Angeles University Foundation Graduate School Angeles City

ERNESTINE WIEDENBACHS

HELPING ART OF CLINICAL NURSING

And

JEAN WATSONS

THEORY OF HUMAN CARING

In partial fulfillment of the requirements in Theoretical Foundations in Nursing

Submitted by: Rosella Marie M. Ocampo, R.N. Submitted to: Mary Grace D. Brackett, R.N., Ph. D. Theoretical Foundations in Nursing Professor March 19, 2011

ERNESTINE WIEDENBACHS HELPING ART OF CLINICAL NURSING

I.

INTRODUCTION

"My thesis is that nursing art is not comprised of rational nor reactionary actions but rather of deliberative action." Wiedenbach, 1964 Nursing encompasses autonomous and collaborative care of

individuals of all ages, families, groups and communities, sick or well and in all settings. Nursing includes the promotion of health, prevention of illness, and the care of ill, disabled and dying people. Advocacy, promotion of a safe environment, research, participation in shaping health policy and in patient and health systems management, and education are also key nursing roles. As Wiedenbach quoted, nursing is a deliberative (responsible action). It is not the result of an instinct but a result of the nurses purpose to help and individual in need. Nursing is both patient and nurse centered which means that it is mutual. More and more people are in need of help and it has been an imperative for nurses to care the people who are in need of help. Helping behavior refers to voluntary actions intended to help the others, with reward regarded or disregarded. It is a type of prosocial behavior (voluntary action

intended to help or benefit another individual or group of individuals, such as sharing, comforting, rescuing and helping). Persons are different from each and it is a challenge for nurses to develop an individualized nursing care plan. Wiedenbachs theory is a solution to the obstacle faced by nurses. It is within this theory that there is a mutual understanding between the nurse and the patient being cared for gearing toward the goal of meeting the needs of the patient.

OBJECTIVES: Upon successful completion of this discussion, the reader will be able to:

Describe

the

historical

background

of

the

development

of

Wiedenbachs model for health

Define Wiedenbachs Prescriptive theory and Helping Art of Clinical Nursing

Present the relationship between Wiedenbachs model and concepts in nursings metaparadigm

Provide an example of use of Wiedenbachs model in clinical practice

II.

THEORY ANALYSIS

HISTORICAL EVOLUTION OF THE THEORY/ BACKGROUND OF THE THEORIST Ernestine Wiedenbach was born on August 18, 1900, in Hamburg, Germany to an American mother and a German father who migrated to the United States when Ernestine was a child. The affluent family supported the idea of a college education for their daughter and she graduated with a Bachelor of

Arts degree from Wellesley College in 1922. Her later interest in a nursing career was reluctantly accepted by her family. Pursuing nursing in this era was atypical for someone who came from a family of gentility (Parker, 2001). Her independent characteristics overruled her parents reluctance and enrolled in a hospital school of nursing. Early in her studies there, her advocacy for quality nursing education and her leadership role with her classmates resulted in dismissal from the school. Through the intervention of friends and faculty, including that of Adelaide Nutting, who realized her potential, she was admitted to Johns Hopkins School of Nursing and graduated in 1925 (Nickel, Gesse, & MacLaren, 1992.) (Parker, 2001). Wiedenbach had many interests and held a variety of professional positions. Because of her interest in education, she began taking graduate courses part time at Columbia University. She was also involved with the New York State Nurses Association and with various nuring committees. After completing a master of arts in 1934, she became a professional writer for the American Journal of Nursing (AJN) (Parker, 2001). This position brought new opportunities to experience many different facets of nursing and to meet national leaders in both nursing and health care. Her tenure in the AJN office included the years during World War II, when she played a critical role in the recruitment of nursing students and military nurses (Parker, 2001). After the war, she returned to clinical practice and to her love of maternal-child nursing. At age 45, she began her studies in nurse-midwifery. At the Maternity Center in New York City, her personal mentors included such pioneers such ad Hazel Corbin and Hattie Hemschemeyer (Parker, 2001). In 1952, Wiedenbach joined the faculty of Yale University School of Nursing where her roles as practitioner, teacher, author, and theorist would

be consolidated. She retired from Yale in 1966 as an associate professor emeritus and subsequently held part-time positions at California State University and the University of Florida. She eventually moved to a Miami, Florida, retirement village with her college roommate and lifelong friend, Caroline Falls (Parker, 2001). In 1972, Marcia Dombro, who was active in Miamis childbirth education movement, heard that Wiedenbach is living nearby. She telephoned and requested Wiedenbachs participation in a childbirth education conference being held at Florida International University (FIU). Wiedenbach graciously accepted and invented Dombro to her house for tea to discuss it further (Parker, 2001). Following this contact and the childbirth education conference, Wiedenbach and Falls became involved in developing and teaching a university course on communication in nursing. Her pattern of intellectual productivity continued with the publication of another book: Communication: Key to Effective NursingI (Wiedenbach & Falls, 1978) (Parker, 2001). Wiedenbachs love for interaction with students persisted even after her mobility decreased. She and Caroline Falls continued to give informal seminars in their home for Professor Theresa Geese and the University of Miami nurse-midwifery students. They enjoyed discussing the past, present, and future of nursing and nurse-midwifery and she always reminded students and faculty of the need for clarity of purpose, based on reality (Parker, 2001). This rekindling of ties to the nursing education community did not deter Wiedenbach from being an advocate for the residents of the retirement village. She was an activist in promoting change in policies and practices related to nutrition and creative activities for many talented residents now in their late stages of life. She was adamant about improvement of the quality

of life and level of independence for those who lived in the village, where she continued to apply her perspective theory of nursing in everyday living. She even continued to use her gift for writing to transcribe books for the blind, including Lamaze childbirth manual, which she prepared on her Braille typewriter. Wiedenbach continued to be productive and maintain a central purpose as long as she was able (Parker, 2001). In 1992, events began to occur that profoundly affected Wiedenbachs remaining years. During this period, her friend Caroline Falls died of heart failure, and Hurricane Andrew destroyed the retirement village, causing a temporary relocation into unfamiliar surroundings. Susan Nickel, who had become a personal friend, searched for Wiedenbach was much in need of the caring that she herself had promoted so strongly in nursing. Wiedenbach stayed at Ms. Nickels home for several months until the retirement village was restored (Parker, 2001). Until the end of her life, Wiedenbach continued to maintain the independent spirit that originality fueled her productivity and creativity. In April 1998, Wiedenbach died at age 98 (Parker, 2001).

APPROACH TO THE DEVELOPMENT OF THE MODEL

WIEDENBACHS THEORY AND NURSINGS METAPARADIGM Wiedenbach (1964) emphasizes that the human or individual possesses unique potential, strives toward self-direction, and needs stimulation. Whatever the individual does represents his or her best judgment at the moment. Self-awareness and self-acceptance are essential to the individuals sense of integrity and self-worth. Wiedenbach believes these characteristics require respect from the nurse (George, 2008).

Wiedenbach (1977) does not define the concept of health. However, she supports the World Health Orgaanizations definition of health as a state of complete physical, mental, and social well-being, and not merely the absence of disease and infirmity (George, 2008). In Wiedenbachs work, she incorporates the environment within the realities- a major component of her theory. One element of the realities is the framework. According to Wiedenbach (1970), the framework is a complex of extraneous factors and circumstances that are present in every nursing situation. The framework may include objects such as policies, setting, atmosphere, time of day, humans, and happenings (George, 2008). According to Wiedenbach (1969), nursing, a clinical discipline, is a practice discipline designed to produce explicit desired results. The art of nursing is a goal directed activity requiring the application of knowledge and skill toward meeting a need for help experienced by a patient. Nursing is a helping process that will extend or restore the patients ability to cope with demands implicit in the situation (George, 2008).

CONCEPTUAL FRAMEWORK Ernestine Wiedenbach, a progressive nursing leader, began her nursing career in the 1920s. Wiedenbach first published Family-centered maternity nursing in 1958. It is of interest that in that book she recommended that babies be in hospital rooms with their mothers rather than in a central nursery. This innovative concept was not widely implemented until 20 years later. In 1964 she wrote Clinical nursing-A helping art in, which she described her ideas about nursing as a concept and philosophy derived from 40 years of nursing experience (George, 2008).

Ernestine Wiedenbach concentrated on the art of nursing and focused on the needs of the patient. Wiedenbach (1964) stated, People may differ in their concept of nursing, but few would disagree that nursing is nurturing or caring for someone in motherly fashion. Wiedenbach specified the following four elements: (1) philosophy, (2) purpose, (3) practice, and (4) art. She postulated that clinical nursing is directed toward meeting the patients perceived need-for-help (Tomey, 1994). That care is given in the immediate present and can be given by any caring person. Nursing is a helping service that is rendered with compassion, skill, and understanding to those in need of care, counsel, and confidence in the area of health (Wiedenbach, 1977) (George, 2008). Nursing wisdom is acquired through meaningful experience

(Wiedenbach, 1964). Sensitivity alerts the nurse to an awareness of inconsistencies in a situation that might signify a problem. It is a key factor in assisting the nurse to identify the patients need for help (Wiedenbach, 1977) (George, 2008). The nurses beliefs and values regarding reverence for the gift of life, the worth of the individual, and the aspirations of each human being determine the quality of the nursing care. The nurses purpose in nursing represents a professional commitment (Wiedenbach, 1970) (George, 2008). Wiedenbach (1964) states the characteristics of a professional person that are essential for the professional nurse include the following (George, 2008): 1. Clarity of purpose. 2. Mastery of skills and knowledge essential for fulfilling the purpose. 3. Ability to establish and sustain purposeful working relationships with others, both professional and nonprofessional individuals.

4. Interest in advancing knowledge in the area of interest and in creating new knowledge. 5. Dedication to furthering the good of mankind rather than to selfaggrandizement. Wiedenbach believed that every individual experiences needs as a normal part of living. A need is anything the individual may require to maintain or sustain himself comfortably or capably in his situation. An attempt to meet the need is made by the intervention of help, which is any measure or actions that enable the individual to overcome whatever interferes with his ability to function capably in relation to his situation. . . To be meaningful, help must be used by an individual and must succeed in enhancing or extending his capability. Wiedenbach combines these two definitions into a more critical concept for her theory of a Need-for-Help. It is crucial to the nursing profession that a Need-for-Help is based on the individuals perception of his own situation. If the individual does not perceive a need as need-for-help, he or she may not take action to relieve or resolve it (Tomey, 1994). Wiedenbachs philosophy of practice is influenced by her conception of nursing is an art. Barnum (1994) quoted that Wiedenbach believed that the intention of the nurse was an important part of her effectiveness, that the same act done with caring and without caring could have a different outcome (Tomey, 1994).: Barnum (1994) quoted that Wiedenbach states that it is the nurses way of giving a treatment, for example, that enables a patient to benefit for it, not just the fact that a treatment is given him; and it is her way of expressing her concern not just the fact that she is present or speaks that enables him to reveal his fears. The nurses way of using the means available to her to achieve the results she

desires in her practice is an individual matter, determined to a large degree, by her central purpose in nursing and the prescription she regards as appropriate to its fulfillment. According to Wiedenbach,, as quoted by Barnum (1994), the nurse is a functioning human being. As such she not only acts, but she thinks and feels as well. The thoughts she thinks and the feelings she feels as she goes about her nursing is important; they are intimately involved not only in what she does but also in how she does it. They underlie every actions she takes, be in the form of spoken word, a written communication, a gesture, or a deed of any kind, for the nurse whose action is directed toward achievement of a specific purpose, thoughts and feelings have a discipline role to play. Barnum (1994) cited that Wiedenbach claimed that the thoughts and feelings, including reactions, are integral parts not only of what we do or say but also of how we do it The thoughts and feelings that precede and accompany each act are the less apparent parts of nursing; yet, because they set direction for each act, they are the real determiners of the results the nurse achieves. According to Barnum (1994), Wiedenbach analyzed the invisible act of caring and found that it was a tool that could be used to the nurses advantage, ensuring her successful practice. According to Wiedenbach, as stated by Barnum (1994), the secret of the helping art of nursing lies in the importance the nurse attaches to her thoughts and feelings and the deliberate use she makes of them as she observes her patient, identifies his need for help, ministers to his need and validates that the help she gave was helpful. If she recognizes her thoughts and feelings, respects their importance, and disciplines herself to harness them to her purpose and her philosophy,

not only will she enrich her nursing practice, but she will in all probability experience enduring satisfaction from the helping service she has rendered. According to Barnum (1994), what Wiedenbach called concern is what we label caring. And although she explored these feelings methodically, this is not the way we usually think about the caring part of nursing. According to Wiedenbach, the art of clinical nursing is directed toward achievement of four main goals: (1) understanding of the patient and his condition, situation, and need; (2) enhancement of the patients capability; (3) improvement of his condition or situation within the framework of the medical plans for his care; and (4) prevention of the recurrence of his problem or development of a new one which may cause anxiety, disability or distress. (Tomey, 1994).

THEORETICAL ASSERTIONS The practice of nursing comprises a wide variety of services, each directed toward the attainment of one of its three components: (1) identification of the patients need for help, (2) ministration of the help needed, and (3) validation that the help provided was indeed helpful to the patient (Wiedenbach, 1977). Within Wiedenbachs (1964) identification of the patients need for help, she presents these principles of helping: (1) the principle of inconsistency/consistency, (2) the principle of purposeful perseverance, and (3) the principle of self-extension. The principle of inconsistency/ consistency refers to the assessment of the patient to determine some action, word, or appearance that is different from the expected-that is, something out of the ordinary for this patient. It is important for the nurse to observe the patient astutely and then critically analyze her observations. The principle of purposeful perseverance is based

on the nurses sincere desire to help the patient. The nurse needs to strive to continue her efforts to identify and meet the patients need for help in spite of difficulties she encounters while seeking to use her resources and capabilities effectively and with sensitivity. The principle of self-extension recognizes that each nurse has limitations that are both personal and situational. It is important that the nurse recognizes when these limitation are reached and that she seek help from others, including through prayer (George, 2008). Wiedenbach affirmed that identification of the patients need-for-help involves four steps. First, the nurse uses powers of observation to look and listen for actual consistencies and inconsistencies in the patients behavior compared with the nurses expectations for patient behavior. Second, the nurse explores the meaning of the patients behavior with the patient. Third, the nurse determines the cause of the patients discomfort or incapability. Finally, the nurse determines whether the patient can resolve his or her problem or if the patient has a need-for-help (Tomey, 1994). Wiedenbach stated that ministration of needed help involves the nurse making a plan to meet patient needs and presenting it to the patient. If the patient concurs with the plan and accepts suggestions for implementing it, the nurse implements it and ministration of needed help occurs. If the patient does not concur with the plan or accept suggestions for implementation, the nurse needs to explore the patients nonacceptance. If the patient has a need-for-help, the nurse once again forms a plan to meet the need, presents the plan, and seeks patient concurrence and acceptance of suggestions for implementation (Tomey, 1994). Wiedenbach posits the validation that the need-for-help was met is important. The nurse perceives whether the patients behavior is consistent with nurses concept of comfort and seeks clarification from the patient to determine whether he or she believes the need-for-help was met. Then the

nurse needs to take appropriate action on the basis of the feedback (Tomey, 1994).

WIEDENBACHS PRESCRIPTIVE THEORY Theory may be described as a system of conceptualizations invented to some purpose. Prescriptive theory (a situation-producing theory) may be described as one that conceptualizes both a desired situation and the prescription by which it is to be brought about. Thus, a prescriptive theory directs action toward an explicit goal. Wiedenbachs (196) prescriptive theory is made up of three factors, or concepts (George, 2008): 1. The central purpose which the practitioner recognizes as essential to the particular discipline. 2. The prescription for the fulfillment of the central purpose. 3. The realities in the immediate situation that influence the fulfillment of the central purpose.

The Central Purpose The nurses central purpose defines the quality of health she desires to effect or sustain in her patient and specifies what she recognizes to be her special responsibility in caring for the patient (Wiedenbach, 1970). This central purpose (or commitment) is based on the individual nurses philosophy. Wiedenbach (1964) states (George, 2008):

Purpose and philosophy are, respectively, goal and guide of clinical nursing Purpose-that which the nurse wants to accomplish through what she does-is the overall goal toward which she is striving, and so is constant. It is her reasons for being and doing Philosophy, an attitude toward life and reality that evolves from each nurses beliefs and code of conduct, motivates the nurse to act, guides her thinking about what she is to do and influences her decisions. It stems from both her culture and subculture, and is an integral part of her. It is personal in character, unique to each nurse, and expressed in her way of nursing. Philosophy underlies purpose, and purpose reflects philosophy. Wiedenbach (1970) identifies three essential components for a nursing philosophy: (1) a reverence for the gift of life, (2) a respect for the dignity, worth, autonomy, and individuality of each human being, and (3) a resolution to act dynamically in relation to one beliefs. Any of these concepts might be further developed. However, Wiedenbach (1964, 1970) emphasizes the second in her work, formulating the following beliefs about the individual (George, 2008): 1. Human beings are endowed with unique potential to develop within themselves the resources that enable them to maintain and sustain themselves. 2. Human beings basically strive toward self-direction and relative independence, and desire not only to make the best use of their capabilities and potentialities but also to fulfill their responsibilities. 3. Human beings need stimulation in order to make the best use of their capabilities and realize their self-worth.

4. Whatever individuals do represent their best judgment at the moment of doing it. 5. Self-awareness and self-acceptance are essential to the individuals sense of integrity and self-worth. Thus, the central purpose is a concept the nurse has thought through-one she has put into words, believes in, and accepts as a standard against which to measure the value of her action to the patient (George, 2008).

The Prescription Once the nurse has identified her own philosophy and recognizes that the patient has autonomy and individuality, she can work with the individual to develop a prescription or plan for his or her care (George, 2008). A prescription is a directive activity (Wiedenbach, 1969). It specifies both the nature of the action that will most likely lead to fulfillment of the nurses central purpose and the thinking process that determines it (Wiedenbach, 1970). A prescription may indicate the broad general action appropriate to implementation of the basic concepts as well as suggest the kind of behavior needed to carry out these actions in accordance with the central purpose. These actions may be voluntary or involuntary. Voluntary action is an intended response, whereas involuntary action is an unintended response (George, 2008). A prescription is a directive to at least three kinds of voluntary action: (1) Mututally understood and agreed upon action (the practitioner has . . . evidence that the recipient understands the implications of the intended action and is psychologically, physically and/or physiologically receptive to it.; (2) recipient-directed action (the recipient of the action essentially directs the way it is to be carried out.); and (3) practitioner-directed action

(the practitioner carries out the action . . . .)(Widenbach, 1969). Once the nurse has formulated a central purpose and has accepted it as a personal commitment, she not only has established the prescription for her nursing but also is ready to implement it (Wiedenbach, 1970) (George, 2008). The Realities When the nurse has determined her central purpose and has developed the prescription, she must then consider the realities of the situation in which she is to provide nursing care. Realities consist of all factorsphysical, physiological, psychological, emotional, and spiritualthat are at play in situation in which nursing actions occur at any given moment. Wiedenbach (1970) defines the five realities as: (1) the agent, (2) the recipient, (3) the goal, (4) the means, and (5) the framework (George, 2008). The agent, who is the practicing nurse or her delegate, is characterized by personal attributes, capacities, capabilities, and most importantly, commitment and competence in nursing. As the agent, the nurse is the propelling force that moves her practice toward its goal. In the course of this goal-directed movement, she may engage in innumerable acts called forth by her encounter with actual or discrepant factors and situations within the realities of which she herself is a part (Widenbach, 1967). The agent or nurse has the following four basic responsibilities(George, 2008): 1. To reconcile her assumptions about the realities. . . with her central purpose. 2. To specify the objectives of her practice in terms of behavioral outcomes that are realistically attainable. 3. To practice nursing in accordance with her objectives.

4. To engage in related activities which contribute to her selfrealization and to the improvement of nursing practice (Wiedenbach, 1970). The recipient, the patient, is characterized by personal attributes, problems, capacities, aspirations, and most important, the ability to cope with the concerns or problems being experienced (Wiedenbach, 1967). The patient is the recipient of the nurses actions or the one on whose behalf the action is taken. The patient is vulnerable, dependent on others for help, and risks losing individually, dignity, worth, and autonomy (Wiedenbach, 1970) (George, 2008). The goal is the desired outcome the nurse wishes to achieve. The goal is the end result to be attained by nursing action. The stipulation of an activitys goal gives focus to the nurses action and implies her reason for taking it (Wiedenbach, 1970) (George, 2008). The means comprises the activities and devices through which the practitioner is enabled to attain her goal. The means includes skills, techniques, procedures, and devices that may be used to facilitate nursing practice. The nurses way of giving treatments, of expressing concern, of using the means available is individual and is determined by her central purpose and the prescription (Wiedenbach, 1970) (George, 2008). The framework consists of the human, environmental, professional, and organizational facilities that not only make up the context within which nursing is practiced but also constitue its currently existing limits (Wiedenbach, 1967). The framework is composed of all the extraneous factors and facilities in the situation that affect the nurses ability to obtain the desired results. It is a conglomerate of objects, existing or missing, such as policies, setting, atmosphere, time of day, humans, and happenings, that may be current, pas, or anticipated (Wiedenbach, 1970) (George, 2008).

The realities offer uniqueness to every situation. The success of professional nursing practice is dependent on them. Unless the realities are recognized and dealt with, they may prevent the achievement of the goal(George, 2008). The concepts of central purpose, prescription, and realities are interdependent in Wiedenbachs theory of nursing. The nurse develops a prescription for care that is based on her central purpose, which is implemented in the realities of the situation(George, 2008).

WIEDENBACHS CONCEPTUALIZATION OF NURSING PRACTICE AND PROCESS According to Wiedenbach (1967), nursing practice is an art in which the nursing action is based on the principles of helping. Nursing action may be thought of as consisting of the following four distinct kinds of actions (George, 2008): Reflex Conditioned Impulsive (Spontaneous) (Automatic)

(Impulsive)

Deliberate (Responsible)

Nursing as a practice discipline is goal-directed. The nature of the nursing act is based on thought. The nurse thinks through the kind of results she wants, gears her actions to obtain those results, then accepts responsibility for the acts and the outcome of those acts (Wiedenbach, 1970). Since nursing requires thought, it can be considered a deliberate responsible action (George, 2008).

Nursing practice has three components: (1) identification of the patients need for help, (2) ministration of the help needed, and (3) validation that the action taken was helpful to the patient (Wiedenbach, 1977). Within the identification component, there are four distinct steps. First, the nurse observes the patient, looking for an inconsistency between the expected behavior of the patient and the apparent behavior. Second, she attempts to clarify what the inconsistency means. Third, she determines the cause of the inconsistency. Finally, she validates with the patient that her help is needed (George, 2008). The second component is the ministration of the help needed. In ministering to her patient, the nurse may give advice or information, make a referral, apply a comfort measure, or carry out a therapeutic procedure. Should the patient become uncomfortable with what is being done, the nurse will need to identify the cause and, if necessary, make an adjustment in the plan of action (George, 2008). The third component is validation. After help has been ministered, the nurse validates that the actions were indeed helpful. Evidence must come from the patient that the purpose of the nursing actions has been fulfilled (Wiedenbach, 1964) (George, 2008). Wiedenbach (1977) views the nursing process essentially as an internal personalized mechanism. As such, it is influenced by the nurses culture, purpose in nursing, knowledge, wisdom, sensitivity, and concern (George, 2008). In Wiedenbachs (1977) nursing process, she identifies seven levels of awareness: sensation, perception, assumption, realization, insight, design, and decision. Wiedenbachs nursing process begins with an activating situation. This situation exists among the realities and serves as a stimulus to arouse the nurses consciousness. This consciousness arousal leads to a

subjective interpretation of the first three levels, which are defined as: sensation (experienced sensory impression), perception (the interpretation of a sensory impression), and assumption (meaning the nurse attaches to the perception). These three levels of awareness are obtained through the focus of the nurses attention on the stimulus: they are intuitive rather than cognitive and may initiate an involuntary response. For example, a nurse enters a patients room and states, My, its hot in here! She immediately goes to the thermostat and sets it to a lower temperature. The sensation is the room temperature. The perception is It feels hot. The assumption is If I am hot, the patient must be hot. The involuntary response is to adjust the thermostat (George, 2008). Progressing from intuition to cognition, the nurses actions become voluntary rather than involuntary. The next four levels of awareness occur in the voluntary phase: realization (in which the nurse begins to validate the assumption previously made about the patients behavior); insight (which includes joint planning and additional knowledge about the cause of the problem); design (the plan of action decided on by the nurse and confirmed by the patient); and decision (the nurses performance of a responsible action) (Wiedenbach,1977) (George, 2008). To continue with the previous example: the nurse ask, Are you too warm? and the patient replies, No, Im not. I have felt cold since I washed my hair. The nurse responds, I will readjust the thermostat and get you a blanket. The patient agrees, That would be wonderful! The nurse readjusts the thermostat and gets a blanket for the patient (George, 2008). The realization is the validation of the patients perception of temperature comfort. The insight is the additional information that the patient had washed his or her hair. The design is the plan to readjust the thermostat and get a blanket as confirmed by the patient. The decision is the

nurse readjust the thermostat and gets a blanket for the patient (George, 2008). In summary, the comparison of Wiedenbachs prescriptive theory, the practice of nursing, and the nursing process as outlined in Chapter 2 of this book is as follows: in the practice of nursing, a nurse with her unique personality, purpose), philosophy, assesses the education, individual and life experiences status and (her central for health potential

development. She identifies the patients need for help (makes a nursing diagnosis). She formulates a plan with the patient, identifying outcomes and setting goals affected by the realities, or the strengths and limitations of the situation (the environment). Their plan is implemented or the nurse provides the help needed. Validation is then obtained that the help provided was indeed helpful to the patient (evaluation) (George, 2008).

III.THEORY SYTHESIS WIEDENBACHS THEORY AND CLINICAL PRACTICE Wiedenbach consistently emphasized purpose and patient in her many writings and presentations about her perspective of nursing practice. She stated: The practice of clinical nursing is goal directed, deliberately carried out and patient centered. (Wiedenbach, 1964). Figure 6-1 represents a spherical odel she created in 1962 that depicts the experiencing individual as the central focus. In a presentation entitled A Concept of Dynamic Nursing at a conference in Pittsburgh, Pennsylvania (Wiedenbach, 1962), she described the model as follows (Parker, 2001):

In its broadest sense, Practice of Dynamic Nursing concentric may be envisioned as a set of circles, with the experiencing individual in the circle at its core. Direct service, with its three components, identification of the individuals experienced need for help, ministration of help needed and validation that the help provided fulfilled its purpose, fills the circle adjacent to the core. The next circle holds the essential concomitants of direct service coordination, i.e., charting, recording, reporting, and conferring; consultation, i.e., conferencing, and seeking help or advice; and collaboration, i.e., giving assistance or cooperation with members of other professional or non-professional groups concerned with the individuals welfare. The content of the circle represents activities which are essential to the ultimate wellbeing of the experiencing individual, but only indirectly related to him; nursing education, nursing administration and nursing organizations. The outermost circle comprises research in nursing, publication and advanced study, the key ways to progress in every area of practice. She explained the elements of the second sphere to her presentation audience in the following way (Parker, 2001): Implicit in identification is the individualization of the individual and what he is experiencing. This calls for awareness of how the individual differs in appearance, manner, and behavior, from any other individual, and from the nurses expectation of him. It calls

for recognition too, that the individuals perception of his condition or situation grows out of his background of experiences and understandings, which many be called his frame-ofreference; while the nurses perception of it is in relation to her background of experiences and understandings, that is, her frame-of-reference. Activity in this unit of Practice (identification)is directed toward ascertaining 1) whether the individual is experiencing discomfort or incapability; 2) the cause of the discomfort or incapability he may be experiencing; 3) the need required to restore comfort or capability; and 4) whether the need represents a need-for-help, one, in other words which the individual is unable to meet himself, unaided. The unit Ministration involves providing the help which is needed. Underlying it, is the assumption that the individual must be accepting of any applied resource, be it a bit of advice, a recommendation, or a comfort or therapeutic measure, if he is to derive maximum benefit from it. Application of resource, thus, is dependent first of all, on selection of one which is appropriate to the need which has been identified, and second, on its acceptability to the individual. In this unit o Practice, i.e., Ministration-of-Help-Needed, the full range of resources to which the nurse has access may come into play, and the greater her stock of resources, the greater her potential for effective services. Included in such range would be her own beliefs, values, knowledge, skills and know-how; those of others whom she knows or whom she has heard, i.e., members of other professions or the laity; and those represented by facilities of the community and beyond. Validation has as its goal, evidence that, as a result of the help that was provided, the individual is experiencing

improvement in his feeling of comfort and capability in relation to his immediate situation. Such improvement may be measured by the individuals verbal and non-verbal behavior, on the assumption that he will respond behaviorally, to how he is currently experiencing his situation. Implicit in this unit are 1) clarification of the meaning to the individual, of his behavior; and 2) classification of his meaning according to the nurses concept of comfort and capability in the context of the individuals situation. Essentially, this means that to validate the effectiveness of Practice, how the individual is experiencing his immediate situation must be consistent with the nurses expectation of the outcome of her ministration. Wiedenbachs clinical application of her prescriptive theory was always evident in her logical clinical examples. They often related to general basic nursing procedures, but more so with maternity nursing practice. In discussing the practice and process of nursing, she stated (Parker, 2001): The focus of Practice is the experiencing individual, i.e., the individual for whom the nurse is caring, and the way he and only he perceived his condition or situation. For example, a mother had a red vaginal discharge on her first postpartum day. The doctor had recognized it as lochi, a normal concomitant of the phenomenon of involution, and had left an order for her to be up and move about. Instead of trying to get up, the mother remained, immobile in her bed. The nurse who wanted to help her out of bed expressed surprise at the mothers unwilling to do so, when she seemed to be progressing so well. The mother explained that she had a red discharge, and this to her was evident of onset of hemorrhage. This terrified her and made her afraid to move. Her sister, she added, had hemorrhaged and almost lost her lfie the day after she had her baby two years ago.

The nurse expressed her understanding of the mothers fear, but then encouraged her to compare her current experience with that of her sister. When the mother tried to do this, she recognized gross differences, and accepted the nurses explanation of the origin of the discharge. The mother then voiced her relief, and validated it by getting out of bed without further encouragement (Wiedenbach, 1962).

IV.

THEORY DERIVIATION

The difference between a helping hand and an outstretched palm is a twist of the wrist. ~Laurence Leamer, King of the Night As the saying goes, no man is an island. Each person has the tendency to have a feeling of need and this need may pertain to a person. As nurses, patients turn to us because they are in need of something; be it physical, emotional or even spiritual. Our role as nurses is helping hands of God to those in need. Nurses should have the sincerity and concern when using our helping hands because our thoughts and feelings are expressed through our actions. If a nurses thought and feeling is to give help to her patient because she is concerned with her welfare, not just because it is in her job description, the patient would sense the nurses concern. We nurses should not only offer our hands to help, but also we have to offer our helping hands with the intention of augmenting the

health of the person. We should put in our hearts and minds the vocation this profession entails. Nurses should define their purpose of entering nursing. It is with their purpose that their actions would radiate their intentions. If the purpose of the nurse is to promote health then that is what the patient would feel. The purpose defined by the nurse would determine their interventions and plans in the care of the patient. Based from Wiedenbachs theory, the role of the nurses is not merely carrying out orders from physicians. We should learn to assess if the patient is in need-of-help. The patient may not always verbalize this need-of-help therefore implying that we nurses should be extra sensitive when it comes to assessment of patients. We do not only base our observations with their subjective cues but also we assess their objective cues. Before nurses begin their day, it is essential that they determine their objectives in working. A nurses objective must comprise of the sincerity of providing the needs of the patient and not just because their job is asking them to do. The nurses helping hand should always be ready in their everyday encounter with patients because these people come to nurses because they are in need-of-help.

V. BIBLIOGRAPHY Barnum, B. (1994). Nursing Theory: Analysis, Application, Evaluation. 4th ed. Philadelphia: J.B. Lippincott Company. George, J. (2008). Nursing Theories: The Base for Professional Nursing Practice. 5th ed. New Jersey: Prentice Hall. Parker, M. (2001). Nursing Theories and Nursing Practice. Philadelphia: F.A. Davis.

Tomey, A. (1994). Nursing theorist and their work. 5th ed. St. Louis, Missouri: Mosby year book.

JEAN WATSONS THEORY OF HUMAN CARING

I. INTRODUCATION Above all, nursing is caring. Margaret Jean Herman Watson R.N., Ph.D.

The said quote connotes that nursing is geared towards providing care. A nurse should prioritize caring as her primary role in dealing with her patients and not merely by what her profession denotes. Nurses have to be conscious of their significance and approach in serving their clients to provide their utmost quality care. In that same occasion, Dr. Watson proposed that nurses engage in a regular practice of cultivating love and caring within themselves, and being and becoming the Caritas Field, as a way of co-creating the profession's future. She called upon nurses to come of age and establish nursing as a full mature health, healing and caring profession, considering the current crisis within healthcare. According to Arnold and Boggs (1989), caring is a commitment by the nurse to become involved since it is relational in character. Nurses enter the experience with their whole being. It involves patients in their struggle for

health rather than simply doing those actions they cannot perform for themselves. It includes the act of giving freely and willingly of oneself to another through warmth, compassion, concern, and interest. Nurses care for others during times of physical discomfort, emotional stress, and health maintenance. As quoted by Arnold and Boggs (1989), Gaut claimed that nurses express caring as concern for others, as exemplified in the statement, I care about your health, as a responsibility, as in the statement, I will be caring for you today, and as a fondness or attachment, as in the statement, I like you and care for you. 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 Watsons caring theory can be seen as indispensable to this goal. Being informed by Watsons 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 Watsons 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 nurses own actualization. In fact, Watson is one of the few nursing theorists who consider not only the caredfor 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.

OBJECTIVES: Upon successful completion of this discussion, the reader will be able to:

Describe the historical background of the development of Watsons theory

Define Watsons Human Caring Theory and the Carative factors and Clinical Caritas

Present the relationship between Watsons theory and concepts in nursings metaparadigm

Provide an example of use of Watsons theory in clinical practice

II. THEORY ANALYSIS HISTORICAL EVALUATION OF THE THEORY The theory of Human Caring was developed between 1975 and 1979, while Watson was engaged in teaching at the University of Colorado; it emerged from her own views of nursing, combined and informed by her doctoral studies in educational-clinical and social psychology. She tried to make explicit nursing's values, knowledge, and practices of human caring that are geared toward subjective inner healing processes and the life world of the experiencing person, requiring unique caring-healing arts and a framework called "carative factors," which complemented conventional medicine, but stood in stark contrast to "curative factors." At the same time, this emerging

philosophy and theory of human caring sought to balance the cure orientation of medicine, giving nursing its unique disciplinary, scientific, and professional standing with itself and its public (Parker, 2002). Watsons work embraces concepts of mind and other concepts. Watsons philosophy and theory of human caring are concerned with spirit rather than matter, flux rather than form, inner knowledge, and power rather than circumstance (Alligod and Tomey, 2002). Watson referred to caring as the essence of nursing practice. It is a moral ideal rather than a task-oriented behavior and includes such characteristics as the actual caring occasion and the transpersonal caring moment, phenomena that occur when an authentic caring relationship exists between the nurse and the patient. She views nursing and caring as both as human science and an art, and as such cannot be considered qualitatively continuous with traditional, reductionistic, scientific methodology (Tomey, 1994).

BACKGROUND OF THE THEORIST Dr. Jean Watson is Distinguished Professor of Nursing and holds an endowed Chair in Caring Science at the University of Colorado Denver and Anschutz Medical Center Campus. She is founder of the original Center for Human Caring in Colorado and is a Fellow of the American Academy of Nursing. She previously served as Dean of Nursing at the University Health Sciences Center and is a Past President of the National League for Nursing. Her latest activities include Founder and Director of a new non-profit foundation: Watson Caring Science Institute (Parker, 2002). Jean Watson was born in a small, close-knit town in the Appalachian Mountains of West Virginia in the 1940s. Jean Watson graduated from the

Lewis Gale School of Nursing in Roanoke, Virginia, in 1961. She continued her nursing studies at the University of Colorado at Boulder, earning a B.S. in 1964, an M.S. in psychiatric and mental health nursing in 1966, and a Ph.D. in educational psychology and counseling in 1973. She is a widely published author and recipient of several awards and honors, including an international Kellogg Fellowship in Australia, a Fulbright Research Award in Sweden. She holds eight (8) Honorary Doctoral Degrees, including 5 International Honorary Doctorates (Sweden, United Kingdom, Spain, British Colombia and Quebec, Canada). She has been Distinguished Lecturer and Endowed Lecturer at universities throughout the United States and been around the world several times. Clinical nurses and academic programs throughout the world use her published works on the philosophy and theory of human caring and the art and science of caring in nursing (Parker, 2002). Dr. Watsons caring philosophy is used to guide transformative models of caring and healing practices for nurses and patients alike, in diverse settings worldwide. Watson has been featured in numerous national videos on nursing theory and the art of nursing. She is the recipient of several national awards, including The Fetzer Institute Norman Cousins Award, in recognition of her commitment to developing; maintaining and exemplifying relationship-centered care practices (Parker, 2002). As author /co-author of over 14 books on caring, her latest books range from empirical measurements of caring, to new postmodern philosophies of caring and healing. Her books have been AJN books of the year awards, seek to bridge paradigms as well as point toward transformative models for the 21st century. A new revised edition of her first book, Nursing The Philosophy and Science of Caring is now available - (www.upcolorado.com) A new edition of Assessing and Measuring Caring was published in September, 2008 (Springer Publication, NY). Currently she is working on a new revised work on

Creating a Caring Science Curriculum for Caring Science (Springer in progress) (Parker, 2002). In 2008 Dr. Watson created a non-profit foundation: Watson Caring Science Institute, to further the work of Caring Science in the world (Parker, 2002).

APPROACH TO THE DEVELOPMENT OF THE MODEL WATSONS THEORY AND NURSINGS METAPARADIGM Watsons earlier works address the metaparadigm concepts of person (human being), health, environment, and nursing as somewhat more discrete concepts than do her later works. As Watson has been inspired by quantum physics and has integrated varied ways of knowing and being and doing, her descriptions of the metaparadigm concepts have been modified. The concepts are dealt with as nondiscrete, intertwined, and discontinuous (George, 2008).

Person (Human Being) Considering the individual human, Watson (1985/88) views (George, 2008): the human as a valued person in and of him- or herself in general a philosophical view of a person as a fully functional integrated self greater than, and different from, the sum of his or her parts. Furthermore, essential to human existence is that the human has transcended nature-yet remains part of it. The human can go forward, through the use of the mind, to higher levels of consciousness ones soul possesses a body that is not confined by objective space and time.

In 1996, Watson elaborated on this transcendent nature of being human. She uses a quote of de Chadrin (1967) (George, 2008): We are not human beings having a spiritual experience. We are spiritual beings having a human experience. Of the basic premises identified by Watson (1985/88) on which her caring model is based, five relate to person (George, 2008). 1. A persons mind and emotions are windows to the soul 2. A persons body is confined in time and space, but the mind and soul are not confined to the physical universe 3. A nurse may have access to a persons mind, emotions, and inner self indirectly through any sphere-mind, body or soul-provided the physical body is not perceived or treated as separate from the mind and emotions and higher sense of self (soul) 4. The spirit, inner self, or soul (geist) of a person exists in and for itself 5. People need each other in a caring, loving way In more recent work (1996), Watsons focus shifts more to the connectedness of all existence. She further develops the concept of the unity of mindbodyspirit/ nature, and of a field of connectedness between and among persons and environments at all levels, into infinity and into the universal or cosmic level of existence. There is an Unbroken wholeness and connectedness of all (subject-object-person-environment-natureuniverse- all living things). This expanded view of what it means to be human, to be healed, and to be whole, considers person to be embodied spirit, both immanent and transcendent (George, 2008).

Health and Illness Watson considers illness to be a perceived state rather than presence of disease. Illness is defined as (George, 2008): Subjective turmoil or disharmony within a persons inner self or soul at some level or disharmony within the spheres of the person, for example, in the mind, body, and soul, either consciously or unconsciously Illness connotes a felt incongruence within the person such as an incongruence between the self as perceived and the self as experienced (Waston, 1985/ 1988). Watson notes that illness can result from a troubled inner soul, and illness can lead to disease, but the two concepts do not fall on a continuum and can exist apart from one another (George, 2008)r. Watsons definition of health, on the other hand, does imply a healthillness continuum. As described in her 1985/1988 work (George, 2008): Health refers to unity and harmony within the mind, body, and soul. Health is also associated with the degree of congruence between the self as perceived and the self as experienced. Encompassing the entire nature of the individual in the physical, social, aesthetic, and moral realms, rather than limited to aspects of behavior and physiology, health or illness results from the congruence or incongruence between the self as perceived and the self as experienced. Disease may result from or be a causal factor in prolonged periods of incongruence. Or, disease may not be present (George, 2008).

Environment In 1996, Watson reiterated the usefulness of her ten carative factors, originally presented in 1979. One of these factors speaks to environment. Carative factor 8 is: Attending to supportive, protective, and/ or corrective mental, physical, societal, and spiritual environments. However, in discussions of her more recent thought, environment is considered in the context of a human-environment field. As noted above, this field form an Unbroken wholeness and connectedness of all (subject-object-personenvironment-nature-universe-all living things) (Watson 1996). It seems, then, that environment can be perceived to be a specific context, such as social, physical, or as the greater context, such as social, physical, or as the greater context of interacting, nondiscrete elements within a phenomenal field (George, 2008).

Nursing as Profession and Praxis In her own words, Watson (1985/ 1988) defined nurse to be both a noun and a verb, and nursing to consist (George, 2008): of knowledge, thought, values, philosophy, commitment, and action with some degree of passion related to human care transactions and intersubjective personal human contact with the lived world of the experiencing person. The verb to nurse is carried out through human care and caring, which Watson views as the moral ideal of nursing and (George, 2008):

consists of transpersonal human-to-human attempts to protect, enhance, and preserve humanity by helping a person find meaning in illness, suffering, pain, and existence; to help another gain self-knowledge, control, and self-healing wherein a sense of inner harmony is restored regardless of the external circumstances. Human care nursing involves a reciprocal relationship between the nurse and others as coparticipants in a pattern of subjectivityintersubjectivity evidenced in consciousness; intentionality; perceptions and lived experiences related to caring, healing, and health-illness condition in a given caring moment; and experience or meanings that transcend the moment and go beyond the actual experience (Watson, 1996) (George, 2008). Watson (1996) determines nursing to be both scientific and artistic, based on caring-healing knowledge and practices drawn from the arts and humanities as well as from traditional and emerging sciences. As a profession, nursing exists in order to sustain caring, healing, and health where, and when, they are threatened biologically, institutionally, environmentally, or politically, by local, national, or global influences (George, 2008). The practice of nursing based on Watsons theoretical and

philosophical concepts differs substantially from biomedical/ natural-science based practice. The physical body is cared for, but the care is never separated from the context of the unity of mindbodyspirit/nature (George, 2008).

OVERVIEW OF WATSONS PHILOSOPHY OF HUMAN CARING

Watsons notions of personhood and life are based on the concept of human being as embodied spirit. Within a transpersonal framework, the body is a living spirit that manifests ones being in the world and ones way of standing and reflects how one holds oneself with respect to ones relation to self and ones consciousness or unconscious. The human soul (also called spirit, geist, or higher sense of self) transcends the physical, mental, and emotional existence of a person at any given time. The soul and spirit are those aspects of consciousness that are not confined by objective space and time and that are unconstrained by linearity. By acknowledging a spiritual dimension to life, Watson is able to speculate on the human capacity to coexist with past, present and future in the moment. She respects the dignity, reverence, chaos, mystery and wonder of life because of the continuous yet unknown journey the soul takes, through the infinite and eternal. Watson view soul as the essence of the person, which possess a greater sense of self awareness, a higher(ascent) degree of consciousness, an inner strength, and a power that can expand human capacities and allow a person to transcend his or her usual self. From this higher sense of consciousness (soul level), one can more fully access the intuitive, deep imagination, the uncanny, the mystical, dream work, and feminine/masculine archetypes, and can come to be utilizing modes of awareness, feeling, and experience the rational scientific culture inhibit (Alligod and Tomey, 2002). Watson affirmed that Human life is defined as being in the world, which is continuous in time and space. The locus of human existence is experience. Broadly defined, experience includes sensory motor experience, mental/emotional experience, and spiritual experience. Experience is translated through multiple layers of awareness. Consciousness has the capacity to create and construct (Alligod and Tomey, 2002).

Watson said the person is a living, growing gestalt that possesses three spheres of being-body, mind and soul-which are influenced by the concept of self. The mind and emotions are the starting point and the point of access to the subjective world. The self is the subjective center that lives within the whole body, thoughts, sensations, desires, memories, life history, and so forth (Alligod and Tomey, 2002). Watson stated Intentionality is the projection of awareness or consciousness with some purpose and efficacy toward some object or outcome. Ones intention and attention shape experiences, as parts of the evolutionary ontological process. Watson has said, if our conscious intentionality is to hold thoughts that are caring, open, loving, kind and receptive, in contrast to an intentionality to control, manipulate and have power over, the consequences will be significant for our actions (Alligod and Tomey, 2002).

MAJOR CONCEPTUAL ELEMENTS The major conceptual elements of the original and emergent theory are (Parker, 2002): Carative Factors (evolving toward "Clinical Caritas Processes") Transpersonal Caring Relationship Caring Moment/Caring Occasion Caring-healing modalities

Other dynamic aspects of the theory which are emerging as more explicit components include (Parker, 2002):

Expanded views of self and person (transpersonal mindbodyspirit unity of being; embodied spirit;

Caring-Healing Consciousness and intentionality to care and promote healing;

Caring consciousness as energy within the human environment field of a caring moment;

Phenomenal field/unitary consciousness: unbroken wholeness and connectedness of all;

Advanced caring-healing modalities/nursing arts as a future model for advanced practice of nursing qua nursing; (consciously guided by ones nursing theoretical-philosophical orientation);

Original and Evolving Ten Carative Factors The original 1979 work was organized around ten carative factors as a framework for providing a format and focus for nursing phenomena. While "carative factors" are still the current terminology for the "core" of nursing, providing a structure for the initial work, the term "factor" is too stagnant for my sensibilities today. Watson offers another concept today that is more in keeping with Watsons own evolution and future directions for the "theory". Watson offers the concept of "clinical caritas" and "caritas processes" as consistent with a more fluid and contemporary movement with these ideas and her expanding directions (Parker, 2002).

Clinical Caritas and Caritas Processes

"Caritas" comes from the Greek word meaning to cherish, to appreciate, to give special attention, if not loving, attention to; it connotes something that is very fine that indeed is precious. The word "caritas" also is closely related to the original word "carative" from Watsons 1979 book. At this time Watson makes new connections between carative, caritas and without hesitation invoke the "L" word, which caritas conveys, that is love, allowing love and caring coming together for a new form of deep transpersonal caring. This relationship between love and caring connotes inner healing for self and others, extending to nature, and the larger universe, unfolding and evolving within a cosmology that is both metaphysical and transcendent with the coevolving human in the universe (Watson, 1998) (Parker, 2002). "Clinical Caritas" is an emerging model of transpersonal caring and moves from carative to caritas. This integrative expanded perspective is both postmodern, in that it transcends conventional industrial, static models of nursing, while simultaneously evoking both the past and the future. For example, the future of nursing is ironically tied back to Nightingales sense of "calling", guided by a deep sense of commitment and a covenantal ethic of human service; cherishing our phenomena, our subject matter, and those we serve. It is when we include caring and love in our work and our life that we discover and affirm that nursing, like teaching, is more than just a job, but a life-giving and life-receiving career for a lifetime of growth and learning. Such maturity and integration of past with present and future, now require transforming self, and those we serve, including our institutions, and the profession itself. As we more publicly and professionally assert these positions for our theories, our ethics and our practices, even our science, we also locate ourselves and our profession and discipline within a new, emerging cosmology. Such thinking calls for a sense of reverence and sacredness with regard to life and all living things (Parker, 2002). It incorporates both art and science, as they are also being redefined, acknowledging a convergence between art, science, and spirituality. As one

enters

into

the

transpersonal

caring

theory

and

philosophy,

one

simultaneously is challenged to relocate themselves in these emerging ideas and question for themselves how the theory speaks to them, inviting them into a new relationship with themselves and their ideas about life, nursing, and theory. In this framework each one is also asked, if not enticed to examine and explore the critical intersection between the personal and the professional; to translate their unique talents, interests, and gifts into human service of caring and healing, for self and others, and even the planet Earth itself (Parker, 2002).

Original Carative Factors The original carative factors served as a guide to what was referred to as the "core of nursing", in contrast to nursings "trim". Core pointed to those aspects of nursing that potentiate therapeutic healing processes and relationships; they affect the one caring and the one-being-cared-for. Further, the basic core was grounded in what I referred to as the philosophy, science, and art of caring. Carative is that deeper and larger dimension of nursing that goes beyond the "trim" of changing times, setting, procedures, functional tasks, specialized focus around disease, treatment and technology. While the "trim" is important and not expendable, the point is that nursing cannot be defined around its trim and what it "does" in a given setting at a given point in time. Nor can nursings trim define and clarify its larger professional ethic and mission to society - its raison detre for the public. That is where nursing theory comes into play and transpersonal caring theory offers another way, that both differs from, yet complements, that which has come to be known as "modern" nursing and conventional medical-nursing frameworks (Parker, 2002).

Watson regards the carative factors as the foundation for advanced practices and caring modalities for healing and health processes and outcomes. Moreover, Watson viewed the Carative Factors as both hierarchical in nature, whereby each preceding factor contributes to the next one and interacting to promote holistic nursing care. The first and most basic carative factor, Forming a Humanistic-Altruistic System of Values, points out that human caring is, according to Watson, grounded on universal humanistic and altruistic values. Furthermore, she claimed that the best professional care is promoted when the nurse subscribes to such a value system. With regard to the second carative factor, Enabling and Sustaining Faith-Hope, Watson pointed out that the nurse must instill in the other person a sense of faith and hope about the treatment and the nurses competence (Fawcett, 2000). Watson noted the development of sensitivity to self and others, which is the focus of the third carative factor, Being Sensitive to Self and Others, plays a part in the nurses development of self, the ability to utilize the self with others, and the ability to give holistic care. The fourth carative factor, and Developing being. a Helping-Trusting, maintained the Caring Relationship, processes She is of accomplished when the nurse views the other person as a separate thinking feeling Watson of the attitudinal relationship. congruence, or genuineness, empathy, and nonpossessive warmth are essential elements helping-trusting further maintained that a helping-trusting relationship is a basic element of highquality nursing care (Fawcett, 2000). The fifth carative factor, Promoting and Accepting the Expression of Positive and Negative Feelings and Emotions, points to the range of feelings and emotions experienced by both nurse and other(s) and the need to facilitate the expression of such feelings and emotions. Watson stated the sixth carative factor, Engaging in Creative, Individualized ProblemSolving Caring Processes, focuses attention on the full use of self and all

domains of knowledge, including empirical, aesthetic, intuitive, affective, and ethical knowledge. (Fawcett, 2000). The seventh carative factor, Promoting Transpersonal TeachingLearning, emphasizes Watsons view that nurses and patients are coparticipants in the process of learning. Watson linked the eight carative factor, Attending to Supportive, Protective, or Corrective mental, Physical, Societal, and Spiritual Environments, with the quality of holistic health care (Fawcett, 2000). The ninth carative factor, Assisting with Gratification of Basic Human Needs while Preserving Human Dignity and Wholeness, Watson identified and hierarchically ordered the needs she regarded as most relevant to nursing as human caring. The tenth carative factor, Allowing For, and Being Open To, Existential-Phenomenological-Spiritual Dimensions of Caring and Healing That Cannot Be Fully Explained Scientifically Through Modern Western Medicine, emphasizes the importance of appreciating and understanding the inner world of each person and the meaning each one finds in life, as well as helping others to find meaning in life. Dealing with another person as he or she is and in relation to what he or she would like to be or could be is, according to Watson, a matter of existential-phenomenological [and spiritual] concern for the nurse who practices the science of [human] caring. Watsons addition of the phrase that cannot be fully explained scientifically through modern Western medicine to this carative factor implies that she recognizes the possibility of phenomena that are more in keeping with nonempirical ways of knowing. (Fawcett, 2000).

While some of the basic tenets of the original carative factors still hold, and indeed are used as the basis for some theory-guided practice models and

research, what I am proposing here, as part of my evolution and evolution of these ideas and the theory itself, is to transpose the "carative factors" into "clinical caritas processes". For example, consider the following within the context of clinical caritas, and emerging, transpersonal caring theory (Parker, 2002).

From Carative Factors To Clinical Caritas Processes As carative factors evolve within an expanding perspective, as my ideas and values evolve, I now offer the following translation of the original carative factors into clinical caritas processes, suggesting more open ways in which they can be considered. For example (Parker, 2002), 1. Formation of humanistic-altruistic system of values becomes: "Practice of loving-kindness and equanimity within context of caring consciousness"; 2. Instillation of faith-hope, becomes: "Being authentically present, and enabling and sustaining the deep belief system and subjective life world of self and one-being-cared- for"; 3. Cultivation of sensitivity to ones self and to others becomes: "Cultivation of ones own spiritual practices and transpersonal self, going beyond ego self"; 4. Development of a helping-trusting, human caring relationship becomes: "Developing and sustaining a helping-trusting, authentic caring relationship"; 5. Promotion and acceptance of the expression of positive and negative feelings, becomes: "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";

6. Systematic use of a creative problem-solving caring process becomes: "creative use of self and all ways of knowing as part of the caring process; to engage in artistry of caring-healing practices"; 7. Promotion of transpersonal teaching-learning becomes: "Engaging in genuine teaching-learning experience that attends to unity of being and meaning attempting to stay within others frame of reference"; 8. Provision for a supportive, protective, and/or corrective mental, physical, societal, and spiritual environment, becomes: "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"; 9. Assistance with gratification of human needs becomes: "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 embodied spirit and evolving spiritual emergence; 10. Allowance for existential-phenomenological-spiritual forces becomes: "opening and attending to spiritual-mysterious, and existential dimensions of ones own life-death; soul care for self and the one-being-care-for." What differs in the Clinical Caritas framework is that a decidedly spiritual dimension and an overt evocation of love and caring merge into a new paradigm for the next millennium. Such a perspective ironically places nursing within its most mature framework, consistent with the Nightingale model of nursing, yet to be actualized, but awaiting its evolution within a caring-healing theory. This direction ironically while embedded in theory, goes beyond theory and becomes a converging paradigm for nursings future (Parker, 2002).

Thus, Watson considers her work more a philosophical, ethical, intellectual blueprint for nursings evolving disciplinary/professional matrix, rather than a specific theory per s. Nevertheless, others interact with the original work at levels of concreteness or abstractness; the caring theory has been, and is being used, as a guide for educational curricula, clinical practice models, methods for research and inquiry, as well as administrative directions for nursing and health care delivery (Parker, 2002). This work posits a values explicit moral foundation and takes a specific position with respect to the centrality of human caring, "caritas" and love as now an ethic and ontology, as well as a critical starting point for nursing's existence, broad societal mission, and the basis for further advancement for caring-healing practices. Nevertheless, its use and evolution are dependent upon "critical, reflective practices that must be continuously questioned and critiqued in order to remain dynamic, flexible, and endlessly self-revising and emergent" (Watson, Blueprint; 1996, p. 143) (Parker, 2002). Ironically, this work is congruent with recent reports on health care and health professional educational reform, which call for "centrality of caringhealing relationships" as the foundation for all health professional education and practice reform. I quote (Parker, 2002): The central task of health professions education - in nursing, medicine, dentistry, public health, psychology, social work, and the allied health professions - must be to help students, faculty, and practitioners learn how to form caring, healing relationships with patients, and their communities, and with each other, and with themselvesthe knowledge, skills, and values necessary for effective relationships Developing practitioners mature as reflective learners and professionals who understand the patient as a person, recognize and deal with multiple contributions to health and illness, and understand the

essential nature of healing relationships. (Pew-Fetzer Task Force Report, 1994, p. 39)

Transpersonal Caring Relationship Watson termed transpersonal and a transpersonal caring relationship as the foundation of the work; transpersonal conveys a concern for the inner life world and subjective meaning of another who is fully embodied, but transpersonal also goes beyond the ego self and beyond the given moment, reaching to the deeper connections to spirit and with the broader universe. Transpersonal caring seeks to connect with and embrace the spirit or soul of others through the processes of caring and healing and being in authentic relation, in the moment (Parker, 2002). According to Watson, such a transpersonal relation is influenced by the caring consciousness and intentionality of the nurse as she or he enters into the life space or phenomenal field of another person, and is able to detect the other persons condition of being (at the soul, spirit level). It implies a focus on the uniqueness of self and other and the uniqueness of the moment, wherein the coming together is mutual and reciprocal, each fully embodied in the moment, while paradoxically capable of transcending the moment, open to new possibilities (Parker, 2002). Transpersonal caring calls for an authenticity of being and becoming, an ability to be present to self and other in a reflective frame; the transpersonal nurse has the ability to center consciousness and intentionality on caring, healing, and wholeness, rather than on disease, illness and pathology. Watson stated within the model of transpersonal caring, clinical

caritas consciousness is engaged at a foundational ethical level for entry into this framework. The nurse attempts to enter into and stay within the others frame of reference for connecting with the inner life world of meaning and spirit of the other; together they join in a mutual search for meaning and wholeness of being and becoming to potentiate comfort measures, pain control, a sense of well-being, wholeness, or even spiritual transcendence of suffering. The person is viewed as whole and complete, regardless of illness or disease (Parker, 2002). Nursings goal is to help persons gain a higher degree of harmony within the mindbodyspirit, which generates self-knowledge, self reverence, self-healing, and self-care processes while allowing for diversity and possibility. In ontology of relation, the nurse pursues this goal through transpersonal caring relationship and the human care process and responds to persons subjective worlds in such a way that individuals can find meaning in their existence through exploring the meaning of their disharmony, suffering, and turmoil within the lived experience. This exploration promotes self-knowledge, self-control, self-love, choice based on subjective intent, and self-determination (Tomey, 2002).

The concept TRANSPERSONAL CARING RELATIONSHIP encompasses three dimensions self, phenomenal field and intersubjectivity. Self Watson identified the self as a transpersonal mind body spirit oneness, an embodied spirit. The self encompasses the self as it is, the ideal self that the person would like to be, the ego self, and the spiritual self, which is synonymous with the geist or soul or essence of the person, and which is the highest sense of self (Fawcett, 2000).

Phenomenal Field The phenomenal field is the totality of human experience (ones being in the world). The individual frame of reference that can be known only to the person (Fawcett, 2000). Intersubjective Transpersonal refers to an intersubjective human-to-human

relationship in which the person of the nurse affects and is affected by the person of the other. They share a phenomenal filed which becomes part of the life history of both and are coparticipants in becoming in the now and the future. Watson said that the intersubjectivity human flow from one to the other (is such that it) has the potential to allow the care giver to become the care receiver (Fawcett, 2000).

The

three

dimensions

of

the

concept

TRANPSERSONAL

CARING

RELATIONSHIP Self, Phenomenal Field, and Intersubjectivity-are regarded as integral. Watson explained: Human care can begin when the nurse enters into the life space or phenomenal field of another person, is able to detect the other persons condition of being (spirit, soul), feels this condition in such a way that the recipient has a release of subjective feelings and thoughts he or she had been longing to release. As such, there is an intersubjective flow between the nurse and patient (Fawcett, 2000).

Assumptions of Transpersonal Caring Relationship Moral commitment, intentionality and caritas consciousness by the nurse protects, enhances and potentiates human dignity, wholeness and healing

whereby allowing a person to create or co-create his/her own meaning for existence. The conscious will of the nurse affirms the subjective and spiritual significance of the patient while seeking to sustain caring in the midst of threat and despair, biological, institutional or otherwise. The result is an honoring of an I-Thou Relationship rather than an I-It Relationship (Parker, 2002). The nurse seeks to recognize, accurately detect, and connect with the inner condition of spirit of another through genuine presencing and being centered in the caring moment; actions, words, behaviors, cognition, body language, feelings, intuition, thought, senses, the energy field, and so on, all contribute to transpersonal caring connection. The nurses ability to connect with another at this transpersonal spirit- to- spirit level is translated via movements, gestures, facial expressions, procedures, information, touch, sound, verbal expressions and other scientific, technical, aesthetic, and human means of communication, into nursing human art/acts or intentional caring-healing modalities (Parker, 2002). The caring-healing modalities within the context of transpersonal caring/caritas consciousness potentiate harmony, wholeness, unity of being by releasing some of the disharmony, the blocked energy that interferes with the natural healing processes; thus the nurse helps another through this process to access the healer within, in the fullest sense of Nightingales view of nursing (Parker, 2002). On-going personal and professional development and spiritual growth, and personal spiritual practice assist the nurse in entering into this deeper level of professional healing practice, allowing for awakening to a transpersonal condition of world and more fully actualizing the "ontological competencies" necessary for this level of advanced practice of nursing. The nurses own life history, previous experiences, opportunities for focused studies, having lived through or experienced various human conditions, or of

having imagined others feelings in various circumstances, are valuable teachers for this work; to some degree the necessary knowledge and consciousness can be gained through work with other cultures, study of the humanities (art, drama, literature, personal story, narratives of illness journeys, etc.) along with an exploration of ones own values, deep beliefs, and relationship with self, others, and ones world. Other facilitators are personal growth experiences such as psychotherapy, transpersonal psychology, meditation, bio-energetics work, and other models for spiritual awakening. Continuous growth is on-going for developing and maturing within a transpersonal caring model. The notion of health professionals as wounded healers is acknowledged as part of the necessary growth and compassion called forth within this theory/philosophy (Parker, 2002).

Caring Moment/ Caring Occasion A caring occasion occurs whenever the nurse and another come together with their unique life histories and phenomenal fields in a human-to-human transaction. The coming together in a given moment becomes a focal point in space and time. It becomes transcendent whereby experience and perception take place, but the actual caring occasion has a greater field of its own in a given moment. The process goes beyond itself, yet arises from aspects of itself that become part of the life history of each person, as well as part of some larger, more complex pattern of life. (Watson, 1985/1988, p. 59; 1996 p.157 reprinted (Parker, 2002)). A caring moment involves an action and choice by both the nurse and the other. The moment of coming together presents them with the opportunity to decide how to be in the moment and in the relationship as where as what to do with and during the moment. If the caring moment is transpersonal, each feels a connection with the other at the spirit level, thus

it transcends time and space, opening up new possibilities for healing and human connection at a deeper level than physical interaction. For example (Parker, 2002): .We learn from one another how to be human by identifying ourselves with others, finding their dilemmas in ourselves. What we all learn from it is self-knowledge. The self we learn about is every self. IT is universal the human self. We learn to recognize ourselves in others(it) keeps alive our common humanity and avoids reducing self or other to the moral status of object. (Watson, 1985/1988, pp. 59-60).

Caring (Healing) Consciousness The dynamic of transpersonal caring (healing) within a caring moment is manifest in a field of consciousness. The transpersonal dimensions of a caring moment are affected by the nurses consciousness in the caring moment, which in turn affects the field of the whole. The role of consciousness with respect to a holographic view of science have been discussed in earlier writings (Watson, 1992, p. 148) and include the following points (Parker, 2002): The whole caring-healing-loving consciousness is contained within a single caring moment. The one caring and the one being cared for are interconnected; the caring-healing process is connected with the other human(s) and the higher energy of the universe; The caring-healing-loving consciousness of the nurse is communicated to the one being cared for;

Caring-healing-loving consciousness exists through and transcends time and space and can be dominant over physical dimensions. Within this context, it is acknowledged that the process is relational

and connected; it transcends time, space, and physicality. The process is intersubjective with transcendent possibilities that go beyond the given caring moment (Parker, 2002).

Implications of the Caring Model The caring model or theory can also be considered a philosophical and moral/ethical foundation for professional nursing and part of the central focus for nursing at the disciplinary level. A model of caring includes a call for both art and science; it offers a framework that embraces and intersects with art, science, humanities, spirituality, and new dimensions of mindbodyspirit medicine and nursing evolving openly as central to human phenomena of nursing practice (Parker, 2002). Watson emphasized that it is possible to read, study, learn about, even teach and research the caring theory; however, to truly "get it," one has to personally experience it; thus the model is both an invitation and an opportunity to interact with the ideas, experiment with and grow within the philosophy, and living it out in ones personal/professional life (Parker, 2002). The ideas as originally developed, as well as in the current evolving phase (see Watson, 1999), provide others a chance to assess, critique and see where or how, or if, one may locate self within the framework or the emerging ideas in relation to their own "theories and philosophies of professional nursing and/or caring practice." If one chooses to use the caring perspective as theory, model, philosophy, ethic or ethos for transforming self

and practice, or self and system, the following questions may help (Watson, 1996, p. 161) (Parker, 2002): Is there congruence between (a) the values and major concepts and beliefs in the model and the given nurse, group, system, organization, curriculum, population needs, clinical administrative setting, or other entity that is considering interacting with the caring model to transform and/or improve practice? What is ones view of human? And what it means to be human, caring, healing, becoming, growing, transforming, etc. For example: In words of Teilhard de Chardin: "Are we humans having a bspiritual experience, or are we spiritual being having a human experience?" Such thinking in regard to this philosophical question can guide ones worldview and help to clarify where one may locate self within the caring framework. Are those interacting and engaging in the model interested in their own personal evolution? Are they committed to seeking authentic connections and caring-healing relationships with self and others? Are those involved "conscious" of their caring-caritas or non-caring consciousness and intentionally in a given moment and at an individual and system level? Are they interested and committed to expanding their caring consciousness and actions to self, other, environment, nature and wider universe? Are those working within the model interested in shifting their focus from a modern medical science-technocure orientation to a true caring-healing-loving model? This work, in both its original and evolving forms, seeks to develop caring as an ontological and theoretical-philosophical-ethical framework for the profession and discipline of nursing and clarify its mature relationship

and distinct intersection with other health sciences. Nursing caring theory based activities as guides to practice, education and research have developed throughout the USA and other parts of the world. Watsons work is consistently one of the nursing caring theories used as a guide. Nurses reflective-critical practice models are increasingly adhering to caring ethic and ethos (Parker, 2002). Because the nature of the use of the caring theory is fluid, dynamic, and undergoing constant change in various settings around the world and locally I am not able to offer updated summaries of activities. Earlier publications seek to provide examples of how the work is used, or has been used in specific settings (Parker, 2002).

III.THEORY SYNTHESIS CLINICAL APPLICATION The intent of this section is to create a better understanding of Watsons 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 Watsons 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). Ive 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 nurses 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 cant 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 Watsons caring values based on respecting and preserving human dignity. Yet, hearing how other peoples 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 patients dignity, humanity, wholeness, and inner harmony. Caring, for me, is what nursing is all about!] (C.C., RN) (http://www.humancaring.org/conted/Pragmatic%20View.pdf)

JEAN WATSONS THEORY OF CARING IN NURSING EDUCATION The past decade has been rich in the advancement of complementary approaches to traditional medicine. Medical science has confirmed the benefits of stress reduction techniques such as yoga, meditation and qigong. Another technique that is increasingly incorporated into the conventional practice of medicine is that of mindfulness training. One mindfulness practitioner is Jean Watson, who promotes a theory of caring as the central tenet in her teaching philosophy. Framework Jean Watson's theory of caring focuses on love as the primary healing tool in nursing. Watson advocates a mental state of caring, focused not on the self but, rather, on the patient. Watson believes that in an ego-less state, a nurse intuitively knows the needs of the patient. This methodology is not new; her focus fits well within the scope of Betty Neumann's theory of nursing, whose seminal work in the mid 20th century outlined the idea of the role of the nurse as an integral tool in creating balance, not only in the physical body but in the patient's emotional state as well.

Energy Awareness Because nurses are on the front lines of caring, Watson believes that nurses should be acutely aware of the type of energy, whether caring or indifference, they exude. According to Watson, there is evidence that a loving approach creates a physical change in the environment, thereby creating a healing energy for those who come in contact with it. Nursing Theory in Practice Nursing theory in practice is a fourfold process which comprises overall education, skill practice, practical application of existing theory, and examination and integration of new theories including psychological and philosophical discoveries. Jean Watson addresses these aspects of nursing theory in her nurse training program at the University of Colorado's Denver Health Sciences Center. Additionally, Watson's own Center for Human Caring promotes her caring philosophy in several forms including multi-continent training sessions, webseminar educational materials, spiritually-centering meditation and devotional media, and an annual professional retreat to discuss practical nursing as well as application of new psychological theories. Influences Jean Watson has been highly influenced by the author Eckhart Tolle, whose work focuses on the benefits of love-centered living. Tolle's writing explores the idea that the human race is currently involved in a shift of consciousness, through the realization that the self is already whole in the present moment. Jean Watson is also a proponent of the work of the HeartMath Institute, a research center directed by physicians, which focuses on recent medical

evidence that our emotions significantly affect our health and well being. HeartMath's philosophy is based on the idea that hormones secreted when we are under stress cause inflammation and, ultimately, disease, while hormones secreted when we are at peace are healing to the body. The HeartMath Institute provides guided meditations as well as centering exercises designed to stop stressful emotions by replacing negative thoughts with helpful ones. Million Nurse Project Jean Watson's Million Nurse Global Caring Field Meditation, held on January 1, 2010, initiated a worldwide day of caring, where nurses across the world shared in love-centered consciousness towards one another and their patients. (http://connected.waldenu.edu/curriculum-resources/learningcenters/item/860-jean-watsons-theory-of-caring-nursing-education)

IV.

THEORY DERIVIATION

Too often we underestimate the power of a touch, a smile, a kind word, a listening ear, an honest compliment, or the smallest act of caring, all of which have the potential to turn a life around. Leo F. Buscaglia We always tend to forget that big things come Small in small we packages. efforts

make everyday might not be a big deal for us but it might be a big deal for others; just as incorporating nursing with love and care. When nurses apply their profession with a little love and care, this would result in the holistic healing of an ill person. Watson stated in her theory that we should not view a person as separate being but rather a unified being. We should consider a persons mindbodyspirit when giving care to them. Nursing is just like seeing and treating one patient as your own child. As a mother, she gives love and care to her children. It is very important that we show our care and our love to our patients. Nursing is not just the mere fact of giving medications and positioning the patient. It is viewing the patient as a whole. Nurses should not only look after the physical illness inflicted in a person, but also they should go deeper with the interaction of a patient. Every person is like a circle. They should be viewed as a whole. It is when we see the person as a whole being that we give our patients the chance to have a holistic wellness.

V. BIBLIOGRAPHY

BOOKS Alligod, M. R. and Tomey, A. M. (2002). Nursing Theory: Utilization and Application. 2nd ed. St. Louis: Mosby. Arnold, E. and Underman-Boggs, K. (1989). Interpersonal Relationships: Professional Communication Skills for Nurses. 4th ed. U.S.A.: Elsevier Science. Fawcett, J. (2000). Analysis and Evaluation of Contemporary Nursing Knowledge: Nursing Models and Theories. Philadelphia: F.A. Davis. George, J. (2008). Nursing Theories: The Base for Professional Nursing Practice. 5th ed. New Jersey: Prentice Hall. Parker, M. (2002). Nursing Theories and Nursing Practice. Philadelphia: F.A. Davis. Tomey, A. (1994). Nursing theorist and their work. 5th ed. St. Louis, Missouri: Mosby year book. INTERNET SOURCES http://connected.waldenu.edu/curriculum-resources/learningcenters/item/860-jean-watsons-theory-of-caring-nursing-education http://www.humancaring.org/conted/Pragmatic%20View.pdf http://www.humancaring.org/conted/Pragmatic%20View.pdf http://www.watsoncaringscience.org/cfwebstorefb/index.cfm/feature/84/theor y-of-human-caring.cfm http://www.watsoncaringscience.org/j_watson/theory.html