Caring -- The Foundation of Advanced

Practice Nursing
Jane F. Sumner, PhD, RN, Guest Editor
Nursing remains practical and hands-on. However, it is also strengthened by conceptual and
theoretical knowledge applied artIully and scientiIically. The practice oI advanced nursing
requires a higher level oI knowledge and skill, but it is still built upon the Iundamental moral
commitment oI caring in nursing. The articles included in this issue oI Topics in Advanced
Practice Nursing have theoretical underpinnings that are (or can be) applied to practice
situations. The theoretical base oI this issue provides advanced practice nurses with an
opportunity to develop a greater understanding oI the Ioundation oI their practice.
Theory may be identiIied as the conceptual knowledge that is the Ioundation to guide and
inIluence practice. Theory also maximizes skill. The authors oI the articles in this edition are
nursing scholars who have thought deeply about the implications oI caring in nursing practice.
They oIIer a variety oI thought-provoking research methodologies and experiences to illustrate
the concepts and their ideas, and they strive to answer questions like: What is caring? What do
we do as caring nurses? Why do we care? How do we care? Answering these questions requires
rigorous thinking, solid knowledge (ie, theoretical understanding), judgment, and practice skills.
The authors demonstrate these characteristics in their articles.
Nursing Literature and Caring
There is much in the literature related to caring in nursing, but it is generally accepted that there
are only 3 complete or grand theories oI caring in nursing:
1 Lelnlngers Carlng A CenLral locus of nurslng and PealLh Care Servlces
1

2 Crems SelfCare ueflclL
2

3 WaLsons hllosophy and Sclence of Carlng
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n addition to grand theories, there are many midrange theories oI caring in nursing. Midrange
theories are imminently doable. Morse claims that the concept oI caring in nursing remains
"murky."
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Paley complains that scholars are "describers on the same treadmill" because they do
not deIine caring in any practical or applicable way.
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On the contrary, the authors oI the papers
included in this edition attempt to clariIy the murkiness and deIine caring in practical ways. They
do so by oIIering examples oI midranges theories, both in concept and in practice.
There are other components oI caring knowledge, however, and Carper's Patterns oI Knowing in
Nursing
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are particularly germane Ior the advanced practice nurse. n addition, Taylor discusses
the "ordinariness" oI nursing, where nurses practice as "knowledgeable and skillIul humans who
are able to transcend the proIessional inhibitions oI their roles to be 'just themselves'" (p. 4).
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This eJournal issue is Iocused on knowledge and skills speciIically applied so that the nurse
emerges as a real human -- in other words, as Iar more than the mere "nurse role."
Nurses and Advanced Practice
The authors posit the role oI the advanced practice nurse in the primary care setting with an
emphasis on health promotion and disease prevention. They also propose that the advanced
practice nurse has Iurther Iunctions in policy making, leadership, and responsibility at the
organizational level. Thomas and colleagues' paper, "The Caring Relationship Created by Nurse
Practitioners and the Ones Nursed: mplications Ior Practice" uses Boykin and SchoenhoIer's
Nursing as Caring model, as well as SchoenhoIer's group interpretive phenomenology, to
identiIy how the advanced practice nurse needs to Iirst (and Ioremost) understand his/her own
being and nursing identity; then, determine how this selI-awareness and insight can Iacilitate
earing the patient and tailoring the treatment according to that person's preIerences and needs.
Mary Enzman Hagedorn, in "Caring Practices in the 21st Century: The Emerging Role oI the
Nurse Practitioner," chooses to Irame her work within the patterns oI knowing and Watson's
theory oI human caring. She, too, uses a qualitative approach by interpreting a narrative and
using poetry to emphasize a case study. Sue Hagedorn and Tracy Quinn, in "Theory-Based
Nurse Practitioner Practice: Caring in Action," oIIer a conceptual Iramework speciIically Ior use
by advanced nurse practitioners in a primary care setting. The components oI their Iramework
are: connection, consistency, commitment, community, and change.
Karen Dorn, in her article "Caring-Healing nquiry Ior Holistic Nursing Practice: Model Ior
Research and Evidence-Based Practice," uses Swanson's midrange theory on caring as the basis
Ior a hospital evidence-based caring practice model. The Iocus oI the model is leadership and
staII mentorship, Iirmly anchored by nursing research. What emerges Irom all oI the articles is
that caring is the critical Ioundation oI practice. With this comes an inherent moral obligation
and responsibility.
Caring in Nursing as Communicative Discourse
The strength oI caring in nursing lies in its moral Ioundation (or the "ought" oI nursing).
Chambliss describes this as the nurse's "commitment to the welIare...oI the 'whole' person" (p.
3).
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The nurse practitioner, even more than other nurses, is educated and able to treat the
"whole" person. Nevertheless, caring in nursing is multiIaceted and complex.
The nurse constituents are knowledge (theoretical and experiential), judgment, and skill in the
practical application oI both. There are 2 other critical components: cognition or thinking ability
and emotion or Ieeling, both oI which inIluence everything a person does. The patient is not only
an illness, but also (and most importantly) a person with the 2 critical components oI cognition
and emotion. The nurse and patient meet in a communicative relationship limited by their
respective roles within the healthcare delivery system.
I nursing is concerned with the human condition oI both nurse and patient, then the innate
vulnerability oI all people, in any social discourse or communication, must be recognized and
considered. As a result, believe that the intention oI caring in nursing, as communicative
discourse based on awareness oI the innate vulnerability oI all individuals, means that there must
be "considerateness" Irom one to another.
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The advanced practice nurse is particularly prepared
to practice communicative discourse eIIectively.
As a communicative intervention, caring in nursing validates both the nurse and the patient as
human. Caring in nursing arises out oI the Iundamental dimensions oI human experience within
a distinct social world. The premise is that eIIective evidence-based practice, Iounded on the
Iacilitation oI positive outcomes Ior selI and others, will lead to "physis" or selI-blossoming.
Caring in nursing as bidirectional communicative discourse is critical in advanced nursing
practice. t might be argued that the advanced practice nurse, because oI greater knowledge and
insight, as well as the autonomy oI the role, has an even greater obligation and responsibility Ior
bidirectionality in the discourse with patients.
These authors have oIIered perspectives on this tenet, adding another piece to the complexity oI
caring in nursing at the advanced level. Bidirectionality ensures that the patient is involved and
responsible Ior his/her own treatment. This leads to greater satisIaction and control. The nurse
has the opportunity to understand "selI" better, to be more comIortable with Iunctions oI
leadership and policy making, and to provide the patient with overall better quality and
continuity oI care.