The caring encounter in nursing

Abstract

Background:

The concept ‘encounter’ occurs in caring literature as a synonym for dialogue and relation describing deeper levels of interaction between patient and nurse. In nursing and caring research, the concept ‘caring encounter’ is often used without further reflection on the meaning of the concept. Encounters are, however, continuously taking place in the world of caring, which calls for a clarification of the concept.

Objectives:

This study is an analysis of the concept of caring encounter in nursing from the patients’ and nurses’ point of view.

Method:

Rodgers’ evolutionary view guided the concept analysis within the theoretical perspective of caritative caring.

Data sources:

Peer-reviewed articles in English published between 1990 and 2014 were retrieved from the databases: CINAHL, PubMed, Web of Science, ScienceDirect (Elsevier), Springer Link, Primo Central (Ex Libris) and Academic Search Premier (EBSCO) using different combinations of encounter, caring and nursing as keywords. In all, 28 articles related to caring encounters were included in the analysis after applying inclusion and exclusion criteria.

Ethical considerations:

This study was conducted according to good scientific practice.

Results:

Four antecedents to the caring encounter are found in the nurse’s way of being: a reflective way of being; openness, sensitivity, empathy and ability to communicate; confidence, courage and professionalism; and showing respect and supporting dignity. The attributes are as follows: being there, uniqueness and mutuality. As a consequence, the caring encounter influences both patient and nurse.

Discussion and conclusion:

The caring encounter is an encounter between two equal persons where one is nurse and the other is patient. They encounter in mutuality, in true presence, and both have allowed themselves to be the person they are. The results clarify the conceptual differences between relationship and caring communion as the mutuality in the caring encounter differs from the dependence on the other pronounced in the relationship.

Keywords

Caring encounter concept analysis nursing theory of caritative caring

Introduction

The concept ‘encounter’ between patient and nurse is often found in nursing literature without a further reflection on the meaning and attributes of the concept. As a result, the concept seems ‘watered down’ and overused which means that its signification may be lost.

The general contextual frame for ‘encounter’ is found in nursing theories. Ever since the mid-twentieth century, the concept has been employed by nursing theorists. It is interesting to note, however, that nursing theorists use the concept with slightly different meanings. Paterson and Zderad¹ view ‘encounter’ and ‘interaction’ as equal, and they interpret nursing as a dialogue with a specific interaction with the patient. Both patient and nurse have a goal or expectation in mind. Even in a spontaneous interaction where a nurse and a patient have met by chance, there is an implicit expectation that the nurse will extend herself in a helpful way if the patient needs assistance.

Travelbee,² in turn, describes ‘encounter’ as something more fundamental that precedes nursing care. She is pointing out that nursing is accomplished through human-to-human relationships that begin with the original encounter, which progresses through stages of emerging identities.

As caring persons, we, according to Travelbee,² honour the bond between self and other. The ultimate knowledge is that we are related to one another and that harmony is present as we live out caring relationships. We live caring from moment to moment, while competency in knowing self as caring and as living caring grows throughout life. Boykin and Schoenhofer³ describe the consequences of the encounter and point out that the encounter between the nurse and the person being nursed gives rise to a phenomenon called ‘caring between’, within which personhood is nurtured. In the nursing situation, a direct invitation opens to true caring in the relationship between the nurse and the patient. For Martinsen,⁴ the encounter is an abstract space created in closeness and distance between individuals. Martinsen refers to person-oriented professionalism, which means having an understanding of one’s position within a specific life context that demands something from oneself as a nurse, and which means placing the other at the centre; the caring encounter’s orientation towards the other. She also refers to an untouchable zone that must not be interfered with in encounters with the other. But the untouchable zone is united with its opposite, which is openness, where closeness, vulnerability and motive have their correct place. Thus, openness and the untouchable zone constitute a unifying contradiction in a caring encounter.

Focus on caring in the encounter is set in Ford’s⁵ study ranging from 1990 on the experiential dimensions of the concept. Here, a new era of the qualitative studies of dimensions in the lived encounter begins. Ford⁵ concludes that caring is a way of being in which nurses give something of themselves and also receive something in return. These caring encounters do not take place, Ford says, every time nurses and patients meet, however. Such encounters might be called uncaring encounters.⁶ In a caring encounter, the nurse who is perceived as caring is competent, genuinely concerned and respects the patient as a person. Openness in the communication with patients is emphasised. Nurses should also know their own limits and ask for help if needed. A caring nurse is able to see the person behind the patient. This reciprocal trust and the caring relation mean that nurses are close to yet at a distance from patients.⁶ Patients are accepted the way they are. According to Takman and Severinsson,⁷ nurses can, in the encounter, attain an increased personal knowledge and understanding of the patients’ ways of showing their experienced suffering. In the encounter, patients can express their feelings and nurses are open and attentive with an ability to understand. Trust for nurses is reinforced when patients are placed at the centre with the intention that they should feel calm and confirmed in the encounter.

As Bakke and King⁸ argue, each caregiving task gives the nurse an opportunity to create a moment of healing through the human encounter. A shared humanity makes a genuine encounter possible in which the patient and the nurse meet as human beings.⁹ This encounter affects both the nurse and the patient for a long time after the actual caring relationship has ended.¹⁰

Nåden and Eriksson¹¹ discuss the difference between confirmation and encounter. Confirmation means being seen, heard, understood and taken seriously. The characteristics of confirmation are also seen in the encounter, and confirmation is a prerequisite for an encounter. Yet, confirmation may be present even if an encounter does not take place. It is the uncontrollable in the encounter that distinguishes it from the confirmation. The art of caring is highlighted in the encounter, where the nurse’s role and function to a certain extent becomes secondary. In the encounter, the two parts are first and foremost two human beings, who through this encounter are given an opportunity to grow.

From the overview of previous research, it is possible to conclude that the phenomenon of encounter has concentrated more on experiences of different encounters, and on the encounter as a part of interaction. As nursing theorists claim, we see the centrality of a caring encounter in the patient’s world and therefore also the necessity for conceptual accurateness. We have not been able to trace any concept analysis on ‘encounter’ and therefore assume that a clarification of the concept through a concept analysis could contribute to a clarification of the relations to the related concepts.

Aim

The aim of this study is to discover dimensions and meaning content in the concept ‘caring encounter’ through a concept analysis within an articulated theoretical perspective. From our theoretical perspective grounded in caring science, the caring encounter is more than a scheduled appointment or a clinical nurse–patient encounter. The encounter has a deeper meaning in terms of patient care, as it is caring in itself.

The theoretical perspective has its starting point in Eriksson’s theory of caritative caring.¹² Eriksson points out that the human being is dependent on the other being in a relationship, where human beings are interrelated to an abstract and/or concrete other in communion. The caring communion is a form of intimate connection that requires an encounter in time and space, an absolute lasting presence. It is characterised by intensity and vitality, warmth, closeness, rest, respect, honesty and tolerance. Caring communion is seen as the source of strength and meaning in caring. The human being longs to be in communion but at the same time wants to be unique.

Method

The concept analysis is a modification of Rodgers’¹³ method adding an articulated theoretical perspective as a starting point and a frame for interpretation. We also looked at the theoretical perspective or framework in the articles chosen for the analysis as the concept ‘caring encounter’ appears more colourless and more as an outer form without a theoretical grounding.

The analysis began by identifying the concept of interest, ‘caring encounter’, instead of the concept of ‘meeting’, which tends to be perceived more of an outer frame, while ‘encounter’ refers to an inner dimension which is in accordance with our theoretical perspective. The analysis proceeded by choosing the setting and sampling articles in nursing and caring research through search in databases. The next step was identifying the relevant aspects of the caring encounter through identification of attributes, antecedents, surrogates and related terms. Consequences and exemplars were also identified. The analysis was conducted in a thematic manner, with emphasis on identifying the content in each component by content analysis, following Rodgers’ structure. Interpretation of the results through a theoretical perspective provided theoretical implications and directions for further enquiry.

Data sources

The search was carried out in the databases CINAHL, PubMed, Web of Science, ScienceDirect (Elsevier), Springer Link, Primo Central (Ex Libris) and Academic Search Premier (EBSCO) using the keywords ‘encounter’, ‘caring encounter’ and ‘nursing’ in different combinations. The search was limited to refereed journals in the English language in the years 1990–2014. The search resulted in 40 articles of relevance for the topic. Our selection criteria were encounters between nurses and patients in articles written in Scandinavian languages and English. Of these 40, 28 articles from 2001 to 2014 were included in the actual concept analysis. The articles that were excluded dealt with encounters with close friends, family members and relatives or encounters regarding existential questions and death. Of these, 9 of the included studies were conducted from a nurse perspective (nurse, midwife, nursing student), 15 were carried out from the perspective of patients and in 4 articles both patient and nurse perspectives were used.

Results

Theoretical frameworks/assumptions are found in 12 of the 28 analysed articles. Halldorsdottir’s theory of caring and uncaring encounters is used in Wiman and Wikblad’s¹⁴ study which attempts to apply the theory to emergency care and is referred to by Friberg et al.¹⁵ Paterson-Zderad’s theory is referred to by Lundgren,¹⁶ Snellman et al.,¹⁷ Westin and Danielson¹⁸ and Wiman et al.,¹⁹ where different aspects and terms in the theory are used. Friberg et al.¹⁵ refer to Parse, saying that the concepts can be related to the human-becoming theory. Westerholm²⁰ examines encountering the other from the perspective of Parse’s theory as a whole. Merleau-Ponty gives studies a lifeworld perspective.^{15,16,21
–23} Säll Hansson et al.²⁴ are looking for the phases in Travelbee’s relationship model in their study of the meaning of experiences in encounters. The concepts of suffering and health in Eriksson’s caritative theory are used in Lundgren¹⁶ and Vatne and Nåden,²⁵ while the conceptual model in Sjöstedt et al.²⁶ reflects the theory. An interesting paradox occurs as only few of these studies use the theories as starting points or frames of reference to the actual study.

The results in our study show dimensions and meaning content in the concept ‘caring encounter’ following Rodgers’ structure by identified surrogate and related terms, antecedents, attributes and consequences, followed by an identified exemplar.

Surrogate and related terms

Surrogate and related terms help define the extent of the concept. The use of the term ‘meeting’ runs parallel with the use of the term ‘encounter’ in many articles.^{16,17,27

–32} The meeting is described as something interpersonal, person-to-person or human-to-human.^{14,19,20,28,33,34} Relationship is used to describe the encounter in some articles.^{14,19,28,34
–36} In these cases, relationship is described as an encounter between two individuals, two human beings, where the encounter takes place on equal terms and the participants are ‘players in the same field’.¹⁵

Terms related to ‘encounter’ are ‘fellowship’, ‘friendship’^27,37 and ‘close relationship’.^27,32,34 Sjöstedt et al.²⁶ suggest that encounter is connected with a relationship, thereby indicating a deeper meaning for the term ‘encounter’.

Antecedents – nurses’ way of being

Antecedents to the caring encounter are found in the nurse’s way of being. This seems to be crucial for the quality and the outcome of the encounter. Four major themes were found: a reflective way of being; openness, sensitivity, empathy and ability to communicate; confidence, courage and professionalism; and showing respect and supporting dignity.

The coming into existence of an encounter depends on the nurse’s way of being.³⁷ Nurses must have a caring attitude,^25,38 that is, they need to be there for patients. In acute situations, nurses should be able to shift modes of being with the patient as the situation or patient demands, between an instrumental and an attentive mode.¹⁹ Nurses’ ability to know themselves reflects on themselves and their attitudes create an opportunity for an encounter.^21,29,30 The nurse’s positive approach facilitates patient trust in the nurse’s competence.^23,39

Another antecedent for an encounter is the nurse’s ability to be open and willing to communicate.^{19,25,27,37,38} Certain sensitivity to the patient’s needs is important,^25,40 as well as empathy and warmth.¹⁷

Admiring a patient’s courage³⁵ and looking beyond the patient⁴¹ influences the nurse’s way of being. Through confidence and courage, nurses are able to show their professionalism and allow an encounter to take place.^15,17,28

To show respect for the patient and support the patient’s dignity appeared in the literature as antecedents for encounters.^{15,16,18,24,38,40}

Attributes – being there as unique in mutuality

Three major themes or attributes of the concept encounter emerged from the literature review: being there, uniqueness and mutuality.

A major theme for the encounter is to be there, and it can be divided into three subthemes: participation and involvement; being with, being close and sharing; and presence, listening and seeing here and now.

To involve patients and enable participation in decisions about care make patients feel as though they participate in their own care^{15,16,24,34,39,40} and also provide context and meaning in their lives.^18,20 Participation and being close also means to take part in the patient’s existential issues,^27,33 having a shared purpose^37,40 and a shared responsibility for the situation.¹⁶ Presence is expressed in the literature as true presence,¹⁴ genuine presence³¹ and full presence,³² as meaning something more than just being present. This implies having the courage to listen to the patient’s story,^25,29 listening actively²⁷ and understanding the patient and the situation at that very moment.³²

An important attribute found in the analysed literature was uniqueness. The patient wants to be seen as a person, an individual, a unique human being.^{15,16,18,24,26,28,34,38,39} Being seen as a unique person gives the patient a feeling of being somebody¹⁸ with unique needs.²³ This means being known as a person⁴¹ and receiving existential confirmation when called by one’s name.^22,33 If this is the case, every encounter is unique.³⁷

A subtheme to uniqueness is means to express the uniqueness of the patient. The nurse may use a gentle touch^22,38 to create comfort.³² Words should be chosen carefully,²⁹ but in some situations eye contact, stillness^16,17 and a wordless encounter are preferred.²⁴ Smalltalk, calming speech and humour may also express the nurse’s way of seeing the patient as a unique human being.^17,22,32

The third attribute is a mutuality that changes the asymmetric situation between the nurse and the human being in need of care. The persons involved are equal, mutual companions^17,27 being nurse, patient and human beings.^29,38 A mutual nourishing responsibility³⁷ and mutual dependency¹⁸ arise in the encounter. There is a verbalised or unspoken mutual understanding,³⁹ such as that between old friends.^18,37 Elmqvist et al.³³ see the mutual narratives that arise from the situation as a foundation for the encounter for those involved.

Consequences – influencing both nurse and patient

Nurses and patients are influenced by the caring encounter. It changes the nurse’s way of being through reflection on the self.^16,30,35 To discover one’s own vulnerability and to learn to know one’s self while learning to know the other has far-reaching consequences beyond the individual encounter.^{15,22,35,37,38} The encounter helps patients express their needs³⁴ and to find words and expressions for their suffering, thus making it bearable.³¹ Gustafsson et al.³⁷ point out the important moments in the encounter that have life-changing effects, creating meaning in the situation and in their overall lives.^18,31 Patients feel understood and confirmed in their suffering²⁵ and are able to trust the nurse.³⁹ The encounter creates a mutual understanding for the other that goes beyond the present and reaches into an unknown future.³⁸

Exemplar

The vignette about mutual encounter⁴² is identified as a description of a caring encounter, comprising antecedents, attributes and consequences. Weir⁴² writes,

Geoffrey was addicted to pain killers and cocaine and had hepatocellular carcinoma. It’s funny, but after I became firm in my resolve to restrict his narcotics, I gained some sort of respect from Geoffrey. I must have moved in his estimation from being a ‘means to an end’ to becoming a person who cared for his well-being. Geoffrey eventually became one of those patients whom I consider a friend. I could never reduce his cancer. Once a month he would sit in my office. I would ask about his difficult life, fill his prescription, shake his hand, and wish him well. I did not add 1 day to his life. He spoke ‘street’ language and I spoke ‘college’; he and I could never discuss football or fishing intelligibly. We shared nothing in common but our humanity. And yet, eventually, his coming to my office brought a breath of joy to my day. I suspect my joy came with Geoffrey because I knew I was helping him in a world where few people cared about his existence. And there is something good about this at the core of things. And I also found joy in the way that I was changed as a human – that somehow my time with him shaped me into a man who could better love another in spite of his mess. As doctors, we seek to help our patients rediscover their humanity through our care but less often do we let them accomplish the same for us. How does one help one human being reach through a complex system to touch another deeply, when the latter is a physician? Part of the answer is time, part of it is focus; the mindful physician is present and critically curious. Part of it is vulnerability; the doctor is able to share personally and genuinely in the patient encounter. It is clear to me now that I need more often to crack my physician-plated armour and let my patients’ humanness touch my own. Part of it is compassion defined as wanting good for another regardless of reward, making a difference solely for the benefit of another.

Discussion

Different approaches for concept analysis and/or concept clarification exist in nursing research. These have been frequently debated, and the most used methods inspired by the pedagogue Wilson have been criticised for being atomistic and for relying on a positivist tradition.^43

–46 In choosing between methods, we agree with the theorists who claim that a concept is always theoretically grounded.^45
–47 Fawcett⁴⁷ states that a concept analysis always begins with selecting a conceptual model to frame the work. In our study, the conceptual framework embedding the concept of ‘caring encounter’ is Eriksson’s theory of caritative caring.¹² The method is inspired by Rodgers’¹³ evolutionary method of concept analysis, because Rodgers’ view of concepts as changing in time and through use is consistent with our view, as it can contribute to clarifying, describing and explaining concepts central to nursing science.⁴⁸ Also, the account of material with qualitative descriptions about encounters in previous research, as our earlier studies show, contributed to our decision. Initially, the identification of the concept under study is made through a theoretical lens, as ‘caring encounter’ is a concept in Eriksson’s theory. We further develop Rodgers’ model through the application of an articulated theoretical perspective, adding an additional step to the model by looking into the theoretical frameworks in the articles included in our analysis. We see this as a fruitful step for assessment of the use of the concept. Further development is still needed for this possible step.

The methodology for concept analysis in basic research often used in the Scandinavian tradition,⁴⁹ further developed by Sivonen et al.,⁵⁰ was not an alternative in this study, but, as earlier studies show, there is much material with qualitative descriptions about encounters in previous research.

The results show that the meaning content of the concept ‘caring encounter’ is ‘to be there as unique in mutuality’. Mutual nourishing, mutual responsibility, mutual dependency and unspoken mutual understanding arise in a caring encounter. But it is the nurse’s responsibility to create the prerequisites for facilitating the encounter as it depends on the nurse’s way of being. Even if the main consequence of a caring is to help the patient to find words and expressions for his or her suffering, the results show that a caring encounter also has an influence on the nurse. The identified attributes, being there, uniqueness and mutuality are not as such found and expressed in earlier research, as earlier studies to a great extent seem to deal with the antecedents and the consequences of the encounter. This is also the case in the chosen articles as the core of the caring encounter is left out of scope.

When looking at the theoretical perspectives in the articles chosen for the analysis of the concept, theoretical frameworks were found in 12 of the 28 analysed articles. In these articles, Paterson and Zderad’s, Travelbee’s, Parse’s, Eriksson’s and Halldorsdottir’s theories of nursing and caring were used as starting points or frames for interpretation. Yet, we were not able to find any intentions to clarify the concept in relation to other concepts in the theories.

Our analysis unveils relations to adjacent concepts as ‘relationship’ and ‘communion’ thereby contributing to further theory-building providing direction for further enquiry. Here, our concept analysis is an effort to demonstrate the impact on further research and theory-building that Draper^51,52 is questioning.

The results clarify the conceptual differences between relationship and caring communion, as the concept ‘encounter’ emphasises the mutuality, which does not exist in relationship where the dependence on the other is more pronounced. The caring encounter as a concept builds bridges between Eriksson’s caring communion and relationship. We claim that the concept of encounter is synonymous with meeting in connection to caring communion, which has to do with an encounter in time and space. The human being’s simultaneous longing for communion and uniqueness is also clearly perceived in this study’s results.

The caring encounter is independent of profession, which is consistent with our theoretical frame, and is illuminated by the fact that Weir,⁴² who has provided our exemplar, is a medical doctor. The result can thus be of interest to all represents for healthcare professionals. Still we think that the results have special importance for the nurse as a representative of nursing and caring science, reminding of the importance of the attributes, the antecedents and the consequences of a caring encounter as it influences both the patient and the nurse.

Most of the analysed articles in this concept analysis were of Scandinavian origin. It is assumed that they were originally written in Swedish or Norwegian and then translated into English. That so few English or American articles were found may indicate that the concept ‘encounter’ is understood differently than the Scandinavian equivalent. Encounter may also have a wider meaning in English than in Swedish as that of a chance encounter, an unplanned encounter. It is also possible that we in our search for articles may have missed something as a result of the terminological variety and that the concept originally may have been encounter, but in translation has become something else. The risk is then that the understanding for the concept’s meaning context and meaning are lost because the results of the search have not been comprehensive enough.

Conclusion

There is a lack of conceptual clarity related to the concept of caring encounter. The concept seems overused, and its meaning and signification seem to be lost. As caring literature shows, the concept of encounter is central for nursing care and there is a need to pay attention to the meaning of the concept. The aim of this study was to discover dimensions and meaning contents in the concept ‘caring encounter’ through a concept analysis within an articulated theoretical perspective. Using this approach, the inner dimension of the concept can emerge, dimensions that might remain hidden if only describing ‘encounter’ as an outer form.

The attributes of the concept seem to be being there, uniqueness and mutuality. Thus, there are conceptual differences between caring encounter and caring relationship as the mutuality in the caring encounter differs from the dependence on the other pronounced in the relationship.

A caring encounter arises between two equal persons where one is a nurse and the other is a patient. They encounter in mutuality, in true presence, and both have allowed themselves to be the person they are. This encounter has consequences far beyond the actual encounter for both the patient and the nurse. The results from the concept analysis can increase the nurses’ awareness of their way of being in the encounter with the patient in everyday praxis. Further research is needed focusing on the attributes further clarifying their meaning in the caring encounter between patients and nurses.

Footnotes

Acknowledgement

The authors would like to thank Dr Marinella Rodi-Risberg for revision and translation of the English language in the manuscript.

Conflict of interest

The author(s) declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was financially supported by the Competitive State Research Financing of the Expert Responsibility Area of Tampere University Hospital (grant no. 100481).

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