A Fundamental Aspect of Supportive CareDelivery: The Nurse’s Opportunity

to Shape the Caring EncounterAndrea Bakke, MN, RN, CPON, and Deborah King, CSW

Recent advances in supportive care therapies have significantly contributed tothe likelihood that a child diagnosed with cancer will be cured. Quantitativelyrecognized supportive care practices, such as central line care management,pain control, nutritional support, and blood transfusions are typically identifiedas the major contributors to these improved rates of survival. However, just asimportant are the more qualitative aspects of the nursing care delivery process.As a fundamental part of nursing’s caring role, the encounter with patients andfamilies offers unique opportunities for nurses to participate in the creation of ahealing environment. Gaining understanding and skill at balancing professionalrelationships, while also knowing the risks of caring, are critical components ofproviding excellent supportive care to pediatric oncology patients and theirfamilies. The professional caring encounter is a complex and multidimensionalprocess. Strategies for developing optimal communication and healthy profes-sional caring relationships within the pediatric oncology setting are discussed.� 2000 by Association of Pediatric Oncology Nurses

TO THE PEDIATRIC ONCOLOGY nurse,the term ‘‘supportive care’’ usually sug-

gests issues including the management ofinfection, blood transfusions, pain control,nutritional support, mouth care, and othertypes of medical therapies that enable chil-dren to better tolerate the cancer treatmentsthey receive. Advances in the area of support-ive care have made it possible to impact thesurvival rates in pediatric oncology duringthe past several decades by allowing moreaggressive therapies to be administered andbetter tolerated by the children receivingthem (Bleyer, 1997). Many types of support-ive care have developed into highly sophisti-

cated care guidelines used in the clinicalsetting. These measures have been incorpo-rated into a comprehensive handbook thatoffers recommendations, or standards of care,that are considered benchmarks of therapy(Albin, 1997). By delivering effective sup-portive care therapies to pediatric cancerpatients, the pediatric oncology nurse playsan essential role in improving the overalloutcomes for children surviving with cancer.

Nursing activities that are specifically in-volved in the delivery of supportive caremeasures do not only include the concreteinterventions or tasks performed every dayas nurses go about their routine work. Regard-less of how many technological advances ornew innovative drug discoveries nurses mightincorporate into their work, a fundamentalingredient of supportive care delivery is thehuman encounter itself. For it is through thehuman encounter—the process of caring forpatients while delivering cancer therapy—that each nurse is offered a unique opportu-nity to participate in the creation of a healingenvironment for each patient and family.

From the Department of Hematology/Oncology, Chil-dren’s Hospital and Regional Medical Center, Seattle,WA.

Address reprint requests to Andrea Bakke, MN, RN,CPON, Children’s Hospital and Regional Medical Center,Department of Hematology/Oncology CH-29, 4800 Sand-point Way NE, PO Box 5371, Seattle, WA 98105abakke@chmc.org.

� 2000 by Association of Pediatric Oncology Nurses1043-4542/00/1703-0007$3.00/0doi:10.1053/jpon.2000.8067

182 Journal of Pediatric Oncology Nursing, Vol 17, No 3 (July), 2000: pp 182-187

Although not readily quantified or easily de-fined, this aspect of supportive care deliveryis an integral component in the role of apediatric oncology nurse. As a fundamentalaspect of the caring role, nursing must con-tinue to wrestle with both the theoreticalconcepts involved and the clinical manifesta-tions of our human caring encounters.

‘‘Knowing’’ in Nursing

What each nurse brings to any clinicalencounter involves the unique foundation ofknowledge acquired through that nurse’s lifeexperiences. More simply stated: individualknowledge uniquely informs individual prac-tice. Carper (1978) describes four patterns of‘‘knowing’’ in nursing that shape the health-care professional as a caring agent within ahuman interaction: empirical, esthetic, ethi-cal, and personal knowledge.

Empirical knowledge consists of observ-able information from which the disciplinestrives toward developing a broader concep-tual framework. The purpose of this aspect ofknowledge is to develop a nursing theory ofpractice that can ultimately describe, ex-plain, and predict phenomena that are impor-tant to nursing. This aspect of knowing isoften referred to as ‘‘nursing science.’’ Itencompasses not only more concrete as-pects of nursing practice, such as the bestpractices for delivering blood products, butalso the more elusive, qualitative aspects,such as the meaning of illness or the percep-tions of the caregiver.

Esthetic knowledge characterizes the ‘‘art’’of nursing, that is, embracing those aspectsof the caregiver that celebrate unique indi-viduality. It reflects intuitive powers, creativ-ity in thinking and actions, the potential tograsp multiple details in any given situation,and the capacity for empathy. This aspect ofknowing enhances and gives texture to actsof caring.

Ethical knowledge involves the moral com-ponent of the nursing role. It includes volun-tary or deliberate choices that are subject tothe judgement of right and wrong. This knowl-edge encompasses a nurse’s responsibilityto act based on an implicit or explicit code ofprofessional ethics. The ethical framework,

however, is always filtered through personalvalues and needs. This area of nursing knowl-edge is difficult to grapple with in that it isqualitative and difficult to verify, and per-sonal values and needs sometimes conflictwith shared professional standards.

Finally, personal knowledge describes theability to understand, relate to, and embraceyour ‘‘self.’’ It is this aspect of knowledge thatprovides the opportunity to truly make adifference in the care of patients and families.The more nursing professionals are able tounderstand and accept their individual ‘‘self,’’with all their capacities and limitations,strengths and weaknesses, the more they areable to engage in authentic relationships withpatients and families. This understandingpromotes a dynamic interaction that allowsthe encounter to be shaped by each partici-pant. By realizing and acknowledging thathuman beings are always in a process ofgrowing and changing, nurses can more eas-ily embrace this realm of personal knowl-edge as never being static. Rather, it is aconstant work in progress.

Smith (1992) claims that every aspect ofknowing is personal knowing. Empirical, es-thetic, and ethical knowledge do not existoutside the context of individual interpreta-tion. Personal knowing can be thought of as afilter through which all other aspects of knowl-edge must pass. This personal filter encom-passes the knowledge of ‘‘self,’’ and influ-ences all of an individual’s understandingand behavior. It exists as a result of theperson’s life experiences, values, beliefs, andbiases. This personal filter influences all clini-cal assessment, practice, and choices. Under-standing the implications of one’s own per-sonal filter becomes a critical component ofnursing practice.

Personal knowing is essential to any profes-sion that focuses on interpersonal processeswhile blending artistic and scientific compo-nents within practice—a description thatclearly applies to nursing (Moch, 1990). Per-sonal knowing requires being completelypresent and ‘‘in the moment’’ during anencounter. Approaching any situation withopenness, a heightened awareness, and aquestioning frame of mind requires leaving

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behind prejudices, biases, expectations, andpresumptions. If not left behind, one or all ofthe latter can actually blind a professionalwithin an interaction (Remen, 1996). Oftennurses bring anticipation, expectation, and apresumption of familiarity to clinical encoun-ters and think the outcome is predictable. It iswithin just such circumstances that one canbecome blinded and find oneself more in arelationship of expectations instead of a rela-tionship with another human being.

It is important to realize that this situationis anything but static. Each aspect of know-ing (empiric, esthetic, ethical, and personal)continuously influences nursing practicewithin an interpersonal process. Each is inconstant flux with one another as nursesprovide their own unique style of caringwithin the clinical setting. In addition, al-though all of these areas are necessary, noneof them is sufficient alone nor are they mutu-ally exclusive (Carper, 1978). Rather, expertpractice depends on their fluid, well-bal-anced interdependence, which can enableand enhance the potential for responsiblymonitoring and ultimately modulating thecaring process in practice. This frameworkproposes seemingly endless professionalchallenges, but what it offers each individualis a much greater potential for meaningfullifelong professional rewards.

The Caring Process

The process of providing supportive careto children with cancer requires general em-pirical knowledge about cancer therapy andthe potential effects. A thorough understand-ing of the policies, procedures, or guidelinessurrounding nursing interventions is also im-portant in providing care. Awareness andclarity about the ethical implications within asituation can enhance care delivery, depend-ing on the ethical framework and ability tosynthesize and incorporate these variables.Yet it is the actual way in which the nurseincorporates the caring process that is unique.Each caregiving task, whether administeringan antiemetic, assessing pain, or manipulat-ing an occluded central line, presents thenurse with an opportunity to create the mo-

ment with a patient or family and influencethat process, as well as the potential out-come. In this way, clinical encounters be-come what the participants help to make ofthem and each participant becomes a co-creator, influencing how the caring processunfolds.

When nurses go to work each day, theybring knowledge and skills to the clinicalarena, intent to provide their own specialkind of caring. This human caring is at thevery heart of what nurses do. A wide range ofliterature has explored the concept of ‘‘car-ing’’ as a central component of the nursingdiscipline (Benner & Wrubel, 1989; Burns,1994; Carper, 1979; Clarke & Wheeler, 1992;Cooper, 1988; Fealy, 1995; Gullo, 1997;Halldorsdottir & Hamrin, 1997; Kelly, 1998;Larson, 1992; Larsson, Peterson, Lampic,von Essen & Sjoden, 1998; Morse, 1991;Rittman, Rivera, & Godown, 1997; Rogers,1996; Swanson, 1993; Valentine, 1989).

Burns (1994) explores the meaning of thelived experience of ‘‘engagement’’ as anessential part of the broader process of car-ing within nursing. Her metaphor of ‘‘creatinga safe passage’’ eloquently encompassesnursing’s overall goal of engaging in a rela-tionship with a family in a way that enhancestheir situation. Within the engaged relation-ship, the nurse and the family work togetheras a unit with the goal of caring for the child.The practice of nursing is ‘‘living out the artof caring through the nurse-patient relation-ship’’ (Burns, 1994, p. 220). Caring is abroad, complex, and multidimensional phe-nomenon of which engagement is one as-pect, as enacted through the human relation-ship between the nurse and the patient.

The caring process is also an interpersonalphenomenon that occurs within a particularsocial context (Kelly, 1998). Professional car-ing can be characterized by the nature of theinterpersonal encounters that take place be-tween a nurse and a patient. Caring also hasits costs. Continuously confronted with thereality of human suffering, nurses are at riskfor developing barriers to professional caringif the work of caring becomes overly demand-ing or too stressful. Defensive behaviors that

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allow the nurse to continue to function mayemerge as a mode of protection from suchemotional or psychologic pain, resulting inan inability to fully and effectively participatein the caring process. Getting overly involvedwith a patient and family is another reactionthat may reflect how a nurse is dealing with apersonal sense of inadequacy, with the nurseseeking to satisfy a need for acceptance andincreased self-esteem. An understanding ofthese risks of caring is just as important asappreciating caring’s central role in nursing ifwe are to be ultimately effective and profes-sionally responsible in our daily clinical inter-actions.

There is also a moral dimension to caringwithin a professional nurse’s role that helpsto distinguish it from that of a nonprofes-sional caregiver’s role (Fealy, 1995). There-fore, caring as a way of acting is dependentboth on the context in which the caring istaking place and on the values of thoseinvolved within the caring encounter. Whatdefines professional caring is not only thepossession of a certain level of knowledgeand skills about a specific area of nursingcare but also how the knowledge and skillsare used within the patient encounter. Thisaction of providing professional caring al-ways occurs within the larger context ofmoral and ethical duty. This duty includesbeing responsible for oneself, one’s feelings,one’s emotions, and one’s actions while alsoassuming the moral responsibility of respect-ing the humanity of the person sharing in therelationship. What ultimately distinguishesprofessional caring from nonprofessional car-ing is the added responsibility to ensure thatany caring behaviors are adequately in-formed by the nurse’s knowledge base andare in line with the current standards held bythe profession.

What becomes foundational to clinicalpractice is understanding that the profes-sional caring provided by the nurse involvesbeing in an engaged relationship with a pa-tient and family that carries a moral responsi-bility along with some risks. This type ofcaring relationship brings with it a need tofind a balance between being involved and

committed without burning out (Larson,1992).

Balancing the Caring Relationship

It is through the caring relationships anurse develops with patients and familiesthat this balance gets challenged, day in andday out. Developing skills that promotehealthy relationships within a clinical settingis difficult at best. A mutual relationshipbetween a nurse and a patient occurs on acontinuum from clinical, which representscontact that is usually brief and treatmentoriented, to overinvolved, which occurs whenthe contact is long term and the patient hasextraordinary needs that the nurse choosesto meet. There are no rules to define whattype of relationship is optimal for any givensituation (Morse, 1991). The type of relation-ship that develops depends on many thingsincluding the duration of the contact betweenthe nurse, patient, and family; the patient andfamily’s needs; the commitment of the nurse;the willingness of the patient and family totrust the nurse; and a variety of personalityfactors. Relationships can become more com-plicated if either the nurse or the patient andfamily are unwilling or unable to engagetogether in a productive way. Learning howto make judgements about where profes-sional and personal boundaries should bedrawn in a given situation is not an innateskill. Time, experience, and a commitmentto improving clinical competence in this areais what can make the difference (Totka,1996). Strengthening the ability to managerelationships fluidly can offer a broader rangeof skills to draw from and help the nurse tomaintain control when shaping interactionswhile delivering nursing care.

Therefore, knowing yourself and acknowl-edging the personal filters brought to thecaring relationship is critical. Past experi-ences, both personal and professional, willcolor any interaction. Overidentifying with apatient or family, feeling as if no one else cancare for the patient or family as well as youcan, and experiencing strong feelings thatconfuse or cause increasing anxiety or per-sonal distress, can all be signs of having

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overstepped a boundary (Larson, 1992). Rec-ognizing which families tug at the heart,being able to monitor feelings in an ongoingway, and reflecting on what these feelingsmean are important ways that can help anurse find the way back to a healthy, produc-tive relationship.

Overstepping boundaries can also createconflict between team members. Unclearrelationships with patients and their familiescan cause stress within the team and in turnundermine trust, confuse roles and responsi-bilities, and damage other caregiver’s abili-ties to effectively care for that patient. Anurse who does not want to go home at theend of the shift and works overtime becausea child is becoming more ill encouragesdependence on an individual care provider.This decision can undermine patient or fam-ily trust of the rest of the nursing staff. Thenext nurse that cares for the child may dis-cover barriers to providing appropriate careto the patient, because the family may havedeveloped unrealistic expectations of carebased on their experience with the previousnurse.

Participating in a family’s criticism of othercare providers rather than working with thefamily to constructively problem solve anissue can lead to division between teammembers, further damaging the ability of thefamily to trust the care team. Overextendingone’s role outside of nursing to pursue re-sources that might meet an identified patientor family need may not only encroach uponthe expertise of other members of the mul-tidisciplinary team but can also result in alost opportunity to empower the patient andfamily to enhance self-care.

Implications for Clinical Practice

Identifying strategies that promote goodcommunication is a critical step toward em-powering the nurse to successfully shape theprofessional caring relationships that are rou-tinely developed with patients and families(Table 1). The nursing actions involved in thedelivery of supportive care to children withcancer may be significantly enhanced whennurses seize the opportunity to help shape

each caring encounter with a patient or fam-ily.

The professional caring encounter is acomplex, multidimensional process. It con-tains a moral-ethical dimension that requiresunderstanding and balancing healthy relation-ships in the clinical setting. When focusingon supportive care, nurses must not onlywork to improve quantitatively recognizednursing care practices, such as central linecare management, pain control, and bloodtransfusions but they must also address themore qualitative aspects of the nurse’s ac-tions that are central to the nursing caredelivery process. With recent increases insurvival rates of childhood cancer, which aredue in part to advances in supportive caretherapies, nursing is continuously offeredopportunities to help improve the quality of

TABLE 1.Strategies for Developing Optimal Communicationand Professional Caring Relationships

● Understand that different cultural, ethnic, andreligious beliefs influence the illness experience.

● Acknowledge that each patient and family willdeal with illness in their own way.

● Clarify your intention in interacting with apatient and family.

● Acknowledge your own personal ‘‘filter’’ beforethe interaction.

● Recognize that patients and families have theirown personal ‘‘filters,’’ most aspects of whichare unknown to you.

● Approach the patient and family in a calmmanner.

● Maintain eye contact.● Be aware of your personal biases, expectations,

and assumptions.● Find out what the patient and family know and

determine what they want to know beforestarting a discussion.

● Listen to what is said.● Be receptive to nonverbal cues.● Provide information in manageable doses.● Inquire periodically if they understand the infor-

mation being presented.● Be willing to adjust your point of view.● Respond to their feelings.● Summarize what has been discussed.● Realize that the professional caring encounter is

complex, multidimensional, and has a moral-ethical dimension that requires you to under-stand and respect the boundaries of patient andfamily relationships.

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that survival. The notion of ‘‘caring’’ as acentral component of nursing care shouldnot neglect the qualitative elements that areshown during patient and family encounters.

The opportunity to shape the professionalcaring encounter is a fundamental and criti-cal aspect of supportive care delivery thatmust not be overlooked.

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