Some further questions on the nature of caring

1. Is caring a necessary and/or sufficient component of nursing? 

Nursing is often defined explicitly as ‘the caring profession’, where caring is seen as a necessary and (by some writers) a sufficient condition for nursing to take place. Similarly, the terms ‘nursing care’ and ‘nursing practice’ are often used interchangeably, suggesting that caring is what nurses do. This is the sense in which Maben uses the term, allowing her to refer to ‘routinised and task oriented care giving’ without succumbing to the oxymoron of describing uncaring care. Similarly, Flatley and Bridges use the terms ‘nursing care’, ‘patient care’, ‘medical care’, ‘palliative care’ and so on throughout their paper, and clearly regard ‘care’ and ‘practice’ synonymously. For these writers, it would seem that practice is care. Certainly, if we take Corbin's assertion that caring is the whole package of technical ‘caring for’ and emotional ‘caring about’, and if we further distinguish between nurses who care and doctors who cure, then it is difficult to think of any other discipline for which the term ‘caring profession’ fits quite so snugly.

On the face of it, however, Corbin's paper would appear to challenge this notion that ‘to nurse’ is, de facto, to care. As we have seen, she begins by questioning the very existence of caring as ‘a standard part of nursing practice’, and implies that her own experience as a patient was characterised by a lack of caring, concluding that ‘nurses must determine what [their] practice will be and if caring will be a part of it’. This statement certainly suggests the possibility of nursing practice that does not include caring, although presumably Corbin is referring here to ‘caring about’ rather than ‘the whole package’, since it would be difficult to imagine what would be left if nurses decided that their job entailed neither caring for nor caring about their patients. Similarly, Griffiths refers to nursing practice that includes both ‘caring for’ and ‘caring about’ as ‘true nursing’, presumably to contrast it with untrue or false nursing in which one or other of these components was missing. He also refers to this ‘true nursing’ as ‘therapeutic nursing’, suggesting perhaps that nursing which does not involve caring (about) is untherapeutic or perhaps even, as he states elsewhere, malignant. Maben characterises nursing without caring as ‘just a job’, suggesting that caring about patients transcends mere work and becomes something more than a job (a vocation or a ‘calling’, perhaps).

2. Is it meaningful to talk about ‘caring people’? 

We have already touched upon the issue of whether certain individuals can be classified as ‘caring people’, and the question can be reframed in a more technical sense as: is ‘to care’ an intransitive verb? An intransitive verb is a verb without an object. The question to be answered here, then, is whether it is possible to talk about caring without specifying the object of that care. In other words, does it make sense to talk about ‘a caring person’ in the abstract, or does all caring have to be directed towards someone or something? This might look like an obscure grammatical point, but the answer we give determines whether we should think about people as being intrinsically ‘caring’ or ‘uncaring’, which has profound implications for recruitment and selection as well as nurse education. Of course we all care about specific things, whether it is people, objects or events, but perhaps Corbin means something rather different when she claims that nurses are ‘caring’ people. Indeed, she seems to be singling them out as perhaps different from other people who do not go into nursing, and are perhaps less caring or even uncaring.

Corbin makes the assumption that the concept of caring (in the abstract) is somehow embedded in the very essence of nursing from the seminal texts of the ‘founding mothers’ onwards. Thus, although Nightingale's Notes on Nursing never even mentions ‘caring’, Corbin reads it in, claiming that ‘it was implied in everything that Ms. Nightingale said’. Similarly, although Corbin's own experience of being a patient in hospital appeared to suggest a distinct lack of caring about her as a person on the part of the nurses, she rationalises this by stating that:

I do not mean to imply that nurses are uncaring individuals. I believe quite the opposite. Nurses are indeed caring, that is what brought them into the profession. However, somehow that quality is not necessarily being communicated to persons in their care. (Corbin, 2008, p. 163)

There is a clear implication here that it is possible to be a caring person without specifically caring about anything or anyone in particular. Furthermore, it appears almost inconceivable to Corbin that nurses are uncaring. Indeed, caring is an integral part of being a nurse, it is what brought them into the profession. They would, it seems, not have decided to become nurses if they were not ‘caring’ people. It is simply that, for whatever reason, they are not showing outward signs of that care to their patients. This is in contrast to Griffiths’ argument that there is no intrinsic relationship between being a nurse and being a caring person. Indeed, for him, we are potentially all caring people ‘by virtue of being human’.

3. Is caring a feeling, an attitude or a behaviour? 

Although, for Corbin, nurses are all caring people, ‘being a caring person is not sufficient. Caring has to be put into practice through behaviours …’. Seen in this way, it is clearly possible to separate ‘being caring’ from ‘doing caring’. ‘Being caring’, it seems, is an internal state that is not always manifested through appropriate action, and Corbin appears to be suggesting that we can ‘be a caring person’ without necessarily doing anything. This begs the reciprocal question of whether it is possible to ‘do caring’ without ‘being caring’; that is, whether doing caring is no more than a behavioural repertoire that, with sufficient training, can be enacted by anyone (even those people who do not ‘care about’ other people). Griffiths takes yet another position by suggesting that ‘caring’ cannot be taught, but simply emerges under the appropriate conditions.

Once again, the view we take on this matter has serious implications for education, recruitment and practice. Nursing educators and managers must therefore ask themselves whether they should attempt to select inherently caring people and reject those who are not, whether they should select anyone that they feel is capable of being taught ‘caring skills’ or whether, as Griffiths appears to suggest, they need simply to provide the growth conditions (whatever they might be) in which caring will flourish.

In order to explore further the nature of the caring person, it might be instructive to make the comparison with love. Most people would agree that love is a feeling, and that the feeling of love manifests itself in certain behaviours and actions, although it is (perhaps) possible to love someone without demonstrating that love in any outward form. However, we probably would not want to say that love could exist without the feeling; that love was merely a behavioural repertoire; that love could be demonstrated without being felt. Nevertheless, I might display all the outward signs of love and be described as ‘loving’ without having the feeling inside me. So, is being ‘loving’ the same as being ‘in love’? Could we make the same distinction for caring? Can we say that caring is as caring does; that if I act in a caring way towards my patients then I am a caring person? Or, put another way, is it possible to be described as ‘caring’ without having ‘caring feelings’ towards my patients?

Another possibility would be to regard caring as an attitude rather than as a feeling or a behaviour, that is, as a disposition to behave in a certain way. Just as I can hold the attitude that smoking is antisocial and bad for my health and yet continue to smoke, so perhaps my attitude towards patients might be described as caring despite the fact that I never actually display any so-called caring behaviour towards them. To regard caring in this way is to take a rather different approach to its (re)instatement in nursing than those suggested either by Corbin or Griffiths. For Corbin, much of the problem comes down to a lack of time due to the growth of technological and managerial commitments: if only nurses had more time to do the ‘little things’, then patients would feel cared about as well as cared for. For Griffiths, the solution is for more technical training so that nurses can respond to the technology in a routine way and caring can ‘shine through’. Both these writers, in their different ways, appear to assume that caring is somehow inherent in the nurse and will blossom naturally given half a chance. However, regarding caring as an attitude rather than as a natural disposition or instinct introduces several extra layers of complexity, particularly in the translation from intensions into actions, and places it firmly within the domain of psychosocial education.

4. What is so hard about caring? 

Griffiths claims on several occasions that ‘caring is hard’, although he fails to specify in what way and on what authority such a claim is made. It therefore behoves us to at least consider the possibility that this is simply a story that nurses tell each other (and tell to the outside world) in order to justify what is, in fact something quite easy and natural.

The use of the word ‘hard’ was, I am sure, carefully chosen, but it is nevertheless a curious and perhaps enigmatic word to use. The statement ‘caring is hard’ might simply echo Corbin's assertion that caring is complex rather than simple; that it is intricate and ‘has many facets and forms’. On the other hand, it might be taken to mean that caring is difficult rather than easy; that it takes a lot of effort to master. Or it might mean that caring is hard work to do, that it is arduous, that it is ‘hard emotional labour’. Or, indeed, to say that caring is hard might imply that it is rigorous rather than lax, that it shares a certain affinity with the ‘hard sciences’. Griffiths never really clarifies the meaning of his enigmatic and unsupported statement, but provides us with a clue when he argues that “‘caring” is a difficult “art” to master’ (his punctuation). This view that caring is difficult to become good at is somewhat contradicted by his earlier observation that, given the right conditions, it will simply ‘shine through’ as a natural consequence of our humanity.

5. Is caring an art? 

In both the title and the opening paragraph of her paper, Corbin sets up caring as ‘a lost art’, and repeats this assertion at regular intervals. Although she never explains or justifies this remark, it is picked up and repeated without question by both Maben and Griffiths. Thus, Maben reports on examples given to her by respondents in her study ‘in what can only be described as the “art of caring”’, although why those examples can only be so described is not made clear. Griffiths repeats Corbin's phrase ‘the art of caring’ on several occasions, claiming (as we saw above) that it is a difficult art to master, and at one point comparing caring to ‘great art’. As with the word ‘hard’, ‘art’ has a number of meanings and it is difficult to ascertain which is being referred to here. On the one hand, the label ‘art’ can be applied to distinguish a particular discipline or discourse from ‘science’ or ‘technology’, and I suspect that this is partly what Corbin intends when she talks about the art of caring. On the other hand, the term ‘art’ can be used in a narrower sense to indicate a performance of some kind, for example, when certain writers have described nursing in terms of a dance. Again, I suspect that Corbin was also invoking this meaning in her observation that caring needs to be enacted in order to be effective. She seems to be suggesting, perhaps, that it is not enough merely to learn the lines if you do not intend to put on the play. Unfortunately, this performative meaning of the word ‘art’ also suggests something contrived and artificial; that caring might be an act or performance rather than something real and authentic. Additionally, the term ‘art’ also suggests something to be mastered, as in the art of archery or the art of public speaking, and I think that this was partly the meaning that Griffiths had in mind. However, his comparison of caring with ‘great art’ also suggests at least a hint of caring as a performance or display of some kind.

The words we use to describe what we do are of huge significance when it comes to thinking about how we present ourselves to the outside world, as well as how we attempt to pass on what we know and do. For example, the implications for teaching a science of caring or a craft of caring would be very different from teaching an art of caring. Indeed, Griffiths insists that, ‘like great art’ it is not really possible to teach the art of caring. I would suggest that if, as a profession, we wish to debate the nature of caring, we must think far more carefully about the indiscriminate and unexamined use of terms such as art (and equally, of science and craft) to describe what we do.

6. Conclusion: caring in the (academic) community 

In the paper which triggered the ongoing debate about the nature of caring, Corbin urged that we should move beyond defining what is meant by caring to discuss the more substantive question of whether caring should continue to be a component of nursing. Laudable as that sentiment might be, I hope that I have demonstrated the problems inherent in such a strategy. In particular, I have attempted to show that the term ‘caring’ has been used in at least four distinct ways. Firstly, it is employed a generic term for nursing practice, for example, when Flatley and Bridges refer to ‘nursing care’. Secondly, it is used as a term for a particular aspect of practice such as palliative care or technical medical care. Thirdly, it is used as a very specific term for the ineffable art of ‘caring about’ that sometimes accompanies the more technical ‘caring for’. Fourthly, it is used to describe the ‘complete package’ of caring about and caring for. Thus, when Corbin describes a particularly fine example of caring as ‘something that could only have been done by nurses’, we cannot be sure that she is referring to the same concept as Griffiths when he argues that ‘caring is not the exclusive preserve of professional nurses’. Even more confusingly, however, these different and contradictory meanings are often used interchangeably by the same author. For example, Corbin defines caring as the whole package of what nurses do, but later questions whether caring is or should be a part of nursing practice, leaving us to wonder what would be left if it was removed. On occasion, two of these meaning even sit side by side in the same sentence, as when Griffiths states that ‘caring was being forced out by technical care’.

Coming to some agreement on a shared definition of caring would cause many of the disputes in this debate simply to dissolve into the ether and be revealed as merely misunderstandings over words. However, such an agreement is unlikely and perhaps even undesirable at this early stage in the conversation. Nevertheless, if we are to go on talking and discussing what Corbin calls this ‘elusive term’, we must signal the fact that a large number of concepts are implicit within this single word. Perhaps a way forward would be to follow the strategy proposed by the French philosopher Jacques Derrida (1974) and to put the word ‘caring’ sous rature (under erasure), by both writing it down and crossing through what we have written. By writing it as caring, we are at the same time recognising the need to carry on using the word in the absence of anything better or more precise, but also keeping alive the several different and contradictory meanings that it simultaneously signifies. To write caring is to acknowledge the necessity to continue talking whilst recognising that we might not all be discussing the same concept. Such a strategy might not resolve our disputes, but it will allow us to frame further and perhaps more productive questions. I hope that the questions I have raised in the course of writing this paper will continue to stimulate discussion and debate.