What is caring? Scholars have defined nursing as a caring discipline (Campinha-Bacote, 2013; Watson, 1985; 2012). Although caring is considered essential to nursing, some find the concept nebulous and its meaning difficult to capture (Papastavrou, Efstathiou, & Charalambous, 2011). Nursing scholars and theorists have not come to a consensus in defining caring or the origin of caring (Rieg, Newbanks, & Sprunger, 2012). It is important that nurses understand the origin of and personal characteristics that reflect caring, as the capacity to demonstrate caring (or lack thereof) is reflected in nursing practice.
A consideration of nursing history helps explain the need for this article. Florence Nightingale in her 1860 classic, Notes on Nursing (1969), emphasized the spiritual nature of nursing and believed nursing was a calling from God. Historically, some propose that organized nursing was founded on biblical principles, philosophy, and the caring behaviors and characteristics of Jesus Christ and early Christians who followed his example (Austgard, 2008; Carson & Koenig, 2011; Shelly & Miller, 2006; Shields & Wilson, 2016). However, others have noted that the biblical context has been removed from nursing, and a shift in the perception of what constitutes caring has been altered to a humanistic, postmodern worldview (Grypma, 2009; Salladay, 2000; Stegmeir, 2002; Trafecanty, 2006).
Of concern is that many nurses, including Christians, are not aware of this shift. Humanism (n.d.) is “a system of values and beliefs that is based on the idea that people are basically good and that problems can be solved using reason instead of religion.” Humanists reason that the origin or source of caring comes from within the person. A Christian (n.d.) is “one who professes belief in the teachings of Jesus Christ.” Christians believe caring originates from God.
The focus of this article is to examine what has been published on the concept of caring, as related to the perceived origin and characteristics of caring, from both biblical, Christian, and humanistic worldviews. This integrative literature review is a synthesis of existing ideas, which includes middle range theories on caring in nursing from a humanistic worldview, and publications addressing caring with biblical, theological, and philosophical underpinnings (Sidebars, What Is an Integrative Literature Review? and, Understanding Types of Literature Reviews).
THEOLOGICAL VIEW OF CARING
The purpose of including literature with biblical and theological foundations in this review was to understand how Christians believe God is the origin of their caring characteristics. Theology is the “study of God, his attributes, and his relationship with man and the universe” (Grenz & Olson, 1996, p. 39). Grenz and Olson assert, “Good theology assists Christians because it grounds their lives in biblically-informed, Christian truth” (p. 39).
A key Scripture is Genesis 1:27, as related to the Christian's role in mirroring the image of God, or the Imago Dei. Theologian Gary Ferngren (2009) proposed the “teachings on Imago Dei were formative in shaping the Christian view of humanity, ethics, and ministry” (p. 94). He notes the doctrine of the Imago Dei provides grounds for the belief that every human life possesses intrinsic value as a bearer of God's image. Imago Dei gave a new perception of embodiment and human personality, and formed the basis for Christian compassion and care for those in need (pp. 95-96).
The most noted authority on the origins of caring comes from biblical Scriptures (Ferngren, 2009). Building on the idea of the origin of one's caring, Christians believe that one's being, that is, who you are, is reflected in one's character. Christian nurses' understanding of who they are comes from the Bible, which states that it is in Christ “we live and move and have our being” (Acts 17:28), and without him we can do nothing (John 15:5). Jesus tells his followers that we are the branches and he is the vine, a metaphor to say he is the source of the Christian's way of life and living out Christ-like characteristics.
Shelly and Miller (2006), in their Christian theology of nursing, address caring. They state, “Caring for others is not intrinsic to human nature” (pp. 247-248), and propose that, “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). Shelly and Miller state (p. 252),
The motivation for Christian nursing comes primarily from a sense of gratitude to God, not merely a reaction to a human need or a sense of duty...We can say with the apostle John, “We love because he [God] first loved us” (1 John 4:19).
POPULAR CARING THEORIES
“Caring theories in nursing emerged in the 1980s and were influenced by existential philosophy and by principles of equity in relationships” (Meleis, 2012, p. 171). Popular caring theories have been proposed by Watson (2012), Leininger (McFarland & Wehbe-Alamah, 2018), Eriksson (2002,2006), and Boykin and Schoenhofer (Boykin, Schoenhofer, Smith, St. Jean, & Aleman, 2003). The popular caring theories of Jean Watson and Madeline Leininger, and the Christian perspective of caring, are important to understanding how caring is perceived in nursing.
Jean Watson states her Human Caring Science theory is based on metaphysics (the nonphysical world); and gestalt, existential, and Eastern psychology (2012, p. 67). Watson writes, “The nursing theory I continue to develop attempts to make explicit my metaphysical position regarding mind, body, spirit, and soul and to acknowledge how my beginning position on this issue directs my concept of nursing and caring processes” (p. 52).
Watson's caring theory includes concepts similar to biblical Christianity in that she embraces spirituality and altruism, although from a humanistic view. Altruism reflects caring as a selfless concern for the welfare of others (Paldanius & Maata, 2011). Eriksson (2002), in her discussion of caring science, promotes Caritas (Latin origin; meaning Christian love and caring) as the fundamental motive of caring science and the motive for all caring. Eriksson contends the “human being is fundamentally a religious being...fundamentally holy...accepting the human obligation of serving with love and existing for the sake of others” (p. 62).
Watson holds to Eastern spirituality stating, “Eastern cultures...with their long histories of spiritual valuing and connectedness with the spirit work and nature, can be viewed as more spiritually developed and having greater capacity for higher levels of consciousness than our Anglo-Saxon, Western world....” (2012, p. 68). She proposes “energy work,” that is, the “intentional, caring consciousness of touching the embodied spirit of another as sacred practice, working with the life force/life energy/life mystery of another” (p. 47). Watson explains this energy as the “energetic, phenomenal life field... connected to the universal life source field of infinity” (p. 63).
This humanistic thought pattern promotes transcendence, in which the human spirit can transcend to a higher level of consciousness, possessing enhanced abilities, with possibly more power than conventional methods of healing for the self and others (Stegmeir, 2002; Watson, 2011,2012). Watson states, “The person has one basic struggle: to actualize the real self, thereby developing the spiritual essence of the self, and in the highest sense, to become more god-like” (1985, p. 69). She holds that during self-transcendence, the “caring consciousness transcends time, space, and physicality; that is, caring goes beyond the given moment, and situation, and informs the future experiences of practitioner and patient” (Watson, 2006, p. 90). She proposes that “We must recognize... alternative, expanding/evolving views of science and changing world views and cosmology of the universe and of reality itself...This evolving consciousness/world view shift is uniting us globally to attend to human caring and eco-caring for health and survival of Planet Earth” (2012, pp. 2-3).
In contrast, Dameron (2011) proposes that from a biblical, Christian worldview, only Jesus is capable of such a powerful act as transcendence. Stegmeir (2002) maintains that “Christian[s] seek to transcend self by reaching out to God and allowing his Holy Spirit to work through them” (p. 12). Regarding the universal source of life, Jesus existed and is before all things; in him all things hold together as he is the controlling, cohesive force of the universe (John 1:1-5; Colossians 1:17, AMP).
Self-sacrificing is another attribute of caring discussed by humanistic authors. Nolte (1992) contends that in “self-sacrificing,” the one caring for gives up his or her own needs; therefore, “selflessness” is the better term as it “heightens awareness and greater responsibility” to both the cared for and the care provider (p. 21). Humanists believe that human beings, in and of themselves, are capable of self-sacrifice and are the origin of the nurse's caring. Christians believe that caring originates from God who is different from the human self.
Austgard (2008) proposes that without the Holy Spirit's enabling power, people are not capable of displaying the characteristics of altruism or self-sacrifice. He wrote, “it is only the fruit of Christian belief that can bring about the sincere, self-sacrificing love that can elevate nursing to where it should be...without love, nursing is nothing more than a simple craft” (p. 315). Wong (1997) concurred stating, “only through Christ can we consistently rise above our own selfishness” (p. 11).
Another caring perspective comes from theories that incorporate transcultural and culturally-competent care. Leininger's theory (McFarland & Wehbe-Alamah, 2018) is based on postmodern thought, whereas Campinha-Bacote (2005) offers a Christian perspective.
Campinha-Bacote (2005) proposed a biblical framework to provide culturally competent care stating,
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)
Leininger's theory is “postmodern in the sense that she sees truth as defined by each culture, not by a transcultural reality or God” (Shelly & Miller, 2006, p. 51). McEwen and Wills (2014) acknowledge Leininger as a proponent of the idea that nursing is synonymous with caring. They note that Leininger was instrumental in generating “knowledge related to the nursing care of people in a way that values their cultural heritage and life ways” (p. 233). Major constructs of the Leininger Sunrise Model include culture, culture care, culture care differences, and similarities in transcultural human care (McEwen & Wills).
INTEGRATIVE LITERATURE SEARCH AND ANALYSIS
A computerized search was conducted to retrieve published articles from these databases: CINAHL, Health Source: Nursing Academic Edition, ATLA: Religion Index, Christian Periodical Index, Philosophers Index, and PsycINFO. Articles retrieved spanned from January 1980 to April 2015. Because integrative literature reviews may include both research and nonresearch articles, to fully understand a specific phenomenon or problem (Broome, 1993; Souza, Silva, & Carvalho, 2010, p. 103), both types of articles were included in this review, allowing for comparison of the caring concepts introduced from articles published from humanistic and Christian worldviews.
Literature search term combinations included:
- Care, caring, theory, worldview;
- Caring theory (as one phrase);
- Caring nursing theory;
- Caring, nurse, Christian;
- Caring, origin, Christian;
- Caring, origin, humanistic;
- Caring, humanistic.
Inclusion criteria included publications that described caring as a “state of being.” Identified characteristics of caring nurses were interpreted as a “state of being.” Publications that only described the “act of caring” as a type of behavior were excluded.
Articles were classified as humanistic or Christian based on specific criteria. An article was identified as humanistic, if:
- the author(s) identified themselves as humanistic or;
- used theories, philosophies, or terminology that was clearly identified in the article or elsewhere as humanistic.
Terms identifying articles as from a humanistic worldview included energy fields, healing of self, transcendence, higher levels of consciousness, and God-like.
An article was identified as Christian, if:
- the author(s) identified themselves and their views as being Christian, or;
- biblical references and terminology were used in the article as foundational to caring.
Terms identifying an article as from a Christian worldview included image of God, love, Jesus Christ, Holy Spirit, Bible, and Fruit of the Holy Spirit.
The initial data extraction and evaluation of the publications occurred simultaneously and was conducted by the primary author over a 10-month period. Using the method described by Randolph (2009), a figure was constructed to provide a summary of the databases searched, the key term combinations used, the number of articles resulting from each search, and the number of relevant articles as identified by Tella et al. (2014). Figure 1, showing the steps of the review, can be found as Supplemental Digital Content (SDC) at http://links.lww.com/NCF-JCN/A56.
In Step 1 of the review, the search yielded 1,426 articles from databases using the search term combinations listed above. The articles retrieved for evaluation were shared with other researchers to promote reliability in data collection.
Following the initial database search, a staged review (Step 2) was performed, which consisted of reading each article title and abstract (Torraco, 2011). During this review, 787 articles were excluded based on terminology identifying “caring for” or “taking care of” in the title or abstract. In Step 3, 140 articles, which were duplicated in two or more databases, were excluded, leaving 499 articles.
In Step 4, the title and abstract of the 499 remaining articles were reviewed to identify publications that described, “caring as a state of being” of the provider, rather than an “act of caring,” resulting in 218 articles. Step 5 included a full-text review and summary of each article by the primary researcher, and a second reviewer verified the results. The final analysis of the literature resulted in 155 articles that described caring as a “state of being” of the care provider rather than an “act of caring,” or behavior. Table 1, as SDC http://links.lww.com/NCF-JCN/A56, delineates the number of articles found for each of the seven search term combinations in each of the six databases.
Data about the articles were entered using a spreadsheet for integrative literature reviews as described by Wood and Ross-Kerr (2011). Data headings included: the article reference; identified definition of caring; nursing theory or philosophical underpinnings; worldview; main concepts; identification of type of article (research or nonresearch); and stated or implied source or origin of care. The full spreadsheet is not presented here due to the database size; however, headings are reflected in Figure 2 (SDC at http://links.lww.com/NCF-JCN/A56). As each article was reviewed, the information was entered. This technique provided an organizational tool that allowed visualization of the concepts introduced and what needed to be included in the review.
INTEGRATIVE REVIEW FINDINGS
Twenty-five (25) nursing theorists and philosophers were represented and identified in the 155 articles because they authored a publication, their theory was identified as the underpinning of a research study, or they were heavily cited. Results showed that of the number of research articles represented by each nursing theorist and philosopher, 39% either were authored by or based on Watson's theory (2012). Eriksson's theory (2006) showed the second largest representation at 15%, and Boykin and Schoenhofer's theory (Boykin et al., 2003) was third at 9%.
A review of the nonresearch articles revealed that Watson's theory represented the highest at 54%. Biblical and theological underpinned articles were the second highest at 15%. The third largest was Swanson's (1991) theory at 10%.
Only 5% of the research articles and 15% of the nonresearch articles were based on a biblical, Christian worldview. The other 95% of the research and 85% of the nonresearch publications were written from a postmodern, humanistic worldview.
In the 155 articles, the origin of caring was identified as either: innate; taught, or learned; a member of the Trinity (Jesus, Holy Spirit, or God); or a Higher Power or life force. Some theorists contend that self is the origin of caring. Watson (1988) proposes the human center has energy and power of its own; the human caring-healing consciousness can potentiate healing and release one's own inner power and resources by creating the expanded energy field. Table 2 (SDC at http://links.lww.com/NCF-JCN/A56) lists the 155 articles used in this review.
The origin of caring (Chart 1) was not identified in 23% (36) of the 155 articles. However, in the remaining articles (119), 44% of the articles contend that caring can be taught through nursing education using various teaching strategies or modeling of the behaviors by instructors or through early family training (i.e., Bassett, 2001; Blum, Hickman, Parcells, & Locsin, 2010; Logsdon & Ford, 1998). Twenty percent (20%) identified caring as innate (i.e., Bulfin, 2005; Dyess, Boykin, & Bulfin, 2013; Valentine, 1989). Four percent (4%) of the articles addressed caring as innate, along with family upbringing and the educational learning experiences identified as enhancing the art of caring (i.e., Finfgeld-Connett, 2008). Only 4% recognized that the origin of caring was from God (Father, Jesus Christ, or the Holy Spirit) (i.e., Dameron, 2011; Haldeman, 2006; Lundmark, 2007; Stegmeir, 2002). Another 2% of articles acknowledged a higher power or life force as the origin of caring (Rykkje, Eriksson, & Raholm, 2013). The remaining 3% thought caring developed in the context of the relationship or came from self (i.e., Carmeli, Jones, & Binyamin, 2005; Tonges & Ray, 2011).
Nursing characteristics of being were searched in all the articles; where being (who the nurse is) reflects the source of caring. Both the humanistic (postmodern) and biblical, Christian worldviews identified 20 of the same characteristics. However, 15 unique characteristics were identified in articles written by authors with a Christian worldview. The characteristics included: Agape love, accountable, charity, faithful, forgiving, generous, good, joyful, just, longsuffering, peaceful, self-giving and self-control, warm, and willing. Most of these concepts are identified in the biblical reference of Galatians 5:22 as the characteristics of followers of Christ, and are referred to as the Fruit of the Holy Spirit. It appears that Christian authors not only use language and concepts that are closely related to this biblical reference, they also value and therefore, include, different characteristics than humanistic authors include in their writings. Table 3 lists the terminology used by the humanistic and Christian authors to describe caring characteristics.
IMPORTANCE TO CHRISTIAN NURSES
The foundation of many caring theories is based on modern sciences that include a postmodern, humanistic worldview. From a biblical, Christian perspective, Stegmeir (2002) holds that rather than looking for the “goddess within” as humanistic theorists propose, the “Christian seeks to transcend self by reaching out to God and allowing his Holy Spirit to work through us” (p. 12). Based on the findings of this review, many Christian authors agree there is a need for a caring theory based on a biblical, Christian worldview. For instance, Stegmeir, well over a decade ago, stressed the need to develop a Christian-based theory that supports the belief and value systems of Christian nurses.
Williams (2013) concluded that it comes down to two different 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 it is a verb, “an activity we carry out” (p. 40). Competence without caring can result in robotic motions and burnout of the nurse. For Christians, living out the image of God through caring is something about our being that is reflected in the activities we do, rather than something that is inherent in all people or something that is learned.
A biblical, Christian theory of caring, in keeping with the most outstanding theme of the Bible, begins with God as the origin of caring. The apostle Paul affirms that Agape love invades the heart of the recipient and manifests through biblical caring characteristics that are directed toward those who are suffering and in need (Galatians 5:22).
Raholm (2010) asserts, “We are held responsible for our reasoning, just as we are morally responsible for our conduct” (p. 39). A specified nursing theory is required in education programs for teaching students to practice nursing. However, Christian nursing students have voiced concern about how to adopt a theory for practice that does not align with their values and beliefs (Kroning & Yoon, 2017; Stegmeir, 2002). As Christian scholars, we have a responsibility to provide a Christian-based theory of nursing. The findings of this integrative literature review demonstrate there is a shortage of published research addressing a Christian worldview on caring. Findings support Shelly and Miller's (2006)theology of caring and Campinha-Bacote's (2013)biblically-based model of cultural competence as foundational for the constructs of a theory on caring from a biblical, Christian worldview. Findings also support recently published models of Christian nursing (Christman & Mueller, 2017; Eckerd, 2017).
The need exists for a biblical, Christian theory of caring to be delineated and promoted in nursing literature. A Christian caring theory would support students, nurses, educators, and researchers who hold values that are distinctly different from the humanistic worldview. In addition, further research should be conducted and published on caring from a biblical, Christian worldview.
Further research that would add validity to the findings of this integrative literature review would be a Delphi study. Such a study would determine if a panel of experts who hold a biblical, Christian worldview would identify, or narrow down, the unique concepts that would provide the basis for a biblical, Christian theory of caring.
It is believed that the elaboration of a theory from a biblical, Christian perspective would help nursing students and practicing nurses who embrace a Christian worldview to better understand and verbalize caring, and to contemplate the origin of their caring in a way that is currently not available. Lundmark (2007) noted, “God's love must be the value system that nursing care is dependent on...when God is in me, I am who I should be....” (p. 774).
It is further recommended that nurses who practice faith traditions and beliefs different from a Christian worldview consider similar studies that identify the unique characteristics and source of their caring practice. Such knowledge would not only enhance the ability to develop nursing practice, but would open the dialogue among nurses of the same faith and between faith traditions.
What Is an Integrative Literature Review?
An integrative literature review (ILR) is “the most comprehensive methodological approach” of research reviews that examines past experimental and nonexperimental research and theoretical literature to understand a specific phenomenon or problem (Broome, 1993; Souza et al., 2010, p. 103). Integrative reviews have the potential to identify the state of, and build nursing science, contribute to theory development, and inform research and practice. The “integrative” component allows for the inclusion of diverse methodologies, experimental and nonexperimental research, as well as theories. Integrative reviews may combine data from the theoretical and empirical literature and incorporate a wide range of purposes and to define concepts and review theories and evidence (Broome, pp. 193-215).
Whittemore and Knafl (2005, pp. 548-552) describe an ILR as composed of five stages: problem identification; literature search; data evaluation; data analysis; and presentation of findings. The analysis of the literature consists of data reduction, data display, data comparison, and conclusion drawing. The final stage is presentation of the findings. Whittemore and Knafl's stages served as the framework for this ILR, which was conducted to contribute to theory development.
Torraco (2011, pp. 361-362) describes the critical analysis of an ILR as the action of carefully examining the main ideas and relationships of an issue to determine how well the literature represents the issue. Deconstruction of the topic into basic elements may include, the history and origins of the topic, its main concepts, key relationships through which the concepts interact, and research methods and applications of the topic. The review also includes identifying the strengths of the concept in existing literature, as well as any inaccuracies, omissions, or deficiencies.
Understanding Types of Literature Reviews
Literature reviews are considered the highest level of evidence for evidence-based practice. Because there are many types of literature reviews, it is helpful to know the names and purposes of the most common types. Also note that reviews vary in quality and thus, trustworthiness, for use as evidence.
- Scoping review: Exploratory, nonsystematic review that seeks breadth, not depth.
- Narrative review: The most common type of review; uses words to integrate literature about a particular topic. Usually is limited to either qualitative or quantitative studies.
- Critical interpretive synthesis: Relatively new systematic review technique that integrates both qualitative and quantitative studies.
- Metaanalysis: A statistical technique to integrate the results of multiple quantitative studies and produces average effect sizes; reduces the chance of type 2 error.
- Metasynthesis: Integrating the findings from multiple qualitative studies of the same phenomenon that develops new themes or categories.
- Metasummaries: Integration of qualitative studies with no conceptual reframing—includes counting up results and reporting numbers.
Note that Newbanks, Rieg, and Schaefer took care to explain their methods so that you, as the reader, could evaluate their rigor (accuracy). They also provide rationales for their use of nonresearch literature.
–Amy Rex Smith, JCN Contributing Editor
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