Nursing Theories

1. Nursing theories describe, explain, or predict outcomes based on relationships among the
concepts of nursing phenomena.

2. Theories propose relationships by framing the issue and defining relevant terms.

3. Nursing theories may be developed at various levels of abstraction.

4. Nursing theories at a grand theory level are nearly as abstract as the models from which they
come, but they are considered theories because they propose testable outcomes.

The Theory of Nursing as Caring:

A Model for Transforming Practice Marguerite J. Purnell

“The nature of relationships is transformed through caring” (Boykin & Schoenhofer, 2001a, p. 4).

Credentials and Background of the Theorists

Anne Boykin

Anne Boykin grew up in Kaukauna, Wisconsin, the eldest of six children. She began her career in
nursing in 1966, graduating from Alverno College in Milwaukee, Wisconsin. She received her master’s
degree from Emory University in Atlanta, Georgia, and her doctorate degree from Vanderbilt University
in Nashville, Tennessee. Dr. Boykin is married to Steve Staudenmeyer, and they have four children. Anne
Boykin retired in fall 2011 and is Professor Emeritus of the Christine E. Lynn College of Nursing at Florida
Atlantic University. She has relocated to Asheville, North Carolina, where she enjoys being surrounded
by mountains and lakes.

Dr. Boykin is currently the Director of the college’s new Anne Boykin Institute for the Advancement of
Caring in Nursing. Boykin has a longstanding commitment to the advancement of knowledge in the
discipline, especially regarding the phenomenon of caring. Positions she has held in the International
Association for Human Caring include president elect (1990 to 1993), president (1993 to 1996), and
member of the nominating committee (1997 to 1999). As immediate past president, she served as
coeditor of the journal, International Association for Human Caring, from 1996 to 1999. Boykin’s
scholarly work is centered on caring as the grounding for nursing. This is evidenced in her book
(coauthored with Schoenhofer), Nursing as Caring: A Model for Transforming Practice(1993, 2001a), and
her book, Living a Caring-Based Program (1994b).

The latter book illustrates how caring grounds the development of a nursing program by creating the
environment for study through evaluation. In addition to these books, Dr. Boykin is editor of Power,
Politics and Public Policy: A Matter of Caring (1995) and coeditor (along with Gaut) of Caring as Healing:
Renewal Through Hope (1994). She has written numerous book chapters and articles and serves as a
consultant locally, regionally, nationally, and internationally on the topic of caring

Savina O. Schoenhofer

Savina Schoenhofer was born the second child and eldest daughter in a family of nine children and spent
her formative years on the family cattle ranch in Kansas. She is named for her maternal grandfather,
who was a classical musician in Kansas City, Missouri. She has a daughter, Carrie, and a granddaughter,
Emma.

During the 1960s, Schoenhofer spent 3 years in the Amazon region of Brazil, working as a volunteer in
community development. Her initial nursing degree was completed at Wichita State University, where
she also earned graduate degrees in nursing, psychology, and counseling. She completed a PhD in
educational foundations and administration at Kansas State University in 1983. In 1990, Schoenhofer co-
founded Nightingale Songs, an early venue for communicating the beauty of nursing in poetry and
prose. An early study made it apparent to Schoenhofer that caring was the service that patients
overwhelmingly recognized. In addition to her work on caring, including co-authorship with Boykin of
Nursing as Caring: A Model for Transforming Practice (1993, 2001a), Schoenhofer has written numerous
articles on nursing values, primary care, nursing education, support, touch, and mentoring.

Schoenhofer’s career in nursing has been influenced significantly by three colleagues: Lt. Col. Ann
Ashjian (Ret.), whose community nursing practice in Brazil presented an inspiring model of nursing;
Marilyn E. Parker, PhD, a faculty colleague who mentored her in the idea of nursing as a discipline, the
academic role of higher education, and the world of nursing theories and theorists; and Anne Boykin,
PhD, who introduced her to caring as a substantive field of study in nursing.

Dr. Schoenhofer serves on the Ethics Advisory Committee at the University of Mississippi Medical
Center, where she consults and advises on questions of ethics in clinical situations that arise in practice
and health care ethics education in clinical and education settings. She is Professor of Nursing at
University of Mississippi Medical Center School of Nursing in Jackson and Adjunct Professor at the
Florida Atlantic University College of Nursing, Boca Raton. Dr. Schoenhofer is committed to the study of
nursing as caring.

Theoretical Sources

The Theory of Nursing as Caring was borne out of the early curriculum development work at Florida
Atlantic University College of Nursing. Anne Boykin and Savina Schoenhofer were among the faculty
group revising the caring-based curriculum. When the revised curriculum was instituted, each
recognized the importance and human necessity of continuing to develop ideas toward a
comprehensive conceptual framework that expressed the meaning and purpose of nursing as a
discipline and as a profession. The point of departure from traditional thought was the acceptance that
caring is the end rather than the means of nursing, and the intention of nursing rather than merely its
instrument. This work led Boykin and Schoenhofer to conceptualize the focus of nursing as “nurturing
persons living caring and growing in caring” (Boykin & Schoenhofer, 1993, p. 22).

Further work to identify foundational assumptions about nursing clarified the idea of the nursing
situation as a shared lived experience in which the “caring between” (Boykin & Schoenhofer, 1993, p.
26) enhances personhood. Personhood is illuminated as living grounded in caring. The clarified notions
of nursing situation and focus of nursing bring to life the meaning of the assumptions underlying the
theory and permit the practical understanding of nursing as both a discipline and a profession. As
critique and refinement of the theory and study of nursing situations progressed, the notion of nursing
as being primarily concerned with health was seen as limiting. Boykin and Schoenhofer now propose
that nursing is concerned with the broad spectrum of human living.
 Three bodies of work significantly influenced the initial development of the theory. Paterson and
Zderad’s (1988) existential phenomenological theory of humanistic nursing, viewed by Boykin and
Schoenhofer as the historical antecedent of Nursing as Caring, was the source for such germinal ideas as
“the between,” “call for nursing,” “nursing response,” and “personhood,” and it served as substantive
and structural bases for their conceptualization of nursing as caring. Roach’s (1987, 2002) thesis that
caring is the human mode of being finds its natural expression and domain in the assumptions of the
theory. Her “6 C’s”—commitment, confidence, conscience, competence, compassion, and comportment
— contribute to a language of caring (Roach, 2002). Mayeroff’s (1971) work, On Caring, provided rich,
elemental language facilitating recognition and description of the practical meaning of living caring in
the ordinariness of life. Mayeroff’s (1971) major ingredients of caring—knowing, alternating rhythms,
patience, honesty, trust, humility, hope, and courage— describe the wellspring of human living. In the
Theory of Nursing as Caring, these concepts are essential for understanding living as caring, and for
coming to appreciate their unique expression in the reciprocal relationship of the nurse and the nursed.

Boykin and Schoenhofer’s conception of nursing as a discipline was influenced directly by Phenix (1964),
King and Brownell (1976), and Orem (1979), and as a profession by Flexner’s (1910) ideas. In addition to
the work of these thinkers, Boykin and Schoenhofer are longstanding members of the community of
nursing scholars whose study focuses on caring. Their collegial association and mutual support also
undoubtedly influenced the work.

Nascent forms of the Theory of Nursing as Caring were first published in 1990 and 1991, with the first
complete exposition of the theory presented at a theory conference in 1992 (Boykin & Schoenhofer,
1990, 1991; Schoenhofer & Boykin, 1993). These expositions were followed by Nursing as Caring: A
Model for Transforming Practice, published in 1993 (Boykin & Schoenhofer, 1993) and re-released with
an epilogue in 2001 (Boykin & Schoenhofer, 2001a). Gaut points out in Boykin and Schoenhofer (2001a)
that the theory is an excellent example of growth by intension, or gradual illumination, characterized by
“the development of an extant bibliography, categorization of caring conceptualizations, and the
further development of human care/ caring theories” (p. xii).

MAJOR CONCEPTS & DEFINITIONS

Focus and Intention of Nursing

Disciplines of knowledge are communities of scholars who develop a particular perspective on the
world and what it means to be in the world (King & Brownell, 1976). Disciplinary communities hold a
value system in common that is expressed in its unique focus on knowledge and practice. The focus of
nursing from the perspective of the Theory of Nursing as Caring is that the discipline of knowledge and
professional practice is nurturing persons living and growing in caring. The general intention of nursing is
to know persons as caring and to support and sustain them as they live caring (Boykin & Schoenhofer,
2006). This intention is expressed uniquely when the nurse enters the relationship with the nursed with
the intention of knowing the other as a caring person, and affirming and celebrating the person as caring
(Boykin & Schoenhofer, 2001a). Caring is expressed in nursing and is “the intentional and authentic
presence of the nurse with another who is recognized as living in caring and growing in caring” (Boykin &
Schoenhofer, 1993, p. 24). Sensitivity and skill in creating unique and effective ways of communicating
caring are developed through the nurse’s intention to care.

Perspective of Persons as Caring

 The fundamental assumption is that all persons are caring. Caring is lived by each person moment to
moment and is an essential characteristic of being human. Caring is a process, and throughout life, each
person grows in the capacity to express caring. Person therefore is recognized as constantly unfolding in
caring. From the perspective of the theory, “fundamentally, potentially, and actually each person is
caring” (Boykin & Schoenhofer, 2001a, p. 2), even though every act of the person might not be
understood as caring. Knowing the person as living caring and growing in caring is foundational to the
theory.

Nursing Situation

Caring is service that nursing offers and lives in the context of the nursing situation (Boykin &
Schoenhofer, 2006). The nursing situation is the locus of all that is known and done in nursing (Boykin &
Schoenhofer, 2001a) and is conceptualized as “the shared, lived experience in which caring between
nurse and nursed enhances personhood” (Boykin & Schoenhofer, 1993, p. 33). The nursing situation is
what is present in the mind of the nurse whenever the intent of the nurse is “to nurse” (Boykin &
Schoenhofer, 2001a). It is within the nursing situation that the nurse attends to calls for caring or
reaching out of the one nursed. The practice of nursing and the practical knowledge of nursing are
situated in a relational locus of the person being nursed with the person nursing in the nursing situation.
The nursing situation involves an expression of values, intentions, and actions of two or more persons
choosing to live a nursing relationship. In this lived relationship, all knowledge of nursing is created and
understood (Boykin & Schoenhofer, 2006).

Personhood

Personhood is a process of living that is grounded in caring. Personhoodimplies being who we are as
authentic caring persons and being open to unfolding possibilities for caring. We are constantly living
out the meaning of our caring from moment to moment. Within the nursing situation, the shared lived
experience of caring within enhances personhood, and both the nurse and the nursed grow in caring. In
the intimacy of caring, respect for self as person and respect for other are values that affirm
personhood. “A profound understanding of personhood communicates the paradox of person-as-person
and person-in-communion all at once” (Boykin & Schoenhofer, 2006, p. 336).

Direct Invitation

Within the nursing situation, the direct invitation opens the relationship to true caring between the
nurse and the one nursed. The direct invitation of the nurse offers the opportunity to the one nursed to
share what truly matters in the moment. With the intention of truly coming to know the one nursed, the
nurse risks entering the other’s world and comes to know what is meaningful to him or her. The focus is
on what is meaningful for the one being nursed. Invitations to share what matters, such as “How might I
nurse you in ways that are meaningful to you?” or “What truly matters most to you at this moment?”
are communicated in the personal language of the nurse. The power of the direct invitation reaches
deep into the humility of the nursing situation, uniting and guiding the intention of both the nurse and
the one nursed. These uniquely expressed invitations of caring call forth responses of mutual valuing in
the beauty of the caring between.

Call for Nursing

 Calls for nursing are calls for nurturance perceived in the mind of the nurse (Boykin & Schoenhofer,
2001a, 2001b). Intentionality (Schoenhofer, 2002a) and authentic presence open the nurse to hearing
calls for nursing. The nurse responds uniquely to the one nursed with a deliberately developed
knowledge of what it means to be human, acknowledging and affirming the person living caring in
unique ways in the immediate situation (Boykin & Schoenhofer, 1993). Because calls for nursing are
uniquely situated personal expressions, they cannot be predicted, but originate within persons who are
living caring in their lives and who hold hopes and aspirations for growing in caring. “Calls for nursing are
individually relevant ways of saying ‘Know me as caring person in the moment and be with me as I try to
live fully who I truly am”’ (Boykin & Schoenhofer, 2006, p. 336).

Caring Between

When the nurse enters the world of the other person with the intention of knowing the other as a
caring person, the encountering of the nurse and the one nursed gives rise to the phenomenon of caring
between, within which personhood is nurtured (Boykin & Schoenhofer, 2001a). Through presence and
intentionality, the nurse comes to know the other, living and growing in caring. Constant and mutual
unfolding enhances this loving relation. Without the caring between the nurse and the nursed,
unidirectional activity or reciprocal exchange can occur, but nursing in its fullest sense does not occur. It
is in the context of caring between that personhood is nurtured, each expressing self and recognizing
the other as caring person (Boykin & Schoenhofer, 2001a).

Nursing Response

In responding to thenursing call, the nurse enters the nursing situation with the intention of knowing
the other person as caring. This knowing of person clarifies the call for nursing and shapes the nursing
response, transforming the knowledge brought by the nurse to the situation from general, to particular
and unique (Boykin & Schoenhofer, 2001a). The nursing response is co-created in the immediacy of
what truly matters and is a specific expression of caring nurturance to sustain and enhance the other
living and growing in caring. Nursing responses to calls for caring evolve as nurses clarify their
understanding of calls through presence and dialogue. Such responses are uniquely created for the
moment and cannot be predicted or applied as preplanned protocols (Boykin & Schoenhofer, 1997).

Story as Method for Knowing Nursing

Story is a method for knowing nursing and a medium for all forms of nursing inquiry. Nursing stories
embody the lived experience of nursing situations involving the nurse and the nursed. As a repository of
nursing knowledge, any single nursing situation has the potential to illuminate the depth and complexity
of the experience as lived, that is, the caring that takes place between the nurse and the one nursed.
The content of nursing knowledge is generated, developed, conserved, and known through the lived
experience of nursing situations (Boykin & Schoenhofer, 2001a). The nursing situation as a unit of
knowledge and practice is re-created in narrative or story (Boykin & Schoenhofer, 1991). Nursing
situations are best communicated through aesthetic media such as storytelling, poetry, graphic arts, and
dance to preserve the lived meaning of the situation and the openness of the situation through text.
These media provide time and space for reflecting and for creativity in advancing understanding (Boykin
& Schoenhofer, 1991, 2001a, 2006; Boykin, Parker, & Schoenhofer, 1994). Story as method re-creates
and re-presents the essence of the experience, making the knowledge of nursing available for further
study (Boykin & Schoenhofer, 2001a).