Caring is the fundamental concept of nursing that differentiates it from other health care professions and provides a framework to guide the nursing practice (Cook & Peden, 2017). According to Calong & Soriano (2018), many nursing theorists identified that caring is the fundamental principle in nursing practice applied to achieve and maintain the well-being of patients. One of the first theorist, Leininger, stated that caring is the principle, dominant and unifying focus of nursing (Cook & Peden, 2017). The concept of care is an integral component of holistic nursing practice. It integrated with knowledge, skills, and competence to provide safe quality care (Como, 2007). According to Leyson, caring is the interaction between the nurse and the patient with the goal of preserving life (Calong & Soriano, 2018). Just as the role of the nurse has changed over the years, the concept of caring has also similarly evolved over time and has also influenced nursing practices, education, and research (Calong & Soriano, 2018).
Nurses have a wide range of roles from educators, to researchers, to policymakers, in order to satisfy the complex needs of healthcare consumers (Davidson, Rushton, Kurtz, Wise, Jackson, Beaman, & Broome, 2018). This article elaborates the concept of caring in nursing by using different ontological lenses such as Human science, Complexity, and Critical theory, besides identifying ethical issues related to nursing care. This article also describes controversies and intersections that occur when comparing the concept of caring in nursing across ontological traditions.
The concept of caring with different ontological traditions.
The concept of caring in nursing as a human science emphasizes on life and health as human experiences (McIntyre & McDonald, 2013). This concept suggests that patients are subjects with the ability to take charge of their own lives, rather than as mere objects (Pilkington, 2005). Nurses provide care to vulnerable individuals with ailments such as illness, mental or social problems. According to my clinical practice, patients with dementia are unique human beings who can feel and respond to any stimuli, that possess a unique history, values, beliefs, and experiences (Bell & Troxel, 2013). The human science hypothesis enables medical caretakers to think about the patient’s life direction and encounters, including the moral and individual setting (Federal, Porto, & Grande, 2018). Hence, this theory allows patients with dementia to require the same level of holistic care as other patients, regardless of their current competencies.
According to human science ontological tradition states that human beings are unitary wholes in continuous interrelationship with their dynamics, historical, and cultural world (Mitchell & Cody, 1992). Watson suggested the need for cultivation of intentionality and caring consciousness to be mindful about what is most important for patients to provide the best possible care (Pilkington, 2005). Patients with dementia have the right to live in a safe and stimulating environment where they can experience meaningful engagement (Bell & Troxel, 2013). The caring theory suggested by Watson narrows down to the application critical reasoning to center around the humanistic components of patient consideration in the distinctive settings to accomplish ideal results (Federal et al., 2018).
The complexity theory of nursing is a way to understand the communities and the healthcare organization where patient care remains the central focus of a complex health care system (Mitchell, Jonas-Simpson & Cross, 2013). Nursing happens within complex intersections where human relationships, social determinants, global forces, and personal realities mingle and influence health (Mcsherry & Douglas, 2011). It offers an appropriate perspective to understand the unpredictable nature of a complex health system and multiple determinants that influence organizational culture for the health care of a patient (Thompson, Fazio, Kustra, Patrick & Stanley, 2016). The complexity theory is nonlinear dynamics that offers a perspective to studying complex systems in a manner to understand how minor changes have an impact on the overall health outcome (Thompson et al., 2016). Inter-professional collaboration is the best strategy to achieve desired health outcomes effectively by monitoring health status, coordinating care, and developing an evidence-based care plan in the complex health system (Martin, Ummenhofer, Manser, & Spirig, 2010).
Complexity theory provides a better framework for understanding the impact of the different factors influencing health while maintaining the distinctiveness of each nursing interaction (Walsh, 2000). Nowadays, clinical care is becoming more complex and multi-disciplinary cooperation is crucial to facilitate a well-coordinated health care provision framework to deliver safe quality care; where one patient needs more than one professional to be satisfied (Martin, Ummenhofer, Manser, & Spirig, 2010). Inter-professional collaboration is achieved by bringing skills and knowledge of all health professionals in one platform and working together as a team to deliver better care to maximize health benefits (Engel & Prentice, 2013). Collaborative practice is an ethical responsibility of nurses to maximize health benefits of the patient by recognizing and respecting the knowledge, skills, and perspectives of the specialties (Ewashen, McInnis-Perry & Murphy, 2013).
The ontology of critical theory is derived from the Marxist philosophy. It focusses on the idea understanding human activities and how the influences are felt by the large social structures (Mosqueda-Diaz, Vilchez-Barboza, Valenzuela-Suazo, & Sanhueza-Alvarado, 2014). Human beings are a product of their environment, history, society, and culture. Experiences are viewed as a major contributor of their perspective of the world (Gathercoal, Gathercoal, Seegobin, & Hadley, 2017). Watson’s human care theory assists nurses to consider patient’s life experiences, and also develop skills for holistic assessments to understand the historical bio-psycho-social context and cultural context of the patient (Federal et al., 2018). When nurses understand the health of a society is shaped by the social, political, and economic influences, and they are more likely to acknowledge social action as a part of nursing care to reduce social inequities and take actions on behalf of their patients (Butterfield, 1990). According to Watson caring theory that humans cannot be separated from the social environment because it is centrality focus on therapeutic healing processes and relationships and it affects both the one who is caring and the one who is being cared for (Pilkington, 2005).
According to the critical theory nurses should offer culturally acceptable care, identify social disparities, and implement creative strategies to find a practical solution to modify differences and provide quality care (Mosqueda-Diaz, Vilchez-Barboza, Valenzuela-Suazo, & Sanhueza- Alvarado, 2014). The caring concept in nursing is socially constructed, thus the value of nursing care may be different depending on the basis of attitudes and contexts (Dick, Patrician & Loan, 2017). Nursing care takes place in a many different individuals, societal cultures and practice environments (Davidson, Rushton, Kurtz, Wise, Jackson, Beaman, & Broome, 2018). Nursing care is critical in different healthcare settings because nurses proudly focus on to provide holistic care and contribute to the positive health outcomes of their patients in tangible and intangible ways (Dick, Patrician, & Loan, 2017). Critical theory helps to examine the interaction between power and the social structures that produce the societal inequalities (Mosqueda-Diaz et al., 2014). Nursing care focusses on the protecting and promoting of health, prevention of illness, alleviation of suffering, and advocacy in the care of individuals, families, and communities (Davidson et al., 2018). Nurses need to understand the complex social, cultural, environmental, political and economic forces have a more profound influence on health behaviors to promote health in individuals and groups (Butterfield, 1990).
Nurses practice in assorted settings where different extents of training, social insurance directions, and approaches, impact moral basic leadership to give the most ideal consideration. Despite the setting, nurses must hold fast to an arrangement of expert and philosophical qualities that are reflected in their codes of morals (Rooddehghan, Yekta, and Nasrabadi, 2018). A portion of the normal moral issues emerges in expert nursing practice while giving consideration to accomplish wellbeing objectives are the regard for the self-governance of patients, helpfulness, equity, and non-perniciousness (Vryonides, Papastavrou, Charalambous, Andreou, and Merkouris, 2015).
complexity ontology theory underscored that people are living in complex versatile frameworks where intelligent process, non-straight change, organized associations, and changes persistently developing to deliver new substances and new potential outcomes (Mitchell, Jonas-Simpson and Cross, 2013). Comprehensive nursing care considers the experience of the patient and makes a social insurance condition concentrated on patient wellbeing, nature of consideration, and enhanced soundness of the populace through interdisciplinary cooperation (Dick et al., 2017). Inter-professional care is fundamental to give the most ideal consideration as indicated by their claim, yet now and then it is the most conspicuous hindrance to accomplish ideal wellbeing results. Multidisciplinary team member comes with different viewpoints according to their unique knowledge and skills which may evoke a disagreement within the inter-professional team and can cause moral distress for the nurse (Engel & Prentice, 2013). Sometimes circumstance raises serious issues about the viability of true collaboration in health care. Lack of collaboration and communication between healthcare professionals have a negative impact on patient health outcomes and the delivery of safe quality care (Martin, Ummenhofer, Manser, & Spirig, 2010). A lack of communication or intervention during some situations raises ethical issues for nurses (HL Preshaw, Brazil, McLaughlin, & Frolic, 2016). The most significant barrier is resulting mainly from a lack of proper articulation, awareness, and recognition of the role of the other professionals (Supper, Catala, Lustman, Chemla, Bourgueli, & Letrilliart, 2015).
Critical social theory helps nurses to expose social inequities that prohibit people from reaching their full potential and limited the choices truly available for them (Butterfield, 1990). Nursing care focus beyond scientific knowledge to gain a better understanding of lived experiences of patients, systems, and communities that are affected by social determinants of health (Davidson et al., 2018). Nursing care aims at preserving and promoting the dignity of individuals and ensuring the provision of fundamental rights to achieve social justice, foster the economic and social development of the community (Wood, 2011). Salmon supports that principles of western medicine focus the health and illness of the individual while obscuring the exploration of their social, economic conditions (Butterfield, 1990). Critical theory supports the identification of social disparities and the promotion of quality care to improve health outcomes for society (Mosqueda-Diaz et al., 2014). It is tough for nurses to distribute recourses equitably according to organizational policies due to a lack of resources when patients health get compromised (HL Preshaw, Brazil, McLaughlin, & Frolic, 2016). Nursing care includes advocacy on behalf of patients when the wellbeing of patients is threatened (Butterfield, 1990).
Human science theory focuses on the importance of the nurse-client relationship by exploring the life experience of the client in connection with the universe (Mitchell & Cody, 1992). This crucial time spent with the patient can help to identify their unique experience and health goals. Patients always perceive compassion as closely linked to the broader concept of conveying care within the nursing practice. Compassion requires time and commitment by practitioners in order to build an honest relationship (Bramley & Matiti, 2104). Nurses proudly provide holistic care to contribute to the best health outcomes of patients. However, at times nurses experience ethical dilemma when trying to balance highly acute patient needs with limited resources, and the physical demands of nursing overload (Duffy, 2009). Inadequate staffing and unrealistic workloads place an unnecessary burden on nursing staff members, reduce the quality of care that nurses can provide, lead to fatigue and unachievable expectations, and result in uncompleted tasks (Garrett, 2008). Evidence suggests that inadequate nursing staffing level can be a danger to patients since burnt-out nurses are less likely able to provide holistic and compassionate care (Scott et al., 2014).
Nursing care includes patient-centered care planning, critical thinking, advocacy, and care coordination within complex health systems to achieve the best health outcomes. All different philosophical, ontological traditions are interconnected and make a significant contribution to gain proper knowledge to provide safe quality care according to a specific situation. All different ontological traditions are based on self-reflection of life experiences and how external factors such as societal, historical, ideological, cultural influence the health outcomes of an individual (McIntyre & McDonald, 2013). Nursing care is fundamental to achieve high-quality healthcare by addressing the social determinants of health and enabling people to make choices regarding health promotion, and illness prevention (Mcsherry & Douglas, 2011). Some of the controversies related to the different ontological traditions are more complex and inconsistent for application in clinical practice. In modern society, evidence-based research is focused on treating illness and achieving the best health outcomes. Therefore, nursing care emphases solely on the biomedical and clinical aspects of healthcare delivery in hospitals because complex realities are too big to address (Mcsherry & Douglas, 2011).
Nurses continuously provide care to different patients on a daily basis and continuously fulfill patient’s needs and expectations (Calong & Soriano, 2018). It is clear that one particular ontological tradition can not offer a complete view of nursing care. Nurses need to critically evaluate and incorporate different ontological traditions to determine the most effective and appropriate nursing action to provide the best possible care. The Complexity theory is the best ontological tradition that emphasizes to understand the complex health system and elements existing within the nursing system interact with one another to produce specific behavior, in relation to the safe quality nursing care (Chandler, Rycroft-Malone, Hawkes & Noyes, 2016). Nowadays, health care is becoming more complex and specialized necessitating different healthcare professionals to work together as a team to coordinate patient’s care to reduces the number of medical errors and increases patient safety (Manser, 2009). Watson’s theory argues that the application of critical thinking is focused on the humanistic dimensions of patient care in the different contexts to provide the optimal level of care (Federal, Porto, & Grande, 2018). Nurses have a central role to support the family participation and collaboration in care to positively enhance the quality of patient care (Mackie, Marshall & Mitchell, 2018). In conclusion, nursing practice is a blend of all different ontological traditions to provide the best possible care to ultimately achieve the well-being of the patient.
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