**Abstract**

In Sweden as well as in many other countries, nursing and caring science exist in a health care context that is characterised by increasing reliance on the economics of diagnoses and measureable symptoms. This presents a challenge for caring science to defend person - and lifeworld-centred care. Nursing as a caring science must make clear its position in modern health care. The objective of this paper is to show how health oriented nursing, grounded in caring science, advocates expanded nursing care. The paper revisits the relationship between nursing and caring science, specifically the insights from new caring science research that emphasises carers' capacity for expanded awareness. In addition, the ever-present question of evidence is addressed.

**Key words** caring science, clinical sensitivity- theoretical reflection, expanded awareness, expanding caring, evidence, nursing

# Expanded Awareness as a Way to Meet the Challenges in Care that is Economically Driven and Focused on Illness – A Nordic Perspective

ALBERTINE RANHEIM & KARIN DAHLBERG

## Introduction

Caring is the primary focus of nursing. From a Nordic perspective, we believe that highlighting nurses' expanded awareness contributes to health and well-being by providing contemporary health care with a focus that includes both economics, and processes of health and illness.[1]

Nursing and caring are difficult concepts to define and distinguish, and globally the significance of both is unclear (2). In Swedish Universities alone there exist five different definitions of the nursing and caring discipline[3] and in international theory, the parameters of caring and nursing

are even more unclear than in Nordic countries.[4]

However, lately North European researchers have revisited the idea that caring science tradition emanates from explicit, distinguishable values derived from existential knowledge and understanding.[1,5,6] These scholars conclude that the aim of caring is to support and strengthen the individual patient's health processes, and it is the aim of caring science to create the knowledge that renders such care possible. With this definition of caring, Dahlberg and Segesten[6] go further, describing caring that supports and strengthens health, including the experience of well-being, which is defined as the ability to carry through one's large and small life projects. Understood this way, health means life-power, life-lust and life-courage. In this context, health is also related to meaning and coherence, and there is a balance between the vulnerability and freedom of existence.[7] Further, health means having a capacity for movement and activity as well as stillness, peace and life rhythm.[5,6]

Nursing that is grounded in caring science is faced with
several challenges. One is that health care in general and medicine in particular is focused on illness. The economically driven ideals of today demand diagnoses and measurable symptoms. Nurses who practise caring science often find it hard to convince professional colleagues, e.g. physicians, that caring science supports patients' well-being and enhances health autonomy, and the value of this. It can be a challenge for those outside caring science to accept abstract concepts such as life-power let alone see it in movement, stillness and life-rhythm.

Economically driven care also means that professionals are required to provide care that is measureable and reliable. In this context, health care in general, and not least nursing, is focused on doing more than being. As Pearcey[8] comments, in the current health care atmosphere, caring is those things you are not supposed to do. Granted, it is possible to provide nursing care without caring, but then the extent to which nursing engenders positive change for health is curtailed.

For nursing, caring means embracing the particular basic value that comprises the core question of caring: how can nursing care support and strengthen the patient's health processes? From a caring science perspective, nurses are more relationally-focused than task-oriented. It is in the relationship between nurses and patients that health, well-being and competence thrive.

## Method

This excursus is based on previously published research.[1] The aim of the original project was to reveal the meaning of caring to nurses working in municipal elderly care. Using reflective lifeworld research[9,10], we returned to the empirical findings of the project, which were further interpreted using a Nordic philosophy and research in caring science and nursing published by Dahlberg and Segesten[6], Galvin and colleagues[11], Finlay[12], and Finlay and Gough[13]. We also drew on Gadamer's[14] view of health.

## Nurses' expanded awareness

Encountering patients in ways that give room for existence, the experience of health and well-being, and that helps them to go on with their life projects demand an expanded awareness[15] from nurses. Expanded awareness means the cultivation and widening of one's experiential horizons. With acuity of the senses, self-awareness and self-confidence, nurses may more readily recognize patients' unspoken needs and encounter deeper, existential concerns.

With expanded awareness, the world becomes enlivened

and immediate. When patients open up their lifeworlds, nurses can respond with open wondering, lingering and dwelling, all the while aware of "not knowing." Nurses are health and caring experts, but do not necessarily know how patients experience health phenomena. Nurses who believe they already "know" run the risk of having their preconceptions confirmed as the opportunities for patients to divulge something previously unknown is lost. When this happens, a patient has nothing to say to the nurse.

Open wondering includes the sense-aesthetics of human life, which Martinsen[16] emphasizes. In hectic, everyday caring work, nurses are situated in movements of rapid reflection where the expeditious intellect dominates the senses. As Martinsen says, these caring encounters are "pregnant with impressions of meaning".[17 p135] She claims that sense impressions have a two-fold function: the impressions touch us sexually and lead us to work on being open to what the impression wants to reveal to us.

The above-mentioned research[1] was further interpreted using a meta-synthesis of caring science research that focused on the general phenomenon of health and caring, including philosophical analysis.[6] We argue that in order to meet patients' lifeworlds, nurses need to open up their senses, feelings and sensitivity. Expanded awareness is essential in caring encounters where a nurse can reach a patient's lifeworld. In such encounters there is a "wakefulness and being-in-the-world as authentic presence".[18, p74] According to Gadamer, there is a self-evident immediacy to this kind of presence. He refers to Aristotle's concept of "entelechia" which reveals the meaning of such caring presence: "a kind of presence in which our authentic existence, so to speak, realizes its telos, its perfect form /.../ the full completion and realization of a living meaning".[18 p74] Expanded awareness increases a nurse's ability to see the other person and her/his lifeworld.

Expanded awareness and the sense-aesthetic attention that Martinsen and Gadamer talk about open up one's capacity for the existential that can be cultivated, developed, or, conversely, closed down. Such openness carries an inherent risk of leaving nurses feeling vulnerable and less inclined to remain open. If not trained for reflection, openness withers. In the economically driven and illness focused health care system of today, the sense-aesthetic dimension of caring runs the risk of vanishing. Consequently, the question of strengthening and supporting the sense-aesthetic meaning of caring is urgent.
## The development of experiential horizons

Developing one's experiential horizons means letting go of the emphasis on doing, and giving room for an open encounter between lifeworlds. Open wondering, dwelling and lingering are about the art of "bridling" which is a term developed for human science research epistemology and methodology.[10] Bridling means abstaining from immediate intellectualizing in order to let something appear, to let impressions stay for a while, to just sense without conceptualizing and reframing with theories. Bridling requires concentrated effort and demands cultivation of open awareness, self-awareness and reflexivity.[19] The challenge is to endure the frustration produced by endeavouring "to not understand" and "to not make definite what is indefinite".[10, p121]

Nurses are given multiple opportunities to expand awareness in encounters and practical tasks during everyday care. Feeding, bathing, helping to dress a patient, teaching situations, giving an injection or other treatments are all examples of everyday situations where nurses can practice and strengthen expanded awareness. In particular, caring encounters that emphasize the intersubjective aspect of caring, e.g. caring dialogues and caring touch, offer opportunities to cultivate one's capacity for presence, attentiveness and expanded awareness. In a clinical context it is, at least partly, an act of will and intention to be open to sensory impressions.

However, for professionals to remain in a state of "not immediately knowing" is a challenge since it means adventuring into the unknown. It is so much easier to remain in one's usual mode of unchallenged expert. Todres (20) has described "home and adventure" as an eternal movement of the human mind. The challenge, he argues, is to make friend with the unknown and bring the adventure home. Understood this way, the movement between home and adventure is an excursion out into the unknown and return back home to that which is known. It is thus an intertwining of what is known and unknown.[18] The crucial moment in this movement is not, in fact, the adventure or the excursion into the unknown, but the return. Gadamer makes explicit the engraftment of the unknown and the art of making the unknown known - and to put it in play. After the task of educating one's senses and developing an expanded awareness, there is the issue of transforming the experience into language and communicating it in nursing.

One cannot demand from a person who does not read Swedish to understand a text written in Swedish and grasp the intentions of that text. Likewise, one cannot demand from

carers, if they are educated in the restricted perspective of medicine, to recognize patients' lifeworlds, their suffering and existential demands.[6] The education of one's senses and feelings, and the development of an expanded awareness, are the tasks of all health care practitioners, but they must be given opportunities to learn and they must themselves be open to such learning opportunities.

## It takes time but does not need time

What Ranheim (1) describes is an approach to nursing that can nourish all caring activities. To adopt and develop a stance of expanded awareness requires time. But the approach to patients needs no extra time. The understanding of care that is explicated here is the foundation of every nursing act.

Thinking is quick. In our contemporary culture, one's intellectual mind is highly stimulated and challenged. Intellectual knowledge is the most cultivated knowledge and the intellectual mind is in demand - for good and for bad. The relatively slower knowledge of one's senses and feelings is dismissed or left unacknowledged.[21,22] Without doubt, professional and scientifically based nursing and caring need cultivated, intellectual minds, but such caring also needs the nurturing of all the senses and of "entelechia".

However, we want to avoid a dualistic conflict that separates intellectual minds from the sense-aesthetical dimensions. Instead, we want to see these human capacities intertwined by cultivating the expression and expansion of intellect and thinking blended with pre-cognitive, sensual impressions. Such understanding characterizes the reflective practice that is developed from a phenomenological perspective.[7,12,13,19,20] We also argue that the caring intellect is nurtured by the sense-aesthetical dimensions. Nurses with such an expanded awareness are more likely to draw correct conclusions about the nature of the care needed for patients.

## The question of evidence

The economically driven care of today is closely related to the demands for evidence-based care. Only what can be measured is valued. Let us therefore take a quick look at the world of caring and make explicit that the demand for evidence cannot be reduced to a question of statistics.

Research on caring phenomena offers insights into context-specific inter-relational processes between caring professionals and their patients. Both parties have their own as well as shared lifeworlds, and on both sides there are questions of life meanings, intentions, dreams and goals.
Their common ground is support and strengthening of the patient's health processes. For the professional side of the caring relationship there are further aspects, such as personal and professional maturity and ethical beliefs. It is, as Galvin and Todres put it, a complex view of knowledge that is "relevant to nursing because immersion in practice demands a way to overcome the 'deep inseparability' of truth, ethics and action in the complex and marginal situations that nurses have to manage".[11, p523] None of these aspects of care can be fully measured.

Further, it is indeed unscientific to force caring phenomena, epistemologically understood as unmeasurable, into matrices that reduce them to measurable entities, sometimes past recognition.[9] Mathematics is a wonderful gift to science and should be used whenever the numbers match the phenomenon properly. When the focus of research is on the world of experience, words are better than numbers. By looking for both explicit and implicit meanings in descriptions of caring phenomena, we can come closer to the truth of caring.[10,23]

Quantification does not fit the phenomenon of expanded awareness, which demands insights into the lifeworld. From our empirical experience and a phenomenological perspective, we argue that mediating caring through expanded awareness should become second nature in nurses' work. Nurses form a caring science agency by mediating caring actions and intentions. The mediation of care and the affects of a caring science agency must essentially be evaluated by patients. From our research[1,6], we have enough evidence to confidently say that patients benefit from nurses' expanded awareness that opens their minds for the individual patient's lifeworld.

Scientific research, no matter the approach or method, must be interpreted and transformed in order to establish validity and evidence. All research results have an original context from which the results are extrapolated to other situations and give rise to new questions. For example, statistical research, always group-based, is interpreted in relation to individual lifeworlds in order for the knowledge to be properly transformed and practised. The meaning of research results for patients depends on how practitioners understand and use such knowledge.

## Conclusions

In Sweden as well as in many other countries, nursing and caring science exist in a health care context dominated by the economics of curing through diagnoses and measureable

symptoms. There is a belief today that by integrating general quality insurance programs based on statistics and protocols, the quality of caring will increase and healthcare will be more economically sound. We believe that the opposite is more likely: by implementing standardized programs, individual discernment gets lost, along with the possibilities for developing an expanded caring awareness. As a result, the cultivation of clinical sensitivity and the humanity of caring are greatly diminished.

We have evidence of the value of an expanded awareness in our common research.[6,15] We encourage nurses to include more of caring science in their horizons of knowledge in order to be more health oriented and thereby improve their caring and nursing ability. To achieve an expanded awareness, professionals not only need critical reflection but also sensitive reflection; and most of all, they need the strength to maintain openness long enough for new insights to grow about patients' lifeworlds and health processes. Professionals are experts, but must also be expert enough to be receptive to their patients' own expertise in their lifeworld. In such a way, nursing can be the power that supports patients' health processes and by including caring science, nursing can make clear its position in modern health care.

## References

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Acknowledgements:
We thank professor emeriti Nancy Drew, Saint Joseph College,
West Hartford, CT, for her gracious help with our manuscript.

Contact Information for Authors:
Albertine Ranheim, RN, Med.Dr.
Lecturer
University of Mälardalen
Academy of Health and Welfare
Institute of Caring Sciences
72123 Västerås
Sweden
E-mail: tine@jdb.se

Karin Dahlberg
Guest Professor at Linnaeus University