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“Doing For” and “Being With” Patricia K. Young ● Susan Lampe

C H A P T E R 13

C H A P T E R O B J E C T I V E S

1. Differentiate between the constructs of “ doing for” and “ being with.” 2. Explain nursing actions linked with “ doing for” and “ being with.” 3. Explain the aspects of relationship-based family nursing practice. 4. Analyze perceived barriers to cultivating caring relationships. 5. Define the scope of caring in family nursing practice. 6. Examine personal strengths and limitations that enhance or threaten caring relationships.

C H A P T E R C O N C E P T S

● “ Being with” ● Burnout ● Caring ● Caring barriers ● “ Doing for”

● Intentional care ● Mindfulness ● Personal barriers ● Refection ● Self-care skills

Introduction

This chapter discusses a conflict often found in nursing that pertains to ideas about “doing for” and “being with” those receiving care in clinical care situations. Task-oriented nurses are busily doing nursing activities, trying to fulfill expected roles and meet employer’s ex- pectations. Most work favors the “doing for” task-oriented actions, but this aspect of care is different from “being with” a person. “Being with” is about sensitively providing care. Some nurses might say that “being with” not only uses nursing skills and competencies, but it helps them form individual-nurse-family relationships. Technology can help extend the scope of care, but it is not the same as the presence of a nurse. Those seeking care want someone who cares, listens, and is available.

Since the 1980s, much has been published about the importance of nurses’ caring roles. Many have discussed values and meanings associated with giving nursing care. In a busy world, clinical practice is often reduced to tasks. Work is measured by outcomes, compliance with regulations, and meeting accreditation standards. Sometimes nurses are uncertain about the limits of professional boundaries. You might ask, “How can nurses give care without

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Denham, Sharon, et al. Family Focused Nursing Care, F. A. Davis Company, 2015. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/mnsu/detail.action?docID=1963709. Created from mnsu on 2022-06-02 03:07:26.

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being too friendly or overly involved? What about invading a family’s privacy?” At the end of a workday, nurses might be unsure about how they will find time to truly give care.

Many people become nurses because they want to help others. However, the demands of daily work leave little time to do extra things. Getting family members involved just seems like an additional burden. How do you fit family members into an already too busy day? Nurses are often asked to “do more with less.” Complete more tasks. Prioritize care. Achieve the desired outcomes. Most activities seem to focus on “doing for.” All of the tasks and activities distract nurses from “being with” those who need their care. Nurses who think family know the difference between “doing” and “being.” They are adept at enacting both. Listening, thinking, and reflecting are tools for “being.” This chapter identifies what nurses can do to strengthen the caring aspects of practice. Ideas about “being with” and the development of meaningful relationships are explained.

Understanding the Concepts

The ideas of “doing for” and “being with” seem to reflect different ways to provide care. In nursing practice, more attention seems to be given to “doing for.” But “being with” is just as important. These two caring expressions are central to nursing values in providing family-focused care (Fig. 13.1).

“ Doing For”

“Doing for” involves tasks and action. This work includes the person needing care and their family members. “Doing for” implies action, busyness. Some might say the opposite of “doing for” is doing nothing. That is not what is implied here.

“ D oing For” th e Person

Virginia Henderson (1991), a nursing theorist, focused many of her ideas on “doing for.” She said nurses’ roles were to assist the sick to accomplish tasks they are unable to do

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FIGURE 13 -1 “ Doing for” and “ being with” are two important concepts in ways of providing care.

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independently. This view is about performing activities for individuals and was often em- phasized in the 1960s. “Doing for” describes the actions nurses take to provide care to a person to promote or maintain health, recover, manage an illness or disease, or even have a peaceful death. “Doing for” is done with psychomotor skills. These actions in- clude taking vital signs, giving medications, helping with personal hygiene, monitoring intravenous fluids, and changing dressings. Consider the following examples:

• A nurse cares for the physical needs (e.g., bath, nutrition, elimination, vital signs) of an unconscious person. “Doing for” is direct care given when a physical limitation exists, such as wearing a cast or dealing with hemiparesis from a stroke.

• While changing a dressing the nurse is completing a procedure and teaching a family member how to do needed tasks. “Doing for” can benefit the person and the family.

“ D oing For” th e Person’s Family

Think about a family that does not understand what is happening with a member. The nurse will “do for” the person and family by giving needed care. At the same time, the nurse evaluates what questions the family might have. Family nurses know that recognizing and acknowledging family has great potential for healing (Wright & Leahey, 1999). Family nurses know it is important that families be able to manage care at home. They want to be sure that family units have the knowledge and skills needed. In ambulatory care settings, “doing for” might be health teaching or giving counseling. Families need to know what to do when persons have complex or extensive care needs. They might even be concerned about things nurses think of as usual care (e.g., bathing, grooming, toileting, diet, activity, medications). “Doing for” is more than just taking care of the obvious care needs. Think about a family that has a child with a developmental disability. “Doing for” could mean the nurse acts as an advocate and speaks to a physician on their behalf. Nurses who think family notice unique family situations and anticipate future needs. These nurses provide needed information and help locate resources. “Doing for” can also imply the nurse reflects about family care needs and helps family members get information they need.

“ B eing With”

“Being with” can mean sitting quietly with individuals or families without visible actions— doing nothing. However, this is only partially true. “Being with” involves sharing an emo- tional presence. This includes listening, seeking to understand a point of view, and learning what matters most. “Being with” might mean assisting family members to understand an elder’s point of view in an end-of-life decision.

B eing E motionally Present and L istening

“Being with” is somewhat like the idea of presence. To be present means that the nurse is available and willing to connect with another human being (Benner & Wrubel, 1989). It is a way of recognizing a shared humanity and is different from being aloof, when one is physically present but one’s thoughts are elsewhere. Nurses can use eye contact, body lan- guage, and tone of voice to enhance a sense of presence or “being with.” For example, a new mother may need emotional support and health teaching for breastfeeding. A spouse of an individual with newly diagnosed diabetes may need to learn to give insulin. “Being with” means the nurse listens to concerns. Questions are answered. Empathy is given. Nurses who think family know that coaching usually requires a caring presence.

“Being with” is not passive or a one-way activity. “Being with” is a skill that can be learned. Some nurses maintain that “being with” individuals or a family is the essential

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core of nursing practice (Hartrick Doane, 2002; Idczak, 2007). When nurses focus on “being with” they are in tune and alert for opportunities to notice and respond to individual and family cues. “Being with” implies an open mind and willingness to understanding other perspectives, providing a calm, reassuring presence during a crisis. This presence means listening to needs in a situation because needs for individuals and families differ. Dame Cicely Saunders, an English nurse, physician, medical social worker, and writer, is best known for her role in beginning the hospice movement. She taught that “being with” was a key element in the care of the dying. Presence is important for building trust through an individual-nurse-family relationship. Nurses learn how to treat pain, care for those who are dying, and empathize with those who are suffering by being present.

U nderstanding O th ers

Family members know how a member responds to pain. They can share information about what impedes treatment, care management, or rehabilitation; one another’s food prefer- ences and physical activity; each other’s medical history; and how other members view ill- ness experiences. Family members can discuss reasons why self-care practices are not being done. To “be with” a woman newly diagnosed with breast cancer, the nurse may ask her to share feelings about the diagnosis. As the nurse listens, she may describe her fears and concerns, providing an opportunity for the nurse to explain or answer troubling questions. The nurse might note some of her inner strengths and offer positive feedback. Dr. Erla Svavarsdottir has worked extensively at Landspitali University Hospital in Reykjavik, Iceland to involve families of those experiencing chronic conditions (Box 13.1).

L earning W h at Matters to th e Person and th e Family

Therapeutic relationships are built by “being with” individuals. Showing respect and build- ing trust come through “being with” those needing care services. Learning “little things,” like the preference for tea rather than coffee, can demonstrate care and empathy. Nursing presence implies care that can be experienced by others. A classic study about expertise in

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BOX 13-1

Family Tree

Erla Svavarsdottir, PhD (Iceland)

Erla Kolbrun Svavarsdottir, PhD, RN, is a professor and academic chair of Family Nursing, Faculty of Nursing, School of Health Sciences, at the University of Iceland. She established the clinical specialization of Family Systems Nursing at the master’s and doctoral levels. She also serves as the head of the Section of Research and Development in Family Nursing at Landspitali University Hospital in Reykjavik, Iceland. Dr. Svavarsdottir completed her doctoral program in 1997 at the University of Wisconsin–Madison under the supervision of Dr. Marilyn McCubbin. She has provided sustained leadership in cutting- edge knowledge translation efforts in family nursing as co-principal investigator of the Landspitali University Hospital Family Nursing Implementation Project (2007–2011). This landmark 4-year project implemented Family Systems Nursing on every unit of a large university hospital in Reykjavik. Dr. Svavarsdottir has worked extensively with Icelandic researchers on family intervention research projects with families of children and adolescents experiencing cancer, asthma, diabetes, anorexia, and bulimia. She received an Innovative Contribution to Family Nursing Award in 2005 from the J ournal of Family Nursing for her outstanding leadership in family nursing in Iceland. In 2009 she chaired the Ninth International Family Nursing Conference held in Reykjavik, Iceland. She is co-editor of a family nursing textbook called Family Nursing in Action (2011) and co-authored a chapter in this book. Dr. Svavarsdottir has served on the Board of Directors for the International Family Nursing Association.

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nursing practice said that families have vital secrets that are important for optimal indi- vidual care (Benner, Hooper-Kyriakidis, & Stannard, 1999). When student nurses estab- lished connections with children in their care, they were better prepared to connect with others in the future (Coetzee, 2004). Family nurses are likely to have similar experiences with adults. Opening oneself to human relationships is at the core of nursing practice (Hartrick Doane, 2002). Nurses who only concentrate on “doing for” can overlook the uniqueness of the individuals, families, and situations found through “being with” others.

The Practice of “ Doing For” and “ Being With”

Consider this excerpt from the novel Cutting for Stone (Verghese, 2009). A surgeon, Dr. Stone, is reading a letter he received from a patient’s mother—a patient who had died recently in the emergency department. The mother wrote:

Dr. Stone—My son’s terrible death is not something I will ever get over, but perhaps in time it will be less painful. But I cannot get over one image, a last image that could have been different. Before I was asked to leave the room in a very rough manner, I must tell you that I saw my son was terrified and there was no one who addressed his fear. The only person who tried was a nurse. She held my son’s hand and said, “Don’t worry, it will be all right.” Everyone else ig- nored him. Sure, the doctors were busy with his body. It would have been merciful if he had been unconscious. They had important things to do. They cared only about his chest and belly. Not about the little boy who was in fear. Yes, he was a man, but at such a vulnerable moment, he was reduced to a little boy. I saw no sign of the slightest bit of human kindness. My son and I were irritants. Your team would have preferred for me to be gone and for him to be quiet. Eventually they got their wish. Dr. Stone, as head of surgery, perhaps as a parent yourself, do you not feel some obligation to have your staff comfort the patient? Would the patient not be better off with less anxiety, less fright? My son’s last conscious memory will be of people ignoring him. My last memory of him will be of my little boy, watching in terror as his mother is escorted out of the room. It is the graven image I will carry to my own deathbed. The fact that people were attentive to his body does not compensate for their ignoring his being.

This narrative illuminates the significance of not only “doing for” the body, but of also attending to the person through “being with” them. “Doing for” the body is necessary and important, especially in critical care situations. However, “being with” the person or family is equally necessary.

Rather than considering “doing for” and “being with” as two different things, nurses can consider them to be interrelated aspects of effective nursing care. More than a few things are always happening in every care interaction. A student nurse reflects about a care experience with a person having difficulty speaking after a stroke:

The [student] understood that the patient was upset during her morning care. Through patience and a willingness to spend time with the patient, the [student] was able to make a connection with her. She learned that the sponge used to clean the patient’s teeth was not “minty” enough and she wrote [in her reflective journal]:

Although the conversation took a while because of my difficulty understanding her, I finally understood how it meant a lot to her if I would clean her mouth thoroughly. After I finished with her teeth she expressed how she felt much better and how she could taste the mint. Through her facial expression I was able to see how much she appreciated my time in trying to understand her and thoroughly cleaning her teeth and mouth. I felt I was making a differ- ence in this patient’s life even though it was very minor compared to the difficulties she was going through with her stroke.” (Idzcak, 2007, p 70)

The student realized what this woman needed—taking the time to be with her helped the student nurse better understand exactly what was needed, both “doing” and “being” actions.

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Connecting With Persons and Their Families

Family nurses use both “doing for” and “being with” during family interactions. Nurses can “be with” individuals and families at the first meeting. Use eye contact as introductions are made. As questions about the person’s current condition are asked, nurses listen carefully to responses and address unique needs. A meeting might occur because “doing for” is needed, but the nurse’s presence or “being with” can change levels of satisfaction with what occurred.

O bserving Nonverbal Cues

Nurses make better connections when they have a “being with” presence. Assessments and careful observations help nurses collect needed information. The nurse notes things that provide clues to needs beyond the biophysical. Is the person grimacing or do they have a flat affect? Are they calm or chaotic? Are significant family members present? Do family members ask questions that show concern? Although hearing oral responses is important, observing nonverbal cues is equally important. Nurses who have spent time “being with” those seeking care are more apt to be aware of nonverbal cues (Fig. 13.2). The nurse can adjust care based on cues and provide more personal care. The nurse might make a pro- posal (e.g., try sitting up instead of lying down). Or, the nurse might question: Besides medicines, what else has been helpful in relieving pain?

Assessing Personal and Family Needs

Family nurses accompany individuals and families through illness experiences to assure that things they value are addressed. Here are some questions the nurse might ask:

• What does this illness experience mean to you and your family? • Is the person seeking care the family’s primary breadwinner or does he or she play

certain vital roles in the family? • Will a significant monetary loss occur because of the situation at hand?

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FIGURE 13 -2 Nurses need to be aware of nonverbal cues.

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• How long will this situation exist? • Do the person and family understand the diagnosis and treatment? • Is this a recurrence of a progressive disease that causes future concerns? • What is your family’s previous experience with illness, suffering, and healing? • Does the treatment require lengthy time away from family, work, school, or other

tasks?

When nurses ask questions about family needs, they better discern specific concerns. Nurses who think family know that addressing the specific needs of a family unit is the hallmark of family-focused nursing practice.

Providing Intentional Care

Nurses who think family are intentional in the care provided. They consider these things:

• What is the goal of this interaction? • What is the most important thing that needs to be given attention? • Is the priority to tell, show, or do? (“doing for”) • Is the priority to listen, notice, or respond? (“being with”)

The nurse uses “doing for” and “being with” as intentional actions. Family-focused care requires both. Thinking about “doing for” and “being with” is important because what the nurse does and how it is done make a difference (Karlsson & Bergbom, 2010). People need human connections that affirm their humanity. Those interactions can occur while the nurse is giving other care. For instance, if the family shows interest in what is being done, the nurse can use this as a teachable moment. Thinking family shows genuine care as questions are asked. Commendations are given when family effectively demonstrates techniques. Nurses use their presence to guide, coach, and support.

Ways of Caring

Caring is an expected standard of nursing practice (American Association of Colleges of Nursing, 2008). Caring behaviors need to be used with family units, peers, and other health care team members.

“Doing for” and “being with” are two expressions of caring. “Doing for” is often seen as an instrumental behavior of caring. “Being with” is an expressive caring behavior. Florence Nightingale taught us first about caring. In her book Notes on Nursing (1859), she wrote of her frustration with nursing:

. . . nursing has been limited to signify little more than the administration of medicine and the application of poultices. It [nursing] ought to signify the proper use of fresh air, light, warmth, cleanliness, quiet and the proper selection and administration of diet—all at the least expense of vital power to the patient. . . the very elements of nursing are all but unknown. (Nightingale, 1992, p 6)

Nightingale thought nursing was more than “doing for” patients; it requires care for the whole.

During the 1960s and 1970s, nursing moved away from emphasizing caring in favor of being more “scientific.” Emphasis was placed on the physical sciences and psychomotor skills. In 1985, Jean Watson published her caring theory and encouraged nurses to recog- nize that caring is an essential aspect of nursing care. Consumers of nursing services want and need caring practices. Caring is a way to be in relationship with self, others, and the

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broader environment. The care experience cannot be separated from family, culture, community, and society (Watson & Foster, 2003).

Practicing nurses are expert role models who can provide first-person accounts to help our understanding of being healthy and being ill (Benner & Wrubel, 1989). These ideas made critical differences for persons and families. Note three ways nurses with expert fam- ily care skills care for persons in critical care units:

• Ensure that the family can be with the patient. • Provide the family with information and support. • Encourage family involvement in caregiving activities.

During the 1990s, the nursing literature said much about nursing’s caring role. Nursing is informed caring for the well-being of others and this caring preserves human dignity and well-being (Swanson, 1993). For example, an infant and a new mother have many needed care areas (e.g., physiology, developmental, neurobehavioral, mother’s beliefs, values, and understanding) (Swanson,1993). Nurses use caring techniques and knowledge in subtle ways. For example, a newborn intensive care unit nurse places a pacifier in a preterm infant’s mouth before diapering. The nurse realizes that non-nutritive sucking is a self-soothing and oxygen-conserving infant self-care behavior. Nurses sense that an infant’s overall well-being needs attention. They use caring ethics that treat the child as a person whose self-soothing abilities matter. Nurses apply their personal self-knowledge as they realize how they would wish to be treated if in the infant’s position. Swanson’s caring theory described five caring processes (Box 13.2).

Caring is one of nursing’s four core values along with diversity, integrity, and excellence (National League for Nursing [NLN], 2010). Caring is a significant and necessary quality for nursing practice. The NLN (2007) defines caring as “promoting health, healing and hope in response to the human condition.” Not only do nurses care for individuals, families, and communities, but they also need to care for each other and themselves. A tool that can be used by nurses to care for themselves and one another is the Commitment to My Cowork- ers pledge from Creative Health Care Management (Box 13.3). The goal is that the group accepts the commitment as the unit’s working philosophy. The caring commitment has be- havioral expectations. It provides personal ways for staff to address one another. It can help establish positive relationships in a healthy work environment.

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BOX 13-2

K risten Sw anson: Five Caring Processes

1. Maintaining beliefs: Basic to nurse caring is an orientation of a “ fundamental belief in persons and their capacity to make it through events and transitions and face a future with meaning” (Swanson, 1993, p 354).

2. Knowing: The nurse strives to “ understand events as they have meaning in the life of the other.” It “ involves avoiding assumptions, centering on the one(s) cared for, thoroughly assessing all aspects of the client’s condition and reality, and ultimately, engaging the self or personhood of the nurse and client in a caring transaction” (Swanson, 1993, p 355).

3. Being with: Being emotionally present to the other. Practices include being there, enduring, listening, attending, disclosing, and not burdening.

4. Doing for: Examples of doing for include both psychomotor activities and emotional support. 5. Enabling: The nurse enables the other to practice self-care. Enabling is defined as “ facilitating

the other’s passage through life transitions and unfamiliar events” (Swanson, 1993, p 356).

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Caring and Nurse-Family Relationships

Caring for the family is challenging, complex, and multifaceted (Benner et al, 1999; Jeon, 2004; Ward-Griffin & McKeever, 2000). It is an interdependent activity. Both the family and the nurse must actively participate as they work together to build a therapeutic rela- tionship. Nurses who think family recognize that the nurse must build the relationship and purposefully move with the family toward mutuality (Jeon, 2004). Mutuality involves col- laboration, empathy, interdependence, equality, and reciprocal trust between the nurse and the caregiver (Jeon, 2004). When nurses share positive family experience stories with peers, others can transform beliefs and learn ways family care can improve outcomes. When nurses know what families need and expect when their loved ones seek health care services, they can practice and become competent family nurses. Families of critically ill persons have many needs (e.g., information, assurance, presence, support), but their greatest need is to be an integral part of the illness experience (Eggenberger & Nelms, 2007). Nurses who think family recognize how important it is to validate the importance of family in their loved one’s care (Jeon, 2004).

Caring for Families in the Community

Financial costs have moved many health care services to shorter institutional stays and more care delivered at home by the family unit. Today, 85% of elder care is provided at home by family members—usually wives, daughters, or daughters-in-law (Ward-Griffin & McKeever, 2000). The U.S population has reached about 309 million people with expectations that it will grow to almost 440 million persons by 2050 (Shrestha & Heisler, 2011). In 1950, the older population made up 8.1% of the population, but that number will reach 20.2% in

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BOX 13-3

Commitment to My Cow ork ers

As your coworker with a shared goal of providing excellent nursing care to our patients, I commit to the following:

● I will accept responsibility for establishing and maintaining healthy interpersonal relationships with you and every member of this staff. I will talk to you promptly if I am having a problem with you. The only time I will discuss it with another person is when I need advice or help in deciding how to communicate with you appropriately.

● I will establish and maintain a relationship of functional trust with you and every member of this staff. My relationships with each of you will be equally respectful, regardless of job titles or levels of educational preparation.

● I will not engage in the “3Bs” (bickering, back-biting, and blaming) and will ask you not to as well. ● I will not complain about another team member and ask you not to as well. If I hear you doing

so I will ask you to talk to that person. ● I will accept you as you are today, forgiving past problems and ask you to do the same with me. ● I will be committed to finding solutions to problems, rather than complaining about them or

blaming someone for them, and ask you to do the same. ● I will affirm your contribution to quality patient care. ● I will remember that neither of us is perfect, and that human errors are opportunities, not for

shame or guilt but for forgiveness and growth.

Compiled by Marie Manthey; used with permission of Creative Health Care Management.

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2050 when one in five persons will be age 65 or older. Better medical practices, technologies, and medicines mean the baby-boom population will live longer and possibly be healthier, but their chronic illnesses and disabilities still need to be managed at home.

Many in this generation will live with family or independently in communities rather than in care facilities. Home situations are less predictable and nurses who think family are aware of risks and member concerns. Families have rules for the ways things get done and family nurses know that they have less control in a family’s home and they are ready to work within family rules and values. Four distinct yet interconnected types of relation- ships are important in caring for frail elderly persons and others in their homes based on the amount of care required (Ward-Griffin & McKeever, 2000):

• Nurse-helper—The nurse gives and coordinates the majority of care; family members provide support.

• Worker-worker—The nurse teaches the family and helps the family members take increased responsibility for care based on their competence and skills.

• Manager-worker—The nurse gradually transitions from providing direct care to monitoring the family caregivers’ skills and coping.

• Nurse-patient—Family caregivers need supportive care owing to caregiver burdens.

R elationsh ip s B etw een C ommunity N urses and Families

Considerable tension can occur in nursing relationships because of (1) unclear expectations between the community nurse and the family caregiver, and (2) an increased amount of phys- ical, emotional, and intellectual labor care transferred from the nurse to family caregivers (Ward-Griffin & McKeever, 2000). Nurses who think family consider the potential caregiver role strain of providing 24-hours-a-day care and help find ways to increase support. Com- munity mental health nurses who worked with families of older people suffering from de- pression found that use of therapeutic relationships improved quality of life for the families (Jeon, 2004). Nurses who form sensitive and caring relationships have also reported increased satisfaction in their practice (Wright & Leahey, 1999).

Barriers to Caring and Nurse-Family Relationships

Many things can be barriers to providing family care and developing therapeutic relation- ships. Some barriers are intrinsic barriers and belong to the nurse (e.g., attitudes, beliefs, assumptions). Others are extrinsic (e.g., information, technology, hospital systems)—they come from outside the nurse.

Intrinsic B arriers to Caring and Individual-Nurse-Family Relationships

Intrinsic barriers include multitasking, time concerns, belief that caring cannot be learned, lack of preparation or knowledge, assumptions, and fear of emotional pain, unmanaged anxieties, and burnout.

Multitasking

Millennial learners (born 1980–1999) embrace multitasking, often making it hard to focus on one thing. Quiet contemplation and critical reflection that characterize “being with” must be intentionally cultivated so that multitasking does not become a barrier (de Ruiter & Demma, 2011; Pardue & Morgan, 2008). Nurses can cultivate a contemplative attitude

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by reflecting on care experiences. Responding to questions in writing is useful; here are some ideas (Idczak, 2007):

• Describe an interaction (positive and negative) you had with a family today. • What thoughts or emotions did you have while you were in the interaction? • Describe how you experienced yourself during the interaction. • Describe the emotions you noticed during the individual and family interaction. • What things about this time seem most important? • What other thoughts or feelings do you want to share?

Reflecting about experiences generates insights about self and others. Reflection is a way that nurses who have been mostly focused on “doing for” tasks can realize their need for engagement with individuals and families (Bail, 2007). Reflecting can help one think about better ways to “be with” individuals and their families.

C oncerns About Time

A stressful barrier that prevents nurses from developing individual-nurse-family relationships is the belief that there is no time to care. Some think “being with” takes extra time. Nurses who think family know that caring is an attitude, a way of being or interacting, and doesn’t always take more time. For instance, dressing changes take a certain amount of time, regardless of the caring or noncaring attitude by the nurse. Looking like one is pressed for time and hurried might be perceived as a lack of care. Both nonverbal or verbal cues are important. Nurses who think family are mindful that how they are “doing for” individuals and families expresses whether they are “being with” them. Dr. Cristina Garcia Vivar is a Spanish nurse studying ways families care for their dependent members (Box 13.4).

Th e B elief Th at C aring C annot B e L earned and a L ack of Prep aration

Another barrier is thinking that caring cannot be learned. Caring can be cultivated; students and experienced nurses can practice and learn caring behaviors. One study identified instru- mental and noninstrumental caring factors as important (Palese et al, 2011). Instrumental

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BOX 13-4

Family Tree

Cristina G. Vivar, PhD, MSc, RN (Spain)

Cristina Garcia Vivar, PhD, MSc, RN, is a nursing professor at the Faculty of Nursing, University of Navarra, Spain, and serves as the Assistant Director of the Department of Community and Maternal and Child Health Care. As a graduate student of Dr. Dorothy Whyte at the University of Edinburgh, Dr. Vivar developed a keen interest in family nursing, which led her to conduct her doctoral research with families experiencing cancer recurrence. Her current program of research focuses on families caring for a dependent relative. In Spain, nursing first became integrated into universities in 1997 with a 3-year diploma degree. This has recently expanded to include bachelor, master’s, and doctoral degrees. Dr. Vivar has helped move family nursing in Spain forward through many initiatives, including organizing family nursing courses for practicing nurses; teaching family nursing courses to undergraduate and postgraduate students; supervising doctoral students conducting research in family nursing; and presenting her research in family nursing at seminars and at national and international conferences. In her current research, funded by the Spanish Ministry of Education, Dr. Vivar is examining the effectiveness of an educational intervention in Family Systems Nursing (using the Calgary Family Assessment and Intervention Models) with practicing nurses as a way to prepare more nurses to care for families in Spain.

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caring is described as knowledge and skills. Patients ranked these acts as the most frequent caring behaviors used. However, the same individuals said that what gives them the greatest satisfaction with nursing care is “positive connectedness.” These noninstrumental actions in- volved “being with” and include spending time, helping them understand, being patient, and involving them in care.

People must feel safe with others before positive connections can be made—a shared humanity with another person (Storr, 2010). For example, when personal thoughts, feelings, fears, and hopes are shared, one becomes vulnerable. Students can plan “being with” in ways similar to preparing for doing technical skills. First, review what has been learned about ther- apeutic communication and family connections. Next, identify positive and negative responses that might occur in a particular situation. Anticipate a variety of possible responses. Practice can help nurses recognize biases, assumptions, values, beliefs, and attitudes about situations and make needed adjustments. Reflection about experiences can transform nursing practice.

Assump tions

A major barrier to thinking family is a “know it all” attitude. If one appears arrogant or “not present,” it is unlikely that others will want to share personal thoughts or feelings. Family-focused nurses explore needs of specific family units in tailored plans of care. Nurses listen to their needs and questions before a plan is made and then the plan is made cooperatively. Nurses need answers to questions such as these:

• What is the family’s current level of well-being? • What is important to this family that relates to the goal of well-being? • What are the most important things needed at this particular time? • How can I best learn what is most needed in this situation?

Use of active listening skills will help the nurse to notice and attend to what the family views as most important. Effective listening requires the nurse to be sensitive to personal bias that may influence what is noticed or observed about the family and the things indi- viduals and family members verbalize. Preconceived notions, expectations, and ideas that say families should act in particular ways can interfere with or become barriers to the open stance necessary for family-focused care.

Identifying Personal Assumptions

All nurses have assumptions that shape what and how they notice things around them. Becoming aware of personal thoughts, bias, and prejudices can limit the negative effect of using them in practice (Johns, 1996).

Assumptions are our taken-for-granted beliefs about the world and our place within it; they seem so obvious to us as not to need to be stated explicitly. Assumptions give meaning and purpose to who we are and what we do. In many ways, we are our assumptions. So much of what we think, say, and do is based on assumptions about how the world should work and what counts as appropriate, moral action within it. . . . Ideas and actions that we regard as commonsense conventional wisdom are often based on uncritically accepted assumptions. . . . Critical thinking, at its core, is the process of hunting down and checking these assumptions. (Brookfield, 2005, pp 49–50)

Discovering one’s assumptions involves reflection. What guides decisions, actions, and choices related to a particular situation? What can be done to check the accuracy of as- sumptions? How could one learn whether ideas are true or not? Try looking at the situation from another perspective. Imagine another possible viewpoint or explanation. What might happen if you had a different assumption? Knowing oneself and cultivating authentic caring

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relationships means assumptions are evaluated. Take a look at the Family Circle case study in Box 13.5, then review the questions and reflect on ways a family-focused caring nurse would respond.

Fear of Personal E motional Pain and U nmanaged Anx ieties

Nurses may be uncertain about what to say in response to those who express fears or con- cerns about death (Haraldsdottir, 2011). Fear of the emotional pain linked with suffering can be a barrier. However, family interactions provide excellent opportunities to develop confidence and overcome fears (Idczak, 2007; James & Chapman, 2009/2010). At end- of-life care or other critical times, nurses may think they are unprepared to know what to say or do. Previous life experiences influence responses.Those who have difficulty with personal distress or sorrow may shy away from others but those who have wrestled with loss or grief can use their experiences to offer empathy.

Being with an individual or family at end of life can be difficult. Using reminiscing to explore life experiences can be very useful at these times. One of this book’s editors recalls a spontaneous review with six adult grandchildren as they stood around their grandmother’s bedside for several hours while she was dying. The shared stories and

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BOX 13-5

Family Circle

Jason, a married middle-aged father of three grade-school-age children, has decided to move his mother into the guest room in his home. Over the past few months, Jason has observed that his mother is having increased difficulty in her ability to care for herself in her home. She has been having trouble managing her multiple medication regimen and has had increased difficulty with mobility. She has become frail since the death of his father 1 year ago. Jason is afraid she will fall and have no one there to help. He expects his two siblings would be happy to contribute financially to help offset the expense of needed home modifications. He thinks they would rather pay for things like safety rails in the bathrooms and other miscellaneous expenses of the move, rather than see her move to a nursing home. He knows that his mother is happier living with family than with strangers and thinks she gets better care from family members. She could develop a closer relationship with their grandchildren and would want to contribute to child care when needed. This arrangement would allow him to fulfill his family obligation to care for her, just as his mom cared for him as a child. Besides, he does not think he could ever live down the guilt that he would experience if he put his mother in a nursing home.

1. What assumptions— explicit and implicit— do you think Jason is operating under in this situation? List as many as you can, then compare your list with that of a peer.

2. Of the assumptions you’ve listed, which ones could Jason check by simple research and inquiry? What things would he need to do?

3. Give an alternate interpretation of this scenario— a version of what is happening that is consistent with the events described, but that you think Jason would disagree with.

4. What barriers do you perceive for yourself as a nurse cultivating a family-based caring relationship in this home-care situation?

5. As a nurse in this home-care situation, discuss in a small group how you could enhance relationship-based care through “ doing for” this family.

6. As a nurse in this home-care situation, discuss in a small group how you could enhance relationship-based care through “ being with” this family.

7. Discuss the new thoughts this chapter has offered you in caring for this family. 8. Discuss the new thoughts from this chapter you have learned about caring for yourself as a

nurse and a person.

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memories about their grandmother caused them to laugh and cry together. The nurse was present, but in the background. If hearing is the last sense to go, then this grandmother faced her dying encircled by love knowing her life was important to her granddaughters.

Nurses might believe that a cheerful and upbeat attitude is better than engaging in the emotional experience. They sometimes think that treating critical situations as if they were normal is the best approach, but that is rarely the case (Haraldsdottir, 2011). Individuals and families appreciate sensitive responses to their unique personal needs. They often need someone to “be with” them during difficult times, even if this means sitting silently or using touch as a signal of care. If nurses compartmentalize or wall off their feelings, it could be that they block the reciprocity needed for a deeply caring relationship (Gerow et al, 2010).

Fear of B urnout

Nurses may also fear that caring too much will cause them to “burn out.” However, re- search about nurses’ experiences shows the opposite to be true—engaging with individuals and families is viewed as meaningful (Gerow et al, 2010; Johnston & Scholler-Jaquish, 2007). Nurses who believe they make a difference tend to be more satisfied with their work and have more positive responses when human connections are made (James & Chapman, 2009/2010). A nursing student wrote a reflection that said:

The nursing internship enhanced my understanding about what it means to be a nurse by doing hands on nursing work full-time. Now, I really grasp that nursing is fundamentally caring for someone. The way my mind works, I always think about nursing as treating patients with highly skilled medical interventions. Diagnostics. Assessments. All that jazz. But a nurse per- forms so many functions of care. Whether it is administering medication or answering a call light to grab a patient something to drink. A nurse is so many things: a hybrid of a medical professional, a teacher, a hotel concierge, and so on. It is not so much the highly trained skills that patients appreciate, it is the things you do on instinct, your bedside manner that makes the biggest difference to a patient.

Note how this student’s experience involves “doing for” and “being with” persons. This student understands that how one does things—one’s “bedside manner”—is what truly makes a difference for individual and family experience. Another student writes:

Despite all of the technical skills in nursing, the one part of nursing care that has inspired me the most has been the patient-to-nurse interaction. Just listening to patients’ stories, giving them the love, support, and care they need, has been an incredible experience. I find it amazing how many people share their life story. People trust us, as nurses, and they can open up and share how they are feeling. I’ve been touched by so many people, young and old, and this has made me a more loving and compassionate person.

This reflection illuminates how nursing students learn the “being with” of nursing; they become self-aware and develop identity as a nurse and a person (Idczak, 2007). Human connections help nurses know they make a difference and affirm that nursing is a good career choice.

Ex trinsic B arriers to Caring and Individual-Nurse-Family Relationships

Extrinsic barriers to caring and the individual-nurse-family relationships include outcomes- based work, understaffing, the use of technology, cultural or social barriers, modeled incivility, lack of cultural competence, and labeling.

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O utcomes- B ased W ork

An extrinsic barrier to caring is the demand for task-based work. The value of nurses as em- ployees is often measured in tasks completed and outcome achievement. Emphasis on priority setting keeps nurses focused on tasks and “doing for.” Prioritization aims to improve effi- ciency and avoid errors. These goals are often measured by spending less time or money and using fewer staff members while ensuring safety, competency, and regulatory compliance.

In the current outcomes-based context, caring and “being with” those seeking care often seems less important because that work is less visible and difficult to measure or quantify. Its critical importance is often overlooked. “Doing for” can be measured. Stress on “doing for” might explain why students view physically based caring behaviors (e.g., patient monitoring, completing delegated tasks) as most important (Khademian & Vizeshfar, 2007). “Being with” often occurs in isolated settings and is less easily observed by others or counted as work done.

Health care organizations use tools to measure outcomes. Press Ganey is a company that works with health care organizations to help them innovate and become high-perfor- mance organizations (Press Ganey Associates, 2012). Performance is based on the collection and analysis of data to assess patient satisfaction. Their philosophy says that if positive patient experiences are provided, then positive clinical and financial outcomes will follow. High Press Ganey scores are viewed as a reflection of excellence in health care delivery. Press Ganey scores are widely accepted but they only measure perception of nursing care activities that are customer service oriented (e.g., respectfulness, giving clear directions, length of wait time for service). These fail to capture the important relational outcomes of individual-nurse-family relationships.

U nderstaf f ing

Understaffing can also be a barrier to caring or “being with” because it places demands on the nurses’ time. Inadequate staffing is stressful and distracts from fully meeting less visible needs. The Magnet hospital movement, a recognition program run by the American Nurses Credentialing Center (2012), distinguishes nursing excellence. The program somewhat ad- dresses the low staffing barrier by recognizing that appropriate staffing—with a highly edu- cated staff—makes differences. Adequate staff improves outcomes, work satisfaction, and the likelihood of staying employed in nursing.

Th e U se of Tech nology

Technology can also be a barrier to “being with” others. Care providers focused on com- puters, digital screens, or equipment may pay less attention to care recipients, so care seekers think their needs and questions are less important. If communication via text messages or Facebook is preferred over face-to-face interactions, the value of personal relationships can be unknown, forgotten, or minimized.

C ultural or Social B arriers

Nurses may have personal or familial experiences that interfere with caring behaviors. Some families are less communicative or less demonstrably affectionate. If one has not ex- perienced caring family relationships or seen caring behaviors modeled, it may be hard for them to use them. Educational practices can also be a deterrent. If competition among stu- dents rather than cooperation is promoted, introverted students might choose to be less visible or isolate themselves. Students compete to access specific clinical experiences, attain a job, or move up the ladder. Students who lack family experiences with valued caring relationships might avoid “being with” others (Young, Hayden-Miles, & Brown, 2010).

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Modeled Incivility

Another extrinsic barrier is incivility. Students who see teachers as autocrats, dictatorial, or uncivil may mimic similar behavior in clinical practice (Clark & Davis Kenaley, 2011). How can students learn caring in an uncaring environment? Nursing actions should incor- porate others, promote work as partners, employ coordinated efforts, and use collaborative environments. Academic incivility (e.g., rudeness, being discourteous) is behavior that dis- rupts the teaching-learning process (Feldman, 2001). Horizontal violence describes the phenomenon of nurses’ disrespect for each other. All forms of incivility are barriers to caring, regardless of where it occurs.

L ack of C ultural C omp etence

Not understanding cultural differences can be a barrier to family-focused caring. Cultural constructs of cultural awareness, humility, knowledge, skill, and desire were discussed in Chapter 6. Knowledge about cultural differences can be institution based and is an ongoing learning process. Cultural competence implies:

• The nurse understands diverse worldviews, avoids stereotyping and misapplying sci- entific knowledge, and applies knowledge so care quality and health outcomes are improved (Fernandez & Fernandez, 2012).

• Nurses have cultural beliefs, practices, and flexibility that are respectful of others. Their actions involve listening, learning about unique qualities and situations, and providing care that supports health behaviors and eliminates barriers (Fernandez & Fernandez, 2012).

Th e Practice of L abeling

Labels for persons or families (e.g., the colon resection in room 308, a fresh open heart, overinvolved, demanding) erect barriers to caring. Labeling depersonalizes and causes nurses to be distant and detached (Barry & Purnell, 2008; Ironside, Diekelmann, & Hirschmann, 2005). Applying labels may influence the attention given or the ways things are heard. Labels project interpretations or meanings that might be false. Respect implies acceptance without labels. It is important not to label people by their disease (e.g., using the term diabetic instead of person with diabetes) and consider the household and com- munity needs that influence their care needs (Box 13.6).

“ Doing For” and “ Being With” Means Knowing Oneself

Self-knowing or self-care are prerequisites to therapeutic relationships. One needs to iden- tify and understand personal emotions. Knowing oneself is fundamental to maintaining personal health, empathizing with others, and having effective therapeutic relationships. Knowing oneself is developed through reflective self-discovery (Box 13.7).

B ecoming a Reflective Practitioner

Reflecting on one’s practice experience is a hallmark of being a professional (Schon, 1983). It is an essential skill that helps nurses connect previous learning and experience with current actions and outcomes. Reflection helps one construct meaning from experiences, interpret events, and identify important factors in complex situations. It can help one understand and make sense of experiences and events. Reviewing situations can increase

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BOX 13-6

Evidence-Based Family Nursing

Diab etes: A Family Matter

The Family Health Model (FHM) was used to devise a plan for a toolkit that could be used in the Appalachian region of the United States to prevent type 2 diabetes and its complications. This most rural area follows the Appalachian Mountains from north to south, and includes 420 counties and parts of 13 states; only West Virginia is included in its entirety. Although type 2 diabetes is known to be preventable and manageable, it continues to spread across the nation and world. This region is recognized as part of what is called the “ diabetes belt,” and the disease is of epidemic proportions in a largely Caucasian population. This area has a disproportionate level of poverty and its associated problems compared to the rest of the nation. Theory was used to guide thinking about the research conducted as part of this focused work and to think about the consequences and needs of people living with risks for type 2 diabetes in this region. The contextual, functional, and structural domains of the FHM proved useful for thinking about the complex interactions faced by families as they live with and try to manage the disease in their homes and social settings in their communities (Denham, 2003). As family members live in their households, they share established routines and habits that can place members at risk for this disease. This region’s high rates of obesity and physical inactivity are just two social factors that put rural residents at risk. The spread of type 2 diabetes is occurring at increasingly younger ages, and disease complications are widespread. Over many years, numerous research studies were conducted to learn more about this regional problem and to better understand the family experience of living with the disease. The toolkit devised uses community volunteers to promote healthy lifestyles, increase knowledge about the importance of active living, and spread knowledge about the disease. A variety of materials were created (e.g., a brochure series, plays, films, fotonovellas, activities) to spread culturally sensitive messages to rural Appalachian residents. An evaluation project and other research that has studied parts of this toolkit has shown that it is culturally sensitive for use with the target audience. The toolkit, Diabetes: A Family Matter and the Family Health Model, can be viewed online at < www.diabetesfamily.net> .

Source: Denham, S. A. (2011). Diabetes: A family matter. In E. K. Svavarsdottir & H. Jonsdottir (Eds.), Family nursing in action (pp 309–332). Reykjavik, Iceland: University of Iceland Press.

BOX 13-7

Q uestions for Self-Discovery

These questions offer some guidance for personal self-reflection and thinking about your relationships with peers, coworkers, and other professionals. Reflection can help nurses prepare to think family and offer family-focused care. Reflect on answers to these questions to better understand yourself:

● How do I feel cared for? ● How do I express my care for others? ● What are the areas of myself that do not feel nurtured? ● How do I replenish myself? ● How does self-replenishment relate to the leadership service of others? ● What makes me happy? ● What are my personal routines and rituals for letting go of work/obligations at the end of the day? ● Am I growing healthier in body, mind, and spirit? ● Am I helping others to grow professionally?

Source: Pipe, T. B., & Borst, J. J. (2009). Mindful leadership as healing practice: Nurturing self to serve others. International J ournal for Human Caring, 1 3 (2), 35–39.

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awareness of personal patterns or experiences and reveal how single events are part of a whole. One’s perspective is only one of many possible ways to see a situation. Nurses can examine perceptions as they reflect on experiences and this learning has the potential to transform one’s practice.

Reflection can be cultivated and nurtured. As the nurse reviews what went right or wrong, what is and is not known get clearer. These viewpoints offer new ways to consider how to do things differently next time. Reflecting on good and bad experiences can prevent repeating similar mistakes. It is a way to identify things that really matter in nursing practice. Use the following questions to guide your reflections:

• What confused, surprised, or worried me today? • What do I now understand for the first time? • What am I still wondering about or questioning? • Who did I disagree with today and why? • What did I do today that makes me proud? • In what ways did I practice “doing for” and “being with” today?

These questions can stimulate reflective thinking, a process (i.e., noticing, interpreting, responding, reflecting) important for thinking like a nurse (Tanner, 2006).

Nurses engage in public reflection all the time as they give reports at shift changes. When stories are shared about challenging, standout, or memorable experiences, reflection occurs. Reviewing stories can help nurses make sense of complex situations. They can help one ask questions and rehearse behaviors for doing things differently next time. Debriefings following a critical incident, a clinical experience, or a simulation scenario are reflective experiences. As participants talk about what did and did not happen, listeners see situations differently. Ideas can be reconstructed in meaningful ways. These kinds of activities enable lifelong learning, earmarks of the professional nurse (Fig. 13.3).

Taking Care of Oneself

The work of nursing—caring for others—demands that nurses stay fit. Physical, mental, emotional, and spiritual fitness are all important. Nurses cannot help anyone beyond where they themselves are at a particular point. Self-esteem must be maintained at a

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FIGURE 13 -3 Reflections and debriefing are important experiences for nurses.

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healthy level. Virginia Satir (1988) in her classic book, The New Peoplemaking, talks about the importance for those in helping professions to maintain a full “pot of self- esteem.” Nurses need to understand what it takes to fill the “pot” as well as what depletes it. Use of reflection throughout a career can help nurses stay in tune with things and check their caring-potential temperature.

Doing a Personal Assessment

It is possible to be a member of a caring profession and neglect oneself. Self-care needs to be intentional, just like caring for others. It might mean conducting a personal inventory, taking stock of one’s physical and emotional temperature. This may be as simple as asking oneself, Do I feel rested? Did I get enough sleep last night to keep me energized for the day or do I need to be gentle with my expectations for myself today? Am I eating healthy? Am I exercising? Do I have good work-family balance? Do I maintain healthy relationships? Taking stock also means knowing one’s strengths so they can be built upon and limitations so they can be strengthened. What energizes me and makes me feel good about myself? Questions about what characterizes one’s inner source of energy or happiness are useful (Box 13.8). Lack of self-care can impede or threaten one’s ability to care for others.

Regular reflection about self-care helps develop the awareness needed to be a caring person (Wilson & Grams, 2007). A nurse involved in a structured self-care assessment noted: “When I care for myself, I ultimately help others. My cup is filled so I can fill other cups” (Wilson & Grams, 2007, p 19). The nurse who regularly cares for self embraces car- ing as a way of being. Another nurse stated, “Caring as a way of being rather than doing has been a new way of thinking. . . . I believe that being caring encompasses doing caring” (Wilson & Grams, p 19).

Developing Self-Care Goals

Following a personal assessment, self-care goals, along with strategies to meet identified goals, can be developed (Wilson & Grams, 2007). This step helps develop positive ways to care for self. Finding a positive role model or a clinical mentor can help in developing effec- tive coping skills. Some nurses use faith and spirituality as ways to manage grief, stress, or emotional upheaval in order to strengthen themselves (Gerow et al, 2010). Personal caring rituals can be used—small acts of doing for others can ground everyday nursing

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BOX 13-8

Q uestions for Ex ploring Sources of Strength, Meaning, and Joy

Q uestions such as the following can provide useful direction for personal reflections:

● What brought me to nursing/health care? ● What brings me strength? ● What/who inspires me? ● Where do I find joy and meaning? ● What legacy do I hope to leave with my leadership influence? ● What rituals can I build into my daily routine that will help me remember my connection with

self and source?

Source: Pipe, T. B., & Borst, J. J. (2009). Mindful leadership as healing practice: Nurturing self to serve others. International J ournal for Human Caring, 1 3 (2), 35–39.

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practice. One can be comforted by doing familiar tasks, things that can involve “doing for” and “being with.” Each nurse needs to find favorite ways to care for mind, body, spirit, and relationships as intentional care for self (Brown, 2009). A simple way to care for self might involve being mindful: “Whatever I do first, that’s what gets done.” This statement reflects the realization that life is busy and complex—people get pulled in many directions. Whatever one chooses to do first in the day may be the only guaranteed thing done that day. It illu- minates the importance of setting priorities when doing for oneself. For example, taking a walk first thing in the morning ensures that exercise is accomplished and reflective time occurs. Pick one’s “first things” wisely—be intentional; it may be all one can do that day.

Slow ing Dow n

Being busy is a hallmark of contemporary nursing practice (Olson, 2009). But being busy or looking busy often precludes engaging others in meaningful ways. Clearing a space for authentic relating with others—that is, without pretenses of any kind—is an attitude. Slow- ing down the busyness of daily living opens a space for anticipatory thinking—or, thinking about what might be coming next—and reflecting that characterizes expert nursing prac- tice. One practical way to reduce one’s busyness is to simply pause before saying “yes” to a request or agreeing to a new project. “Let me think about this for a bit—I’ll get back to you” is all that needs to be said initially. This reply provides the freedom to fully examine one’s reaction to the new activity—rather than saying “yes” out of habit. Pausing allows time for a cost-benefit analysis to be done before taking on more work.

Learning to slow down can be particularly challenging. E-mail, instant messaging, pagers, cell phones, and other emerging technologies seem to demand immediate response. Communication in health care is often high stakes, time sensitive, and centers on the preser- vation of life, health, and human dignity (Pipe & Borst, 2009). Being mindful in practice can help nurses attend to what is happening, being present in the moment. Mindfulness is paying attention and slowing down to pay attention, to consider being given a clinical nurs- ing assignment with many unknowns and uncertainties. Mindfulness means avoiding automatic responses and stopping to take a breath and organize a plan. Mindfulness (e.g., aliveness, self-awareness, self-control) can be developed through training (Scheick, 2011). Breathing exercises, meditation, and yoga are approaches to practicing mindfulness. These actions can help reduce stress, increase healing, and relieve suffering.

Developing an Aesthetic Attitude

Aesthetics involves paying attention to the things that move one emotionally—things that are beautiful, thought provoking, or personally satisfying. Aesthetics reflects the art of nursing—recognizing and holding dear the human experience of illness, health, and healing (Leight, 2002). Cultivating this appreciation implies grasping the full scope of human po- tential while being open to new possibilities. Paying attention to human experience means seeing the person and not a diagnosis. Developing an aesthetic attitude requires listening to intuition, an inner voice about what matters (Barry & Purnell, 2008).This reflection may occur when obtaining a health history, debriefing after a critical incident, or reading a qual- itative report that describes a particular phenomenon or social process. Photos, film, paint- ings, sculpture, poetry, music, and other art forms tell stories that can be reflected upon and interpreted. What is the artist trying to say about what matters in the experience of being human? Developing one’s creative self may feel risky to the nurse grounded in science or caught up in the tasks of “doing for” individuals and families. Nurses need aesthetics; this reflection is the nourishment that inspires and helps connect with core beliefs (Box 13.9).

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Chapter Summary

The core of nursing work is caring—in this instance, family-focused caring. Caring relation- ships are essential to professional nursing practice and require personal strength. Nurses might find caring relationships challenging when personal experiences conflict with what is met in practice. Nurses can develop the inner strength needed to watch families struggle with issues. They can learn ways to support them as they handle unfamiliar situations. Nurses can use intentionally focused efforts to build skills and confidence for working with family units. Nurses who think family use their roles to provide safe and competent care as they “do for” and “be with” others. Family nurses collaborate with family unit members as they establish new life patterns or make sense of critical and unexpected life events. Nurses can use self- care actions to prepare them to “do for” and “be with” those to whom they give care.

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BOX 13-9

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