Dunphy and Winland-Brown’s Circle of Caring

01 · Definition

What is the Circle of Caring model?

The Circle of Caring is a model of advanced practice nursing, developed by nurse theorists Lynne M. Dunphy and Jill E. Winland-Brown, that layers the four-step nursing process, assessment, diagnosis and planning, intervention, and evaluation, over the structure of the traditional medical model, and encircles the entire sequence with the concept of caring. Caring, in the model, is not a fifth step performed before or after the others; it is the surrounding orientation that shapes how every other step is carried out.

That distinction is the reason the model is named for a circle rather than a list. A conventional clinical checklist reads as a sequence: gather data, form a diagnosis, treat, reassess. The Circle of Caring keeps that same clinical backbone but draws a ring around it made of six attributes, knowing, courage, authentic presence, advocacy, commitment, and patience, so that the backbone is never presented on its own. An assessment performed without authentic presence and an assessment performed with it can produce the same vital signs and the same lab orders, yet the model treats them as clinically different events, because the surrounding attributes change what the patient experiences and, the theorists argue, what the clinician actually learns.

The model was built specifically for the advanced practice registered nurse, or APRN, a nurse practitioner or similarly prepared clinician who is trained in both nursing’s holistic, relationship-centered tradition and medicine’s diagnostic, disease-oriented tradition. Dunphy and Winland-Brown’s central claim is that this dual training is a genuine strength rather than a divided loyalty, and that a model was needed to show, concretely, how the two traditions combine in a single clinical encounter rather than competing for the clinician’s attention.

Entity in focus: why a “template,” not just a theory

Dunphy and Winland-Brown describe their own work as a template rather than an abstract philosophy of nursing. That word choice matters. A template is meant to be laid directly over practice, used to structure an actual patient visit, a case write-up, or a teaching plan, rather than read as background theory. This practical, applied character is part of why the model shows up in APRN curricula and primary care textbooks rather than remaining a purely academic framework, and it is the reason this guide treats the model’s four processes and six attributes as concrete, usable entities rather than as loose metaphors.

02 · Origins

Origins: Dunphy, Winland-Brown, and the 1998 paper

The Circle of Caring was introduced in 1998 by Lynne M. Dunphy and Jill E. Winland-Brown in an article titled “The Circle of Caring: A Transformative Model of Advanced Practice Nursing,” published in Clinical Excellence for Nurse Practitioners. The model has since been reprinted and expanded in nursing theory anthologies and built directly into a widely used primary care textbook the two authors went on to co-edit.

The late 1990s were a period of rapid change for advanced practice nursing in the United States. Nurse practitioner roles were expanding into primary care settings that had historically been the domain of physicians, reimbursement structures were increasingly organized around the International Classification of Diseases, and nurse practitioners were, in Dunphy and Winland-Brown’s assessment, often left describing their own practice using borrowed medical language that did not fully capture what they were doing or why it worked. The two theorists set out to build a model that could name the nursing contribution explicitly, without discarding the diagnostic rigor of the medical model that APRNs also rely on.

A template built on two traditions

Rather than replacing the medical model, the Circle of Caring was built as a synthesis of it and the nursing process, a deliberate choice the original article frames as necessary rather than merely diplomatic. The nursing process itself, assessment, diagnosis, planning, implementation, and evaluation, had already been in use as a professional standard for decades by 1998; Dunphy and Winland-Brown’s contribution was not to invent a new process but to show how that process and the medical model’s diagnostic sequence could be understood as two views of the same clinical event, held together by caring rather than treated as competing frameworks.

From a single article to a textbook chapter

The model first appeared as a single journal article, but it has had a longer life as the opening chapter of Primary Care: The Art and Science of Advanced Practice Nursing, the textbook Dunphy and Winland-Brown co-authored with Brian O. Porter and, in later editions, Debera J. Thomas. In that textbook, the model functions as the organizing frame for the entire book: the chapters that follow on history-taking, physical examination, diagnostic reasoning, and specific disease management are all presented as elaborations of the four core processes introduced in the opening Circle of Caring chapter. This is part of why the model is more often encountered by nursing students as a course framework than as a stand-alone journal citation.

03 · Core processes

The four core processes at the center of the circle

At the center of the model sit four clinical processes, adapted from both the nursing process and the traditional medical model: assessment, diagnosis and planning, intervention, and evaluation. These four are meant to be read as a cycle rather than a one-way sequence, since evaluation routinely generates new information that feeds back into assessment.

Assessment: building a comprehensive database

Assessment in the Circle of Caring is deliberately broader than a medical history and physical exam alone. It is described as building a comprehensive database that includes biomedical data, laboratory findings, and physical findings, alongside the patient’s own account of their symptoms, health beliefs, family and social context, and goals for the encounter. The model treats the second half of that database, the patient’s own account, as clinically necessary rather than optional context, on the reasoning that a diagnosis built from biomedical data alone routinely misses information that changes both the differential diagnosis and the eventual plan of care.

Diagnosis and planning: two disciplines, one plan

The second process combines medical differential diagnosis, identifying the most likely disease process from a set of possibilities, with nursing diagnosis, which frames the patient’s response to a health condition, and with a plan of care negotiated with the patient rather than delivered to them. Where a purely medical model might stop once a diagnosis is confirmed and a treatment ordered, the Circle of Caring treats the plan as incomplete until it has been checked against the patient’s own capacity, preferences, and circumstances.

Intervention: medical treatment plus nursing action

Intervention in the model includes conventional medical treatments, medication, procedures, referral, alongside nursing interventions such as patient education, counseling, symptom management strategies, and coordination across other members of a care team. The model does not rank one category of intervention above the other; it presents them as jointly necessary, reflecting the APRN’s dual scope of practice.

Evaluation: outcomes and the patient’s own account

Evaluation closes the cycle by assessing whether an intervention achieved its intended clinical outcome, and, just as importantly in this model, whether the patient experienced the care as effective and respectful of their own goals. A treatment that resolves a lab value while leaving the patient confused, unsupported, or unwilling to continue a regimen is treated in this model as an incomplete evaluation, not a successful one, which routinely sends the cycle back to a fresh assessment.

04 · The encircling concept

The encircling concept: caring itself

Caring is what gives the model its name and its shape. Rather than positioning caring as a value statement or a chapter on communication skills, Dunphy and Winland-Brown place it structurally around the four core processes, so that every assessment, every diagnosis, every intervention, and every evaluation is understood as happening inside a caring relationship rather than alongside one.

This placement is a direct response to a criticism the theorists level at the unmodified medical model: that a purely biomedical, disease-classification approach to care is reductionistic, meaning it can accurately describe a disease process while missing most of what determines whether a patient actually gets better, follows a plan, or trusts the clinician enough to return for follow-up care. The Circle of Caring does not argue that the medical model’s diagnostic rigor should be abandoned; it argues that rigor alone is an incomplete account of what advanced practice nursing actually is, and that caring supplies the missing half.

Caring as demonstrated behavior, not just an attitude

A distinguishing feature of this model, compared to more philosophical caring theories, is that it operationalizes caring into six specific, describable attributes rather than leaving it as a general disposition. That choice is largely what makes the model teachable: a nursing student can be shown what authentic presence looks like in a fifteen-minute visit, or asked to identify where advocacy appeared in a case write-up, in a way that a purely abstract commitment to “caring about patients” does not easily support.

05 · Caring attributes

The six caring attributes

Six attributes make up the ring of caring in the model: knowing, courage, authentic presence, advocacy, commitment, and patience. Each is described below as a distinct entity, since APRN students and case studies applying the model are typically asked to identify each attribute separately in a given clinical encounter.

The six attributes that encircle assessment, diagnosis, intervention, and evaluation

Knowing

Knowing combines three separate kinds of knowledge: formal clinical knowledge acquired through education and training, particular knowledge of the individual patient in front of the clinician, and an honest awareness of the limits of one’s own expertise. The third component is treated as inseparable from the first two; a clinician who cannot recognize the edge of their own knowledge is, in this model, not fully exercising the attribute of knowing, regardless of how much formal training they hold.

Courage

Courage is the willingness to act on sound clinical judgment and ethical conviction, including when that action is uncomfortable, uncertain, or likely to meet disagreement from a patient, family member, or colleague. The model ties courage directly to decision-making under uncertainty, since advanced practice frequently requires committing to a course of treatment before every diagnostic question has been fully resolved.

Authentic presence

Authentic presence describes a clinician’s capacity to be genuinely and attentively present with a patient during an encounter, rather than merely physically in the room while attention is divided elsewhere. It requires a degree of self-knowledge on the clinician’s part, since being fully present with another person is described in the model as depending on the clinician first being settled enough in themselves to offer that attention.

Advocacy

Advocacy in the everyday sense means speaking up on a patient’s behalf, and the model includes that meaning. It also extends the concept further, into what the original theorists describe as existential advocacy: affirming that a patient’s own worth, hopes, and life goals are legitimate, and presenting clinical alternatives in a way that respects the patient’s perspective rather than simply directing them toward the clinician’s preferred outcome. This broader form of advocacy is meant to apply even when a patient’s choices differ from what the clinician would choose.

Commitment

Commitment describes sustained, reliable investment in a patient’s wellbeing across the life of a therapeutic relationship, rather than attentiveness confined to a single visit. In primary care and chronic disease management, where the same APRN may see a patient across years, commitment is what the model uses to describe the accumulated trust and continuity that a single well-run encounter cannot, by itself, produce.

Patience

Patience is the capacity to remain steady and supportive while a patient processes new information, weighs a decision, or works through behavior change at their own pace, rather than the clinician’s preferred pace. The model treats patience as clinically consequential rather than simply a personal virtue, since rushing a patient toward a decision they are not ready to make is described as undermining the very outcomes the clinician is trying to achieve.

None of the six caring attributes functions as an isolated skill to check off. They are meant to be read together, as a single ring of caring surrounding assessment, diagnosis, intervention, and evaluation, rather than as six separate competencies to be demonstrated one at a time. Synthesis of Dunphy and Winland-Brown’s Circle of Caring framework

06 · Nursing and medicine

How the model bridges nursing and medicine

The Circle of Caring is explicitly built as a bridge between two traditions that APRNs are trained in simultaneously: the nursing process, which centers the whole person and the therapeutic relationship, and the traditional medical model, which centers disease classification and treatment. Dunphy and Winland-Brown’s core argument is that describing APRN practice using only one of these traditions leaves out a real, functioning half of what the clinician actually does.

What the traditional medical model contributes

From medicine, the model draws a structured approach to differential diagnosis, a reliance on biomedical evidence, and an orientation toward identifying and treating a specific disease process. This structure gives the Circle of Caring its diagnostic discipline: the model does not ask clinicians to set aside medical reasoning in favor of a purely relational approach.

What the nursing process contributes

From nursing, the model draws a holistic assessment that includes the patient’s psychosocial context, a diagnosis framed around the patient’s response to a health condition rather than the disease alone, and a plan of care built collaboratively with the patient rather than delivered as an instruction. This is the half of the model that keeps the four-process cycle from collapsing into a narrow, disease-only checklist.

Why the synthesis, not either tradition alone, is the point

The model’s central claim is that neither tradition alone accurately describes advanced practice nursing, and that treating them as competing rather than complementary has historically made it harder for nursing’s contribution to be recognized inside a healthcare system organized, for billing and administrative purposes, around a diagnosis-first medical framework. The Circle of Caring is, in this sense, as much a piece of professional advocacy for the discipline of nursing as it is a clinical model, a dual purpose the original authors state directly rather than leaving implicit.

07 · Theoretical context

Where the Circle of Caring sits among nursing theories

The Circle of Caring belongs to a family of nursing theories built around the concept of caring, but it occupies a distinct position within that family: narrower in scope than the broad philosophies of caring it draws on, and more directly tied to the day-to-day structure of a clinical visit.

Compared with Jean Watson’s theory of human caring

Jean Watson’s theory of human caring, developed through the Watson Caring Science Institute, is a broader philosophical and spiritual account of caring, organized around ten caritas processes and a relational, transpersonal view of the nurse-patient encounter that extends well beyond any single clinical visit. The Circle of Caring shares Watson’s basic premise that caring is central to nursing, but it is built as a narrower, applied clinical template rather than a full philosophy of practice, designed specifically to map onto the assessment-diagnosis-intervention-evaluation sequence that structures a typical primary care visit.

Compared with Boykin and Schoenhofer’s Nursing as Caring

Anne Boykin and Savina Schoenhofer’s Nursing as Caring theory holds that caring is the essence of nursing itself, present in every person and expressed uniquely in each nursing encounter, rather than a set of attributes to be developed or assessed. The Circle of Caring differs by treating caring as a describable set of six attributes that can be identified, taught, and evaluated in a specific clinical case, a more operational stance suited to its role as a teaching template for APRN students.

A model built for a specific role

Where many caring theories were developed with bedside or generalist nursing practice primarily in mind, the Circle of Caring was built specifically around the advanced practice registered nurse, a clinician who diagnoses, prescribes, and manages care in a role that overlaps substantially with primary care medicine. That specificity is why the model has traveled further into APRN and nurse practitioner curricula than into general nursing theory courses, and why it appears as the organizing frame of a primary care textbook rather than a stand-alone philosophical text.

08 · In practice

The Circle of Caring in advanced practice

Beyond its origin as a journal article, the Circle of Caring functions in practice as a teaching and documentation framework: a way for APRN students and clinicians to structure case write-ups, patient education plans, and reflective practice around a shared, describable model rather than an unstated intuition about what good care looks like.

As a curricular framework

Nurse practitioner and other APRN programs that adopt the model, particularly those using Dunphy and Winland-Brown’s Primary Care textbook, use it to organize an entire course of study: units on history-taking and physical assessment map onto the model’s assessment process, units on differential diagnosis and pharmacology map onto diagnosis and planning, and clinical rotations are framed as opportunities to practice intervention and evaluation while explicitly attending to the six caring attributes.

As a documentation and reflection tool

Published case studies applying the Circle of Caring, including analyses of medication education for cardiac transplant patients and adaptations for specialized settings such as neonatal transport, use the model’s four processes as a structure for describing a specific patient’s course of care, and use the six caring attributes as a lens for reflecting on how the clinician’s manner, not just their clinical decisions, shaped the outcome. This use of the model as a structured reflection tool, rather than only a diagnostic checklist, is one of its more distinctive applications in practice.

09 · Worked example

Applying the model: a worked example

A brief, composite scenario illustrates how the four core processes and six caring attributes interact in a single encounter. It is offered here as an illustration of the model’s structure, not as a substitute for a full clinical case study.

Notice that the four core processes here are the same sequence a purely medical model would also use. What the Circle of Caring adds is visible in the attributes named alongside each process: the clinical decisions are the same kind of decisions a disease-focused model would produce, but the model insists that how those decisions are reached, communicated, and revisited is itself part of the care being delivered, not a separate soft skill layered on top of it.

10 · Strengths

Strengths of the model

Several features of the Circle of Caring are consistently cited as strengths in nursing theory literature and APRN curricula that adopt it.

It is practical rather than purely abstract

Because the model maps directly onto a clinical visit’s structure, assessment, diagnosis, intervention, evaluation, it is unusually easy to teach and to apply to a specific case, compared with more abstract philosophies of caring that are harder to translate directly into a documented patient encounter.

It names nursing’s contribution explicitly

By identifying six specific caring attributes rather than treating caring as an unstated background quality, the model gives APRNs and nursing students concrete language for describing what their training adds to a clinical encounter beyond diagnosis and treatment, which is useful both pedagogically and in professional advocacy contexts.

It does not ask clinicians to choose between two traditions

Rather than positioning nursing’s holistic tradition and medicine’s diagnostic tradition as being in tension, the model treats them as jointly necessary, which several commentators argue reflects the lived reality of advanced practice more accurately than models built from either tradition alone.

It is cyclical rather than linear

By framing evaluation as feeding back into a fresh assessment, the model resists being used as a one-time checklist, and instead supports the kind of ongoing, longitudinal relationship that is typical of primary care and chronic disease management.

11 · Critiques

Critiques and limitations

The Circle of Caring is not without criticism, and an honest account of the model includes the limitations most often raised in nursing theory discussion, without treating those criticisms as disqualifying.

Attributes that are difficult to measure

Because attributes like authentic presence and knowing are internal and relational, they are harder to measure objectively than a lab value or a documented intervention, which makes the model harder to use as a basis for standardized quality metrics or research outcomes compared with more behaviorally defined nursing frameworks.

A relatively narrow evidence base

Compared with theories that have generated decades of dedicated empirical research, such as Watson’s theory of human caring, the Circle of Caring has a smaller published body of applied case studies and empirical testing, drawing more heavily on its use as a teaching framework than on a large independent research literature.

Built for a specific role

Because the model was designed specifically around advanced practice nursing, its direct applicability to bedside or generalist nursing roles, where the diagnostic scope of the medical model half of the framework is less relevant, is more limited than theories built explicitly for the full range of nursing practice.

Risk of becoming a checklist despite its intent

Some commentators note that any model built around a clear visual structure, four processes, six attributes, risks being taught and applied as a rote checklist, the very outcome Dunphy and Winland-Brown were trying to move nursing away from, unless it is taught alongside genuine reflective practice rather than as a form to complete.

12 · Common errors

Common misconceptions, addressed directly

A handful of misunderstandings recur in student summaries and secondary sources describing this model. Naming them directly clarifies what the model does and does not claim.

“The Circle of Caring replaces the medical model”

It does not. The model explicitly retains the medical model’s diagnostic structure and incorporates it as one of its two foundational traditions; it adds the nursing process and the six caring attributes rather than discarding medical reasoning.

“Caring is one of the four steps”

Caring is not a fifth step positioned after evaluation or before assessment. In the model’s own structure, it encircles all four processes simultaneously, meaning it is meant to be present during assessment and diagnosis just as much as during intervention.

“This is the same model as Watson’s caring theory”

The two theories share an emphasis on caring but are distinct frameworks with different scopes, origins, and intended audiences, as covered in the theoretical context section above; treating them as interchangeable obscures what is specific to each.

“The six attributes are just a list of nice personality traits”

Within the model, each attribute is tied to a specific clinical function, courage to acting under diagnostic uncertainty, advocacy to representing a patient’s own goals, patience to respecting a patient’s pace of change, rather than functioning as generic descriptions of a pleasant bedside manner.

13 · Current use

Where the model is used today

The Circle of Caring’s clearest ongoing presence is in advanced practice nursing education, particularly through its role as the organizing chapter of Primary Care: The Art and Science of Advanced Practice Nursing, now in multiple editions with co-authors Brian O. Porter and Debera J. Thomas joining Dunphy and Winland-Brown.

Beyond the textbook, the model continues to appear in applied case studies across different clinical settings, from chronic disease medication education to specialized adaptations built for neonatal transport, where authors have extended the original template to fit a specific patient population while keeping its core four-process, six-attribute structure intact. It is also frequently referenced in nursing theory courses as a concrete example of how caring can be built into, rather than added onto, a clinical model, making it a common point of comparison alongside Watson’s and Boykin and Schoenhofer’s caring theories in graduate nursing coursework.

Closing

Key takeaways on the Circle of Caring

The Circle of Caring is a template, not just a philosophy: four clinical processes, assessment, diagnosis and planning, intervention, and evaluation, drawn from both the nursing process and the traditional medical model, encircled by six caring attributes, knowing, courage, authentic presence, advocacy, commitment, and patience. Introduced by Lynne Dunphy and Jill Winland-Brown in 1998, it was built specifically to describe what advanced practice registered nurses do when they combine medical diagnostic training with nursing’s relational and holistic tradition in a single clinical encounter. It sits alongside broader caring theories like Jean Watson’s theory of human caring and Boykin and Schoenhofer’s Nursing as Caring, but is distinguished by its practical, teachable structure and its specific focus on advanced practice. Like any clinical model, it has real limitations, particularly the difficulty of measuring relational attributes with the same precision as clinical outcomes, but its central claim, that caring should shape every step of clinical reasoning rather than sit apart from it, remains its most durable contribution to how advanced practice nursing describes itself.

14 · Notes

Frequently asked questions