Caring
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In the May 31, 2002 Washington Post, staff writer, Lib Copeland, visited the “bone guys” at the Smithsonian’s Museum of Natural History. (“Skeleton Keys: Smithsonian Anthropologists Unlock Secrets in Bones of Ancestors and Crime Victims,” page C1.) The stories and deductions that these scientists can uncover by studying bones fascinate me.
Doug Owsley is one of the anthropologists whom Copeland interviews. During their discussion, Owlsey picked up an attached pelvic and femur. “Look at this, he says, setting the ancient bones against his hip to show how the femur is fused at a 90-degree angle to the socket. As best Owsley can tell, the bone was broken and when it healed, without the benefit of physical therapy [or occupational therapy], it set permanently in a sitting position. This person would have had to use a crutch to walk.”
The individual’s surviving a fracture of the femur was not what really captured my interest but what I read in the next paragraph. “Such a discovery can teach not only how tough the human body is but also – if the person lived for years with a serious problem – how well society CARED for the injured and infirm. The emphasis on the word “cared” is mine.
I remembered an earlier article about a skull from the ice age that showed scarring over a hole, determined to have been made by a machete-like knife or sword. (Washington Post, April 23, 2002, page A3) The title, “Behaving like Neanderthals: An Ice Age Skull Shows Results of Tools and Temper, “ tells you the emphasis of the article by Guy Gugliotta was on violence not on caring. However, approximately 36,000 years ago, this person suffered a significant injury and survived, as the bone regeneration showed. “And survival without infection would have meant that other members of the community would have had to tend to the victim’s needs. Earlier research . . . has shown that Neanderthals cared for the sick and infirm . . . “ There is that word, cared, again. Perhaps looking at caring is a reasonable follow-up to the Resource Note on Empathy.
This thought was sealed when I spied an article in the December 2001 issue of the Australian Occupational Therapy Journal by Valerie Wright-St Clair, “Caring: The moral motivation for good occupational therapy practice,” volume 48, pages 187-199. Actually, this article is the 2000 New Zealand Association of Occupational Therapists Frances Rutherford Lecture. In summarizing ideas on caring shared with her during a dialogue with colleagues, Wright-St Clair wrote “Caring is more than feeling empathy. It is about connectedness and attunement.” Depths of relations between humans are described as perhaps existing “ . . . in a continuum: sympathy is at one end, empathy in the middle, and attunement [or caring] is at the other end” (p. 189).
While exploring her idea that an ethic of care might provide a moral motivation for good occupational therapy practice, the author looks at the nature of caring as described not only by occupational therapy practitioners, but also by psychologists and nurses. Three key references that underpin this discussion are the works of two psychologists, Carol Gilligan and Milton Mayeroff and a nurse, Nel Noddings:

Gilligan, C. (1982). In a different voice: Psychological theory and women’s development. Cambridge, MA: Harvard University Press.
Mayeroff, M. (1971). On caring. New York, NY: Harper and Row Pubs.
Noddings, N. (1984). Caring: A feminine approach to ethics and moral education. Berkeley, CA: University of California Press.

This article is dense with ideas and paths to follow; so, I encourage you to read it. For this Resource Note, I am concentrating on the place of caring in the occupational therapy literature on which Wright-St Clair expounds. Her overall belief is that caring is fundamental to occupational therapy practice but that intentional addresses to the study of caring make sporadic appearances in the profession’s literature. She describes three different periods with a unique emphasis in each (p. 190).

Historical references to occupational therapy’s philosophical origins and moral treatment:

Bockoven, J.S. (1971. Legacy of moral treatment - 1800's to 1910: Occupational therapy - A historical perspective. The American Journal of Occupational Therapy, 25(5), 223-224.

Briggs, L.V. (1982. Worth repeating: Occupational and Industrial Therapy. How can this important branch of treatment of our mentally ill be extended and improved? Occupational Therapy in Mental Health, (22), 57-76.
ABSTRACT: This paper provides a fascinating glimpse of the early days of occupational therapy in mental health before the profession was formed, and a recollection of its early heritage from the moral treatment era.

Meyer, A. (1922). The philosophy of occupation therapy. Archives of Occupational Therapy, 1(1), 1-10.

Peloquin, S.M. (1994). Looking Back: Moral treatment: How a caring practice lost its rationale. The American Journal of Occupational Therapy, 48(2), 167-173.
Abstract: The 19th-century practices of moral treatment and phrenology serve as historical examples of a narrowing focus in health care and reveal the manner in which theories can shape practice. The story of moral treatment, as it is told in connection with phrenology, emphasized the push for success and right solutions. Both moral treatment and phrenology emerged within a context in which patients and practitioners, sure of their old beliefs, used methods that addressed the relationships between persons and environments and between the mind and the body. Both moral treatment and phrenology floundered when this rational construction was debunked. If practitioners in this century hope to ensure that the heart of moral treatment will withstand the effects of ever-changing theories, they must hold caring attitudes, words, and actions at the center of their practice.

Woodside, H.H. (1971). The development of Occupational Therapy 1910-1929:
Occupational therapy - A historical perspective. The American Journal of Occupational Therapy, 25(5), 226-230.
ABSTRACT: Between 1910 and 1929 changes in the world and in medicine gave rise to two forces that led to the formal beginning of occupational therapy: the rebirth of moral treatment in psychiatry and the numbers of chronically disabled soldiers arising from the First World War. Occupational therapy was founded in 1917 and this event led to public support, formal professional education, and national professional organization. Early patterns developed that have had a lasting influence. The death of occupational therapy practice in psychiatry is considered as a hypothesis.

Yerxa, E.J. (1980). Occupational therapy's role in creating a future climate of caring.
The American Journal of Occupational Therapy, 34(8), 529-534.

The early 1980s with a reclaiming of caring in practice:

Baum, C.M. (1980). Eleanor Clarke Slagle Lectureship - 1980: Occupational therapists put care in the health system. The American Journal of Occupational Therapy, 34(8), 505-516.

Devereaux, E.B. (1984). Occupational therapy's challenge: The caring relationship. The American Journal of Occupational Therapy, 38(12), 791-798.
ABSTRACT: Caring brings an order to our lives and relationships that frees our energy to be creative and productive and provides parameters for our daily decisions. The development of a caring relationship between therapist and patient reinforces the wholistic approach of occupational therapy treatment. The capacity to care for others is related to the ability to care for self, and this ability is shaped by all of our life experiences. Caring forms the basic element in the development of a therapeutic relationship and provides the counterbalance: the “high-touch” human response to the introduction of “high tech” in today‘s health care environment.

Gilfoyle, E.M. (1980). Caring: A philosophy for practice. The American Journal of Occupational Therapy, 34(8), 517-521.

Hightower-Vandamm, M.D. (1980). Nationally Speaking: Caring is the key, it always has been. The American Journal of Occupational Therapy, 34(3), 239-240.

King, L.J. (1980). Creative caring. The American Journal of Occupational Therapy, 34(8), 522-528.

Note: At least one of the Eleanor Clarke Slagle Lectureships, analogous to the Frances Rutherford Lecture, is on the topic of caring, and that three of the four articles are published in the same issue of AJOT. Ms. Wright-St. Clair points out that “Caring is the Key” was the theme of the 1980 annual conference of the American Occupational Therapy Association.

The more recent literature on the meaning of, and challenges to, caring:

Cannon, N.M. (1994). Eighth Nathalie Barr Lecture: Caring for the patient. Journal of Hand Therapy, 7(1), 1-4.
Note: A third lectureship on the topic of Caring. This is a prestigious award by the American Society of Hand Therapists, and Cannon is an occupational therapist.

Corring, D.J. (1999). The missing perspective on client-centred care.
Occupational Therapy Now, 1, 8-10.
ABSTARCT: Did you know that the term client-centred was first used by Carl Rogers as far back as 1939? Did you know that Canadian occupational therapists have been discussing the concept for some 15 years now? Have you noticed that one perspective has been pretty much missing from the discussion?

Crepeau, E.B. (1991). Achieving intersubjective understanding: Examples from an
occupational therapy treatment session. The American Journal of Occupational
Therapy, 45, 1016-1025.
ABSTRACT: Occupational therapists, like other health care professionals, must balance their application of treatment techniques with an understanding of their patients' life experiences. This paper reviews the literature from interpretive and medical sociology regarding the interplay between professional power and the achievement of an understanding of another person. It analyzes how an occupational therapist, during a single treatment session, enters into her patient's life-world and simultaneously controls and manages the treatment process. The concepts of knowledge schemata (the expectations and beliefs people bring to a situation) and footings (the shifts in alignment, or focus, that occur during interaction) are central to this analysis. The process of achieving a balance between professional power and an understanding of the patient's experience may be fostered in education and in clinical supervision through increased emphasis on the importance of understanding the val!
ues and beliefs of patients and on the development and refinement of interactive skills.

Dychawy-Rosner, I., Eklund, M., Isacsson, A. (2001). Caring dynamics as perceived by staff supporting daily occupations for developmentally disabled adults. Scandinavian Journal of Caring Sciences, 15, 123-132.
ABSTRACT: This study addresses caring staff experiences of hindrances and help
in the support of daily occupations among people with developmental disabilities. Data were collected by means of a questionnaire consisting of open-ended questions about the staff perceptions of their work experiences. The respondents (n=81), corresponding to 94.1% of all care staff employed in a geographically defined care area in southern Sweden, worked in various day activity units supporting the daily occupations of their clients. A constant comparative method of data analysis was used. Staff expressions were classified in two main categories of caring dynamics; an operational level and a managerial level. Four areas were identified at the operations level: encountering realities of practice, attitudes to the clients and work demand, using the potential of knowledge and strategies and applying helping actions to the client. The managerial level included two areas, generalized work strategy and individualized work strategy. It is suggested that to develop the quality!
of interventions for supporting daily activities among persons with developmental disabilities, efforts should be made to identify caring dynamics as experienced by the caring staff.

Hamlin, R.B. (1992). Embracing our past, informing our future: A feminist re-vision of health care. The American Journal of Occupational Therapy, 46(11), 1028-1035.
ABSTRACT: Using a feminist perspective, this paper explores the roots of the practice of healing and medicine. It traces the role of women in health care from prehistoric times, through the present, and into the future discussing the changing paradigms that the author identifies as (a) the Prototypic Paradigm: Mysticism and Healing; (b) the Scientific Paradigm: Curing; and (c) the Paradigm of Inclusion: Caring, Curing, and Healing. The role and status of women in society are reflected within these paradigms, and the changing status of the profession of occupational therapy is discussed within this framework. The unique skills and contributions of occupational therapy more closely fit within the Paradigm of Inclusion and can support us as health care leaders within the changing world of the 21st century.

Peloquin, S.M. (1993). The patient-therapist relationship: Beliefs that shape care. The American Journal of Occupational Therapy, 47(10), 935-942.
ABSTRACT: The results of a previous inquiry suggest that three images of occupational therapists dominate patients' stories about them: the images of technician, parent, and collaborator or friend. These ways of being in practice can be said to reflect the various understandings that therapists have about how to enact the profession's commitment to both competence and caring. When therapists act as technicians or authoritarian parents, patients register their disappointment over a valuation of competence that excludes caring actions. In a more current inquiry into the climate of caring, patients and caregivers reflect about the current health care system and identify three societal constructs that shape a preference for competence over caring: (a) emphasis on the rational fixing of the health care problem, (b) over reliance on methods and protocols, and (c) a health care system driven by business, efficiency, and profit. . .

Peloquin, S.M. (1991). Art in practice: When art becomes caring. Galveston, TX: The University of Texas Medical Branch at Galveston. [Doctoral Dissertation]
ABSTRACT: This work gives meaning to the metaphor Art in Practice as it explores the dilemma of a health care practice said to be depersonalized. The theme of caring that courses through writings about health care, the history of medicine, art, and literature yields this suggestion: there is an art to health care practice whose enactment requires fellow-feeling, sensitivity, and suppleness of response. Depersonalization reflects a popular disregard for the emotional and imaginative aspects of illness and care, and the disregard follows a longstanding preference in Western culture for reason over emotions. Health care practitioners treat those who are ill with highly rationalized skills that fall short of understanding. Helpers see patients and their experiences of illness through the model of technical rationality, a narrow misconstrual of science that misses the personal aspects of illness and care. . .

Peloquin, S.M. (1990). The patient-therapist relationship in occupational therapy: Understanding visions and images. The American Journal of Occupational Therapy, 44(1), 13-21.
ABSTRACT: The patient-therapist relationship in occupational therapy has been a blend of competence and caring with the emphasis fluctuating over the years between these two features. When patients tell stories about their experiences, they reveal widely differing views of occupational therapists, partly because of different ways therapists manifest competence and caring during patient-therapist interactions. Images from stories suggest that some therapists unwittingly disappoint their patients. This paper examines the patient-therapist relationship as envisioned by therapists and patients to help occupational therapists recommit to the patient as a vital partner in a collaborative relationship.

Rahman, H. (2000). Journey of providing care in hospice: Perspectives of occupational therapists. Qualitative Health Research, 10, 806-818.
ABSTRACT: The purpose of this study was to explore the perspective of occupational therapists with regard to their role in hospice and examine whether occupational therapists experienced a conflict in supporting the dual status of living and dying for individuals with terminal illness. A qualitative analysis revealed the following themes: tuning in and comfort care, loss, working toward death, journey with patient, team player, use of occupational therapy, and dichotomous role. These themes demonstrated that occupational therapists played a significant role in hospice, helping individuals with terminal illness to live life fully and comfortably in while facing death. The study found that occupational therapists used a holistic approach in their work by addressing the physical, social, emotional, and spiritual aspects of care.

Sachs, D. (2000). Professional caring: How do female occupational therapists
use knowledge, skills, and emotions in their professional work? The Israel Journal of Occupational Therapy, 9(2/3), E19-E37.
ABSTRACT: This paper analyzes the concept of caring and presents the results of a study that highlights the characteristics of professional caring as perceived by female occupational therapists. Data were collected through ethnographic interviews with seven occupational therapists from different professional backgrounds. The main theme that emerged from the data was that the interviewees had a distinctive, yet comparable definition of "professional caring." The three sub-themes identified were: a) professional caring was experienced as a synthesis of knowledge, skills and emotions, although conceptualizing the emotional component of caring was somewhat difficult; b) the uses of knowledge, skills and emotions were balanced differently with different clients, and c) maternal care was compared with professional care.

Sachs, D. (1989). The perceptions of caring held by female occupational therapists: Implications for professional role and identity. New York, NY: New York University, School of Education, Health, Nursing, and Arts Professions. [Doctoral Dissertation].
ABSTRACT: For years there has been a sense of crisis of professional identity within the occupational therapy (OT) profession. This research explores two dimensions of the profession not heretofore examined: (a) the fact that OT has always been a female predominated profession and, (b) that caring, which is related to women's societal roles, has been a central component of OT work. Once these dimensions are recognized as central to the role and status of the profession it becomes clear that a feminist conceptual framework is needed, rather than the conventional ideology of professionalism with which these problems have been approached thus far in OT. In the present study the researcher investigates the perception of caring for female occupational therapists and its implications for professional role, identity and status. Seven occupational therapists representing a variety of professional realities participated in the study....

Sachs, D. & Labovitz, D.R. (1994). The caring occupational therapist: Scope of professional roles and boundaries. The American Journal of Occupational Therapy, 48(11), 997-1005.
ABSTRACT: Objective. This article links two dimensions of occupational therapy within the context of professionalism: the role of caring and the implications of occupational therapy being a predominantly female profession. Method. Seven occupational therapists representing various levels of professional experience were interviewed to determine (a) how female occupational therapists perceive caring and (b) the implications of this perception for professional role definitions. Results. Participants' daily professional work role was determined by three factors: the interpretation of holistic philosophy in their everyday activities as occupational therapists, the influence of their caring attitude in broadening their responsibilities beyond the occupational therapists' role definition, and the organizational settings in which their work took place. Conclusion. The seven participants had a broad definition of the scope of their professional responsibilities and experienced di!
fficulty defining the limits of their role: therefore, perceptions about caring are central to the role definition of occupational therapists.

Weinstein, E. (1998). The nature of artful practice in psychosocial occupational therapy. New York, NY: New York University. [Doctoral Dissertation]
RESEARCH QUESTION: The therapeutic relationship has been described as one that is personal, meaningful and intimate (Mosey, 1981a). It is a complex relationship that can be played out in diverse ways depending on the therapist's competence, understanding and ability to communicate caring in a way that is meaningful to the client (Peloquin, 1989, 1990). The researcher explored the complex nature and meaning of the therapeutic relationship between an occupational therapist and clients in psychosocial treatment settings by investigating the following questions: 1) How does a therapist construct a practice that embodies artfulness? 2) What is the nature of the interpersonal relationship between therapist and client in an artful practice? a. What is the therapist's experience? b. What is the client's experience? 3) How do the use of specific activities impact: a. the therapeutic relationship? b. the healing process? 4) How does the environmental context influence!
: a. the therapeutic relationship? b. the healing process?

Wheeler, N. (1990). 'Working for patients' and 'caring for people': The same philosophy? The British Journal of Occupational Therapy, 53(10), 409-414.
ABSTRACT: The article looks at the two recent white papers, “Working for Patients” and "Caring for People", in terms of their philosophy, content and driving forces. Consideration is given to the effect of simultaneous implementation.

Wright-St Clair speaks to the fact that “caring” is identified more with the profession of nursing and wonders if the occupational therapy profession’s silence on “caring” from 1980 to the early 1990’s was due to its adopting “enabling” as its identifying feature. This is one of the various paths to pursue at another time. In addition, the author mentions a few concerns about being caring.

“Is it proper to be caring about clients? Is it possible to engage in caring relationships with clients when we are not naturally drawn toward caring about them? And, what are the reasonable limits to caring in a client-therapist relationship?” (p. 193).

In addition, the author spends a significant time on discussing ethical caring, as would be expected from the title of her lecture. As I wrote earlier, I think this paper gives the reader a good deal to ponder.

Following is a SMALL sample of references in the nursing literature on the science of caring, with one from physical therapy literature. Note that they raise similar issues as Valerie Wright-St Clair does.

Brunton, B. & Beaman, M. (2000). Nurse practitioners' perceptions of their caring behaviors. Journal of the American Academy of Nurse Practitioners, 12(11), 451-6.
ABSTRACT: PURPOSE: To explore nurse practitioners' (NPs) perceptions of their own caring behaviors, the relationship between sociodemographic variables, environmental factors, and NP's perceptions of their caring behaviors. DATA SOURCES: A mailed survey to a systematic random sample of 200 members of an Illinois NP group. CONCLUSIONS: The top ten caring behaviors in rank order were appreciating the patient as a human being, showing respect for the patient, being sensitive to the patient, talking with the patient, treating patient information confidentially, treating the patient as an individual, encouraging the patient to call with problems, being honest with the patient, and listening attentively to the patient. IMPLICATIONS FOR PRACTICE: The quality of instruction in the biomedical aspect of nursing education is relatively easily assessed. Caring is nurses' hidden work that may go unrecognized except when the caring behaviors are missed by the patients or their famili!
es.

Eriksson, K. (2002). Caring science in a new key. Nursing science quarterly, 15(1), 61 5.
ABSTRACT: A reorientation is going on in caring science. It could be called a new key characterized by more humanistically oriented thinking, which gives new significance to caring science. The sounding board of the new key is to be found in its ontological core. Its progress depends on whether we will succeed in laying bare the core of caring and developing its fundamental concepts and main theory. We need to regain the hermeneutical approach to penetrate into the core. Caring today needs this knowledge to help the patient in an increasingly complex world.

Montgomery, C.L. (1997). Coping with the emotional demands of caring.
Source. Advanced Practice Nursing Quarterly, 3(1), 76-84.
ABSTRACT: A grounded theory investigation produced a model for how caregivers are affected by the experience of caring. Whether nurses felt fulfilled by caring or traumatized by the risks of personal loss and emotional overload was determined by the meanings they were able to create from the experience. These meanings were derived from both inner personal resources as well as contextual resources. Positive meanings produced an alchemical effect described as a "peak experience," which reinforced engagement and the commitment to caring.
Negative meanings associated with emotional depletion and trauma lead to disengagement and withdrawal from caring. Implications are discussed. (C) 1997 Aspen Publishers, Inc.

Paley, J. (2001). An archaeology of caring knowledge. Journal of Advanced Nursing, 36(2), 188-98.
ABSTRACT: BACKGROUND: There have been repeated attempts, especially during the last 20 years, to say precisely what caring in nursing is. Authors who undertake this task usually begin with the observation that the concept of caring is complex and elusive, and suggest that their contribution will help to clarify this most confused of notions. However, they are always followed by other authors, who do exactly the same thing. We seem to be no closer, now, to a clarification of caring than we have ever been. AIM: The paper offers a diagnosis of this situation, and explains why the project of retrieving caring from its elusiveness is an impossible one. I will suggest that this has nothing to do with the concept of caring, as such. Rather, the impossibility of the task follows from what these authors take to be knowledge of caring. METHOD: I present an analysis of some presuppositions about what knowledge is. These presuppositions pervade the literature on caring, and can be su!
mmarized as follows: knowledge of caring is an aggregate of things said about it, derived from a potentially endless series of associations, grouped into attributes on the basis of resemblances, and conceived as a holistic description of the phenomenon. Further, I suggest that this analysis is akin to the one which Foucault offers of sixteenth century knowledge. CONCLUSIONS: The analysis suggests that this way of knowing is approximately 350 years out of date, and explains why the task of arriving at knowledge (in this sense) is impossible. Moreover, Foucault's claim that sixteenth century knowledge is 'plethoric yet absolutely poverty-stricken' applies, with equal force, to nursing's knowledge of caring.

Romanello, M. & Knight-Abowitz, K. (2000). The "ethic of care" in physical therapy practice and education: challenges and opportunities. Journal of Physical Therapy Education, 14(3), 20-5.
ABSTRACT: Numerous forces affect the development of caring relationships between health care practitioners and their patients. The purpose of this article is to use moral philosophy to elucidate and discuss care and caring as we explore what it means to practice an ethic of care in the physical therapy work environment. We discuss the importance of an ethic of care to physical therapy practice, the barriers to an ethic of care found in contemporary physical therapy work, and considerations for educators attempting to develop an ethic of care in physical therapy students. Though we recognize the difficulty in building and maintaining caring relationships with patients in the present health care environment, we believe health care dynamics necessitate that we combine scientific and moral knowledge with caring skills in order to discover forms of physical therapy practice that consider the patient first while achieving physical therapy outcomes.

Saewyc, E.M. (2000). Nursing theories of caring. A paradigm for adolescent nursing practice. Journal of Holistic Nursing, 18(2), 114-28.
ABSTRACT: In the past four decades, caring has emerged as a central paradigm in nursing. Caring as a central focus in nursing care of adolescents is developmentally appropriate and has been documented as the primary mechanism of effective health promotion for working with teens throughout the world. Other disciplines in adolescent health are beginning to realize the importance of caring therapeutics in practice, but nursing remains in the forefront of theory development and research in this area and is well positioned to provide leadership in further articulating caring theory within adolescent health care. Beyond theory development and testing, however, nurses need to include advocacy for the legitimacy and the importance of caring modalities in promoting the health of adolescents.

Schoenhofer, S.O. (2002). Choosing personhood: intentionality and the theory of nursing as caring. Holistic Nursing Practice, 16(4), 36-40.
ABSTRACT: Drawing on a story of a nursing situation for practical context, this article explores the meaning of intentionality within the theoretical context of Nursing as Caring. May's definition of intentionality as the structure that gives meaning to experience is interwoven with the concepts of the theory of Nursing as Caring to explore the topic. Mayeroff's concepts of hope and commitment contribute to an understanding of intentionality in relation to Nursing as Caring. The major thesis of this article, that intentionality is consistently choosing personhood as a way of life and the aim of nursing, is demonstrated in the practice situation.

Warelow, .PJ. (1996). Is caring the ethical ideal? Journal of Advanced Nursing, 24(4), 655-61.
ABSTRACT: This paper will examine the claim that caring is an appropriate ethical ideal for nursing. Initially it will examine nursing's philosophy of care and caring, highlighting some areas of difficulty and dissatisfaction articulated by many of its contemporary theorists. Evaluation of the notion of caring as an appropriate ethical ideal for nursing will be balanced against those in opposition, and in this process their critique will be discussed. This discussion will focus on areas such as virtue, virtue ethics, moral responsibility, feminine values, mothering and the debate between male and female caring. Different forms of caring will be evaluated and balanced against different forms of nursing. The paper will then suggest that current views which hold aloft nursing as a bedmate of caring may be detrimental to both the cared-for and the carer, advocating in the process a move toward change.

Watson, J. (2002). Intentionality and caring-healing consciousness: a practice of transpersonal nursing. Holistic Nursing Practice, 16(4), 12-9.
ABSTRACT: This article explicates some theoretical and scientific dimensions of intentionality and consciousness as a framework for transpersonal nursing. New connections are made between noetic sciences and transpersonal caring theory, both of which cultivate intentionality as a form of focused consciousness as a formal field of study. What emerges is Intentional Transpersonal Caring, whereby intentionality, consciousness, and universal energy-field are posited as the foundation of a caring moment, potentiating healing for both practitioner and patient. The theoretical and scientific are translated into the practical by a series of practice guidelines that activate intentionality into a living theory of transpersonal caring-healing praxis.

Watson, J. & Smith, M.C. (2002). Caring science and the science of unitary human beings: a trans-theoretical discourse for nursing knowledge development. Journal of Advanced Nursing, 37(5), 452-61.
ABSTRACT: BACKGROUND: Two dominant discourses in contemporary nursing theory and knowledge development have evolved over the past few decades, in part by unitary science views and caring theories. Rogers' science of unitary human beings (SUHB) represents the unitary directions in nursing. Caring theories and related caring science (CS) scholarship represent the other. These two contemporary initiatives have generated two parallel, often controversial, seemingly separate and unrelated, trees of knowledge for nursing science. AIM: This paper explores the evolution of CS and its intersection with SUHB that have emerged in contemporary nursing literature. We present a case for integration, convergence, and creative synthesis of CS with SUHB. A trans-theoretical, trans-disciplinary context emerges, allowing nursing to sustain its caring ethic and ontology, within a unitary science. METHODS: The authors critique and review the seminal, critical issues that have separated contem!
porary knowledge developments in CS and SUHB. Foundational issues of CS, and Watson's theory of transpersonal caring science (TCS), as a specific exemplar, are analysed, alongside parallel themes in SUHB. By examining hidden ethical-ontological and paradigmatic commonalities, trans-theoretical themes and connections are explored and revealed between TCS and SUHB. CONCLUSIONS: Through a creative synthesis of TCS and SUHB we explicate a distinct unitary view of human with a relational caring ontology and ethic that informs nursing as well as other sciences. The result: is a trans-theoretical, trans-disciplinary view for nursing knowledge development. Nursing's history has been to examine theoretical differences rather than commonalities. This trans-theoretical position moves nursing toward theoretical integration and creative synthesis, vs. separation, away from the 'Balkanization' of different theories. This initiative still maintains the integrity of different theories, while !
facilitating and inviting a new discourse for nursing science. The result: Unitary Caring Science that evokes both science and spirit.

Wuest, J. (1998). Setting boundaries: a strategy for precarious ordering of women's
caring demands. Research in Nursing & Health, 21(1), 39-49.
ABSTRACT: OBJECTIVE: A central discovery of this study is that women set boundaries for caring through the processes of determining legitimacy and by attending to one's own voice. Little has been written about the need for, or process of, establishing limits on caring. The findings of this study of women's caring reveal that caring women do set boundaries in response to caring demands, but also demonstrate that personal growth through caring informs the limit-setting process. The discussion of the process illuminates the place of reciprocity, commitment, love, and obligation in the process of caring. DESIGN: Grounded theory. SETTING: Mutually agreed upon location between researcher and interviewee. POPULATION: The initial source of data for this study was information about child-rearing women, collected through interviews and observation of women's groups. Over the course of the study, theoretical sampling resulted in interviews being conducted with 21 heterosexual and le!
sbian women of diverse physical abilities ranging in age from adolescence to old age, from varied socioeconomic backgrounds, and with elementary to doctoral education. Also, data from four previous studies were theoretically sampled to identify further variation in the central concepts.
INTERVENTIONS: Women were interviewed twice either individually or in groups to discuss their experiences, beliefs, and concerns about caring. Initially, they were asked to talk about the scope of caring, family beliefs, other demands, support systems, and feelings. The interviews were unstructured with the interviewer introducing topics and using follow-up probes as necessary. The emerging theory guided questions in later interviews. MAIN OUTCOME MEASURE(S): In grounded theory, the goal is to discover what is most problematic and the means used to process or solve this problem. Competing and changing caring demands were most problematic for women. The central process identified for managing these demands was precarious ordering. The initial response to competing and changing demands is fraying connections, a reactive process characterized by daily struggles, altered prospects, and ambivalent feelings. The strategy of setting boundaries, the focus of this discussion, has two s!
ubprocesses: determining legitimacy of caring demands and attending to one's own voice. RESULTS/CONCLUSIONS: Within the study, there were instances where the motivation to care was obligation and duty, not love or commitment. In those situations, the expectation to care was reinforced by social, professional, or familial expectations. The findings suggest the need for nurses to support women from an early age to identify their own needs and own values. The findings have the potential to be useful to women themselves by uncovering and naming the processes-determining legitimacy, and attending to one's own voice-used by women to order the dissonance created by caring demands. [CINAHL abstract]

Caring is neither easy to do nor to define. Fortunately, society and individuals manage to CARE, naturally, at least some of the time. Arguably, improvement is needed.

Compiled and written by Mary Binderman, MLS

Director of Information Resources
American Occupational Therapy Foundation
Bethesda, MD.