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"Within the boundaries of the health and human services, there are thousands of employees providing a great variety of services. The process of...

"Within the boundaries of the health and human services, there are thousands of employees providing a great variety of services. The process of dealing with humans in need is not simplistic. One practitioner, Dr. Jean Watson, has become a leader in Caring Theory. After reading the article, A pragmatic view of Jean Watson’s caring theory, you are asked to do the following:

Summarize the general aspects of Dr. Watson’s Caring Theory.
Formulate a set of values that should be the foundation of a caring Perspective in the health and human services.
Post your 300 word discussion


Introduction
The changes in the health care delivery systems around the world have intensified nurses’ responsibilities and workloads. Nurses must now deal with patients’ increased acuity and complexity in regard to their health care situation. Despite such hardships, nurses must find ways to preserve their caring practice and Jean Watson’s caring theory can be seen as indispensable to this goal. Through this pragmatic continuing education paper, we will explore the essential elements of Watson’s caring theory and, in a clinical application, illustrate how it can be applied in a practice setting.
Being informed by Watson’s caring theory allows us to return to our deep professional roots and values; it represents the archetype of an ideal nurse. Caring endorses our professional identity within a context where humanistic values are constantly questioned and challenged (Duquette & Cara, 2000). Upholding these caring values in our daily practice helps transcend the nurse from a state where nursing is perceived as “just a job,” to that of a gratifying profession. Upholding Watson’s caring theory not only allows the nurse to practice the art of caring, to provide compassion to ease patients’ and families’ suffering, and to promote their healing and dignity but it can also contribute to expand the nurse’s own actualization. In fact, Watson is one of the few nursing theorists who consider not only the cared-for but also the caregiver. Promoting and applying these caring values in our practice is not only essential to our own health, as nurses, but its significance is also fundamentally tributary to finding meaning in our work.
For a more comprehensive, philosophical, or conceptual perspective pertaining to Watson’s Caring Theory, the readers can refer to the original work (Watson, 1979, 1988a, 1988b, 1989, 1990a, 1990b, 1990c, 1990d, 1994, 1997a, 1997b, 1999, 2000, 2001, 2002a, 2002b, 2002c; Watson & Smith, 2002d), as well other sources, such as McGraw (2002).

Overview of Watson’s Caring Theory
First, we begin with an introduction of Dr. Jean Watson. Dr. Watson is an American nursing scholar born in West Virginia and now living in Boulder, Colorado since 1962. From the University of Colorado, she earned her undergraduate degree in nursing and psychology, her master’s degree in psychiatric-mental health nursing, and continued to earn her Ph.D. in educational psychology and counseling. She is currently a Distinguished Professor of Nursing and the Murchinson-Scoville Chair in Caring Science at the University of Colorado, School of Nursing and is the founder of the Center for Human Caring in Colorado. Dr. Watson is a Fellow in the American Academy of Nursing and has received several national and international honors, and honorary doctoral degrees. She has published numerous works describing her philosophy and theory of human caring, which are studied by nurses in various parts of the world. The following is a summary of the fundamentals of the caring theory.
According to Watson (2001), the major elements of her theory are (a) the carative factors, (b) the transpersonal caring relationship, and (c) the caring occasion/caring moment. These elements are described below, and will be exemplified in the clinical application that follows. Additionally, the reader may consult Table 1 and Table 2 for the theoretical values and assumptions.

Carative Factors
Developed in 1979, and revised in 1985 and 1988b, Watson views the “carative factors” as a guide for the core of nursing. She uses the term carative to contrast with conventional medicine’s curative factors. Her carative factors attempt to “honor the human dimensions of nursing’s work and the inner life world and subjective experiences of the people we serve” (Watson, 1997b, p. 50). In all, the carative factors are comprised of 10 elements:
Humanistic-altruistic system of value.
Faith-Hope.
Sensitivity to self and others.
Helping-trusting, human care relationship.
Expressing positive and negative feelings.
Creative problem-solving caring process.
Transpersonal teaching-learning.
Supportive, protective, and/or corrective mental, physical, societal, and spiritual environment.
Human needs assistance.
Existential-phenomenological-spiritual forces. (Watson, 1988b, p. 75)
As she continued to evolve her theory, Watson introduced the concept of clinical caritas processes, which have now replaced her carative factors. The reader will be able to observe a greater spiritual dimension in these new processes. Watson (2001) explained that the word “caritas” originates from the Greek vocabulary, meaning to cherish and to give special loving attention. The following are Watson’s (2001) translation of the carative factors into clinical caritas processes:
Practice of loving kindness and equanimity within context of caring consciousness.
Being authentically present, and enabling and sustaining the deep belief system and subjective life world of self and the one-being-cared-for.
Cultivation of one’s own spiritual practices and transpersonal self, going beyond ego self, opening to others with sensitivity and compassion.
Developing and sustaining a helping-trusting, authentic caring relationship.
Being present to, and supportive of, the expression of positive and negative feelings as a connection with deeper spirit of self and the one-being-cared-for.
Creative use of self and all ways of knowing as part of the caring process; to engage in artistry of caring-healing practices.
Engaging in genuine teaching-learning experience that attends to unity of being and meaning, attempting to stay within others’ frames of reference.
Creating healing environment at all levels (physical as well as non-physical), subtle environment of energy and consciousness, whereby wholeness, beauty, comfort, dignity, and peace are potentiated.
Assisting with basic needs, with an intentional caring consciousness, administering “human care essentials,” which potentiate alignment of mindbodyspirit, wholeness, and unity of being in all aspects of care; tending to both the embodied spirit and evolving spiritual emergence.
Opening and attending to spiritual-mysterious and existential dimensions of one’s own life-death; soul care for self and the one-being-cared-for. (Watson, 2001, p. 347)

Transpersonal Caring Relationship
For Watson (1999), the transpersonal caring relationship characterizes a special kind of human care relationship that depends on:
The nurse’s moral commitment in protecting and enhancing human dignity as well as the deeper/higher self.
The nurse’s caring consciousness communicated to preserve and honor the embodied spirit, therefore, not reducing the person to the moral status of an object.
The nurse’s caring consciousness and connection having the potential to heal since experience, perception, and intentional connection are taking place.
This relationship describes how the nurse goes beyond an objective assessment, showing concerns toward the person’s subjective and deeper meaning regarding their own health care situation. The nurse’s caring consciousness becomes essential for the connection and understanding of the other person’s perspective. This approach highlights the uniqueness of both the person and the nurse, and also the mutuality between the two individuals, which is fundamental to the relationship. As such, the one caring and the one cared-for, both connect in mutual search for meaning and wholeness, and perhaps for the spiritual transcendence of suffering (Watson, 2001). The term “transpersonal” means to go beyond one’s own ego and the here and now, as it allows one to reach deeper spiritual connections in promoting the patient’s comfort and healing. Finally, the goal of a transpersonal caring relationship corresponds to protecting, enhancing, and preserving the person’s dignity, humanity, wholeness, and inner harmony.

Caring Occasion/Caring Moment
According to Watson (1988b, 1999), a caring occasion is the moment (focal point in space and time) when the nurse and another person come together in such a way that an occasion for human caring is created. Both persons, with their unique phenomenal fields, have the possibility to come together in a human-to-human transaction. For Watson (1988b, 1999), a phenomenal field corresponds to the person’s frame of reference or the totality of human experience consisting of feelings, bodily sensations, thoughts, spiritual beliefs, goals, expectations, environmental considerations, and meanings of one’s perceptions—all of which are based upon one’s past life history, one’s present moment, and one’s imagined future.
Not simply a goal for the cared-for, Watson (1999) insists that the nurse, i.e., the caregiver, also needs to be aware of her own consciousness and authentic presence of being in a caring moment with her patient. Moreover, both the one cared-for and the one caring can be influenced by the caring moment through the choices and actions decided within the relationship, thereby, influencing and becoming part of their own life history. The caring occasion becomes “transpersonal” when “it allows for the presence of the spirit of both—then the event of the moment expands the limits of openness and has the ability to expand human capabilities” (Watson, 1999, pp. 116-117).

Clinical Application
The intent of this section is to create a better understanding of Watson’s theory through a clinical story. For this reason, whenever a single or several clinical caritas process(es) (CCP) are encountered, their appropriate numbers are identified within parentheses. The reader shall also notice that this story deviates from the traditional format as it includes reflection and analysis, the purpose of which is to provide an expeditious grasp related to these abstract concepts. Additionally, the reader can also refer to Table 3 for an example of a caring process using Watson’s caring theory (adapted from Cara, 1999; Cara & Gagnon, 2000).

It is December 5th, I am assigned to take care of Mr. Smith, a 55-year-old Caucasian man who will undergo his 5th amputation. Gangrene has ravaged both feet and legs. He is scheduled for an above knee amputation of his right leg, because the last amputation did not heal properly. I know him quite well, since I took care of him during his past hospitalizations (CCP#4). I’ve always liked this patient (CCP#1), it seems that we connected right away after our first meeting (CCP#4). He shared with me his life story [referred to as phenomenal field by Watson], which allowed me to know him as a person not just “a case” going for surgery on our unit.
I welcome him as he is admitted onto the unit. As we glance to each other, he returns a faint smile. [At this moment, a caring occasion takes place.] I ask him how he is doing and tell him that since our last meeting I thought of some creative ways of how he could remember to take his medicine (CCP#6, CCP#7). [According to Watson, the nurse’s creativity contributes to making nursing an art.] He responds that he will be happy to discuss it and also asks how I have been doing. Mr. Smith knows me as a person, he does not consider me as just another nurse, I am “his nurse.” He knows that I care for him and that I am committed to helping him through his ordeal (CCP#4). [This is an example of what Watson means by our relationship becoming part of both our life history.]
From his faint smile I can sense that he is depressed. Probably since part of his leg has to be amputated some more. However, I cannot make this assumption and will have to discuss his perceptions and feelings pertaining to his lived experience (CCP#3, CCP#5, CCP#10). While I help him settle in his room, I arrange his environment so that he can feel at ease (CCP#8). Right away, I use the time we have together to ask about himself, his feelings, and his priorities for his care plan and hospitalization (CCP#5, CCP#10). He explains that he wants to be home for Christmas because his son and grandson are coming to visit. Consequently, we will have to plan everything according to his priority. [Although caring takes “too much time” according to some people, I have found, through experience, that focusing on the patients’ priorities and meaning will often help them participate more actively in their healing process. Therefore, even though more time was taken initially, I noticed that, eventually, more time is saved in caring for patients. As Watson (2000) emphasizes, the outcomes that may arise, develop from the process and are characterized and guided by the inner journey of the one being cared-for, not the one caring (or attempting to cure).]
While I help him settle in his bed, he asks for the bedpan (CCP#9). As I install the bedpan delicately underneath him, he says to me, “Look at me, I can’t even manage by myself anymore! I feel like a piece of meat in this bed! Will this surgery work this time or is it a waste of time and money?” I am troubled by his comment and ask him to clarify (CCP#5). He says that people used to respect him but losing his legs also made him lose this respect. I am speechless! [My patient makes me realize the importance of Watson’s caring values based on respecting and preserving human dignity. Yet, hearing how other people’s reaction affects him, I understand more than ever that Mr. Smith and his environment are interrelated (CCP#8, CCP#10)]. He continues to say, “If only you knew me back then, when I was walking and working. Without my legs, I am no longer the same guy!” I ask how losing his legs made him different (CCP#5, CCP#9, CCP#10). He says that he no longer has social recognition and usefulness. [I find it difficult to consider how people can disrespect a human being for being different! Yet, one has to look beyond the body, and look at the mind and the soul.] Sensing that he wants to be alone, I tell him that I will return in a few minutes and I gently pull the curtains to provide privacy and comfort (CCP#8). Trusting that I will return, he thanks me for my help (CCP#4). As I leave the room, I feel powerless towards my patient, not knowing what to say or what to do. [Watson (2000) reminds us that being caring is being vulnerable. “If we are not able to be vulnerable with ourselves and others, we become robotic, mechanical, detached and de-personal in our lives and work and relationships” (p. 6). I want to help him reach some harmony (mindbodyspirit) in his life again (CCP#9). Promoting hope to patients when their situation is somber can be quite overwhelming (CCP#2). But since I believe that giving hope is essential to his harmony, I will have to be somewhat creative (CCP#6). Caring for him is important to me, it is my motivation that contributes to the way I actualize myself professionally. Caring allows me to work with passion! It becomes clear that my most important goal is establishing a transpersonal caring relationship that will, as Watson states, “protect, enhance, and preserve my patient’s dignity, humanity, wholeness, and inner harmony.” Caring, for me, is what nursing is all about!] (C.C., RN)

Viewing the Person Through Watson’s Caring Lens
Watson (1988b) defines the person as a being-in-the-world who holds three spheres of being—mind, body, and spirit—that are influenced by the concept of self and who is unique and free to make choices. Referring to Mr. Smith (see story above) as a “being-in-the-world” entails that I cannot consider him without his context or environment (family, culture, community, society, etc.). In fact, using such definition accentuates the interconnectedness between the person and the environment. Therefore, in my data collection, I inquire about his family, friends, resources within his community, etc. In essence, I am concerned on how he relates with his environment.
In Watson’s later work, she revisits Nightingale’s concept of environment and discusses how the healing space or environment can expand the person’s “awareness and consciousness” and promote mindbodyspirit wholeness and healing (1999, p. 254). This is why Watson recognizes the importance of making the patient’s room a soothing, healing, and sacred place. It is not uncommon in this day and age to enter in a patient’s room only to find it disorganized and unsanitary. One wonders how patients can heal their mindbodyspirit in such an environment.
Watson (1979, 1988b, 1999) acknowledges also the unity of the person’s mindbodyspirit. Therefore, while collecting the data, I do not consider his body alone but will inquire about his mind and spirit as well. The mind corresponds in our example, to Mr. Smith’s emotions, intelligence, and memories. For Watson, the mind is the point of access to the body and the spirit. The spirit relates to Mr. Smith’s soul, the inner self, the essence of the person, the spiritual self. It is the spirit that allows Mr. Smith to transcend the here and now coexisting with past, present, and future, all at once through, for example, creative imagination and visualization. In other words, your spirit allows you to read this article in the present time, while thinking about patients you had in the past, along with visioning how you can utilize this knowledge in the future. Watson believes that spirituality upholds a foremost importance in our profession. In fact, she ascertains that the care of the soul remains the most powerful aspect of the art of caring in nursing (Watson, 1997a). The following questions are examples of how one could enter in a patient’s phenomenal field:
Tell me about yourself?
Tell me about your life experiences?
Tell me about your bodily sensations?
Tell me about your spiritual and cultural beliefs?
Tell me about your goals and expectations?
Such questions generally assist people to share their life story.
Another important aspect of Watson’s perspective corresponds to the respect for the other person’s choices and decisions. Essentially, respect is easily acquired until the person disagrees with your recommendations, at which point, respecting the other person’s choices can become more complex. Of course, it does not mean that you cannot share your point of view, especially if the patient asks for your perspective.

Viewing the Person’s Health Through Watson’s Caring Lens
Watson’s definition of health does not correspond to the simple absence of disease. In her earlier work, she defines the person’s health as a subjective experience. Health also corresponds to the person’s harmony, or balance, within the mindbodyspirit, related to the degree of congruence between the self as perceived (for example, Mr. Smith is perceiving his condition as deteriorating) and the self as experienced (for example, Mr. Smith is being informed by the health care professionals that his situation is deteriorating and that another amputation will be required). Watson (1988b) believes as one is able to experience one’s real self, the more harmony there will be within the mindbodyspirit, so that a higher degree of health will be present.
The following are example questions that can help assess the patient’s perspective about health:
Tell me about your health?
What is it like to be in your situation?
Tell me how you perceive yourself in this situation?
What meaning are you giving to this situation?
Tell me about your health priorities?
Tell me about the harmony you wish to reach?
Such questions usually contribute to helping people find meaning to the crisis in their life.

Viewing Nursing Through Watson’s Caring Lens
Watson defines nursing “as a human science of persons and human health—illness experiences that are mediated by professional, personal, scientific, esthetic, and ethical human care transactions” (1988b, p. 54). In addition, she also views nursing as both a science and an art. Unfortunately, artistry, along with creativity, is often seen as incongruent with an institution’s policies and procedures. However, according to Watson, being an artist is part of our role and certainly part of caring for patients and their families. In 1999, she exemplifies the artistic domain of nursing as emerging transpersonal caring-healing modalities. Such transpersonal caring-healing modalities correspond to providing comfort measures, helping the cared-for to alleviate pain, stress, and suffering, as well as to promote well-being and healing.
Congruent with other nursing scholars, Watson (1988b) acknowledges caring as the essence of nursing. She also adds that caring can be viewed as the nurse’s moral ideal of preserving human dignity by assisting a person to find meaning in illness and suffering in order to restore or promote the person’s harmony. You may be inclined to view such “moral ideal” as being extremely intangible and inaccessible. However, as one usually aspires to be the best nurse possible, one tends to evaluate oneself to such ideal. Consequently, the nurse can experience frustrations if he/she feels incongruent with his/her own moral ideal. Instead, an ideal is a guide for shaping practice.
Watson’s (1999) present definition includes caring as a special way of being-in-relation with one’s self, with others, and the broader environment. Such relationship requires both an intention and a commitment to care for the individual. In other words, the nurse has to be conscious and engaged to care in order to connect and establish a relationship with the cared-for to promote health/healing.
The following self-reflective questions are examples that you may ask yourself in regard to your role as a nurse:
What is the meaning of caring for the persons and their families? For myself?
How do I express my caring consciousness and commitment to the persons and their families? To working colleagues? To other health care professionals? To my superiors? To the institution?
How do I define the person, environment, health/healing, and nursing?
How do I make a difference in people’s life and suffering?
How can I be informed by the clinical caritas processes in my practice?
How can I be inspired by Watson’s caring theory in my practice?
Such questions can help the nurse reflect upon his/her caring practice and contribute to the meaningfulness of professional life.

Conclusion
Through this continuing education paper, we were able to learn the essential elements of Watson’s caring theory and explore an example of a clinical application of her work through a clinical story. Aiming to preserve our human caring heritage, this paper offered some suggestions and ideas in order to help nurses grasp and utilize Watson’s caring theory in their work environment.
“Nursing can expand its existing role, continuing to make contributions to health care within the modern model by developing its foundational caring-healing and health strengths that have always been present on the margin.” (Watson, 1999, p. 45)

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