truth and the nature of the universe are typically not discussedat least not in a way that says This is what I believe. It seems we assume ideas about caring are either worldview neutral (i.e., have no impact on what we think), or because worldviews are all equally valid and correct, worldview doesnt matter. If asked, all of us would exclaim,Of course everything comes from a worldview. Nothing is worldview typically isnt openly acknowledged, at least not in writing. Not acknowledging worldview in our discussions of caring is problematic.Why? Stating ones worldview gives a broader understanding of information. Say an author wrote:My theory of caring stems from my belief that the universe evolved through natural, evolutionary, scientific, processes.There is no intelligent design or designer; the world consists only of what we experience.How would you evaluate what you read? Say that you read, My theory of caring is derived from my neutral! But worldview

belief in a Higher Power (i.e. not the God of the Bible), which underlies all of life and is in all things.This Power unites us so that everything we do impacts all other living things.What would your

interpretation be of that authors ideas? The worldview of Christian nurses originates and centers on God.We seek to discern worldviews and compare them to biblical truth. Colossians 2:8 explains why: See to it that no one takes you captive through philosophy and empty deceit, according to human tradition, according to the elemental spirits of the universe, and not according to Christ. Ultimately, caring is modeled in the life of Jesus, and our understanding of caring is found in vigilant study of the Bible.KSS 1American Nurses Association, Nursings Social Policy Statement, 2nd ed. (Washington, DC:ANA, 2003): 5. What Determines Caring? editorial Caring is an elusive concept to nail down. Caring is an elusive concept to nail down. C JCN/Summer 2006 1

Guest Editorial Take Time to Care This issue deals with Caring Competencies for a Complex Healthcare Environment. This is an important topic in an era where many marketing slogans talk about caring, but the focus of most organizations seems to be on everything except caring. Caring does not just happen, and we often take it for granted. Getting more done with less is our focus. Multitasking and doing more faster is the life many experience in healthcare, and it seems to be so in our home lives as well. When we are multitasking, how often have we missed a vital part of a conversation, or had to redo a task or deal with the consequences of doing something wrong? These consequences are a result of being in a hurry and not truly being present. Have you ever heard the saying slow down to produce more? This is about identifying and responding to those moments during the day when you truly need to be present, such as setting up medications for a patient, conducting a critical procedure, conversing with a staff member, or attending to a child at home. These are moments when we should not be multitasking and truly need to focus on the present, the task, or the person we are with. We need to take the time to care. This is true in caring for patients and their families, as well as for us as leaders to care for our staff and ourselves. Somehow we have gotten the message that it is not ok to care. Do not get too involved, too close, do not become vulnerable. In other words, detach yourself from the situation, the patient, or your staff. Stay

isolated and just do what you need to do. It is time to change this assumption. It is OK to care, to be involved to connect with your patient, your staff, and your loved ones at home. Work is important, but it is only part of life. In nursing, we are losing touch with what is truly important because of the everincreasing demands that the work place (and ourselves) has put on us. When will we realize that we cannot be everything to everybody? We cannot do it all. Life is too important and precious to let it pass by. We are called to engage in life, feel life, care, and enjoy everyday. In the article, in this issue on Evoking the Essence of Caring, I was there first on the scene, deep in the Andes, holding my colleague in my arms as I experienced nurses evoking the essence of caring. There was no multitasking, there was no assumption of dialogue, there was just being present and pure love and caring. We were all improvising with what we had to do to save a life. That is nursing and that is the essence of a nursing leader. This issue on Caring Competencies was such a topic of interest that too many articles were received for one issue. So we have expanded this topic to be covered in 2 consecutive issues so you will have an opportunity to read all that is happening in the field. Enjoy. Copyright c_ 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Philip Authier, MPH, RN Guest Editor Partner, Edgework Institute Grand Rapids, Mich 5

ARTIKEL 3 Guest Editorial The Caring Role of Nurse Leaders The challenges facing nursing leaders in every healthcare practice and setting today are remarkable. There are more conversations today than I remember hearing even 5 years ago about succession planning and encouraging nurses to consider leadership and management roles as a career track. A recurring theme at nursing leadership conferences is, Who will do this work in the future How can we recruit and develop future nursing leaders and managers? One key approach is to highlight the important role that caring plays in the relationship between leaders and staff. This guiding principle of caring for the staff and nurses caring for each other needs to be paramount in our leadership beliefs, values, and practices. As clinicians we can easily draw the connection to the key role of caring for our patients. It is interesting to me that there is at times a notable lack of consciousness about how we demonstrate caring practices toward each other: nurse to nurse and nursing leaders with staff. This plays itself out in both subtle and covert expressions of intergroup conflict, petty negativity, and an us against them tension that of itself further creates divisiveness. This has been referred to as horizontal violence, or lashing out where it is perceived to be safe to do so and meeting ones self-esteem needs at anothers expense. This can become the culture of both the clinical nurses and nursing leaders within a unit or an organization

and become a self-fulfilling cycle of negativity. These characteristics are often symbolic of a lack of caring and lack of attention to a supportive professional practice environment. I wonder sometimes if the fear of tackling this negative energy is one reason that holds back potential leaders and managers from stepping forward. Todays nurses and nursing leaders can transform and ensure a culture based on caring and positive regard. We can avoid the trap of speaking of each other in judgmental way. We can cut one another some slack and speak with each other directly and from a framework of caring about concerns and issues by reaching out and trying to understand different perspectives. We can be conscious of the power imbalances in relationship and aware of the impact this can have on honesty, trust, and fear. These are caring practices that effective leaders and managers bring to their role every day. And, often these are the same skill sets we use with patients and families. In their hallmark book, The Primacy of Caring, Patricia Benner and Judith Wrubel make the case that caring sets up what counts as stressful and what coping options are available.1p(1) When caring comes first, nursing leaders bother to notice the hidden story, the

untold reality, the underlying issue. The nurses we are leading can sense this caring from a mile away. Phil Authier and I were delighted that this topic generated so much interest and outstanding articles. A common theme that emerges in this edition is that the most successful and happy nursing leaders and clinical nurses have found a way to hold on to their caring ethic with the support of the right environment, resources, knowledge, and skills. We hope you will find a gem in here that gives you some support or inspiration for your complex and challenging role. Copyright c_ 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Lois Napier Skillings, MS, RN, CNAA,BC Guest Editor Vice President Nursing and Patient Care Services Mid Coast Hospital Brunswick, Me 85

ARTIKEL 4

Guest Editorial
Leadership in Caring Many nursing theorists, from Nightingale to Watson, and Henderson to Benner, describe the essential mission of caring as the foundation of nursing practice. The concept of caring in nursing practice is often thought of as a given. There is an assumption that compassion and therapeutic relationships serve as the underpinning of all our intentions as nurses. Caring is like motherhood and apple pie. Yet, in todays complex healthcare world, clinical nurses and nursing leaders are increasingly challenged to uphold an ethic of

caring in practice environments laden with barriers and competing priorities. It is our hope that this issue of the Nursing Administration Quarterly will explore and challenge these assumptions while offering practical, inspiring strategies for supporting caring competencies in nursing leadership and clinical practice. Maybe it is my New England worldview, but I have always seen caring competencies from a practical sense as carried out through effective relationships and communication skills, whether as a clinician or as a leader. It has fascinated me that while we spend some time learning the theory of caring and therapeutic relationships in nursing school, actual support for practicing and improving these skillssuch as empathy, collaboration, communication, and conflict resolutiongets very little attention in the work setting. There is perhaps an assumption that nurses are innately gifted in relationship and communication skills rather than seeing these as competencies that require practice, coaching, and ongoing development. Clinical nurses and nursing leaders work in highly complex, often-fractured, and risky work environments. Nurses are faced with extremely challenging relationship dilemmas unparalleled by many other professions, such as life and death situations, anger and frustration, intractable physical and emotional pain. These scenarios bring high emotions with patients, their families, and the rest of the healthcare team, and create many opportunities for relationship and communication breakdown. Other role dimensions, such as patient advocacy, nursing the system, ethical dilemmas, and leadership and management practices, require effective communication and relationship skills to achieve successful outcomes.
Copyright c_ 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins

sustaining change. Barriers to care are real and plentiful in our healthcare environment. Nursing leadership matters. Nursing leaders are critical in setting a tone of support for

So, what is the role of nursing leaders in promoting and creating an environment conducive to caring practice? In reviewing the articles included in this issue with this question in mind, interesting themes emerged. Attention to training, ongoing mentoring, and development is worth the effort to enhance communication and relationship skills of clinical nurses and nursing leaders. Emotional intelligence and personal reflection are essential to developing effective interpersonal relationships with patients, families, and colleagues. Caring is a practice. The work environment has a major impact on nurses ability to care. Cultural transformation and organizational infrastructure are needed to build and sustain caring practices. Interdisciplinary collaboration is critical. Understanding the impact of organizational culture is an important principle in implementing and

ARTIKEL 5

hank you for addressing the issue of caring at the

heart of effective leadership. As nurses, we learn to be compassionate and provide care for our patients, but whos caring for our nurses when their fuel needs to be replenished? With expanded nurse manager roles and overly stretched management responsibilities, nurse managers may not recognize the compassion fatigue syndrome that a nurse may experience. This was illustrated in the April 2010 article entitled, Compassion Fatigue: Nothing Left to Give?

I agree that, as a nurse manager, its essential to develop a one-on-one relationship with the individual nurse to provide support and guidance for our nurses who may be in need of counseling referrals to programs such as the employee assistance program. Nurses are educated to provide care to their patients unselfishly, but as nurse managers we must remind our staff nurses that they need to take care of themselves first in order to provide quality patient care. The nurse management team may also facilitate this by having one of the counselors from the employee assistance program give an in-service during staff meetings on stress management or tips on managing daily life. We all know that compassion fatigue syndrome may affect nurses or nurse managers. As we become aware of the signs and symptoms of compassion fatigue that depend on the daily stressors in our lives, we should seek early intervention to lead healthier lives and possibly help with nurse retention as well. Im an RN and an MBA/MSN graduate student at Holy Names University in Oakland, Calif. Ill share this article in my clinical leadership class and at the nurse managers meeting to increase awareness of compassion fatigue syndrome. Suzanne Lee, BSN, RN Fremont, Calif.

care they deliver along with outcomes. Education programs need to be maintained in order to retain those nurses who pride themselves on professional development. Hiring new graduates is essential for building a nursing workforce for the future generation. Using mature or older nurses to mold and guide new graduates in the right direction needs to be the main focus in all hospitals. Educating the nurses on the effects of working too many hours was accentuated very well in this article. Unfortunately, there are no laws pertaining to this issue and patients suffer. Hospital administrators need to take the time to listen to nursesthe core of hospital bedside careand not just look at everything on a spreadsheet in order to handle the economic downfall. There are many more answers to these issues, but the main focus should be giving great, not just good, care to all patients and maintaining their safety. NM Pamela Anstead, RN El Paso, Tex.

Letters Nurses must care for themselves, too

www.nursingmanagement.com 8 July 2010 Nursing Management

Focus on nurse and patient satisfaction

Ive just finished reading the article entitled, From Wall Street to Main Streetto Your Hospital from the January 2010 issue. I have to say that the authors really did a great job focusing on some of the problems that hospital administrators are facing with the economic downfall that this nation has experienced. Having been mainly a staff nurse with only a few supervisory jobs, Ive never had to work on a budget or cutbacks. My main concern was always taking care of the nurses and keeping the patient care in mind along with their safety. After reading this article, I was amazed by the ways hospitals are attempting to remedy the problem. Taking away paid time off, incentive pay, health benefits, and retirement plans isnt the answer to retain seasoned nurses who have the experience to give good-quality patient care. If you look at any Magnet-recognized hospital system, youll find that nurse satisfaction reflects on patient care. Happy nurses are happy at work, and therefore their positive outlook shows in the patient

The authors really did a great

job focusing on some of the problems that hospital administrators are facing with the economic downfall that this nation has experienced.
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