Intention in Nursing Practice

Intention in Nursing Practice

Intention is distinct; it is purposeful (Zahourek & Larkin, 2009) and prompts action. It is defined as “the action of straining or directing the mind or attention to something; mental application or effort; attention, intent observation or regard” (“intention,” n.d.). Intent is akin to intention and can be defined as a noun, adjective, or a verb. All three iterations of intent can be found in the nursing literature. As a verb, intent is defined as “to direct the mind or attention, to give heed, to attend to;” as an adjective “having the mind strenuously bent upon something; earnestly attentive;” and as a noun “the act or fact of intending or purposing; intention, will, inclination” (“intent,” n.d.).

When used in the nursing literature in a manner beyond the dictionary definition, intention is found primarily in holistic theoretical frameworks and in theories focused on caring. Watson (2014) wrote that the caring moment invites intentional preparation. For Watson, nursing practice is intentional as the nurse provides love and holistic care through carative factors that evoke the caritas process (Lukose, 2011). Boykin and Schoenhofer (2015) wrote of their theoretical perspective of nursing as caring and focused on the intention of nursing as a discipline.

Several authors, in addressing various aspects of holistic nursing, offered definitions for intention. McKivergin (2009) in her description of the nurse as an instrument of healing defined intention as “the conscious alignment with creative essence and divine purpose that allows the highest good to flow through a healing intervention or through life itself” (p. 722). Mariano (2009) defined intention as “the conscious awareness of being in the present moment to help facilitate the healing process; a volitional act of love” (p. 49), reiterating the definition posited by Dossey (2009, 2015). For Jackson and Keegan (2009) intention is “the direction of one’s inner awareness and focus for healing” (p. 348). Slater (2009) defined intention simply as “purpose, aim, or objective; the choice to act in a certain way” (p. 648). She discussed the intention exercised by the nurse healer prior to energy healing, denoting it as a purposeful act that affects the healing encounter. These definitions all highlight the fact that intention is a conscious choice of the nurse to act in a way that promotes healing; intention denotes purpose. Therefore, the nurse’s intention may promote healing.

The purposeful, action-oriented nature of intention is reflected in conceptual work. Purnell (2003) in developing a model of intentionality to denote individual praxis conceptualized intention as the ability of the nurse to extend the consciousness into a plan or framework of thought. This is consistent with findings from a principle-based concept analysis that revealed the concepts of intention and intent to be distinct from intentionality (Aghebati et al., 2015). Aghebati and colleagues defined intent and intention as motivators behind action, whereby a nurse acting with intention does so with a purpose, plan, or goal in mind. The importance of the nurse’s intention is underscored by Sayre-Adams and Wright (1995) who argued that what matters most is not what nurses do, but how and with what intent they do it. They were referring to the influx of complementary therapy techniques in nursing practice. Slater (2009) reiterated that it is not the technique itself, but the intention of the nurse toward the person that matters.

Pilkington (2005) noted that both Parse and Watson imply that intention refers to the nurse’s purpose to be in relationship with others; albeit, the nature of that relationship and the focus of intention are quite different. For Parse (2015), the goal of the nurse is true presence, an intentional way of being, unique to the art of humanbecoming that denotes a free flowing attentiveness and intentional reflective love. Watson (2002) wrote of the transpersonal caring-healing practice of the nurse and offered intention exemplar exercises aimed at cultivating and activating the nurse’s intention in order to more fully engage in caring.

The ability to activate intention is implied by da Silva Borges and Soares dos Santos (2013) who wrote that nurses choose their state of mind when administering care, and what they label as conscious attention directly influences their care and the persons’ health outcomes. The mental pattern of the caregiver can have a direct effect on the person receiving the care (da Silva Borges & Soares dos Santos; Slater, 2009). Conscious attention is consistent with the definitions of intention offered earlier.

The ability of nurses to actively choose their intention prior to delivering care is reflected in the construct, manifesting intentions. Smith (1999) engaged in a process of concept clarification to arrive at the essentials of caring from a unitary perspective. Manifesting intentions as an essential of caring was not seen by Smith as having a goal-directed outcome or purpose for directing another, but rather as “creating, holding, and expressing thoughts, images, feelings, beliefs, desires, will (purpose), and actions that affirm possibilities for human betterment or well-being” (p. 21). She described these actions as powerful, possessing the potential to ignite dynamic change.

Others have embraced the essence of Smith’s (1999) manifesting intentions, although they did not label it as such. In reference to the levels of understanding that come when nurses recognize the connection between a person’s life and health, McKivergin (2009) wrote of a shift in the nurse’s attitude from the intention of doing for to being with the person in the moment. Similarly, the idea of exercising intention when providing comfort to a patient is posited in Kolcaba’s comfort theory (Kolcaba, 2015). For Kolcaba, this intention is expressed as the nurse tunes into the patient as a whole person when carrying out activities that provide comfort.

Nursing Practice Implications

The ability of nurses to choose and activate their intention prior to delivery of care is labeled manifesting intentions by Smith (1999), and setting intention by those engaged in holistic therapies (Dossey & Keegan, 2009). In this context, intention in nursing practice is not about what is to be accomplished by the nurse, but rather about being with patients in their experiences. Intention from the view of these authors is value-free and has no attachment to outcomes. Viewing the nurse-patient experience in this manner and letting go of preconceived notions in regard to care can be liberating; patient outcomes are not owned by the nurse and should not be the focus of intentions according to Watson and others.

To more fully attend to intention on the patient, nurses must focus primarily on engaging in personal, inner work. The implication is that setting intention in nursing practice can only be successfully accomplished with attention to self-work. What nurses hold in their hearts matters and makes a difference (Cowling, Smith, & Watson, 2008). Watson (2002) stressed the need for nurses to identify their intentions and wrote about cultivating and activating intention for caring-healing practice. She offered eight intentional practices for nurses that include engaging in daily reflection, mindfulness, gratefulness, and spiritual practices. An abbreviated version of the practices includes: intention one “Upon awakening each day, begin the day with a spiritual practice, even if it is being silent to receive the day and to give gratitude for life” (p. 18); intention two “Honor nursing as the spiritual, spirit-filled practice that it is, keeping in touch with the ancient roots of Nightingale and ancestors across time “(p. 18); intention three “Work to cultivate discernment in your daily life and work: using an intentional awareness of the reflection and a return to the ‘now’” (p. 18); intention four “Make an effort to ‘see’ who the spirit-filled person is behind the patient or colleague” (p.18); intention five “Use whatever presents itself in your life, including the dark and difficult times, as lessons to teach you to grow more deeply into your own humanity” (p. 18); intention six “Fold these intentions into your heart and commit yourself to cultivating a practice of these or other heart-felt intentions as best you can, every day” (p. 18); intention seven “At the end of the day, offer gratitude for all” (p. 19); and intention eight “Create your own intentions and your own authentic practice to cultivate caring consciousness and meaningful intentionalities” (p. 19). Although stemming from her caring theoretical perspective, the need to identify and cultivate intention is applicable to all nurses who strive to practice with intention. Consequently, the selective use by nurses of various healing modalities is encouraged by a number of authors (Dossey, 2015; Dossey & Keegan, 2009; Cowling, Smith, & Watson, 2008; Watson, 2008).

Once nurses have engaged in the proper inner work there are mechanisms that can enable nurses to set intention on the patient. Smith (2015), referred to the works of Watson (2008) and Cowling, Smith, and Watson (2008) who wrote that rituals established in daily nursing practice can provide structure to the process of setting intentions,. For example, frequent hand-washing in care environments provides an opportunity to create a hand-washing ritual whereby nurses can use this time to center (Watson, 2008) and reconnect with their intention. Watson (2002) also suggested a ritual that involves a brief pause before entering the patient’s room. During this pause, nurses focus intention on the patient. Although their work is focused on caring practice, Cowling and colleagues (2008) suggested that rituals connected with shift-to-shift reports could be developed. In select practice settings patient reporting might conclude with a brief meditative mantra or prayer focusing intention on the patient. Morning huddles, a common practice in many acute care settings, could be used to set intention prior to nursing practice (Smith, 2015).

Conclusion

Intention in nursing practice in the nursing literature was explored and clarified. Definitions of the concepts of intentionality, intention, and intent were provided. Intentionality is a philosophical term that underlies a number of holistic theoretical perspectives. Intention and intent are focused on the actions of nurses toward patients and the care provided. Through setting intention nurses consciously choose to be with patients in a life-affirming manner. The need for nurses to engage in self-care to enhance the ability to practice intentionally was addressed. Suggestions for setting intention in clinical practice through the establishment of rituals were offered. Will practicing nurses answer the call to set intention on the patient before initiating care?