Caring occurs at the intersection of human suffering and hope. The concept of caring has been evaluated as a human trait, moral imperative, interpersonal relationship, and therapeutic intervention (Morse, Solberg, Neander, Bottorff, & Johnson, 1990). Hickman (2006) defines caring as the “watchful attention to and meeting the needs of another person” (p. 3). Nurse scholars have described caring as the essence of nursing, and nursing as a caring discipline (Eriksson, 1997 , 2007 ; Leininger, 1993 ; Watson, 2011).
Caring science emerged as a focus for nursing, studied from varied philosophical viewpoints (e.g., Eriksson, 1997 , 2007 ; Heidegger, 1996 ; Swanson, 2015 ; Watson, 2011). Caring from a Christian worldview may be implied in some philosophies, but is not directly discussed. This raises the question of the appropriateness of applying caring theories in contexts that adhere to the Christian worldview identified in the Bible. In describing Christian caring, Shelly and Miller (2006) state, “Caring for others is not intrinsic to human nature” (p. 248), especially caring for a stranger. They propose that because of our response, gratitude, and acceptance of God's grace and care, Christian nurses are able to “see patients with great value, dignity and worth,” rendering the ability to minister to the whole person with compassionate care (p. 253).
HISTORY OF CARING
Caring, compassion, and the call to love God and serve others are emphasized throughout Judeo-Christian Scriptures. One early example of nurses caring for others is found in Exodus 2, when midwives would not kill infant boys because they feared God more than they feared Pharaoh. Galatians 5:14 states, “For the entire law is fulfilled in keeping this one command: ‘Love your neighbor as yourself’” (NIV). The apostle Paul defined charity, or love, the English form of caritas, as “reasoning, intentional, spiritual devotion such as is inspired by God's love for and in us” (1 Corinthians 13:1, AMP). One of the most well-known biblical accounts of caring is the parable of the Good Samaritan where we discover a man who met the emergent and recovery needs of a stranger (Luke 10:25-37). The upmost model of caring is modeled in the form of Jesus Christ through his life and death (1 John 3:16).
Christian caring also is found throughout history. St. Benedict founded the Benedictine nursing order. Military, religious, and lay orders of men, including the Knights Hospitallers, the Teutonic Knights, the Knights of St. Lazarus, and the Hospital Brothers of St. Anthony provided nursing care during the Middle Ages (Evans, 2004). Additionally, members of the Catholic Church developed almshouses where untrained caregivers provided care “as a way of taking care of those who couldn't take care of themselves” (Sweet, 2012, p. 8).
Later, Florence Nightingale highly valued education and advocated raising the standard of education for nurses. However, she also emphasized nursing as a calling—a vocation, stating, “but more than this, she must be a religious and devoted woman; she must have a respect for her own calling, because God's precious gift of life is often literally placed in her hands” (Nightingale, 1860, p. 71).
The Biblically Based Model of Cultural Competence (BBMCC) was used as the basis for developing this study. The BBMCC stems from the belief that all human beings are created in God's image and, therefore have inherent dignity, value, and worth. Imago Dei is the Latin term for the “image of God” in human beings. Imago Dei is based on a biblical worldview of cultural competence and is the foundational concept for this study. This paradigm permeates the constructs from Campinha-Bacote's (2013) model of cultural desire, cultural awareness, cultural knowledge, cultural skill, and cultural encounters.
Theologian Kenneth Gardoski (2004) defines Imago Dei as the composite of uniquely personal characteristics (intelligence, desire, morality) that God imparted to human beings at creation, which together comprise his or her spiritual nature. Erickson (2013) suggested three views for understanding the image of God: 1) the substantive view consisting of qualities or characteristics within the nature of man, 2) the relational view defining the image as the experiencing of a relationship between human and God, and 3) the functional view in which some consider the image to be not something a human is or experiences, but rather something a human does. However, Williams (2013) concludes it comes down to the two concepts: “the image of God is something about us, something we are, or the image of God is something we do” (p. 11). In other words, either Imago Dei is a noun, “something about our being,” or a verb, “an activity we carry out” (p. 40).
Because of Imago Dei, each caring encounter is a sacred encounter that must be recognized as “holy ground” (O'Brien, 2011). To achieve Christian caring, as proposed by Shelly and Miller (2006), “a body of knowledge, an attitude of service, and a vital relationship with God are required to make that caring truly Christian nursing” (p. 251).
Campinha-Bacote (2013), in her description of the BBMCC, challenges Christian nurses to incorporate a biblical framework as they provide culturally competent care. She states, Christ's love for the church motivates a person to want to engage in the process of cultural competence. Spiritual caring and spiritual love are intrinsic qualities in the nurse-client relationship that cannot be directly measured. However, clients perceive these qualities positively, sensing that they are being cared about and valued.... This type of caring and spiritual love comes from the heart, not from the mouth. It results from one's relationship with God. (p. 21)
EXPLORING CARING IN CHRISTIAN NURSES
The purpose of this research study was to explore the concept of caring from a biblical, Christian worldview in a sample of Christian nurses. A research question was developed: “Do Christian nurses who more strictly adhere to characteristics of biblical faith (as defined by the BBMCC Model as fellowship, service, giving, and personal walk), view their source of caring differently than Christian nurses who do not adhere as strictly?” A one-group cross-sectional survey method was utilized, with a mixed-methods approach using quantitative questions, qualitative questions, and demographics. The sidebar, Operational Definitions of Terms, defines concepts as used in this study.
A convenience sample was recruited from two sites. Site one in the U.S. recruited faculty and students in the prelicensure, postlicensure, and MSN programs in a nursing school at a midwest Christian university. The second site recruited international nurses who attended a Christian nursing conference in Santiago, Chile. Table 1, found online as supplemental digital content (SDC) at http://links.lww.com/NCF-JCN/A59, describes the demographic characteristics of the sample.
After Institutional Review Board approval, a survey management service (Healthcare Environment) prepared the online study survey. An invitational email was sent to faculty members and nursing students in the prelicensure, postlicensure, and graduate divisions. The email included an explanation of the study and a secure internet link to the survey. Informed consent was provided through completion of the survey. Data collection occurred over a 3-month period in 2016.
Participants at the international conference were given opportunity to complete the survey online at a computer set up for that purpose, or to complete a hardcopy and mail to the researchers using an addressed stamped envelope. The survey was available in English and Spanish. A Columbian nurse, fluent in English, translated the Spanish version, and translated responses from Spanish-speaking participants to English.
The survey included qualitative, quantitative, and demographic questions. Six qualitative questions were developed by the researchers with consultation from Dr. Campinha-Bacote; Dr. Jane Kelley, a nurse researcher; and Dr. John Nelson, a survey expert. These open-ended questions were designed to address the participant's perception of caring and the source of caring. Five quantitative questions were used to identify participants' faith behavior characteristics and how they perceived nursing (job, career, profession, calling). Faith behavior characteristics were used, rather than religious affiliation, because the researchers believed these would more accurately identify those who embraced a Christian worldview, compared to identifying with a specific faith community. Responses were used to compare the themes of caring with those who self-identified as embracing or not embracing the faith behavior characteristics.
To evaluate if the nurse held to Christian beliefs and practices, four items assessed characteristics of the Christian faith. Campinha-Bacote's BBMCC describes four key Christian characteristics—fellowship, personal walk, giving, and service to others (Campinha-Bacote, 2012, personal communication; Hebrews 10:25; 2 Timothy 2:15; 2 Corinthians 9:6-7; Matthew 20:26-28). Responses to questions regarding the four key Christian characteristics were ranked from 1 to 4, with higher scores indicating more frequent and regular practice of Christian faith.
Eleven demographic questions were designed to stratify respondents into groups according to gender, age, nursing program (if a student), and years of practice (if a nurse), type of work setting, home country, and self-described race/ethnic descriptions. All 22 survey questions can be found online as SDC at http://links.lww.com/NCF-JCN/A59.
A total of 380 surveys were collected (N = 380) but not all participants completed all survey questions. The majority of respondents were from the U.S. (n = 330, 88% of 376 responses); white (n = 290, 85% of 341 responses); female (n = 363; 93%); identified with a Christian religious community (n = 351, 97% of 360 responses); and worked in a hospital setting (n = 163, 45% of 364 responses). Table 1, online as SDC at http://links.lww.com/NCF-JCN/A59, reports on the demographic variables. Figure 1 shows participant responses regarding their identified source of caring.
Qualitative data were analyzed using standard content analysis procedures (Hsieh & Shannon, 2005). Thematic analysis was used to understand dimensions of caring from a Christian worldview. All researchers reviewed participant comments on the qualitative questions, agreed-upon themes, and coded the data based on those themes. Interrater reliability was established by determining the percentage of agreement between the study coinvestigators. Only items with a high percentage of agreement by the researchers were used for further analysis. Two of six qualitative questions met a high level of interrater reliability: “If you and others would describe you as caring, what do you believe is the source of your caring?” (91%) and “What do you believe is the source of caring found in others?” (87%).
Descriptive statistics revealed that Bible reading and prayer (personal walk) were practiced with the greatest frequency (mean score, M = 3.20 on 4.0 scale). Meeting together with a community of believers (fellowship) had a mean score M = 3.10. Service to others in some sort of volunteer capacity had a mean score M = 2.66. The least adhered to practice was giving (M = 2.62).
Participants were asked to identify what most clearly reflected their view on the following question: To me nursing is a: calling, profession, career, or job? Of the 376 respondents who answered this question, the majority reported that being a nurse was a calling (n = 292, 78%); 15% (n = 58) reported that nursing is a profession; 6% (n = 23) said nursing is a career; whereas 1% (n = 3) reported nursing as a job. Table 2 provides a summary of the quantitative questions regarding the characteristics of faith.
Chi-square analysis was used to determine if there were any similarities or differences in the trends identified within groups that had been stratified through the 11 demographic and 4 characteristics of faith questions. Cross tabs were used to examine if there was a statistically significant difference between faith characteristics and select demographics.
Analysis revealed that participants who reported Deity as their source of caring: viewed nursing as a calling; were likely not to be a student; likely to be an educator or work in public health; work in a religiously affiliated organization; and to have completed a nursing program at least 21 years earlier. In addition, nurses who reported Deity as the source of caring were more likely to report a higher degree of volunteering (serving), giving (financially to a religious community), devotions and prayer (personal walk), and fellowship (meeting together with a community of other believers).
SOURCE OF CARING, FAITH, AND DEMOGRAPHIC CHARACTERISTICS
Sources of caring were divided into two groups, those with: 1) multiple sources of caring, and 2) Deity as source of caring. When source of caring was examined with faith characteristics, chi-square analysis revealed statistical significance (p = .001) for all four faith characteristics. Nurses who reported Deity as the sole source of caring were much more likely to report high levels of fellowship (more than once weekly); higher levels of giving; more likely to report service; and more likely to engage in personal devotions and prayer. Table 3, available online as SDC at http://links.lww.com/NCF-JCN/A59, provides an overview of the faith characteristics and source of caring, and chi-square results.
Nurses who identified Deity as the source of caring were more likely to report nursing as a calling and not a job, career, or profession (p = .002) (Table 4). Nonstudent participants were much more likely to report Deity as their source of caring than students. The researchers considered that many of those who were nonstudents, were faculty in a Christian academic institution and thus, may have been more solidified in this belief. Participants who worked in a religiously affiliated organization were more likely to report Deity as the source of caring. This is a reasonable finding because many nurses migrate to a religious organization congruent with their values and worldview. Nurses who completed their nursing program 21 years or more ago were more likely to report Deity as the source of caring (p = < .001).
It was noted that 82% of those in education and 80% from public health reported Deity as their source of caring. It is likely that the educators who teach in a Christian university are most entrenched in the concepts of caring from a Christian worldview, as they teach this concept. It is not clear why those in public health would view Deity as their source of caring. The proportion of education and public health respondents reporting Deity as the source of caring was statistically significant (p = < .003). No previous researchers have reported studies examining source of caring by location of practice.
Whether a respondent identified her or his source of caring as Deity was not associated with gender, nursing program, education, year in nursing program, country, race, ethnicity, or age. Table 5, available online as SDC at http://links.lww.com/NCF-JCN/A59, presents the demographic data with source of caring on significant chi-square results.
CONCLUSIONS AND RECOMMENDATIONS
This cross-sectional, nonexperimental, mixed-methods study used an intentional convenience sample of nurses from Christian faith-based settings. Descriptions of caring and the source of caring for nurses who embrace a biblical model of Christianity were examined. Results have implications for understanding the concept of caring within the context of a Christian worldview.
This study supports Shelly and Miller's (2006) position that holistic caring is made possible by the Christian nurse's belief in God, as revealed in the Bible, who regards all human life as innately valuable. Data indicate that as faith-related behaviors increased, the more likely participants were to view their work as a calling, and their source of caring emanating from God. The concept of Imago Dei supports how these Christian nurses can see each patient as a reflection of God in human form. The vital worth of each patient provides motivation, persistent strength, and nurturing tendencies in the nurses' daily lives.
This study included English- and Spanish-speaking nurses from several countries; however, to broaden the scope of these research findings and provide transferability, future inclusion of international nurses from various cultures is vital. Gathering data from diverse university settings will provide information needed to better understand caring from a Christian worldview and implications for further development of caring and nursing as a calling.
Several limitations impact the study findings and interpretation of results. First, the sample was predominantly from the U.S. Second is the inclusion of non-Christians in the sample (n = 9). Finally, the majority of participants were from one midwestern Christian university.
Further caring research should be conducted among diverse populations. Findings from this study, along with the theoretical foundations of caring, will be used toward the development of a middle-range theory of caring from a biblical, Christian worldview. In addition, it is recommended to develop a collaborative team of international nurses to conduct further research to build on these findings and develop an international perspective on caring. It is our hope that as we study caring from a biblical, Christian worldview, that faith in God may be found as a durable source of strength, persistence, and joy for nurses.
The authors express special appreciation to Dr. John Nelson, President and Data Scientist of Healthcare Environment, for his expert consultation and data analysis.
Operational Definition of Terms
Caring. The “watchful attention to and meeting the needs of another person” (p. 3). The essence of nursing practice (Eriksson, 1997 ; Leininger, 1993 ; Watson, 2011).
Imago Dei. Latin term for the image of God in man. Reflective of Genesis 1:27 that states God created man in his own image, not in physical form, but moral, spiritual, and intellectual nature.
Biblically based caring. An attitudinal response to the teachings and example of Jesus Christ in serving others, while promoting optimum health and exercising therapeutic interventions to meet the holistic needs of individuals (Campinha-Bacote, 2013 ; Hickman, 2006 ; Shelly & Miller, 2006).
Source of caring. The self-described basis that is the reason for caring.
Deity. Reflected by terms of God, Jesus, or Holy Spirit.
Home country. The country in which the subjects were born and raised, regardless of the present country of residence and citizenship.
Racial/ethnic. The self-described racial or ethnic group with which the subject most closely identifies.
Biblical model of Christianity. Behaviors found in the Bible that describe Christian characteristics and faith practices, which include fellowship, giving, service, and personal walk (Campinha-Bacote, 2012, personal communication).
Personal walk. The practice of individual Bible devotions and prayer.
Giving. The practice of sharing resources to support a place of worship and other ministries.
Service. The practice of volunteering time to help others.
Fellowship. The practice of meeting together with a community of believers.