Family Caring and Caring in Nursing 1

Family Caring and Caring in Nursing Jacinthe 1. Pepin

Knowledge concerning family caring is developing within the caregiving literature while knowledge of caring is growing separately in the nursing literature. Both nurses (identified with caring) and family carers (identified with caregiving) experience a division of the affective and the instrumental dimensions of caring. Moreover, a historical perspective reveals that caring in nursing and family caring are faced with a common dilemma: caring in a society that undervalues caring. It is suggested that nurses, in the process of reconciling the dimensions of caring for their profession, consider family caring as a unified experience as well.

* * *

C aring and caregiving are viewed by scholars as two distinct areas of knowledge development. Publica- tions related to each have mushroomed at approxi- mately the same pace since 1975. The caregiving literature has been developed mainly by gerontolo-

gists, nurses, sociologists and social workers to describe the care given by family members to elderly or chronically ill persons with the consequences for primary caregivers. The caring literature has been furnished by nurses, feminists of various disciplines and philosophers. Anthropological, phenomenological and nursing perspectives have been used mainly to describe caring in the nurse-client relationship; psychological and feminist perspectives portray caring as one of women’s ways of expression, while ethics and philosophy perspectives have provided more general perspectives.

The purpose of this paper is to examine the professional conceptualization of caring and caregiving. Given the two bodies of literature, one wonders if caring and caregiving are conceptualized as two separate entities and if this separation best represents the reality experienced by both nurses and family carers. Considering the importance attributed recently to caring and family caregiving in the nursing discipline, it is worth examining the two concepts together. In fact, reflecting on the assumptions upon which nursing knowledge is being built is an essential part in furthering nursing knowledge.

The approach will first consist of a brief review of the meanings and expressions of caring through nursing and feminist history texts. Second, writings that explicitly deal with conceptions and terminology of caring and of caregiving for the elderly will be examined considering the two dimensions of caring described by Graham (1983) as love and labor.

The visibility of caring as a concept and a phenomenon has rapidly increased in the nursing literature. In a desire to identify nursing’s unique perspective, Leininger (198 l), Watson (1979, 1985) and others have distinguished between cure and care. They identify caring as “the essence of nursing” and “the central and unifying domain for the body of knowledge and practices in nursing” (Leininger, 1981, p. 3). Watson (1979) suggested a

balance of science and humanism in nursing in order to form the science of caring. Benner and Wrubel(1989) proposed the expert practice of nursing based on the primacy of caring as an alternative approach to health promotion, restoration and curing practices.

The concepts of caring, nurturance and connectedness in women’s lives have been studied in parallel from a feminist perspective. Gilligan (1983) noted that women “not only define themselves in a context of human relationships but also judge themselves in terms of their ability to care” (p. 17). According to Miller (1976), women’s sense of self is related to the cultural organization of women’s lives around the principle of serving others. In our society, learning to nurture is part of the experience of being a woman (Eichenbaum & Orbach, 1983).

The interest in family caregiving arose with the growing number of situations in which an impaired elderly or a chronically ill person is taken care of by a family member at home (Brody, Poulshock & Masciocchi, 1978). With chronic diseases predominate over acute diseases and with the continued growth of the elderly population, especially the growth in number of persons over 85 years old (Botwinick, 1984; Bowers, 1987), the preoccupation with the care of those who are impaired became urgent. Attention has been focused on the consequences of caregiving on family members.

As we will see, the caring literature has been developed on a conceptual level and brings philosophical perspectives on human caring to the understanding of caring in nursing and caring in women’s lives. The caregiving literature, however, has grown differently, mainly through atheoretical research. The urgency dictated by the present home-care situation called on researchers

Jacinthe I. Pepin, RN, MSc, Epsilon Xi is Assistant Professor, Faculty oi Nursing, University of Montreal and PhD Candidate, School of Nursing, Universityof Rochester, NY. Supported in part bythe UniversityofMontreal and the Canadian Nurses Foundation. The author thanks Dr. Bethel Powers and Dr. Catherine Kane, University of Rochester, for their thoughtful review ofapreviousversionofthis manuscriptandThomasC. Barnwell foracareful review of the present version. Correspondence to Faculty of Nursing, UniversityofMontreal, P.O. Box 61 28, Station A, Montreal, Quebec H3C 317 Canada.

Accepted for publication November 19,1991,

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Family Caring and Caring in Nursing

to explore different questions such as: What are home caring situations really like? What are the stress factors associated with certain types of caregiving? What are the physical and emotional costs of caregiving and their extent? There is little mention of caring throughout the caregiving literature and vice versa. Writ- ers on caregiving have recognized the physical, emotional, social and economical support that family members provide (Brody et al., 1978), but they have addressed mainly the role, the tasks and the consequences of caregiving. The focus of research in the 1980s was on measurement of concepts such as burden (Mont- gomery, Gonyea & Hooyman, 1985; Montgomery, Stull 8z Borgatta, 1985; Poulshock & Deimling, 1984), caregiver function (Gallagher, 1985) and caregiver strain (Robinson, 1983). The orientation of the 1990s is on theory development (Mancini, 1989).

Caring has been described by Graham (1983) as consisting of the two dimensions of love and labor. According to Graham (1983) the two dimensions cannot be separated: they are interde- pendent and they nourish one another. “Caring defines a specific type of social relationship based upon both affection and service, ... two interlocking transactions” (p. 28). However, as we examine the history of caring by family members and by nurses, we observe that caring has come to be viewed as consisting solely of the love aspect. The following discussion will provide insight into how the division between love and labor in both familial and institutional settings occurred.

A Historical Perspective

Home Versus Institution Families have traditionally provided care for their members

during life related experiences (giving birth, taking care of a sick or an elderly family member, death). With the development of medical science, the place of care has changed from the home to the institution disrupting the flow of knowledge about health- and life-related experiences from one generation to another. According to Ehrenreich and English (1978), “...the experts’ authority rested on the denial or destruction of women’s autono- mous sources of knowledge: the old networks of skill-sharing, the accumulated lore of generations of mothers” (p. 4). With the growth of scientific and technological knowledge the types of caring activities have changed. More precisely, the “scientific” or “specialized” aspect of caring has been separated from the more human, “non-scientific” aspect. According to Keller (1985), our view of science is based on the division between objective fact and subjective feeling. Further, the association of objectivity with power and masculinity has been valued for its remove from the world of women and love.

In the transition of health care from home to institution, knowledge of lifehealth-related experiences has not been re- placed within the family but rather, the sources of information and the services (caregiving) have been surrendered to professionals. Families have been almost completely excluded from the institutional care while the compassion, the presence, the comfort and sometimes the most intimate care (caring) has remained the family’s responsibility. Family caring has been stripped of its experiential knowledge while the personal, non-technical and

humanistic aspects of institutional care have remained underde- veloped.

Professional Versus Non-professional Carers Through the history of caring, women have been the predomi-

nant players. Women in general and nurses in particular played the first act of home care together. In 1860, Nightingale wrote not only for nurses but for all women who had personal charge of the health of others at home. Nursing has evolved from what has been known as women’s work (Reverby, 1987). The content and cultural meaning of nursing have been altered by the development of medical science and practice, the growth of health services and women’s changing prospects and life choices, especially their increasing participation in the public world of paid labor (Melosh, 1982). “As medical care became more complex and more tied to hospitals, nursing gradually separated from the sphere of women’s domestic work and became estab- lished as paid work that required special training” (Melosh, 1982, p. 3).

Many nurses initiated and participated in the dissemination of sanitary practices in private homes. The first mission of public health nurses, aside from the care of the sick, was to spread knowledge about physical and mental hygiene (Buhler-Wilkerson, 1985). Often nurses demonstrated proper care to the available women of the family (Reverby, 1987). However, under the influence of the technological era, critical care came to be what is more valued, and with scientific growth, professionalization has been idealized. With a desire to take a place in the professional world, it became imperative that nurses’ work be separated from women’s work. Gradually, nurses worked more closely with physicians in institutional settings and shared with them the “specialized” knowledge. Whether or not they partly relin- quished their advocacy role and humanistic root remained a question.

Invisibility and Division of Caring Denied professional and scientific roles, caring was considered

a woman’s traditional role and chief contribution to society through nurturance and nursing. As nurses separated their work from women’s work, women at home continued to provide caring (personal care, health care) to family members. Mainly in the form of mothering, caring at home did not carry as much value as work outside the home. Over time, caring became invisible work (unrecognized, unpaid and under studied) in an increas- ingly industrialist and technological society oriented toward mass productivity (Colliere, 1986). The invisibility of caring developed as love and labor came to be seen as separate dimensions of caring, experienced in different settings (home versus institutions and work places), with labor coming to predominate over love.

It has been said that nursing has reflected the ambivalence of our society concerning womanhood and caring (Fagin & Diers, 1983; Reverby, 1987). Although rooted in women’s work, nursing in institutions became ‘‘routinized” as it was partly deprived of the affective aspect of caring and of the shared knowledge of experience. In striving for recognition, nurses faced the necessity of emphasizing the work aspect of caring running the risk of

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rejecting altruism and caring itself (Reverby, 1987). It was only through helping relationships and nurse-client interactions that nurses kept sight of the affective aspect of caring. The recent interest of nursing in caring marks a return to the feminine perspectives and to a more balanced view of caring.

In contrast, caring at home was viewed mainly as affective. Women’s work has been deprived of its knowledge and of its original worth: it became sentimentalized and privatized. Like nurses, women were expected to take on caring more as an identity than as work, expressing altruism and love (Reverby, 1987). In caregiving literature, it is evident that the responsibility of care for the elderly has fallen on women (Brody, 1981; Soldo & Myllyluoma, 1983; Stoller, 1983; Stone, Cafferata & Sangl, 1987) and has not been viewed as shared in the family. When compared with men, women offer significantly higher levels of in-home assistance to the elderly person (personal care, household tasks or simply being there) (Horowitz, 1985a; Stoller, 1983).

Conceptual and Terminological Issues So far, caring comprises two dimensions described by the

following words: 1) Love, the affective aspect, encompasses emotion, touch, compassion, presence, comfort, altruism, nurturance and connectedness; it refers to the identity; 2) Labor, the work or the service aspect, encompasses knowledge, role, task and function; it refers to the activity. Graham (1983) said:

the experience of caring touches simultaneously on who you are and what you do ... On the one hand, the experience of caring and being cared for is intimately bound up with the way we define ourselves and our social relations. On the other, caring is an integral part of the process by which society reproduces itself and maintains the physical and mental health of its work force ... It suggests that caring demands both love and labor, both identity and activity, with the nature of the demands being shaped by the social relations of the wider society (pp. 13-14).

Curiously, the affective aspect, which was for a long time relegated to the family realm, is now represented in the literature on caring which studies mainly professional caring. In parallel, the work aspect, formerly relegated to professionals, is now represented in the literature on family caregiving.

Caring Literature

It seems that caring by individuals, family members or friends, in their day-to-day life has not been of concern aside from studying other cultures (Leininger, 1981, 1985; Watson, 1985) and from distinguishing between professional caring (mainly nursing) and non-professional caring (Green, 1987/88; Kitson, 1987). In the latter case, a different terminology has been used. When a family member, friend or significant other, who is not a professional caregiver, is referred to as the person who cares, the expressions used are lay-caring (Kitson, 1987); lay nursing (Orlando, 1987), informal caring (Goodman, 1986; Nolan & Grant, 1989), caretaking (Anderson & Elfert, 1989) andcaregiving (Archbold, 1983; Bowers, 1987; Bunting, 1989; Given, Stommel, Collins, King, Given, 1990). Throughout this paper, the expression family caring is used.

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If caring has sometimes been perceived as synonymous with nursing (McFarlane, 1976), the concept of caring has been analyzed mainly “within” nursing (Ray, 1981) or “as applied to” nursing (Griffin, 1983). Within the nursing literature, while the work aspect of caring was recognized, the affective aspect has been emphasized. According to McFarlane (1976), “caring signifies a feeling of concern, of interest, of oversight with a view to protection” (p. 189). Using historical and contemporary sources of information in nursing and philosophical works about human relationships, Ray (198 1) udderlined a recurrent theme: “caring refers to growth or mutual self-actualization” (p. 27). However, in a philosophical analysis, Griffin (1983) maintained that “activities” and “attitudes and feelings” are complementary aspects of caring in nursing (p. 291). Caring is a rich concept reflecting respect, attunement, personal worth and other aspects of growth, as well as performance of activities through which the relationships occur. In a recent analysis of conceptualizations of caring in nursing (Morse, Solberg, Neander, Bottorff, Johnson, 1990; Morse, Bottorff, Neander, Solberg, 1991), one of the five identified categories focused on the work aspect of caring, the practical or technical concerns (therapeutic intervention) while the other four emphasized the affective aspect, the humanistic concerns (human trait, moral imperative, affect, interpersonal interaction). Linkages were made among the five conceptualizations reflecting the recognition by nurses of two dimensions of caring.

In general, nurses agreed with Graham’s (1983) view of caring which comprises two interlocking dimensions, namely love and labor. The affective aspect of caring was described by nurses as: their primary motivation; the enhancement of the quality of the nurse-client relationship; and a way of being a nurse. In an effort to restore the balance between the affective and the instrumental aspects of caring, the nursing literature in the last 15 years has reemphasized the affective aspect as the essence of nursing. The emphasis on the affective aspect however was sometimes perceived as widening the gap between the theory and the practice of nursing, the academic and the clinical worlds. Two recently proposed conceptualizations of caring in nursing present system- atic attempts at integrating the two dimensions: Koldjeski (1990), connects the humanistic qualities of caring with the scientific nursing actions, and Ray (1989), bridges the elements of a bwwcratic S ~ I U ~ U R with what was recogIllzed as caring elements.

“The caring role is central to nursing but shared with patients themselves, their relatives and with other health professions” (McFarlane, 1976, p. 187). Kitson’s (1987) major focus was on a comparative analysis of professional and non-professional caring relationships. She argued that they share the same attributes: respect, commitment, knowledge and skills. “Where lay caring and professional care differ is in the extent to which professional carers set themselves up as a specialist service meeting the care needs of those who are either unable to care for themselves or others in an acceptable manner” (Kitson, 1987, p. 164). Ray (1981) did not distinguish between professional and non-professional caring. She gave to caring in nursing the attributes of caring outside of a professional context: giving and receiving, co-presence as a mystery, oblative love and growth of both partners through effective dialogue. In contrast, Orlando (1987) insisted that a distinction be made between “lay nursing”


and professional nursing. Interestingly, she used the term nursing rather than caring. “Everybody does a lot of lay nursing,” she wrote. They “nurse themselves, or get nursed, or nurse others, a lot, if not most of their lives” (p. 408). In a sense, she brought back Nightingale’s idea: “Every woman is a nurse” (Nightin- gale, 1860/1969, p. 3) but at the same time, she was very precise about what, for her, was a necessary distinction. Since caring is shared with others, this discussion takes place in the context of clarifying the nature of nursing.

Caregiving Literature

The conceptual issues of caregiving arise differently. For the purpose of research, caregiving has mainly been defined and measured in terms of the amount and extent of help provided to a family member (Horowitz, 1985b). The concern has been with the specific tasks of providing care for a parent, often referred to as activities of daily living (Bowers, 1987). Horowitz (1985b) presented a hierarchy of instrumental assistance: 1) Tasks that required intermittent help (shopping, transportation, financial management); 2) In-home assistance that required regular time commitment (meal preparation, household help); and 3) The most intensive and intimate caregiving assistance (personal and health care).

Through analysis of qualitative data, two nurse researchers, Archbold (1981, 1982) and Bowers (1987), have proposed broadening the scope of caregiving. First, Archbold (1981,1982) identified the following modes of parent-caring by women: 1) Care provision, the performance of care activities; 2) Care management, the delegation and management of activities; and 3) Care transfer, the “complete transference of care to another caregiving agent” (p. 38) or mainly to an institution. Archbold (1982) defined parent-caring as “the provision of needed services to functionally impaired elderly parents” (p. 5) and, thus, was concerned with the work aspect of caring. Her exploratory study of the impact of parent-caring on the lives of 30 women revealed the following care providers’ strategies: direct assistance of the parent with activities of daily living; manipulation of the environment to facilitate the daily activities of the parent; and in some situations, modification of the parent’s behavior. The managers’ strategies with caring included obtaining and retaining services to assist the parent with activities of daily living, major environmental manipulation and parent education to facilitate independence. Finally and most important for this group was the provision of direct psychological and social support as part of the strategies of parent-caring.

The focus of Archbold’s (198 1, 1982) conceptualization was still on the activities or tasks but family caring was reorganized to comprise care management as well as care provision. It seems that only the care managers’ strategies of caring included an affective aspect through the provision of psychological and social support. The affective aspect of caring was not addressed in the categorization of the care providers’ strategies. Archbold’s discussion showed that the care providers gave everything they could (time and energy) mainly through physical care. This leaves little time for the psychological and social needs of the parent and leaves no time for the care providers themselves.

However, in searching exclusively for behaviors of psychological and social support, other expressions of the affective aspect of caring will remain overlooked.

Second, Bowers (1987) questioned the focus on tasks to represent caregiving. She interviewed 27 parents and 33 of their offspring. Through grounded theory method, she came to reconceptualize caregiving activities by meaning or purpose rather than by tasks or behaviors. Analysis of data revealed five conceptually distinct, yet overlapping categories of caregiving: anticipatory, preventive, supervisory, instrumental (more com- monly recognized as caregiving) and protective. Four of these categories “are not observable behaviors but are processes crucial to intergenerational caregiving and to an understanding of the experience of intergenerational caregiving” (p. 20). Anticipation of possible needs of a parent, prevention of possible injuries or complications and supervision of care given to the parent were all categories of caregiving defined by their purposes. The protective category was experienced as the most difficult and important type by the caregivers interviewed. Among other things, it involved protection of the parent’s identity and the parent-child relationship. “The centrality and invisibility of protective caregiving was repeatedly confirmed by the caregivers’ experiences” (Bowers, 1987, p. 25). This was particularly true when the aged parent had a mild to moderate cognitive impairment.

Data from Bower’s (1987) study introduced what is recognized as caring into the caregiving literature. Caregiving is redefined “by the meaning or purpose a caregiver attributes to a behavior rather than by the nature of demands of the behavior itself’ (p. 24). The affective aspect of caring (concern, protection, respect) was evidenced within the caregiving categories, primarily anticipatory, supervisory and protective caregiving. The description of the caregiving categories by Bowers (1987) fits the philosophical discussion of the caring experience by Griffin (1983) where the affective aspect of caring is complementary to the activities performed.

Conclusions and Implications for Nursing

The experiences of family caring and of caring in nursing encompass both the affective and the instrumental aspects. Caregiving has been conceptualized mainly as an activity or a set of tasks, while caring has been conceptualized mainly as commitment, respect and protection toward the cared for, as well as an activity. However, as Bowers’ research reinforces, the affective aspect recognized as caring is attached to the caregiving experience. Current nursing research in family caring for the elderly continues to define caring mainly by its work aspect (Bunting, 1989; Given et al, 1990; Killen, 1990). Inspired by the conceptualizations of caring in the nursing literature, nursing research could bring to family caring a balanced view of family caring. Reciprocally, works on family caring could help clarify nurses’ conceptualizations of caring and participate in the development of theories.

Nursing has been striving for proper recognition in the scientific world. It has been done by letting go of the woman’s world and its love connotation and by creating a distance between the

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professional and the non-professional carers. Now, if a reconcili- ation of the dimensions of caring in nursing is on its way, will the distance between the carers still be necessary? A clear focus for the discipline of nursing is important, but collaborative work with family carers is equally important in understanding caring in various health situations and in elaborating a caring community. Collaborative research and practice, empowering both family and nursing carers, could be a sign of a better integration of caring as central to nursing, and, perhaps, a sign of maturity of our discipline.

Caring is not reducible to either one of the two dimensions, whether expressed in a professional or a non-professional context. It is important to understand the experience of caring as a whole in a way that will avoid the exclusion of one or the other dimension.

For what we mean by “understanding” or “comprehension” is seeing how parts fit into a whole and then realizing that they don’t compose the whole, as one assembles a jigsaw puzzle, but that the whole is a pattern, a complex wiggliness, which has no separate parts ... Parts exit only for purposes of figuring and describing and as we figure the world out we become confused if we do not remember this all the time. (Watts, 196611972, p. 90).

It only remains for nursing, which is in the process of reconciling the two dimensions, to consider family caring as a unified experience as well. gEQ

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