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1 Authentic caring: Rediscover the essence of nursing By Pat McClendon, DNP, RN Amyth exists in today s healthcare landscape that all forms of caring are equal. But authentic caring provides deeper meaning for both patients and nurses. It has a reciprocal nature; both the patient and nurse benefit. Authentic caring moments can significantly impact patients lives and renew nurses commitment to their work. 1,2 For patients experiencing a health crisis or event, this level of connection with a nurse can create a lasting sense of well-being and healing. Formulaic caring dominates in today s healthcare organizations. This creates confusion and resistance among nurses, fuels workplace conflicts, and results in nurse dissatisfaction and attrition. In contrast, authentic caring generates patient and nurse satisfaction. Nurse leaders are called on to form a collective voice advocating for the transformation of caring. Here, we explore the distinctions and benefits of authentic caring and provide strategies to help your staff achieve this level of patient connection. Monetization of patient satisfaction Healthcare is the most complex industry in existence. Its unique demands of science and technology combined with its inherently high-risk, high-touch environment are challenging for all healthcare professionals. Yet, it s the nurses responsibility to attend to patients deep human caring needs. Nurses caring is now a commodity. It s accepted in the healthcare industry that nurses have the greatest impact on patients care experiences and satisfaction scores, which are directly related to nurses domain scores. 3-5 If the services delivered by nurses receive high scores, the overall hospital scores are sure to be high as well. This not only provides public validation of nursing s value and impact on patients, 36 October 2017 Nursing Management

2

3 Authentic caring but also has a positive impact on hospital revenues. 3,4,6 Monetization of caring drives the stakes even higher for nurses to succeed in creating the best caring experience possible for patients. Formulaic caring The current race to higher patient satisfaction scores has taken the healthcare industry in a different direction. 6 For the sake of consistency and expediency, formulaic caring scripts and pr grams dominate the definition of caring throughout healthcare which recognizes examples of authentic caring. 9 However, its scope is limited and can t fill a systemwide gap. Creating confusion Many nurse leaders are caught between their organization s promotion of formulaic caring and nurses resistance to it. The pressures from evidence-based practice, technologies, and safety risks are challenging enough for nurses. The lack of attention to the importance and meaning of authentic caring nurse leaders, educators, and, at its worst, patients and each other. Caring science theory Nurse leaders across the nation have advanced nursing practice through nursing programs that focus on leadership development, work environments, structural empowerment, and practice standardization. These include shared governance, Magnet recognition, Transforming Care at the Bedside, and the Center for Nursing Excellence initiatives. 6,10,11 These programs have Monetization of caring drives the stakes even higher for nurses to succeed in creating the best caring experience possible for patients. organizations. 7,8 In some cases, these programs come from nonhealthcare industries and fall flat in clinical situations. The purpose of formulaic programs is to achieve a culture of caring where all staff are friendly and responsive to patients needs. These programs are well intentioned and can be effective in culture building in nonclinical areas. The challenge for organizations and nurse leaders is learning how to go beyond this level of scripted caring and tap into nursing s essence and science. Formulaic caring programs come at a price. These programs don t acknowledge the deeper caring efforts of nurses. One exception is the DAISY Award program, within organizations creates confusion among nurses, leaders, and educators, and diminishes growth in authentic caring programs. This lack of clarity surrounding caring practices and expectations contributes to the energy that fuels our workplace conflicts regarding work demands and working conditions. But that s not where it ends. Most nurses are too distracted and consumed by clinical demands to consider authentic caring as a realistic option in their work settings. Too many nurses feel that it isn t possible to increase their frequency of authentic caring in their current practice. This frustration can shift to blaming healthcare and raised quality, engagement, professionalism, education, leadership, and retention throughout organizations. 12 However, they haven t uniformly addressed caring s intrinsic nature and elements. Definition and clarity around caring does exist. Clinical research led to a classification continuum of nurse-patient relationships based on patients experiences. 13 Five levels were defined ranging from uncaring to caring (biocidic, biostatic, biopassive, bioactive, and biogenic). 13 The biocidic level (life-destroying) is where the nurse causes distress for the patient. The biostatic mode (life-restraining) is created by an insensitive or indifferent 38 October 2017 Nursing Management

4 nurse. The biopassive level (life neutral) reflects It s just a job behaviors. The bioactive level (life-sustaining) is given by a caring nurse who is kind, concerned, reassuring and responsive to patients needs. This is the nearest fit to the characteristics defined in formulaic caring programs. The highest level of caring relationships is biogenic, which is consistent with what experts describe as authentic caring moments and the transpersonal caring relationship. 2 This highest level of caring is lifegiving and life-receiving for both the nurse and patient. Caring science theory provides foundation for development of caring practices throughout schools and organizations worldwide. The journey to authentic caring It s nurses internal resources that propel nurses engagement in authentic caring. These connections originate within the nurse, spark from a connection between the nurse and patient, are nurtured by the nurse s internal resources, and can only be sustained by the nurse. Nursing schools introduce authentic caring, but its development, acknowledgment, and support virtually suspend upon entering employment in healthcare organizations. From there, it s an individual journey for nurses to develop and sustain their authentic caring, which certainly exists today, but not at the frequency or systemic level it could if it was a conscious part of our work environments. Open and routine dialogues, acknowledgments, and promotions of caring among and by nurses and nurse leaders would confirm that caring is the central anchor of nursing s contribution to healthcare. Most nurses yearn to connect more often with patients on meaningful levels. They entered the profession with a desire to tap into something larger than themselves. Intrinsic drivers motivate 21st-century individuals, and there s a vast disconnect between the science behind motivation and what businesses do. 14 There s no profession more intrinsically motivated than nursing. It s likely that many nurses are more motivated by their own intrinsic experiences in their high-level caring connections with patients than by their organizations missions. Nurse leaders are in a good position to tap into this phenomenon and partner with nurses in their caring endeavors. Nurses desire to authentically care is often greater than their inner resources, leaving nurses feeling burned out. 15 Research supports that tapping into intrinsic motivators such as authentic caring decreases nurse stress, and increases job satisfaction and retention Authentic caring relationships are intertwined with resiliency in successful nurse leaders. 19 Authentic connections restore both patient and nurse, and potentiate learning and healing. 2,13 Compassion fatigue and burnout are treated as unavoidable work hazards in nursing. 15 This mindset usurps exploration of caring consciousness programs and caring resilience potential for nurses and patient s health and healing. One expert suggests that burnout doesn t happen because we care too much, but rather because we wall ourselves off from love, nourishment, and human connectedness. 20 How we got here Being a nurse or nurse leader in healthcare organizations can dull one s sensibilities, largely related to the high-demand, low-reward ratio in caring experiences within organizations. It isn t uncommon for conscientious, caring nurse leaders to get caught in the miscarriage of formulaic caring programs. The reality is that the rate of change in healthcare has outpaced the available bandwidth for nurses and nurse leaders. Nursing education and resources are consumed by these advancements in science and technology, making time and opportunities for development of authentic caring programs and skills nearly impossible. Caring consciousness programs can t be mandated, managed, or measured in the same way as other programs; the processes and the evidence are distinct. This presents a unique challenge for nurses, leaders, and educators alike. 21 Society has also changed. The public s current shift from all things science and technology to wellness consciousness creates new opportunities and demands in healthcare organizations in nursing s domain. Wellness consciousness is the recognition that health isn t just absence of disease and illness; it involves the whole person s unity of mind, body, and spirit. Patients are bringing their holistic values, needs, and expectations into their healthcare encounters, Nursing Management October

5 Authentic caring seeking meaning and connection, focusing on health, healing, and quality of living and dying. These are the essence of nursing. Call to action No doubt, these are extraordinary challenges for nursing. The shift in society s wellness consciousness, plus the monetization of caring, significantly escalates the value and demand for expanded caring practices. These trends within the healthcare system open opportunities for caring development initiatives. But the direction is unclear. Nursing leadership in organizations hasn t provided a collective voice for caring. 22 All disciplines within the healthcare industry, including nurses, would benefit from a collective voice informing them of what caring is, its science and research, its range of impact on people s lives, its source, and how it s developed. Nursing is the voice of caring, and these current shifts reinforce nursing s position as the industry leader to transform caring in healthcare. This opportunity invites nurses and nurse leaders to lead organizations in expanding the development of caring programs. Nurse leaders can close the knowledge and practice gaps, and access the untapped resources of caring within nurses with a clear collective voice throughout healthcare, locally, nationally, and globally. Here are specific strategies to promote authentic caring: Integration of the classification of caring and uncaring nursepatient relationships into existing theory-guided professional practice models broadens the foundation of caring conversations by using a shared caring language among nurses. 13 Use of these terms and concepts can help nurses clarify and expand their own caring consciousness and practice. 1,2 Using caring language during nurse leader rounding acknowledges caring experiences in nurses real time and space. Routinely naming, claiming, and articulating the phenomenon of caring helps champion the growth of biogenic caring. 22 This provides situational and environmental support that builds on mutual language and experiences, and creates a path for ongoing progress. 10,23-27 The path is open for Magnet and other programs to promote transformation in nursing leadership, professional practice, and work environments that improve nursing practice and quality of care. Integration of caring definitions and caring language into theory-guided practice standards can advance caring recognition, knowledge, development, and innovation in organizations. Amplifying nursing s voice of caring can intensify nurse engagement and the image of nursing in healthcare. 28 Each nurse is responsible for his or her self-development and well-being. Many nurses are Caring consciousness skills are as critical as clinical skills to patients well-being, nurses caring connections, healthcare s organizational culture, and society s wellness. engaged in lifelong practices of personal self-care, professional self-development, or spiritual practices. Caring consciousness development is unique for each nurse. Resources that lend themselves to caring consciousness development are caring science, mind-body science, and emotional intelligence. Examples of useful practices are spiritual practices, mindfulness, reflection, meditation, yoga, healing arts, creative arts, and time in nature. Watson Caring Science Institute offers education and programs that inform and inspire the use of Dr. Jean Watson s Theory of Human Caring/Caring Science. These programs guide 40 October 2017 Nursing Management

6 transformative models of caring and healing practices for hospitals, nurses, and patients in diverse settings worldwide. There s a range of online programs available, which include free courses and a more extensive 6-month Caritas Coach Education Program specifically for caring consciousness development. To access events and programs, visit science.org. Find the center The essence of nursing is caring. Patients need and want deeper levels of nurse connection and caring. Healthcare depends on it. Society expects it. Nurses need it to sustain meaning in their practice. And nurse leaders are positioned to lead it in healthcare organizations and beyond. Expanding nursing s unique focus on caring benefits nurses, patients, healthcare, and society. Caring consciousness skills are as critical as clinical skills to patients well-being, nurses caring connections, healthcare s organizational culture, and society s wellness. How nurses and nurse leaders communicate caring impacts how it s understood and valued by all. NM REFERENCES 1. Watson J. Nursing: The Philosophy and Science of Caring. Rev. ed. Boulder, CO: University Press of Colorado; Watson J. Human Caring Science: Theory of Nursing. 2nd ed. Sudbury, MA: Jones & Bartlett Learning; Wolosin R, Ayala L, Fulton BR. Nursing care, inpatient satisfaction, and valuebased purchasing: vital connections. J Nurs Adm. 2012;42(6): MacLeod L. Three keys to patient satisfaction: nursing, nursing, and nursing. Nurse Lead. 2012;10(5): Dempsey C, Reilly B, Buhlman N. Improving the patient experience: realworld strategies for engaging nurses. J Nurs Adm. 2014;44(3): Brewer BB, Watson J. Evaluation of authentic human caring professional practices. J Nurs Adm. 2015;45(12): Dempsey C, Wojciechowski S, McConville E, Drain M. Reducing patient suffering through compassionate connected care. J Nurs Adm. 2014;44(10): Billingsley R. Working together to improve the patient experience. Nurs Manage. 2015;46(4): Barnes B, Barnes M, Sweeney CD. Putting the meaning in meaningful recognition of nurses: The DAISY Award. J Nurs Adm. 2016;46(10): Ray MA, Turkel MC. Caring as emancipatory nursing praxis: the theory of relational caring complexity. ANS Adv Nurs Sci. 2014;37(2): Linnen D, Rowley A. Encouraging clinical nurse empowerment. Nurs Manage. 2014;45(2): Spence Laschinger HK, Fida R. Linking nurses perceptions of patient care quality to job satisfaction: the role of authentic leadership and empowering professional practice environments. J Nurs Adm. 2015;45(5): Halldorsdottir S. Five basic modes of being with another. In: Gaut DA, Leininger MM, eds. Caring: The Compassionate Healer. New York, NY: National League for Nursing Press; Pink DH. Drive: The Surprising Truth About What Motivates Us. New York, NY: Riverhead Books; Neville K, Cole DA. The relationships among health promotion behaviors, compassion fatigue, burnout, and compassion satisfaction in nurses practicing in a community medical center. J Nurs Adm. 2013;43(6): Tucker SJ, Weymiller AJ, Cutshall SM, Rhudy LM, Lohse CM. Stress ratings and health promotion practices among RNs: a case for action. J Nurs Adm. 2012;42(5): Amendolair D. Caring behaviors and job satisfaction. J Nurs Adm. 2012;42(1): Dotson MJ, Dave DS, Cazier JA, Spaulding TJ. An empirical analysis of nurse retention: what keeps RNs in nursing? J Nurs Adm. 2014;44(2): Dyess SM, Prestia AS, Smith MC. Support for caring and resiliency among successful nurse leaders. Nurs Adm Q. 2015;39(2): Watson J. Caring Science and Caritas Processes. Presentation in online class: Caring Science, Mindful Practice. Canvas Network. January Ray MA, Turkel MC, Cohn J. Relational caring complexity: the study of caring and complexity in health care hospital organizations. In: Davidson AW, Ray MA, Turkel MC, eds. Nursing, Caring, and Complexity Science. New York, NY: Springer Publishing Company; D Alfonso J. Economics, caring, and complexity. In: Davidson AW, Ray MA, Turkel MC, eds. Nursing, Caring, and Complexity Science. New York, NY: Springer Publishing Company; Kingston MB, Turkel MB. Caring science and complexity science guiding the practice of hospital and nursing administrative practice. In: Davidson AW, Ray MA, Turkel MC, eds. Nursing, Caring, and Complexity Science. New York, NY: Springer Publishing Company; McDowell JB, Williams RL, Kautz DD. Teaching the core values of caring leadership. Int J Human Caring. 2013; 17(4): Jackson C. Using loving relationships to transform health care: a practical approach. Holist Nurs Pract. 2010;24(4): Sitzman K, Watson J. Caring Science, Mindful Practice. New York, NY: Springer Publishing Company; Lee SM, Palmieri PA, Watson J. Global Advances in Human Caring Literacy. New York, NY: Springer Publishing Company; Birk LK. The magnetism of theory: resonance to radiance. J Nurs Adm. 2007;37(3): Pat McClendon is the founder of Saving Nurses, a nurse leader professional development service, in Temecula, Calif. The author has disclosed no financial relationships related to this article. DOI /01.NUMA c Nursing Management October

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