Great Tenderness in All Things
The concept of great tenderness in all things is unique to the Careful Nursing Philosophy and Professional Practice Model (Careful Nursing). It emerged from the historical documents describing the practice of the early to mid-19th century Irish nurses on which Careful Nursing is based, because it infused their practice.
In the 1820s, when Catherine McAuley began walking the streets and alleys of Dublin to bring desperately needed nursing care to the poverty-stricken population, she considered great tenderness central to her evolving nursing work (McAuley 1832). She and her fellow-nurse contemporaries drew deeply on the widely established Christian faith of their time and understood Christ's 'great tenderness for the Sick' (McAuley 1832, p.5.) as the prototype of great tenderness in nursing practice.
Around twenty years later during the Crimean War when some of their followers, now recognised as skilled nurses with 'brilliant prestige in nursing' (Nutting & Dock 1907/2000. p.86), joined Florence Nightingale to nurse the sick and wounded, great tenderness in all things was an established aspect of their nursing practice..
In Careful Nursing practice, great tenderness in all things is a concept of the practice competence and excellence dimension. However, it calls for a more specific definition. The following brief exploration, guided by a number of questions, is an attempt to prompt a comprehensive examination and analysis of great tenderness in all things as a nursing concept.
What did the 19th century Irish nurses mean by tenderness?
Sullivan (2012) observes that '"Tender" and "tenderness" were characteristic words' in McAuley's expression of ideas related to nursing practice (p.169.) She uses them in relation to care of all types of patients and all aspects of nursing practice. In caring for patients, she writes that 'Great tenderness must be employed and when death is not immediately expected it will be well to relieve the distress first and to endeavour by every practicable means to promote the cleanliness, ease and comfort of the Patient' (McAuley 1832, p.8.). Even though spiritual care was considered vital, patients' physical needs were attended to first because of their natural priority (Sullivan 1996).
In giving advice about the care of one of her companion sisters who became ill, McAuley uses the phrase 'Great tenderness of all things.' (Sullivan 2004, p.90.), appearing to advise that in providing the things that she suggests to help the sister's recovery, great tenderness should be employed. It can be noted that this example of McAuley's care prefigures contemporary nursing problem identification; nursing diagnosis; desired nursing-sensitive patient outcomes, and defined ways to achieve outcomes; nursing interventions.
It can also be noted that the wording of this example as 'of all things' could indicate that McAuley meant that providing the helping things she suggests would, in itself , bring great tenderness to the sister's care. This suggestion is based on her using 'of' to mean 'that from which anything proceeds; indicating origin' (Porter 1864-1891, p.997.).
McAuley (1832) also instructs her fellow-nurses to employ tenderness in the ways they relate to one another; to 'vie with each other in tender concern and regard' (p.37.). In the 19th century the word 'vie' was understood as a shortened form of the French envien; in English to invite. A common meaning of vie was to 'strive for superiority' and in doing so to 'use emulous effort' (Porter 1864-1891, p.1609.). Thus in the context of Christian charity, McAuley directs nurses working together to invite one another to strive to equal and outdo one another in tender concern and regard for one another, as they work together to achieve the aims of their nursing practice.
An enduring feature of McAuley's use of the words tenderness and tender is that they are invariably used in relation to nurses' expression of unconditional patience, generosity, kindness and compassion towards patients and one another. This was understood to encompass a calm manner and respect for inherent human dignity.
Qualitatively, tenderness and tender reflect an inner experience or feeling that motivates practical assistance in the care of sick, injured and vulnerable people. Sullivan (2012) characterises McAuley's use of the words tender and tenderness as the motivation that underlay her nursing work.
McAuley probably qualified tenderness as great because she considered its depth to be of particular importance in motivating nursing attentiveness to and care for patients and because it was expressed within the context of the abundant spiritual love. The practical nature of her nursing work gives her use of these terms a connotation of physical action marked by gentleness.
Was there a prior history of tenderness in nursing practice?
Emphasis on tenderness in nursing probably dates back to the first century when early nurses, such as Phoebe and Fabiola (Jamieson et al 1960), would have expressed tenderness in the context of Christian charity because this is what motivated their work. Thus, it is likely that tenderness had been associated with nursing practice in the Western world for many centuries.
How did the word tenderness originate and develop?
Tender and tenderness – the quality or state of being tender – evolved from the prehistoric Indo-European root ten meaning to stretch. Tender developed to mean stretching or extending toward and paying attention to something or someone, offering something, and stretching oneself forward eagerly with intention and all one's strength (Partridge 1958). Over time slants on its meaning diverged to refer to different types of activities, one of which was care-giving.
The care-giving meaning of tender became specifically associated with nursing. As a noun, tender came to mean 'one who tends; one who takes care of any person or thing; a nurse' (Porter, 1864-1891, p.1484). Tender as an adjective came to mean 'being susceptible to softer feeling', such as love, kind concern, forgiveness and compassion; being careful not to injure; being gentle and unwilling to cause pain.
Overall, the meaning of tender and tenderness in nursing practice is two-fold. They mean extending or offering oneself to patients, paying attention to and attending to them with the intention to protect them and foster their health. They also mean carrying out these intentions and actions lovingly, that is, with kind concern, compassion and gentleness, being careful not to injure or cause pain.
How is tenderness addressed in contemporary literature?
Only one study linked to the idea of tenderness appears in the nursing literature. In a climate of major advances in technology and rapidly increasing social and healthcare delivery change, Meyer (1960) examined professional nurses' and nursing students' preferences for different types of relationships with patients. A total of almost 700 nurses and students responded to a picture-test questionnaire which offered responses ranging from exclusively close nurse-patient relationships to nurse-patient relationships dominated by technical-administrative concerns. Almost 30% of nurses preferred exclusively close relationships with patients and almost 30% preferred relationships dominated by technical-administrative concerns. The remaining 40% preferred close relationships with patients that were shared to some extent with other nurses and were open to new technical and administrative ideas.
Meyer (1960) categorises exclusively close nurse-patient relationships as tenderness in nursing practice and relationships dominated by technical-administrative concerns as technical nursing practice. She likens tenderness to an older, historical approach to nursing and technique to a new over-reaction to technology, advanced knowledge and administrative concerns, at the expense of tenderness. The in-between group who prefer to share patient relationships with other nurses and to be open to technical and administrative ideas are considered to represent integration of old (tenderness) and new (technique) and a desired balance between tenderness and technique.
Meyer (1960) argues that tenderness must be maintained in nursing so that nurses practice with a synthesis of knowledge and feeling. She predicts that this will happen because 'nursing the whole patient has given new dignity and meaning to the concept of tenderness' (p.11). While Meyer's study does not address tenderness per se, it highlights a turning point in nurses' perception of the value of tenderness in nursing practice.
Research on tenderness per see is reported in the psychology literature. In a comprehensive overview of emotions, Frijda (1986) proposes that tenderness is an emotional impulse toward 'tender – that is, care-giving – behaviour; or else as the acute act of recognition of an object as a fit object for such behaviour' (p. 83.).
Building on earlier work on emotions, Kalawski (2010) examined tenderness in relation to love, empathy and sympathy. He views love not as an emotion but as a disposition which has many varieties. He conceptualizes tenderness as a momentary emotional surge which specifically 'corresponds to the love of caregiving' (p. 159.) and as a probable basic emotion. He conceptualizes empathy as a complex, other-oriented emotional feeling, which is not a basic emotion, and may include the emotion of sympathy arising from sadness.
His findings suggest that tenderness may be a necessary component of empathy and sympathy. Viewing his findings in the light of theory and previous research, he distinguishes tenderness as a distinct elementary emotion which can be considered in the same category as anger, fear and joy.
Lishner et al., (2011) propose that tenderness arises from a parental or parent-like concern to nurture and protect another from harm. They examined emotions associated with current needs and with vulnerability alone and found that only people perceived to be vulnerable elicited feelings of tenderness, whether or not they were perceived to have current needs. In a series of studies designed to distinguish between tenderness and sympathy, Niezink et al., (2012) found that while sympathy was elicited by current need, tenderness was elicited by perceiving in another, long term vulnerability and need for protection.
These studies provide some insight into tenderness and situations which elicit it as a helping response, but more research is needed to clarify its nature. The absence of research on the actual nature of tenderness in nursing suggests that it is not recognized by contemporary nurses as a nursing concept. But, its close association with nursing indicates that nursing research on this topic is needed. Its study in psychology, conducted in laboratory settings, offers a foundation for clinical study of tenderness in nursing practice.
Meyer's (1960) prediction that tenderness will be maintained in nursing is barely reflected in discursive nursing literature, although the large number of articles on caring in nursing might be thought to include tenderness in a vague way. Occasional articles about tender care or tender loving care appear and their authors claim these to be essential characteristics of nursing practice. But most fail to define tender. In only one article (Kendrick & Robinson 2002) is the meaning of tender explored, and is concluded to be a type of behaviour related to spiritual love in nurse-patient relationships.
However, one striking example of a nurse's evolving conscious awareness of tenderness in practice and its clinical action quality appears in one of the few articles in the nursing literature titled tenderness, 'A little tenderness goes a long way' (Galland 2008). It describes an unexpected encounter of an exceedingly rushed, over-worked, impatient staff nurse with a very sick, dying patient. The patient's indirect but persistent request for comfort and consolation and the nurse's unanticipated response to him opens for the nurse an unforgettable experience of the simplicity and profound importance of tenderness in nursing practice. Analysis of this article could offer pointers for exploratory clinical research of this concept.
What is a more specific definition of great tenderness in all things?
The current definition of the concept is based on the historical documentation of the 19th century nurses:
An attitude of sensitivity, loving kindness, compassion, gentleness and patience in attending to all experiences and needs of patients. It is linked to awareness of an infinite transcendent reality and mediated through the therapeutic milieu dimensions of caritas and contagious calmness. It is proposed to infuse all nurses' clinical attitudes and actions with the healing love of an infinite transcendent reality (Meehan 2012, p. 2911).
The findings of this brief review provide a basis for a more specific definition of great tenderness in all things. For the 19th-century nurses, it was a Christ-centred feeling they experienced powerfully when they became aware of the helplessness of sick, injured and vulnerable people and the nursing care and protection they required. It motivated them to respond with unconditional patience, generosity, kindness and compassion and by reformulating and providing skilled nursing as a public service. Their qualification of tenderness as great signified its deep importance in their practice.
The origin and development of the words tender and tenderness indicates that for nursing they mean an eager and strongly felt reaching-out response to people in need. It qualifies how nurses respond, engage with, and attend to people who elicit their response; with love, kind concern, and gentleness. It suggests that some nursing-associated words derived from the Indo-European root ten; such as tend, extend, intend, intention, attend, attentive, and attention; signify the presence of tenderness in nursing practice.
Psychology theory and research suggests that the feeling of tenderness is a distinct basic emotion elicited by perceiving in others long-term vulnerability and need for protection and is supported by a loving, caregiving disposition. All sources reviewed emphasise the deeply human relational quality of tenderness.
A more specific definition of great tenderness in all things could be:
A powerfully motivating feeling experienced in response to perceived vulnerability in helpless sick or injured people mediated though awareness of Infinite Transcendent Reality in life processes. It elicits a deeply relational, distinctively nursing reaching-out response to people, characterised by unconditional generosity, patience, gentleness, kindness and compassion, and facilitated by a calming, loving disposition. In clinical practice settings it motivates nurses to assess peoples nursing needs and meet them in terms of nursing diagnoses, measurable nursing-sensitive outcomes and nursing interventions.
In keeping with all the concepts of the professional practice model, great tenderness in all things is infused by the meaning of the Careful Nursing philosophical principles. Its role in the practice competence and excellence dimension of the practice model is to motivate the best possible care of patients.
Frijda, N.H. (1986) The Emotions. Cambridge University Press, Cambridge.
Galland, L. (2008) A little tenderness goes a long way. Nursing, 38 (9), 56.
Jamieson, E.M., Sewall, M.F., & Gjertson, L,S. (1960) Trends in Nursing History. W.B. Saunders Company, Philadelphia.
Kalawski, J.P. (2010) Is tenderness a basic emotion? Motivation and Emotion, 34, 158-167.
Kendrick, K.D. & Robinson, S. (2002) 'Tender loving care' as a relational ethic in nursing practice. Nursing Ethics, 9, 291-300.
Lishner, D.A., Batson, C.D. & Huss, E. (2011) Tenderness and sympathy: distinct empathic emotions elicited by different forms of need. Personality and Social Psychology Bulletin, 37, 614-625.
McAuley M.C. (1832) [Hand-written Manuscript of the Original Rule of The Sisters of Mercy]. Archives of the Sisters of Mercy, Dublin.
Meehan, T.C. (2012) The Careful Nursing philosophy and professional practice model. Journal of Clinical Nursing, 21, 2905–2916.
Meyer, G.R. (1960) Tenderness and Technique: Nursing Values in Transition. University of California Institute of Industrial Relations, Los Angeles.
Niezink, L.W., Siero, F.W., Dijkstra, P., Buunk, A.P. & Barelds, D.P. (2012) Empathic concern: distinguishing between tenderness and sympathy. Motivation and Emotion, 36, 544–549.
Nutting, A. & Dock L. (1907/2000) A History of Nursing From the Earliest Times, to the Present Day With Special Reference to the Work of the Past Thirty Years. Vol.3, Thoemmes Press, Bristol, UK.
Partridge, E. (1958) A Short Etymological Dictionary of Modern English. The Macmillan Company, New York. pp. 703-704.
Porter, N. (1964-1891) Webster's International Dictionary of the English Language. G.C. Merriman & Co., Springfield, Mass., p. 1891.
Sullivan, M. (1996) Catherine McAuley and the care of the sick. The Mast 6 (2), 11-22.
Sullivan, M.C. (2004) (Ed.) The Correspondence of Catherine McAuley 1818-1841. Four Courts Press, Dublin.
Sullivan, M.C. (2012) A Path of Mercy. Four Courts Press, Dublin.
Great topic very educational to nurses and nurses to be, really learnt a lot on this topic