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O R I G I NA L A R T I C L E
INTRODUCTION
Caring is an essential part of human growth, devel- opment and survival, and is a process with each per- son growing in caring throughout life (Boykin & Schoenhofer, 2001; Gaylin, 1976). Thus, caring is grounded in the human mode of being (Newman, 1979). The presence of caring between people facili- tates particular behaviors and actions, which is espe- cially true in acute hospital settings where patients’ illnesses are superimposed with loss of function, bod- ily disintegration, and separation from everything familiar, leading to loss of control and inability to change the situation. Caring in nursing is the core and essence of the profession. There is no other discipline that is so
directly and intimately involved with caring needs and behaviors than the discipline of nursing (Gaylin, 1976; Leininger, 1978). Nursing as a caring science is viewed as the major caring profession (Briggs, 1972; Watson, 1985), and has always held a human-care and caring stance. Caring is also a basic philosophical concern of nursing practice. Humanitarian science through theory development in nursing is a major element in producing effective caring (Knowlden, 1998). Nurses attempt to cure and comfort through care and treatment (Watson). Indeed, healing in nursing is based on caring and treatment. The caring of nurses evokes the essence of human encounters such as empathy, congruence, identification, mutual awareness, the intrusion of one into the private world of another that may facilitate rediscovery of trust as
Interpersonal Caring: A Theory for
Improved Self-Esteem in Patients with
Long-Term Serious Mental Illness — I
Susie Kim 1 *, APRN, DNSc, FAAN , Sue Kim 2 , RN, PhD, NP
(^1) President, Seoul Cyber University, Seoul, Korea (^2) Assistant Professor, Research Fellow, College of Nursing, Nursing Policy Research Institute, Yonsei University, Seoul, Korea
This article describes a process of theory development in nursing care. The Interpersonal Caring theory empirically arose from a problematic nursing situation of caring for patients with long-term serious mental illness, to guide practical applications of interpersonal caring behaviors. The authors describe the phases of theory development with patient statements that illustrate how to conceptualize the phenomenon, and present theoretical and statistical analyses that validate the 10 domains of interpersonal caring: noticing, participating, sharing, active listening, companioning, complimenting, comforting, hoping, forgiving, and accepting. [ Asian Nursing Research 2007;1(1):11–22] Key Words caring, interpersonal relation, interpersonal caring, serious mental illness
*Correspondence to: Susie Kim, APRN , DNSc , FAAN, Seoul Cyber University, Mia3-Dong 193, Gangbuk-Gu, Seoul 142-700, Korea. E-mail: president@iscu.ac.kr
a therapeutic turning point as defined by Weigert (Grotjahn, 1951). As a nurturing interpersonal com- munication between nurse and patient (Knowlden; Swanson, 1993), caring in nursing is a way to empower the sick and needy. The relationship between the nurse and the patient is another key concept in nursing. Peplau (1991, 1994), a leading interactive theorist, emphasized the importance of the nurse–patient relationship, and asserted that nursing is a significant, therapeutic, interpersonal process (1952, p. 16). Peplau (1952) used the term psychodynamic nursing as “being able to understand one’s own behavior to help others iden- tify felt difficulties, and to apply principles of human relations to the problems that arise at all levels of experience” (p. xiii). This approach to nursing enables the nurse to begin to move away from a disease ori- entation to one whereby the psychological meaning of events, feelings, and behaviors can be explored and incorporated into nursing interventions (Knowlden, 1998). This psychodynamic nursing process offered nurses an opportunity to teach clients how to identify and express their feelings and to explore with them how to bear their experiences. Peplau’s theory of interpersonal relations in nursing seeks to develop the nurse’s skill in applying major mental health concepts, requiring a nurse to be empathetic and observant of what the patient does and says, apply theoretical concepts and determine what intervention to pursue (McQuiston & Webb, 1995). Thus, Peplau’s theory allows nurses to move away from doing to to doing with patients. However, Peplau and others who have studied human caring did not fully dis- cuss the forms of doing with the patient and how it is done. The interpersonal caring (IC) theory developed by Kim (1994) was originally based on Peplau’s inter- personal relations and involves both caring and inter- personal relationship. Vaguely acknowledging that caring is the essence of nursing is not enough. It must be applied and passed on to clients/patients through developing a relationship. IC is a form of caring seen in the nurse–patient relationship. This relationship represents a collaborative partnership based on mutual trust, connection, and respect for the patient’s right
to be him/her self. IC is developed through trust based on compassion, a deepening and qualitative transformation of the relationship, and is carried on through direct and indirect nurse–patient interac- tions. The nurse in the relationship does not exercise power over or dominate, but rather helps.
DEVELOPMENT AND VALIDATION OF THE
INTERPERSONAL CARING THEORY
The initial step of developing the IC theory stemmed from a qualitative study that focused on the lived experiences of long-term psychiatric patients (Kim, 1989). Using Glaser and Strauss’ (1967) grounded theory approach, which generates theory from data gathered from people living their ordinary everyday lives, the lived experiences of 13 persons with serious mental illness (SMI) who were diagnosed with schiz- ophrenia (9 persons), manic-depressive disorder ( person), and schizo-affective disorder (3 persons) were revealed.The research question asked was, “Would you share with me how you have lived all these years as a person with mental illness?” In their own lengthy but incredible stories, participants mentioned several times such comments as “I was cared for as a human, which made me feel better about myself and value myself, and strengthened me to go forward” or “being cared for motivated me to take care of myself better, to get well.” One person who was diagnosed with schizophrenia 10 years ago said:“ When that nurse helped me with such good caring, I felt good…you know I was cared for! … All of a sudden I felt that I am an important person…, she listened and talked to a patient like a friend…helped me to think about myself…as a worthy human being, not a jerk, you see. Those kinds of feelings were good and made me keep going…I decided to take care of myself better. I started taking my medication regularly. ” Another female schizophrenic patient, diagnosed 14 years ago, stated: “When I was in YS hospital, the nurse who worked in the evenings cared for me so well … I mean, she was wonderful. I was scared and afraid…I could not even eat anything, I was so sick, she sat beside me and talked to me for a while. And she fed me, telling me I would be all right…She gave me a good hug, and
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cared for descriptions were added and factor analysis was done to validate the categories (Table 2). As a result of this statistical analysis, IC actions/behaviors were revised by renaming encouraging as complimenting and adding two additional categories, forgivin g and accepting. The final 10 descriptors of being cared for identified by persons with SMI that emerged were
noticing, participating, sharing, active listening, compan- ioning, complimenting, comforting, hoping, forgiving, and accepting. As shown in Table 2, these 10 categories accounted for 95.6% of variance in the data. Mental illness in Korean culture alters the patient’s life completely; leaving the patient cut off, confused, losing self and unable to function as an independent
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Table 1 ( Continued ) Domain Descriptions of experiences of being cared for Companioning Stays with me, Walks with, Holds hand, Protects, Lets me lean on him/her, Cares for, Holds my hand, Lives life together, Sits beside me whenever I have a need, Spends time together, Includes me in all things, Accompanies me everywhere, Does not forsake, Leads, Holds, Does not forget, Guards, Sustains someone Complimenting Says “well done” or “you accomplished it”, Does not rebuke, Does not pick on weaknesses or shortcomings, Lifts up, Restores lost reputation, Boasts about (me), Happy because of (me) and is delighted, Looks up to, Likes (me), Blesses (me), Builds (me) up, Thanks (me), Being pleased with, Praises, Acknowledges, Rewards (me) Comforting Is not hostile, Is truthful, Treats with kindness and genuineness, Reassures (me), Uses a positive expression, Restores lost reputation, Advocates for someone, Defends (me), Raises up, Comforts, Makes comfortable, Becomes the other person’s strength, Heals, Knows other person’s pain, Surrounds, Making feel comfortable, Becomes advisor, Suffers with (me), Tells joyful news, Rises and helps, Supports, Becomes the other person’s ally, Takes revenge for (me), Worries about (me), Cares for, Protects, Answers requests immediately, Does not scorn, Loves, Serves, Does not judge, Talks with a gentle expression and attitude, Does not rebuke, Agrees with (my) opinions, Treats with generosity, Is considerate of, Does not blame, holds, trusts, Does not forget (remembers me), keeps safe Hoping Opens up the future, Raises out from the current situation, Delivers, Keeps promises, Does not give up but does their best, Provides light to shine, Rewards (me), Is truthful with, Loves (me) unconditionally, Breathes hope/bravery/life in me, Raises (me) up to be strong and firm, Brings joy, Teaches to understand the meaning, Grants wishes, Shows the possibilities, Encourages, Rescues from trouble, Restores (my) spirit, Frees from suffering, Corrects wrongdoings, Cares for, Raises up, Enables to see, Becomes (my) guide, Makes me happy, Makes hopeful, Fills (me) with pleasant thoughts, Stays by (my) side, Does not demand hastily but explains, Systematically observes me and continuously supports me, Has a bright radiant smile for me, Has hope in me, Blesses me, Accepts me, Prays for me Forgiving Not getting angry, Attitude that is gentle and shows remorse, Calmly expressing, Not shouting, Not scolding (or reproaching), Not projecting the anger onto other person or things, Not judging, Expressing “sorry” by holding the person’s hand or making sincere eye contact, Believing in the person Accepting Saying “It’s okay, you did well”, “I see why you felt that way”, Not getting angry, Not making excuses, Concurring with patient, Listening to and acknowledging patient as if in his/her eyes, Hugging, Welcoming with a smile, Accepting with leniency, Not scolding, Being lenient, Believing in the person, Having sympathy for the person
human being with integrity (Kim, 1989, 1998b; Kim et al., 1998).The nurses’ caring actions were very influential to patients’ feelings of worth as a person, with patients reporting that when nurses approached them with warmth, sensitivity, a smile, and a kind and comforting manner, they became less anxious and more stabilized. On the contrary, nurses with a reserved attitude and unwillingness to approach made patients feel distanced, a sharp, short tone of voice and fast-paced talking made patients feel cold, and bureaucratic and stereotypical attitudes of nurses gave patients the impression of being looked down upon (Kim, 1989, 1994, 2000). It was clear that inpa- tients’ experiences with nurses in the psychiatric ward were both positive and negative.
OVERVIEW OF INTERPERSONAL CARING
THEORY
This section includes further details on IC and how it affects persons with SMI, presented to give a fuller understanding of its meaning and impact on per- sons with illness as well as the nurses who care for them. More importantly, it is hoped that such a com- prehensive look at the nurse–patient interaction will contribute to understanding the lives of persons with SMI.
Assumptions of interpersonal caring The underlying assumptions of IC are as follows.
- Human beings grow, live, and achieve self- actualization through caring.
- Every nurse–patient relationship is an interper- sonal situation that requires specific knowledge and skills of caring as well as personal qualities.
- Nursing restores, maintains and promotes health; treating, curing and rehabilitating the patient through IC.
Characteristics of interpersonal caring
- IC is a person-to-person interaction between nurse and patient. An effective interactive mode is through collaborative partnerships. The focus of IC is on helping the patient to build up a sense of worth and self-esteem. Dominating and power over the patient makes him/her more vulnerable to dependency with feelings of humiliation.
- IC should be initiated with genuine love and con- cern toward the person conveying trust and hope. It is compassion-based caring. Compassion is the fundamental mindset of the nurse providing IC.
- IC is not limited or restricted by place, time, or physical contact. It transcends space, time, and culture. IC not only influences the direct and immediate feeling level but also permeates to a deeper level at different times.
- IC involves a holistic approach. Its process involves the wholeness, integrity and connectedness of the person. Patients’ and nurses’ becoming whole is made manifest in thoughts, feelings and behav- iors in the process of wellbeing and becoming healthy. With the lack of a holistic approach, IC loses the richness of its nature.
- IC is expressed through a comprehensive and dynamic mode of communication. IC is possible whatever state the patient is in. Even if a patient is comatose or out of the context of reality, he may be aware of being cared for through IC.
- IC helps the patient focus on his/her self-worth, which is the base for building self-esteem. It is this strengthened self-esteem that is necessary to overcome not only the problematic situation,
Interpersonal Caring — I
Table 2 Factor Analysis
Factors Eigen Percentage Cumulative value of variance percentage
- Noticing 5.3225 18.1 18.
- Participating 4.3240 14.8 32.
- Sharing 3.8846 13.2 46.
- Active listening 3.8743 12.4 58.
- Companioning 3.6493 10.6 69.
- Complimenting 2.3043 8.1 77.
- Comforting 2.2442 7.9 85.
- Hoping 1.2337 4.6 89.
- Forgiving 1.1419 2.7 92.
- Accepting 1.1032 3.2 95.
Interpersonal Caring — I
Table 3
Example Statements and Situational Context of Interpersonal Caring
Interpersonal
Example statements identified by patients
Patient’s feelings regarding domain
Situational context of domain
caring domains Noticing
Recognizing strengths and characteristics,
“I felt good”, “She did not ignore (disregard
Patient feels good
Self-esteem
status in front of others; Taking interest and
or treat lightly) me”, “She treats me as if I
is bolstered
Patient is
finding out about mood, interests, or wishes;
were an important person. It makes me feel
motivated to comply with what
Being observant of changes in appearance
worthy”, “I feel good. It boosts my self
has to be done
Facilitates to
or situation, and responding; Focusing
esteem and makes my life joyful”, “She
apply
noticing
in his own life
attention on the other person; Approaching
recognizes me as a unique individual,
closely with kindness; Making every effort to
different from others. I feel good”, “She
help with the other person’s needs
sees me as a person of integrity”, “She isdifferent from other treatment teammembers, and makes me feel good”, “Shelooked at me with concern to see if I wasall right”, “She explained slowly andcarefully so that I understood”, “bolstersmy self esteem”, “I feel like I am animportant person”, “I am thankful for that”
Participating
Doing something together: shopping, studying,
“I am not feeling left out or inferior”, “It
Being/doing together
Feels not
activities, games, sports, giving an opportunity
makes me recognize that I am not a useless
lonely and feels strengthened
to help with housework; Working together
person”, “It enables me to join in activities
Increased self-confidence
towards a common goal; The process of
and feel a sense of community”, “I’m
Increased hope of
working through something
encouraged because you do this with me”,
accomplishing things
“I don’t feel isolated”, “I am grateful”
Sharing
An unconditional readiness to an openness of
“Feel less stressed and have a lighter heart”,
Feel grateful for believing in,
the inner horizon; Mutually shares thoughts,
“Gives me a new mindset”, “Encourages me
(waiting for, and being a
feelings, dreams, plans, worries, the good and
to speak about my problem (open up my heart)”,
companion to me)
Becoming
bad, and talks honestly about her/him self;
“Nurse shares her innermost thoughts with
able to treat the other person
Experiences common things together; Tells
me…makes me feel close”, “I am grateful
as a close friend
Motivates
some valuable things to the other person
and feel close”, “I feel peaceful”, “Provides
to give and repay
me a new mindset”, “I also can open upmy heart”, “I am grateful and feel close”
( Contd.
)
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Table 3 ( Continued
)
Interpersonal
Example statements identified by patients
Patient’s feelings regarding domain
Situational context of domain
caring domains Active listening
Listening to the other person’s words with all
“I feel great! Because she does not treat me
Less burdened
Wants to
nurse’s heart and genuineness; Trying to
frivolously, but as a person of great
share and discuss innermost
understand each word and its meaning;
importance!”, “Treats me with kindness,
worries
Feel better
Come
Listening intently to the other person’s words,
sincerity, and interest”, “Tries to comfort
to see a possible solution
with all your heart and body; Listening
me”, “Treats me as an important and valuable
earnestly, without a superficial attitude
person”, “I am grateful because nurses takeinterest in me and help me to move”
Companioning
Spending time together; Experiencing life
“Not feeling lonely or anxious”, “Feel trusting
“I’ll help you” or “I’ll be here,
together; Includes me in everything and takes
and glad to have somebody to reside with”,
close to you”
Not lonely or
care of me; Makes me feel as if s/he is with
“Feel secure, as I feel I can lean on her”,
afraid but feel secure and
me everywhere; Am confident that s/he will
“Feel as if I have a guardian that I can
happy
Feel a sense of
accompany me in my life journey; Becomes my
depend on”, “I do not falter because you
community and companion-
friend; Tells me that s/he will help me and be
watch over me”, “Trust develops that you
ship
It empowers me to do
close, and does so; Someone understands what
will accompany me in my life’s journey”
things
my experience feels like to me, walks with mefor a few moments in my journey and its depth
Complimenting
Encourages me by saying thank you for what
“Feel proud of myself”, “I become excited
Increased self-esteem
Life
you’ve done, hang in there, you’re doing well;
and want to do better”, “Feel a zest for life”,
becomes exciting
Want to do
Treats me as an important person in front of
“Want to praise the person who is praising
better
Become positive in
others; Singles out my strengths and recognizes
me”, “The whole world looks beautiful”,
views of surroundings
them; Acknowledges/confirms what I have
“I feel proud of myself and want to do even
Motivated to praise other people
done well and praises me
better”, “I feel I am worthwhile”, “I also
Feel a sense of community
want to praise the person who praised me”
and companionship
Comforting
Saying how hard it must be or how upset you
“I feel as if I have a great ally and I feel
Feel supported because there
must be; Treating the oppressed, the ill person
utterly confident because s/he always takes
is a force that pushes for me
warmly and gently; Warmly and gently leads
my side”, “I find great comfort because there
Develop confidence
Fear
me by the hand; Does not hesitate in
is a force that pushes for me”, “I feel
disappears
extending a helping hand; Does not make
supported, and my worries disappear”,
excuses for others, but is unconditionally on
“I am really comforted that you believe
my side; Does not criticize but shares empathy
in me”, “My heart opens up and worries
for my feelings; Tells me “how hard this must
disappear”
experience and upholding each other. Companioning is extending oneself to the other person through being with (presence). It is the nurse encountering the patient as a unique person being in a unique situation. This is accomplished through words, actions, spirit, and closeness, so that the patient may feel emotionally supported and able to recognize positive aspects. This helps patients to realize that they are neither isolated nor forgotten, but cared for as valuable human beings. Caring communicates through com- panioning or the presence of the caring person in a nursing situation.
Complimenting Complimenting is acknowledging the other person’s strengths and potential and expressing gratitude for it. Such complimenting extends to encouraging, the act of trusting in, affirming, boosting self-confidence, building growth and development, and supporting the person’s strengths. Complimenting supports patients to have courage and a can-do spirit in their daily lives, work, and relationships with other patients, family members, and health care providers. Complimenting helps patients to discover their own strengths and potential by recognizing them, praising good actions, assuring patients that they can do it, encouraging them in areas where confidence is lacking, remind- ing them of good things in the past, and discovering and talking about positive aspects.
Comforting Comforting is taking sides with the other person with an empathizing attitude. It is the action of under- standing and comforting the person in their sadness or pain. It involves the skill of acknowledging the person’s feelings through his/her perspective, of accepting the person, of pulling together his/her greater strength, and instead of defending the third party that caused hurt, becoming an unconditional ally of the hurt person. For example, agreeing without criticism when patients share their problems and emotional difficulties, being on their side, and sup- porting them to take heart. In this way, comforting is a skill of providing what they need, offering addi- tional strength and shelter.
Hoping Hoping means shedding light on possibilities for the person. It is the act of blowing hope into the other person’s life. Examples of hoping include telling patients that today will be a good day, seeking things together that can be done now as preparation for the future, emphasizing that they can do it, expressing the belief that the current situation will improve, and seeking the meaning behind the pain, suffering or disease they face. Hoping rekindles hope for. With hope, it is possible to overcome even the worst difficulties.
Forgiving Forgiving is the act of acknowledging wrong conduct, and seeking leniency with a genuine expression by saying “I am sorry” and asking for forgiveness. In expressing this act, there is no attempt to explain or make excuses. Being forgiven leads to assurance of unconditional acceptance and initiates a sense of relief from anger and humiliation, gratitude, peace- fulness, and growing confidence. Forgiveness thus strengthens respect and trust in the relationship.
Accepting Accepting is an act of acknowledging and receiving the patient as s/he is without any judgment. It con- tains the actions of listening to, understanding, allow- ing, and concurring with the person as if in his/her shoes. Accepting needs willing involvement with a patient with a constant and mutual unfolding of relationship.
CULTURALLY INFORMED INTERPERSONAL
CARING
Previous studies on caring conducted by nurses in Western countries (Brown, 1981; Henry, 1975; Larson, 1984; Paternoster, 1988) identified two dimensions of care: the task (what the nurse does) and the affect (the emotion underlying what the nurse says). These terms seem to be analogous to the care for and care about dimensions of the caring process described by Gaut (1986). Paternoster (1988) defined
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that care for refers to providing for or being respon- sible for another, while care about refers to valuing and bringing quality to the caring process. However, in Korean culture, care/caring implicitly includes not only the task and affective response, but also social, environmental, developmental, and spiritual dimen- sions of the person (Byun, 1989; Kim, 1989, 1997a, 1997b, 2000). Indeed, patient responses, identified throughout the phases of theory development as illus- trated in Table 3, are notable in references to rela- tional and spiritual dimensions, e.g., being recognized as a unique individual, not being alone in the difficult journey of SMI, having a new mindset and lighter heart in viewing the current situation, restoring the spirit, giving real life examples of faith, and focusing all senses towards God. While the domains of IC were culturally derived, IC is not limited to one cul- ture but requires culturally relevant and sensitive nursing to be effective. Thus, IC has great potential to be a relevant and appropriate approach for nurses across cultures. Gaylin (1976, p. 68) stated that to be cared for refers to all aspects of that word: to be taken care of, to be concerned about, to be worried over, to be supervised, to be attended to, and to be loved. The IC theory encompasses Gaylin’s statement, enabling the nurse to initiate and maintain therapeutic rela- tionships with patients and their families in the process of caring. It facilitates people to discern their problems and to recognize possible solutions. It also helps the nurse to assess which intervention will help, or see subtle signs and symptoms of the patient throughout the nursing process. It leads to involve- ment and togetherness with the patient and his/her family members, treatment teams and even resources in the community for better solutions toward a nor- mal life for the patient. In summary, Kim’s IC is the compassion-based therapeutic behaviors built through the collaborative partnership process between nurse and patient that enable the patient to value self worth and esteem, thus motivating him/her to comply with various treatment regimens for optimal wellbeing. In the most significant context of psychiatric nursing situations, IC in its therapeutic process facilitates one’s sense of
self-worth and self-esteem, the inner strength of the patient to move toward wellbeing and normalcy. As an inductive theory building on the subjective experiences of people with SMI, IC may be integrated into the nursing curriculum as a guiding principle. In terms of nursing practice, IC can also benefit patients from the initial stage of illness and onward, in pro- viding support and facilitating education, such as managing side effects of pharmacological therapy and adhering to the treatment plan. However, fur- ther clarification and empirical support for IC in nurs- ing education and with a wider variety of patients must follow before useful applications can be devel- oped. For example, identifying tangible ways to meas- ure and stimulate personal development and growth in the IC domains would facilitate its application in nursing education. Also, questions such as whether the effect of IC varies by patient characteristics, such as cultural background, importance of spiritu- ality, degree of family involvement, or availability of and accessibility to resources within the community that address the uniqueness of the patient, remain to be answered and further clarified. Finally, along with applying IC to nursing education, practice and research, policy level measures to increase public awareness and understanding and establish and mobilize community-based resources along a contin- uum of inpatient care are equally significant as a frame and foundation for IC.
REFERENCES
Boykin, A., & Schoenhofer, S. O. (2001). Nursing as caring: A model for transforming practice. New York: National League for Nursing. Briggs, A. (1972). Report of the committee on nursing. London: Her Majesty’s Stationery Office. Brown, L. (1981). Behaviors of nurses perceived by hospital- ized patients as indicators of care. Unpublished doctoral dissertation, University of Colorado. Byun, Y. S. (1989). The meaning of caring concept_. Journal of Nursing Science_ , 1 , 95–105. Gaut, D. A. (1986). Evaluating caring competencies in nursing practice. Topics of Clinical Nursing, 8 , 77–83. Gaylin, W. (1976). Caring. New York: Alfred A. Knopf.
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