Family Caring and

Caring in Nursing
Jacinthe 1. Pepin

Knowledge concerning family caring is developing within the caregiving literature while knowledge of caring is
growing separately in the nursing literature. Both nurses (identified with caring) and family carers (identified with
caregiving) experience a division of the affective and the instrumental dimensions of caring. Moreover, a historical
perspective reveals that caring in nursing and family caring are faced with a common dilemma: caring in a society that
undervalues caring. It is suggested that nurses, in the process of reconciling the dimensions of caring for their profession,
consider family caring as a unified experience as well.

aring and caregiving are viewed by scholars as two

distinct areas of knowledge development. Publications related to each have mushroomed at approximately the same pace since 1975. The caregiving
literature has been developed mainly by gerontologists, nurses, sociologists and social workers to describe the care
given by family members to elderly or chronically ill persons
with the consequences for primary caregivers. The caring literature has been furnishedby nurses, feminists of various disciplines
and philosophers. Anthropological,phenomenologicaland nursing perspectives have been used mainly to describe caring in the
nurse-client relationship; psychological and feminist perspectives portray caring as one of womens ways of expression, while
ethics and philosophy perspectives have provided more general
perspectives.
The purpose of this paper is to examine the professional
conceptualization of caring and caregiving. Given the two
bodies of literature, one wonders if caring and caregiving are
conceptualizedas two separate entities and if this separation best
represents the reality experienced by both nurses and family
carers. Considering the importance attributed recently to caring
and family caregiving in the nursing discipline, it is worth
examining the two concepts together. In fact, reflecting on the
assumptions upon which nursing knowledge is being built is an
essential part in furthering nursing knowledge.
The approach will first consist of a brief review of the meanings
and expressions of caring through nursing and feminist history
texts. Second, writings that explicitly deal with conceptions and
terminology of caring and of caregiving for the elderly will be
examined considering the two dimensions of caring described by
Graham (1983) as love and labor.
The visibility of caring as a concept and a phenomenon has
rapidly increased in the nursing literature. In a desire to identify
nursings unique perspective, Leininger (198 l), Watson (1979,
1985) and others have distinguishedbetween cure and care. They
identify caring as the essence of nursing and the central and
unifying domain for the body of knowledge and practices in
nursing (Leininger, 1981, p. 3). Watson (1979) suggested a
Volume24, Number2, Summer 1992

*
balance of science and humanism in nursing in order to form the
science of caring. Benner and Wrubel(1989) proposed the expert
practice of nursing based on the primacy of caring as an alternative
approach to health promotion, restoration and curing practices.
The concepts of caring, nurturance and connectedness in
womens lives have been studied in parallel from a feminist
perspective. Gilligan (1983) noted that women not only define
themselves in a context of human relationships but also judge
themselves in terms of their ability to care (p. 17). According
to Miller (1976), womens sense of self is related to the cultural
organization of womens lives around the principle of serving
others. In our society, learning to nurture is part of the experience
of being a woman (Eichenbaum & Orbach, 1983).
The interest in family caregiving arose with the growing
number of situations in which an impaired elderly or a chronically ill person is taken care of by a family member at home
(Brody, Poulshock & Masciocchi, 1978). With chronic diseases
predominate over acute diseases and with the continued growth
of the elderly population, especially the growth in number of
persons over 85 years old (Botwinick, 1984; Bowers, 1987), the
preoccupation with the care of those who are impaired became
urgent. Attention has been focused on the consequences of
caregiving on family members.
As we will see, the caring literature has been developed on a
conceptual level and brings philosophicalperspectives on human
caring to the understanding of caring in nursing and caring in
womens lives. The caregiving literature, however, has grown
differently, mainly through atheoretical research. The urgency
dictated by the present home-care situation called on researchers
Jacinthe I. Pepin, RN, MSc, Epsilon Xi is Assistant Professor, Faculty oi
Nursing, University of Montreal and PhD Candidate, School of Nursing,
Universityof Rochester, NY. Supported in part bythe UniversityofMontreal
and the Canadian Nurses Foundation.The author thanks Dr. Bethel Powers
and Dr. Catherine Kane, University of Rochester, for their thoughtful review
ofapreviousversionofthismanuscriptandThomasC. Barnwell foracareful
review of the present version. Correspondence to Faculty of Nursing,
UniversityofMontreal, P.O. Box 61 28, Station A, Montreal, Quebec H3C 317
Canada.
Accepted for publication November 19,1991,

127

Family Caring and Caring in Nursing

to explore different questions such as: What are home caring

situations really like? What are the stress factors associated with
certain types of caregiving? What are the physical and emotional
costs of caregiving and their extent? There is little mention of
caring throughout the caregiving literature and vice versa. Writers on caregiving have recognized the physical, emotional, social
and economical support that family members provide (Brody et
al., 1978),but they have addressed mainly the role, the tasks and
the consequences of caregiving. The focus of research in the
1980s was on measurement of concepts such as burden (Montgomery, Gonyea & Hooyman, 1985; Montgomery, Stull 8z
Borgatta, 1985; Poulshock & Deimling, 1984), caregiver function (Gallagher, 1985) and caregiver strain (Robinson, 1983).
The orientation of the 1990s is on theory development (Mancini,
1989).
Caring has been described by Graham (1983) as consisting of
the two dimensions of love and labor. According to Graham
(1983) the two dimensions cannot be separated: they are interdependent and they nourish one another. Caring defines a specific
type of social relationship based upon both affection and
service,...two interlocking transactions (p. 28). However, as we
examine the history of caring by family members and by nurses,
we observe that caring has come to be viewed as consisting solely
of the love aspect. The following discussion will provide insight
into how the division between love and labor in both familial and
institutional settings occurred.

A Historical Perspective
Home Versus Institution

Families have traditionally provided care for their members

during life related experiences (giving birth, taking care of a sick
or an elderly family member, death). With the development of
medical science, the place of care has changed from the home to
the institution disrupting the flow of knowledge about healthand life-related experiences from one generation to another.
According to Ehrenreich and English (1978), ...the experts
authority rested on the denial or destruction of womens autonomous sources of knowledge: the old networks of skill-sharing, the
accumulated lore of generations of mothers (p. 4). With the
growth of scientific and technological knowledge the types of
caring activities have changed. More precisely, the scientific
or specialized aspect of caring has been separated from the
more human, non-scientific aspect. According to Keller
(1985), our view of science is based on the division between
objective fact and subjective feeling. Further, the association of
objectivity with power and masculinity has been valued for its
remove from the world of women and love.
In the transition of health care from home to institution,
knowledge of lifehealth-related experiences has not been replaced within the family but rather, the sources of information
and the services (caregiving) have been surrendered to professionals. Families have been almost completely excluded from the
institutional care while the compassion, the presence, the comfort and sometimes the most intimate care (caring) has remained
the familys responsibility. Family caring has been stripped of its
experiential knowledge while the personal, non-technical and
128

humanistic aspects of institutional care have remained underdeveloped.

Professional Versus Non-professional Carers

Through the history of caring, women have been the predominant players. Women in general and nurses in particular played
the first act of home care together. In 1860,Nightingale wrote not
only for nurses but for all women who had personal charge of the
health of others at home. Nursing has evolved from what has been
known as womens work (Reverby, 1987). The content and
cultural meaning of nursing have been altered by the development of medical science and practice, the growth of health
services and womens changing prospects and life choices,
especially their increasing participation in the public world of
paid labor (Melosh, 1982). As medical care became more
complex and more tied to hospitals, nursing gradually separated
from the sphere of womens domestic work and became established as paid work that required special training (Melosh,
1982, p. 3).
Many nurses initiated and participated in the dissemination of
sanitary practices in private homes. The first mission of public
health nurses, aside from the care of the sick, was to spread
knowledge aboutphysical and mental hygiene (Buhler-Wilkerson,
1985). Often nurses demonstrated proper care to the available
women of the family (Reverby, 1987). However, under the
influence of the technological era, critical care came to be what
is more valued, and with scientific growth, professionalization
has been idealized. With a desire to take a place in the professional world, it became imperative that nurses work be separated
from womens work. Gradually, nurses worked more closely
with physicians in institutional settings and shared with them the
specialized knowledge. Whether or not they partly relinquished their advocacy role and humanistic root remained a
question.
Invisibility and Division of Caring

Denied professional and scientific roles, caring was considered

a womans traditional role and chief contribution to society
through nurturance and nursing. As nurses separated their work
from womens work, women at home continued to provide caring
(personal care, health care) to family members. Mainly in the
form of mothering, caring at home did not carry as much value
as work outside the home. Over time, caring became invisible
work (unrecognized, unpaid and under studied) in an increasingly industrialist and technological society oriented toward
mass productivity (Colliere, 1986). The invisibility of caring
developed as love and labor came to be seen as separate dimensions of caring, experienced in different settings (home versus
institutions and work places), with labor coming to predominate
over love.
It has been said that nursing has reflected the ambivalence of
our society concerning womanhood and caring (Fagin & Diers,
1983; Reverby, 1987). Although rooted in womens work, nursing in institutions became routinized as it was partly deprived
of the affective aspect of caring and of the shared knowledge of
experience. In striving for recognition, nurses faced the necessity
of emphasizing the work aspect of caring running the risk of
IMAGE:Journal of Nursing Scholarship

rejecting altruism and caring itself (Reverby, 1987). It was only

through helping relationships and nurse-client interactions that
nurses kept sight of the affective aspect of caring. The recent
interest of nursing in caring marks a return to the feminine
perspectives and to a more balanced view of caring.
In contrast, caring at home was viewed mainly as affective.
Womens work has been deprived of its knowledge and of its
original worth: it became sentimentalized and privatized. Like
nurses, women were expected to take on caring more as an
identity than as work, expressing altruism and love (Reverby,
1987).In caregiving literature, it is evident that the responsibility
of care for the elderly has fallen on women (Brody, 1981; Soldo
& Myllyluoma, 1983; Stoller, 1983; Stone, Cafferata & Sangl,
1987) and has not been viewed as shared in the family. When
compared with men, women offer significantly higher levels of
in-home assistance to the elderly person (personal care, household tasks or simply being there) (Horowitz, 1985a; Stoller,
1983).
Conceptual and Terminological Issues

So far, caring comprises two dimensions described by the

following words: 1) Love, the affective aspect, encompasses
emotion, touch, compassion, presence, comfort, altruism,
nurturance and connectedness; it refers to the identity; 2) Labor,
the work or the service aspect, encompasses knowledge, role,
task and function; it refers to the activity. Graham (1983) said:
the experience of caring touches simultaneously on who you
are and what you do...On the one hand, the experience of
caring and being cared for is intimately bound up with the way
we define ourselves and our social relations. On the other,
caring is an integral part of the process by which society
reproduces itself and maintains the physical and mental
health of its work force...It suggests that caring demands both
love and labor, both identity and activity, with the nature of
the demands being shaped by the social relations of the wider
society (pp. 13-14).

Curiously, the affective aspect, which was for a long time

relegated to the family realm, is now represented in the literature
on caring which studies mainly professional caring. In parallel,
the work aspect, formerly relegated to professionals, is now
represented in the literature on family caregiving.

Caring Literature
It seems that caring by individuals, family members or friends,
in their day-to-day life has not been of concern aside from
studying other cultures (Leininger, 1981, 1985; Watson, 1985)
and from distinguishing between professional caring (mainly
nursing) and non-professional caring (Green, 1987/88; Kitson,
1987). In the latter case, a different terminology has been used.
When a family member, friend or significant other, who is not a
professional caregiver, is referred to as the person who cares, the
expressions used are lay-caring (Kitson, 1987); lay nursing
(Orlando, 1987), informal caring (Goodman, 1986; Nolan &
Grant, 1989),caretaking(Anderson & Elfert, 1989)andcaregiving
(Archbold, 1983;Bowers, 1987;Bunting, 1989;Given, Stommel,
Collins, King, Given, 1990). Throughout this paper, the expression family caring is used.
Volurne24, Nurnber2,Summer1992

Family Caring and Caring in Nursing

If caring has sometimes been perceived as synonymous with

nursing (McFarlane, 1976), the concept of caring has been
analyzed mainly within nursing (Ray, 1981) or as applied
to nursing (Griffin, 1983). Within the nursing literature, while
the work aspect of caring was recognized, the affective aspect has
been emphasized. According to McFarlane (1976), caring
signifies a feeling of concern, of interest, of oversight with a view
to protection (p. 189). Using historical and contemporary
sources of information in nursing and philosophical works about
human relationships, Ray (1981) udderlined a recurrent theme:
caring refers to growth or mutual self-actualization (p. 27).
However, in a philosophical analysis, Griffin (1983) maintained
that activities and attitudes and feelings are complementary aspects of caring in nursing (p. 291). Caring is a rich concept
reflecting respect, attunement, personal worth and other aspects
of growth, as well as performance of activities through which the
relationships occur. In a recent analysis of conceptualizations of
caring in nursing (Morse, Solberg, Neander, Bottorff, Johnson,
1990; Morse, Bottorff, Neander, Solberg, 1991), one of the five
identified categories focused on the work aspect of caring, the
practical or technical concerns (therapeutic intervention) while
the other four emphasized the affective aspect, the humanistic
concerns (human trait, moral imperative, affect, interpersonal
interaction).Linkages were made among the fiveconceptualizations
reflecting the recognition by nurses of two dimensions of caring.
In general, nurses agreed with Grahams (1983) view of caring
which comprises two interlocking dimensions, namely love and
labor. The affective aspect of caring was described by nurses as:
their primary motivation; the enhancement of the quality of the
nurse-client relationship; and a way of being a nurse. In an effort
to restore the balance between the affective and the instrumental
aspects of caring, the nursing literature in the last 15 years has
reemphasized the affective aspect as the essence of nursing. The
emphasis on the affective aspect however was sometimes perceived as widening the gap between the theory and the practice of
nursing, the academic and the clinical worlds. Two recently
proposed conceptualizations of caring in nursing present systematic attempts at integrating the two dimensions: Koldjeski (1990),
connects the humanistic qualities of caring with the scientific
nursing actions, and Ray (1989), bridges the elements of a
bwwcratic S ~ I U ~ U Rwith what was recogIllzed as caring elements.
The caring role is central to nursing but shared with patients
themselves, their relatives and with other health professions
(McFarlane, 1976, p. 187). Kitsons (1987) major focus was on
a comparative analysis of professional and non-professional
caring relationships. She argued that they share the same attributes: respect, commitment, knowledge and skills. Where
lay caring and professional care differ is in the extent to which
professional carers set themselves up as a specialist service
meeting the care needs of those who are either unable to care for
themselves or others in an acceptable manner (Kitson, 1987, p.
164). Ray (1981) did not distinguish between professional and
non-professional caring. She gave to caring in nursing the
attributes of caring outside of a professional context: giving and
receiving, co-presence as a mystery, oblative love and growth of
both partners through effective dialogue. In contrast, Orlando
(1987) insisted that a distinction be made between lay nursing
129

Family Caring and Caring in Nursing

and professional nursing. Interestingly, she used the term nursing

rather than caring. Everybody does a lot of lay nursing, she
wrote. They nurse themselves, or get nursed, or nurse others, a
lot, if not most of their lives (p. 408). In a sense, she brought
back Nightingales idea: Every woman is a nurse (Nightingale, 1860/1969,p. 3) but at the same time, she was very precise
about what, for her, was a necessary distinction. Since caring is
shared with others, this discussion takes place in the context of
clarifying the nature of nursing.

Caregiving Literature
The conceptual issues of caregiving arise differently. For the
purpose of research, caregiving has mainly been defined and
measured in terms of the amount and extent of help provided to
a family member (Horowitz, 1985b). The concern has been with
the specific tasks of providing care for a parent, often referred to
as activities of daily living (Bowers, 1987). Horowitz (1985b)
presented a hierarchy of instrumental assistance: 1) Tasks that
required intermittent help (shopping, transportation, financial
management); 2) In-home assistance that required regular time
commitment (meal preparation, household help); and 3) The
most intensive and intimate caregiving assistance (personal and
health care).
Through analysis of qualitative data, two nurse researchers,
Archbold (1981, 1982) and Bowers (1987), have proposed
broadening the scope of caregiving. First, Archbold (1981,1982)
identified the following modes of parent-caring by women: 1)
Care provision, the performance of care activities; 2) Care
management, the delegation and management of activities; and
3) Care transfer, the complete transference of care to another
caregiving agent (p. 38) or mainly to an institution. Archbold
(1982) defined parent-caring as the provision of needed services to functionally impaired elderly parents (p. 5) and, thus,
was concerned with the work aspect of caring. Her exploratory
study of the impact of parent-caring on the lives of 30 women
revealed the following care providers strategies: direct assistance of the parent with activities of daily living; manipulation
of the environment to facilitate the daily activities of the parent;
and in some situations, modification of the parents behavior.
The managers strategies with caring included obtaining and
retaining services to assist the parent with activities of daily
living, major environmental manipulation and parent education
to facilitate independence. Finally and most important for this
group was the provision of direct psychological and social
support as part of the strategies of parent-caring.
The focus of Archbolds (198 1, 1982) conceptualization was
still on the activities or tasks but family caring was reorganized
to comprise care management as well as care provision. It seems
that only the care managers strategies of caring included an
affective aspect through the provision of psychological and
social support. The affective aspect of caring was not addressed
in the categorization of the care providers strategies. Archbolds
discussion showed that the care providers gave everything they
could (time and energy) mainly through physical care. This
leaves little time for the psychological and social needs of the
parent and leaves no time for the care providers themselves.

However, in searching exclusively for behaviors of psychological and social support, other expressions of the affective aspect
of caring will remain overlooked.
Second, Bowers (1987) questioned the focus on tasks to
represent caregiving. She interviewed 27 parents and 33 of their
offspring. Through grounded theory method, she came to
reconceptualize caregiving activities by meaning or purpose
rather than by tasks or behaviors. Analysis of data revealed five
conceptually distinct, yet overlapping categories of caregiving:
anticipatory, preventive, supervisory, instrumental (more commonly recognized as caregiving) and protective. Four of these
categories are not observable behaviors but are processes
crucial to intergenerational caregiving and to an understanding
of the experience of intergenerational caregiving (p. 20).
Anticipation of possible needs of a parent, prevention of possible
injuries or complications and supervision of care given to the
parent were all categories of caregiving defined by their purposes. The protective category was experienced as the most
difficult and important type by the caregivers interviewed.
Among other things, it involved protection of the parents
identity and the parent-child relationship. The centrality and
invisibility of protective caregiving was repeatedly confirmed by
the caregivers experiences (Bowers, 1987, p. 25). This was
particularly true when the aged parent had a mild to moderate
cognitive impairment.
Data from Bowers (1987) study introduced what is recognized
as caring into the caregiving literature. Caregiving is redefined
by the meaning or purpose a caregiver attributes to a behavior
rather than by the nature of demands of the behavior itself (p.
24). The affective aspect of caring (concern, protection, respect)
was evidenced within the caregiving categories, primarily anticipatory, supervisory and protective caregiving. The description of
the caregiving categories by Bowers (1987) fits the philosophical
discussion of the caring experience by Griffin (1983) where the
affective aspect of caring is complementary to the activities
performed.

Conclusions and Implications for Nursing

The experiences of family caring and of caring in nursing
encompass both the affective and the instrumental aspects.
Caregiving has been conceptualized mainly as an activity or a set
of tasks, while caring has been conceptualized mainly as commitment, respect and protection toward the cared for, as well as an
activity. However, as Bowers research reinforces, the affective
aspect recognized as caring is attached to the caregiving experience. Current nursing research in family caring for the elderly
continues to define caring mainly by its work aspect (Bunting,
1989; Given et al, 1990; Killen, 1990). Inspired by the
conceptualizations of caring in the nursing literature, nursing
research could bring to family caring a balanced view of family
caring. Reciprocally, works on family caring could help clarify
nurses conceptualizations of caring and participate in the development of theories.
Nursing has been striving for proper recognition in the scientific world. It has been done by letting go of the womans world
and its love connotation and by creating a distance between the
IMAGE: Journal of Nursing Scholarship

Family Caring and Caring in Nursing

professional and the non-professionalcarers. Now, if a reconciliation of the dimensions of caring in nursing is on its way, will the
distance between the carers still be necessary? A clear focus for
the discipline of nursing is important,but collaborativework with
family carers is equally important in understanding caring in
various health situations and in elaborating a caring community.
Collaborative research and practice, empowering both family
and nursing carers, could be a sign of a better integrationof caring
as central to nursing, and, perhaps, a sign of maturity of our
discipline.
Caring is not reducible to either one of the two dimensions,
whether expressed in a professional or a non-professional context. It is important to understand the experience of caring as a
whole in a way that will avoid the exclusion of one or the other
dimension.
For what we mean by understanding or comprehension
is seeing how parts fit into a whole and then realizing that they
dont compose the whole, as one assembles a jigsaw puzzle,
but that the whole is a pattern, a complex wiggliness, which
has no separate parts...Parts exit only for purposes of figuring
and describing and as we figure the world out we become
confused if we do not remember this all the time. (Watts,
196611972, p. 90).

It only remains for nursing, which is in the process of reconciling

the two dimensions, to consider family caring as a unified
experience as well. gEQ
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