“They Have Our Backs”:

Abstract

The Dance of Caring Persons is a relational model based on the theory of Nursing As Caring. Through the lens of a nursing situation involving a family affected by COVID-19, nursing-theory–based nurse leader behavior in 3 circles of caring is explored. Lessons learned from this experience and analysis can be translated into the practice of nursing leadership in any care environment.

Key Points.

• •The language of nursing is the language of caring.
• •Nursing practice grounded in the theory of Nursing As Caring ensures that all nursing activities are focused on maintaining and supporting an environment of care in which nursing leadership at all levels responds to that which matters in the moment.
• •The focus on coming to know what matters to patients, families, and staff transforms practice and increases nurse satisfaction.

Nurse leaders within health care systems are called to infuse the organization with an understanding of what it means to “live caring.”

Boykin and Schoenhofer¹

The purpose of this article is to share the story of how one team of nurse leaders are living caring creatively in the midst of the coronavirus disease (COVID) pandemic. These nurse leaders practice in a health care organization grounded in a theory-based relational model of caring, the Dance of Caring Persons. In 2006, the nursing professional practice council at St. Lucie Medical Center in Port St. Lucie, Florida, researched and selected Nursing as Caring as their nursing theory for their Journey to Magnet Excellence™. Over the next 2 years, Nursing As Caring was enculturated in the nursing philosophy and principles implemented through bedside shift report and the nursing care bundles. One of several research studies conducted revealed that caring and courage had the highest correlation displayed by the nurses as they nursed their patients.² Two years later, the nurses embraced their colleagues and their community to create a visible circle of caring.³

Because all nursing activity is undertaken for the ultimate purpose of caring for persons, groups, and communities in ways that matter, we set the stage with a story of a nursing situation shared by one of the coauthors (Abby Scott). In this story, you are introduced to nurse leaders living caring in various ways in various positions within the circle of caring involving a man hospitalized with COVID and his daughter who is a nurse.

Nursing Situation

Abby said:

A gentleman I’ll call Larry had been hospitalized for over a month with COVID. He had suffered a stroke 2 years earlier. He had already expressed his wishes for no heroic efforts, and his family was realistic—they just wanted him to be comfortable and happy. My primary contact had been with Larry’s daughter who is a nurse in another state. She would call and we would FaceTime to talk about his care and how anxious she was for him. Being a nurse, she was very aware of the isolation persons with COVID experienced, not being able to see and talk with family. Just thinking about that being my dad, whether I was so far away or in the same state, it would hurt me because I wouldn’t be able to come into the hospital and see him because of the patient restrictions. What comfort it would have given me as a daughter for him to see and talk to me and see my face. I feel like the virus is just isolating us and as caring individuals, emotion and body language are huge, and I feel like we’re limited. Wearing a full gown and a mask and a face shield and gloves, it’s just not a caring persona walking in there, so you do everything you can to show the patient what’s underneath.

I wanted to make it possible for the daughter and father to see and hear each other; however, it was difficult for her to manage the technology to connect with our hospital WebEx system. So while I was FaceTiming with her, I put my cellphone in a baggie and handed it to the primary nurse who facilitated the FaceTime call between father and daughter. It not only helped her, but it helped her father also—seeing her put a smile on his face. I was not in on the conversation, but from what the nurse said, he was very grateful, he had a big smile on his face, and it really brightened his mood.

He had been really struggling, getting short of breath; as I said, he was bedridden from his stroke previously, and in the end, he went to a hospice house that was strictly for persons with COVID that permitted family members to come in. He passed with his 2 daughters and his wife by his side. The daughter I had been in contact with sent us an e-mail as a thanks to us, saying “Thank your staff for the advocacy and support in listening to my concerns and his wishes in getting him to hospice as it’s so difficult to navigate during this pandemic.” With her being a nurse and in the thick of it herself, it was interesting to be able to hear from her and to have her respond back because we don’t get that all the time.

Organizational and Theoretical Frame

The chief nursing officer (CNO) at this health care organization led the nursing staff in creating a guiding philosophy for the nursing department that is grounded in the theory of Nursing As Caring,⁴ the nursing theory that led to the Dance of Caring Persons, a person-centered, caring-focused relational model adopted by the organization.2, 3, 4, 5 Our discussion of nurse leaders involved in the story of the nursing situation will reflect that theoretical perspective; key concepts of the theory of Nursing As Caring are italicized. Further, our discussion follows the circles of caring involving these nurse leaders: clinical nurse coordinator (Abby Scott); nurse director (Lori Smith); and CNO (Nancy Hilton).

Circle of Caring Leadership: Clinical Nurse Coordinator

Abby as nurse leader in the role of charge nurse came to know the patient as a person in the context of a loving family through dialogues with the primary nurse and FaceTime calls with the family member. Through this “coming to know” process, she discerned for this family that which mattered: connecting as family. Members of Larry’s family were recognized as participants in the Dance of Caring Persons. Abby heard the call for nursing as “accept and honor us as caring persons who value family.” Abby’s nursing response was unique to the moment, creative, and appropriately relevant to the call for nursing within this particular nursing situation: she enclosed her cell phone in a plastic bag and passed it to the primary nurse who held it while father and daughter communicated through a video call. In this nursing response, Abby was also cognizant of urgency (circumstances did not favor taking time to make formal arrangements for a call through the hospital’s video-conferencing system) and of safety (enclosing the phone in protective covering). In addition, she was recognizing her administrative role as support to the primary nurse and honoring her commitment to the administrative nursing role as an extension of primary nursing grounded in caring. In the story of Abby, Larry, and his family, we have evidence of caring between nurse and the patient and his family, and enhanced personhood (effectiveness of the nursing response) in Larry’s smile and brightened mood, and in the daughter’s subsequent e-mail expressing gratitude to the staff for their care. The caring between Abby and the family also promoted enhanced personhood (living grounded in caring) in Abby and other nurses involved in this nursing situation. That was evidenced as Abby (clinical nurse coordinator), Lori (nurse director), and Nancy (CNO) shared the story with the primary authors (Anne and Savina).

To clearly illustrate examples of nurse leader caring, we draw on the rich language of Roach’s 5 C’s of caring⁶ and Mayeroff’s⁷ caring ingredients in our discussion. Abby described caring as nursing practice in the COVID unit as it has changed:

• Right now things have shifted so much with COVID that our nurses are focused on getting in, bundling nursing care, getting as much done in as short a time as they can to limit exposure for themselves.

• Then, once they come out of the room, they think about the interaction that they had with that patient, how can they better it the next time they go in…making connection with his family and helping to bring a smile to his face as a man who was in pain and who was suffering, and that was on their mind.

Here, we see the caring expression of alternating rhythm as nurses altered the pace, reflected on their care, and created new ways of connecting; caring for self and caring for other are also evident here.

Reflective practice is a cornerstone of caring in nursing. It provides an opportunity for the nurse to appreciate the beauty and depth of practice. The reflection fosters compassion and increased knowing of self as caring person. Compassion and competence go hand in hand, for as Roach so eloquently cautioned, “While competence without compassion can be brutal and inhumane, compassion without competence may be no more than a meaningless, if not harmful, intrusion into the life of a person or persons needing help.”^{6 (p.4)} Abby explained another change in the pattern of nursing with COVID:

• …another thing that is happening with our patient population is that we have been caring for them for a very long time, where before we would have a patient for 3 to 5 days and then they would move on. With the virus, between day 5 and day 7, our patients actually worsen and then they get into more respiratory distress…they stay for weeks—I think we had Larry for over a month so the nursing staff would really come to know him and having him multiple times throughout his stay, get to know who he was, get to know what he did, which is something our nurses get to do every single shift but then to expand upon knowing just 1 thing about them, knowing multiple things and coming to know them as person and their families. I think that is making a big difference in how we connect with these patients.

Abby makes clear the value of truly being with and listening to the person nursed. Coming to know person as caring is facilitated by the longer stays and offers multiple opportunities for direct invitation to the patient to share that which matters in the moment. This full engagement in practice helps the entire nursing staff know themselves and each other as caring persons as well.

• And if I could facilitate a call with his daughter, that’s what I would do. And when I talk about nursing care now, on a COVID floor, the compassion and the empathy—we’re in the middle of a very scary environment now. The nurses are going in, they are preparing themselves, they are doing everything they can to not bring this home to their family, and it’s changing our environment that we work in every day…when they come out of that room, they are struggling with that, and they want to make that connection, and I think just trying to find new ways to do that. It almost makes it more personal—instead of just updating our whiteboards to show personal connection, they are living that connection and trying to make a difference.

In this glimpse into caring practice, nurse leader Abby shows us how vital it is to be committed to nursing and to be grounded in the knowledge and practice of caring. She ministers to the nurses in her charge daily in ways small and large as she recognizes calls for caring from them and responds effectively. Conscience, another of Roach’s Cs, is clearly reflected in Abby’s story, in her own caring leadership.⁶ Her caring responses are guided by “what ought to be”; what are the concerns of the nurses; and responding to that which matters to their patients.

Circle of Caring Leadership: Nurse Director

The care unit that provides the environment for our discussion has for 3 years earned the highest employment engagement rating in the hospital. Both Abby (clinical nurse coordinator) and Nancy (CNO) attributed that rating in large part to the caring leadership of Lori, the nurse director. Abby related that:

• …our employment score is being driven by what an amazing leader Lori is, and the connections she forms with each of her employees…for a few weeks there, when the numbers were high, she saw that I was taking patients and for her to stop and take a look and drop whatever she had to do, whatever meeting was going to be happening in that moment to help man the desk while I was in caring for patients, the way she can adapt and help us like that means the world. It keeps the rhythm, the flow, the pace, and that’s always been her priority, and also just checking on us. She can gauge someone’s emotions very easily, can see when someone is struggling, and she can lend a hand even when she has her own battles happening…so I think many of her actions and her overall checking on everyone’s well-being—yeah, I wouldn’t be on the same unit for almost 12 years because of anyone else but her.

CNO Nancy added reflections from the wider organizational circle of caring:

• Several times Lori had to be the charge nurse and work 12-hour shifts on the weekend because there really was no other way to provide safe patient care than for her to come in and do that. And so to me, alternating rhythms. Another thing—I think of the courage—Lori calls me or texts me at home at 6:30 in the morning and says “We’ve got to talk about PPE for my staff—we’re looking at the organization’s guidelines, and I want to make sure my staff are protected and I’m doing as much as I can possibly do, and I need for everyone to come up to the floor, and we need to have this discussion.” So the infection control practitioner and I came up to the floor that morning. We really had a heart-to-heart conversation about what the staff felt was needed and even though we had to be kind of careful of how much PPE [personal protective equipment] we were using (I’m the PPE czar, I’ve got to decide the PPE for the entire hospital). Both Lori and Abby had a lot of courage to bring up a delicate situation, but it was not easy for them to kind of step out on a limb and disagree with what I had shared with them before, because they didn’t think it was best for their staff.

Nancy spelled out 2 caring expressions she observed as integral ways Lori lived her nursing commitment to caring leadership—alternating rhythm and courage. Nancy continued to describe Lori as caring leader.

• I think the way Lori nurses her staff is through her presence. She spends a lot of time at the nurses’ station and not in her office. It’s really Lori’s presence—we talk about an open door policy, but it’s so much more than that. She is so present for the nurses. And to me, her listening and her presence is how she nurses her nurses more than anything.

Nurse leader Lori describes in her own words her commitment to caring leadership:

• I would like to say, like Abby has said, I’m there for them and they know that. So I feel like I was facilitating their ability to be present with the patient and provide authentic care—to be really extraordinary and not just do what they have to do and get out of the room quickly. Because that is what you may think nurses might do in the situation, but that’s not the culture we have here. I feel like the way I help the nurses is to support them, and also be a role model. I will never ask anyone to do what I won’t do myself. Although I know that certain things are not my job, I will show them that I am by their side and I’m willing to work hard with them—through the tears and through sweat and through whatever it takes.

Circle of Caring Leadership: CNO

In the Dance of Caring Persons,3, 4, 5 everyone involved in a nursing situation contributes within their own role and in their own ways. It has long been shown and accepted that the culture of an organization is at least supported by, if not originated in, the widest circle of leadership. In our story of nurse leaders who are grounded in caring science and who live informed caring practice, the formal leadership role for nursing and all patient services is exemplified by CNO Nancy. Clinical Coordinator Abby gives an example:

• We’re not there to be heroes. We’re there to be caring and to be empathetic and to make a difference…I don’t know many CNOs who would be up on the unit talking to me for almost an hour and a half regarding my concerns about our organization’s new PPE policy—I don’t. So, thank you!

Director Lori adds:

• I have trust in my leadership that they have our backs. They’re going to make sure we can take care of our patients.

Nancy explains her practice of caring leadership in her role as CNO:

• You’ve heard me say this before—I truly communicate through storytelling…and connections. It’s not a good day for me when I’m not interacting with the staff. On Monday and Tuesday, I had been stuck in my office with no connection, but Wednesday I was able to get out and do a fair amount of rounding and hearing stories from physical therapy and from fourth floor. A physical therapist was so excited that one of her patients hospitalized for COVID and had been on a vent for a week was probably going to be discharged that day. One of the things I really enjoyed doing at the beginning of COVID hospitalizations when the staff was so afraid, was asking them what’s most important to you right now as a person, as a nurse. And it can be something to do with your family and home schooling, or bringing the virus home, or taking care of patients—whatever it is, we took that thought process that we use in caring for our patients of what’s most important and how can I best nurse you. I was trying to nurse the staff by hearing what was their anxiety, what were their safety needs, and what we could as a hospital leadership team do for them. And I make a point of not just going to the nursing units, but by going to all the departments in the hospital with storytelling and finding out what matters most.

It seems clear, in hearing Nancy speak in her own words, that she lives a commitment to the values of the Dance of Caring Person³ as:

• •A person-centered, caring-focused relational model
• •An acknowledgement that all persons have the capacity to care, by virtue of their humanness
• •Commitment to respect for persons in all institutional structures and processes
• •Recognition that each person in the enterprise has a unique valuable contribution to make to the whole and is present in the whole
• •Appreciation for the dynamic, rhythmic nature of the relating, enabling opportunities for human creativity

Expressions of caring that are exemplified in the caring leadership practices by the CNO include humility, courage, trust, alternating rhythm, honesty. Role modeling theory makes it no surprise that these patterns of caring are evident in the other 2 leadership circles discussed here. This nursing situation and the comments of Abby, Lori, and Nancy make clear the meaning of being a true nurse leader. All their intentions, actions, and reflections were focused on living caring for Larry and his family in ways that mattered, and for supporting nurses to nurse. They brought to their roles an awareness of self as caring person that directly influenced the personal nature of care.

Lessons Learned

Through the use of a story of a nursing situation viewed through the lens of the theory of Nursing As Caring,⁵ this paper has offered examples and insights into the value of caring science, caring theory, and caring practice for nurse leaders. One realization that comes through beyond doubt is that the language of nursing is the language of caring. When philosophy, principles and strategies are explicitly formalized in the language of caring, all that we do as nurses and nurse leaders clearly brings espoused core values to life. The demands placed on health care by the COVID-19 pandemic have called for extraordinary responses by nurse leaders. It is obvious in the words of these 3 nurse leaders that a strong foundation in nursing theory fortifies creativity and ingenuity in creating effective nursing responses of caring. Another important lesson is that a commitment to coming to know what matters to patients, family, and staff transforms practice and increases nurse satisfaction. Nursing practice guided by the theory of Nursing As Caring ensures that all nursing activities are focused on maintaining and supporting an environment of care in which nursing leadership at all levels responds to that which matters in the moment. The lessons learned from this experience and its analysis can be translated into nursing leadership in any care environment.

Biography

Anne Boykin, PhD, RN, is a consultant in Mills River, North Carolina. Savina O. Schoenhofer, PhD, RN, is a consultant in Jackson, Mississippi. She can be reached at savibus@gmail.com. Nancy Hilton, MN, RN, NEA-BC, is chief nursing officer, Abby J. Scott, BSN, RN, PCCN, CMSRN, is clinical coordinator, and Lori A. Smith, MSN, RN, PCCN, is nurse director at St. Lucie Medical Center in Port St. Lucie, Florida.