2011,Williams2011)andofnurses - PDF document

2011,Williams2011)andofnursesÞndingthemselvespowerlesstoimplementtheirprofessionalvaluesinsomehealthcaresettings(MacKusick&Minick2010,Georges2011,Sellman2011).Clearly,suchfailuresmustbeaddressedurgently.NursesÕpracticeandtheirabilitytosustaintheirpracticedependonrelevantnursingknowledge;thatis,relevantnursingmodelsandthetheoriesandresearchthattheygenerate.Thesearchmustcontinuefornursingmodelsthatwillengageandstrengthennursesandprovidemeaningfuldirectionforthemintheirprofessionalpractice.Tothisend,twocuespresentthemselves.Bradshaw(2011)suggestsnursinghistoryasasourceofarenewedvisionofnursing.Lynaugh(1996)observesthatnursinghistoryisÔoursourceofidentity,ourculturalDNAÕ(p.1).Likewise,Black(2005)proposesthatseriousshortcomingsinpatientcareinhospitalsintheUnitedKingdom(UK)canbemosteffectivelyreversedbyanurse-ledtransformationofhospitals,asoccurredinthe19thcentury.Nurse-ledtransformationofhospitalsisalreadyoccurringintheUnitedStates(US)throughthehighlyregardednursingMagnetRecognitionProgram(AmericanNursesCredentialingCenter2008).Thisleadstothesecondcue:TheMagnetRecognitionProgramrequiresthatnursingpracticebebasedonanursingprofes-sionalpracticemodel,thatis,anursingmodelthatdirectlyaddressesthestructure,processesandvaluesthatareinherentinprofessionalnursingpractice.ThisstudypresentstheCarefulNursingphilosophyandprofessionalpracticemodel.CarefulNursinghasitssourcein19thcenturynursinghistoryandabriefoverviewofitsbackgroundispresented.TheinitialdevelopmentofCarefulNursingasaconceptualmodelisdescribedanditslimitationsidentiÞed.Furthercontentanalysisofhistoricaldocumentsisthenoutlined,followedbypresentationanddiscussionofCarefulNursingasaphilosophyandprofessionalpracticeThehistoryofnursingismarkedbyalongdarkperiodinBritainandIreland,beginningwithHenryVIIIÕsdissolutionofthemonasteriesandterminationoftheirnursingservicesinthe16thcenturyandlastingintothe19thcentury(Dock&Stewart1920).ThereformulationofnursingasapublicservicebeganinIrelandassoonascircumstancesallowedinthe1820s,ledbyCatherineMcAuleyandMaryAikenhead.Inaccordancewiththeculturalandsocialmoresofthetime,theyformedneworganisationsofmainlywell-educatedreligioussisterswhowentoutdailytonursethesick,injuredandvulnerableintheirhomes.Over7monthsin1832,duringtheÞrstgreatcholeraepidemic,theyprovidedcrucialnursingserviceinDublincholerahospitals,McAuleybeinggivenÔthefullestcontrolÕofpatientcare(Carroll1883,p.295).Duringthistime,theyfurtherexpandedtheirknowledgeandskillsincaringforcriticallyillpatientsthroughworkingcloselywithdoctorsandapothecaries.In1833,AikenheadsentthreeSistersofCharitytohospitalsinParisforspecialisedtrainingandin1835foundedSt.VincentÕshospitalinDublin,theÞrstmajorhospitalownedandoperatedbynursesinBritainandIrelandinmodernBythetimeoftheCrimeanwarof1853Ð1856,theyhaddevelopedadistinctivenursingsystem.TheywererecognisedasskillednursesandhadattainedÔbrilliantprestigeinnursingÕ(Dock&Nutting1907,p.86).TheBritishgovern-mentlookedtoIrelandfornursestoassistFlorenceNight-ingale.TwelveIrishnurses,SistersofMercy,servedatthewarovera16-monthperiod.MaryClareMoore,whohadÔtrainedÕwithMcAuleyduringthe1832choleraepidemic,workedcloselywithNightingale(Meehan2005).Culturalandpoliticalconßictsprecludedtheirpublicrecognition,butNightingaleacknowledgedprivatelyherrelianceontheirnursingknowledgeandskill,particularlythatofMoore.ÔYouwerefarabovemeinÞtnessfortheGeneralSuperintendencyÕNightingalewrotetoMoore,ÔwhatyouhavedonefortheworknoonecaneversayÕ(Letter,29April1856),andinalaterrecollection,ÔhowIshouldhavefailedwithoutyourhelpÕ(Letter,21October1863).MoorehasbeenrecognisedasoneofthegreatestinßuencesonNightingaleinnursingmatters(Baly1997).Beginningin1843,theIrishnursingsystemalsospreadinternationallyasthenursesaccompaniedtheIrishDiaspora,foundingandoperatinghospitalsandschoolsofnursinginmanycountries.CarefulNursingasaconceptualmodelCarefulNursingwasinitiallydevelopedasconceptualmodel(Meehan2003).Apreliminarycontentanalysisofhistoricaldocumentswasconducted.Primarysourcesweredocumentswrittenbythe19thcenturyIrishnursesandothernurses,surgeons,armyofÞcersandpurveyorswhoworkedwiththemorobservedthemworking.Theseincludedjournals,letters,conventannals,Britisharmyrecords,loosepapersandpublishedbooks,whichwereidentiÞedthroughanextensivesearchofconventandnationalarchivesinIrelandandtheUK.Genuinenessofdocumentswascheckedtoeverypossibleextentbythecomparisonofhandwritingandconsultationwithotherhistoriansfamiliarwiththedocuments.Authen-ticityofdocumentcontentwasveriÞedbythecomparisonofeventsreportedacrossdocumentsfromdifferentsources.SpeciÞcdocumentsincludedMcAuleyÕsguidetotheTCMeehan2012BlackwellPublishingLtdJournalofClinicalNursing,2905Ð2916 visitationofthesick(1832),acompilationofMcAuleyÕsletters(Neumann1969),acompilationoflettersandmanu-scriptsofMcAuleyÕsclosestnursingassociates(Sullivan1995),thenursesÕCrimeanwarjournals(BridgemanMF,ArchivesoftheSistersofMercy,Dublin,unpublishedmanuscript,Croke1854Ð1856a,Croke1854Ð1856b,Doyle1897),descriptionsbyafellownurse(Taylor1856,1857)andrelatedBritisharmycorrespondence(Codrington1856).SecondarysourceswerebiographiesofMcAuley(Moore1841/1995,Harnett1864,Carroll1866)andpublishedsecond-handdescriptionsofthenursesÕpractice(Murphy1847,Carroll1883).Documentswerereadandrereadindepth.ContentwascategorisedandclassiÞedaccordingtoWeber(1985)andmappedontothenursingmetaparadigmconceptsofhumanbeing,environment,healthandnursingproposedbyFawcett(2000).Mostcontentrelatedtonursingandwassummarisedinaconceptualmodelcomposedoftenpracticeconceptsgroupedunderfourheadings,asshowninFig.1.Thename,CarefulNursing,wasselectedfromalettersentbythenursestotheBritishWarOfÞcein1854inwhichtheywrote;ÔAttendanceonthesickis,asyouareaware,partofourInstitute;andsadexperienceamongstthepoorhasconvincedusthat,evenwiththeadvantageofmedicalaid,manyvaluablelivesarelostforwantofcarefulnursingÕ(WhittytoYore18thOctober1854).ThestructureandutilityofthemodelwasassessedandcriticallyanalysedbynursesineducationandpracticeinIreland(Meehan2006,McMullinetal.2009)andtheUS(Roemer2006).FurtherelaborationofthemodelwasrequiredtoprovidemorespeciÞcdirectionforpracticeandtheorydevelopment.However,reßectiononthemappingofthedocumentsÕcontentontoFawcettÕs(2005)metaparadigmconceptsshowedthattheywereinadequateforfullexplica-tionofthedocumentsÕcontent.ImportantphilosophicalprinciplesinherentinthedocumentswereobscuredandatoddswithFawcettÕsproposedworldviews.FawcettÕsapproachtoknowledgedevelopmentwasputasideandasecondmorecomprehensive,contentanalysiswasunder-takenwhereinthedocumentsweregiventhefreedomtospeakforthemselves.ThedocumentsearchandveriÞcationproceduresdescribedforthepreliminaryanalysiswererepeated.AdditionalprimarysourceswereidentiÞedandexamined(Barrie1854,1855a,b,Moore1854Ð1856,1855,Fitzgerald1855)aswereadditionalsecondarysources(Atkinson1879,Terrot1898,Doona1995,Sullivan2004).Again,documentswerereadandrereadindepth.FollowingKrippendorff(2004),primarysourceswereanalysedformanifestandlatentcontent.Textualunits,eachrelatingtothesamecentralmeaning,wereidentiÞedandhandcodedandsortedintocategoriesandsubcategories.Secondarysourcesprovidedbackgroundinformation.Sevenbroadcategoriesemerged.Threecategories,humanperson,aninÞnitetranscendentrealityandhealth,werejudgedtoprimarilyconcernphilosophicalassumptionsunderlyingnursingpractice.Fourcategories,withatotalofeighteensubcategories,werejudgedtoprimarilyconcernattitudesandactionsofskillednursingasapublicservice.Thisprocess,asshowninFig.2,wasusedtoreformulatea19thcenturynursingsystemintoa21stcenturynursingphilosophyandprofessionalpracticemodel.CarefulNursingphilosophyDatagivingrisetothephilosophicalassumptionsmarkedlymatchedthethinkingofThomasAquinas(1256Ð1259/1953,1265Ð1274/1948),ashebuiltonandextendedthethinkingofAristotle(Ross1915).Thus,thethinkingofAquinaswasdrawnuponinelaboratingtheseassumptions,showninTable1.Theyprovidethefoundationforhownursesthinkaboutthemselvesasnurses,thepatientstheycarefor,thenurseÐpatientrelationshipandtheattitudesandactionstheyengageintoprotectpatientsandfostertheirhealingand Nurses’ therapeutic capacityNurses’ care for themselvesThe therapeutic milieuContagious calmnessCreation of restorative environmentClinical competence ‘Perfect’skill fostering safety Nursing interventionsManagement of practice influence on health systemParticipatory-authoritative managementTrustworthy collaborationPower derived from service Figure1CarefulNursingasaconceptualmodel.DiscursivepaperCarefulNursingphilosophyandprofessionalpracticemodel2012BlackwellPublishingLtdJournalofClinicalNursing,2905Ð2916 Attentiontothenatureofthepersonisespeciallyimpor-tantbecausenurseÐpatientrelationshipsarecentralinnursingpractice.Theinherentdignityofallpersonsisemphasised.Intheirrelationshipswithpatientsandwithoneanother,nursesareguidedtobeconsciousoftheirownunitarynature,inwardandoutwardlives,intrinsicorderandbeautyand century primary source documents describing Irish nursing systemContent analysis (Krippendorff (2004) Categories: Philosophical assumptions: Human person - Infinite transcendent reality - Health Categories subcategories: Nursing practice: Therapeutic milieu Contagious calmness Nurses’ care for selves one another Intellectual engagement Safe restorative physical environment Practice competence Great tenderness in all things ‘Perfect’ skill in fostering safety comfort Watching Clinical reasoning decision-making Patient engagement in self-care Diagnoses outcomes interventions Family friends community supportive participation in care Health education Management of practice & influence in health systems Support of nursing practiceTrustworthy collaborationParticipative-authoritative managementProfessional authority self-confidence visibility century nursing philosophy and professional practice model Figure2Reformulationofa19thcenturynursingsystemintoa21stcenturynursingphilosophyandprofessionalpracticemodel. Table1CarefulNursingphilosophicalassumptionsAunitary,rationalbeingencompassingtwoexplicitrealities,abio-physicalrealityandapsycho-spiritualreality.Isnotcomposedoftheserealitiesbutisaunitarybeinginwhomtheserealitiescanhedistinguished(Aquinas1265Ð1274/1948,IQ76).Lifeisexperiencedastwofold:anoutwardlifeofthebodyandsensesand,simultaneously,aninwardlifeofthemind,spiritandcommunionwithaninÞnitetranscendentreality(II,IIQ23).Theoutwardlifepredominatesinconsciousness.Theinwardlife;experiencedmainlyduringinnerreßection,contemplation,meditationorprayer;encompassesawareness,orpotentialawarenessofthelove,purposefulnessandhealingpresenceofaninÞnitetranscendentrealitywhichthepersonhasanactualorpotentialdesiretosearchforandtoknow(1Q12).Eachpersonisuniqueandpossessesintrinsicorderandbeauty,inestimabledignityandworth,distinctivecreativepotential,ameaningfulpurposeinlife,inalienablerights;andifabletoreason,hascertainresponsibilities.Whilepersonsinessencearenotinconsiderateormalevolent,theycanexperienceinconsiderateandmalevolentinßuenceswhichcan,inturn,generateintheminconsiderateandmalevolentideasandintentionsandattitudesandactions(IQ49).AninÞnitetranscendentTheabundantlylovingsourceofallcreation,unitarywholenessandhealingintheuniverse(Aquinas1265Ð1274/1948,IQ2).Infuseshumanpersonswithboundlessloveandgoodnessthattheycanapprehendthroughtheirpsycho-spiritualrealityorinwardlifeduringinnerreßection,contemplation,meditationorprayer;orthroughsensitiveperceptionofsplendidbeauty,forexample,innatureoramusicalsymphony.Isexperiencedasthespiritualaspectoflife.HealthHumanßourishing;thepersonÕsunitaryexperienceofpersonaldignity,harmony,relativeautonomy,contentednessandsenseofpurposeinlife.HasitssourceinaninÞnitetranscendentrealityandinnatureandcanbefosteredbyrestorativepsycho-spiritual,bio-physicalandsocialinßuencesinthepersonandthepersonÕsenvironment(Aquinas1256Ð1259/1953,Q11).Isideallyassociatedwiththerelativeabsenceofdiseasebutcanstillbefullyexperiencedinstatesofdisabilityorchronicillness.Includestheability,orpotential,toexperienceapersonalrelationshipwithaninÞnitetranscendentrealitythroughinnerreßection,contemplation,meditationorprayer;andtoexpressthisexperienceinlovingrelationshipswithothersandinseekingtofulÞllaperceivedpurposeinlife.ItincludestheabilitytoacceptwithequanimityinßuencesandcircumstanceswhichareseeminglyunjustbutmaybeverydifÞculttoalter.ThestandardmethodofreferencingAquinasÕspublicationsisbyparts[I,II,IIIIorIII,questions(Q)andsometimesarticles(Art.)].TCMeehan2012BlackwellPublishingLtdJournalofClinicalNursing,2905Ð2916 dignityandworth,aswellastheirownpotentialforinconsiderateattitudesandactions.AquinasÕselaborationofthepersonÕsunitarynatureandsimultaneouslydistin-guishableexplicitrealitiesprovidesapracticalperspectivefornursesintheircommitmenttoprovideholisticcare.AsRisjord(2010)observes,attentiontotheunitarypersonandthepersonÕsÔpartsÕisnotconceptuallyinconsistent.Thisperspectivecanhelpnursestobemoreeasilymindfuloftheunitarynatureofpatientsandthemselves,whilstatthesametimeattendingtodistinguishableandveryrealbio-physicalandpsycho-spiritualneeds.Historically,theexperienceofaninÞnitetranscendentrealityhasbeencentraltonursingintheWesternworldandiswidelyknowntohavebeenfundamentaltoNightingaleÕsexperienceofherselfasanurse.FollowingAristotle,AquinasreferstothisrealityastheÔÞrstmoverÕorÔÞrstefÞcientcause,towhicheveryonegivesthenameofGodÕ(1265Ð1274/1948,IQ2Art.3),whoseexistenceissupportedbynaturalreasonandreßectiononthedataofsenseexperiencesoffamiliarfeaturesoftheworld.BothNight-ingaleandthe19thcenturyIrishnurseswereinspiredandstrengthenedbytheirawarenessofaninÞnitetranscendentrealityintheirworkasnurses,inthelivesofthepeopletheyservedandintheirunderstandingofhealingandhealth(Sullivan1999).Healthashumanßourishing(DeYoungetal.2009)isreßectedinthedescriptionsofthenursesÕideasandtheirpracticeattitudesandactions.TheysharedwithNightingaletheassumptionthatnaturehealspatientsandthatthepurposeoftruenursingisÔtoputthepatientinthebestconditionfornaturetoactuponhimÕ(Nightingale1859/1970,p.133).Aquinas(1256Ð1259/1953Q11)alsoarguedthatitwasthenaturalpowerwithinthesickpersonthatbroughtthepersontohealthandthattheroleofhealthprofessionalsandtheirtreatmentswastoactasinstrumentstoaidnatureinhealing.CarefulNursingprofessionalpracticemodelThefourcategoriesconcernedwiththeattitudesandactionsofskillednursingasapublicservicewereusedtoconstructthenursingprofessionalpracticemodel,asshowninFig.3.Toconstructthemodel,thefourcategorieswereviewedasinterrelatedconcepts,andtheirsubcategoriesasinterrelateddimensionsoftheconcepts:thetherapeuticmilieuwithÞvedimensions,practicecompetenceandexcellencewitheightdimensions,nursingmanagementandinßuenceinhealthsystemswiththreedimensionsandprofessionalauthoritywithtwodimensions.ThenamesanddeÞnitionsoftheconceptsanddimensionswerederivedfromthehistoricaldata carefor selves restorativeenvironmentTrustworthyWatching reasoning interventionsin self-careProfessionalGreat Perfect skill comforProfessionalProfessional Figure3CarefulNursingprofessionalpracticemodel.DiscursivepaperCarefulNursingphilosophyandprofessionalpracticemodel2012BlackwellPublishingLtdJournalofClinicalNursing,2905Ð2916 butexpressedincontemporarylanguage.Thepositionsoftheconceptsandtheirdimensionsshowninthemodelrepresentapreliminaryproposalofrelationshipsamongstthem.Thus,themodelprovidesaconceptualfoundationforthesubse-quentdevelopmentofnursingtheoriesandcontributiontothedevelopmentofnursingscience.DeÞnitionsofthemodelconceptsandtheirdimensionsarepresentedinTables2Ð5.AlthoughthetermÔtherapeuticmilieuÕemergedindependentlyfromthehistoricaldataasaclearandcompellingconceptualimpression,ithasbeenevidentinthementalhealthnursingliteratureforsometimeanditsimpor-tancerecentlyemphasisedbyMahoneyetal.ThedeÞnitionofthetherapeuticmilieudimensionofcaritasfollowsAquinasÕsdescriptionofthetypeoflove,whichwascommonlytranslatedinLatinasfromtheduringthe1stcentury(Batten1948).ThetermcaritasisusedbecauseitsEnglishtranslationascharityhaslostitsoriginalmeaning.Caritasisalsoincludedinothernursingmodelswhereitisequatedwithcaring(Eriksson2002,Watson2006).However,thetermcaringisnotusedinCarefulNursingbecauseitscommonuseasasynonymfornursingisconfusing.WatsondeÞnescaritasasalovingconsciousnessrelatedtodeeperdimensionsofhumanexpe-rience.ErikssondeÞnescaritasmorespeciÞcallyasuncondi-tionalloveunitedwithcharityandrelatedtoÔagodorabstractotherÕ(p.63),whichissimilartotheCarefulNursingdeÞnition.Asaqualityofcaritas,nursesÕexperienceoftrueempathywithpatientsistheinsightful,practicalapproachtoempathyinnursingsuggestedbyMabasedonthephilosophicalresearchofEdmundHusserlÕsassistantEdithStein(1916/1989).DeÞnitionsofthedimensionsofthepracticecompetenceandexcellenceconceptthatincorporatestandardisednursinglanguages(Flanagan&Jones2007)andemphasiseaccuracy(Lunny2009)clinicaljudgement(Thompson&Dowding2009)andmonitoringcollaborativeproblems(Carpenito-Moyet2010)mayseemunlikelyanaloguesto19thcenturypractice.Nonetheless,theyreßectincontemporarytermstheprecise,innovativeandefÞcientpracticeactivitiesofthe19thcenturynurses. Table2TherapeuticmilieuconceptanditsÞvedimensionsTherapeuticThenursing-createdsurroundingandatmospherethatprovidesthecontextwithinwhichclinicalpracticeandmanagementtakeplace.Itismorethananenvironment.Itisaculturerichinhealinginterpersonalrelationships,cooperativeattentivenesstopatientsandphysicalfeatureswhichsoothpatientsandprovideforoptimumsafety.ItisfurtherdeÞnedbyitsÞvedimensions.CaritasNursesÕexperienceandexpressionofloveforpatientsasthebenevolentaffectionofonehumanpersonforanotherthatßowsthroughnursesÕinnerawarenessoftheirsharingintheinfusedloveofaninÞnitetranscendentreality.Itisalovegivenirrespectiveofthecharacteristicsofthepersonwhoisloved.Itisimpartial;unbiasedbypersonalinterestordesireforadvantage.Itdisposesnursestoattendtopatientswithkindness,compassion,greattendernessandajoyousspiritandtoexperiencemomentsoftrueempathywithpatients.Thesequalitiesariseintheinwardlifeandresideinthewill,notintransientemotions.NursesÕabilitytopreserveandprojectaninnersenseofcalmevenunderthemostadversecircumstances.Itiscloselyassociatedwiththeexperienceandexpressionofcaritasandcharacterisedbyagentlemanner,soothingvoiceandimpressionofquietdependability.ReßectedinnursesÕattitudesandactions,itiscommunicatednaturallytopatientsandothersinthetherapeuticmilieu.Itsetstheemotionaltoneofthepracticesettingandcountersanxietythatcanariseinresponsetostressfulsituations.Itengendersinnursesanattitudeofcomposedself-conÞdenceandalertnesstotheever-changingneedsofpatientsandpracticesituations.IntellectualengagementNursesÕabilitytoconceptualise,thinkcreativelyandcritically,andtheoriseaboutnursingpracticeusingnursingandotherrelatedknowledgeandtodothisinrelationtoknowledgeofthesocial,politicalandeconomiccontextoftheirpractice.BecausethelifeofthemindislinkedpartlytothecreativeinßuenceofaninÞnitetranscendentreality,itincludesusingcontemplationandempathyaswellasnaturalreason,logicalanalysisandscientiÞcresearchtoguide,implementandevaluatenursingpracticeandhealthcare.NursesÕcareforselvesandoneanotherNursesÕattentivenesstotheirownhealthandthehealthofoneanother.Thisisessentialtosupportingandaugmentingtheirtherapeuticcapacity.Itincludesthemnourishingtheirinwardlivesthroughthecreativeuseoftheirmindsandspendingatleastashorttimeeachdayininnerreßection,contemplation,meditationorprayer.Italsoincludesthemnourishingtheiroutwardlivesinrelationtoaspectssuchasnutrition,rest,relaxationandexercise,enjoymentofsocialactivitiesandhavingasenseofhumour.AsafeandenvironmentTheresultofactionsnursestaketoprotectpatientsfromphysicalharmandpromotehealing.Itismeticulouslycleanandorderly,freefrompotentiallyharmfulphysicalfactors,asquietaspossible,andmaximisestheeffectsofnaturallyoccurringhealingelementssuchaslight,freshairandcolour.Althoughcontemporarynursesmainlydelegatetoappropriateassistantsactivitiesthatensurecleanliness,safetyandorder,theyremainresponsibletoensurethattheseactivitiesarecarriedouttothehighestpossiblestandard.TCMeehan2012BlackwellPublishingLtdJournalofClinicalNursing,2905Ð2916 CarefulNursingisÞttinglydevelopedasaphilosophyandprofessionalpracticemodelratherthanasaconceptualmodeldevelopedaccordingtotheoreticallypredeterminedcriteria.Thephilosophyisimportantbecauseitbringstotheforeanursing-sensitiveunderstandingofthenatureofthepersonandtheinnatedignityandworthofallpersons.Althoughthemodelconceptsanddimensionswillbemostlyfamiliartonurses,itgroupsandemphasisestheminparticularways.ItbalancesthehealinginßuenceofattentivetendernessinnurseÐpatientrelationshipsandthenursingmilieuwithknowledgeablenursingjudgementandprecisioninclinicalskills.ItshistoryandemphasisonprofessionalauthorityremindsnursesoftheirlegacyasprimeprovidersofhealthcareforvulnerableandunderservedpopulationsandasatransforminginßuenceintheprovisionofhospitalBecausethephilosophyandmodelpresentenduringandwidelyrecognisedvalues,attitudesandactionsdistinctivelyinherentinskillednursingpractice,itislikelytobefoundrelevantbypracticingnurses.Itsimplementationcouldhelptominimiseincompetentandinsensitivepracticeaswellassustainalreadyexemplarypractice.ThemessageofCarefulNursingtocontemporarynursesisthatÔbrilliantprestigeinnursingÕistheirsforthetaking.But,atthesametime,itisfornursesinpracticetojudgewhetherCarefulNursingmatchestheirprofessionalidentity,theirculturalDNA.CarefulNursingisaphilosophyandprofessionalpracticemodelthatcancontributetoclosingtherelevancegapbetweennursingpracticeandnursingscience.Itproposesa Table3PracticecompetenceandexcellenceconceptanditseightdimensionsPracticecompetenceandexcellenceTheeightdimensionsofthisconceptencompasswhatisoftenviewedasclinicalcareandthenursingprocess.Itsattitudesandactionsarecarriedoutatleastwithcompetenceandalwayswiththeintentofdevelopingexcellence.GreattendernessinallthingsAnattitudeofsensitivity,lovingkindness,compassion,gentlenessandpatienceinattendingtoallexperiencesandneedsofpatients.ItislinkedtoawarenessofaninÞnitetranscendentrealityandmediatedthroughthetherapeuticmilieudimensionsofcaritasandcontagiouscalmness.ItisproposedtoinfuseallnursesÕclinicalattitudesandactionswiththehealingloveofaninÞnitetranscendentreality.ÔPerfectÕskillinfosteringsafetyandcomfortNursesÕmeticulousattentiontodetailinallaspectsofpatientcare,rangingfromthemostelementarypersonalcaretothemostcomplexclinicalinteractionsandtechniques.Italsoincludesprecisioninintellectualskills,suchastheorisingaboutprocessesofcare,clinicaldecision-makingandnursingdiagnosticaccuracy.ThequotationmarksaroundÔperfectÕemphasisethatalthoughfaultlessdetailcanbeessential,forexample,inmedicationadministration,perfectionisalsoanidealtobeworkedtowards.WatchingandAcompositeofnursesÕconstantvisualandperceptiveattentivenesstopatientsandalertnesstotheirbio-physicalandpsycho-spiritualconditionandneedsinordertobeawareasimmediatelyaspossibleofanychangesintheirconditionsorlevelsofresponsivenesstomedicaltreatments,collaborativeproblemsandnursinginterventions.Itprovidesthefoundationforclinicalreasoninganddecision-making.Clinicalreasoninganddecision-makingThecognitiveprocessesandstrategiesusedbynursestounderstandpatientdata,choosebetweenalternativesandmakenursingdiagnoses.Particularemphasisisplacedontheimportanceofnursingdiagnosticaccuracy.Theseprocessesarealsousedtoidentifyneedsforassessmentandinterventionbyotherhealthprofessionals,especiallyinrelationtoactualorpotentiallife-threateningsituations.Patientengagementinself-carePatientsÕparticipationindecision-makingabouttheirnursingneedsandcare,asthisisdesiredandpossibleontheirpart.ItincludesnursesÕencouragement,educationandon-goingsupportsothatpatientsmayachieveindependenceorrelativeindependenceincaringforthemselves.Nursingdiagnoses,outcomesandinterventionsThewidelyrecognisedinternational,standardisedlanguagesofnursingdiagnoses,nursingoutcomesandnursinginterventionsselectedincollaborationwithpatients.NursingdiagnosesarethespeciÞcclinicaljudgementsnursesmakeaboutactualandpotentialpatientresponsestohealthproblemsand/ormedicaldiagnosesthatarewithinthescopeofnursing.Thesearelinkedtodesirednursing-relatedpatientoutcomes.Nursinginterventionsareimplementedtoachievetheoutcomesandtheentireprocessiscontinuouslyevaluated.Patientfamily,friends,communitysupportiveparticipationincareTheencouragementandsupportnursesÕprovideforpatientsÕfamilymembers,friendsandcommunityservicestoparticipateinpatientsÕcare,accordingtopatientsÕwishesandasthisispossibleandappropriate.HealtheducationProvidingpatients,aswellassupportivepersons,withtheknowledgetheyneedtomaximisepatientsÕcareandengagementinon-goinghealthygrowthanddevelopment.Thismaybeformalorinformal,speciÞcorgeneralandincludesattentiontopatientsÕbroadknowledgeofhealthandneedsspeciÞctoparticularvulnerabilities,illnessesorinjuries.DiscursivepaperCarefulNursingphilosophyandprofessionalpracticemodel2012BlackwellPublishingLtdJournalofClinicalNursing,2905Ð2916 viewofthedomainandnatureofnursingresponsibility,itsconceptscanbedevelopedandrelationshipsamongstthemexaminedandtheoriesdeveloped.But,onlyifCarefulNursingbecomesaÔmusthaveÕmodelforprofessionalpracticeandincreasespublicsatisfactionwithnursingpractice,woulditsfulldevelopment,bothphilosophicallyandtheoretically,becomeworthwhile.RelevancetoclinicalpracticeTheCarefulNursingphilosophyandprofessionalpracticemodelprovidesastructure,processesandvaluesfornursingpractice,supportsnursesÕcontrolovertheirpracticeandcanbeusedinalltypesofpracticeareasandsettings.Itisconsistentwiththeprinciplesofnursingsharedgovernanceetal.2007)andcouldstrengthentheimplementa-tionofsharedgovernance,especiallythroughthedimensionoftrustworthycollaboration.Nursesreportthatimplemen-tationofthepracticecompetenceandexcellencedimensionsenablesthemtore-establishanddocumentclearlytheirdiscipline-speciÞcresponsibilitiesforpatientcareinmulti-disciplinarycontextsandthatthis,inturn,strengthenstheirprofessionalself-conÞdence(Murphy2011).Theuseofnursingstandardisedlanguagescandramaticallychangenursesfromanalmostexclusivefocusonmedicaldiagnosesandprocedurestoafocusthatgivesprominencetotheirprofessionalnursingresponsibilities(Jonesetal.2010,Mur-phy2010).Suchexperiencessupportnursesintheimportantprocessofestablishingmoreclearlytheirprofessionalpracticeboundariesinmultidisciplinaryhealthcaresettingsetal.TherelationshipbetweentheCarefulNursingconceptsofthetherapeuticmilieuandpracticecompetenceandexcel-lencebalancestwolong-standingthemesinnursingpractice;ÔtendernessandtechniqueÕ(Meyer1960,p.1);thatis,betweenthepersonaldispositionofnursesandtheirknowl-edgeandtechnicalskill.Further,incontemporaryhealthcaresettings,increasinglydominatedbycriticallyimportantbutoftenalienatingmachinesandcost-cuttingmeasuresthatcanbedehumanising,CarefulNursingprovidesanessentialcorrectivebysupportingnursesÕenduringroleinfosteringandmodellingrespectfortheinnatedignityandworthofall Table4ManagementofpracticeandinßuenceinhealthsystemsconceptanditsthreedimensionsManagementorpracticeandinßuenceinhealthsystemsTheinitiativenursestakeinplanningandmanagingpatientcareinhealthsystemsthroughsupportofnursingpracticeandthroughparticulartypesofrelationshipswithotherhealthcarepersonnel.SupportofnursingNursesÕengagementinsupportingandaugmentingimplementationofthetherapeuticmilieuandpracticecompetenceandexcellenceconceptsatallorganisationallevels,andincludingtheirownprofessionaldevelopmentrelatedtotheseconcepts.TrustworthycollaborationNursesÕrelationshipswithotherhealthprofessionalsandhealthcareadministratorswhereintheyoftentaketheinitiativeinaddressingpatientneedsandproblems.Theyarerespectedanddependedontorespondtoneedswithperceptiveness,prudentjudgementandfortitude.Problemsareaddressedwithpatience,respectfulnessandaneyetotheenhancementofhumanrelations.QuestioningofsituationsormethodsisdonewithÔexquisitetactÕandalwayswithdeterminationtoactinpatientsÕbestinterest.ParticipativeÐauthoritativemanagementNursesÕrelationshipswithnursingorcareassistantsandotherassistivehealthcarepersonnelwhereinassistantsworkaccordingtothedirectionsofprofessionalnurseswhohaveauthoritativeresponsibilityforassistantsÕcareofpatients.Nursesparticipatewithassistantstosomeextentinordertomodelhowtocarryouttaskswithskillandattitudeswhichreßectcaritas,contagiouscalmnessandgreattendernessinallthings. Table5ProfessionalauthorityconceptanditstwodimensionsProfessionalEncompassesthepower,relativeautonomy,intellectualandpoliticalinßuenceaswellastherespectthatprofessionalnursesareaccordedwithinhealthcaresystemsandsocietyat-largebecausetheyprovidetheirdistinctiveserviceverywell.Thisrecognitionhelpsnursestogrowinprofessionalself-conÞdenceandvisibilityand,inturn,enhancesfurthertheirdevelopmentofprofessionalknowledgeandskill.Professionalself-conÞdenceNursesÕstrong,yetgraciousandunassuming,senseofprofessionalafÞrmationthatarisesfromprovidingaskilledandvaluablepublicservice.Itisreinforcedbytheirdeepcommitmenttotheirprofessionalvaluesandskillsandconvictionthatthereisverylittleinthedomainofnursingservicethattheycannotaccomplish.ProfessionalRecognitionofthenursingprofessionatalllevelsofsocietyforitsdistinctandeffectivecontributiontohealingandhealth.IncontemporarysocietyitincludesnursesÕwillingnesstocontributetotheprofessionalliteratureandlaypressandengageinmediaandotherpublicdebatesonhealthissues.TCMeehan2012BlackwellPublishingLtdJournalofClinicalNursing,2905Ð2916 persons.ItcallsnursesÕattentiontowhatthisrolemeansforthemintermsoftheircareforthemselvesandoneanotherasprofessionalnursesaswellasforhowtheyengageinrelationshipswithpatients.CarefulNursingoffersaperspectiveonthemuch-discussednatureofthespiritualinnursingpractice.Itdoesnotguidenursestofocusonspiritualassessments,diagnosesandinterventions,althoughthesecouldemergenaturallyinpractice.Rather,throughthedimensionsofcaritas,conta-giouscalmnessandgreattendernessinallthings,itproposesthatthespiritualaspectofhumanlifepermeatesnurseÐpatientrelationshipsandisattheheartofhownursespractice.Thisperspectiveisconsistentwiththeviewthatnursescanprovidespiritualcarebybeingawareoftheirownspiritualnatureandthatoftheirpatients(Ellis&Naray-anasamy2009)andwithresearchindicatingthatspiritualcareoccursnaturallyinattentivenurseÐpatientrelationships(Carr2008).WhilstthemodelpresupposestheexistenceofaninÞnitetranscendentreality,italsoallowsforthefactthatnursesÕpersonalunderstandingofthespiritualrangesalongapsycho-spiritualcontinuum,whichcanextendfromahumanistoratheisticunderstandingwherethespiritualisunderstoodaspurelypsychological(Costello2009),toadeeplyreligiousunderstandingwhereaninÞnitetranscendentrealityisprofoundlyacknowledged.HospitalnursingdepartmentsintheUS(Weldon2009,Clayton2010,Ellerbe2011)andIreland(McMullinetal.2009)areÞndingthephilosophicalassumptionsandmodelconceptsrelevanttopractice.Theyarealsobeingusedtoinspireaparticularnursingpracticemodelinalargehealthcaresystem(Goedken2011).Theideaofcreatingatherapeuticmilieuforpatientsisattractivebecauseofitspotentialforcounteractingstressandpromotingsafety.Contagiouscalmnessisinvariablythemostpopulardimen-sionofthetherapeuticmilieubecausenursesÞndthatjustrememberingtheideahelpsthemtofeelandactcalmly.Theeffectivenessofcontagiouscalmnessinmanagingstressfulacutecaresettings,originallydescribedbyProudfoot(1983),hasbeenmorerecentlyconÞrmedbyBorgatti(2003).NursesÕcareforthemselvesandoneanotherhasbeenidentiÞedasanimportantprerequisiteinimplementingCarefulNursing(Goedken&Rocklage2010).Togetherwithcaritasandcontagiouscalmness,itcanstrengthennursesÕabilitytorecognisetheirowninnatedignityandworthandenhancetheirdispositiontolookuponthemselvesandoneanotherwithcompassionandkindness.Thiscouldhelptocountertheinternationalproblemofbullyingamongstnurses(Johnson2009).Clearyetal.(2010)alsoemphasisetheimportanceofÔcultivatinganenvironmentinwhichnursestreateachotherwithdignityandrespectÕ(p.335).Finally,thepotentialofCarefulNursingfornurse-ledtransformationofhealthcaresettingsdependsonnursestakingtheinitiativetoengageallhealthcarepersonnelinunderstandingitsphilosophyandconcepts.NursesÕtrust-worthycollaborationwithotherprofessionalsandparticipa-tiveÐauthoritativerelationshipswithhealthcareassistantsandsupportivepersonnelcanenhancetheworksatisfactionofallandcontributefurthertopatientsÕoverallsatisfactionwiththecaretheyreceive.ThisresearchreceivednospeciÞcgrantfromanyfundingConßictofinterestNoconßictofinterestisdeclaredbytheauthor.AbrahamA(2011)CareandCompassion?ReportofthehealthserviceOmbuds-manonteninvestigationsintoNHScareofolderpeople.FourthReportoftheHealthServiceCommissionerforEngland,Session2010–2011.TheSta-tionaryOfÞce,London.AmericanNursesCredentialingCenterMagnetRecognitionProgramNewWorld,SilverSpring,MD.AquinasT(1256-1259/1953)TheDisputedQuestionsonTruth,volII,QuestionsX-XX(translatedfromLatinbyJVMcGlynn).HackettPublishingCom-pany,Cambridge,MA.AquinasT(1265Ð1274/1948)SummaTheo-logica(translatedfromLatinbytheFathersoftheEnglishDominicanProv-ence).BenzigerBrothers,NewYork,NY.AtkinsonS[S.A.](1879)MaryAikenhead:HerLife,HerWork,andHerFriendsMHGill&Son,Dublin.BattenRJ(1948)Thevocabularyisimportant(Englishtranslationnote)InAquinasT.SummaTheologica,vol34(translatedfromLatinbyRJBatten).BenzigerBrothers,NewYork,NY,pp.4.BalyM(ed.)(1997)AsMissNightingale,2ndedn.BailliereTindall,BarrieG(1854)LetterfromGonzagaBarrietoJuliaBoodle,November13th.BarrieCollection,CharlesWoodwardMemo-rialRoomRareCabinet27,UniversityofBritishColumbia,Vancouver.BarrieG(1855a)LetterfromGonzagaBarrietoJuliaBoodle,March3rdor.BarrieCollection,CharlesWood-wardMemorialRoomRareCabinet27,UniversityofBritishColumbia,BarrieG(1855b)LetterfromGonzagaBarrietoJuliaBoodle,March25thBarrieCollection,CharlesWoodwardMemorialRoomRareCabinet27,DiscursivepaperCarefulNursingphilosophyandprofessionalpracticemodel2012BlackwellPublishingLtdJournalofClinicalNursing,2905Ð2916 UniversityofBritishColumbia,Van-BlackN(2005)Riseanddemiseofthehospital:areappraisalofnursing.ishMedicalJournal,1394Ð1396.BorgattiJC(2003)ThegiftofcontagiousNursingSpectrum,7.BradshawA(2011)Editorial:thefutureofclinicalnursing:meetingtheneedsofpatientsforcompassionandskilledJournalofClinicalNursing1797Ð1800.Carpenito-MoyetLJ(2010)NursingDiag-nosis:ApplicationtoClinicalPractice13thedn.Lippincott,Williams&Wil-kins,Philadelphia,PA.CarrT(2008)Mappingtheprocessesandqualitiesofspiritualnursingcare.QualitativeHealthResearch,686ÐCarrollMA(AMemberoftheOrderofMercy)(1866)LifeofCatherineMcAu-.D&JSaddler&Co.,NewYork,NY.CarrollMA(AMemberoftheOrderofMercy)(1883)LeavesfromtheAnnalsoftheSistersofMercy,vol2.CatholicPublicationSociety,NewYork,NY.ClaytonM(2010)ReportontheCarefulNursingTeam.DepartmentofNursing,MercyHospitalandMedicalCenter,Chicago,IL.ClearyM,HuntGE&HorsfallJ(2010)IdentifyingandaddressingbullyinginIssuesinMentalHealthNurs-,331Ð335.CodringtonW(1856)LetterfromWilliamCodringtontoJohnHall,April6thArchivesoftheSistersofMercy,CostelloJ(2009)Spirituality:whatdowemean?(Editorial).InternationalJournalofPalliativeNursing,263.CrokeMJ(1854Ð1856a)DiaryofSisterM.JosephCroke.ArchivesoftheSistersofMercy,Dublin.CrokeMJ(1854Ð1856b)LinesontheEasternMissionoftheSistersofMercy:FromOctober1854toApril1856ArchivesoftheSistersofMercy,Dublin.DeYoungRK,McCluskeyC&VanDykeCAquinas’sEthics.UniversityofNotreDamePress,NotreDame.DockL&NuttingA(1907)AHistoryofNursing:TheEvolutionofNursingSystemsfromtheEarliestTimestotheFoundationoftheFirstEnglishandAmericanTrainingSchools,Vol.III.GPPutmanÕsSons,London.DockL&StewartI(1920)AShortHistoryofNursing.GPPutnamÕsSons,NewYork,NY.DoonaME(1995)SisterMaryJosephCro-ke:anothervoicefromtheCrimeanwar,1854Ð1856.NursingHistory,3Ð41.DoyleMA(1897)MemoriesoftheCrimeaBurns&Oates,London.DunbarB,ParkB,Berger-WesleyM,Cam-eronT,LorenzBT,MayesD&AshbyR(2007)Sharedgovernance:makingthetransitioninpracticeandpercep-JournalofNursingAdministration,177Ð183.EllerbeS(2011)Suellyn’sNursingNotesCarefulNursingNewsletter2,NursingDepartments,SaintClareÕsHealthSystem,Sussex,NJ.EllisHK&NarayanasamyA(2009)Aninvestigationintotheroleofspiritualityinnursing.BritishJournalofNursing,886Ð890.ErikssonK(2002)CaringscienceinanewNursingScienceQuarterlyFawcettJ(2000)AnalysisandEvaluationofContemporaryNursingKnowledge:NursingModelsandTheories.FADa-visCompany,Philadelphia,PA.FawcettJ(2005)ContemporaryNursing,2ndedn.FADavisCom-pany,Philadelphia,PA.FitzgeraldD(1855)CondentialReportofDavidFitzgeraldonTheNursingSys-temsinTheCrimeanHospitals(copy)ArchivesoftheSistersofMercy,Dublin.FlanaganJ&JonesDA(2007)Nursinglanguageinatimeofchange:capturingthefocusofthediscipline.InternationalJournalofNursingTerminologies&Classications,1Ð2.GeorgesJM(2011)Evidenceoftheunspeakable,biopower,compassion,andnursing.AdvancesinNursingSci-,130Ð135.GoedkenJ(2011)Historyinthemaking:mercynursingprofessionalpracticemodel(conferencepaper).Nursing:BuildingonOurHeritage,DesigningOurFuture,St.Louis,MO,12September.MercyHospital,St.Louis,MO.GoedkenJ&RocklageMR(2010)NursingModelWebinar,12thJulySistersofMercyHealthSystem/CHAUSA,St.Louis,MO.HarnettMV(AMemberoftheOrderofMercy)(1864)TheLifeofRev.MotherCatherineMcAuley.JohnFowler,JohnsonSL(2009)Internationalperspec-tivesonworkplacebullyingamongnurses:areview.InternationalNursing,34Ð40.JonesD,LunneyM,KeenanG&MoorheadS(2010)Standardizednursinglan-guages:essentialforthenursingwork-AnnualReviewofNursing,253Ð294.KrippendorffK(2004)ContentAnalysis:AnIntroductiontoItsMethodology2ndedn.Sage,ThousandOaksCA.LunnyM(2009)Assessment,clinicaljudgement,andnursingdiagnoses:howtodetermineaccuratediagnoses.InNursingDiagnoses2009–2011manTHed.).NANDAInternational,Wiley-Blackwell,Chichester,pp.3Ð17.LynaughJ(1996)Editorial.NursingHistory,1.S(2006)Closenessanddistanceinthenurse-patientrelation.Therele-vanceofEdithSteinÕsconceptofNursingPhilosophy,3Ð10.MacKusickCI&MinickP(2010)Whyarenursesleaving?Findingsfromaninitialqualitativestudyonnursingattrition.MEDSURGNursing,335Ð340.MahoneyJS,PalyoN,NapierG&Giord-anoJ(2009)Thetherapeuticmilieureconceptualisedforthe21stcentury.ArchivesofPsychiatricNursingMcAuleyMC(1832)Hand-WrittenManu-scriptoftheOriginalRuleofTheSis-tersofMercy.ArchivesoftheSistersofMercy,Dublin.McMullinR,MurphyS&MeehanTCarefulNursingProject.DepartmentofNursing,St.VincentÕsUniversityMedicalCentre,McNamaraM,FealyGM,CaseyM,Gera-ghtyR,JohnsonM,HalliganP,TreacyP&ButlerM(2011)Boundarymatters:clinicalleadershipandthedistinctivedisciplinarycontributionofnursingtomultidisciplinarycare.nalofClinicalNursing,2502Ð3512.MeehanTC(2003)CarefulNursing:amodelforcontemporarynursingprac-TCMeehan2012BlackwellPublishingLtdJournalofClinicalNursing,2905Ð2916 JournalofAdvancedNursingMeehanTC(2005)Intheshadowsofnursinghistory.ReectionsonNursingLeadership,32Ð33,42.MeehanTC(2006)CarefulNursingModel,TheoreticalBasesofNursingModuleUniversityCollegeDublin,Dublin.MeyerGR(1960)TendernessandTech-nique:NursingValuesinTransitionUniversityofCaliforniaInstituteofIndustrialRelations,California,CA.MiltonCL(2011)AnethicalexplorationofqualityandsafetyinitiativesinnurseNursingScienceQuarterlyMooreMC(1841/1995)AlifeofCatherineMcAuley(theBermondseyManu-script).InCatherineMcAuleyandtheTraditionofMercy(SullivanMCed.).UniversityofNotreDamePress,NotreDame,pp.99Ð129.MooreMC(1854Ð1856)Annals,Book1,ConventofOurLadyofMercy,Ber-.ArchivesoftheConventofMercy,Bermondsey,London.MooreMC(1855)Hand-WrittennotesandLettersfromScutariBarrackHospitalArchives,St.MaryÕsConventofMercy,MurphyD(1847)Theorderofmercyanditsfoundress.TheDublinReview,1Ð25.MurphyS(2010)ReportontheImplemen-tationofCarefulNursing.DepartmentofNursing,St.VincentÕsUniversityHospital,Dublin.MurphyS(2011)NursingDiagnosis,NursingInterventionsandNursingOutcomes(NNN):TheirPurposeandHowtoImplementtheminaPracticeTheoreticalBasesofNursing.UniversityCollegeDublin,NeumannMI(1969)TheLettersofCath-erineMcAuley:1827–1841.Helicon,Baltimore,MD.NightingaleF(1856)LetterfromFlorenceNightingaletoMaryClareMoore,April29th.ArchivesoftheConventofMercy,Bermondsey,London.NightingaleF(1859/1970)NotesonNurs-ing:WhatItIsandWhatItIsNotDuckworth&Company,Ltd.,London.NightingaleF(1863)LetterfromFlorenceNightingaletoMaryClareMoore,October21st.ArchivesoftheConventofMercy,Bermondsey,London.ProudfootM(1983)Contagiouscalmness:asenseofcalmnessinacutecaresettings.TopicsinClinicalNursing,18Ð30.RisjordM(2010)NursingKnowledgeWiley-Blackwell,Chichester.RoemerJ(2006)ReportsonCarefulNurs-ingtoSeniorLeadershipTeamandNursingDivision.MercyHospitalandMedicalCenter,Chicago,IL.RossWD(1915)TheWorksofAristotle(translatedbyWDRoss).OxfordUni-versityPress,Oxford.SellmanD(2011)ProfessionalvaluesandMedicine,HealthCareand,203Ð208.SteinE(1916/1989)OntheProblemof.ICSPublications,Washing-ton,DC.SullivanMC(1995)CatherineMcAuleyandtheTraditionofMercy.UniversityofNotreDamePress,NotreDame.SullivanMC(1999)TheFriendshipofFlorenceNightingaleandMaryClare.UniversityofPennsylvaniaPress,Philadelphia,PA.SullivanMC(2004)TheCorrespondenceofCatherineMcAuley1818–1841.FourCourtsPress,Dublin.TaylorFA(ALadyVolunteer)(1856)EasternHospitalsandEnglishNurses,volsI&II.Hurst&Blacket,London.TaylorFA(ALadyVolunteer)(1857)EasternHospitalsandEnglishNurses:TheNarrativeofTwelveMonths’ExperienceintheHospitalsofKoulaliandScutari.Hurst&Blacket,London.TerrotSA(1898)ReminiscencesofScutariHospitalsinWinter1854–1855Stevenson,Edinburgh.ThompsonC&DowdingD(2009)tialDecisionMakingandClinicalJudgementforNurses.ChurchillLiv-ingstoneElsevier,Oxford.WatsonJ(2006)CarativefactorsÐcaritasprocessesguidetoprofessionalnursing.Klinisksygeplege(DanishClinicalNursingJournal),21Ð27.WeberRP(1985)BasicContentAnalysisSagePublications,Inc.,NewburyPark,WeldonJ(2009)PresentationonCarefulNursingtoSeniorLeadership18th.DepartmentofNursing,MercyMedicalCenter,DesMoines,IA.WhittyMV(1854)LetterfromMaryVin-centWhittytoWilliamYore,October.ArchivesoftheSistersofMercy,WilliamsJ(2011)Overview,DignityandNutritionInspectionProgramme.CareQualityCommission,NewcastleuponTyne,pp.3Ð5.DiscursivepaperCarefulNursingphilosophyandprofessionalpracticemodel2012BlackwellPublishingLtdJournalofClinicalNursing,2905Ð2916 TheJournalofClinicalNursing(JCN)isaninternational,peerreviewedjournalthataimstopromoteahighstandardofclinicallyrelatedscholarshipwhichsupportsthepracticeanddisciplineofnursing.Forfurtherinformationandfullauthorguidelines,pleasevisitJCNontheWileyOnlineLibrarywebsite:http://ReasonstosubmityourpapertoJCN:High-impactforum:oneoftheworldÕsmostcitednursingjournals,withanimpactfactorof1118Ðranked30/95(Nursing(SocialScience))and34/97Nursing(Science)inthe2011JournalCitationReports(ThomsonReuters,2011)Oneofthemostreadnursingjournalsintheworld:over19millionfulltextaccessesin2011andaccessibleinover8000librariesworldwide(includingover3500indevelopingcountrieswithfreeorlowcostaccess).EarlyView:fullycitableonlinepublicationaheadofinclusioninanissue.Fastandeasyonlinesubmission:onlinesubmissionathttp://mc.manuscriptcentral.com/jcnur.Positivepublishingexperience:rapiddouble-blindpeerreviewwithconstructivefeedback.OnlineOpen:theoptiontomakeyourarticlefreelyandopenlyaccessibletonon-subscribersuponpublicationinWileyOnlineLibrary,aswellastheoptiontodepositthearticleinyourpreferredarchive.TCMeehan2012BlackwellPublishingLtdJournalofClinicalNursing,2905Ð2916