Alison L. Kitson
I have been in nursing over half a century. My specialism is how we provide person-centred fundamental care (PCFC) to our patients/clients/family. My journey began in my undergraduate and registered nursing experiences leading to exploring in my doctoral studies the therapeutic role of the nurse. Such a role was closely aligned with nurses' articulation of PCFC, and the importance of being able to combine its physical, psychosocial and relational aspects within a setting that supported such work. Not knowing how to get this knowledge into practice, I set off on another journey around standard setting, quality improvement, clinical guideline development, evidence-based practice and implementation science. A crisis in the UK in the early 2000s (Francis 2013) prompted a return to researching PCFC. I was not convinced that the outcomes of the Francis report told the whole story. Through a systematic collaborative process, I explored how we could redefine, reclaim and promote better PCFC (Kitson et al. 2013; Feo et al. 2018). Getting PCFC right was a global challenge, not unique to one country, health or political system: the challenges being ontological, epistemological, professional, societal and political. The Journal of Advanced Nursing (JAN) has been a stalwart in both my personal and professional journey. I will argue that we are on the cusp of a paradigm shift in health and care and one that nursing could and should be leading on behalf of society. Nursing has progressed significantly over the past 50 years. These transformations have been recorded in the growing number of academic, professional nursing and healthcare journals that document ways that knowledge is generated and tested in practice. Acknowledging the interdependency of discipline contributions is important – how philosophy, sociology, psychology, pure and applied science have shaped nursing knowledge. Areas for further development and testing are notably and paradoxically aspects of PCFC that are essential for sustaining life, for promoting health and wellbeing, but seem resistant to sustained investigation and implementation. To explain why such self-evident PCFC needs are unmet is complicated. It may be that if ‘caring’ rather than ‘nursing’ was one of the four metaparadigms first described by Jacqueline Fawcett in 1984 to shape nursing knowledge and practice, we would have made more progress in getting other professionals on board with the central importance of PCFC. Just as the core constructs of ‘human being’, ‘environment’, and ‘health’ are central to nursing, so ‘care’ in all its complexity and universality must be recognised. These constructs shape the theories, models and frameworks used by nursing and shape data collection methods, ways to measure interventions and determine models of practice. Yet our ongoing challenge remains how we effectively, efficiently and ethically deliver PCFC. Despite the continued acknowledgement that this is indeed the nurse's ‘unique’ role as articulated by Virginia Henderson back in 1978 in this journal, evidence shows failures. Indeed, there are growing concerns that with the increased use of technology and robots to deliver care, the ‘caring’ role of the nurse could disappear altogether. Care could return to the private world of unpaid carers with the emergence of another carer subset in organisations who are cheaper, less educated, and unregulated. How nursing determines its leadership role in moving the ethics, science and politics of PCFC forward in the next 50 years is the central argument of this paper. The analysis will cover three phases: firstly, following a short summary of the issues around caring and nursing in JAN will be a presentation of two emerging themes from the analysis, namely missed nursing care (MNC) and PCFC. The findings section will compare the body of evidence linking antecedents, interventions and consequences to prior debates about the nature of caring and nursing. The discussion section will present three strategies for consideration: the centrality of establishing care as the philosophical and ethical foundation not only of nursing but of our health and care systems; supporting and sustaining research into the science of caring; and finally shifting the discourse around care, nursing and PCFC from a private, personal model into a community, system and political/societal responsibility. This discursive paper is part analytical and part autobiographical. Data sources were predominantly derived from a review of all JAN titles from 1976 to 2025 relating to caring and nursing philosophies, and the development of the science of caring with a focus on the emergence of the MNC movement and the development of the PCFC movement. This 50-year review is a reflective and experiential account of being a nurse, a theorist, a researcher and a leader over the last decades and is presented for future consideration and research. I enrolled in the first undergraduate nursing programme at the University of Ulster in 1975, the year before JAN was established. As an undergraduate student, I read about nursing theories and the nursing process, and tried to make sense of the lived experience of being a student nurse, being paid to work on the wards, and learning about the ‘hidden curriculum’. Reading health economics, sociology, philosophy, and social policy as well as anatomy, physiology, pathology, biochemistry provided an excellent grounding. Our undergraduate group established the Nursing Students’ Association in 1978, and we invited Jim Smith, the Editor of JAN, to our inaugural meeting; we were overwhelmed by his presence, generosity and wisdom. The development of JAN over the last 50 years mirrors my own lived experience of being in the profession. Why, as nursing students, were we to focus on the rigid following of work routines whilst ignoring the obvious distress, concern, and quest for comfort, support, and meaning from patients that we (or at least I) saw regularly on the wards? Things did not necessarily improve after qualification; had I made the wrong decision in my career? What right had I to think that nursing could be any different to the status quo, and why should I think that nursing had anything to do with providing a humanistic, relationship-centred, or individualised approach to care? After registering for a PhD in the early 1980s and reading JAN, I realised that such hard questions were legitimate and consistent. Caring and nursing, individualised versus routine care, nursing autonomy, agency and professional confidence highlighted nursing as organisational collateral to a vacuous beast called healthcare. The core question for me was how to embrace an individualised approach to PCFC. Early papers in JAN (1976–1986) provide a strong sense of the consistency in philosophical, theoretical and methodological approaches. Strongly influenced by the seminal work of philosophers James Dickoff and Patricia James in the 1960s and nurse theorists as outlined by Afaf Meleis in her 1985 book it was clear that UK and European nursing leaders such as Nancy Roper, Jean McFarlane, and Katie Eriksson were creating conceptual frameworks around nursing practice that separated nursing care from following medical orders, thus providing a more holistic experience for the patient. These developments were influenced by significant parallel shifts in sociology (qualitative and biographical or narrative-based inquiry), psychology (social, humanistic, organisational and psychotherapeutic methods), and philosophy (phenomenology, hermeneutics). The richness of this discourse was communicated through the pages of JAN, and nurses had access to new and valued ways of thinking about the ‘what’, the ‘how’ and the ‘why’ of care. In addition to this conceptual refinement, industrialised ways of thinking about and providing quality patient care became significant. Organisational design thinkers such as Edwards Deming in the US had a significant impact on systems and quality approaches. Additionally, Avedis Donabedian's framework related quality care to three main dimensions—the structure (resources, workforce, and other contextual factors); the process (policies, procedures, and ways of working); and the outcomes (clinical, patient, and staff satisfaction and experience). This activity reflected the earlier conceptual refinement around theories of nursing, articulating what was the ‘nursing intervention’ being introduced with testing against routine care. Here, UK nursing leaders like Sue Pembrey with Alan Pearson in Oxford in the late 1980s set up experimental sites to demonstrate the therapeutic impact of nursing care on patient outcomes using the range of new methodologies and quality assurance measures. Parallel to these developments, the UK Royal College of Nursing (RCN) established its Standards of Care Program in the late 1980s early 1990s. Using Donabedian's framework and bringing together teams of specialist nurses in the RCN, the Dynamic Standard Setting System was co-designed and tested, looking at expertly and locally derived evidence-based criteria and their introduction into everyday practice. This preparatory work heralded the introduction of more significant change in quality assurance and quality improvement techniques. These included clinical effectiveness and clinical guidelines activities, where clinical audits and data registries were used to assess medical effectiveness. Organisations to generate evidence-based clinical guidelines were established, and the RCN partnered with several royal medical colleges to lead this groundbreaking work that spanned into the early 2000s. Meanwhile, two landmark publications, To Err is Human and Crossing the Quality Chasm from the Institutes of Medicine in 2000 and 2001 heralded in a significant shift in the global healthcare delivery landscape. While the motivation and desire to improve patient care, reduce unnecessary harm and improve effectiveness, efficiency, equity and access were laudable, two unintended consequences happened. Firstly, individualised or person-centred or relationship-centred care as articulated in nursing theories, together with the actual physical, functional, ‘body work’ of nursing care, were made more invisible in systems because they were subsumed in the quality, effectiveness and safety language and measures promoted by the new movement. Secondly, the safety and quality approach shifted the role of the nurse from primarily someone responsible for the delivery of relationship-centred care (incorporating physical, psychosocial and relational dimensions) to someone who undertook safety and risk audits, managed quality improvement activities and reported on patient experiences of care while often delegating actual care to unqualified workers as the less important activity as perceived by the system. These unintended consequences would create more challenges for the health systems than the problems they were trying to solve. Thus, as a shared definition of nursing, which embodied a person-centred approach was developing within the nursing academy, the reality of routinised care remained reinforced by a culture that focused on safety at a system level without necessarily understanding how that was translated into person-centred care (PCC). Coupled with this, there was less agreement on which theories, models and conceptual frameworks would promote such philosophical and consequential shifts in real practice. Whilst the practice development movement, standard setting, clinical effectiveness, and evidence-based practice approaches provided opportunities for nursing to begin to systematically test its interventions in more rigorous ways, the parallel advances and the impact of the safety and quality movement shifted the focus of nursing care away from the patient and the relationship toward a concentration on safety, risk mitigation, continuous quality improvement and systems issues. By the end of the 2000s and early 2010s two trends in the nursing literature emerged: evidence on MNC (Jones et al. 2015) and PCFC (Kitson et al. 2013; Feo et al. 2018). As discussed above, the consequence of minimising direct patient care in relation to a focus on safety, risk and quality management priorities was seen as contributing to such trends. Kalisch first introduced MNC in a qualitative study, which identified that types of care such as ambulation, patient teaching, and hygiene were missed. Consequently, a measurement and has been used to measure the and of studies in the and have that MNC is a global the of MNC on In a JAN the evidence on nursing activities and the culture of to that the of MNC was not one of providing more nursing but it was both a and a research from by and that was not necessarily an of confidence in more care and were issues. the (Kitson et al. approach to nursing care is into healthcare systems and the of being identified as a of the of quality as articulated by the Institutes of is measures of focus on patient and experience and of clinical outcomes such may not care that is The was established in in to the and that has with global to and reclaim fundamental care (Kitson et al. research teams has progressed from the to creating language and ways of and PCFC in practice. This work has to measure leadership and teaching, organisational and how to PCFC into the nursing studies are how on PCFC reduce the of such as and and hygiene and as in a systematic review by and Additionally, the these issues deliver for a health system. development has been research the the of the nurse to with their patients and the in physical, psychosocial and relational care et al. This research shows we are to what nurses that and are to with patients in a person-centred This what the who in JAN in the Yet like PCFC studies this to be a global studies and systematic have established a direct MNC and a to provide PCFC. often missed ambulation, personal care, hygiene and care, support, patient and with and as in a review by and to provide these activities is to patient outcomes such as increased of and and The evidence generated and healthcare systems which that PCFC is not and safety and quality for patients should be used to generate to the rather than to These three strategies are what we to focus on for the The opportunities for nursing to lead a change in the ways we do and research care and in PCFC are Care is both an activity that a of as well as a set of and It is private and It is and science. It or if not it to and Nursing must more of the PCFC and care and shape the systems and to deliver and care. has been a strong and in nursing and practice the centrality of care and its importance as an ethical in society. the evidence that in of care to experience we to what we do to make In addition to the and nursing must the of how caring is in and the consequences for Caring without the nurse a relationship with the being this is why care should be identified as one of the four metaparadigms nursing with our understanding of and the Nursing has a significant to make in of these but it not any of Nursing needs to work with other and to and its unique to care, and The framework that all caring has been described by on seminal philosophical work on four of caring about the for care and to the needs of care of to to care care is by the the future philosophers and nursing theorists have identified the nature of caring and its and Care is a set of by three and it we do to the development and sustaining of and unnecessary in has the of and in nursing caring theories, and approaches that the psychosocial care to of nursing further aligned the and psychosocial of care and caring with its fundamental role in society. Care is a fundamental activity for and our our and our society. Care the of work to both private and The of caring and the (Kitson to be for into and to create more This shifts caring and care from a private, personal to a political and social identified were not getting care The first was that only care they were in or thus to account of a fundamental care was how care needs were and the complexity of that have to for their needs to be rather than knowing that in the system would be to their care care as a rather than a process, it to around and which create problems for care who care to be in with the to care Care should not be as a of but as a relational process and all who provide care. are at risk of in their caring they these of these are new to nurses who have to create where care the in not care what may be is that we must make the for an of care to be at organisational and societal and at of society. In and will often around care, and What will be important in the future will be to how nursing to for an of care in all where care is Nursing needs to think through the unintended consequences of care from psychosocial and relational care. How nursing leaders to their organisations to that the quality and safety systems are on the and of relationship-centred care? how and frameworks which to provide care be to these The science of care the model and health research. The of and caring interventions is a in the science of care has significantly and is as an that caring science with other such as safety, implementation and science. Henderson ‘nursing with their essential nurses to the fundamental needs of the activities of and approaches that will continuous and care were as well as knowledge from other and a of health care and and learning as has been through the work of research teams testing the of the work of and and and on and the work of of the testing how PCFC be and This body of work has from studies to developing et al. Feo et al. and models that are providing evidence on the contextual the of nurses to with patients and their in physical, psychosocial and relational care et al. or organisational a part in quality care has been but we are able to demonstrate the impact on experiences of PCFC. It that what at the level of care of patients will impact on their and and on their research on the organisational and is essential and understanding how technology will and how and shape nursing in the future by the around an of care. that and care activities be on by robots and technology but that are on agency and a are the of in this What nurses to to robots is an important research as is understanding how to or work that is of to patient care. research in understanding care and caring will to embrace a approach (Kitson et al. will be able to how a experience of care from the of their to their shape their health and et al. et al. The theoretical development and testing of this approach are as well as into how and be better into a This work is necessarily and and will data collection and analytical systems that a for care their is or system to care interventions other than or of that are often by the professional by a range of different professionals using different rather than articulated by the the this is a significant of future work. will to be in and as we have measures and interventions of health so we will to use the work in caring and to generate better and for and professionals in better understanding how to care for This work will challenge the of professional healthcare we more on technology for and so the role of the nurse or health professional will to more one of of and and their care their care and Additionally, there will be an to and ethical models of care for the number of at and on and of care, by by unpaid and by these and are all challenges for in the next are all of the shifts that have in around of and global issues such as and These have the leading to care as an rather than a with other the that it was to shift the that think about and in care. growing evidence on the of social to improve social and care have new A new of care three the level where in better care systems and will lead to better outcomes such as increased more more in the as well as better of paid and unpaid care society. The is with to as they their workers in of an of care as an on the of care, they generate and create a culture of care in the The is that by and the in at level would to around social of access to care and and that the of caring by is a political used to and and to the made around the in personal and caring as well as the providing care that is what called (or and it in an system of a care would be through and in ways that promote care and care work as a societal a and an These outcomes would be around in access to care of who care or being perceived as a or that they would be and have provided in ways that are and to that the quality and measures are in as well as the and This shift in care as a societal and core to needs to the future of healthcare and care will be in care approaches is a to be and the future will determine we have the and political will to Nursing has a role to in and PCFC as it is from the of the end of a How we the knowledge to do it effectively, and how we it into our systems and to be for nursing. should all that nursing is on Nursing is about that a fundamental care needs are understanding how or any other a care needs and how these are in with the and providing to and their own care To do this a framework for it in knowledge and testing and it the political will of and to shift their thinking about care from that is of to a that and in as well and as they It all health and care around a set of and it nursing to to and on PCFC for future I would like to Feo and for with the and providing on the paper The has to The is of the the global promoting person-centred fundamental care. Data not to this as were generated or the