Jean Watson’s Theory of Human Caring using Evidenced Based Practice across the Clinical Spectrum of Nursing

1. Jean Watson’s Theory of Human Caring using Evidenced Based Practice across the Clinical Spectrum of Nursing Presented by Patricia Bell, Carol Gibbs, Jennifer Gilbert, Jennifer Hales and Sarah Rooks

2. Key Components of Jean Watson’s Theory • Focuses on the ten caritas processes, these are processes Watson believes the nurse must consider and exemplify in order to be an effectively caring nurse (Alligood & Tomey, 2010) • The word ‘caritas’ “comes from the Greek word meaning to cherish, to appreciate, to give special attention; it connotes something very fine, that indeed is precious” (Medscape Nurses, 2005). • Watson’s theory calls upon nurses to go beyond procedures and tasks, but instead focuses on the nurse-patient relationship resulting in a therapeutic outcome and transpersonal caring process (Alligood et al., 2010)

3. Watson’s Theory Continued… • Focuses on care of self and care of others • Focuses on spiritual dimension of human relations and caring • Intentional presence and authentic presence are key • Regard for the whole-person and being in their world (mind, body, spirit) • Caring moments • Physical and spiritual needs are tended to in a healing environment • Patient is at the center of care, rather than the task or technology • Caring as a method of healing (Alligood et al., 2010)

4. Rationale for use of Nursing Theory • Nurses who use theory to structure their practice are able to sort patient data quickly, make decisive nursing actions, and deliver outcome-based care, while also improving quality of care (Alligood et al., 2010) • Using theory applied to nursing practice helps develop critical thinking while clarifying values and assumptions, and provides a basis for future practice, education, and research (Alligood et al., 2010) • Alligood et al. also states “models and theories guide theory-based research for evidence-based practice” (2010, p. 14). • Nursing theory is the bridge between learning new information and applying it to clinical practice!

5. Reason for Selecting Watson’s Theory of Human Caring • Caring is unique to nursing, whereas medicine focuses on curing disease (Alligood et al., 2010) • Watson’s theory is the basis for Relationship Based Care (RBC), which is being implemented in countless hospitals and facilities nationwide. This makes this theory relevant and applicable for many of us!

6. Watson’s Theory Used in Research We will explore how Jean Watson’s theory has been used in research in a variety of clinical settings. Evidence Based Research Includes These Topics: 1.) Creating a Profile of a Nurse Effective in Caring 2.) Applying Watson’s Theory for Caring Among Elders 3.) Patient Perceptions of Care in a Multicultural Environment 4.) Minimizing Preoperative Anxiety with Alternative Caring- Healing Therapies 5.) The Attending Nurse Caring Model T. The

7. Creating a Profile of a Nurse Effective in Caring

8. Profile of a Caring Nurse The intent of this study was to create a profile of nurses effective in caring within Jean Watson’s Caritas framework Caritas nursing is described as acknowledging caring and love as integral aspects of a mutual, humanistic, caring interaction Identifying unique characteristics between patients and nurses in a context that portrays caring and love has implications for understanding the power of human healing, and also helps gain knowledge of the type of environment in which this type of Caritas nursing can occur (Persky, Nelson, & Watson, 2008)

9. Background A formal study of the profile of nurses effective in caring occurred at New York Presbyterian Hospital/Columbia University Center. Study was done prior to implementation of the Relationship Based Care (RBC) delivery model at this establishment. Both qualitative and quantitative data identified demographics and environmental perceptions of caregivers who received the highest score of caring identified by the patients they served. (Persky et al., 2008)

10. Study Details 85 nurses responded to a Health Environment Survey (HES) Nurses were selected based on amount of time caring for a patient during their inpatient stay 85 patients responded to the Caring Factors Survey (CFS) Patients were selected on basis of admission to six medical/surgical units and one mental health unit Average length of stay for the patient was 7 days Nurses who were paired with these patients were considered the primary caregiver during that patient’s hospital stay Correlations of these 85 pairs were examined to identify two factors: -the nurse’s report of the environment -the patient’s report of caring Participation for both groups was voluntary and consent was given (Persky et al., 2008)

11. Research Process Research process of surveys HES and CFS measured: -unit-based employee job satisfaction -patient’s perception of caring Study then linkednurse factors in relation to patient satisfaction scores to identify specific traits of the nurse who received caring effectiveness scores by the patient. (Persky et al., 2008)

12. Research Findings: Nurses reported to be caring by their patients were found to: Report the greatest frustration with every work environment variable measured, especially workload Have the most hospital and professional experience Work their scheduled hours of work, not more than scheduled hours Be of any age Be most affected by stress in the relationship with the patient, especially “difficult” patients Be those who most enjoyed coworker relationships Be those who most often provided continuity of patient care from admission to discharge (Persky et al., 2008)

13. Implications Speculation of the study considers that nurses who receive the highest scores of caring and love may be frustrated by the incongruence between healthcare environments and values of caring Further frustration among these nurses may also be rooted in the fact that Caritas nursing takes more time and resources than the nurse has available Understanding this profile of Caritas nurses (those who receive high caring scores) is essential to refining work environment systems in order to improve caring/healing processes (Persky et al., 2008)

14. Critique and Reflection Limitations of this study A single study using limited pairs (85 total) of nurses and patients Took place at only one institution Article states this is the first study the authors are aware of which examines attributes of caring nurses Theory about caring attributes is in early stages and needs further exploration and research Possibilities Future studies on effective caring and related patient outcomes can be used to demonstrate the interdependence of this relationship. This can help restore caring back into healthcare, while reducing costs and improving outcomes.

15. Applying Watson’s Theory for Caring Among Elders

16. Caring Among Elders A nurse’s “c0nscious intentionality,” or conscious effort to “be with” the patient and not just “do for” him or her fosters “transpersonal encounters” in which both the nurse and patient fully participate. Such human exchanges promote healing in not only the patient, but in the nurse as well (Watson, 1985).

17. Jean Watson’s “Carative Factors” 1.) Humanistic-altruistic system of values 2.) Faith-hope 3.) Sensitivity to self and others 4.) Helping-trusting, human care relationship 5.) Expressing positive and negative feelings 6.) Creative problem-solving caring process 7.) Transpersonal teaching-learning 8.) Supportive, protective, and/or corrective mental, physical, societal, and spiritual environment 9.) Human needs assistance 10.) Existential-phenomenological-spiritual forces Watson (1995)

18. IntroducingLaughing Spirit Listening Circles • True healing comes from a place deep within us (Strickland, 1996). • This place is “the laughing spirit,’’ where “universal perspective and self • awareness” dwell (Glickstein, 1995). • Laughing Spirit Listening Circles are group sessions with no leaders allowing • members to tell their stories in a place that lets them safely and fully express • themselves in true dialogue (Glickstein, 1995). • This research was conducted to validate Glickstein’s Circles naturally • embodied Watson’s theory and these two approaches could be successfully • combined in a project with the elderly (Strickland, 1996).

19. Study Details Six residents of a retirement community, women ages 83 – 95, were invited to participate in this pilot project by the center’s activities director. All of them agreed without hesitation to the 5 – hour commitment. There were 4 sessions at 1.25 hours each for one week. These residents had lived in the nursing care center from 2 months – 10 years, half of them were college educated, one was visually impaired, one was hearing impaired, and the remainder suffered no major disabilities. Two thirty-seven year old, female volunteers, a nurse and a graduate sociology student, would act as facilitators for the Listening Circle based on Watson’s Science of Human Caring (1994). Strickland (1996)

20. Research Process 1.)The volunteers provided initial guidelines for the participants that their stories could consist of past events, fantasies, ideas, dreams, thoughts, feelings, or anything else they wished to share. 2.) Each Laughing Spirit Listening Circle begins with a warm-up round, during which each participant shares a one-minute story and then receives positive feedback from the group. Then, each member of the Circle shares a longer story approximately 3 minutes long and again receives positive feedback. 3.) The feedback is to be related to one’s own experience of the storyteller and one’s own experience of self while listening. 4.) The flow of the conversation should come naturally, without direction from any one member of the circle. 5.) The stories shared did not need to be connected in any way, they were to arise spontaneously from each participant. Strickland (1996)

21. Research Findings Every member of the Circle told at least one story during each session, which lasted 5 – 7 minutes. Most of the women appeared uncomfortable receiving positive feedback from others. The subject would be changed, attention diverted away from self and to another woman in the group. When the women were asked about the observation they stated this “total attention” was not something they were used to, and even though it felt good, they weren’t sure what to do with the feedback. One of the participants, a retired librarian, called this positive feedback “reciprocal altruism” The participants described their experience in the sessions as a “peaceful, restful, quiet place to come and be listened to,” and “ very neighborly and civilized.” There was much laughter, comforting silence, eye contact, physical reaching out to one another by patting each other’s hand or leg. Strickland (1996)

22. Implications for Nursing Practice Simple presence, listening, and witnessing another’s personal experience creates a healing-caring environment The caring-centered involvement produced a connectedness known as “spiritual transcendence” “Conscious intentionality” to be truly present and authentic There was eye contact, comforting touch, and silence displayed through the sessions between all members Reciprocal altruism Strength and hope Restful/Peaceful Making a conscious effort “to be with” the patient and not just “do for” fosters transpersonal encounters

23. Critique and Reflection Limitations of the Study This study was conducted one time This study was conducted only with female residents This study was conducted in a retirement community The female residents were familiar with one another, so they felt more comfortable in sharing their personal stories Possibilities The elderly make it clear that personalized, sincere interactions mean the most to them. It is possible for nurses to provide personal care developing a stronger bond with the elderly simply by “presencing” ourselves during the interventions provided.

24. Patient Perceptions of Care in a Multicultural Environment

25. Caring in a Multicultural Setting Jean Watson’s caring theory addresses caring relationships among people and the deep experiences of life itself In the Kingdom of Saudi Arabia, little is known about the view of the patient in terms of feeling cared for in the clinical setting The purpose of this study is to explore the patient’s perception of being cared for in the Kingdom of Saudi Arabia

26. Research Findings The study was designed to explore if caring behaviors displayed by the nurse were considered important to the patient. Most of the nurses in this area came from cultural backgrounds that were different from their patients, making a caring relationship and communication difficult. A questionnaire survey was used to explore the discrepancies existing between the perceived importance of caring behaviors and how frequently these behaviors were experienced. A probability sample of 393 patients was drawn from three different hospitals in three regions in Saudi Arabia. Patients rated caring behaviors as important (97.2%) and these behaviors were frequently experienced (73.7%).

27. Research Findings Overall, the Saudi patients valued the caring behaviors based upon Jean Watson's theory despite the cultural difference between the nurse and patient. The frequency of caring behaviors attended to by the nurse in teaching/learning and helping/trust behavior subcategories were rated lower. This mostly occurred because of the culture differences and language barriers between patients and their nurses. The results indicated the carative factors in Jean Watson's theory were applicable to patients in Saudi Arabia and should be implemented by nurses to meet patient needs.

28. Critique The article is missing which caring behaviors the patients ranked as important. This information is important to know when providing care in a different culture. It is important to know the behaviors the patient ranked as important in order to incorporate them into nursing practice. The article is credible since the probability sample was a large number of patients from three different hospitals in various regions of the area. This is important because there are more nurses used in the study instead of just one hospital and one unit.

29. Implications for Practice There are many cultures a patient may come from that may differ from the nurse providing care. It is important to be able to display caring behaviors to these patients even though language and culture may present barriers. One of Jean Watson’s carative factors is to be sensitive to self and others by nurturing individual beliefs and practices. The nurse can practice this by utilizing an interpreter to enhance communication between patient and nurse. The nurse can ask the patient using the interpreter, if there is any cultural or religious practice the healthcare team should be aware of regarding care. If the patient knows the nurse cares from the very beginning, this assists in developing a helping, trusting and caring relationship which is also a carative factor.

30. Reflections It is important to integrate theory and research into nursing practice, but theory requires evidence through research in order to be applicable in the clinical setting. In this article, patients evaluated how important Jean Watson’s caring behaviors were and according to the results, they were very important to the patient. This helps the nurse to provide better care to the patient, by understanding the patient values.

31. Minimizing Preoperative Anxiety with Alternative Caring-Healing Therapies

32. Recognizing that preoperative anxiety is a common and distressing problem for most surgical patients, incorporating skilled holistic nursing interventions can be humane acts of caring for the surgical patient” (Norred, 2000, p. 842).

33. Minimizing Preoperative Anxiety Dr. Watson believes that through intentional, compassionate, caring, therapeutic use of self, the holistic perioperative nurse can assist the patient in healing. Examples of benefits of holistic caring-healing therapies are: 1. Decreased Anxiety 2. Less pre-op sedation 3. Less post-op pain medication 4. Reduced stress

34. Research A controlled study of 60 patients undergoing plastic surgery Use of local anesthesia with sedation Hypnosis , nurse’s calming words, and comforting techniques used to reduce patients discomfort and anxiety. Results Patients under hypnosis used less anti-anxiety medication and narcotics; they were less painful and anxious compared to the patients who received no therapy (Norred, 2000).

35. How Watson’s Theory framed this research Watson states that there is “a new paradigm emerging in health care that blends the compassion and caring of nursing in harmony with the curative therapies of medicine” (Norred, 2000, p. 838). In a qualitative analysis of the preoperative concerns of surgical patients, the need for caring was second to the fear of dying (Norred, 2000). It is believed with the integration of alternative therapies in the OR, they can assist the surgical patient to balance their anxiety, stress, and pain (Norred, 2000).

36. Implication for Nursing Practice Develop a therapeutic, trusting relationship with every patient Use more relaxation techniques with patients Spend more time with patients to demonstrate Watson’s caring, holistic therapies

37. Critique and Reflection Limitations This study did not observe a larger patient population. More research and case studies are needed in order to prove the decrease in pain and anxiety is directly related to Watson’s caring theory. Possibilities To explore new ways to improve patient care and satisfaction. To improve the safety of our patients by using less medication before, during, and after surgery.

38. The Attending Nurse Caring Model

39. The Attending Nurse Caring Model Integrates theory, evidence and advanced caring-healing therapeutics for transforming professional practice. Provides examples for advancing and transforming nursing practice within a reflective, theoretical and evidence-based context. (Watson & Foster 2003)

40. Background Due to the fast paced healthcare delivery system, “nurses are torn between the human caring model of nursing”. (Watson & Foster 2003, p. 360) For many nurses, this is what attracted them to the profession. (Watson & Foster 2003) Nurses who are not able to practice within this caring context are reported to be: hardened, oblivious, robot-like, frightened and worn down. (Swanson, 1999). Nursing will need to be reconnected with the foundations of nursing, requiring a renewal of the profession in order for a resolution to the conflict.

41. Research A pilot project has been developed where nurses will: Volunteer to apply and participate in applying the Attending Nurse Caring Model as described previously. Be introduced to a series of educational sessions of caring theory. This includes the ten Carative Factors (Watson, 1979) to understand the structure of the caring process. Initiate the search for evidence by defining clinical problems regarding pain management. (Watson & Foster 2003)

42. This pilot project is: Underway at The Children’s Hospital in Denver, Colorado. Being held on one post-surgical unit consisting of thirty-seven beds. Constructed and will be applied as a Nursing-Caring Science, theory-guided, evidence-based, collaborative practice model. (Watson & Foster 2003)

43. Findings: Nurses participating in the project are learning the Attending Nurse Caring Model: Can increase their caring consciousness. Intentionally use knowledge and evidence Help increase autonomy Enhance interdisciplinary teamwork Reduce suffering in children (Watson & Foster 2003)

44. Implications The Attending Nurse Caring Model evaluates: Contemporary nursing caring values Relationships Therapeutics Responsibilities to a higher/deeper order of caring science and professionalism (Watson & Foster 2003)

45. Application to Practice Nurses are using caring-healing modalities and nursing therapeutics for: Comfort measures Pain control Creating a sense of well-being Relaxation These modalities are used to work in correlation with physician’s orders for analgesics. (Watson & Foster 2003)

46. Critical Reflection The Attending Nurse Caring Model Offers: New options to address disagreements between nursing theory and practice; between nursing caring philosophy, between knowledge, values and system constraints. Hope for both nurses and systems in place to make transformations, while continuing to work within contemporary crises, current systems, today’s society, and current healthcare. (Watson & Foster 2003)

47. References Alligood, M.A., & Tomey, A. M. (2010). Nursing theorists and their work. (7th ed.). Maryland Heights, MO.: Mosby Elsevier. Glickstein, L. (1995). Unpublished raw data. Berkeley, CA: Center for Transformational Speaking. Medscape Nurses. (2005, September 30). Caring science and the caritas field: Lighting our path. Retrieved from http://www.medscape.com/viewarticle/513614 Norred, C. L. (2000). Minimizing preoperative anxiety with alternative caring-healing therapies. AORN Journal, 72(5), 838-844. Persky, G. J., Nelson, J. W., & Watson, J. (2008). Creating a profile of a nurse effective in caring. Nursing Administration Quarterly, 32(1), 15-20. doi:10.1097/01

48. References Strickland, D. (1996). Applying Watson’s theory for caring among elders. Journal of Gerontological Nursing 22(7), 6-11. Suliman, W.A., Welmann, E., Omer, T., & Thomas, L. (2009). Applying Watson’s nursing theory to assess patient perceptions of being cared for in a multicultural environment. The journal of nursing research: JNR., 17(4), 293-297. Swanson, K. (1999). What is known about caring in nursing science. In Handbook of Clinical Research (Hinshaw A.S., Feetham S.L., & Shaver J.L.F., eds). Sage, Thousand Oak, CA, USA, 31-60.

49. References Watson, J. (1985). Nursing: Human science and human care. A theory of nursing. Norwalk, CT: Appleton-Century-Crofts. Watson, J. (1994). Applying the art and science of human caring. New York, NY: National League for Nursing.