INTRODUCTION:

Swanson’s Theory of Caring was explored in view of developing a theoretical framework for the research study
entitled ‘effect of structured nursing care rounds on selected nursing quality indicators’. Swanson’s Theory of
Caring is structured around five caring principles that encompass the overall definition of caring in nursing practice. 
This theory states that caring proceeds in a sequence of five categories: knowing, being with, doing for, enabling,
and maintaining belief1. When applied to nursing practice, each of these five stages stimulates the caregiver’s
attitude and improves the overall patient well-being. The theory aims at helping nursing personnel to deliver care
that promotes dignity, respect, and empowerment.  This model was framed to ensure consistent caring behaviours
which would in turn improve patient satisfaction.2,3
 
The expansion of nursing science in history is evidenced by caring, and that has long been recognized as a central
concept of professional nursing4. In Modern nursing science, the heritage of caring is widely considered as an art 5,
expressed by the compassionate behaviours of nurses, measured by patient outcomes and nurses’ satisfaction 6.
Caring, acknowledged as the core of nursing, has at all times, been put across as the focal point among the existing
theoretical structures of caring. 4 Surprisingly, caring is the attraction towards the development of the theoretical
framework of nursing science. While nursing is basically grounded in the relationship, unity and connection between
a professional nurse and apatient,3 the application of  the art and science of  caring through theoretical concepts,
scientific research, conscious commitment and caring behaviours are embedded in each nurse patient interation 6 .
 
 

 
 

Copy: Kristen M Swanson, Nursing as Informed Caring for the Well-being of Others.1 IMAGE Journal of Nursing Scholarship: Volume 25,
Number 4, winter – 1993, pages 352-357.
 
 

Definition of caring:
Caring is defined as a nurturing way of relating to a valued other towards whom one feels a personal sense of
commitment and responsibility7. More specifically, caring is growth and health producing (nurturing) occurs in
relationships (relating) to the one cared-for (a valued other); individualized and intimate (personal), with a sense of
commitment (passion), accountability and duty (responsibility) 1.Together with this, nurturing is delivered as a set of
interrelated processes that evolve from the nurse’s own convictions, knowledge and interaction with a patient 7.  The
caring process: being with, doing for, enabling, and maintaining belief, moreover, are grounded in real nursing
behaviours8,9.
 
Maintaining belief:
An orientation to caring begins with a fundamental belief in persons and their capacity to get through events and
transitions and face their future with meaning. Importantly, this conviction is the base or foundation to the practice
of nursing care. Besides, whatever health conditions the patient is facing, a nurse believes in her/his the capacity and
power to accept or welcome upcoming days with meaning. Such an orientation intensifies his/her commitment to
serve humanity in general, and each patient specifically1.
 
For this reason, Swanson describes maintaining belief as holding others in esteem, and believing in their ability to
achieve their goal.10 It involves accepting others in high regard and more importantly with a hop-filled attitude.
Meanwhile, the nurse also assists them in recapturing a positive outlook towards their experiences. Along with this,
a humanistic view, harmonious balance, hope, love, compassion, and spiritual orientation, affix magnificence to the
process of maintaining belief.11 The recognition of a person as a spiritual being who has faith in God – a
supernatural being, a life force-with a dynamic quest for a transcendent relationship, is central to the concept of
maintain belief.  This acknowledgement of the uniqueness and individual differences of patients help nurses to
respect each and every one of them as the creation of God.4,12
 
Knowing:
In knowing, one perceives events according to the meaning they have in the life of the other. It involves a thorough
assessment of all the aspects of a patient’s condition and reality, engaging the self or personhood of the nurse as well
as the patient, in a caring style of approach. 1 The important nursing behaviours for knowing are: a humanistic view
of the other,12 nurturing, understanding of his/her situation, analysis and interpretation, compassion, empathy,
insight, academic cognition and imagination,13 assessment and communication skills, respect for individual
differences and recognition of the other as a significant being. 1 When the process knowing occurs there develops a
bond of empathy and understanding between the care provider and the care recipient.7
 
By being physically and mindfully present, in view of knowing one’s patients, a nurse displays attentiveness,
commitment, deeper involvement and going beyond routine. 14 While  emphasizing a respectful15 and non-judgmental
attitude16 towards the uniqueness of persongs,12 knowledge of clinical practice, well developed skills in assessment,
data gathering, clinical reporting, documentation, and communication – both verbal and non – verbal. 17,18 A
comprehensive initial assessment is very vital to knowing. They include the assessment of physical psycho-
spiritual16 and existential needs, with careful attention to patients’ perceptions, beliefs, values, wishes and family
traditions. The course of knowing also includes esteem for demographic differences such as age, gender, marital
status, education, and social influences from cultural backgrounds, health care experiences, length of stay,
environmental and economic aresources.12,15-19
 
Being with:
Being with, as well as being emotionally present conveys to patients the message that they and their experiences are
significant to the nurse. Similarly, emotional presence is a technique by which the nurse shares the meanings,
feelings and lived experience of the one-cared for.  The nurse assures the patients of her readiness and willingness to
be in their reality. it’s a side-by-side physical presence of clearly conveying one’s availability. Basically, the
message is, “you are not alone, what happens to you matters to us and we are here for you”. Actually, being with, is
giving time to the other for authentic presence, attentive listening and reflective responses 4. Since being with is
regarded as personal relationship, emotional adaptability and progressive availability to patients in both joyful and
painful experiences, goes further than knowing4. Consequently, the impact of being with is measured not only by
interpersonal warmth and friendly interaction but also by proficient nursing practice. 20 Therefore, nurses are to be
interested in authentic presence as well as standard nursing practice. Moreover, sensitive and kind-hearted nursing
caregivers through interpersonal compassion place themselves into the shoes of patients to get into their thoughts
and feelings16.
 
In a nutshell, the qualities of being with include mutual trust 21, availability, mutual linking, faithfulness, patience and
compliance.13,14    In being emotionally present, a health professional attempts to calm fears through their action of
making themselves present to the patients 15. As said above, being with, therefore encapsulates traits like showing
interest, concern and commitment22, compassion and empathy, sympathy, honesty, sincerity and sensitivity 20.
Additionally, other key factors in being with are protective and anticipative behaviour in avoiding harm and danger.
Being with also consists of daring, being firm and doing even things that the patient does not like14.
 
Doing for:
The real meaning of doing for is found in the definition of nursing: The unique function of a nurse is to assist the
individual, sick of well, in the performance of those activities contributing to health or its recovery (or to peaceful
death) that s/he would perform unaided it s/he had the necessary strength, will, or knowledge and to do this in such a
way as to help her/him gain independence as rapidly as possible 23. In other words, doing for refers to the activities in
which a nurse engages with patients for what they would do for themselves if at all it were possible to them. Doing
for as seen in the above definition, involves on the part of the nurse, measures that are performed on behalf of a
patient’s long term welfare. They include comforting patients, anticipating their needs, performing procedures
skilfully, protecting them from harm and ultimately preserving their human dignity1.
 
Furthermore, such an approach also encompasses professional competence, professional attitude, professional
presentation and caring capacities15. The features of professional competence take into consideration nurses’
education and training, clinical knowledge, personal qualities, enduring adjustment, learning, skill mix and self
confidence.12-15  Professional competency is seen in the capacity for detecting, preventing, listening, anticipating,
educating, advocating, monitoring and practicing surveillance which can produce both positive and negative
outcomes. Rendering reassurance, support, comfort, acceptance, legitimacy, confidence, healing, reduction of injury
and suffering also comprise the various facets of professional competency .20-23
 
However, the formal sign posts to professional competency such as technical skills regarding procedures, tests and
medication administration, effective management symptoms, minimising toxicity and relief of pain are form the
various facets of professional competence. 14-15. The corner stone of a nurse’s professional competency is comfort
giving, which includes promptness in response, listening and giving time to speak, using touch, prayer eye contact
and verbal reassurance 24, 25.
 
Enabling:
Enabling is defined as facilitating the other’s passage through life transitions and unfamiliar events 7. As in the case
of doing for, enabling fosters an environment of self-healing26, 27. Such an enabling process enhances the patient’s
capacity to heal, actualize oneself and in particular practice self-care 11. Moreover, self-care animated by intrinsic
motivation, self determination and competence are the results of empowering 15,18  that means, a nurse by positively
altering one’s self concept, knowledge, attitude and skill–level empowers patients in order to facilitate healing. Even
more, the external environment such as provision of safety devices, removal of physical, social or emotional threats
or obstacles also contribute to the healing process1.
 
Here, patients are partners, with knowledge and self management skills 18.  The cornerstone of enabling is
appropriate communication with patients and their families. This involves regular and frequent contacts with
patients, qualified by empathy and sensitivity to family dynamics, cultural and religious beliefs and previous
experience, along with the nature of illness 27. Communication also embodies providing information 12, explanation
about the given care, medications, tests, and the overall condition of the patient 15. Written materials, phone calls,
emails, internet use, independent learning with software and counselling could also be encouraged as well in the
process of enabling the patients18. Nursing care, ultimately involve enabling patients to carry out self care. The
process of enabling entails training, informing, illuminating, supporting during painful experiences, guiding in issues
through helping to generate alternatives, offering advice and authenticating patient reality. With regards to enabling,
the objective is patient’s enduring well-being.
 
Research evidences:
The Carolina Care Model, based on Swanson Caring Theory, developed practices that promote patient care, at the
University of North Carolina hospitals. The application of the ‘caring theory’ ensured consistently high standards of
nursing performance. This style of giving care improved patients’ and families’ hospital experience and accelerated
caring process and outcomes. Multi-level rounds, standardized tours for new patients, action plans that incorporated
caring behaviours and model units displayed nursing innovations related to patient care. On the whole, with the
implementation of Carolina Care, patient satisfaction steadily increased over 6 years. Areas that showed positive
trends included concern for privacy, meeting emotional needs, attention to personal needs and pain control5.
 
Wang and Hsu describe their experience of a case study using Swanson’s Caring Theory in the care of a terminal
lung cancer patient, suffering from spiritual distress. They assessed the patient’s relationship with self, others,
environment and God, and found him to be distressed. Interventions such as knowing, being with, doing for,
enabling and maintaining belief were applied to deal with the patient’s spiritual suffering and spiritual needs.
Application of Swanson’s Caring Theory increased the understanding and compassion of nurses to their patients
spiritual needs and to provide effective spiritual care28.
 
The caring model, developed by Kristen Swanson has been incorporated in hospitals and physician practices. It has
created a way for nurses to care for each other and themselves. One of the achievements in nursing units of the
hospitals that adopted the Swanson’s Theory of Caring was serenity. Standards and metrics were registered into the
hospitals’ production system; so too how nurses improved care, efficiency and satisfaction for patients and staffs
were also tracked. The application of the theory elevated comfort level of the patients and the nurses as well, next to
their safety29.
 
CONCLUSION:
The structure of caring in ‘Swanson’s Middle Range Caring Theory’ enlightens nursing care givers on the
significance of caring. Caring process and its observable and practical criterion are distinguishing humanitarian
behaviours which are mandatory in nursing. The highly significant qualities that were highlighted were those of
compassion, knowledge, optimism, reflection, concern and commitment, communication skills, focus on the others
experience, respect for individual dignity/worth and being present to the other. If this theory could effectively used
to guide clinical practice, the nurses can ensure a personal approach to care.