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Kristen Swanson began her career in nursing, after receiving her bachelors degree from the University of Rhode Island, at the University of Massachusetts. She picked this hospital, “because of that institution’s clear articulation of how nursing could and should be.”(Parker & Smith, 2010, p. 429). After she received her Master’s Degree, three years later, she began to teach undergraduate Med-Surg nursing in Philadelphia. “It was here that she met Dr. Jacqueline Fawcett and heard her speak of the health, environment, persons and nursing concepts. She enrolled in Dr. Fawcett’s new course on conceptual basis of nursing. ‘ I finally knew that it was nursing, a discipline that I was starting to understand from an experiential, personal and academic point of view, was more suited to my beliefs about serving people who were moving through the transitions of illness and wellness.’ ” (Parker & Smith, 2010, p. 430).
“Swanson has drawn on various theoretical sources while developing her Theory of Caring. She recalls that from the beginning of her nursing career, knowledge obtained from book learning and clinical experience made her acutely aware of the profound difference caring made in the lives of people she served” (Alligood & Tomey, 2010, p. 742).
This confused me, as it seemed that Swanson had very little clinical experience. The only clinical experience, that I was able to find in all the literature, was based in adult medicine. So I was curious as to how, having an adult medicine background and having so little clinical experience, Swanson was able to develop a nursing theory of caring, from perinatal research.
“In September 1982, it was Jean Watson, who encouraged her to examine caring in the context of miscarriage. ‘I believe that the key to my program of research is that I have studied human responses to a specific health problem (miscarriage) in a framework (caring) that assumed from the start that a clinical therapeutic had to be defined.’ Swanson’s preparation for studying caring-based therapeutics began from a psychosocial perspective in a cardiac care unit. ‘I realized that there was a powerful force that people could call upon to get themselves through incredibly difficult times.’ ” (Parker & Smith, 2010, p. 429).
“Swanson applied for her doctoral studies and her area of study, psychosocial nursing, emphasized such concepts as loss, stress, coping, caring, transactions and person-environment fit” (Parker & Smith, 2010, p. 430). It was here that she attended a cesarean support group, shortly after the birth of her first son. The OB physician who lectured that night was informing the women of the incidence of miscarriage with C-section births, but Swanson noted that the woman just wanted to talk about their loss. “From that day on, Swanson decided to learn more about human experience and responses to miscarrying. Caring and miscarriage became the focus of her doctoral dissertation and her program of research” (Alligood & Tomey, 2010, p. 742). This is where Swanson began with a question, derived from observation, and began to develop a nursing theory from her research.
Having had a miscarriage 14 years ago, I had some difficulty reading this research. It brought up my own experience and to my surprise, made me aware that I have not fully recovered from it. I was like many of the women, who were shuffled off for a dilatation and curettage and sent home with instructions to try again in “x” months. I was 41 years old, with a 2 year old at home. We had just moved into our new house, boxes need to be unpacked and my daughter need to be cared for. I had no time to grieve. No one was able to tell me what I needed to hear. Even my husband did not discuss it with me. All anyone had told me was how common it was for a woman to miscarry and that there may have been a deformity, so it was God’s way. I often wonder how our lives would be with two children, instead of one. I came from a large family and that was always my hope, to have children running around my house.
Swanson’s first research study involved 20 women who had miscarried within 16 weeks of her interview process. “This in depth analysis brought Swanson to her first model of caring. She describes her early concepts of caring as defined and related only to miscarriage” (Swanson, 1998, p. 3). Swanson wrote two articles after her research and dissertation was complete. One discusses “the step-by-step process the researcher used to move from initial curiosity to sharing of discovered categories” (Swanson-Kauffman, 1986, p. 58) The second article summarized Swanson’s research and ” hoped to address to caregivers how it is that women who miscarried wished to be cared for” (Swanson-Kauffman, 1986, p. 37). It was also in this article, when something came to light for me. “The move toward specialized medicine and rapid technological advances have led to tremendous depersonalization of health care” (Swanson-Kauffman, 1986, p. 39).
Having worked clinically for 35 years, mostly in the Emergency Department (ED), I recognized that due to the nature of Emergency Medicine, this last statement of Swanson’s rang true for me. How many times had I been involved with nursing care of a patient and been swept up in the frenzy of quickly doing my job, so as to get ready for the next emergency, without truly identifying all the needs of this present patient. Yes, we fixed the broken bone or stopped the bleeding laceration, but what is this going to mean for the patient when he/she goes home? Has this caused a new difficulty for them, to carry on in their daily lives? The other point of this is that with Press Ganey surveys and patient satisfaction, we are forced to expedite care and treat all, who come to us, in a timely fashion. Throughput is even on my performance review.
Patient satisfaction also encompasses having the patient seen as a person, using compassion and caring. This is one of the hardest aspects of my job. There is a dichotomy of moving patients quickly through the system and doing it with feeling. Many of my staff are exhibiting care giver fatigue and burnout, due to being constantly caught in the middle, when patients are waiting angrily and feeling that their emergency is most important. Patients and families become verbally and sometimes physically abusive, because they are stressed at the situation that brought them to the Emergency room in the first place. With ED overcrowding, due to a multitude of factors, this becomes a vicious cycle. I will address Swanson’s theory application, in relation to my area of focus, later in the paper.
“When she later developed her research with NICU caregivers and new mothers of high social risk, she further developed her five concepts of caring. ‘So those three studies combined – miscarriage, NICU and high risk moms – helped me to keep clarifying a bit further what each of the categories meant. At the end of that time, I ended up saying I had a theory of caring and I was able to publish it Nursing Research, talking about how this had been developed across three different pregnancy situations’ ” (Swanson, 1998, p. 3).
In 1991, Swanson was published in Nursing Research, in which her middle range theory of caring was explained. Swanson’s theory was “inductively derived and validate through phenomenological investigations in three separate perinatal contexts” (Swanson, 1991, p. 161). Here, Swanson stated that there were nursing investigators that had identified caring, such as Leininger and Watson, however, “a universal definition or conceptualization of caring does not exist” (Swanson, 1991, p. 161).
“In the theory’s most recent form, caring consists of five categories or processes. They are: (a) knowing, (b) being with, (c) doing for, (d) enabling (e) maintaining belief. Although each of these categories is presented separately, the categories are not mutually exclusive” (Swanson, 1991, p. 163).
“Knowing is striving to understand an event as it has meaning in the life of the other; avoiding assumptions, centering on the one cared-for, assessing thoroughly, seeking cues and engaging the self of both” (Swanson, 1991, p. 163).
“Being with is being emotionally present to the other; being there, conveying ability, sharing feelings, not-burdening” (Swanson, 1991, p. 163).
“Doing for entails doing for the other what she or he would do for the self if it were at all possible; comforting, anticipating, performing competent/skillfully, protecting, preserving dignity” (Swanson, 1991, p. 164,163).
“Enabling means facilitating the other’s passage through life transitions and unfamiliar events; informing/explaining, supporting/allowing, focusing, generating alternatives/thinking it through, validating/giving feedback” (Swanson, 1991, p. 164,163)
“Maintaining Belief is sustaining faith in the other’s capacity to get through an event or transition and face a future with meaning; believing in/holding in esteem, maintaining a hope-filled attitude, offering realistic optimism, ‘going the distance’ “(Swanson, 1991, p. 165,163).
“Ultimately, the following definition of caring was inductively derived: Caring is a nurturing way to relate to a valued other toward whom one feels a personal sense of commitment and responsibility” (Swanson, 1991, p. 165).
In 1993, Swanson wrote an article on the” assumptions of the four phenomena of concern to nursing and an elaboration is made of the structure of a theory of caring” (Swanson, 1993, p. 352). Her conclusion is that “nurse caring frequently consists of subtle, yet powerful, practices which are often virtually undisclosed to the casual observer, but are essential to the well-being of its recipient (Swanson, 1993, p. 357).
When I read this statement, it brought to mind many of the times, some which I discussed in my autobiography, were I can remember really empathizing with a patient or using my intuition to guide my nursing care. It is being able to pick up certain cues, whether blatant or subtle, and acting upon them. Swanson theory, in its simplicity and ease of use, makes it seem as though we are doing each and every concept without being conscious of it.
Swanson continued to perform research on the impact of miscarriage and the effects of a woman’s well-being in relation to caring (Swanson, 1999). She notes that the limitation of this research was the “sample had minimal ethnic diversity and was quite highly educated, thus limiting generalization” (Swanson, 1999, p. 297). It appeared unclear to me, as to whether care-based nurse counseling was most effective in decreasing overall emotional disturbances, as healing/grieving differ with each woman. So was it really time or counseling that helped these women.
In 2008, Swanson and 4 other authors conducted a “randomized controlled clinical trial was to examine the effects of three couples-focused interventions and a control condition on women and men’s resolution of depression and grief during the first year of miscarriage” (Swanson, Chen, Graham, Wojnar, & Petras, 2008, p. 1245) “Consistent with prior reports, we found that men and women responded differently to miscarriage. Likewise their experiences of grief and depression were differently impacted by our three couples-focused interventions” (Swanson et al., 2008, p. 1255) Once again, her research group was not diversified and I wondered why Swanson kept using the same population. Why did she continue to use her theory in the perinatal population?
Swanson theory of caring has been tested and used by nursing to further test her concepts and prove validity, both nationally and internationally. In Sweden, there was a research paper, used to validate both Swanson and Watson’s theories of caring in relation to” involving relatives in the care of the dying.” (Andershed & Ternestedt, 1999, p. 45). I was unsure if this study actually validated Swanson’s theory with the study group involved. There was evidence of the use of Swanson’s concepts; however, I found the discussion confusing, as it took into account other theorist, such as Leininger and Watson. The study did neither support nor disproved Swanson’s theory.
Later, in 2009, Andersted co-authored a review of Swanson’s theory of caring. Here, the authors tried to “identify and describe how Kristen Swanson’s middle range theory has been used in nursing practice/research presented in international journals” (Andershed & Olsson, 2009, p. 598). “A conclusion is that people are guided through discussions of their experiences and feel understood, informed, provided for, validated and believed in, they would be better prepared to integrate difficulties into their lives” (Andersted & Olsson, 2009, p. 609). This became evident to me, as previously stated, in my miscarriage account.
A midwife in Northern Ireland wrote a paper on “a case study developed utilizing Swanson’s theory of caring and Carper’s ways of knowing. ‘Midwifery needs a theory or model suitable for holistic care provided by midwives. Swanson’s theory of caring goes part of the way as it encourages an individualistic approach to care’ ” (Anderson, 2002). I could see Swanson’s theory being relevant to Midwives, as Swanson performed her research in the perinatal area. The author concluded, however, that maybe more than one theory could be used in this disciple. I tend to agree with this, as I believe there are concepts of different theories that would be better suited for a particular event or patient.
Here in the United States, Swanson’s theory has been used in different areas of nursing, such as critical care. “This study challenges nurses to look at and examine their own life experiences and place themselves in the role of the patient. This study, however, supports the theory that caring is an essential component in the nurse-patient relationship” (Hanson, 2004, p. 25). This paper is closely related to the personal experiences of the nurse and how it translates into their nursing care. I find this particularly fascinating, as this goes along with our autobiographical reviews of our past experiences, values and morals and how they shaped our lives in becoming nurses. We could not be the nurses that we are today, without knowing where we came from. This research paper also brings up the point that there needs to be more research as to whether caring is a learned or instinctive characteristic.
The article that most closely relates to my area of practice is “The Carolina Care Model. ‘This article describes how one organization operationalized Swanson’s Caring Theory and changed practice to ensure consistently high standards of performance.’ ” (Tonges & Ray, 2011, p. 374). Many of the performance improvements used by the University of North Carolina have been instituted in many facilities that I am familiar with and currently work in. I am uncertain if they are influenced by Swanson’s theory of caring or merely best practice.
I put Swanson’s theory to a small test on my unit. I work in a community ED with the challenge of throughput, while holding admissions in the ED. This poses the difficulty of providing care for those who are walking in or transported by ambulance. The wait times, to be seen by a physician and receiving an inpatient bed assignment, have more than doubled in the past two years. I had noticed that this was causing stress on the staff and complaints were developing from patients and families, that the staff were not “caring and compassionate, but rather cold and callus.”
Knowing – I met with small groups of staff and reserved my assumptions of their concerns, listened to them and tried to understand how this was affecting them, what it meant to them.
Being with – I tried to convey that I was available to them and shared their concerns, having worked clinically with many of them.
Doing for – I established meetings with a counselor for the Employment Helpance Program.
Enabled -This gave them the opportunity to explain their feelings and have them validated. My hope was for them to move from this experience richer, with this new found knowledge.
Maintaining Belief – I encouraged them to use the resources from these meeting and told them that I believe we can return to the vibrant team that we once were and can grow from this even stronger, as a team.
I still have many questions about Swanson’s theory. I find it hard to understand how someone, with such limited clinical experience, could formulate a theory involving nursing and patient care. Also, as stated before, her theory was derived from a small population and diversity. That being said, I found Swanson’s theory to be logical and simple to test.
As a Clinical Director, I believe that I can use Swanson’s theory on the staff that I am responsible for, but due to the nature of the fast pace of emergency medicine, I am not sure that all five of her concepts can be used on any given patient, depending on the amount of time we have with them. I would be courteous to know if this theory has been used in an administrative setting, as I was unable to find any in the literature search. The closest one I could find was the “Carolina Care Model”, which I see as an institution care model, as opposed to an adaptation of Swanson’s theory of caring.
Swanson’s theory does possess many qualities needed for nursing care and her conceptual work is a good starting point to further studies and application in all areas of nursing. I enjoyed reading her works and that of others that used her theory. I was also genuinely honored that she responded to my email, even though the questions that I presented were not addressed.
