A framework for caring in the human resource management process of nurses

The aim of this paper is to describe the provision of a human value system in nursing m anagem ent that would lead to an environment conducive to quality of care to nurses. Caring is a complex phenomenon with caring concepts which emphasized the human element in human resource management in the health serv­ ices. Watson (1985) focused on the philosophical and spiritual basis of caring. The ten carative factors as described by Watson (1985) were used as a framework for the application o f caring to the human resource management process in nursing. This framework ena­ bles a basis for the development of a caring environ­ ment for the nurse manager, in which the nurse could experience caring. It served as a point of departure for a research study undertaken during 2000 on caring to the caregivers in health services. Opsomming


Introduction
Concepts of caring in health services are well defined and described in the literature.Watson in M olzahn (1996:247) views caring as 'the m oral ideal o f nursing whereby the end is protection, enhancement and presentation o f human dig n ity '.The nature o f caring with emphasis on the nurse/pa tient interaction has been researched and described by vari ous authors.For the purpose of this paper the em phasis will be on caring in the human resource m anagem ent process of nurses, according to the caring theory of Watson (1985).
Lim ited emphasis is placed on the im plem entation of caring concepts in hum an resource management in nursing accord ing to Shriber and Larson (1991:57).M ost literature concen trates on patient's expectations of caring, with little descrip tion o f the how nurses view caring with the result that too little em phasis is placed on the meaning of caring in human resource management o f nurses (Nyberg 1993:11, Boykin andSchoenhofer 1990:149).This paper explains a fram ework for the application of W atson's Caring Theory in the human re source management process of nurses.

Significance of caring in human resource management in nursing
In the current health care services in South Africa more em phasis is being placed on quality care than in the past.The key to quality in nursing services is, according to Molzahn (1997: 247) the creation of a caring culture in health care organizations.Within a caring culture, the human dignity of both patients and staff will be preserved.Bringing the ethic of care and responsibility into dialogue with the general pub lic will ensure human rights, a practice of commitment and quality nursing care (Molzahn 1997:249).
The research findings by M innaar (1994:85) on the impor tance o f the concept of caring to nursing personnel, indicated that nurse managers are aware of the importance of caring in nursing management but nurses did not voice experiences of being cared for in the m anagement environment of the health services.Nurses indicated that their experience of caring in the nursing management environm ent were only moderate to poor.Caring is a complex phenomenon and the importance of caring concepts in hum an resource m anagem ent in the health services need to be emphasized.
The application of the caring theory of watson (1985) in the hu man resource management proc ess of nurses b a framework Watson (1985:7) describes caring in nursing practice as a therapeutic interpersonal process with the assum ption that caring can be effectively demonstrated and practiced only in terpersonally.Watson (1985) em phasizes the fact that caring is a deeply human activity as described by Kyle (1995: 507).Caring has existed in every society.A caring attitude is not transmitted from generation to generation by genes, but by the culture of the caring professions.Nurse managers play a major role in setting the culture of a health service.There is often a discrepancy between theory and practice and the rea son may be the difference between scientific and humanistic values (Watson 1985: 12).Watson (1985: 8) identifies basic assumptions for a science of caring as follows: The seven basic assumptions for a science of caring of watson (1985:8) Watson (1985:10) identified ten carative factors in nursing practice: These ten factors form the fram ework for under standing and studying the science o f caring.Watson (1985:12) emphasized that no one o f the factors could be implemented on its own, and stressed the im portance of the first three carative factors in providing a philosophical foundation for caring in nursing.The provision of a human value system in nursing m anagem ent would give nurses an environm ent con ducive to quality nursing care.Nurses should nurture hope in their patients and the nurturing of hope in the management environm ent could contribute to the willingness of nurses to instill hope in their patients and contribute to the recovery process.
The ten carative factors for a science of caring of watson (1985:9) Watson (1985:10) stated that the recognition and develop ment of feelings helped in the self-actualization and growth of a person.She singled out the main responsibility of human resource m anagement as being to help nurses towards growth and self-actualization and to enable them to encourage growth in others.According to W atson (1985:10) the first three fac tors are interdependent and function together in a process that promotes positive changes in the individual.These carative factors are valuable reminders o f the steps we must take i f we are to give others what they really need from us as caregivers (Stickland 1996:10).
Factor 1 The formation of a humanistic-altruistic system of values.
The formation of a hum anistic-altruistic system of values in nursing management is the basis for caring and should guide all management decisions.Caring leaders establish with each nurse a dynamic process o f exchanges, interaction and open communication.Caring has been found to be a complex set of affective, cognitive and interactional elements which are put into purposeful action between nurse managers and nurses (Bergen 1999:39).Nurse managers should work at rem em bering nurses' names and discovering each one's unique pro-Curationis fessional and personal needs.The follow ing are universal hum an needs in any interactive situation: Friendliness In the human resource environm ent friendli ness is a basic and sometimes neglected caring concept.G reet ing the nurses in a friendly way or addressing them by their names shows the nurses that nurse managers are interested in them as individuals (Brand 1994:69).Kindness To say that caring is being nice or kind is to miss the cognitive aspects of caring (Valentine 1989: 30-31).K ind ness is a part of the other caring elem ents in a caring rela tionship.Nurse managers could show kindness by accepting the nurse as an individual with specific needs.Nurse m anag ers should assess the needs of nurses and try to accommodate these needs (Wadas 1993:40).

Concern
People are the greatest asset of any organisa tion.Caring human resource management affirms the unique ness, im portance and potential o f every individual nurse.
Caring for and about the nurses combines justice, equity and respect with genuine concern.W hen nurses feel valued and appreciated by the nurse manager, they are motivated to give their best when they care for patients (Wolf 1986:86).Love According to Brandt (1994: 69) good management is largely a m atter of love.M anagers must have the courage to care for the good things the health service can do in the com munity, as well as caring for the caregivers.Dedication to the com m on goal of nursing is what patient care is all about.M anagem ent of nurses is like being in love and the courage to care is the challenge for health services of today.Nurses should be viewed as partners rather than subordinates.Nurse managers should see the needs of the employees (nurses) as no different from their own needs.Caring is seen by Fromm (1957) as a basic element of love, but it must be infused with knowledge (M orrison & Cowley 1999:30) Caring should be grounded in humanistic values such as kind ness, empathy, concern and love for others and altruistic val ues that bring meaning to one=s life through relationships with other people (Watson 1985:12).

Factor 2 The instilling of faith and hope
The emphasis on faith and hope in the human resource m an agem ent process should be a natural development from the humanistic-altruistic system of values.The instilling of faith and hope should ensure a professional and positive environ ment in nursing m anagement and is never a completed proc ess.The nurse manager should instil faith and hope in each one o f her/his nursing personnel.The instilling of faith and hope would contribute to the most important caring task in human resource management, which is to encourage nurses to believe in their own potential to care for patients and their families (Wadas 1993:4).The instilling o f fa ith and hope in patients is basic to the healing process and helps to deter mine the outcome o f disease.A person's m ind and soul should be inspired before the illness can be treated (Watson 1985: 13-16).

Factor 3 The cultivation of sensitivity to oneself and to others
Sensitivity to oneself and to others is grounded on the form a tion o f a humanistic-altruistic system of values with the aim o f satisfaction, comfort, and a high level of health (in nursing managem ent this means low stress levels and no burnout of nurses).Burnout results when the individual is not allowed to develop, and when the individual works in an organization that is only bottom line driven.W ithout the cultivation of sensitivity to oneself and to others, nursing care would fail, because nurses need to be sensitive towards their own needs and to the needs of others to develop the ability to learn about another person's view of the world (Watson 1985:17).
The nurse m anager should try to help nurses to develop a sensitivity towards their own feelings.People who are not sensitive towards their own feelings, might find it difficult to be sensitive and responsive to feelings of others.If nurses fail to be hum an in sensitive situations, then they fail in their nursing task, to nurse and care for the p atien t (W atson 1985:19).
In a m anagement environm ent sensitivity provides a climate for understanding and acceptance of nurses as individuals with individual needs.Moving towards higher levels of m a turity and self-actualization is only possible when nurses are accepted and understood by nurse managers.Watson (1985:19) believes that the more self-actualized a person is, the higher is his/her quality of living.Self actualization is the need to maximize one's potential.Nurse managers have a m ajor role to play in helping nurses towards self actualisation.M anage m ent perform ance is an opportunity for m anagers where, nurses could be encouraged towards further developm ent of potential.Individual needs could be identified and career goals could be set, and planning towards career goals could be fa cilitated.
Com petence is a m ajor desire o f hum an beings.In human resource management of nurses, insistence on com petence is of special importance, since patients expect high levels of competence from nurses.Nurse managers could help to im prove the com petence of nurses by providing means for pro fessional growth and development.
Factor 4 The development of a helping-trusting relationship between the care-receiver and the caregiver to ensure a relationship of quality.
A helping-trusting relationship evolves from a certain qual ity of congruence, empathy, warmth, communication and lis tening.Patients and others that feel another person really cares about them are more likely to establish a trusting relationship with that person.The first three factors namely, the form a tion o f a hum anistic-altruistic system of values, the instilling of faith and hope, and the cultivation of sensitivity to oneself and to others, determine the quality of the relationship.The nurse who experiences caring in the human resource m an agement situation will be more willing to discuss sensitive inform ation concerning herself and her problems and needs with the nurse manager, with the possibility that nurses could becom e more sensitive to the needs of patients under her/his care.Watson (1985:25) states that patients showed signs of receiving high quality care when they experienced good in terpersonal relations with nurses.A basic element of quality care is the developm ent o f a helping-trusting relationship (M olzahn 1997:247).Knowledge of the other person is of utmost importance.For the helping-trusting relationship cer tain attitudinal processes, for example, sensitivity to self, open ness and altruism, are prerequisites.Other processes that are interrelated to the helping-trusting relationship are as fol lows: Congruence is a critical element in the helping-trusting re lationship and is tied to sensitivity to self and others that in cludes an openness towards feelings.Guidelines for congru ence in nursing management are honesty at all times, and genuineness and openness on the side o f the nurse manager.Honesty must be shown in identifying problems in the health services and a readiness to communicate with nurses (Watson 1985:26).

Empathy
is a basic elem ent essential for the de velopment of a helping-trusting relationship.Empathy refers to the ability to experience the other person=s personal world and feelings.It includes the ability to communicate under standing to the other person.According to Watson (1985:28) the working conditions of nurses could change positively for nurses with the understanding and acceptance of nurses in the hum an resource m anagem ent environm ent (Yegdich 1999:84).Nurse m anagers should show appreciation and understanding of the work that nurses do.W armth refers to the degree to which the nurse m anager communicates caring to others.Warmth could be com municated to others in a variety of ways, for example, gestures, posture, tone of voice, touch and facial expressions (Watson 1985:32) These aspects are important aids that could be used by the nurse m anager in handling difficult human resource management aspects such as dealing with discipline and handling of grievances.Chappel (1993:218) as cited in Kerfoot (1997:51) notes that people from happy, loving fam i lies will do anything for each other as will people who work for happy loving companies.

Communication
with effective feedback to nurses will ensure the development of effective helping-trusting relation ships.Open communication helps to facilitate a trusting re lationship in nursing between nurse m anager and nurses (Watson 1985:23).The nurse manager should m aintain open communication channels with staff (Dyson 1996:263).The m ajority o f grievances in nursing are the direct result of management failing to listen to their staff ("Potgieter & Muller, 1998:14-23).Effective listening skills should be developed by nurse managers to ensure a helping-trusting relationship in the human resource management environment of nurses (Strickland 1996:6-9).
Nurse managers should concentrate on maintaining relation ships and avoiding thoughtless things that might damage the relationship between m anagement and nurses.Nurse manag ers should concentrate on setting the right example to staff, the caring role model, and being consistent in temperament so that nurses know how to read the nurse manager.The nurse m anager must always try to be fair, impartial, and consistent regarding staffing matters, for example, applying the rules, executing discipline procedures and rewarding nurses.A sin cere personal interest in nursing staff as individuals, and coun selling staff on matters that affect their jobs are important Factor 5 The promotion and acceptance of the expression of positive and negative feelings.
This factor forms an inherent part o f the helping-trusting re lationship and encourages a move to a deeper and more hon est level of the relationship between nurse management and nurses.This factor seems to be so basic that it could easily be taken for granted.In reality this factor is often not recog nized or used in the m ost effective way.It includes aspects such as communication and interaction between people.This factor is im portant for the nurse manager in the human re source m anagem ent position because communication and in teraction form part of the functions of nurse managers (Watson 1985:41).
Factor 6 The systematic use of the scientific problem-solving method for decision-making.
A creative problem -solving approach is the basis of a science of caring in patient care.The emphasis is on the art and sci ence of caring in nursing.The use of the scientific problem solving decision-m aking m ethod is as important as the hu man caring approach in nursing.According to Watson (1985), a student in nursing needs additional knowledge and under standing for the application of the scientific problem-solving decision-making method in nursing.Firstly nurses must have the conceptual and theoretical understanding of a phenom enon or a problem, and theoretical background to solve the problem (Nyberg 1989:12).N urse managers could set the example for scientific problem -solving in nursing by using this method when solving patient care problems, together with the nurses.caring strategies in nursing m anagem ent (Ray 1995:56).
The scientific problem -solving decision-making process tries to solve problems or answer questions and was introduced as a method of nursing that considers an in d iv id u a ls physical, social, psychological reactions to disease, the individual as a member of society with his own stresses which may affect her/his reaction to disease (M orrison & Cowley 1999:26).Nursing, as a science o f caring, becomes a more complete science and profession as it incorporates systematic use of the scientific problem solving method (Watson 1985: 59).
The scientific process of nursing includes the following proc esses: Assessm ent Observing, distinguishing relevant from irrel evant data, distinguishing important from unimportant data, validating data, organizing data and categorizing data; Analysis/diagnosis Finding patterns and relationships, mak ing inferences, stating the problem and suspending judgm ent; Planning Generalizing, transferring knowledge from one situ ation to another, developing evaluative criteria and hypoth esizing; Im plem entation Applying knowledge and testing hypoth Evaluation Deciding whether hypotheses are correct, m ak ing c riterio n -b a sed evaluations and ju d g m e n ts (W atson 1985:65).
Factor 7 The promotion of interpersonal teaching and learning.
Learning is more than receiving information, as it also de pends on the nurse's ability to accurately scan, assess, for mulate, appraise, plan, implement, evaluate and to make a decision.Nurse managers have a major task to ensure that all nurses are sufficiently skilled and knowledgeable to cope with m odem demands.The factor of interpersonal teaching and learning is part of nearly all nursing interventions with pa tients/nurses/others (Grigsby & M egel 1995:441).W atson (1985:74) identifies seven clinical care phases for problem solving in the interpersonal teaching-learning process:

Scanning
Identify the major problems and goals that are important to the specific person.Discover potential as well as actual problems within the other person=s fram e work according to his/her own perceptions.The nurse m an ager could use scanning to help with identification of staff problems in time, and to be able to plan interventions (Watson 1985:76).
• Formulating This includes exploring the issue of con cern and examining the significance o f the problem together with the nurse.

A ppraising
A joint decision about the problem is taken, with willingness to solve it on both sides, including nurse managers and nurses (Watson 1985:77).

P roblem solving
This phase involves the willingness to solve the problem, to take action and to learn from the expe rience.The helping-trusting relaljonship and interpersonal processes become critical elements at this stage.The nurse m anager and nurses should display honesty, empathy, warmth and a com m itm ent towards learning and problem -solving in the nursing management environment (Watson 1985:78).

Planning
Includes joint decision-making by nurse m anagers and nurses and the identification of ways in which to solve the problem.Active participation on both sides to generate alternatives is of critical importance.

Im plem enting
This stage includes traditional learning such as cognitive information.The nurse manager with her/ his higher level of experiences should take the lead and teach the nurses how to implement decisions; Evaluation At this stage whether or not the learn ing did in fact takes place is investigated (Watson 1985: 78).
Factor 8 The provision of a supportive, protective, and (or) corrective mental, physical, socio cultural, and spiritual environment.
The goal of this carative factor is to strengthen the self-con cept and self-worth of nurses through a holistic approach to the health environment.This carative factor em phasizes the low er needs of Maslow.The nurse m anager could support the nurses towards motivation and success by acknowledgment o f their achievements.The im plementation of m anagem ent by objectives and the provision of guidelines to attain the ob-eses; jectives could motivate the nurses.The following are im por tant for the provision of a supportive, protective, and (or) cor rective mental, physical, socio-cultural, and spiritual envi ronm ent as described by Watson (1985:80)

Comfort
The nurse manager could control stress and pro vide comfortable working conditions by ensuring that nurses are well equipped for the task ahead and that enough com pe tent nurses are employed with enough equipment and resources to care for the patients (Watson 1985:88).

Privacy
This is a m ajor factor in caring in the sense that the privacy of an individual must always be respected.Depersonalisation that sometimes occurs during hospitalisa tion contributes to the factor of privacy in nursing.Privacy is often linked to health and well being.M aslow 's early find ings showed that healthy people have a strong liking for pri vacy or even a need for it.Privacy maintains the nurse's hu man dignity and integrity.A violation of privacy could mean a violation o f a nurse's dignity.All personal inform ation should be treated as confidential by the nurse m anager and the nurses (Watson 1985: 93).Safety This is a basic hum an need, a basic function of the nurse m anager and the nurse is to ensure the safety of all individuals working or users of the service, and a critical con sideration in the health of patients.The nurse m anager and the nurses must be constantly on the alert to safety factors in health services for both the patients and nurses (Watson 1985: 96-98).Environm ent This factor includes more than safety and com fort.It is the provision o f support, protection and correction of the environment.Cleanliness is closely linked with quality care.Watson (1985:98-100).Nurse managers should visit the units in the hospitals and acquaint themselves with the con ditions under which nurses have to work.Nurse m anagers should ensure that the environment in the hospital is condu cive to health and safety of all concerned.
Factor 9 Assistance with the gratification of human needs.
It is important to the nurse managers and the nurse's role to help others in their daily activities as well as facilitating growth and d e v e lo p m e n t o f p a tie n ts to w a rd s h e a lth .W atson (1985:104) classified M aslow 's needs as follows, for the pur pose of nursing: Low er order needs (survival needs) that include food and w a ter, elim ination and ventilation and the functional needs that include activity and rest (Watson 1985:105).H igher order needs (integrated needs) that include aspects such as success and affiliation and the growth-seeking needs that include needs of self-actualisation (Watson 1985:106).This order of needs could be useful to the nurse m anager to assess the individual needs of nurses.It is im portant for nurse managers to assess the needs of nurses towards self-actuali sation as well to provide opportunities for fulfilm ent of these needs.The most im portant aspect for nurse m anagers is to mend broken spirits and to develop a supportive work atm os phere that encourages worker involvement and fosters em ployee growth (Watson 1985: 198).
The goal of nurse managers is to create an environment in which nurses may live up to their potential or at the highest level of need attainment.Nurse managers should care about what nurses think, feel and believe.Nurse managers, who still believe in old outdated approaches, like using threats and intimidation to get results, need to rethink their position.Caring is the chief building block upon which new business and professional relationships should be built (B ickham 1996:47).

Factor 10
The allowance for existential-phenomenological forces.
This factor emphasizes understanding of people from their frame of reference in order to help the person to find his or her own meaning and solution to problems.The understand ing o f people from their frame of reference is an ideal, and different situations will allow different levels of caring in the health services (Watson 1985:209).Nurse managers should try to understand the nurses from their (the nurses) frame of reference for better identification of the individual needs and problems of nurses.

Conclusion
The importance and the need for caring in patient care envi ronments demand the application of caring concepts in the human resource management process of nurses.The descrip tion of the ten caring factors from W atson's theory in relation to the human resource m anagement process could be used by nurse managers as a framework in which caring in nursing management could be implemented.This framework enables development of a caring environm ent in nursing management in which nurses could experience caring.Watson (1985) cited in Boykin and Schoenhofer (1990:149 155) provides insight as to what it entails when a nurse is caring for a patient.Watson mentions that caring is expressed through commitment, compassion, confidence, conscience and competence.These caring concepts are of considerable im portance in the human resource managem ent process in nurs ing.Health services should provide a human environment for nurses to practise nursing with the enactment of values such as commitment, support and the development of human re sources, sensitivity to the needs of nurses, helping and trust ing relationships with nurses and the provision of a safe and protective environment.Kerfoot (1997:50) emphasised that a leader's greatest gift to followers is a community of caring.

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