Journal of Advanced Nursing, 1998, 28(4), 728±736 Nursing theory and concept development or analysis

Caring and cancer nursing: framing the reality

using selected social science theory
Daniel Kelly MSc BSc RGN NDN Cert Onc Cert PGCE RNT
Senior Nurse (Research & Development), University College London Hospitals,
John Astor House, Mortimer Street, London W1N 8AA, England

Accepted for publication 10 October 1997

KELLY D. (1998) Journal of Advanced Nursing 28(4), 728±736

Caring and cancer nursing: framing the reality using selected social science
theory
Despite the recent interest in caring for both academic and clinical nursing, the
theoretical basis of this concept may appear somewhat elusive as the research
and debate vary widely in their focus. As a result, the available literature may
fail to consider the speci®c contextual issues which characterize caring as it is
understood across different health care settings. Consideration of theory from
disciplines close to nursing, it is suggested, may be useful in understanding the
nature of such `real world' caring. In this discussion the concept of caring
within cancer nursing is explored by drawing on a number of social science and
nursing sources. It is known that cancer provokes unique caring demands for
nurses practising in this area. By examining the context of cancer, it is argued
that effective caring deserves to be recognized as an important clinical variable
which can in¯uence a diverse range of issues such as patient satisfaction or
therapeutic outcome. It is suggested that other nursing specialisms should also
explore the psychosocial dimensions of caring in relation to their own role.

Keywords: caring, cancer nursing, sociological and psychological theory

caring process, de®ned here as an interpersonal phenom-

INTRODUCTION AND RATIONALE
enon which takes place within particular social contexts.
The diversity of debate exploring the concept of caring By focusing on cancer nursing, it will be argued that
suggests that this fundamental nursing concept has been caring in this area is in¯uenced by a range of psycholog-
de®ned from a number of theoretical perspectives. In ical and social factors which are amenable to closer
terms of clinical nursing, it is also clear that different examination.
specialisms view caring in relation to the nature of human
needs being met (Benner & Wrubel 1989, Clarke &
THE NATURE OF CARING THEORY
Wheeler 1992, Bottoroff et al. 1995). Within cancer nurs-
ing the concept of caring is becoming increasingly recog- Recent debates around the concept of caring re¯ect a
nized as an issue worthy of closer examination. This sustained and growing interest in this key concept for
stems from a realization that caring helps to clarify the contemporary nursing. This interest is represented by an
speci®c contribution of nursing within a culture which is expanding nursing literature on the topic and a growing
dominated by biomedicine (Corner 1997). The argument debate which examines this concept from a variety of
presented here is centred on the need for theoretical perspectives (e.g. Benner & Wrubel 1989, Forrest 1989,
constructions of human caring to acknowledge more Swanson 1991, Clarke & Wheeler 1992, Barker et al. 1995,
openly the role of social and psychological in¯uences. Bottoroff et al. 1995, Smith 1995). The speci®c nature of
Within this paper it is suggested that such social caring across different health settings, however, could be
science theory can provide valuable insights into the more closely examined within this literature.

728 Ó 1998 Blackwell Science Ltd

Nursing theory and concept development or analysis Caring and cancer nursing

As a result, theoretical constructions of caring could be withdrawal and a tendency to focus on less stressful
developed which relate more closely to the realities of work, such as routine tasks, in order to protect the
clinical nursing. Social science theory may be particular- individual from acknowledging the reality of their dis-
ly relevant to consider as caring is itself primarily a tress.
psycho-social concept. A range of such theory is offered The seminal work of Menzies (1975) is considered one
here to explore caring within the context of cancer of the most in¯uential in highlighting the demands of
nursing. nursing, and the role which ritual played in protecting
nurses from unmanageable anxiety. As Menzies (1975
p. 284) claimed:
THE CONTRIBUTION OF PSYCHOLOGY
Nurses are confronted with the threat and the reality of suffering
The contribution which psychological theory has contrib-
as few lay people are.
uted to our understanding of human caring is clearly
substantial (Watson 1994). I would argue, however, that In order to function in the face of such threat, Menzies'
this contribution now requires signi®cant reassessment work uncovered a number of common defensive behav-
within the caring debate. The reason for this may become iours such as preoccupation with tasks, a depersonalised
clearer if what is meant by caring in this discussion is approach to patient±nurse interactions, a tendency to
clari®ed: professional caring is characterized primarily by share responsibility for decisions, an avoidance of change
the nature of the interpersonal encounters which take and an idealization of the nursing role.
place between patient and nurse. These encounters focus These ®ndings still have relevance today and highlight
on helping and are carried out as part of the professional the importance of the psychological barriers to caring which
nursing role in speci®c social settings. may be present in particularly demanding nursing roles.
A range of psychological theory is helpful in illustrating Encouraging nurses to explore their personal reactions
the complex nature of such interactions and behaviours. to caring may be one way to acknowledge such demands.
A number of questions may be explored from the psy- This may only be possible, however, if suf®cient emo-
chological perspective including what motivates nurses to tional space is created where a range of feelings can be
care, or how they cope with the emotional demands of the explored as they emerge. As Casement (1991 p. 4) sug-
caring role. gests, the value of applying psychodynamic understand-
The nurse who comes into contact with cancer patients ing to the caring role is that `theory helps to moderate the
on a daily basis, for instance, may commonly witness helplessness of not knowing'.
suffering on a physical, emotional and existential level.
Psychological insights are useful in explaining why
Clinical supervision, caring
people are attracted to this work or how they can be
and self-understanding
helped to cope with working so closely with the threats of
cancer (Smith 1992). Freud's construction of emotional life also suggested that
The ®rst aspect of psychological theory to be considered overwhelming feelings, such as anger or sadness, might be
will focus on the role of emotions in the caring experi- managed more effectively by encouraging the individual
ence. This topic raises a number of challenging questions to develop more self-insight. One way to achieve this is by
including whether caring for people with cancer, or re¯ecting on past experiences; a principle which may
coping with this work, can always be considered an have relevance to nurses seeking more understanding of
entirely conscious process on the part of the nurse. the personal costs of caring in cancer settings.
A con¯ict exists between the rewards of cancer nursing
and the negative consequences of this role which can
Caring as a conscious process
include emotional exhaustion. The importance of this
The role of the unconscious in motivating human actions con¯ict has been acknowledged for some time in the
was ®rst explored by Freud (1936). He suggested that cancer nursing literature (Yasko 1983, Brown Ceslowitz
many choices and behaviours in life, including the desire 1989, Hanson 1994).
to care for others, may be shaped by psychological One strategy which has been suggested to help nurses
processes outwith our conscious knowledge. Similarly, cope with the demands of caring for seriously ill patients
the emotional responses to everyday life, such as fear or is clinical supervision. Through a process of re¯ection
anger, may be controlled by being repressed or projected and self-insight, clinical supervision offers an opportuni-
onto the people or events around us. Thus, the sense of ty to develop an understanding of how the individual
emotional pain or threat, which is likely to be encoun- manages the demands of nursing practice (Boyd & Fales
tered when caring for people with life-threatening condi- 1983, Butterworth & Faugier 1992)
tions such as cancer, may be contained at the unconscious Clinical supervision may also prove helpful in explor-
level by the nurse. This, in turn, may lead to emotional ing related issues, such as co-dependency or over-in-

Ó 1998 Blackwell Science Ltd, Journal of Advanced Nursing, 28(4), 728±736 729
D. Kelly

volvement, which can develop between the nurse and Motivational aspects of caring
patient in cancer settings (Hardy & Park 1996).
Psychological theory into human motivation provides a
number of useful insights to help clarify this aspect of
Therapeutic caring caring. Over 40 years ago, by combining the essential
features of motivation with the nature of human needs,
On the other hand, the therapeutic possibilities of the
Maslow produced a theory of the biopsychosocial con-
nurse±patient relationship have long been recognized as a
tinuum against which motivation could be understood
unique dimension of professional nursing. The early and
(Maslow 1954). By suggesting the role of higher order
valuable work of Hildegard Peplau (1952), for instance,
motives, such as self-actualization, Maslow also con-
acknowledged this in relation to patient empowerment in
®rmed the importance of primary survival needs. This
psychiatric settings. She also suggested that the everyday
theoretical construction of motivation can be seen to have
encounters between nurse and patient could be recog-
had a profound impact on the development of nursing
nized as important opportunities to facilitate greater
theory.
levels of independence and self-awareness.
The impact was perhaps most obvious in helping to
As a result of the growing importance now being placed
conceptualize the complexity of caring responses needed
on self-awareness within caring roles generally, the ther-
to address patients' different levels of need.
apeutic potential of effective communication has itself
In later work, Hoffman (1981) suggested that a key issue
been re-examined (Morse 1991).
of psychological importance lay in understanding the
Reciprocal styles of communication, for instance, op-
human capacity to produce an empathetic response to
erate from the premise that both parties may assist each
another's need. Hoffman proposed that a series of cogni-
other's understanding of a dif®cult situation through a
tive stages existed through which the nurse must pass
process of mutual learning. This approach has particular
before such a response could be expected.
relevance in cancer settings where the professionals may
According to this theory, the nurse must ®rstly become
have few certainties to offer the patient. Treatment
aware of the other's distress and then some psychological
choices, for example, could be explored more openly
mechanism is `switched on' to produce an affective
through an honest exchange of views. Marck (1990 p. 51)
response. This `switching on', it was suggested, was
helps to clarify the therapeutic value of this approach
dependant on a number of variables such as the emotional
below:
capacity of the nurse to deliver the caring response
Where the reciprocity is therapeutic, however, the authentic required. Negative in¯uences which reduced this capac-
exchange occurring transforms `the cost of care' with shared ity could include unresolved personal demands or a
experiences that produce positive growth for both nurse and prolonged exposure to the distressing stimulus. Thus, the
client. Insights that freely ¯ow between the nurse and the client capacity and the motivation to care were claimed to be
guide the decision-making process to those outcomes that are limited in humans; a theme which has been explored in
best suited to the unique individuals concerned. more depth elsewhere (Gaut 1986, Benner & Wrubel 1989,
Brown Ceslowitz 1989).
Caring and empowerment Insights gained from this work may be especially rele-
vant to those seeking to encourage caring within the
The psychological importance of the relationship which
nursing workforce. Applying motivational research to
exists between nurse and patient has also been explored
cancer care settings, for instance, could highlight new
by humanistic theorists such as Rogers (1990 p. 40):
research questions such as whether effective nurse-caring
a helping relationship might be de®ned as one in which one of can be linked to symptom control or even disease outcome.
the participants intends that there should come about, in one or
both parties, more appreciation, more expression, more function-
al use of the latent inner resources of the individual. Environmental and behavioural in¯uences
Rogers, however, also acknowledges the dif®culties in Psychological research into environmental factors has
achieving this ideal situation. Translating this approach indicated that a signi®cant reduction in human motiva-
to all clinical nursing encounters involving patients with tion can result from a lack of sensory stimulation (Crow
cancer is clearly unrealistic. Its relevance, however, may 1980). This ®nding could be applied to examine the
lie in suggesting a useful framework upon which to working environments of nurses. By changing clinical
reassess the importance of effective communication with- routines, adapting the physical environment or introduc-
in cancer care. Before this may be achieved, however, ing new styles of management and leadership, the satis-
more emphasis needs to be placed on how nurses can be faction and motivation of staff may be increased which, in
helped to cope with witnessing the suffering of others so turn, could motivate them to care more effectively
closely (Kleinman 1991). (Mans®eld et al. 1989, James et al. 1990, McMahon 1990).

730 Ó 1998 Blackwell Science Ltd, Journal of Advanced Nursing, 28(4), 728±736
Nursing theory and concept development or analysis Caring and cancer nursing

Understandings gained from behavioural research can subtle differences could signi®cantly in¯uence the ®nd-
also provide additional understandings into the psycho- ings and limit their generalizability to other settings.
logical nature of caring. Early research by Watson &
Rayner (1920), for instance, suggested that fear, anger and
Psychological insights and the speci®c needs
love were the three core emotions underpinning human
of children
behaviour. It is still possible to link one of Watsons' core
emotions (love) with interventions which have come to Finally, psychological theory into human development
represent caring within nursing practice. has demonstrated how the nature of caring needs may
Gentle stroking, for example, was demonstrated by change across the life span. Erikson (1963), for instance,
Watson to act as a positive reinforcement in infants when emphasized the importance of caring, in the form of
employed by a parental ®gure. Similar behaviours when attachment and emotional support, for children to grow
employed within health care settings (such as therapeutic and achieve emotional and physical maturity. Maladjust-
massage) have become increasingly popular in recent ment was suggested to result from the emotionally cold or
years and have been subjected to evaluation to determine unstimulating environments which characterized some
their therapeutic bene®ts (Simms 1986, Wilkinson 1995). institutions at that time. Applying this theory to nursing
Whilst the primary aim of such research was not to has resulted in more awareness of the need for appropri-
demonstrate a link with Watson's theory of emotional ate caring as a component of child health services, for
motivation, it is worth noting that a number of holistic both the well and sick child.
interventions, such as therapeutic massage, have become It also stresses the in¯uence of impersonalized or
symbolic of supportive and caring-centred practices uncaring attitudes and how they may hamper the intel-
(Ferrell-Torry & Glick 1993, Trevalyan 1993). lectual and emotional development of children with
chronic illnesses, including those living with cancer. By
building on this developmental theory, it has become
Caring and the `deserving' patient
clearer how families can be helped to adapt to the caring
Interactional studies over the past two decades have needs of a child with cancer (Kna¯ & Detrick 1986, Eiser
questioned nurses' perceptions of diverse patient groups. et al. 1994, Birenbaum 1995).
Such perceptions may play an important role in dictating
whether certain patients may be considered more worthy
Summary
of a caring response. For instance, the concept of the
`good' or `bad' patient was described in the work of Kelly The insights which cancer nursing can gain from psycho-
& May (1982). The perceived needs of speci®c patient logical theory can be seen to be wide-ranging when the
groups in psychiatric settings were highlighted by Pro- nature of this role is considered. Whilst the above
fessor Altschul (1972) and the role which prognosis discussion is clearly open to further development, evi-
played in altering the attitudes of professionals was dence for the important role which psychological pro-
examined by Simpson et al. (1979). cesses play in shaping the nature of human caring has
been highlighted. In the following section the debate will
be widened further by exploring the role of social and
Nurse and patient constructions of caring
contextual in¯uences on caring.
Studies which have questioned the relevance of caring to
cancer nurses themselves also provide a useful contribu-
SOCIOLOGICAL AND CONTEXTUAL
tion to this discussion. Larson (1986), for instance, after
ISSUES: CARING AS WORK
questioning a sample of cancer nurses, suggested that
listening, touching, talking and adopting an individual Within this section it will be argued that the professional
approach to patient's needs represented examples of caring caring expected of the cancer nurse should be considered
in practice. Whilst each of these could be considered caring against the context of its occurence. Caring takes place
skills applicable to any patient group, they do appear to mainly within institutional settings; a fact which is highly
capture the essential nature of skilled cancer nursing. signi®cant as the role of patient and nurse in such
Interestingly, however, cancer patients' views of caring environments are shaped by strong social expectations.
may differ from those of their nurses, as Larson's study For example, one of the main expectations in cancer
also suggested. Instrumental (or technical) knowledge settings is that nurses can successfully negotiate caring
was actually rated most highly by patients; a ®nding relationships whilst also being involved in the adminis-
which reinforces the need to be alert to the assumptions tration of aggressive and toxic treatments to people who
which professionals may themselves have acquired about are already seriously ill.
the concept of caring. The culture in which research into This role con¯ict has been discussed by authors such as
caring is conducted, however, also needs to be noted as Kitson (1988) who calls for nursing to distinguish (by

Ó 1998 Blackwell Science Ltd, Journal of Advanced Nursing, 28(4), 728±736 731
D. Kelly

models, theories or direct action) between striving to `get the importance of positivism and rationality in medical
the patient better' and helping the patient to `feel better'. practice (Larson 1978). Recently, however, the impor-
This dilemma is present in the daily demands on the tance of the social interaction between doctor and patient
specialist cancer nurse when the treatments are notori- has been re-examined. For example, the importance of
ously arduous, the numbers of patients are increasing and more personalized and supportive interactions in helping
the presence of sophisticated technology is becoming people cope with a cancer diagnosis have been explored.
more common. Such caring±focused interactions, it is claimed, can even
Kitson (1988 p. 31) illustrated the dilemma further in serve as therapeutic interventions in their own right
the following statement: (Molleman et al. 1984, Suchmann & Mathews 1988).
Questioning the importance which is placed on cure
It is as if the nursing profession, pleased at the idea of having
rates by medicine and science has also added to the
penetrated the world of objectivity and science, remains incapa-
debate about how, as a society, we view the needs of
ble of the extra effort of imagination needed in order to endow
cancer patients (Jecker & Self 1991, Faithfull 1994, Corner
patient care with its own particular and personal character,
1997). Concentrating on scienti®c research to the detri-
which is the quality it lacks. It appears that we do not know how
ment of supportive services may mean that patient's
to care nor do we think that helping people feel better is as
needs are under-researched and unmet. The caring ethic,
important as getting them better.
therefore, has special relevance for those seeking to
Whether or not this argument is completely accepted, it develop effective and humane cancer services which are
is apparent that social expectations do exert powerful balanced against the contribution of scienti®c and treat-
pressures on the nurse. These may combine to obscure the ment advances.
realization of a caring philosophy which Kitson advo-
cates.
The value of caring for nursing
The lack of natural science paradigms for much of current
Organizational in¯uences on caring behaviours
nursing practice suggests the need to re-evaluate the
Seminal work by Goffman (1961) described the complex importance of caring and its relationship to nursing
nature of institutions, such as hospitals, and the speci®c expertise (Benner & Wrubel 1989, Taylor 1992). The value
social climates existing therein. These settings were of skilled caring could also be explored to con®rm the
characterized by the presence of complex social rituals unique contribution which nursing makes to specialist
which discouraged a personalized approach to clinical healthcare settings. Exploring the relationship between
practice; ®ndings which were con®rmed in the work of caring and disease outcomes, for example, could provide
Menzies (1975). Indeed, the ability to display detachment valuable evidence when the professional status of nursing
and to minimize any overt demonstrations of caring or is questioned.
concern for an individual's suffering may come to be Furthermore, recognizing that caring is itself a valuable
valued as measures of stoic professionalism within nurs- social resource supports the claim that nursing values
ing. Other social expectations, such as `getting through should be incorporated more openly into health care
the work', may also take precedent over connecting with policy. Maintaining the centrality of caring within the
the patient's suffering (Melia 1982). Melia went further to theory base of nursing, however, will be essential if such a
suggest that a clinical incident, initially perceived by the goal is to be achieved (Barrett 1992).
novice nurse as capable of evoking a caring response, may
gradually be viewed as routine due to desensitization and
Learning from lay carers
socialization to the values of the professional nursing
role. Comparative studies into the settings of cancer care, or
These ®ndings remain important and are clearly worthy interventions available for patients' families with speci®c
of more attention. This is especially true in relation to needs, provide further insights into the social dimensions
how caring, both in a practical and theoretical sense, can of caring (Hall 1991). The role of the nurse as professional
most usefully be incorporated into nurse education pro- carer, for instance, has been compared to that of the
grammes to emphasize its importance. skilled lay carer (Kitson 1987). Qualities implicit in the
lay caring relationship such as commitment and the
personalization of task-orientated activities have, in turn,
Caring and the status of nursing
been used as markers to measure the quality of profes-
Social factors may also in¯uence the perceived relevance sional caring. Whilst the lay carer may exhibit desirable
of caring to other occupational groups within health care. caring behaviours due to kinship or friendship, the nurse
Scienti®c discoveries which led to the professionalization must somehow nurture these attitudes whilst operating
of medicine in the 19th century, for instance, established in a professional role within the institutional setting

732 Ó 1998 Blackwell Science Ltd, Journal of Advanced Nursing, 28(4), 728±736
Nursing theory and concept development or analysis Caring and cancer nursing

(James 1992). The essence of lay caring therefore may be The emerging voice of the patient
worth examining further to determine its therapeutic
The changing expectations of patients themselves have
potential.
led to demands for caring to be characterized by individ-
uality rather than the `sameness' of institutionalized
Power and abuse of caring relationships routines (Morse et al. 1991, McNammara et al. 1994).
This growth in patient empowerment, noticeable recently
The abuse which can occur within caring relationships is
within cancer care, has also resulted in a new awareness
a topic requiring more serious exploration in cancer
of the unclear boundaries which exist between paternal-
circles. This is especially important in relation to the
ism and caring when dealing with vulnerable patient
in¯uence of corporate bodies, such as the pharmaceutical
populations (Gibson 1992).
industry, within cancer care (Moss 1989).
The powerlessness of patients in the hospital environ-
ment may have an important bearing on how decisions Summary
are reached regarding the use of trial therapies or between The above discussion illustrates how diverse the range of
different treatment options (Madder 1997). This power- social theory is which can be used to broaden the caring
lessness raises a number of rather uncomfortable moral debate. The issues raised demonstrate how complex the-
questions, including whether caring roles are used to oretical constructions of caring may also need to become
persuade people to participate in clinical trials or consent when the realities of the social world are considered.
to treatments which may, in reality, not be in their best
interest.
CARING AS A RESOURCE

Stigma and caring Nursing is primarily a `sharp-end' discipline which is

required to advance its body of knowledge whilst provid-
The social stigma surrounding some cancer diagnoses, ing services within de®ned philosophies and the con-
such as cervical cancer or AIDS-related tumours, suggest straints of clinical situations (Buerhaus 1986). Current
that certain patient groups may have speci®c care needs economic pressures also place demands on the nurse's
arising out of their increased risk of social isolation. Such ability to deliver caring within environments which are
isolation may stem from the socially constructed attitudes increasingly concerned with cost control. These are not
which their diagnosis has acquired (Newcomb 1963, inconsiderable demands and it is suggested that the
Ferriman 1986). Caring in such situations may require caring literature has yet to examine them in suf®cient
the professionals to recognize the consequences of this depth. Some of the issues which arise when caring is
isolation and to develop interventions to minimize its recognized as a health care resource are explored in the
impact. Whilst the concept of individualized care seems following section.
to have become a somewhat ubiquitous slogan within
healthcare, this needs to be supported by evidence to
Dilemmas inherent in cancer care
show how needs of those patients experiencing stigma-
tized illness can best be met. Treatment choices which are led by ®nancial constraints
often strike nurses as cold blooded; particularly in cancer
nursing where life expectancy may be directly affected by
Gender and caring
the choice of therapy and its outcome (Stoll 1988).This
The question of gender has also been the subject of dilemma is further compounded by the moral dilemmas
considerable social research examining, in particular, role inherent within the randomization process of the clinical
expectations in relation to caring practices (Gore 1984, trial, accepted as the `gold standard' approach for evalu-
Waerness 1987). There is considerable potential to ex- ating cancer treatments (Lurie & Shapiro 1987).
plore this issue further. The topic is especially relevant It is becoming increasingly imperative that cancer nurs-
when the gender of the nurse and patient are examined in es contribute to these debates and acquaint themselves
relation to the caring experience (Boughn 1994, Davies with the economic and ethical dimensions of the issues
1995, MacDougall 1997). involved. The nursing perspective may, for instance, focus
Studies which have explored gender-roles have re- primarily on the ethic of caring to be considered within
vealed attitudes such as men being expected to display such moral dilemmas (Seedhouse 1994).
stoicism in the face of illness and requiring less caring
support than women (Archer & Lloyd 1982). A possible
Can caring be measured?
consequence of such attitudes is that resources and
research dedicated to men's health have largely been Attempts have been made to model and quantify caring in
lacking (Bradford 1995). terms of the processes which characterize the nursing role

Ó 1998 Blackwell Science Ltd, Journal of Advanced Nursing, 28(4), 728±736 733
D. Kelly

rather than concentrating only on tasks or competencies. can be seen to provide valuable insights into this complex
Valentine (1989 p. 29), for example, suggested a model of theoretical concept, now accepted as central to nursing's
caring which belief system. Before a ®nal conclusion is offered on this
issue, however, the value of caring to the everyday practice
consists of psychological elements (which are affective or cogni-
of nursing requires some additional consideration.
tive in nature) put into action in an interaction which is either
social or physical in nature.
The centrality of nursing practice
This model presents caring as a ®nite resource (like any
other) for those involved in health care policy. It is Any theoretical examination such as this must extend
perhaps most useful in stressing that caring is a skill beyond semantics to re-emphasize the importance of
which can be actioned by the nurse. Thus, the image of caring as a fundamental concept for cancer nursing
being `kind' or `nice' is not enough Ð caring is being practice, as well as nursing generally. The importance of
rede®ned here as a central component of health care encouraging further debates into the nature of caring can
where nursing makes the most signi®cant contribution. be seen to be even more relevant within the increasingly
harsh world of cost-driven health care. The same is true in
cancer nursing where more questioning views of the role
Towards a more functional construction
of caring are beginning to emerge (Corner 1997).
of caring
Caring essentially is a practical concern; appreciated by
Models such as Valentine's (1989) might also be used to patients and admired by nursing colleagues especially
develop instruments in the future to assess the presence when pressure of work seem to make its realization
of caring across different clinical settings, or to recognize increasingly dif®cult. Given the importance of this con-
what factors prevent its occurrence (such as a lack of cept to emerging philosophies of nursing, it will continue
appropriate resources). to require further exploration from both a theoretical and
Modelling caring in this way may then be useful to practical perspective. Cancer nursing is a specialism
practitioners who are seeking ways to capture the limita- where the importance of human caring can be witnessed
tions to caring within their roles. Whilst such models may in the everyday nature of clinical practice. The psycho-
be criticised as reductionist or over-simplifying a partic- logical and social in¯uences, discussed here, are also
ularly complex phenomenon, their strength can perhaps evident in the daily demands of this role.
best be judged against their `®ttedness' for the real world
of nursing work. Perhaps the ®nal judgement of their
Expanding the basis of caring theory
worth should be left to practitioners themselves.
As nurses often function at a level below which Whilst the recent expansion of published debate on caring
resource allocation is decided, rede®ning caring as a is welcomed, there is a need to incorporate insights from
resource may help to identify those factors which in¯u- psychological and social theory to clarify the nature of
ence the likelihood of its occurence. Resources, for caring within specialized nursing roles. Failure to ac-
instance, may then be directly implicated in preventing knowledge their in¯uence on caring may lead to a
nurses and patients from realizing their full potential. situation where theoretical debates remain largely di-
Attempts to conceptualize and model caring may also vorced from the complexities of clinical practice.
help in refuting claims about its nebulous nature. The Furthermore, by appreciating the complexity of caring,
health economist and the nurse, for instance, whilst a better understanding may emerge of related issues, such
sharing broadly similar values, may seem to speak differ- as the concept of suffering, which is also relevant for
ent languages when caring is being discussed. A challenge cancer nursing to consider.
which faces cancer nursing at present is the need for As a result of the argument presented here, it is
substantive evidence to support the importance of caring proposed that theory from the social sciences is useful
in clinical practice when questions of quality or effec- and could be more closely incorporated into future
tiveness are being considered. constructions of caring. Acknowledging these social and
Whilst any research which sets out either to cost or psychological dimensions may also serve to encourage
measure caring will face considerable methodological and more relevant nursing research questions which focus on
conceptual challenges, it is clear that only through such the functional role of caring within health care. It is
evidence will its importance be established. suggested that such research may also prove to be more
useful, and more relevant to practice, as a result.
Further bene®ts of drawing on theory from the social
CONCLUSION
sciences is that it is already available and can help both
This discussion has explored the multidimensional nature academic and practising nurses make sense of caring as a
of caring in relation to cancer nursing. The social sciences `real-world' issue.

734 Ó 1998 Blackwell Science Ltd, Journal of Advanced Nursing, 28(4), 728±736
Nursing theory and concept development or analysis Caring and cancer nursing

In cancer nursing, such `real-world caring' is shaped by Faithfull S. (1994) The concept of cure in cancer care. European
a number of complex psychological and social variables Journal of Cancer Care 3(1), 12±17.
which, once considered, can help to clarify the demands Ferrell-Torry A.T. & Glick O.J. (1993) The use of therapeutic
of this role. The social sciences may also prove useful to massage as a nursing intervention to modify anxiety and the
perception of pain. Cancer Nursing 16(2), 93±101.
other nursing specialists seeking to clarify the essence of
Ferriman A. (1986) Promiscuous men cause cancer. The Observer.
caring within their own practice.
18 June.
Forrest D. (1989) The experience of caring. Journal of Advanced
Nursing 14(10), 815±823.
References
Freud S. (1936) The nature of anxiety. Norton, New York.
Altschul A. (1972) Patient±nurse interaction: A study of interac- Gaut D.A. (1986) Evaluating caring competencies in nursing
tion patterns in an acute psychiatric ward. Churchill Living- practice. Topics in Clinical Nursing 8(2), 77±83.
stone, Edinburgh. Gibson (1992) A concept analysis of empowerment. Journal of
Archer J. & Lloyd B. (1982) Sex and Gender. Penguin, Harm- Advanced Nursing 16(3), 354±361.
ondsworth. Goffman E. (1961) Asylums, Doubleday, New York.
Barker P.J., Reynolds W. & Ward T. (1995) The proper focus of Gore W.P. (1984) Gender differences in mental and physical
nursing: a critique of the `caring' ideology. International illness: the effects of ®xed roles and nurturant roles. Social
Journal of Nursing Studies 32(4), 386±397. Science and Medicine 19(2), 77±91.
Barrett E.A.M. (1992) Response: a uni®ed perspective within Hall M. (1991) Hospice nurses: caring support for caregiving
nursing. Nursing Science Quarterly 5(4), 154±155. families. Cancer Nursing 14(2), 63±70.
Benner P. & Wrubel J. (1989) The Primacy of Caring: Stress and Hanson EJ (1994) An exploration of the taken-for-granted world
Coping in Health and Illness. Addison-Wesley, Menlo Park, of the cancer nurse in relation to stress and the person with
California. cancer. Journal of Advanced Nursing 19(1), 12±20.
Birenbaum, L. (1995) Family research in paediatric oncology. Hardy S. & Park A. (1996) Supervision and professional practice.
Journal of Paediatric Oncology Nursing 12(1), 25±38. In Mental Health Nursing, Principles and Practice (Thomas B.,
Bottoroff J.L., Gogag M. & Engelberg-Lotzkar M. (1995) Comfort- Hardy S. & Cutting P. eds), Mosby, London, pp. 133±145.
ing: exploring the work of cancer nurses. Journal of Advanced Hoffman M.C. (1981) Is altruism part of human nature? Journal of
Nursing 22(6), 1077±1084. Personality and Social Psychology 40, 121±137.
Boughn S. (1994) Why do men choose nursing? Nursing and James N. (1992) Care ˆ organisation + physical labour +
Healthcare 15(8), 406±411. emotional labour. Sociology of Health and Illness 14(4), 488±
Boyd E. & Fales A. (1983) Re¯ective learning: key to learning from 509.
experience. Journal of Humanistic Psychology 23(1), 99±11. James I., Milne D. & Firth H. (1990) A systematic comparison of
Bradford N. (1995) Men's Health Matters. Vermillion Press, feedback and staff discussion in changing ward atmosphere.
London. Journal of Advanced Nursing 15(3), 329±336.
Brown Ceslowitz S. (1989) Burnout and coping strategies among Jecker N.S. & Self (1991) Separating care and cure: analysis of
hospital staff nurses. Journal of Advanced Nursing 14(7), 553± historical and contemporary images in nursing. The Journal of
557. Medicine and Philosophy 16, 285±306.
Buerhaus P.I. (1986) The economics of caring: challenges and Kelly M.P. & May D. (1982) Good and bad patients: a review of
opportunities for nursing. Topics in Clinical Nursing 8(2), 13± the literature and a theoretical critique. Journal of Advanced
21. Nursing 7(2), 147±156.
Butterworth T. & Faugier J. (1992) Clinical supervision and Kitson A. (1987) A comparative analysis of lay-caring and
mentorship in nursing. Chapman & Hall, London. professional (nursing) caring relationships. International Jour-
Casement P. (1991) On Learning from the Patient. Routledge, nal of Nursing Studies 24(2), 155±165.
London. Kitson A. (1988) On the concept of nursing care. In Ethical Issues
Clarke J. & Wheeler S. (1992) A view of the phenomenon of caring in Caring (Fairbairn G. & Fairbairn S. eds), Avebury, Aldershot,
in nursing practice. Journal of Advanced Nursing 17(11), 1283± pp. 21±31.
1290. Kleinman A.K. (1991) Suffering and its professional transforma-
Corner J. (1997) Beyond survival rates and side effects: cancer tion: towards an ethnography of interpersonal experience.
nursing as therapy. Cancer Nursing 20(1), 3±11. Culture, Medicine and Psychiatry 15, 275±302.
Crow R. (1980) Sensory deprivation Ð recognition of its effects in Kna¯ K. & Deatrick J.A. (1986) How families manage chronic
caring for patients with cancer. In Cancer Nursing Update Ð conditions: an analysis of the concept of normalisation.
Proceedings of the Second International Conference on Cancer Research in Nursing and Health 9(3), 215±222.
Nursing. Balliere Tindall, London. Larson M.S. (1978) The Rise of Professionalism: A Sociological
Davies C. (1995) Gender and the professional predicament in Analysis. California University Press, Los Angeles.
nursing. Open University Press, Bristol. Larson P.J. (1986) Cancer nurses perceptions of caring. Cancer
Eiser C., Parkyn T., Havermans T. & McNinch A. (1994) Parents Nursing 9(2), 86±91.
recall on the diagnosis of cancer in their child. Psycho- Lurie N. & Shapiro M. (1987) Is the pursuit of scienti®c truth
Oncology 3(3), 197±203. always the greatest good? Ethical issues in health care research.
Erikson E.H. (1963) Childhood and Society. Norton, New York. Clinical Research 35(6), 517±520.

Ó 1998 Blackwell Science Ltd, Journal of Advanced Nursing, 28(4), 728±736 735
D. Kelly

MacDougall G. (1997) Caring-a masculine perspective. Journal of Rogers C. (1990) On Becoming a Person Ð A Therapists View of
Advanced Nursing 25(4), 809±813. Psychotherapy. Constable, London.
Madder H. (1997) Existential autonomy: why patients should make Schafer A. (1985) The randomised clinical trial; for whose
their own choices. Journal of Medical Ethics 23(4), 221±226. bene®t? IRB: A Review of Human Subjects Research 7(2), 4±7.
Mans®eld P.K., Yu L.C., McCool W., Packard J.S. & Vicary J.R. Seedhouse D. (1994) Fortress NHS, A Philosophical Review of
(1989) The Job Context Index: a guide for improving the `®t' The National Health Service. Wiley, London.
between nurses and their work environment. Journal of Ad- Simms S. (1986) Slow stroke back massage for cancer patients.
vanced Nursing 14(6), 501±508. Occasional paper. Nursing Times 82(13), 47±50.
Marck P. (1990) Therapeutic reciprocity: a caring phenomenon. Simpson I.H., Back K., Ingles T., Kerckhoff A. & McKinney J.C.
Advances in Nursing Science 13(1), 49±59. (1979) From student to nurse: a longitudinal study of sociali-
Maslow A.H. (1954) Motivation and Personality. Norton, New sation. University Press, Cambridge.
York. Smith P. (1992) The Emotional Labour of Nursing: How Nurses
Mc Nammara B., Waddell C. & Colvin M. (1994) The institution- Care. Macmillan, London.
alisation of the good death. Social Science and Medicine Smith A. (1995) An analysis of altruism; a concept of caring.
39(11), 1501±1508. Journal of Advanced Nursing 22(4), 785±790.
McMahon R. (1990) Power and collegial relations among nurses Stoll B.A. (1988) Balancing cost and bene®t in the treatment of
on wards adopting primary nursing and hierarchical ward late cancer. Lancet 1(8585), 579±580.
management structures. Journal of Advanced Nursing 15(2), Suchmann A.L. & Mathews D.A. (1988) What makes the doctor-
232±239. patient relationship therapeutic: exploring the dimensions of
Melia K. (1982) Tell it as it is. Journal of Advanced Nursing 7(4), medical care. Annals of Internal Medicine 108(1), 125±130.
327±335. Swanson K.M. (1991) Empirical development of a middle range
Menzies I. (1975) A case-study in the functioning of social theory of caring. Nursing Research 40(3), 161±166.
systems as a defence against anxiety. In Group Relations Taylor B.J. (1992) From helper to human: a reconceptualisation of
Reader (Coleman A. & Bexton W.H. eds), Rice Institute Pub- the nurse as a person. Journal of Advanced Nursing 17(9),
lications, Spring®eld, Virginia, pp. 281±312. 1042±1049.
Molleman E., Krabbendam P.J., Anngas A.A., Koods H.S., Sleijfer Trevalyn J. (1993) Massage. Nursing Times 89(19), 45±47.
D.T. & Verney A. (1984) The signi®cance of the doctor Ð Valentine K. (1989) Caring is more than kindness. Modelling its
patient relationship in coping with cancer. Social Science and complexities. Journal of Nursing Administration 19(11), 28±34.
Medicine 18(6), 475±480. Waerness K. (1987) On the rationality of caring. In Women and
Morse J.M. (1991) Negotiating commitment and involvement in the State: The Shifting Boundaries of Public and Private.
the nurse-patient relationship. Journal of Advanced Nursing (Showstack-Sassoon A. ed.), Hutchison, London, pp. 207±234.
16(4), 455±468. Watson J. (1994) Applying the art and science of caring. National
Morse J.M. & Johnson J.L. (eds) (1991) The Illness Experience: League for Nursing Press, New York.
Dimensions of Suffering. Sage, Beverley Hills, California. Watson J.B. & Rayner R. (1920) Conditioned emotional reactions.
Moss R.W. (1989) The Cancer Industry, Unravelling the Politics. Journal of Experimental Psychology 3, 1±14.
Paragon Press, New York. Wilkinson S. (1995) Aromatherapy and massage in palliative
Newcomb T.M. (1963) Persistence and regression of changed care; does it improve patient's quality of life? International
attitudes. Long range studies. Journal of Sociological Issues 19, Journal of Palliative Care 1(1), 15±20.
3±14. Yasko J.M. (1983) Variables which may prevent burnout experi-
Peplau H.E. (1952) Interpersonal Relations in Nursing. Putnam, ences by oncology clinical nurse specialists. Cancer Nursing
New York. 6(2), 109±116.

736 Ó 1998 Blackwell Science Ltd, Journal of Advanced Nursing, 28(4), 728±736