Nursing Theory alligood 8th edition

132 UNIT II  Nursing Philosophies realized that learning needs at the early stages of
clinical knowledge development are different from
Benner & Tanner, 1987; Benner, Tanner, & Chesla, those required at later stages. These differences need
1996, 2009; Benner, Hooper-Kyriakidis, & Stannard, to be acknowledged and valued to develop nursing
1999, 2011). Benner edited a clinical exemplar series education programs appropriate for the background
in the American Journal of Nursing during the 1980s. experience of the students.
In 2001, she began editing a series called “Current
Controversies in Critical Care” in the American Jour- In Expertise in Nursing Practice, Benner, Tanner,
nal of Critical Care. Benner’s work with the National and Chesla (1996) emphasized the importance of
Council of State Boards of Nursing constitutes a learning the skills of involvement and caring
major contribution to error recognition and enhance- through practical experience, the articulation of
ment of the safety of nursing practice (Benner, Sheets, knowledge with practice, and the use of narratives
Uris, et al., 2002). This research examines practice in undergraduate education. This work provides
breakdowns from a systems perspective, with the goal further support for the thesis that it may be better
of transforming the culture of blame in the health to place a new graduate with a competent nurse
care system to dramatically reduce health care errors preceptor who can explain nursing practice in ways
(Benner, Malloch, & Sheets, 2010). that the beginner comprehends, rather than with
Education the expert, whose intuitive knowledge may elude
Benner (1982) critiqued the concept of competency- beginners who do not have the experienced know-
based testing by contrasting it with the complexity of how to grasp the situation. This work, now in its
the proficient and expert stages described in the second edition (Benner, Tanner, & Chesla, 2009),
Dreyfus Model of Skill Acquisition and the 31 compe- led to the development of internship and orienta-
tencies described in the AMICAE project (Benner, tion programs for newly graduated nurses and to
1984a). In summary, she stated, “Competency-based clinical development programs for more experi-
testing seems limited to the less situational, less inter- enced nurses.
actional areas of patient care where the behavior can
be well defined and patient and nurse variations do In Clinical Wisdom in Critical Care, Benner,
not alter the performance criteria” (1982, p. 309). Hooper-Kyriakidis, and Stannard (1999) urged greater
attention to experiential learning and presented the
Fenton (1984, 1985) applied the domains of clini- work as a guide to teaching. They designed a highly
cal nursing practice as the basis for studying the interactive CD-ROM to accompany the book (Benner,
skilled performance of clinical nurse specialists Stannard, & Hooper-Kyriakidis, 2001). The second
(CNSs). Her analysis validated that the CNSs studied edition (Benner, Hooper-Kyriakidis, & Stannard,
demonstrated competencies in common with those 2011) includes a chapter on the educational implica-
skills of expert nurses reported in the AMICAE proj- tions of this research on knowledge embedded in
ect. She also identified additional areas of skilled acute and critical care nursing and incorporating
performance for CNSs, including the consulting the teaching approaches recommended in Benner,
role, and she delineated five preliminary categories Sutphen, Leonard, & Day (2010). Two major types of
relevant for curriculum evaluation in the graduate integrative strategies presented in the 2011 edition are
program. Ethical, clinical, and political dilemmas, multiple examples of coaching situated learning and a
positions, or stances that promote success or failure, thinking-in-action approach to integrating classroom
and new knowledge that blends the empirical and the with clinical teaching.
theoretical were among these categories.
A national study of nursing education was de-
According to Barnum (1990), it was not Benner’s signed to identify and describe “signature pedago-
development of the seven domains of nursing prac- gies” that maximize the nurse’s ability to cope with the
tice that has had the greatest impact on nursing edu- challenges of nursing that have developed during the
cation, but the “appreciation of the utility of the 30 years since the last national study of nursing edu-
Dreyfus model in describing learning and thinking in cation (Schwartz, 2005). The book Educating Nurses
our discipline” (p. 170). As a result of Benner’s appli- (Benner, Malloch, & Sheets 2010) reports details
cation of the Dreyfus model, nursing educators have of this national study of nursing education, and it

concludes that nursing education is in need of a major CHAPTER 9  Patricia Benner 133
transformation to close the practice—that is, an edu-
cation gap. An education gap is developed from the scholars. Benner (1994) edited and contributed to
difficulty of addressing competing demands and Interpretive Phenomenology: Embodiment, Caring, and
keeping pace with the increasing complexity of Ethics in Health and Illness, a collection of essays and
practice driven by research and new technologies. studies selected from the community of interpretive
The authors recommend that nurse educators make phenomenological researchers that she has inspired
four major shifts in their focus: (1) from covering and taught during her career. The book offers a philo-
abstract knowledge to emphasizing teaching for par- sophical introduction to interpretive phenomenology
ticular situations; (2) from separations between clini- as a qualitative research method, a guide to under-
cal and classroom teaching to integration of these standing the strategies and processes of this approach,
components; (3) from critical thinking to clinical and a varied selection of studies that convey its
reasoning; and (4) from emphasizing socialization resemblances and variations. Interpretive phenome-
and role-taking to professional identity formation. nology cannot be explained as a set of procedures and
These findings and recommendations have been pre- techniques. Instead: “each interpreter enters the inter-
sented at national and international conferences, and pretive circle by examining preunderstandings and
to faculty at many schools of nursing. confronting otherness, silence, similarities, and com-
monalities from his or her own particular historical,
McNiesh, Benner, and Chesla (2011) studied how cultural, and personal stance” (Benner, 1994, p. xviii).
students in an accelerated master’s degree entry pro-
gram experientially learned the practice of nursing. A second volume of interpretive phenomenologi-
They found that independent care of a patient was cal readings and studies edited by Chan, Brykczynski,
pivotal in the development of students’ identity and Malone, and Benner (2010) arose from a Festschrift
agency as nurses. Crider and McNiesh (2011) incor- (retirement celebration for a scholar) honoring the
porated a three-pronged apprenticeship approach impact and significance of the research tradition Ben-
(Benner, Sutphen, Leonard, & Day, 2010) that inte- ner established. This book presents the interpretive
grates intellectual, practical, and ethical aspects of the phenomenology philosophy and research approach
professional role in teaching students in psychiatric that continues to evolve. The first section explores
nursing to develop practical reasoning skills. theoretical and philosophical discourses and issues
within the interpretive phenomenological tradition,
Research while the second section is a collection of studies that
Benner maintains that there is excellence and power exemplify the similarities and variations in the ap-
in clinical nursing practice that can be made visible proaches across studies.
through articulation research. Intricate nuanced de-
scriptions of situational contexts (clinical narratives) Further Development
are the essence of this research approach, which dic-
tates that data be collected through situation-based Benner’s current research involves a large-scale collab-
dialogue and observation of actual practice. The situ- orative study with The Tri-Service Military Nursing
ational context guides interpretation of meanings Research group (De Jong, Benner, Benner, et al., 2010).
such that there is agreement among interpreters. This They are investigating knowledge development and
is a holistic approach that emphasizes identification experiential learning from nursing practice during the
and description of meanings embedded in clinical Iraq and Afghanistan Wars.
practice. The holistic approach is maintained through-
out the research process. The situational context is Benner (2012a) discussed the progress to date in
maintained as narratives are interpreted through implementing recommendations from the Educating
dialog among researchers and clinicians. Nurses study, reporting that several states have
started to implement suggested changes in nursing
Benner’s numerous research studies and projects education and that many hospitals and health sci-
with research colleagues and graduate students have ence campuses have instituted nurse residency pro-
created a community of interpretive phenomenological grams. Two websites have been created to facilitate
the dissemination and implementation of the study
recommendations as follows: Educating Nurses.com

134 UNIT II  Nursing Philosophies A degree of complexity is encountered in the
subconcepts for differentiation among the levels of
(http://www.educatingnurses.com) provides video- competency and the need to identify meanings and
taped teaching resources, curriculum development, intentions. This interpretive approach is designed to
and teacher training resources, and NovicetoExpert. overcome the constraints of the rational-technical
org (http://www.NovicetoExpert.org) offers online approach to the study and description of practice.
evidence-based learning and applies the recommen- Although a de-contextualized (object) description
dations of the Educating Nurses study. In addition, of the novice level of performance is possible, such
an educational newsletter was initiated to share a description of expert performance would be diffi-
study recommendations and create ongoing dialog cult, if not impossible, and is of limited usefulness
with nurse educators (Benner, 2011; 2012b, 2012c; because of the limits of objectification. In other
2012d). words, the philosophical problem of infinite regress
would be encountered in attempts to specify all the
Critique aspects of expert practice. Rather, a holistic under-
Clarity standing of the particular situation is required for
expert performance.
The clarity of Benner’s Novice to Expert model has
led to its utilization among nurses around the world. Generality
An identification with the idea of clinical wisdom and The Novice to Expert skill acquisition model has uni-
varying levels of clinical expertise development pro- versal characteristics, that is, it is not restricted by age,
gressed very quickly. Benner’s work not only contrib- illness, health, or location of nursing practice. How-
uted to appreciative understanding of clinical practice ever, the characteristics of theoretical universality
but also revealed nursing knowledge embedded in imply properties of operationalization for prediction
practice. that are not a part of this perspective. Indeed, this
Simplicity phenomenological perspective critiques the limits of
Benner has developed interpretive descriptive universality in studies of human practices. The inter-
accounts of clinical nursing practice. The concepts pretive model of nursing practice has the potential
are the levels of skilled practice from the Dreyfus for universal application as a framework, but the
model, including novice, advanced beginner, compe- descriptions are limited by dependence on the actual
tent, proficient, and expert. She used these five clinical nursing situations from which they must be
concepts to describe nursing practice based on in- derived. Its use depends on an understanding of the
terviews, observations, and the analysis of tran- five levels of competency and the ability to identify
scripts of exemplars that nurses provided. From the characteristic intentions and meanings inherent at
these descriptions, competencies were identified, each level of practice.
and these were grouped inductively into seven do-
mains of nursing practice on the basis of common Although clinical knowledge is relational and
intentions and meanings (Benner, 1984a). Benner contextual and involves local, specific, historical is-
and colleagues’ (1996) study of critical care nursing sues, it is generalizable in terms of the translation of
explored the differentiation of levels of practice in meanings to similar situations (Guba & Lincoln,
depth and suggested that nurses at different levels 1982). To capture the contextual and relational as-
live in different worlds. Benner’s ongoing articula- pects of practice, Benner uses narrative accounts
tion research has produced nine domains of critical of actual clinical situations and maintains that this
care nursing practice (Benner, Hooper-Kyriakidis, approach enables the reader to recognize similar in-
& Stannard,1999). The model is relatively simple tents and meanings, although the objective circum-
with regard to the five stages of skill acquisition, stances may be quite different. An example of
and it provides a comparative guide for identifying generalizability or transferability as used here fol-
levels of nursing practice from individual nurse lows: Upon reading or hearing a narrative about a
descriptions and observations and interpretations nurse connecting with a family whose child is dying,
validated by consensus. other nurses can relate the knowledge and meanings

conveyed to the experiences they may have had with CHAPTER 9  Patricia Benner 135
families of patients of any age who were dying. skilled know-how and action are linked” (Benner,
1999, p. 316). The significance of Benner’s research
Accessibility findings lies in her conclusion that “a nurse’s clinical
The model was tested empirically using qualitative knowledge is relevant to the extent to which its mani-
methods; 31 competencies, 7 domains of nursing prac- festation in nursing skills makes a difference in pa-
tice, and 9 domains of critical care nursing practice tient care and patient outcomes” (Benner & Wrubel,
were derived inductively. Subsequent research suggests 1982, p. 11).
that the framework is applicable and useful for contin-
ued development of knowledge embedded in nursing Generalization is approached through an under-
practice. This approach to knowledge development standing of common meanings, skills, practices, and
honors the primacy of caring and the central ethic of embodied capacities rather than through general ab-
care and responsibility embedded in expert nursing stract laws that explain and predict. Such common
practice (Benner, 1999). meanings, skills, and practices are socially embedded
in nurse schooling and in the practice and tradition of
The use of a qualitative process of discovering nursing. The knowledge embedded in clinical nursing
nursing knowledge is more difficult to address the practice should be brought forth as public knowledge
body of Benner’s work for critique. The qualitative to further a greater understanding of nursing prac-
interpretive approach describes expert nursing prac- tice. Benner (1984a) believes that the scope and
tice with exemplars. Benner’s work can be consid- complexity of nursing practice are too extensive for
ered as hypothesis generating rather than hypothesis nurses to rely on idealized, de-contextualized views of
testing. Benner provides a methodology for uncov- practice or experiments. Benner (1992) stated, “The
ering and entering into the situated meaning of ex- platonic quest to get to the general so that we can get
pert nursing care. Altmann (2007) pointed out that beyond the vagaries of experience was a misguided
criticism of Benner’s work has often developed from turn . . . . We can redeem the turn if we subject our
misinterpretation of her philosophy as theory and theories to our unedited, concrete, moral experience
evaluation of her qualitative research with quantita- and acknowledge that skillful ethical comportment
tive parameters. calls us not to be beyond experience but tempered
and taught by it” (p. 19).
Importance
Although clinical nurses around the world enthusiasti- The generalizations possible with the interpretive
cally received From Novice to Expert (1984a), some approach are depicted through exemplars that dem-
academicians and administrators initially interpreted it onstrate relational and contextually relevant intents
as promoting traditionalism and devaluing education and aspects of clinical knowledge. The applicability
and theory for nursing practice (Christman, 1985). and relevance of the common approaches used for
Benner’s qualitative interpretive approach to interpre- universality or generalization in physics and the natu-
tation of the meaning and level of nursing practice has ral sciences are questioned by the interpretive ap-
generated questions among some researchers. An on- proach, which claims that the basis for generalization
going debate has developed over cognitive interpreta- in clinical knowledge cannot be structural or mecha-
tions of Benner’s concepts of expertise and intuition nistic, but must be based on common meanings and
(Benner, 1996b; Cash, 1995; Darbyshire, 1994; English, practices. Preferred strategies for generalization in
1993; Paley, 1996). Scholarly debate around these phe- clinical practice are based on the skilled knowledge,
nomenological concepts contributed to clarification of intent, content, and notion of good in clinical knowl-
the nature of the research approach. edge depicted by exemplars that illustrate the role of
the situation.
Benner’s perspective is phenomenological, not
cognitive. She stated, “Clinical judgment and caring Benner claims that nurses need to overcome the
practices require attendance to the particular patient limits of subject-object descriptions. Her call is to
across time, taking into account changes and what has “increase public storytelling” to validate nursing as
been learned. In this vision of clinical judgment, an ethical caring practice, and “to extend, alter, and
preserve ethical distinctions and concerns” (Benner,
1992, pp. 19-20). Benner (1996a) stated, “We have

136 UNIT II  Nursing Philosophies 1984a) were incorporated as an interpretive
overlooked practitioner stories that demonstrate that framework. A critical aspect of using Benner’s
compassion can be wise and, in the long run, less approach is the realization that the domains and
costly than ‘defensive’ adversarial commodified tech- competencies form a dynamic evolving interpre-
nocures” (pp. 35-36). Benner’s work is useful in that it tive framework that is used in interpreting the
frames nursing practice in the context of what nurs- narrative and observational data collected. The
ing actually is and does. nurse who described this situation had approxi-
mately 8 years of experience in critical care, and
Summary she noted that this was significant to her practice
because it taught her how to integrate taking
Benner seeks to affirm and restore nurses’ caring care of a family in crisis along with taking care of
practices during a time when nurses are rewarded a critically ill patient. Thus, this was a paradigm
more for efficiency, technical skills, and measurable case for the nurse, who learned many things
outcomes. She maintains that caring practices are from it that affected her future practice.
imbued with knowledge and skill about everyday
human needs, and that in order to be experienced Mrs. Walsh is a pseudonym for a woman in her
as caring, these practices must be attuned to the par- seventies who was in critical condition following
ticular person who is being cared for and to the par- repeat coronary artery bypass graft (CABG) sur-
ticular situation as it unfolds. Benner’s philosophy gery. Her family lived nearby when Mrs. Walsh
of nursing practice is a dynamic, emerging holistic had her first CABG surgery. They had moved out
perspective that holds philosophy, practice, research, of town but returned to our institution, where the
and theory as interdependent, interrelated, and her- first surgery had been performed successfully.
meneutic. Her hope voiced in the preface of From Mrs. Walsh remained critically ill and unstable for
Novice to Expert (1984a) saying that domains and several weeks before her death. Her family was
competencies would not be deified by system builders very anxious because of Mrs. Walsh’s unstable
seems to have been largely realized, as those who have and deteriorating condition, and a family member
sought to apply these concepts have honored the con- was always with her 24 hours a day for the first
textual background on which they are based. Benner’s few weeks.
work exemplifies the interrelationship of philosophy,
practice, research, theory, and education. The nurse became involved with this family
while Mrs. Walsh was still in surgery, because fam-
CASE STUDY ily members were very anxious that the procedure
A case study from the peer-identified nurse was taking longer than it had the first time and
expert project that this author (Brykczynski, made repeated calls to the critical care unit to ask
1993-1995; 1998) conducted as part of a nursing about the patient. The nurse met with the family
service clinical enhancement process is selected and offered to go into the operating room to talk
here to illustrate Benner’s approach to knowl- with the cardiac surgeon so as to better inform the
edge development in clinical nursing practice. family of their mother’s status.
This project was undertaken to identify and
describe expert staff nursing practices at our One of the helpful things the nurse did to assist
institution. Exemplars were obtained and par- this family was to establish a consistent group of
ticipant observations were conducted to yield nurses to work with Mrs. Walsh, so that family
narrative text that then was interpreted through members could establish trust and feel more confi-
Benner’s multiphase interpretive phenomeno- dent about the care their mother was receiving. This
logical process (Benner, 1984a; 1994). In the eventually enabled family members to leave the hos-
final phase of data analysis, Benner’s domains pital for intervals to get some rest. The nurse related
and competencies of nursing practice (Benner, that this was a family whose members were affluent,
educated, and well informed, and that they came in
prepared with lists of questions. A consistent group
of nurses who were familiar with Mrs. Walsh’s

particular situation helped both family members CHAPTER 9  Patricia Benner 137
and nurses to be more satisfied and less anxious.
The family developed a close relationship with the morgue. The nurse took care of all intravenous
three nurses who consistently cared for Mrs. Walsh lines and tubes while the children bathed her.
and shared with them details about Mrs. Walsh and The nurse provided evidence of how finely tuned
her life. her skill of involvement was with this family
when she explained that she felt uncomfortable
The nurse related that there was a tradition in at first because she thought that the son and
this particular critical care unit not to involve daughter should be sharing this time alone with
family members in care. She broke that tradition their mother. Then she realized that they really
when she responded to the son’s and the daughter’s wanted her to be there with them. This situation
helpless feelings by teaching them some simple taught her that families of critically ill patients
things that they could do for their mother. They need care as well. The nurse explained that this
learned to give some basic care, such as bathing was a paradigm case that motivated her to move
her. The nurse acknowledged that involving family into a CNS role, with expansion of her sphere of
members in direct patient care with a critically ill influence from her patients during her shift to
patient is complex and requires knowledge and other shifts, other patients and their families,
sensitivity. She believes that a developmental pro- and other disciplines.
cess is involved when nurses learn to work with Domain: The Helping Role of the Nurse
families. This narrative exemplifies the meaning and in-
tent of several competencies in this domain, in
She noted that after a nurse has lots of experi- particular creating a climate for healing and pro-
ence and feels very comfortable with highly tech- viding emotional and informational support to
nical skills, it becomes okay for family members patients’ families (Benner, 1984a). Incorporating
to be in the room when care is provided. She the family as participants in the care of a criti-
pointed out that direct observation by anxious cally ill patient requires a high level of skill that
family members can be disconcerting to those cannot be developed until the nurse feels compe-
who are insecure with their skills when family tent and confident in technical critical care skills.
members ask things like, “Why are you doing this? This nurse had many years of experience in this
Nurse ‘So and So’ does it differently.” She com- unit, and she felt that providing care for their
mented that nurses learn to be flexible and to reset mother was so important to these children that
priorities. They should be able to let some things she broke tradition in her unit and taught them
wait that do not need to be done right away to give how to do some basic comfort and hygiene mea-
the family some time with the patient. One of the sures. The nurse related that the other nurses in
things that the nurse did to coordinate care was to this critical care unit held the belief that active
meet with the family to see what times worked family involvement in care was intrusive and
best for them; then she posted family time on totally out of line. A belief such as this is based
the patient’s activity schedule outside her cubicle on concerns for patient safety and efficiency of
to communicate the plan to others involved in care, yet it cuts the family off from being fully
Mrs. Walsh’s care. involved in the caring relationship. This nurse
demonstrated moral courage, commitment to
When Mrs. Walsh died, the son and daughter care, and advocacy in going against the tradition
wanted to participate in preparing her body. This in her unit of excluding family members from
had never been done in this unit, but after direct care. She had 8 years of experience in this
checking to see that there was no policy forbid- unit, and her peers respected her, so she was able
ding it, the nurse invited them to participate. to change practice by starting with this one
They turned down the lights, closed the doors, patient-family situation and involving the other
and put music on; the nurse, the patient’s daugh- two nurses who were working with them.
ter, and the patient’s son all cried together while
they prepared Mrs. Walsh to be taken to the Continued

138 UNIT II  Nursing Philosophies excluded from involvement nor do they have
Chesla’s (1996) research points to a gap participation thrust upon them.

between theory and practice with respect to This narrative illustrates how Benner’s ap-
including families in patient care. Eckle (1996) proach is dynamic and specific for each institu-
studied family presence with children in emer- tion. The belief that being attuned to family
gency situations and concluded that in times of involvement in care is in part a developmental
crisis, the needs of families must be addressed to process is supported by Nuccio and colleagues’
provide effective and compassionate care. The (1996) description of this aspect of care at their
skilled practice of including the family in care institution. They observed that novice nurses be-
emerged as significantly meaningful in the nar- gin by recognizing their feelings associated with
rative text from the peer-identified nurse expert family-centered care, while expert nurses develop
study. This was defined as an additional compe- creative approaches to include patients and fami-
tency in the domain called the helping role of the lies in care. The intricate process of finely tuning
nurse and was named maximizing the family’s the nurse’s collaboration with families in critical
role in care (Brykczynski, 1998). The intent of care is delineated further by Levy (2004) in her
this competency is to assess each situation as it interpretive phenomenological study that articu-
arises and develops over time, so that family in- lates the practices of nurses with critically burned
volvement in care can adequately address spe- children and their families.
cific patient-family needs, and so they are not

CRITICAL THINKING ACTIVITIES this situation? What aspects stand out as salient?
What would you say to the family at given points
1. Describe clinical situations from your own expe- in time? How would you respond to your nursing
rience that illustrate how nurses at various levels colleagues who may question your inclusion of
of skill development from novice to expert in- the family in care?
volve patients and families in care. 3. Using Benner’s approach, describe what is meant
by the statement that caring practices, intervention
2. Discuss the clinical narrative provided above skills, clinical judgment, and collaboration skills
following the unfolding case study format to increase the visibility of nursing practice in the
promote situated learning of clinical reasoning following three senses: (1) to the individual nurse,
(Benner, Hooper-Kyriakidis, & Stannard, 2011). (2) to nursing colleagues, and (3) to the health
Regarding the various aspects of the case as they care system.
unfold over time, consider questions that encour-
age thinking, increase understanding, and pro- n Patricia Benner home page at: http://home.
mote dialog such as: What are your concerns in earthlink.net/,bennerassoc/

POINTS FOR FURTHER STUDY n The Carnegie Foundation for the Advancement of
Teaching, Professional and Graduate Education
n Brykczynski, K. A. (2002). Benner’s philosophy in at: http://www.carnegiefoundation.org
nursing practice. In M. R. Alligood & A. M. Tomey
(Eds.), Nursing theory: utilization & application Videotapes
(2nd ed., pp. 123–148). St. Louis: Mosby. n Benner, P., Tanner, C., & Chesla, C. (1992). From

n Benner, P. (2001). From novice to expert: com- beginner to expert: clinical knowledge in critical
memorative edition.Upper Saddle River, (NJ): care nursing (Video). New York: Helene Fuld
Prentice Hall. (Re-published edition of the
original 1984 work.)

n Hubert Dreyfus home page at: http://philosophy.
berkeley.edu/

Trust Fund. Available from Springer Publishing CHAPTER 9  Patricia Benner 139
Company (see Benner home page).
n EducatingNurses.com: See Video Previews of CD-ROM
Expert teachers. n Benner, P., Stannard, D., & Hooper-Kyriakidis, P.
n Moccia, R. (1987). Nursing theory: a circle of
knowledge (Video). New York: National League (2001). Clinical wisdom and interventions in critical
for Nursing. care: a thinking-in-action approach (CD-ROM).
n NovicetoExpert.org: See demonstration of Philadelphia: Saunders.
online clinical simulation of unfolding case
studies. DVD
n Patricia Benner, Novice to Expert (2008). The

Nurse Theorists Portraits of Excellence, Volume 2,
Athens, OH: FITNE, Inc.

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(University Microfilms No. 3289350.)

10C H A P T E R

Kari Martinsen

1943 to Present

Philosophy of Caring

Herdis Alvsvåg

“Nursing is founded on caring for life, on neighbourly love, . . .
At the same time it is necessary that the nurse is professionally educated”

(Martinsen, 2006, p. 78).

Credentials and Background 1 year, while doing preparatory studies for university
of the Theorist entry. Before embarking upon a university degree,
she specialized as a psychiatric nurse in 1966 and
Kari Marie Martinsen, a nurse and philosopher, was worked for two years at Dikemark Psychiatric Hospital
born in Oslo, Norway, in 1943, during the World War near Oslo.
II German occupation of Norway. Her parents were
engaged in the Resistance Movement. After the war, While practicing as a nurse, she became concerned
moral and sociopolitical discussions dominated home about social inequalities in general and in the health
life, a home that consisted of three generations: a service in particular. Health, illness, care, and treat-
younger sister, parents, and a grandmother. Both par- ment were obviously distributed unequally. She also
ents were economists who had been educated at the became disturbed over perceived discrepancies be-
University of Oslo. Her mother worked all of her tween health care theories, ideals, and goals on the
adult life outside the home. one hand, and practical results of nursing, medicine,
and the health service on the other. She began to pose
After high school, Martinsen began her studies at questions about how a society and a profession must
Ullevål College of Nursing in Oslo, graduating in 1964. be constituted to support and aid the ill and the
She worked in clinical practice at Ullevål hospital for unemployed. One particularly poignant question was

Photo credit: Lars Jakob Løtvedt, Bergen, Norway.
Translators: Vigdis Elisabeth Brekke, Bjørn Follevåg, and Kirsten Costain Schou.

147

148 UNIT II  Nursing Philosophies to address this problem. The course was established
jointly by the University of Bergen, the county
how the nursing profession must operate if it is not to authorities, and three nursing colleges. A nurse with
let down its weakest patients and those that need care university level qualifications was needed to head the
the most. The obvious follow-up question was how program. Martinsen was asked to be Dean of the Fac-
the nurse might be able to care for the patient when ulty of Nursing Teachers’ Training in Bergen, which
medical science first and foremost relates to patient’s she accepted from 1976 to 1977.
diseases? In other words, Martinsen wanted to know
how we who represent the health services provide Through her philosophical studies and the socio-
adequate nursing for the subjects of our care, when logical issues she encountered in practical nursing
we are so closely allied with a science that objectifies and in nursing education, Martinsen developed an
the patient. She posed questions about whether that interest in nursing history. How did education of
same objectification would increase with emphasis on nurses in Norway begin, who was responsible for its
a scientific base for the discipline of nursing. inception, and what did they wish to achieve? In
order to look more closely at some of these issues,
These fundamental questions urged Martinsen to Martinsen applied for and received a grant from the
take up additional studies, this time for a bachelor’s Norwegian Nurses’ Association in 1976. She was
degree in psychology at the University of Oslo in 1968, affiliated with the Department of Hygiene and Social
with the goal of obtaining a master’s degree in psychol- Medicine at the University of Bergen, where she lec-
ogy. As a prerequisite, she needed an intermediate tured to students in the nursing teachers’ training
examination in physiology and another free credit at program and also students in social medicine.
the intermediate level; here she chose philosophy. This
encounter with philosophy and phenomenology At that time, an intense debate over nursing educa-
changed her thinking drastically. She realized that tion was raging in Norway. A public commission
philosophy rather than psychology might better illumi- proposed retention of the traditional 3-year degree
nate the existential questions with which she was con- but eventually agreed to alter this to a system of stage-
cerned. The study of phenomenology attracted her to based qualification. This meant that after completion
the University of Bergen, Norway’s second largest city. of 1 year, a student became a qualified care assistant,
and after 2 additional years, a qualified nurse. This
From 1972 to 1974, she attended the Department implied the end of the principle of a comprehensive
of Philosophy at the University of Bergen. In her work 3-year degree. Nurses throughout the country, with
for the graduate degree in philosophy (Magister the Norwegian Nurses’ Association at the forefront,
artium), Martinsen grappled philosophically with marched in protest to save the 3-year nursing degree.
questions that had disturbed her as a citizen, a profes- Sides in this debate remained rigidly opposed, and the
sional, and a health care worker. The dissertation tone of the political discourse on the issue of nursing
Philosophy and Nursing: A Marxist and Phenomeno- education was heated. Martinsen threw herself into
logical Contribution (Martinsen, 1975) created an this debate. She suggested that nursing education be
instant debate and received much critical attention. changed to a 4-year program, but also gave her
The dissertation directed a critical gaze toward the approval to the principle of stage-based education. She
nursing profession for its refusal to take seriously the sketched an educational model in which one is quali-
consequences of the nursing discipline uncritically fied as a care assistant after 2 years and as a nurse after
adopting characteristics of a profession, and uncriti- 4 years (Martinsen, 1976). With the comprehensive
cally embracing only a scientific basis for nursing. 3-year degree as the stated goal for the nursing asso-
Such a development might contribute to distancing ciation, her suggestion was viewed as a provocation.
nurses from the patients who need them most. This
dissertation, the first written by a nurse in Norway, In 1978, Martinsen received a grant from Norway’s
analyzed the discipline of nursing from a critical General Science Research Council. At this time, she
philosophical and social perspective. was attached to the history department at the Univer-
sity of Oslo, where she worked on her new project on
During the mid-1970s, Norway experienced a the social history of nursing, while lecturing master’s
marked shortage of nursing teachers. The rectors of degree students in sociopolitical history. From 1981
three nursing colleges in Bergen took the initiative to
establish a temporary nursing teacher–training course

to 1985, she was a scientific assistant at the history CHAPTER 10  Kari Martinsen 149
department at the University of Bergen. In addition to
conducting her own research, Martinsen lectured and mid-70s, when she wrote about nursing’s social his-
supervised master’s degree students in feminist his- tory and feminist history, and the social history of
tory and developed a database of Norwegian feminist medicine.
history.
From 1986, Martinsen worked for 2 years as
The period from 1976 to 1986 can be described as a Associate Professor at the Department of Health and
historical phase in Martinsen’s work (Kirkevold, 2000). Social Medicine at the University of Bergen. She
She published several historical articles (Martinsen, lectured and supervised master’s degree students, in
1977, 1978, 1979a, 1979b). Close collaborators during addition to writing a series of philosophical and his-
this phase were Anne Lise Seip, professor of social his- torical papers, published in 1989 under the title Car-
tory; Ida Blom, professor of feminist history; and Kari ing, Nursing and Medicine: Historical-Philosophical
Wærness, professor of sociology. In 1979, Martinsen and Essays (Martinsen, 1989c). With this book, the threads
Wærness published a book with the provocative title, of Martinsen’s historical phase were drawn together,
Caring Without Care? (Martinsen & Wærness, 1979). In marking the beginning of a more philosophical
this book, the authors raised important questions: period (Kirkevold, 2000). The book has several
• Were nurses “moving away” from the sickbed? editions, and the 2003 publication includes an inter-
• Was caring for the ill and infirm disappearing view with the author (Karlsson & Martinsen, 2003).
Fundamental problems in caring and interpretations
with the advent of increasingly technical care and of the meaning of discernment are what preoccupied
treatment? Martinsen from 1985 to 1990. In a Danish anthology
• Were nurses becoming administrators and research- published in 1990, she contributed a paper entitled
ers who increasingly relinquished the concrete exe- “Moral Practice and Documentation in Practical
cution of care to other occupational groups? Nursing.” Here she writes:
Aiding ill and care-dependent people was consid-
ered women’s work, and this view has long historical Moral practice is based upon caring. Caring does
roots. However, the existence of the professionally not merely form the value foundation of nursing;
trained nurse is not very old in Norway, originating in it is a fundamental precondition of our life . . .
the late 1800s. The deaconesses (Christian lay sisters), Discernment demands emotional involvement
who were educated at different deaconess houses in and the capacity for situational analysis in order
Germany, were the first trained health workers in to assess alternatives for action . . . To learn
Norway. Martinsen described how these first trained moral practice in nursing is to learn how the
nurses built up a nursing education in Norway, and moral is founded in concrete situations. It is
how they expanded and wrote textbooks and prac- accounted for through experiential objectivity or
ticed nursing both in institutions and in homes. They through discretion, in action or in speech. In both
were the forerunners of Norway’s public health sys- cases learning good nursing is of the essence
tem. This pioneer period was described by Martinsen
in her book, History of Nursing: Frank and Engaged (Martinsen, 1990, pp. 60, 64-65).
Deaconesses: A Caring Profession Emerges 1860-1905
(Martinsen, 1984). Based on this work, Martinsen In 1990, Martinsen moved to Denmark for a 5-year
attained her doctor of philosophy degree from the period. She was employed at the University of Århus to
University of Bergen in 1984. establish master’s degree and PhD programs in nursing.
In defense of her dissertation, Martinsen had to Her philosophical foundation was further developed
prepare two lectures: “Health Policy Problems and during these years mainly through encounters with
Health Policy Thinking behind the Hospital Law of Danish life philosophy (Martinsen, 2002a) and theo-
1969” (Martinsen, 1989a), and “The Doctors’ Interest logical tradition. In Caring, Nursing and Medicine:
in Pregnancy—Part of Perinatal Care: The Period ca. Historical-Philosophical Essays, Martinsen (1989c,
1890-1940” (Martinsen, 1989b). This work emerged 2003b) had connected the concept of caring to the
from her 10-year historical phase, beginning in the German philosopher Martin Heidegger (1889-1976).
While she was living in Denmark, Heidegger’s role as
a Nazi sympathizer during World War II became public
knowledge. At that time, a series of academic articles

150 UNIT II  Nursing Philosophies violation, doubt. These are “big words.” But they
are no bigger than their location in life, our every-
were published, which proved that Heidegger was a day nursing situation. Mercy, writes the Danish
member of the national Socialist Party in Germany and theologian and philosopher Løgstrup, is the
that he had betrayed his Jewish colleagues and friends renewal of life, it is to afford others life. . . . What
such as Edmund Husserl (1859-1938) and Hannah else is nursing but to release the patient’s possibili-
Arendt (1906-1975). Heidegger was banned from ties for living a meaningful life within the life cycle
teaching for several years after the war because of his we inhabit between life and death? We must ven-
involvement with the Nazis (Lubcke, 1983). ture into life amongst our fellow humans in order
to experience the actual meaning of these big words
Martinsen confronted Heidegger and her own
thinking about his philosophy in From Marx to (Martinsen, 1996, p. 7).
Løgstrup: On Morality, Social Criticism and Sensu-
ousness in Nursing (Martinsen, 1993b). Precisely While Martinsen was teaching in Århus, she
because life and learning cannot be separated, it became Adjunct Professor at the Department of
became important for Martinsen to go to sources Nursing Science at the University of Tromsø in 1994.
other than Heidegger to illustrate the fundamental In 1997, she moved north and become a full-time
aspects of caring. Knud E. Løgstrup (1905-1981) professor. However, needing more time for her
was the Danish theologian and philosopher who research and writings, she left after only 1 year in this
became her alternative source, although the two position to become a freelancer in 1998.
never met. Martinsen knew him through his books
and via his wife Rosemarie Løgstrup, who was origi- In 2002 and for a 5-year period, Martinsen made
nally German. She met her husband in Germany, her way back to the University of Bergen as professor
where both were studying philosophy. She later at the Department of Public Health and Primary
translated his books into German. Health Care section for nursing science. Teaching
master’s and doctoral students was central. She
While Martinsen lived and worked in Denmark, arranged doctoral courses and was much in demand
she met with Patricia Benner on several occasions for in the Nordic countries as supervisor and lecturer.
public dialogues in Norway and Denmark, and again
in 1996 in California. One of these dialogues was later The period from 1990 is characterized by philo-
published with the title, “Ethics and Vocation, Culture sophical research. Fundamental philosophical and
and the Body” (Martinsen, 1997b); it took place at a ontological questions and their meaning for nursing
conference at the University of Tromsø. dominated Martinsen’s thought. During this period,
in addition to her own books, she worked on a variety
Martinsen also had important dialogues with Katie of projects and published in several journals and
Eriksson, the Finnish professor of nursing. They met in anthologies. Books from this period have already
Norway, Denmark, Sweden, and Finland. In the begin- been mentioned (Martinsen, 1993b, 1996). In 2000,
ning, their discussions were tense and strained, but The Eye and the Call (Martinsen, 2000b) was
over time, they developed into fruitful and enlighten- published. The chapter titles in this book ring more
ing conversations that later were published as Phenom- poetically than before: “To See with the Eye of the
enology and Caring: Three Dialogues (Martinsen, 1996). Heart,” “Ethics, Culture and the Vulnerability of the
Martinsen’s first chapter in this book is titled “Caring Flesh,” “The Calling—Can We Be Without It?” and
and Metaphysics—Has Nursing Science Got Room for “The Act of Love and the Call.”
This?” the second, “The Body and Spirit in Practical
Nursing,” and the third, “The Phenomenology of Martinsen also worked with ideas about space and
Creation—Ethics and Power: Løgstrup’s Philosophy of architecture. According to her, space and architecture
Religion Meets Nursing Practice.” These headings influence human dignity. She first wrote about this idea
employ impressive language, similar to that of the in an article with the poetic title, “The House and the
dialogues that Martinsen conducted with Benner; in Song, the Tears and the Shame: Space and Architecture
her preface to the book, she elaborates: as Caretakers of Human Dignity” (Martinsen, 2001).

The words about which we speak and write are Martinsen has held positions at three nursing
compassion, hope, suffering, pain, sacrifice, shame, colleges. From 1989 to 1990, she was employed as

researcher at Bergen Deaconess University College, CHAPTER 10  Kari Martinsen 151
Bergen, and from 2006 as an Adjunct Professor.
From 1999 to 2004, she was Adjunct Professor at 1938); and French philosopher and phenomenologist
Lovisenberg Deaconess University College in Oslo. of the body Merleau-Ponty (1908 to 1961). Later, she
In 2007, she became a full-time professor at Harstad broadened her theoretical sources to include other
University College in northern Norway. philosophers, theologians, and sociologists.

Ideas and academic ventures sprouted and flour- Karl Marx: Critical Analysis—
ished easily around Martinsen, and she drew others A Transformative Practice
into academic projects. She edited a collection of arti- Marxist philosophy gave Martinsen some analytical
cles which several nursing college teachers contributed tools to describe the reality of the discipline of nurs-
to, called The Thoughtful Nurse (Martinsen, 1993a). ing and the social crisis in which it found itself. The
Lovisenberg Deaconess University College in Oslo, with crisis consisted of the failure of the discipline to
Martinsen’s assistance, took the initiative to publish a examine and recognize its nature as fragmented,
new edition of the first Norwegian nursing textbook, specialized, and technically calculating, as it pretends
which was originally published in 1877 (Nissen, 2000). a holistic perspective on care. She found that the
In this edition, Martinsen (2000a) wrote an afterword, discipline was part of positivism and the capitalist
placing the text within a context of academic nursing. system, without praxis of liberation. A “reversed
With a colleague in Oslo, Martinsen edited another care–law” rules in such a way that those who need
collection of articles by the editors and college lecturers care most receive the least. Karl Marx criticized indi-
for a book, published as Ethics, Discipline and Refine- vidualism and the satisfaction of the needs of the rich
ment: Elizabeth Hagemann’s Ethics Book—New Readings at the expense of the poor. Martinsen’s view is that it
(Martinsen & Wyller, 2003). This book provides an is important to expose this phenomenon when it
analysis of a text on ethics for nurses published in 1930 occurs in health service. Such exposure of this reality
and used as a textbook until 1965. When the ethics text can be a force for change. She maintains that we must
was republished in 2003, it was interpreted in the light question the nature of nursing, its content and inner
of two French philosophers, Pierre Bourdieu (1930 to structure, its historical origins, and the genesis of the
2002) and Michel Foucault (1926 to 1984), as well as the profession. This questioning results in a critical nurs-
German sociologist Max Weber (1864 to 1920). In ing practice as the practitioner views her occupation
2012, together with colleagues at Harstad University and profession in a historical and social context.
College, Martinsen published a book about narratives Martinsen’s historical interest has a critical and trans-
and ethics in nursing (Thorsen, Mæhre, & Martinsen, formative intention.
2012).
Edmund Husserl: Phenomenology as the
Thus historical and philosophical threads are each Natural Attitude
present in different phases of Martinsen’s thought, Edmund Husserl’s phenomenology is important
and they color her work differently during the differ- for Martinsen’s critiques of science and positivism.
ent periods. In 2011, Martinsen was made Knight, Positivism’s view of the self lies in its attitude of objec-
First Class, of the Royal Norwegian Order of St. Olav tification and a dehumanizing and calculating attitude
for her very significant work, thought, and authorship toward the person. Husserl viewed phenomenology as
in nursing science. a strict science. The strict methodological processes
of phenomenology produce an attitude of composed
Theoretical Sources reflection over our scientific reality, so that we may
uncover structures and contexts within which we oth-
What is Martinsen’s theoretical background? In her erwise perform taken-for-granted and unconscious
analysis of the profession of nursing in the early 1970s, work. This practice is about making the taken-for-
Martinsen looked to three philosophers in particular: granted problematic. By problematizing taken-for-
German philosopher, politician, and social theorist granted self-understanding, we find opportunities
Karl Marx (1818 to 1883); German philosopher and to grasp “the thing itself,” which will always reveal
founder of phenomenology Edmund Husserl (1859 to itself perspectively. Phenomenology works with the

152 UNIT II  Nursing Philosophies two parts as a precondition. One is concerned and
anxious for the other. Caring involves how we relate to
prescientific, what we encounter in the natural atti- each other, and how we show concern for each other
tude, when we are directed toward something with the in our daily life. Caring is the most natural and the
intent to recognize and understand it meaningfully. most fundamental aspect of human existence.
Phenomenology insists upon context, wholeness, in-
volvement, engagement, the body, and the lived life. As mentioned earlier, Martinsen revised her per-
We live in contexts, in time and space, and we live spective on Heidegger (Martinsen, 1993b). At the same
historically. The body cannot be divided into body and time, she did not reject “Heidegger’s original and acute
soul; it is a wholeness that relates to other bodies, to thought” (Martinsen, 1993b, p. 17). She turns back to
things in the world, and to nature. Heidegger when she explains what it means to dwell.
Heidegger had examined precisely the concept that to
Merleau-Ponty: The Body as the Natural dwell is always to live among things (Martinsen, 2001).
Attitude Here we may note that Heidegger reinforces an idea
Maurice Merleau-Ponty (1908 to 1961) builds upon also maintained by Merleau-Ponty: that the things we
Husserl’s thought, but focuses more than any other surround ourselves with are not merely things for us,
thinker on the human body in the world. Both Husserl objectively speaking, but they actually participate in
and Merleau-Ponty criticized Descartes (1596 to 1650), shaping our lives. We leave something of ourselves
who separates the person from the world in which one within these things when we dwell amidst them. It is
lives with other persons. The body is representing the the body that dwells, surrounded by an environment.
natural attitude in the world. The nursing profession
relates to the body in all of its aspects. We use our own Knud Eiler Løgstrup: Ethics as a Primary
bodies in the performance of caring, and we relate to Condition of Human Existence
other bodies who are in need of nursing, treatment, Knud Eiler Løgstrup (1905 to 1981), the Danish
and care. Our bodies and those of our patients express philosopher and theologian, became important for
themselves through actions, attitudes, words, tone of Martinsen in the “void” left by Heidegger. Løgstrup
voice, and gestures. Phenomenology involves acts of can be summarized through two intellectual strands:
interpretation, description, and recognition of lived phenomenology and creation theology, the latter
life, the everyday life that people live together with oth- containing his philosophy of religion (creation the-
ers in a mutual natural world, including the profes- ology should not be confused with the more recent
sional contexts in which caring is performed. “creationism” in the United States). As a phenome-
nologist, he sought to reveal and analyze the essen-
Martin Heidegger: Existential Being as tial phenomena of human existence. Through his
Caring phenomenological investigations, Løgstrup arrived
Martin Heidegger (1889-1976) was a German phe- at what he termed sovereign or spontaneous life
nomenologist and a student of Husserl, among others. utterances: trust, hope, compassion, and the open-
He investigated existential being, that is to say, that ness of speech. That these are essential is to say that
which is and how it is. Martinsen connects the concept they are precultural characteristics of our existence.
of caring to Heidegger because he “has caring as a As characteristics, they provide conditions for our
central concept in his thought. . . . The point is to try culture, conditions for our existence; they make
to elicit the fundamental qualities of caring, or what human community possible (Lubcke, 1983). Accord-
caring is and encompasses” (Martinsen, 1989c, p. 68). ing to Heidegger, caring is such a characteristic. In
She continues: “An analysis of our practical life and an Løgstrup’s opinion, the sovereign life utterances were
analysis of what caring is, are inseparable. To investi- the necessary characteristics for human coexistence.
gate the one is at the same time to investigate the other.
Together, they form an inseparable unit. Caring is a Martinsen maintains that for Løgstrup, metaphysics
fundamental concept in understanding the person” and ethics are interwoven in the concept of creation:
(Martinsen, 1989c, p. 69). With phenomenology and
Heidegger as a backdrop, Martinsen gives content and They are characteristic phenomena which sustain
substance to caring: caring will always have at least us in such a way that caring for the other arises

out of the condition of our having been created. CHAPTER 10  Kari Martinsen 153
Caring for the other reveals itself in human
relationship through trust, open speech, hope Løgstrup og sygepleien (Martinsen, 2012b) (Løgstup
and compassion. These phenomena, which Løg- and Nursing), subsequently published in Norwegian
strup also calls sovereign life utterances, are (Martinsen 2012c).
“born ethical” which means that they are essen-
tially ethical. Trust, open speech, hope and com- Max Weber: Vocation as the Duty to Serve
passion are fundamentally good in themselves One’s Neighbor through One’s Work
without requiring our justification. If we try Max Weber (1864 to 1920) was a German sociolo-
to gain dominance over them, they will be gist who made a major impact on the philosophy of
destroyed. Metaphysics and ethics, or rather social science. Weber sought to understand the
metaphysical ethics, is practical. It is linked to meaning of human action. He was also a critic of
questions of life in which the person is stripped the society he saw emerging with the advent of in-
of omnipotence dustrialization. In Weber, Martinsen found a new
alliance, in addition to Marx, in the criticism of
(Martinsen, 1993b, pp. 17-18). both capitalism and science. While Løgstrup was a
philosopher of religion, Weber was a sociologist of
We must care for that which exists, not seek to religion. Weber also criticized the West for its
control it: “Western culture is singular in its need to boundless intervention and its boundless consump-
understand and control. It has moved away from tion. Science disenchants the created world precisely
the cradle of our culture and our religion in the nar- because it relates to what was created as objects in its
rative of creation from the Old Testament. In The objectification of all that exists (Martinsen, 2000b,
Old Testament ‘guarding,’ ‘watching,’ and ‘caring’ on 2001, 2002b).
one side, and cultivating and using on the other,
formed a unified opposition” (Martinsen, 1996, To a great extent, Martinsen joins Weber in her
p. 79). That these are unified opposites is to say that explication of vocation (Martinsen, 2000b). Weber
they singularly and in themselves are opposites that looked to Martin Luther (1483 to 1546), who dis-
separate and are insurmountable, but when they are cussed vocation in the secular sense, as follows:
adjusted to one another, they enter into an opposi-
tion that unifies and creates a sound whole. To care Vocation is work in the sense of a life’s occupation
for, guide and guard, cultivate, and make use of, or a restricted field of work, in which the indi-
that is to say, cultivate and use in a caring manner vidual will endow his fellow person . . . The young
as a unified opposition, means that we do not be- Luther linked vocation to work, and understood it
come domineering and exploitative, but restrained as an act of neighbourly love. Vocation is under-
and considerate in our dealings with one another stood on the basis of the notion of creation, that
and with nature. we are created in order to care for one another
through work
The ethical question is how a society combats suf-
fering and takes care of those who need help. In a (Martinsen 2000b, pp. 94-95).
nursing context, Martinsen formulates this very
question like this: “How do we as nurses take care of In other words, vocation is in the service of cre-
the person’s eternal meaning, the individual’s unend- ation. With reference to the young Luther, Martinsen
ing worth—independent of what the individual is wrote that vocation “means that we are placed in life
capable of, can be useful for or can achieve? Can I contexts which demand something of us. It is a chal-
bear to see the other as the other, and yet not as lenge that I, in this my vocation, meet and attend to
fundamentally different from myself?” (Martinsen, my neighbour. It lies in Existence as a law of life”
1993b, p. 18). (Martinsen, 1996, p. 91).

Klim, the Danish publishing house, issues works by Michel Foucault: The Effect of His Method
and about Løgstrup under the label The Løgstrup Intensifying Phenomenologists’
Library. Here Martinsen has contributed the monograph Phenomenology
Phenomenologists underscore the importance of his-
tory for our experience. Martinsen (1975) referred to

154 UNIT II  Nursing Philosophies Paul Ricoeur: The Bridge-Builder
Foucault in her dissertation in philosophy, but was Paul Ricoeur (1913 to 2005) is a French philosopher.
especially concerned with this philosopher in connec- His position is often designated as critical hermeneu-
tion with her historical works from 1976 (Martinsen ticsor hermeneutic phenomenology. He seeks to build a
1978, 1989a, 2001, 2002b, 2003a). Foucault (1926 to bridge between natural science and human science,
1984) was a French philosopher and historian of ideas. between phenomenology and structuralism and other
He was concerned with the notions of fracture and opposing positions. He focuses on topics such as time
difference, rather than continuity and context. He and narrative, language and history, discernment and
claimed that some shared common structures, systems science. Ricoeur is concerned with human communi-
of terms, and forms of thought that shape societies cation, on what it is to understand one another. He
reside within each historical epoch and within the dif- points to everyday language and its many meanings,
ferent cultures. In this way, Foucault confronted sub- in contrast to the language of science. Martinsen
jective philosophy, which emphasizes the person as a refers to parallels in the philosophy of language of
private and independent individual. For example, Løgstrup and Ricoeur. Martinsen states:
Foucault asked which fundamental conditions were
present during the historical epoch in which institu- The culture of medicine is dominated by an ab-
tions for the insane were created. In later epochs, he stract conceptual language in which words are
defined the insane as mentally ill. Something new had embedded in different classifications, and in
happened; what did it depend on? Why did it happen which they are not always in accordance with
and what was to be achieved in society? What actions actual practical and concrete situations. . . . In
were undertaken; were there alliances of power and everyday language of the caring tradition on the
did they involve establishing order and discipline? To other hand, words are followed by the manner in
question in this way is to dig through several layers of which they unfold in different contexts of mean-
understanding, getting beyond the general conception ing within concrete caring—in the company of
in order to understand the meaning of history in a the patient and the professional community.
new and different way. Foucault elicits the basic social When spoken in everyday language, the words
distinctions that make it possible to characterize peo- are distinguished by their power of expression.
ple. They are dug out of tacit preconditions (Lubcke, They strike a tone
1983). In this way, Foucault’s method intensified the
phenomenological process. He asked us to think anew (Martinsen, 1996, p. 103).
and differently from the existing mode of thinking
within the epoch and within the contexts in which we Empirical Evidence
live. The gaze became not only descriptive, but also
critical. In Martinsen’s philosophy of caring, language and
reflection involved in professional judgment and nar-
Martinsen stated that, in caring for the other, we rative are ways of accounting convincingly for case
relate to the other in a different way and look for things conditions, situations, and phenomena (Martinsen,
different from those that are looked for within natural 1997a, 2002c, 2003c, 2004b, 2005). She states that
science and objectify medicine using their “classifica- obvious perceptions must be accounted for convinc-
tion gaze” and “examining gaze” (Martinsen, 1989b, ingly. With reference to Husserl, she points to different
pp. 142-168; Martinsen, 2000a). Such gazes require spe- forms of evidence: the undoubtable (apodictic), the
cial space; caring requires different types of space in exhaustive, and the partial. Each type represents
order to develop different types of knowledge. The ques- different evidential requirements. Facts, themes, and
tions we must bring with us into caring in the health situations provide different forms of evidence. For
service are these: Which disciplinary characteristics or example, we cannot accept mathematical evidence
structures are found in our practice today, in nursing that is undoubtable and transfer this to physical
practice and its spatial arrangements? What will it mean objects and persons. In the field of caring, it is discern-
to think differently from those of our particular epoch? ment and narrative that can clarify the empirical facts
Do we find critical nursing here, and, if so, what are the of a case in an evidentiary, enlightening, or convincing
implications for today’s health service and research?

CHAPTER 10  Kari Martinsen 155

MAJOR CONCEPTS & DEFINITIONS in concrete situations and must be accounted for. Our
Martinsen is reluctant to provide definitions of actions need to be accounted for; they are learned and
terms, since definitions have a tendency to close off justified through the objectivity of empathy, which
concepts. Rather, she maintains, the content of con- consists of empathy and reflection. This means in
cepts should be presented. It is important to circum- concrete terms to discover how the other will best be
scribe the meaningful content of a term, explain helped, and the basic conditions are recognition and
what the term means, but avoid having terms locked empathy. Sincerity and judgment enter into moral
up in definitions. practice (Martinsen, 1990).

Care Person-Oriented Professionalism
Care “forms not only the value base of nursing, but is Person-oriented professionalism is “to demand pro-
a fundamental precondition for our lives. Care is the fessional knowledge which affords the view of the
positive development of the person through the patient as a suffering person, and which protects his
Good” (Martinsen, 1990, p. 60). Care is a trinity: integrity. It challenges professional competence and
relational, practical, and moral simultaneously humanity in a benevolent reciprocation, gathered in
(Alvsvåg, 2003; Martinsen, 2003b, 2012b). Caring is a communal basic experience of the protection and
directed outward toward the situation of the other. care for life . . . It demands an engagement in what
In professional contexts, caring requires education we do, so that one wants to invest something of one-
and training. “Without professional knowledge, con- self in encounters with the other, and so that one is
cern for the patient becomes mere sentimentality” obligated to do one’s best for the person one is to
(Martinsen, 1990, p. 63). She is clear that guardianship care for, watch over or nurse. It is about having an
negligence and sentimentality are not expressions understanding of one’s position within a life context
of care. that demands something from us, and about placing
the other at the centre, about the caring encounter’s
Professional Judgment and Discernment orientation toward the other” (Martinsen, 2000b,
These qualities are linked to the concrete. It is pp. 12, 14).
through the exercise of professional judgment in
practical, living contexts that we learn clinical Sovereign Life Utterances
observation. It is “training not only to see, listen and Sovereign life utterances are phenomena that accom-
touch clinically, but to see, listen and touch clinically pany the Creation itself. They exist as precultural
in a good way” (Martinsen, 1993b, p. 147). The phenomena in all societies; they are present as poten-
patient makes an impression on us, we are moved tials. They are beyond human control and influence,
bodily, and the impression is sensuous. “Because and are therefore sovereign. Sovereign life utterances
perception has an analogue character, it evokes are openness, mercy, trust, hope, and love. These are
variation and context in the situation” (Martinsen, phenomena that we are given in the same way that we
1993b, p. 146). One thing is reminiscent of another, are given time, space, air, water, and food (Alvsvåg,
and this recollection creates a connection between 2003). Unless we receive them, life disintegrates. Life
the impressions in the situation, professional knowl- is self-preservation through reception (Martinsen,
edge, and previous experience. Discretion expresses 2000b; 2012b). Sovereign life utterances are precondi-
professional knowledge through the natural senses tions for care, simultaneously as caring actions are
and everyday language (Martinsen, 2005, 2006). necessary conditions for the realization of sovereign
life utterances in the concrete life. We can act in such
Moral Practice Is Founded on Care a way that openness, trust, hope, mercy, and love are
“Moral practice is when empathy and reflection work realized through our interactions, or we can shut
together in such a way that caring can be expressed in them out. Without their presence in our actions,
nursing” (Martinsen, 1990, p. 60). Morality is present
Continued

156 UNIT II  Nursing Philosophies

MAJOR CONCEPTS & DEFINITIONS—cont’d

caring cannot be realized. At the same time, caring human” (Martinsen, 2000b, p. 87). It is an ethical
actions clear the way for the realization of sovereign demand to take care of one’s neighbor. For this
life utterances in our personal and our professional reason, nursing requires a personal refinement,
lives. Caring can bring the patient to experience the in addition to professional knowledge (Malchau,
meaning of love and mercy; caring can light hope or 2000).
give it sustenance, and caring can be that which
makes trust and openness foremost in relations with The Eye of the Heart
the nurse. In the same way, lack of care can block the This concept stems from the parable of the Good
other’s experience of mercy; it can create mistrust Samaritan. The heart says something about the exis-
and an attitude of restraint in relation to the health tence of the whole person, about being touched or
service. moved by the suffering of the other and the situation
the other experiences. In sensuousness and percep-
The Untouchable Zone tion, we are moved before we understand, but we are
This term refers to a zone that we must not interfere also challenged by the afterthought of understand-
with in encounters with the other and encounters ing. To see and be seen with the eye of the heart is a
with nature. It refers to boundaries for which we form of participatory attention based on a recipro-
must have respect. The untouchable zone creates a cation that unifies perception and understanding, in
certain protective distance in the relation; it ensures which the eye’s understanding is led by the senses
impartiality and demands argumentation, theory, (Martinsen, 2000b, 2006).
and professionalism. In caring, the untouchable
zone is united with its opposite, which is openness, The Registering Eye
in which closeness, vulnerability, and motive have The registering eye is objectifying, and the per-
their correct place. Openness and the untouchable spective is that of the observer. It is concerned
zone constitute a unifying contradiction in caring with finding connections, systematizing, ranking,
(Martinsen, 1990, 2006). classifying, and placing in a system. The register-
ing eye represents an alliance between modern
Vocation natural science, technology, and industrialization.
Vocation “is a demand life makes to me in a com- If one as a patient is exposed to, or if one as a pro-
pletely human way to encounter and care for one’s fessional employs, this gaze in a one-sided man-
fellow person. Vocation is given as a law of life con- ner, compassion is lifted out of the situation, and
cerning neighborly love which is foundationally the will to life is reduced (Martinsen, 2000b).

manner (Martinsen 2003c, 2004b, 2005, 2009, Major Assumptions
2012). To exercise discretion is to interpret the
impressions we get of the patient. The professional Nursing
knowledge and experience one has built up give one Although care goes beyond nursing, caring is funda-
a horizon of understanding that is flexible in en- mental to nursing and to other work of a caring na-
counters with the patient’s situation (Martinsen, ture. Caring involves having consideration for, taking
1990, 2002c). The narrative can both describe and care of, and being concerned about the other. When
prescribe action (Kjær, 2000; Martinsen, 1997a, we speak about caring, three things must be simulta-
2012). “A good narrative tells existential morality neously present; we could call them the “trinity of
into being, and makes practical action unavoidable” caring”: caring must be relational, practical, and moral
(Martinsen, 1993b, p. 161). (Alvsvåg, 2011).

• Relational means that caring requires at least two CHAPTER 10  Kari Martinsen 157
people. Martinsen describes it thus:
unit of soul and flesh, or spirit and flesh. The person is
The one has concern for the other. When the one bodily, and as bodies we both perceive and understand.
suffers, the other will “grieve” (in the sense of Health
suffer with) and provide for the alleviation of Health is discussed from a sociohistorical perspective.
pain. . . . Caring is the most natural and the Two rival historical health ideals, the classical Greek
most fundamental aspect of the person’s exis- and the modern one of intervention and expansion,
tence. In caring, the relationship between people form the background when Martinsen writes: “Health
is the most essential element. . . . The essence of does not only reflect the condition of the organism, it
the person is that one is created for the sake of is also an expression of the current level of compe-
others—for one’s own sake. . . . The point here is tence in medicine. To put it pointedly, the tendencies
that caring always presupposes others. Further, of the modern concept of health are such that if one
that I can never understand myself or realise has an unnecessary ‘defect’ or an organ which ‘could’
myself alone or independent of others be better, one is not completely healthy” (Martinsen,
1989c, p. 146). The modern reductionist health ideal
(Martinsen, 1989c, p. 69). on which modern medicine is built is both analytical
and individualistic; it is oriented toward all that is not
• Caring is practical. It is about concrete and practi- “good enough.” Combined with medicine’s autonomy
cal action. Caring is trained and learned through and resources, it has yielded success in terms of treat-
its practice. ment. Martinsen is concerned with the point that this
ideology does not withstand critical examination.
• Caring is also moral: “If caring is to be genuine, Medicine’s sometimes damaging effects and insuffi-
I must relate to the other from an attitude (mood, cient service for people with chronic diseases and
‘befindlichkeit’) which acknowledges the other in illnesses bring Martinsen to turn toward the conser-
light of his situation. . . . [We must] neither overes- vative, classical health ideal. What is important is to
timate nor underestimate his ability to help him- cure sometimes, help often, and comfort always. This
self ” (Martinsen, 1989c, p. 71). requires society to offer people the opportunity to live
Caring requires a correct understanding of the the best life possible and the individual to live sensi-
bly; both requirements have environmental implica-
situation, which presupposes a good evaluation of the tions. We must not change the environment at such
goals inherent in the caring situation: “Performing a speed and to such an extent that the change exceeds
nursing is essentially directed towards persons not our knowledge base; restraint and caution are
capable of self-help, who are ill and in need of care. To required (Martinsen, 1989c, 2003b).
encounter the ill person with caring through nursing Environment: Space and Situation
involves a set of preconditions such as knowledge, The person is always in a particular situation in a par-
skills, and organization” (Martinsen, 1989c, p. 75). We ticular space. In space are found time, ambience, and
need training in all types of caring work. We must power (Martinsen, 2001, 2002b, 2002c). Martinsen
practice and reflect alone and with others in order to asks what time, architecture, and knowledge do to the
develop professional judgment. Caring and profes- ambience of a space. Architecture, our interaction
sional judgment are integrated in nursing (Martinsen, with each other, use of objects, words, knowledge, our
1990, 1997a, 2003c, 2004b, 2005, 2006, 2012b). being-in-the-room—all set the tone and color the situ-
ation and the space. The person enters into universal
Person space, natural space, but through dwelling creates cul-
It is the meaning-bearing fellowship of tradition that tural space. We build houses with rooms, and the ac-
turns the individual into a person. The person cannot tivities of the health service take place in different
be torn away from the social milieu and the commu- rooms. “The sick-room is important as a physical,
nity of persons (Martinsen, 1975). In one way, there is
a parallel between the person and the body. It is as bod-
ies that we relate to ourselves, to others, and to the
world (Alvsvåg, 2000; Martinsen, 1997a). The body is a

158 UNIT II  Nursing Philosophies

material and constructed place, but it is also a place we Metaphysics is not speculation about that of which
share with other people. . . . The room with its interior we cannot know anything. It is an interpretation of
and objects makes visible the patient’s and the nurse’s phenomena we all recognize through our senses and
interpretation of it” (Martinsen, 2001, pp. 175-176). can experience. These phenomena are prescientific
Our challenge is to give patients and each other dig- and foundational.
nity in these spaces. What is needed then is deliberate
knowledge gathered in slowed down, deliberate spaces, Logical Form
“space in which to perceive—smell, listen, see and
care” (Martinsen, 2001, p. 176). Martinsen’s logical form can be described as inductive
and analogous. The inductive aspect of her thought has
Theoretical Assertions its source in that experiences in life and in health ser-
vice are the starting point for her theoretical works. She
People are created dependent and relational. Care is turns toward philosophy and history in the hope of
fundamental to human life. As humans, we live not gaining greater insight and understanding of the con-
merely in fellowship with one another, but we also crete work of nursing and the lived life. In her meeting
enter into relationships with animals and with nature, with the philosophy of life and the phenomenology of
and we relate to a creative force that sustains the creation, she encounters the ontological and meta-
whole. The person is fundamentally dependent upon physical in a different way than that of traditional phi-
community and the creation. To the created belong losophy. Life utterances, the creation, time, and space
the sovereign life utterances, “These are firstly given to are ontological and metaphysical facts. Analogy would
us, and secondly they are sovereign. That is to say it is say that we think these facts and recognize them in our
impossible for the person to avoid their power. . . .  concrete experiences in our practical life. They come to
These are phenomena which are present in the ser- expression in meetings between persons, in narratives,
vice of life. They create life, they release life’s possi- and in the exercise of discernment. “In this way, meta-
bilities” (Martinsen, 1996, p. 80). physics pries at the empirical,” writes Martinsen with
reference to Løgstrup (Martinsen, 1996). Further, she
The body is created as a whole, that is to say that need states, “The narrative takes time, it is slow. It provides
and spirit, or body and spirit, enter into a benevolent context through analogous forms of recognition, that is
interaction, in which sensing cannot be avoided. to say, it is relevant to us when we can recognize our-
Martinsen (1996) writes the following: selves in the life phenomena it relates” (Martinsen,
2002b, p. 267).
Sensing initiates interaction and maintains it.
Care of the body becomes central. In this respect, Kirkevold (1998) writes the following:
nursing is secular vocational work which through
professional care of the body protects and pro- Martinsen does not mean to present a logically
vides space for the life possibilities of the patient. constructed theory. On the contrary, she distances
The vocation is seen as a demand life makes on herself from that view of knowledge that insists
us to care for our neighbour, in this case the theory have a logical structure of terms, principles
patient, through our work. It is work in the and rules. Martinsen’s theory is an interpretive
service of life processes. Vocation, the body and analysis of caring, upon which the author tries to
work are seen as a counterweight to the new shed light from several perspectives. Her treat-
(bodiless) spirituality in nursing (p. 72). ment of this phenomenon must be said to be both
extensive and thorough (p. 180).
Love of one’s neighbor is coupled with a concrete,
practical, professional, and moral discernment. Sen- Acceptance by the Nursing Community
suous and experience-based knowledge is the most Practice
fundamental and essential for the practice of nursing.
Caring is learned through practical experience in Martinsen herself is reluctant to provide concrete direc-
concrete situations under the supervision of expert tions for practical nursing. However, she recommends
and experienced nurses (Martinsen, 1993b, 2003b).

that nurses “think along” and assess what she writes CHAPTER 10  Kari Martinsen 159
and speaks about in their own lives, their own practice
and experience, and, against this background, imagine thinking relevant for both nursing generally and for
their own way to alternatives for action. This is how specific professional issues. For example, several col-
Kirkevold (1998) puts it: lege lecturers in Norway and Denmark produced an
article compilation in 2000, which gives an introduc-
Martinsen’s theory of caring is practically relevant tion to Martinsen’s thought and for which the target
as an overarching/general philosophy of nursing. group is students (Alvsvåg & Gjengedal, 2000). The
It is clearly articulated and encompasses a precise book The Philosophy of Caring in Practice: Thinking
formulation of how (one ought) to understand with Kari Martinsen in Nursing, was published in
and approach patients and nursing. Its strength is 2002 and republished in 2010 (Austgard, 2010).
the ability to promote reflection upon nursing
practice in different contexts, in that it gives a In 2003, a Danish nurse wrote a textbook of spiritual
clear picture of what the author believes must be care. Central to the book is Martinsen’s thinking, in ad-
present so that nursing may be considered caring dition to that of Katie Eriksson and Joyce Travelbee
or moral practice (p. 181). (Overgaard, 2003). In the Danish Encyclopedia of Nurs-
ing, published in 2008, Kari Martinsen is portrayed in
Many of these texts have, she maintains: a separate article, while several other articles refer to
her thinking on caring and judgment (Jørgensen &
. . . a normative character, and are intended to Lyngaa, 2008).
mobilize a counter-culture in nursing, which Research
does not only revolutionize the discipline of In the same way as one in practical nursing can “think
nursing and its practice, but which also stands as along” and assess what she writes, her writings can
a resisting force against the societal tendency in also be applied in research. Countless dissertations
opposition to the concept of care. . . . In recent based on practical, concrete, and more theoretical
years the personal, inspiring and poetic style has issues discuss the relationship between empirical
become more pronounced. It communicates experience in light of Martinsen’s terminology and
Martinsen’s normatively founded philosophy of philosophy. In one doctoral dissertation from 2006,
caring in a gripping way, and has therefore had the Norwegian pedagogue Pål Henning Walstad
great impact on nurses and students addresses Kari Martinsen’s Grundtvig-Løgstrupian
influence, calling it Care for Life, and discusses this in
(Kirkevold, 1998, p. 204). relation to practical work and professional education
(Walstad, 2006). Moreover, nursing teacher Betty-
Martinsen herself addresses practicing nurses through Ann Solvoll has in her 2007 doctoral dissertation
their professional journal, Sykepleien. Kirkevold writes: done a field study of nursing education and is discuss-
“In choosing the journal Nursing as a main vehicle for ing the data in relation to Martinsen’s reflections on
communicating her academic work, she has under- care (Solvoll, 2007). Two Danish doctoral disserta-
scored her roots in practical nursing rather than in tions (Dahlgard, 2007; Mark 2008) reflect Martinsen’s
science” (Kirkevold, 1998, p. 203). theory applied to empirical material dealing with care
for the dying, and with anorectic and diabetic
Education patients, respectively. Similar applications are made
Most nursing colleges in Norway and Denmark with reference to bathing of patients (Jeanne Boge,
make good use of Martinsen’s texts, and her works 2008), dignified encounters in the final phase of life
form part of the curriculum at a variety of educa- (Kari Gran Bøe, 2008), and the importance of space
tional levels. Her books are reprinted regularly and and architecture for psychiatric patients (Inger Beate
have had considerable impact. Several prescribed Larsen, 2009). Else Foss is a preschool teacher who
texts for nursing education deal with her thought analyzes children’s crying in kindergartens in her
(Alvsvåg, 2011; Kirkevold, 1998; Kristoffersen, 2002; doctoral dissertation (Foss, 2009). These examples of
Mekki & Tollefsen, 2000; Nielsen, 2011). In addi- applications of Martinsen’s thought in research are
tion, other books have been written for nursing edu- even beyond those of nursing proper.
cation in which the aim is to make Martinsen’s

160 UNIT II  Nursing Philosophies families with person-oriented professionality, and
that (patient encounter) is at the heart of person-
Further Development oriented professionality.

Caring can be understood on several levels: ontologi- Simplicity
cal, concrete, and practical, or at the level of system or At first glance, Martinsen’s theory seems complex.
organization. In nursing, we are encouraged to act in a At the same time, the question must be asked whether
professional and moral manner, so that caring and life this is because she turns so many of our familiar
utterances are given the space they need to emerge in assumptions on their heads, for example, that we as
nurse-patient encounters. We are continuously chal- human beings are free, independent, and boundless
lenged to reflect critically over whether this happens in our capacity for activity and interference with cre-
or not. It would involve the manifestation of a person- ation. Western societies live in a culture of individual-
oriented professionalism, the manifestation of loving ism. Her view of humanity can be described as
deeds in the profession, over and over (Martinsen, collectivist. She uses a poetic and philosophical rather
1993b, 2000b). than a scientific mode of speaking, which might also
seem alien in a scientized society. She writes about
It is important, moreover, to develop a mode of general phenomena that affect us all, and that we can
thinking about caring in nursing research. Science in easily recognize in our personal lives, either occupa-
nursing might face certain boundaries. The challenge is tionally or in daily life. Seen this way, the theory of
to develop a type of research that does not impoverish caring is not hard to understand. Martinsen asks that
practice, but that upgrades the available knowledge and we read slowly while imagining our own experiences
wisdom developed through practice, in other words to in light of what she writes (Martinsen, 2000b).
develop or create a practice-oriented research, a coop-
eration between researcher and practitioner (Martinsen, Generality
1989c, 1993b). Kirkevold writes as follows: Because Martinsen’s nursing theory deals with essen-
tial phenomena of life and nursing, phenomena pres-
Martinsen’s theory is especially important be- ent in all human situations, it can be seen as relevant
cause it is one of the few existing Norwegian to patients in general (Martinsen, 2006). Her theory of
nursing theories, and because it is one of the first care “seems to be relevant for all patients who, because
Nordic nursing theories that gives expression to a of illness or other reasons, need help and assistance”
new understanding of reality and the need for (Kirkevold, 1998, p. 181).
new nursing theories based upon this
Accessibility
(Kirkevold, 1998, p. 182). The patient’s and the nurse’s worlds of experience are
At the organizational and social levels, the concept diverse, nuanced, and multifaceted. A nuanced and
of care is also highly relevant. It is important to de- varied language is required to deal with a multifac-
velop social systems and organizations, such as the eted reality, one that is on par with what is to be de-
health service, so that a person-oriented professional- scribed. This language is close to philosophy and also
ism can be facilitated. Martinsen writes about both a to everyday language; it is a poetic language. We may
merciful and a political Samaritan (Martinsen, 1993b, say that the poetic language is the most precise in
2000b, 2003b). What is important at both organiza- describing manifold phenomena and situations open
tional and social levels is how the political Samaritans to interpretation. Reflection on professional judg-
facilitate the work of the merciful Samaritans. ment and professional narratives creates the contexts
of a community of nursing and the tradition of nurs-
Critique ing; we recognize situations and thus find profes-
Clarity sional and moral insight. This enables us to perform
situation-dependent, good nursing—a professional
Martinsen’s theory clearly states that life has been moral practice.
created and given to us. We have been created in
dependence on each other and on nature. Caring
for each other and for nature is fundamental. Our
challenge as nurses is to meet patients and their

Importance CHAPTER 10  Kari Martinsen 161
Martinsen’s theory of caring is a critique of the pre- fall outside of society. Her theoretical stance can
vailing system and at the same time an inspiration to be called critical and phenomenological. She takes
individuals in concrete caring situations (Gjengedal, as her starting point the idea that human beings are
2000). Gjengedal writes that Martinsen’s motivation created and are beings for whom we may have
for theoretical work “has precisely a practical point administrative responsibility. We are relational and
of departure, a wish to understand and protect dependent on each other and on the creation.
against devaluation of the aspect of care in nursing” Therefore, caring, solidarity, and moral practice are
(Gjengedal, 2000, p. 38). Devaluation of caring unavoidable realities for us.
might occur if one uncritically accepts “a scientific
perspective blind to the lived life and all that gives In her thought on the subject of caring, Martinsen
meaning to being” (Gjengedal, 2000, p. 54). challenges society, the politics of health care, and
health care workers themselves to realize the values
As persons and as nurses, we are challenged to live inherent in caring through concrete policies and
in a way that allows positive meaning to be expressed practical nursing. She deliberately gives few directives
in our human relations, for example, in relations be- for action. Rather, she asks us to think ourselves into
tween patients and their family members. How we the situations of patients and family members and to
express this in a concrete way in a nursing context is arrive at the best choices for action based on a rich
for us as professionals to decide, and the philosophy situational understanding, professional insight, and a
on which Martinsen bases her thinking provides caring attitude.
ideas for our own reflection in specific situations.
Specific situations present themselves with both pos- Martinsen’s thought has provoked, engaged, and
sibilities and limitations. Socially created structural created debate and professional development in nurs-
arrangements such as lack of personnel, financial re- ing in the Nordic countries over the past 30 years. Her
sources, and lack of institutional beds present serious thought challenges us to both think and act well and
limitations on a daily basis. Opportunities for caring correctly, critically, and differently in nursing, in edu-
become more accessible within a caring community cation, and in research. Martinsen’s “caring thought”
and are shaped by politically aware people: contributes to the enlightenment of nursing and nurs-
ing research through its perspectives, concepts, and
A caring community is not dictatorial, nor is it insights based on historical and philosophical schol-
society’s passive extended arm. The caring com- arship and research.
munity exists only to the extent that we struggle
for its existence. We must form it ourselves: CASE STUDY
through solidarity, through morally responsible As nurses, we meet patients and their family mem-
action, through the fight for greater equality and bers in many different life situations. Patients may
for community and social integration. Caring is be of all age groups, acutely or chronically ill,
an active and radical concept might return to life and health, or are coming to
the end of their lives and must face death as a real-
(Martinsen, 1989c, p. 62). ity. Nurses meet patients and family members in
their homes, the hospital, the nursing home, the
It is important to create conditions for good and school health service, at the local clinic, and so
equitable health care and living standards for all, but forth. Some meetings with patients and family
in the fight over limited budgetary resources, to take as members make a greater impression on us than
our starting point those who are weakest, who most others, and all meetings represent situations of
need help, it is about turning the inverted law of care learning. Against this background, write a brief
around such that those who have least receive most. case study from your personal clinical experience
and discuss how caring was expressed in that par-
Summary ticular case situation.

Martinsen has both personal and sociopolitical in-
terest in the ill and in those who, for other reasons,

162 UNIT II  Nursing Philosophies

CRITICAL THINKING ACTIVITIES 3. From the starting point of the situation in the first
item, discuss what is meant by person-oriented
1. Center your thinking on a concrete nursing situa- professionalism and moral practice.
tion with which you had personal experience as
an active participant or as an observer.

2 . Consider the human caring aspects of the situa-
tion in the first item.

POINTS FOR FURTHER STUDY æresbog til Staf Callewaert. [email protected]
[Modernity, disenchantment and shame. A way of
n Martinsen, K. (2006). Care and vulnerability. reading Western medicine in the modern. In
Oslo: Akribe (English original). K. A. Petersen & M. Høyen (Eds.), Leaving a trail
on the way from Aquinas to Bordieu—honorary
n Martinsen, K. (2008). Modernitet, avtrylling og volume for Staf Callewaert. [email protected]]
skam. En måte å lese vestens medisin på i det
moderne. In K. A. Petersen & M. Høyen (red.), At Bøe, K.G. (2008). Verdige møter mellom helsepersonale og
sette spor på en vandring fra Aquinas til Bordieu— pasienter i livets sluttfase. Avhandling for dr.art.-graden.
Universitetet i Oslo.[Dignified encounters between
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samfunnskritikk og sanselighet i sykepleien. Oslo: Tano

*Norwegian titles are provided with approximate translation into English.

166 UNIT II  Nursing Philosophies år siden (s. 54–56). Oslo: Tiden. [Deconesses. In E.
Mehlum (Ed.), Behind the machines and the banners
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ment. Elizabeth Hagemann’s ethics book—new readings. with “The Christiania (Oslo) exhibition” on the condi-
Oslo: Gyldendal Akademisk.] tion of workers 100 years ago.
Thorsen, R., Mæhre, K.S. & Martinsen, K. (red.) (2012). Martinsen, K. (1979). Sykepleien, historien og den
Fortellinger om etikk. [Narratives on ethics]. Bergen: omvendte omsorgen. I R. Wendt (red.), Utveckling av
Fagbokforlaget. omvårdnadsarbete (s. 90–102). Lund: Studentlitteratur.
[Nursing, history and the converse caring. In R. Wendt
Book Chapters (Ed.), Development of health care (pp. 90–102). Lund:
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Martinsen, K. (1979). Sykepleien i historisk perspektiv: Fra
oppgave. I I. K. Haugen, T. Malmin, S. Midtgaard, & K. omsorg mot egenomsorg. I M. S. Fagermoen & R. Nord
Nicolaysen (red.), Pedialogen (s. 3–14). Oslo: Norsk (red.), Sykepleie: Teori/praksis (s. 5–23). Oslo: Norwegian
Sykepleierforbund. [The crises of society and the Nursing Association. [Nursing in a historical perspec-
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(pp. 3–14). Oslo: Norwegian Nursing Association.] Norwegian Nursing Association.]
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I. K. Haugen, T. Malmin, S. Midtgaard, & K. Nicolaysen Iversen, S. Nørve, T. I. Romøren, R. Slagstad, m.fl.
(red.), Pedialogen (s. 15–36). Oslo: Norsk Sykepleierfor- (red.), Pax leksikon. Oslo: Pax Forlag (s. 89–90).
bund. [Nursing as social and moral practice. In I. K. [Deaconessses. In H. F. Dahl, J. Elster, I. Iversen, S.
Haugen, T. Malmin, S. Midtgaard, & K. Nicolaysen Nørve, T. I. Romøren, R. Slagstad, et al. (Eds.), Pax
(Eds.), Pedialog (pp. 15–36). Oslo: Norwegian lexicon (pp. 89–90). Oslo: Pax Forlag.]
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Martinsen, K. (1978). Fra ufaglært fattigsykepleie til J. Elster, I. Iversen, S. Nørve, T. I. Romøren, R. Slagstad,
profesjonelt yrke—Konsekvenser for omsorg. I B. m.fl. (red.), Pax leksikon (s. 553-554). Oslo: Pax forlag.
Persson, K. Ravn, & R. Truelsen (red.), Fokus på syge- [Guldberg, Cathinka. In H. F. Dahl, J. Elster, I. Iversen,
plejen-79. Årbok (s. 128–157). København: S. Nørve, T. I. Romøren, R. Slagstad, et al. (Eds.), Pax
Munksgaard. [From unskilled nursing the poor to lexicon (pp. 553–554). Oslo: Pax Forlag.]
professional occupation—consequences for nursing. Martinsen, K. (1981). Nightingale, Florence. I H. F. Dahl,
In B. Persson, K. Ravn, & R. Truelsen (Eds.), Focus on J. Elster, I. Iversen, S. Nørve, T. I. Romøren, R. Slagstad,
nursing (Annual 79, pp. 128–157). Copenhagen: m.fl. (red.), Pax leksikon (s. 448–449). [Nightingale,
Munksgaard.] Florence. In H. F. Dahl, J. Elster, I. Iversen, S. Nørve,
Martinsen, K. (1979). Den engelske sanitation-bevegelsen, T. I. Romøren, R. Slagstad, et al. (Eds.), Pax lexicon
hygiene og synet på sykdom. I Ø. Larsen (red.), Synet (pp. 448–449). Oslo: Pax Forlag.]
på sykdom (s. 78–87). Oslo: Seksjon for medisinsk Martinsen, K. (1981). Omsorg i sykepleie. I E. Barnes & S.
historie, Universitetet i Oslo. [The English sanitation Solbak (red.), Sykepleielœre 1.Lœrebok for hjelpepleiere
movement: Hygiene and the view of illness. In Ø. (Kap. 3). Oslo: Aschehoug. [Care in nursing. In
Larsen (Ed.), The view of illness (pp. 78–87). Oslo: E. Barnes & S. Solbak (Eds.), Nursing textbook 1.
University of Oslo, Section for Medical History.] Textbook for licensed practical nurses (Chapter 3).
Martinsen, K. (1979). Diakonissesykepleiens framvekst. Oslo:Aschehoug.]
Fra vekkelser og kvinneforeninger til moderhus og Martinsen, K. (1981). Sykepleier. I H. F. Dahl, J. Elster,
fattigomsorg. I NAVF’s sekretariat for kvinneforskning I. Iversen, S. Nørve, T. I. Romøren, R. Slagstad, m.fl.
(red.), Lønnet og ulønnet omsorg. En seminarrapport (red.), Pax leksikon (s. 179–180). [Nurse. In H. F.
(Arbeidsnotat nr. 5, s. 135–170). Oslo: NAVF. [Devel- Dahl, J. Elster, I. Iversen, S. Nørve, T. I. Romøren,
opment of the professional trained Christian nurses: R. Slagstad, et al. (Eds.), Pax lexicon (pp. 179–180).
From revival and woman’s charitable groups to the Oslo: PaxForlag.]
mother house and care of the poor. In NAVF’s Secre- Martinsen, K. (1981). Sykepleieraksjonen 1972. I H. F. Dahl,
tariat for Feminist Research (Ed.), Paid and unpaid J. Elster, I. Iversen, S. Nørve, T. I. Romøren, R. Slagstad,
care: A seminar report (Working paper no. 5, pp. 135– m.fl. (red.), Pax leksikon (s. 180–181). Oslo: Pax forlag.
170). Oslo: NAVE] [Nurses on strike 1972. In H. F. Dahl, J. Elster, I. Iversen,
Martinsen, K. (1979). Diakonissene. I E. Mehlum (red.),
Bak maskinene, under fanene. Utgitt i forbindelse med
“Kristiania-utstillingen” om arbeidsfolk i byen for 100

S. Nørve, T. I. Romøren, R. Slagstad, et al. (Eds.), Pax CHAPTER 10  Kari Martinsen 167
lexicon (pp. 180–181). Oslo: Pax Forlag.]
Martinsen, K. (1981). Sykepleierforbund, Norsk (NSF). Martinsen, K. (1990). Moralsk praksis og dokumentasjon i
I H. F. Dahl, J. Elster, I. Iversen, S. Nørve, T. I. praktisk sykepleie. I T. Jensen, L. U. Jensen, & W. C.
Romøren, R. Slagstad, m.fl. (red.), Pax leksikon (s. 181– Kim (red.), Grundlagsproblemer i sygeplejen. Etik,
183). Oslo: Pax Forlag. [Nursing association. In H. F. videnskabsteori, ledelse & samfunn (s. 60–84). Aarhus:
Dahl, J. Elster, I. Iversen, S. Nørve, T. I. Romøren, R. Philosophia. [Moral practice and documentation in
Slagstad, et al. (Eds.), Pax lexicon (pp. 181–183). Oslo: practical nursing. In T. Jensen, L. U. Jensen, & W. C.
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I E. Barnes & S. Solbak (red.), Sykepleielœre 1. Lœrebok Philosophia.]
for hjelpepleiere. (Kap. 2). Oslo: Aschehoug. [Aspects of
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nurses (Chapter 2). Oslo: Aschehoug.] Bergen: Bergen Diakonissehjem. [Etichs and Diaconi.
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(red.), Kvinnenes kulturhistorie (s. 131–134). Oslo:
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in Norway. In J. Bjørgum, K. Gundersen, S. Lie, & I H. M. Dahl (red.), Omsorg og kjœrlighet i
K. Vogt (Eds.), Woman’s cultural history (pp. 131–134). velfœrdsstaten (Samfundsvidenskabelig kvindefor-
Oslo: Universitetsforlaget.] skning/Cekvina (s. 7–23). Århus: Universitetet i Århus.
Martinsen, K. (1986). Sykepleierne—Helsemisjonerer, [Caring philosophy and its practice. In H. M. Dahl
oppdragere og profesjonelle yrkeskvinner. I I. Fredriksen (Ed.), Care and love in the welfare state (Social scientifi-
& H. Rømer (red.), Kvinder, Mentalitet og arbejde. Kvin- cally woman studies, pp. 7–23). Århus: The University
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work: research on feminist history in Nordic countries sundhedsvidenskabelige forskningsråds sygeplejeforskn-
(pp. 151–156). Aarhus: Aarhus universitetsforlag.] ingsinitiativ. Betydning for sygeplejepraksis (s. 31–43).
Martinsen, K. (1987). Ledelse og omsorgsrasjonalitet—Gir Århus: Århus Universitet. [Area for care in clinical
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Martinsen K. (1989). Omsorg i sykepleien—In moralsk pleiekonferanse på Nordkalottens tak (s. 111–157).
utfordring. I B. Persson, J. Petersen, & R. Truelsen Tromsø: Universitetet i Tromsø. [Ethics and vocation,
(red.), Fokus på sygeplejen-90 (s. 181–200). København: culture and the body—a dialogue with Patricia Benner.
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samfundsvidenskabelig kvindeforskning). Kvinder og sårbarhet. I K. Christensen & L. J. Syltevik (red.),
kommuner i Norden (s. 61–82), København: Samkvind. Omsorgens forvitring? En antologi om utfordringer i
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Martinsen, K. (2000). Kjærlighetsgjerningen og kallet.
Betraktninger omkring Rikke Nissens “Lærebog i
Sygepleje for diakonisser”. I R. Nissen, Lœrebog i
Sygepleie. Med etterord av Kari Martinsen (s. 245–300).
Oslo: Gyldendal Akademisk. [The loving act and the

168 UNIT II  Nursing Philosophies goodness. In H. Alvsvåg & O. Førland (Ed.), Commit-
ment and learning (pp 315–344) Oslo: Akribe.]
call. Reflections on Rikke Nissen’s Textbook of nursing Martinsen, K., Beedholm, K., and Fredriksen, K. (2007).
for deaconesses. In R. Nissen, Textbook of nursing. With Metadebatten der forsvandt. I K. Fredriksen, K.
afterword by Kari Martinsen (pp. 245–300). Oslo: Lomborg, & U. Zeitler (red.). Perspektiver på forskning
Gyldendal Akademisk.] (s. 43–55). Århus: JCVU udviklingsinitiativet for syge-
Martinsen, K. (2001). Huset og sangen, gråten og skammen. plejerskeuddannelsen. [The Meta debate that disap-
Rom og arkitektur som ivaretaker av menneskets peared. In K. Fredriksen, K. Lomborg, and U. Zeitler
verdighet. I T. Wyller (red.), Skam: Perspektiver på skam, (Eds.). Perspectives on research (pp 43–55). Århus: JCVU
œre og skamløshet i det moderne (s. 167–190). Bergen: udviklingsinitiativet for sygeplejerskeuddannelsen.
Fagbokforlaget. [The house and the song, the tears and Martinsen, K. (2008). Modernitet, avtrylling og skam. En
the shame: space and architecture as caretakers of human måte å lese vestens medisin på i det moderne. In K. A.
dignity. In T. Wyller (Ed.), Shame: perspectives on shame, Petersen and M. Høyen (red.). At sette spor på en
honor and shamelessness in modernity (pp. 167–190). vandring fra Aquinas til Bordieu—æresbog til Staf
Bergen: Fagbokforlaget.] Callewaert. [email protected] [Modernity, disenchant-
Martinsen, K. (2002). Rikke Nissen. Kjærlighetsgjerningen ment and shame. A way of reading Western medicine
og sykestuen. I R. Birkelund (red.), Omsorg, kald og in the modern. In K. A. Petersen and M. Høyen (Eds.),
kamp. Personer og ideer i sygeplejens historie (s. 305– Leaving a trail on the way from Aquinas to Bordieu—
328). København: Munksgaard forlag. [The loving act honorary volume for Staf Callewaert. [email protected]]
and the room for the sick. In R. Birkelund (Ed.), Care, Martinsen, K. (2012). Skammens to sider [The two faces of
vocation and love in action and the sick-room. Persons shame]. In Thorsen, R., Mæhre, K. S., & Martinsen, K.
and ideas in nursing history (pp. 305–328). (Eds.), (2012). Fortellinger om etikk [Narratives on eth-
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Martinsen, K. (2002). Rommets tid, den sykes tid, pleiens Martinsen, K. (2012). Etikk i sykepleien—mellom spon-
tid. I I. T. Bjørk, S. Helseth, & F. Nortvedt (red.), Møte tanitet og ettertanke [Ethics in Nursing—between
mellom pasient og sykepleier (s. 250–271). Oslo: spontaneity and reflection]. In: M. Pahuus & P.K.
Gyldendal Akademisk. [The room’s time, the ill person’s Telleus (Eds.), Antologi—Anvendt etikk—problemer og
time, nursing time. In I. T. Bjørk, S. Helseth, & F. Nort- arbejdsområder [Anthology—Applied Ethics— Problems
vedt (Eds.), The meeting between patient and nurse and areas of application]. Aalborg: Aalborg Univer-
(pp. 250–271). Oslo: Gyldendal Akademisk.] sitetsforlag [Aalborg University Press].
Martinsen, K. (2003). Disiplin og rommelighet. I K.
Martinsen & T. Wyller (red.), Etikk, disiplin og Journal Articles
dannelse. Elisabeth Hagemanns etikkbok—Nye lesinger Martinsen, K. (1976). Historie og sykepleie—Momenter til
(s. 51–85). Oslo: Gyldendal Akademisk. [Discipline
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ethics book—new readings (pp. 51–85). Oslo: trast, 7(12), 430–446.]
Gyldendal Akademisk.] Martinsen, K. (1977). Nightingale—Ingen opprører bak
Martinsen, K. (2005). Å bo på sykehuset og erfare arki- myten. Sykepleien, 18(65), 1022–1025. [Nightingale—
tektur. I K. Larsen (red.), Arkitektur, kropp og løring. No rebel behind the myth. Nursing, 18(65),1022–1025.]
København: Reitzels forlag. [To dwell in hospitals Martinsen, K. (1978). Det ‘kliniske blikk’ i medisinen og i
and experience architecture. In K. Larsen (Ed.), sykepleien. Sykepleien, 20(66), 1271–1272. [The “clini-
Architecture, body and learning. Copenhagen: cal gaze” in medicine and in nursing. Nursing, 20(66),
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Martinsen, K. (2005). Sårbarheten og omveiene. Løgstrup og Martinsen, K. (1981). Omsorgens filosofi og omsorg i
sykepleien. I D. Bugge, P. Bøvadt and P. Sørensen (red.). praksis. Sykepleien, 8(69), 4–10. [The philosophy of
Løgstrups mange ansikter (s. 255–270). Fredriksberg: caring—And the practice. Nursing, 8(69), 4-10.]
Anis. [Vulnerability and detours. Løgstrup and nursing. Martinsen, K. (1982). Den tvetydige veldedigheten. Sosiologi i
In D. Bugge, P. Bøvadt, and P. Sørensen (Eds.). Løgstrup’s dag, temanummer Kvinner og omsorgsarbeid, 1(12), 29-41.
many faces (pp. 255–270). Fredriksberg: Anis.] [The ambiguity of charity. Sociology, 1(12), 29–41.]
Martinsen, K. (2007). Angår du meg? Etisk fordring og Martinsen, K. (1982). Diakonissene—De første faglærte
disiplinert godhet. I H. Alvsvåg & O. Førland (red.). sykepleiere. Sykepleien, 7(70), 6–9. [The deaconesses—
Engasjement og lœring (s. 315–344). Oslo: Akribe. [Do The first professionally trained nurses. Nursing, 7(70), 6–9.]
you concern me? Ethical demand and disciplined

Martinsen, K. (1985). Kallsarbeidere og yrkeskvinner: CHAPTER 10  Kari Martinsen 169
Diakonissene—Våre første sykepleiere. Forskningsnytt, power, word and body in nursing profession. Nursing,
temanummer: Kvinner og arbeid, 1,18-23. [Women 2(78), 2–11,29.]
with a calling and a profession: the deaconesses—our Martinsen, K. (1991). Under kjærlig forskning. Fenome-
first nurses. News in Science, 1,18–23.] nologiens åpning for den levde erfaring i sykepleien.
Perspektiv—Sygeplejersken, 36(91), 4–15. [Compassion-
Martinsen, K. (1985). Sykepleiertradisjonen—Et nødvendig ate research. Phenomenology opening up for lived
korrektiv til dagens sykepleieforskning. Sykepleien, experience in nursing. Perspective—Nursing (Danish),
15(73), 6–14. [The nursing tradition—a necessary cor- 36(91), 4–15.]
rective to today’s nursing science. Nursing, 15(73), Martinsen, K. (1993). Grunnforskning—Trofast og
6–14.] troløs forskning—Noen fenomenologiske overvei-
elser. Tidsskrift for Sygeplejeforskning, 1(9), 7–28.
Martinsen, K. (1986). Omsorg og profesjonalisering—Med [Basic research—Faithful and faithless research—
fagutviklingen i sykepleien som eksempel. Nytt om Some phenomenological considerations. Nursing
kvinneforskning, 2(10), 21–32. [Care and professionalism— Research (Danish), 1(9), 7–28.]
an example from the development in nursing. News in Martinsen, K. (1997). De etiske fortellinger. Omsorg, 1(14),
Woman Science, 2(10), 21–32.] 58–63. [The ethical narratives. Caring, 1(14), 58–63.]
Martinsen, K. (1997). Kallet—Kan vi være det foruten?
Martinsen, K. (1987). Arbeidsdeling—Kjønn og makt. Tidsskrift for sygeplejeforskning, 2(13), 9–41. [The
Sykepleien, 1(74), 18–23. [Division of labor—gender vocation—Can we do without it? Nursing Science,
and power. Nursing, 1(74), 18–23.] 2(13), 9–41.]
Martinsen, K. (1998). Det fremmede og vedkommende (I).
Martinsen, K. (1987). Endret kunnskapsideal og to plei- Klinisk Sygepleje, 1(12), 13–19. [Strangeness and rele-
egrupper. Sykepleien, 4(74), 20–25. [A changing para- vance (I). Clinical Nursing, 1(12), 13–19.]
digm and two types of nurses. Nursing, 4(74), 20–25.] Martinsen, K. (1998). Det fremmede og vedkommende
(II). Klinisk Sygepleje, 1-2(12), 78–84. [Strangeness and
Martinsen, K. (1987). Helsepolitiske problemer og helse- relevance (II). Clinical Nursing, 2(12), 78–84.]
politisk tenkning bak sykehusloven av 1969. Historisk Martinsen, K. (2001). Er det mørketid for filosofien? Et svar
tidsskrift, 3(66), 357–372. [Health policy problems and til Marit Kirkevold. Tidsskrift for sygeplejeforskning
health policy thinking underlying the new hospital law. (dansk), 1(17), 1923. [Is philosophy in shadow? A reply to
History, 3(66), 357–372.] Marit Kirkevold. Nursing Science (Danish), 1(17), 19–23.]
Martinsen, K. (2002). Livsfilosonske betraktninger. I Dia-
Martinsen, K. (1987). Ledelse og omsorgsrasjonalitet—Gir koninytt, 3(118), 8–12. [Reflections on the philosophy
patriarkatbegrepet innsikt? Sykepleien, 1(74), 18–23. of life. Deaconry News, 3(118), 8–12.]
[Management and caring rationality—Does the concept Martinsen, K. (2002). Samtalen, kommunikasjonen og
of patriarchate give insight? Nursing, 1(74), 18–23.] sakligheten i omsorgsyrkene. Omsorg, 1(19), 14–22.
[Conversation, communication and professionality in
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En del av den perinatale omsorg. Tidsrommet ca. 1890- Martinsen, K. (2003). Talens åpenhet og evidens—Dialog
1940. Historisk tidsskrift, 3(66), 373–390. [Doctors’ in- med Jens Bydam. Klinisk Sygepleje, 4(17), 3–46. [The
terests in pregnancy—a part of perinatal care. History, openness of speech and evidence—Dialogue with Jens
3(66), 373–390.] Bydam. Clinical Nursing, 4(17), 36–46.]
Martinsen, K. (2004). Skjønn—Språk og distanse: dialog
Martinsen, K. (1987). Norsk Sykepleierskeforbund på bar- med Jens Bydam. Klinisk Sygepleje, 2(18), 50–56.
rikadene for utdanning fra første stund. Sykepleien, [Discernment—Language and distance: Dialogue with
3(74), 6–12. [The Norwegian Nursing Association on Jens Bydam. Clinical Nursing, 2(18), 50–56.]
the barricades from day one. Nursing, 3(74), 6–12.] Martinsen, K. (2008). Innfallet—og dets betydning i liv og
arbeid. Metafysisk inspirerte overveielser over innfall-
Martinsen, K. (1988). Ansvar og solidaritet. En moral- ets natur og måter å vise seg på. Klinisk Sygepleje,
filosofisk og sosialpolitisk forståelse av omsorg. Syke- 1(22), [The Innfall (impulse)—and its significance in
pleien, 12(75), 17–21. [Responsibility and solidarity. A life and work. Metaphysically inspired reflections on
moral-philosophical and sociopolitical understanding the nature of the Innfall and its ways of showing itself.
of caring. Nursing, 12(75)17–21.] Clinical Nursing, 1(22)]

Martinsen, K. (1988). Etikk og omsorgsmoral. Sykepleien,
13(75), 16–20. [Ethics and the moral practice of caring.
Nursing, 13(75), 16–20.]

Martinsen, K. (1990). Diakoni er fellesskap og samhørighet.
Under Ulriken, 5(30), 6–10. [Diaconi is community and
fellowship. Under Ulrikken, 5(30), 6–10.]

Martinsen, K. (1991). Omsorg og makt, ord og kropp i
sykepleien. Sykepleien, 2(78), 2–11, 29. [Caring and

170 UNIT II  Nursing Philosophies Austgard, K. (2010). Omsorgsfilosofi i praksis. Å tenke med
filosofen Kari Martinsen i sykepleien. Oslo: Cappelen
Martinsen, K. (2012).Filosofi og fortellinger om sårbarhet Akademisk Forlag. [Philosophy of caring in practice:
[Philosophy and narratives of vulnerability]. In Klinisk Thinking with philosopher Kari Martinsen in nursing.
Sygepleje [Clinical Nursing], 2(26), 30–37. Oslo: Cappelen Akademisk Forlag.]

Sviland, R., Martinsen, K., & Råheim, M. (2007).Hvis ikke Boge, J. (2011). Kroppsvask i sjukepleie. Eit politisk og
kropp og psyke—hva da? [If not body, not psyche—what historisk perspektiv [Bathing the patient. A political
then?] Fysioterapeuten [The Physiotherapeut] 12, 23–28. and historical perspective]. Oslo: Akribe.

Sviland, R., Råheim, M. & Martinsen, K. (2009).Å komme Jørgensen, B. B., & Lyngaa, J. (red.) (2008). Sygeplejeleksikon.
til seg selv – i bevegelse, sansingog forståelse [Coming København: Munksgaard. [Encyclopedia of Nursing.
to one’s senses—in moving, sensing, understanding]. Copenhagen: Munksgaard.]
Matrix; 2, 257–275.
Mathisen, J. (2006). Sykepleiehistorie [History of Nursing].
Sviland, R., Råheim, M., & Martinsen, K. (2010).Språk— Oslo: Gyldendal Akademisk.
uttrykk for inntrykk [Language—expressing impressions].
Matrix, 2, 132–156. Mekki, T. E., & Tollefsen, S. (2000). På terskelen. Introduk-
sjon til sykepleie som fag og yrke. Oslo: Akribe. [On the
Martinsen, K., & Wærness, K. (1976). Sykepleierrollen— threshold: An introduction to nursing as discipline and
En undertrykt kvinnerolle i helsesektoren (I). Sykepleien, profession. Oslo: Akribe.]
4(64), 220–224. [The nursing role—An oppressed female
role in National Health Service. Nursing, 4(64), 220–224.] Olsen, R. (1998). Klok av erfaring? Om sansing og
opp-merksomhet, kunnskap og refleksjon i praktisk
Martinsen, K., & Wærness, K. (1976). Sykepleierrollen— sykepleie. Oslo: Tano Aschehoug. [Wise with experi-
En undertrykt kvinnerolle i Helsesektoren (II). Syke- ence? On sensation and attention, knowledge and reflec-
pleien, 5(64), 274–275, 281–282. [The nursing role—An tion in practical nursing. Oslo: Tano Aschehoug.]
oppressed female role in National Health Service. Nurs-
ing, 5(64), 274–275, 281–282.] Overgaard, A. E. (2003). Åndelig omsorg—En lœrebog. Kari
Martinsen, Katie Eriksson og Joyce Travelbee i nytt lys.
Martinsen, K., & Wærness, K. (1980). Klientomsorg og København: Nyt Nordisk Forlag Arnold Busck. [Spiri-
profesjonalisering. Sykepleien, 4(68), 12–14. [Client tual care—A textbook. Kari Martinsen, Katie Eriksson
care and the professionalization. Nursing, 4(68), 12–14.] and Joyce Travelbee in a new light. Copenhagen: Nyt
Nordisk Forlag Arnold Busck.]
Publications in Press
Sviland, R., Råheim, M., & Martinsen, K. Touched in Walstad, P. B. (2006). Dannelse og Duelighed for livet. Dan-
nelse og yrkesutdanning i den grundtvigske tradisjon.
sensation—moved by respiration. Embodied narrative Trondheim: Norges teknisk-naturvitenskapelige univer-
identity—a treatment process. Scandinavian Journal of sitet. Doctoral dissertation 2006:88. [Education and Ca-
Caring Sciences. pability for life. Education and professional training in
Secondary Sources the Grundtvigian tradition. Trondheim: Norges teknisk-
Alvsvåg, H., & Gjengedal, E. (red.) (2000). Omsorgsten- naturvitenskapelige universitet, NTNU Doctoral Dis-
kning. En innføring i Kari Martinsens forfatterskap. Ber- sertations 2006:88.]
gen: Fagbokforlaget. [Caring thought: An introduction to
the writings of Kari Martinsen. Bergen: Fagbokforlaget.]

11C H A P T E R

Katie Eriksson

1943 to Present

Theory of Caritative Caring

Unni Å. Lindström, Lisbet Lindholm Nyström, and Joan E. Zetterlund

“Caritative caring means that we take “caritas” into use when caring for the human being in health and
suffering . . . Caritative caring is a manifestation of the love that ‘just exists’ . . . Caring communion,
true caring, occurs when the one caring in a spirit of caritas alleviates the suffering of the patient”
(Eriksson, 1992c, pp. 204, 207).

Credentials of the Theorist where she received her MA degree in philosophy in
1974 and her licentiate degree in 1976; she defended
Katie Eriksson is one of the pioneers of caring science her doctoral dissertation in pedagogy (The Patient
in the Nordic countries. When she started her career Care Process—An Approach to Curriculum Construc-
30 years ago, she had to open the way for a new science. tion within Nursing Education: The Development of a
We who followed her work and progress in Finland Model for the Patient Care Process and an Approach
have noticed her ability from the beginning to design for Curriculum Development Based on the Process of
caring science as a discipline, while bringing to life the Patient Care) in 1982 (Eriksson, 1974, 1976, 1981). In
abstract substance of caring. 1984, Eriksson was appointed Docent of Caring Sci-
ence (part time) at University of Kuopio, the first
Eriksson was born on November 18, 1943, in docentship in caring science in the Nordic countries.
Jakobstad, Finland. She belongs to the Finland- She was appointed Professor of Caring Science at Åbo
Swedish minority in Finland, and her native lan- Akademi University in 1992. Between 1993 and 1999,
guage is Swedish. She is a 1965 graduate of the she held a professorship in caring science at University
Helsinki Swedish School of Nursing, and in 1967, of Helsinki, Faculty of Medicine, where she has been
she completed her public health nursing specialty a docent since 2001. Since 1996, she has also served
education at the same institution. She graduated in as Director of Nursing at Helsinki University Cen-
1970 from the nursing teacher education program tral Hospital, with responsibilities for research and
at Helsinki Finnish School of Nursing. She contin-
ued her academic studies at University of Helsinki, 171

172 UNIT II  Nursing Philosophies a research program for caring science, was created.
development of caring science in connection with The result of her planning was the Department of Car-
her professorship at Åbo Akademi University. ing Science in 1987. It became an autonomous depart-
ment within the Faculty of Education of Åbo Akademi
In the late 1960s and early 1970s, Eriksson worked University until 1992, when a Faculty of Social and
in various fields of nursing practice and continued Caring Sciences was founded. Eriksson developed an
her studies at the same time. Her main area of work academic education for Masters and Doctoral degrees
has been in teaching and research. Since the 1970s, in Caring Science. The doctoral program started in
Eriksson has systematically deepened her thoughts 1987 under Eriksson’s direction, and 44 doctoral dis-
about caring, partly through development of an ideal sertations have been published.
model for caring that formed the basis for the carita-
tive caring theory, and partly through the develop- With her staff and researchers, Eriksson has further
ment of an autonomous, humanistically oriented developed the caritative theory of caring and caring
caring science. Eriksson, one of the few caring sci- science as an academic discipline. The department has
ence researchers in the Nordic countries, developed a leading position in the Nordic countries with stu-
a caring theory and is a forerunner of basic research dents and researchers. In addition to her work with
in caring science. teaching, research, and supervision, Eriksson has been
the dean of the Department of Caring Science. One
Eriksson’s scientific career and professional experi- of her central tasks has been to develop Nordic and
ence comprise two periods: the years 1970 to 1986 international contacts within caring science.
at Helsinki Swedish School of Nursing, and the period
from 1986, when she founded the Department of Eriksson has been a very popular guest and keynote
Caring Science at Åbo Akademi University, which she speaker, not only in Finland, but in all the Nordic
has directed since 1987. countries and at various international congresses. In
1977, she was a guest speaker at the Symposium of
In 1972, after teaching for 2 years at the nursing Medical and Nursing Education in Istanbul, Turkey;
education unit at Helsinki Swedish School of Nursing, in 1978, she participated in the Foundation of Medical
Eriksson was assigned to start and develop an educa- Care teacher education in Reykjavik, Iceland; in 1982,
tional program to prepare nurse educators at that she presented her nursing care didactic model at the
institution. Such a program taught in the Swedish lan- First Open Conference of the Workgroup of European
guage had not existed in Finland. This education Nurse-Researchers in Uppsala, Sweden; and for several
program, in collaboration with University of Helsinki, years, she participated in education and advanced edu-
was the beginning of caring science didactics. Under cation of nurses at the Statens Utdanningscenter for
Eriksson’s leadership, Helsinki Swedish School of Helsopersonell in Oslo, Norway. In 1988, Eriksson
Nursing developed a leading educational program in taught “Basic Research in Nursing Care Science” at
caring science and nursing in the Nordic countries. the University in Bergen, Norway, and “Nursing Care
It was the forerunner of education based on caring sci- Science’s Theory of Science and Research” at Umeå
ence and integration of research in education. Eriksson University in Sweden. She consulted at many educa-
was in charge of the program for 2 years, until she tional institutions in Sweden; she has been a regular
became dean at Helsinki Swedish School of Nursing in lecturer at Nordiska Hälsovårdsskolan in Gothenburg,
1974. She remained the dean until 1986, when she was Sweden. In 1991, she was a guest speaker at the 13th
nominated to start academic education and research at International Association for Human Caring (IAHC)
Åbo Akademi University. Conference in Rochester, New York; in 1992, she pre-
sented her theory at the 14th IAHC Conference in
Toward the end of the 1980s, nursing science be- Melbourne, Australia; and in 1993, she was the key-
came a university subject in Finland, and professorial note speaker at the 15th IAHC Conference, Caring as
chairs were established at four Finnish universities and Healing: Renewal Through Hope, in Portland, Oregon
at Åbo Akademi University, the Finland-Swedish uni- (Eriksson, 1994b).
versity. In 1986, Eriksson was called to plan an educa-
tion and research program within the subject of caring Eriksson has been a yearly keynote speaker at the
science at Åbo Akademi University’s Faculty of Educa- annual congresses for nurse managers and, since 1996,
tion in Vaasa, Finland. A fully developed education
program for health care, with three focus options and

at the annual caring science symposia in Helsinki, CHAPTER 11  Katie Eriksson 173
Finland. In many public dialogues with Kari Martinsen Award in Finland; in 1987, she received the Sophie
from Norway, Eriksson has discussed basic questions Mannerheim Medal of the Swedish Nursing Associa-
about caring and caring science. Some dialogues tion in Finland; and in 1998, she received the Caring
have been published (Martinsen, 1996; Martinsen & Science Gold Mark for academic nursing care at
Eriksson, 2009). Helsinki University Central Hospital. Also in 1998,
she received an Honorary Doctorate in Public Health
Eriksson worked as a leader of many symposia: the from the Nordic School of Public Health in Gothenburg,
1975 Nordic Symposium about the Nursing Care Pro- Sweden. Other awards include the 2001 Åland Islands
cess (the first Nordic Nursing Care Science Symposium Medal for caring science and the 2003 Topelius Medal,
in Finland); the 1982 Symposium in Basic Research in instituted by Åbo Akademi University for excellent
Nursing Care Science; the 1985 Nordic Symposium in research. In 2003, she was honored nationally as a
Nursing Care Science; the 1989 Nordic Humanistic Knight, First Class, of the Order of the White Rose of
Caring Symposium; the 1991 Nordic Caring Science Finland.
Conference, “Caritas & Passio in Vaasa, Finland”; and
the 1993 Nordic Caring Science Conference, “To Care Theoretical Sources
or Not to Care—The Key Question” in Nursing in
Vaasa, Finland. Ever since the mid 1970s, Eriksson’s leading thoughts
have been not only to develop the substance of caring,
Eriksson’s caritative theory of caring came into but also to develop caring science as an independent
clearer focus internationally in 1997, when the IAHC discipline (Eriksson, 1988). From the beginning,
for the first time arranged its conference in a European Eriksson wanted to go back to the Greek classics by
country. The Department of Caring Science served as Plato, Socrates, and Aristotle, from whom she found
the host of this conference, which was arranged in her inspiration for the development of both the sub-
Helsinki, Finland, with the topic, “Human Caring: The stance and the discipline of caring science (Eriksson,
Primacy of Love and Existential Suffering.” 1987a). From her basic idea of caring science as a
humanistic science, she developed a meta-theory
Eriksson is a member of several editorial committees that she refers to as “the theory of science for caring
for international journals in nursing and caring science. science” (Eriksson, 1988, 2001).
She has been invited to many universities in Finland
and other Nordic countries as a faculty opponent for When developing caring science as an academic
doctoral students and an expert consultant in her field. discipline, Eriksson’s most important sources of inspira-
She is an advisor for her own research students and for tion besides Plato and Aristotle were Swedish theolo-
research students at Kuopio and Helsinki Universities, gian Anders Nygren (1972) and Hans-Georg Gadamer
where she is an associate professor (docent). Eriksson (1960/1994). Nygren and later Tage Kurtén (1987) pro-
served as chairperson of the Nordic Academy of Caring vided her with support for her division of caring science
Science from 1999 to 2002. into systematic and clinical caring science. Eriksson
introduces Nygren’s concepts of motive research, con-
Eriksson has produced an extensive list of text- text of meaning, and basic motive, which give the disci-
books, scientific reports, professional journal articles, pline structure. The aim of motive research is to find the
and short papers. Her publications started in the essential context, the leading idea of caring. The idea of
1970s and include about 400 titles. Some of her pub- motive research applied to caring science is to show the
lications have been translated into other languages, characteristics of caring (Eriksson, 1992c).
mainly into Finnish. Vårdandets Idé [The Idea of Car-
ing] has been published in Braille. Her first English The basic motive in caring science and caring for
translation, The Suffering Human Being [Den Lidande Eriksson is caritas, which constitutes the leading idea
Människan], was published in 2006 by Nordic Studies and keeps the various elements together. It gives both
Press in Chicago. the substance and the discipline of caring science a
distinctive character. In development of the basic
Eriksson has received many awards and honors for motive, St. Augustine (1957) and Søren Kierkegaard
her professional and academic accomplishments. In (1843/1943) became important sources. In further
1975, she was nominated to receive the 3M-ICN
(International Council of Nurses) Nursing Fellowship

174 UNIT II  Nursing Philosophies ethic, Emmanuel Lévinas’ (1988) idea that ethics pre-
development of the discipline, Eriksson’s thinking cedes ontology has been a guiding principle. Eriksson
was influenced by sources such as Thomas Kuhn agrees especially with Lévinas’ thought that the call
(1971) and Karl Popper (1997), and later by American to serve precedes dialogue, that ethics is always
philosopher Susan Langer (1942) and Finnish phi- more important in relations with other human be-
losophers Eino Kaila (1939) and Georg von Wright ings. The fundamental substance of ethics—caritas,
(1986), all of whom support the human science idea love, and charity—is supported further by Aristotle’s
that science cannot exist without values. (1993), Nygren’s (1972), Kierkegaard’s (1843/1943),
and St. Augustine’s (1957) ideas. In the formulation
For many years, Eriksson collaborated with Håkan of caritative ethics, Eriksson has been inspired by
Törnebohm (1978), holder of the first Nordic profes- Kierkegaard’s ideas of the innermost spirit of a human
sorial chair in the theory of science at the University being as a synthesis of the eternal and temporal, and
of Gothenburg, Sweden. It is especially Törnebohm’s that acting ethically is to will absolutely or to will
research in and development of paradigms related the eternal (Kierkegaard, 1843/1943). She stresses the
to various scientific cultures that inspired Eriksson importance of knowledge of history of ideas for
(Eriksson, 1989; Lindström, 1992). the preservation of the whole of spiritual culture and
finds support for this in Nikolaj Berdâev (1990), the
The thought that concepts have both meaning and Russian philosopher and historian. In intensifying
substance has been prominent in Eriksson’s scientific the basic conception of the human being as body,
work. This appears through a systematic analysis of soul, and spirit, Eriksson carries on an interesting dia-
fundamental concepts with the help of a semantic logue with several theologians such as Gustaf Wingren
method of analysis rooted in the idea of hermeneu- (1960/1996), Antonio Barbosa da Silva (1993), and
tics, which professor Peep Koort (1975) developed. Tage Kurtén (1987), while developing the subdisci-
Koort was Eriksson’s mentor and unmistakably the pline she refers to as caring theology.Perhaps the most
most important source of inspiration in her scientific prominent feature of Eriksson’s thinking has been her
work. Building on the foundation of his methodology, clear formulation of the ontological, epistemological,
Eriksson subsequently developed a model for concept and ethical basic assumptions with regard to the disci-
development that has been of great importance to pline of caring science.
many researchers in their scientific work.

In her formulation of the caritas-based caring
ethic, which Eriksson conceives as an ontological

MAJOR CONCEPTS & DEFINITIONS meeting in time and space, an absolute, lasting
Caritas presence (Eriksson, 1992c). Caring communion is
Caritas means love and charity. In caritas, eros and characterized by intensity and vitality, and by
agapé are united, and caritas is by nature uncondi- warmth, closeness, rest, respect, honesty, and tol-
tional love. Caritas, which is the fundamental motive erance. It cannot be taken for granted but pre-
of caring science, also constitutes the motive for all supposes a conscious effort to be with the other.
caring. It means that caring is an endeavor to medi- Caring communion is seen as the source of
ate faith, hope, and love through tending, playing, strength and meaning in caring. Eriksson (1990)
and learning. writes in Pro Caritate, referring to Lévinas:

Caring Communion Entering into communion implies creating op-
Caring communion constitutes the context of the portunities for the other—to be able to step out
meaning of caring and is the structure that deter- of the enclosure of his/her own identity, out of
mines caring reality. Caring gets its distinctive that which belongs to one towards that which
character through caring communion (Eriksson, does not belong to one and is nevertheless one’s
1990). It is a form of intimate connection that own—it is one of the deepest forms of commu-
characterizes caring. Caring communion requires nion (pp. 28–29).

CHAPTER 11  Katie Eriksson 175

MAJOR CONCEPTS & DEFINITIONS—cont’d

Joining in a communion means creating possibili- means that we are willing to sacrifice something of
ties for the other. Lévinas suggests that considering ourselves. The ethical categories that emerge as basic
someone as one’s own son implies a relationship in caritative caring ethics are human dignity, the car-
“beyond the possible” (1985, p. 71; 1988). In this rela- ing communion, invitation, responsibility, good and
tionship, the individual perceives the other person’s evil, and virtue and obligation. In an ethical act,
possibilities as if they were his or her own. This the good is brought out through ethical actions
requires the ability to move toward that which is no (Eriksson, 1995, 2003).
longer one’s own but which belongs to oneself. It is one
of the deepest forms of communion (Eriksson, 1992b). Dignity
Caring communion is what unites and ties together Dignity constitutes one of the basic concepts of cari-
and gives caring its significance (Eriksson, 1992a). tative caring ethics. Human dignity is partly absolute
dignity, partly relative dignity. Absolute dignity is
The Act of Caring granted the human being through creation, while
The act of caring contains the caring elements (faith, relative dignity is influenced and formed through
hope, love, tending, playing, and learning), involves culture and external contexts. A human being’s abso-
the categories of infinity and eternity, and invites to lute dignity involves the right to be confirmed as a
deep communion. The act of caring is the art of unique human being (Eriksson, 1988, 1995, 1997a).
making something very special out of something
less special. Invitation
Invitation refers to the act that occurs when the carer
Caritative Caring Ethics welcomes the patient to the caring communion. The
Caritative caring ethics comprises the ethics of car- concept of invitation finds room for a place where
ing, the core of which is determined by the caritas the human being is allowed to rest, a place that
motive. Eriksson makes a distinction between caring breathes genuine hospitality, and where the patient’s
ethics and nursing ethics. She also defines the foun- appeal for charity meets with a response (Eriksson,
dations of ethics in care and its essential substance. 1995; Eriksson & Lindström, 2000).
Caring ethics deals with the basic relation between
the patient and the nurse—the way in which the Suffering
nurse meets the patient in an ethical sense. It is about Suffering is an ontological concept described as a hu-
the approach we have toward the patient. Nursing man being’s struggle between good and evil in a state
ethics deals with the ethical principles and rules that of becoming. Suffering implies in some sense dying
guide my work or my decisions. Caring ethics is the away from something, and through reconciliation, the
core of nursing ethics. The foundations of caritative wholeness of body, soul, and spirit is re-created, when
ethics can be found not only in history, but also in the human being’s holiness and dignity appear. Suffer-
the dividing line between theological and human ing is a unique, isolated total experience and is not
ethics in general. Eriksson has been influenced by synonymous with pain (Eriksson, 1984, 1993).
Nygren’s (1966) human ethics and Lévinas’ (1988)
“face ethics,” among others. Ethical caring is what we Suffering Related to Illness, to Care,
actually make explicit through our approach and the and to Life
things we do for the patient in practice. An approach These are three different forms of suffering. Suffering
that is based on ethics in care means that we, without related to illness is experienced in connection with
prejudice, see the human being with respect, and illness and treatment. When the patient is exposed to
that we confirm his or her absolute dignity. It also suffering caused by care or absence of caring, the
patient experiences suffering related to care, which

Continued

176 UNIT II  Nursing Philosophies

MAJOR CONCEPTS & DEFINITIONS—cont’d

is always a violation of the patient’s dignity. Not suffering. In reconciliation, the importance of sacri-
to be taken seriously, not to be welcome, being fice emerges (Eriksson, 1994a). Having achieved
blamed, and being subjected to the exercise of power reconciliation implies living with an imperfection
are various forms of suffering related to care. In with regard to oneself and others but seeing a way
the situation of being a patient, the entire life of forward and a meaning in one’s suffering. Reconcili-
a human being may be experienced as suffering ation is a prerequisite of caritas (Eriksson, 1990).
related to life (Eriksson, 1993, 1994a; Lindholm &
Eriksson, 1993). Caring Culture
Caring culture is the concept that Eriksson (1987a)
The Suffering Human Being uses instead of environment. It characterizes the to-
The suffering human being is the concept that Eriksson tal caring reality and is based on cultural elements
uses to describe the patient. The patient refers to the such as traditions, rituals, and basic values. Caring
concept of patiens (Latin), which means “suffering.” culture transmits an inner order of value preferences
The patient is a suffering human being, or a human or ethos, and the different constructions of culture
being who suffers and patiently endures (Eriksson, have their basis in the changes of value that ethos
1994a; Eriksson & Herberts, 1992). undergoes. If communion arises based on the ethos,
the culture becomes inviting. Respect for the human
Reconciliation being, his or her dignity and holiness, forms the goal
Reconciliation refers to the drama of suffering. A of communion and participation in a caring culture.
human being who suffers wants to be confirmed The origin of the concept of culture is to be found in
in his or her suffering and be given time and space such dimensions as reverence, tending, cultivating,
to suffer and reach reconciliation. Reconciliation and caring; these dimensions are central to the basic
implies a change through which a new wholeness motive of preserving and developing a caring cul-
is formed of the life the human being has lost in ture (Eriksson, 1987a; Eriksson & Lindström, 2003).

Use of Empirical Evidence the other. The evidence concept developed by Eriksson
has been shown to be empirically evident when
From the beginning development of her theory, tested in two comprehensive empirical studies in
Eriksson established it in empiricism by systemati- which the idea was to develop evidence-based caring
cally employing a hermeneutical and hypothetical cultures in seven caring units in the Hospital District
deductive approach. In conformity with a human sci- of Helsinki and Uusimaa (Eriksson & Nordman, 2004).
ence and hermeneutical way of thinking, Eriksson A further development of evidence resulted in caring
developed a caring science concept of evidence scientific evidence concept and theory (Martinsen &
(Eriksson, Nordman, & Myllymäki, 1999). Her main Eriksson, 2009).
argument for this is that the concept of evidence in
natural science is too narrow to capture and reach During the 1970s, Eriksson initially developed a
the depth of the complex caring reality. Her concept nursing care process model (Eriksson, 1974), which
of evidence is derived from Gadamer’s concept of later, in her doctoral dissertation (1981), was formu-
truth (Gadamer, 1960/1994), which encompasses the lated as a theory. Since then, Eriksson, step by step, has
true, the beautiful, and the good. She points out, in deepened her conceptual and logical understanding of
accordance with Gadamer, that evidence cannot be the basic concepts and phenomena that have emerged
connected solely with a method and empirical data. from the theory. She has tested their validity in em-
Evidence in a human science perspective contains pirical contexts, where the concepts have assumed
two aspects: a conceptual, logical one, which she calls contextual and pragmatic attributes (Kärkkäinen &
ontological, and an empirical one, each pre-supposing Eriksson, 2004b). This logical way of working, a constant

movement between logical and empirical evidence, CHAPTER 11  Katie Eriksson 177
has been summarized by Eriksson in her model of
concept development (Eriksson, 1997b). The validity The theses are as follows:
of this model has been tested in several doctoral dis- • Ethos confers ultimate meaning on the caring
sertations since 1995 (Gustafsson, 2008; Hilli, 2007;
Kasén, 2002; Lassenius, 2005; Lindwall, 2004; Nåden, context.
1998; Näsman, 2010; Rundqvist, 2004; Sivonen, 2000; • The basic motive of caring is the caritas motive.
Wallinvirta, 2011; von Post, 1999). She started more • The basic category of caring is suffering.
comprehensive systematic as well as clinical research • Caring communion forms the context of meaning
programs on caring when she was appointed director
of the Department of Caring Science at Åbo Akademi of caring and derives its origin from the ethos of
University. All 44 doctoral dissertations written at the love, responsibility, and sacrifice, namely, caritative
Department of Caring Science between 1992 and 2012 ethics.
are in different ways a test and validation of her ideas • Health means a movement in becoming, being, and
and theory. doing while striving for wholeness and holiness,
which is compatible with endurable suffering.
Major Assumptions • Caring implies alleviation of suffering in charity,
love, faith, and hope. Natural basic caring is ex-
Eriksson distinguishes between two kinds of major pressed through tending, playing, and learning in a
assumptions: axioms and theses. She regards axioms sustained caring relationship, which is asymmetrical
as fundamental truths in relation to the conception of by nature.
the world; theses are fundamental statements con- The Human Being
cerning the general nature of caring science, and their The conception of the human being in Eriksson’s
validity is tested through basic research. Axioms and theory is based on the axiom that the human being
theses jointly constitute the ontology of caring science is an entity of body, soul, and spirit (Eriksson, 1987a,
and therefore also are the foundation of its epistemol- 1988). She emphasizes that the human being is funda-
ogy (Eriksson, 1988, 2001). The caritative theory of mentally a religious being, but all human beings have
caring is based on the following axioms and theses, as not recognized this dimension. The human being
modified and clarified from Eriksson’s basic assump- is fundamentally holy, and this axiom is related to
tions with her approval (Eriksson, 2002). The axioms the idea of human dignity, which means accepting
are as follows: the human obligation of serving with love and exist-
• The human being is fundamentally an entity of ing for the sake of others. Eriksson stresses the necessity
of understanding the human being in his ontological
body, soul, and spirit. context. The human being is seen as in constant
• The human being is fundamentally a religious being. becoming; he is constantly in change and therefore
• The human being is fundamentally holy. Human never in a state of full completion. He is understood
in terms of the dual tendencies that exist within him,
dignity means accepting the human obligation of engaged in a continued struggle and living in a ten-
serving with love, of existing for the sake of others. sion between being and nonbeing. Eriksson sees
• Communion is the basis for all humanity. Human the human being’s conditional freedom as a dimen-
beings are fundamentally interrelated to an abstract sion of becoming. She links her thinking with
and/or concrete other in a communion. Kierkegaard’s (1843/1943) ideas of free choice and
• Caring is something human by nature, a call to decision in the human being’s various stages—aesthetic,
serve in love. ethical, and religious stages—and she thinks that the
• Suffering is an inseparable part of life. Suffering human being’s power of transcendency is the founda-
and health are each other’s prerequisites. tion of real freedom. The dual tendency of the human
• Health is more than the absence of illness. Health being also emerges in his effort to be unique, while
implies wholeness and holiness. he simultaneously longs for belonging in a larger
• The human being lives in a reality that is character- communion.
ized by mystery, infinity, and eternity. The human being is fundamentally dependent on
communion; he is dependent on another, and it is in the

178 UNIT II  Nursing Philosophies Natural basic caring is expressed through tending,
playing, and learning in a spirit of love, faith, and
relationship between a concrete other (human being) hope. The characteristics of tending are warmth, close-
and an abstract other (some form of God) that the hu- ness, and touch; playing is an expression of exercise,
man being constitutes himself and his being (Eriksson, testing, creativity, and imagination, and desires and
1987a). The human being seeks a communion where he wishes; learning is aimed at growth and change. To
can give and receive love, experience faith and hope, tend, play, and learn implies sharing, and sharing,
and be aware that his existence here and now has mean- Eriksson (1987a) says, is “presence with the human
ing. According to Eriksson (1987b), the human being being, life and God” (p. 38). True care therefore is “not
we meet in care is creative and imaginative, has desires a form of behavior, not a feeling or state. It is to be
and wishes, and is able to experience phenomena; there—it is the way, the spirit in which it is done, and
therefore, a description of the human being only in this spirit is caritative” (Eriksson, 1998, p. 4). Eriksson
terms of his needs is insufficient. When the human be- brings out that caring through the ages can be seen as
ing is entering the caring context, he or she becomes a various expressions of love and charity, with a view
patient in the original sense of the concept—a suffering toward alleviating suffering and serving life and health.
human being (Eriksson, 1994a). In her later texts, she stresses that caring also can be
Nursing seen as a search for truth, goodness, beauty, and the
Love and charity, or caritas, as the basic motive of eternal, and for what is permanent in caring, and mak-
caring has been found in Eriksson (1987b, 1990, ing it visible or evident (Eriksson, 2002). Eriksson
2001) as a principal idea even in her early works. The emphasizes that caritative caring relates to the inner-
caritas motive can be traced through semantics, an- most core of nursing. She distinguishes between car-
thropology, and the history of ideas (Eriksson, ing nursing and nursing care. She means that nursing
1992c). The history of ideas indicates that the foun- care is based on the nursing care process, and it repre-
dation of the caring professions through the ages has sents good care only when it is based on the innermost
been an inclination to help and minister to those suf- core of caring. Caring nursing represents a kind of car-
fering (Lanara, 1981). ing without prejudice that emphasizes the patient and
his or her suffering and desires (Eriksson, 1994a).
Caritas constitutes the motive for caring, and it is
through the caritas motive that caring gets its deepest The core of the caring relationship, between nurse
formulation. This motive, according to Eriksson, is and patient as described by Eriksson (1993), is an
also the core of all teaching and fostering growth in all open invitation that contains affirmation that the
forms of human relations. In caritas, the two basic other is always welcome. The constant open invitation
forms of love—eros and agapé (Nygren, 1966)—are is involved in what Eriksson (2003) today calls the act
combined. When the two forms of love combine, gen- of caring. The act of caring expresses the innermost
erosity becomes a human being’s attitude toward life spirit of caring and recreates the basic motive of cari-
and joy is its form of expression. The motive of caritas tas. The caring act expresses the deepest holy element,
becomes visible in a special ethical attitude in caring, the safeguarding of the individual patient’s dignity.
or what Eriksson calls a caritative outlook, which she In the caring act, the patient is invited to a genuine
formulates and specifies in caritative caring ethics sharing, a communion, in order to make the caring
(Eriksson, 1995). Caritas constitutes the inner force fundamentals alive and active (Eriksson, 1987a) (i.e.,
that is connected with the mission to care. A carer appropriated to the patient). The appropriation has
beams forth what Eriksson calls claritas, or the the consequence of somehow restoring the human
strength and light of beauty. being and making him or her more genuinely human.
In an ontological sense, the ultimate goal of caring
Caring is something natural and original. Eriksson cannot be health only; it reaches further and includes
thinks that the substance of caring can be understood human life in its entirety. Because the mission of the
only by a search for its origin. This origin is in the human being is to serve, to exist for the sake of others,
origin of the concept and in the idea of natural caring. the ultimate purpose of caring is to bring the human
The fundamentals of natural caring are constituted by being back to this mission (Eriksson, 1994a).
the idea of motherliness, which implies cleansing and
nourishing, and spontaneous and unconditional love.

Environment CHAPTER 11  Katie Eriksson 179
Eriksson uses the concept of ethos in accordance with
Aristotle’s (1935, 1997) idea that ethics is derived from Health
ethos. In Eriksson’s sense, the ethos of caring science, as Eriksson considers health in many of her earlier writ-
well as that of caring, consists of the idea of love and ings in accordance with an analysis of the concept in
charity and respect and honor of the holiness and dig- which she defines health as soundness, freshness, and
nity of the human being. Ethos is the sounding board well-being. The subjective dimension, or well-being,
of all caring. Ethos is ontology in which there is an “in- is emphasized strongly (Eriksson, 1976). In the cur-
ner ought to,” a target of caring “that has its own lan- rent axiom of health, health implies being whole in
guage and its own key” (Eriksson, 2003, p. 23). Good body, soul, and spirit. Health means as a pure concept
caring and true knowledge become visible through wholeness and holiness (Eriksson, 1984). In accor-
ethos. Ethos originally refers to home, or to the place dance with her view of the human being, Eriksson has
where a human being feels at home. It symbolizes a developed various premises regarding the substance
human being’s innermost space, where he appears in and laws of health, which have been summed up in an
his nakedness (Lévinas, 1989). Ethos and ethics belong ontological health model. She sees health as both
together, and in the caring culture, they become one movement and integration. The health premise is a
(Eriksson, 2003). Eriksson thinks that ethos means that movement comprising various partial premises:
we feel called to serve a particular task. This ethos she health as movement implies a change; a human being
sees as the core of caring culture. Ethos, which forms is being formed or destroyed, but never completely;
the basic force in caring culture, reflects the prevailing health is movement between actual and potential;
priority of values through which the basic foundations health is movement in time and space; health as
of ethics and ethical actions appear. movement is dependent on vital force and on vitality
of body, soul, and spirit; the direction of this move-
At the beginning of the 1990s, when Eriksson rein- ment is determined by the human being’s needs and
troduced the idea of suffering as a basic category of desires; the will to find meaning, life, and love consti-
caring, she returned to the fundamental historical tutes the source of energy of the movement; and
conditions of all caring, the idea of charity as the basis health as movement strives toward a realization of
of alleviating suffering (Eriksson, 1984, 1993, 1994a, one’s potential (Eriksson, 1984).
1997a). This meant a change in the view of caring real-
ity to a focus on the suffering human being. Her start- In the ontological conception, health is conceived
ing point is that suffering is an inseparable part of as a becoming, a movement toward a deeper whole-
human life, and that it has no distinct reason or defini- ness and holiness. As a human being’s inner health
tion. Suffering as such has no meaning, but a human potential is touched, a movement occurs that be-
being can ascribe meaning to it by becoming recon- comes visible in the different dimensions of health as
ciled to it. Eriksson makes a distinction between doing, being, and becoming with a wholeness that is
endurable and unendurable suffering and thinks that unique to human beings (Eriksson, Bondas-Salonen,
an unendurable suffering paralyzes the human being, Fagerström, et al., 1990). In doing, the person’s
preventing him or her from growing, while endurable thoughts concerning health are focused on healthy
suffering is compatible with health. Every human life habits and avoiding illness; in being, the person
being’s suffering is enacted in a drama of suffering. strives for balance and harmony; in becoming, the
Alleviating a human being’s suffering implies being a human being becomes whole on a deeper level of
co-actor in the drama and confirming his or her suf- integration.
fering. A human being who suffers wants to have
the suffering confirmed and be given time and space Theoretical Assertions
to become reconciled to it. The ultimate purpose of
caring is to alleviate suffering. Eriksson has described Eriksson’s fundamental idea when formulating theo-
three different forms: suffering related to illness, suf- retical assertions is that they connect four levels of
fering related to care, and suffering related to life knowledge: the meta-theoretical, the theoretical, the
(Eriksson, 1993, 1994a, 1997a). technological, and caring as art. The generation of
theory takes place through dialectical movement be-
tween these levels, but here deduction constitutes the

180 UNIT II  Nursing Philosophies for, Eriksson has used various logical models for the
basic epistemological idea (Eriksson, 1981). The the- hypothetical deductive method and hermeneutics
ory of science for caring science, which contains the guiding principles.
fundamental epistemological, logical, and ethical
standpoints, is formed on the meta-theoretical level. Eriksson stresses the importance of the logical
Eriksson (1988), in accordance with Nygren (1972), form being created on the basis of the substance of
sees the basic motive as the element that permeates caring (i.e., caritas), not on the basis of method. It is
the formation of knowledge at all levels and gives thus deduction combined with abduction that formed
scientific knowledge its unique characteristics. A the guiding logic. The language, words, and concepts
clearly formulated ontology constitutes the founda- carry the content of meaning, and Eriksson stresses
tion of both the caritative caring theory and caring the necessity of choosing words, concepts, and lan-
science as a discipline. The caritas motive, the ethos of guage that correspond to human science.
love and charity, and the respect and reverence for
human holiness and dignity, which determine the In the dynamic change between the natural world
nature of caring, give the caritative caring theory its and the world of science, there has constantly oc-
feature. This ethos, which encircles caring as science curred a striving toward the source of the true,
and as art, permeates caring culture and creates the the beautiful, and the good—that which is evident.
preconditions for caring. The ethos is reflected in the Eriksson (1999) shapes her theory of scientific
process of nursing care, in the documentation, and in thought, as reflection moves between patterns at
various care planning models. different levels and interpretation is subject to the
theoretical perspective. The movement takes place
Caring communion constitutes the context of mean- distinctly between doxa (empirical-perceptive knowl-
ing from which the concepts in the theory are to be edge) and episteme (rational-conceptual knowledge),
understood. Human suffering forms the basic category and “the infinite.” Movement thus takes place between
of caring and summons the carer to true caring the two basic epistemological categories of the theory
(i.e., serving in love and charity). In the act of caring, the of knowledge: perception and conception.
suffering human being, or patient, is invited and wel-
comed to the caring communion, where the patient’s Eriksson applied three forms of inference—
suffering can be alleviated through the act of caring in deduction, induction, and abduction or retroduction
the drama of suffering that is unique to every human (Eriksson & Lindström, 1997)—that give the theory
being. Alleviation of suffering implies that the carer is a a logical external structure. The substance of her car-
co-actor in the drama, confirms the patient’s suffering, ing theory has moved simultaneously by abductive
and gives time and space to suffer until reconciliation is leaps (Peirce, 1990; Eriksson & Lindström, 1997),
reached. Reconciliation is the ultimate aim of health or which sometimes created a new chaos but also car-
being and signifies a reestablishment of wholeness and ried Eriksson’s thinking toward new discoveries.
holiness (Eriksson, 1997a). Through abduction, the ideal model for caritative
caring was shaped, proceeding from historical and
Logical Form self-evident suppositions (Nygren, 1972). Eriksson in
this way made use of old original texts that testify to
Meta-theory has always had a fundamental place caritative caring as her research material. Through
in Eriksson’s thinking, and her epistemological work induction and deduction, the validity of the theory
is anchored in Aristotle’s theory of knowledge has been tested.
(Aristotle, 1935). Searching for knowledge, which is
intrinsically hermeneutic, and which takes place Theory as conceived by Eriksson is in accordance
within the scope of an articulated theoretical perspec- with the Greek concept of theory, theoria, in the sense
tive, is understood as a search for the original text in of seeing the beautiful and the good, participating in
a historical-hermeneutic tradition, that which in the the common, and dedicating it to others (Gadamer,
old hermeneutic sense represents truth (Gadamer, 2000, p. 49). Theory and practice are different aspects
1960/1994). To achieve the depth in the development of the same core. The convincing force and potential
of knowledge and theory she has consistently striven of the whole theory are found in its innermost core,
caritas, around which the generation of theory takes
place. The caring substance is formed in a dialectical

movement between the potential and the actual, the CHAPTER 11  Katie Eriksson 181
abstract general and the concrete individual. With
the help of logical abstract thinking combined with process model work in practice has been verified by
the logic of the heart (Pascal, 1971), the Theory of everything from a multiplicity of essays and tests of
Caritative Caring becomes perceptible through the learning in clinical practice to master’s theses, licen-
art of caring. tiates’ theses, and doctoral dissertations produced all
over the Nordic countries.
Acceptance by the Nursing Community Education
Practice Since the 1970s, Eriksson’s theory has been integrated
into the education of nurses at various levels, and her
A characteristic feature of Eriksson’s manner of work- books have been included continuously in the exami-
ing is her way of structuring abstract thinking as a nation requirements in various forms of nursing edu-
natural and obvious precondition of clinical activity cation in the Nordic countries. The education for
and an evidence-based form of caring that opens up a master’s and doctoral degrees that started in 1986 at
deeper insight. Several nursing units in the Nordic the Department of Caring Science, Åbo Akademi
countries have based their practice and caring philoso- University, has been based entirely on Eriksson’s
phy on Eriksson’s ideas and her caritative theory of ideas, and her caritative caring theory forms the core
caring. These include the Hospital District of Helsinki of the development of substance in education and
and Uusimaa in Finland, Stiftelsen Hemmet in the research.
Åland Islands of Finland, and Stora Sköndal in Sweden.
Because Eriksson’s thinking and process model of car- Development of the caring science–centered curric-
ing are general, the nursing care process model has ulum and caring didactics continued in the educational
proved to be applicable in all contexts of caring, from and research program in caring science didactics.
acute clinical caring and psychiatric care to health- Development of teachers within the education of nurses
promoting and preventive care. forms a part of the master’s degree program and has
resulted in the first doctoral dissertation in the didactics
Since the 1970s, Eriksson’s nursing care process of caring science (Ekebergh, 2001).
model was systematically used, tested, and developed as
a basis of nursing care and documentation at Helsinki Eriksson realized at an early stage the importance
University Central Hospital. From the beginning of of integrating academic courses in the education of
the 1990s, Eriksson served as director of the clinical nurses; nowadays, academic courses in caring science
research program, “In the World of the Patient.” In based on Eriksson’s theory are offered as part of con-
various studies, Eriksson’s theory has been tested, and tinuing education for those who work in clinical
the results have been presented in doctoral and master’s practice. Approximately 200 nurses take part annually
theses and published in professional and scientific jour- in these academic courses.
nals. The study, “In the Patient’s World II: Alleviating
the Patient’s Suffering—Ethics and Evidence” led to Because Eriksson sees caring science not as profes-
recommendations for the care of patients and is an sion oriented but as a “pure” academic discipline, it
ongoing research project that will become a handbook has aroused interest among students in other disci-
for clinical caring science. plines and other occupational groups, such as teach-
ers, social workers, psychologists, and theologians.
Eriksson’s model has been subjected to more Eriksson stresses that it is necessary for doctors
comprehensive academic research (Fagerström, 1999; as well to study caring science, so that genuine inter-
Kärkkäinen & Eriksson, 2003, 2004; Lukander, 1995; disciplinary cooperation is achieved between caring
Turtiainen, 1999). Eriksson’s thinking has been in- science and medicine.
fluential in nursing leadership and nursing adminis- Research
tration, where the caritative theory of nursing forms Eriksson and her teaching and research colleagues
the core of the development of nursing leadership at the Department of Caring Science designed a
at various levels of the nursing organization. That research program based on her caring science tradi-
Eriksson’s ideas about caring and her nursing care tion. This program comprises systematic caring sci-
ence, clinical caring science, didactic caring science,