Postmodern nursing and beyond
10 CARITAS PROCESSES®
1. Sustaining humanistic-altruistic values by practice of loving-kindness, compassion and equanimity with self/others.
2. Being authentically present, enabling faith/hope/belief system; honoring subjective inner, life-world of self/others.
3. Being sensitive to self and others by cultivating own spiritual practices; beyond ego-self to transpersonal presence.
4. Developing and sustaining loving, trusting-caring relationships.
5. Allowing for expression of positive and negative feelings – authentically listening to another person’s story.
6. Creatively problem-solving-‘solution-seeking’ through caring process; full use of self and artistry of caring-healing practices via use of all ways of knowing/being/doing/becoming.
7. Engaging in transpersonal teaching and learning within context of caring relationship; staying within other’s frame of reference-shift toward coaching model for expanded health/wellness.
8. Creating a healing environment at all levels; subtle environment for energetic authentic caring presence.
9. Reverentially assisting with basic needs as sacred acts, touching mindbodyspirit of spirit of other; sustaining human dignity.
10. Opening to spiritual, mystery, unknowns-allowing for miracles.
Jean Watson: Caring Science as Sacred Science
Jean Watson’s (2008) Philosophy and Science of Caring, a recent publication, builds on her previous work, Nursing: Human Science and Human Care: A Theory of Nursing. This theory is one of the newest of nursing’s grand theories, having only been completely codified in 1979, revised in 1985 (Watson, 1988), and broadened and advanced more recently (Watson, 2005, 2008). Watson called her earlier work a descriptive theory of caring and stated that it was the only theory of nursing to incorporate the spiritual dimension of nursing at the time it was first conceptualized. The theory was both deductive and inductive in its origins and was written at an abstract level of discourse.
It is somewhat difficult to categorize Watson’s work with the works of other nursing theorists. It has many characteristics of a human interaction model, although it also incorporates many ideals of the unitary process theories, which are discussed in Chapter 9 . Watson (2005) has always described the human as a holistic, interactive being and is now explicit in describing the human as an energy field and in explaining health and illness as manifestations of the human pattern (Watson, 2008), two tenets of the unitary process theories. Parse (2004) points out, however, that although theorists profess belief in unitary human beings, other definitions and relationships still separate theories from the interactive process paradigms and the unitary process nursing paradigms. Based on overall considerations, the philosophy and science of caring reflects the interactive process nursing theories.
Background of the Theorist
Jean Watson was born in West Virginia and attended Lewis Gale School of Nursing in Roanoke, Virginia. She earned a bachelor’s degree in nursing, a master of science degree in psychiatric–mental health nursing, and a doctorate in educational psychology and counseling, all from the University of Colorado (Neill, 2002). Watson is an internationally published author, having written many books, book chapters, and articles about the science of human caring (Watson, 1994, 1996, 1999, 2005, 2008).
Watson is the former Dean of the School of Nursing at the University of Colorado, and she founded and directed the Center for Human Caring at the Health Sciences Center in Denver. She has received numerous awards and honors (Neill, 2002) and is currently Distinguished Professor of Nursing and Dean Emerita at the University of Colorado Denver College of Nursing and Anschutz Medical Center, “where she held an endowed chair in Caring Science for 16 years. She is a fellow of the American Academy of Nursing and past president of the National League for Nursing” (Watson Caring Science Institute and International Caring Consortium [WCSIICC], 2013). Some of her honors include Fetzer Institute Norman Cousins Award; an International Kellogg Fellowship in Australia; a Fulbright research award in Sweden; and 10 honorary doctoral degrees, including those from Sweden, United Kingdom, Spain, British Columbia and Quebec in Canada, and from Japan (WCSIICC, 2013).
Philosophical Underpinnings of the Theory
Watson (1988) noted that she drew parts of her theory from nursing writers, including Nightingale and Rogers. She also used concepts from the works of psychologists Giorgi, Johnson, and Koch, as well as concepts from philosophy. She reported being widely read in these disciplines and synthesized a number of diverse concepts from them into nursing as a science of human caring. In a recent work, Watson (2005) continues to “bridge paradigms and point toward transformative models for the 21st century” (p. 2).
Major Assumptions, Concepts, and Relationships
The value system that permeates Watson’s (1988, 2008) theory of human caring includes a “deep respect for the wonders and mysteries of life” (1988, p. 34) and recognition that spiritual and ethical dimensions are major elements of the human care process. A number of assumptions are both stated and implicit in her theory. Additionally, several concepts were defined, refined, and adapted for it. From this, 10 carative factors were developed ( Box 8-4 ; Watson, 1985, 2008).
Box 8-4: Watson’s 10 Carative Factors
· 1. Humanistic–altruistic system of values
· 2. Faith–hope
· 3. Sensitivity to self and others
· 4. Developing helping–trusting, caring relationship
· 5. Expressing positive and negative feelings and emotions
· 6. Creative, individualized, problem-solving caring process
· 7. Transpersonal teaching–learning
· 8. Supportive, protective, and/or corrective, mental, physical, societal, and spiritual environment
· 9. Human needs assistance
· 10. Existential-phenomenologic and spiritual forces
Source: Watson (1999, 2005).
Watson (2008) describes the tenets of caring science and sacred science. She proposed that caring and love are universal and mysterious “cosmic forces” that comprise the primal and universal psychic energy. Further, she believes that health professionals make social, moral, and scientific contributions to humankind and that nurses’ caring ideal can affect human development. Further, she believes that it is critical in today’s society to sustain human caring ideals and a caring ideology in practice, as there has been a proliferation of radical treatment and “cure techniques,” often without regard to costs or human considerations.
Explicit assumptions that were derived for Watson’s (2005) work include:
· An ontologic assumption of oneness, wholeness, unity, relatedness, and connectedness.
· An epistemologic assumption that there are multiple ways of knowing.
· Diversity of knowing assumes all, and various forms of evidence can be included.
· A caring science model makes these diverse perspectives explicitly and directly.
· Moral-metaphysical integration with science evokes spirit; this orientation is not only possible but also necessary for our science, humanity, society-civilization, and world-planet.
· A caring science emergence, founded on new assumptions, makes explicit an expanding unitary, energetic worldview with a relational human caring ethic and ontology as its starting point (Watson, 2005, p. 28).
Watson (1988) defined three of the four metaparadigm concepts (human being, health, and nursing). She coined several other concepts and terms that are integral to understanding the science of human caring ( Table 8-7 ). Her 10 carative factors are caring needs specific to human experiences that should be addressed by nurses with their clients in the caring role. She continues to value those carative factors (Watson, 2008). The carative factors are listed in Box 8-4 .
Table 8-7: Major Concepts of the Science of Human Caring
|Human being||A valued person to be cared for, respected, nurtured, understood, and assisted.|
|Health||Unity and harmony within the mind, body, and soul; health is associated with the degree of congruence between the self as perceived and the self as experienced.|
|Nursing||A human science of persons and human health–illness experiences that are mediated by professional, personal, scientific, esthetic, and ethical human care transactions.|
|Actual caring occasion||Involves actions and choices by the nurse and the individual. The moment of coming together in a caring occasion presents the two persons with the opportunity to decide how to be in the relationship—what to do with the moment.|
|Transpersonal||An intersubjective human-to-human relationship in which the nurse affects and is affected by the person of the other. Both are fully present in the moment and feel a union with the other; they share a phenomenal field that becomes part of the life history of both.|
|Phenomenal field||The totality of human experience of one’s being in the world. This refers to the individual’s frame of reference that can only be known to that person.|
|Self||The organized conceptual gestalt composed of perceptions of the characteristics of the “I” or “ME” and the perceptions of the relationship of the “I” or “ME” to others and to various aspects of life.|
|Time||The present is more subjectively real and the past is more objectively real. The past is prior to, or in a different mode of being, than the present, but it is not clearly distinguishable. Past, present, and future incidents merge and fuse.|
|Sources: Watson (1999); online site: http://www.uchsc.edu/ctrsinst/chc/index.html|
Watson has refined and updated the relationships of the theory, bringing them closer to her current way of understanding human caring and spirituality. Her continued study has involved lengthy examination of her beliefs about caring, spirituality, and human and energy fields (Watson, 2005, 2008). The following are some of the relationships of the theory:
· A transpersonal caring field resides within a unitary field of consciousness and energy that transcends time, space, and physicality.
· A transpersonal caring relationship connotes a spirit-to-spirit unitary connection within a caring moment, honoring the embodied spirit of both practitioner and patient within a unitary field of consciousness.
· A transpersonal caring relationship transcends the ego level of both practitioner and patient, creating a caring field with new possibilities for how to be in the moment.
· The practitioner’s authentic intentionality and consciousness of caring has a higher frequency of energy than noncaring consciousness, opening up connections to the universal field of consciousness and greater access to one’s inner healer.
· Transpersonal caring is communicated via the practitioner’s energetic patterns of consciousness, intentionality, and authentic presence in a caring relationship.
· Caring-healing modalities are often noninvasive, nonintrusive, natural-human, energetic environmental field modalities.
· Transpersonal caring promotes self-knowledge, self-control, and self-healing patterns and possibilities.
· Advanced transpersonal caring modalities draw upon multiple ways of knowing and being; they encompass ethical and relational caring, along with those intentional consciousness modalities that are energetic in nature (e.g., form, color, light, sound, touch, vision, scent) that honor wholeness, healing, comfort, balance, harmony, and well-being (Watson, 2005, p. 6).
Watson’s works on the Theory of Human Caring and the Art and Science of Human Caring are used by nurses in diverse settings; for example, Brockopp and colleagues (2011) details an evidence-based, practice-based practice model rounded in Watson’s theory of caring. The 10 carative factors are explicated throughout the hospital to provide a framework for nursing activities in this magnate hospital. The outcomes include 34 research projects, 9 published articles, and 9 funded research studies. Furthermore, the nurses “maintain high levels of work satisfaction, strong retention rates and a large percentage of associate-degree nurses return to school for baccalaureate degrees” (p. 511).
Hills and colleagues (2011) developed a text to promote caring science curriculum in nursing, which they called an emancipatory pedagogy for nursing. It is based on Watson’s science of caring and explores an alternative method of student evaluation. Lukose (2011) developed a practice model for Watson’s theory of caring that “can be used by nurse educators to teach staff nurses and students” (p. 27). Noel (2010) reviewed Watson’s theory of human caring for occupational health and nursing and found it relevant in that context. The author also found that other disciplines are using the theory of human caring as their guiding principle in contact with people.
The University of Colorado School of Nursing implemented the model not only in its education programs (BSN, MSN, and PhD), but also in clinical practice at the Center for Human Caring (Watson, 1988). In addition, the School of Nursing at Georgia Southern University in Statesboro taught both undergraduate courses and the nurse practitioner program from the human caring philosophy (Watson, 1988). Writings that detail how Watson’s work is used in nursing education include Bevis and Watson (1989), Leininger and Watson (1990), and Watson (1994). Furthermore, schools around the world are using Watson’s science of caring in nursing education. They include Scandinavia (Wicklund-Gustin & Wagner, 2013), Japan (Ishikawa & Kawano, 2012), and throughout the United States in nursing curricula (Hills et al., 2011). Numerous nationwide community caring projects have made a difference in such areas as immediate care for victims of natural disasters, veterans returning from Iraq and Afghanistan, and homeless people (J. Laroussini, personal communication, March 2013).
Testing of Watson’s theory and dissemination of findings are progressing. The science allows both quantitative and qualitative research methods. For example, Watson’s work was used as the framework for a study by Perry (2009), who discussed findings from an investigation of nurses whom their colleagues identified as exemplary using a phenomenologic approach. Perry found that those nurses were also excellent clinical role models. The paper describes elements such as attending to the little things, making connections, and remaining lighthearted that made these nurses exemplary practitioners. Watson’s Science of Caring has recently been researched by an extremely large number of nurses. Additional research articles are listed in Box 8-5 .
Box 8-5: Examples of Research Using Watson’s Model
· Arslan-Ozkan, I., & Okumus, H. (2012). A model where caring and healing meets: Watson’s theory of Human Caring. Turkish Journal of Research & Development in Nursing, 14(2), 61–72. (in Turkish with abstract translated).
· Hermanns, M., Mastel-Smith, B., Lilly, M. L., Deardorff, K., & Price, C. (2009). Teaching theoretically based interventions: Use of life review. International Journal of Human Caring, 13(4), 44–49.
· Hill, K. S. (2011). Work satisfaction, intent to stay, desires of nurses, and financial knowledge among bedside and advanced practice nurses. Journal of Nursing Administration, 41(5), 211–217.
· Ishikawa, J., & Kawano, M. (2012). Caring practice of a psychiatric nursing in Japan—Analyzing from caring theory focusing on the inner process of the individual. International Journal for Human Caring, 16(3), 80–81.
· Schmock, B. N., Breckenridge, D. M., & Benedict, K. (2009). Effect of sacred space environment on surgical patient outcomes: A pilot study. International Journal for Human Caring, 13(1), 49–59.
· Suliman, W. A., Welmann, E., Omer, T., & Thomas, L. (2009). Applying Watson’s nursing theory to assess patient perceptions of being cared for in a multicultural environment. Journal of Nursing Research (Taiwan), 17(4), 293–300.
· Vandenhouten, C., Kubsch, S., Peterson, M., Murdock, J., & Lehrer, L. (2012). Watson’s theory of transpersonal caring: Factors impacting nurses professional caring. Holistic Nursing Practice, 26(6), 326–334.
· Wicklund-Gustin, L., & Wagner, L. (2013). The butterfly effect of caring—Clinical nursing teachers’ understanding of self-compassion as a source to compassionate care. Scandinavian Journal of Caring Sciences, 27(1), 175–183.
Watson’s theory is comparatively parsimonious. Although a number of new concepts and terms are defined, there are only 10 carative factors or areas to be addressed by nurses. In addition, there are six “working assumptions” (Watson, 2005, p. 28) and three considerations as to how to frame caring science.
Value in Extending Nursing Science
The Philosophy and Science of Caring (Watson, 2008) explicitly describes the connection between nursing and caring. It is used in education and in practice internationally and in numerous research studies. Collectively, findings present impressive indicators of the value of Watson’s theory of caring to the discipline of nursing.
The models presented in this chapter all focus on human interactive processes as the basis for nursing care, research, and education. Some of the theories described (e.g., King and Levine) are among the oldest of the grand nursing theories, whereas others (e.g., Watson and Artinian) are among the most recently developed. There is a wide variety of complexity among the models, but each has demonstrated applicability to the discipline, and all are currently used in schools of nursing, hospital clinical and community settings, and nursing research.
Like Jean, the nurse in the opening case study, nurses in all settings will be able to relate to the perspective described by these theorists. Indeed, the premise that humans are adaptive, holistic beings, in constant interaction with their environment, is easily applied in nursing practice. Some philosophical bases, concepts, assumptions, and relationships (e.g., systems focus, adaptation, goal of nursing, and interaction) are relatively consistently held within the works of this group of theorists, whereas others (e.g., situational sense of coherence [Artinian], conservation principles [ Levine], cognator and regulator subsystems [Roy], and carative factors [Watson]) are unique to just one theory. Evidence-based practice (EBP) fits well with these theories and models because they ascribe to outcomes-based quantitative and to reality-based qualitative research principles.
Nurses studying this group of theories will become aware of how they present and prescribe nursing practice. Many will undoubtedly consider adopting one as a basis for their own professional practice.
· 1. The theories in this chapter depend on the ideal that nurses, other health care professionals, and patients are constantly interacting. The environment defined by most of these theorists is also foremost in individuals’ interactions.
· 2. The theorists who have developed these theories and models generally include and provide definitions of the four metaparadigm concepts of person, health, environment, and nursing. Several also include spirituality among their concepts.
· 3. Most interactive process theories are practice-based and correspond closely to the work of nurses in clinical practice.
· 4. Several interactive process theories are well suited to and are chosen to guide EBP and research to gather that evidence.
· 5. Several of the theories and models in this group have been used or are being used to guide and structure educational programs in university nursing schools worldwide.
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