Watson’s Theory of Transpersonal Caring applied to BSN students

1. Watson’s Theory of Transpersonal Caring applied to BSN students Seton Hall University Emerging Nursing Theory NUR 8101 Dr. Marie Foley, PhD, RN, CSN-NJ Jeannie Couper, MSN, RN-BC November 17, 2011

2. Theory of Transpersonal Caring (WTTC) (1979) • Caring for the purpose of: • Promoting healing • Preserving dignity • Respecting the wholeness • Nursing is healing art and science dedicated to the pursuit of harmonious and sacred relationships • Challenges nursing: • To rediscover its healing traditions • Expanding its mission for caring relationships

3. Based on Nightingale's concepts • Transform the professional • Used by schools and hospitals- return the human element back into study and the practice of nursing • Advocates for liberal art education • Emphasis on philosophy and values • Watson’s intent was not to be prescriptive but a paradigm • Biomedical/natural science model ->postmodern/human science perspective • Distinct from medicine with emphasis on disease and curing

4. Human Science Paradigm • Concerned predominantly with the meaning of the lived experience • Key elements of knowledge formation: • human environment • personal-life spirit or the human-to-human interaction • Multiple ways of knowing • Emphasis on “being” and cocreation of RN- pt interactions

5. “Ever evolving theory” • Employs language to reflect on own life journey and beliefs • 10 “carative factors” → “clinical caritas processes” • ↑ emphasis on metaphysical and spiritual dimensions (love) • “Love as an ethic” as the basis for caring-healing practices adapted from Pearson Publication

6. Major conceptual elements • Original theory included: • transpersonal caring relationship • 10 carative factors • Caring occasion/moment • Current dimensions which evolved/ emerged from theory: • Transpersonal mind/body/spirit oneness • Importance of caring-healing consciousness • Consciousness as energy • Phenomenal field / unitary consciousness • Advanced caring-healing modalities/ nursing arts • Ultimate form of healing and transcendence is love • Nurse as sacred healing environment

7. Nursing as Profession and Praxis • Caring in Nursing: • Reciprocal relationship btw nurse and “others • Nurse is the co-participant with patient (the change agent) • Coparticipants in a pattern of subjectivity-inter subjectivity • “Consciousness • Intentionality • Perceptions and lived experiences R/T caring, healing, and health-illness conditions given in a ‘caring moment’. • Experiences or meanings that transcend the moment and beyond the actual experience” (Watson, 1996, p. 146). • Care is never separated from the context of the unity of mind-body-spirit-nature • Profession exists in order to sustain caring, healing, and health

8. Nursing interventions, “human care processes” • Goals defined by Watson (1985/1988) • R/T mental spiritual growth for self and others • Finding meaning in one’s own existence & experiences • Discovering inner power & control • Potentiating instances of transcendence & self-healing • Nurse intervenes through “a way of being” & “presence” • Require a wide scope of knowledge • Presuppose a knowledge base and clinical competence • Require intent, a will, a relationship, & actions. • “heart-centered awareness & loving/caring consciousness”

9. Nursing student caring behaviors during blood pressure measurement Minnesota Baccalaureate Psychomotor Skills Faculty Group (MBPSFG) Journal of Nursing Education, 2008, 47(3) Study partially funded by Kappa Phi Chapter of STTI and 6 participating nursing programs

10. Nursing student caring behaviors during blood pressure measurement • Multi-site (6), non-experimental, descriptive study • Organizing framework: Watson’s Theory of Transpersonal Caring and a combination of cognitive and connectionist learning theories • teaching strategy included: • required reading: Caring made visible, Swanson, 1998 • Video tape analysis • Feedback • BP measurement taught in nursing perspective based on Watson’s theory of caring in the human health experience

11. Watson’s (1988) Theory of Transpersonal Caring caring “operationalized” • Watson’s definition of caring: A moral commitment to protect human dignity & preserve humanity Morse, Solberg, Neander, Bottoff, and Johnson (1990) • Caring conceptualized by Morse et al. 1990 A human trait, a moral imperative, an affect, an interpersonal relationship, and a therapeutic intervention (MBPSFG,2008, p. 100) Moral commitment illuminated in research as interpersonal and therapeutic interactions influencing the pt’s experience and physical response. Involves intentionality

12. Caring in human health experiences • Operationalized caring from the perspective of the nurse and patient (Morse et al, 1990) • Intentionality : basis for teaching, understanding, developing , and adopting caring behaviors

13. Watson’s Theory of Transpersonal Caring “operationalized” (1994) • Focused on five caring dimensions or categories: • Respectful deference to others • Assurance of human presence • Positive connectedness • Professional knowledge and skills • Attentiveness to the other’s experience • Wolf, Giardino, Osborne, & Ambrose (1994)

14. Watson’s (1988)Transpersonal Caring Theory “operationalized” by Wolf et al., 1994 • Watson’s Carative Factors: • 1. Formation of a humanistic-altruistic system of values • 2. The instillation of faith-hope • 5. Promotion and acceptance of the expression of + and - feelings • 7. Promotion of transpersonal teaching-learning • 4. development of a helping-trusting relationship and #5. • five caring dimensions: • Respectful deference to others • Assurance of human presence • Positive connectedness • Professional knowledge and skills • Attentiveness to the other’s experience

15. Research Question: • “Is there a change in objective and subjective caring behaviors demonstrated by baccalaureate nursing students completing blood pressure measurement when these behaviors are taught in nursing psychomotor skill curricula?” Minnesota Baccalaureate Psychomotor Skills Faculty Group, 2008, p.100.

16. The Descriptive Study • Sample: Jr-level nursing students at 6 independent BSN prog • Teaching strategies: • BP measurement served as the forum for integrating caring behaviors • Students viewed demonstration videotape of BP measurement based on the objective tool (Caring Behaviors During BP Measurement instrument ) • Teaching included caring behaviors as an integral component of professional nurses’ role • Student identification of caring and non-caring behaviors

17. The Descriptive Study continued • Evaluation: BSN students videotaped (VT) and evaluated twice 8 weeks apart • VT analysis: reviewed for evidence of caring and non-caring behaviors • In response to analysis: Students discussed thoughts and feelings • Specific instruction was not standardized amongst BSN programs • Both tools created by the researchers

18. #1 Caring Behaviors During BP Measurement instrument • Designed as an objective tool: • 30-item procedure (behavior present; 1= yes; 0= no) • Total score = sum of item procedure scores (max=30) • Content validity established via AHA/NHLB guidelines • Relevant caring behaviors (CB) r/t caring dimensions • Evaluators: faculty as patient-role player

19. #2 Role Player Survey of Caring Behaviors During BP Measurement instrument • 3-item Liker-scale evaluating student caring behaviors • A) respect • B) conveyed warmth and caring • C) conveyed competence • Score; 1= not at all 2= some 3=much • Documented the role players perception of caring during BP • 5 Caring dimensions based on CBI consistent with WTTC • Content validity was established using caring dimensions as described by Wolf, et al. ( 1994)

20. Objective Caring Behaviors During BP Measurement Caring Behavior Caring Dimension 9. Posture reveals relaxed muscle tone B 10. Voice congruent with patient's emotions A, B, C 11. Leans toward patient when talking B 12. Asks patient about comfort during procedure B, E 13. Physical contact is performed with a gentle touch C 14. Seats patient with feet flat on floor, uncrossed legs A, D 15. Uses right arm unless unable to do so D D = professional knowledge and skill; E =attentiveness to the other’s experience (Wolfet al. 1994) Caring Behavior Caring Dimension 1. Washes hands D 2. Cleans equipment D 3. Introduces self A, B 4. Calls patient by preferred name A, B 5. Explains procedure and elicits questions A, B, E 6. Provides privacy A 7. Faces client throughout procedure A 8. Maintains appropriate eye contact A A = Respectful deference to others; B = assurance of human presence; C = positive connectness;

21. Objective Caring Behaviors During BP Measurement cont. Caring Behavior Caring Dimension 16. Gently supports patient's arm at heart level C, D 17. Measures arm for correct cuff size D 18. Centers bladder of cuff over palpated brachial artery D 19. Wraps cuff gently, snugly, 1 inch above antecubital A, D 20. Use palpation or patient's reported blood pressure to estimate systolic D 21. Deflates bladder, waits 15 to 30 seconds A, D 22. Applies stethoscope correctly D A = Respectful deference to others; B = assurance of human presence; C = positive connectness; Caring Behavior Caring Dimension 23. Inflates cuff to 30 mm Hg above estimated systolic A, D 24. Deflates cuff 2 mm Hg/second A, D 25. If mercury, keep centered at eye level D 26. Obtains systolic and diastolic blood pressure D 27. Allows 10 mm Hg before complete deflation D 28. Explains findings to patient A, B, E 29. Completes calmly, confidently A, D 30. Obtains accurate blood pressure D D = professional knowledge and skill; E =attentiveness to the other’s experience (Wolf et al. 1994)

22. Comparison of Scores of Student Caring Behaviors Before and After Role-Playing Subjective data: Score Range Mean Score SD Caring Behavior Conveyed Pretest Posttest Pretest Posttest Pretest Posttest • Genuine respect 1-3 2-3 2.43 2.82 0.53 0.39 • Warmth and caring 1-3 1-3 2.40 2.70 0.58 0.49 • Competence 1-3 1-3 2.25 2.68 0.63 0.50 Minnesota Baccalaureate Psychomotor Skills Faculty Group, 2008, p.102

23. Findings and limitations • ↑ in students’ subjective and objective caring behaviors • Greatest gains in professional knowledge and skill caring dimensions • Little to no gain in respect, presence, & attention to other’s experience caring dimensions • Feedback is required in clinical settings as is facilitating understanding within the nursing disciplinary context • Limitations included • Absence of a control group • Absence of standardized information, approaches to teaching and learning, and varying methods to determine role-player inter-rater reliability

24. Discussion and Evaluation of tool • ↑ in students’ subjective and objective caring behaviors • Greatest gains in professional knowledge and skill caring dimensions • Little to no gain in respect, presence, & attention to other’s experience caring dimensions • Caring dimensions addressed by tool: • A= respectful deference to others 14/30 46.6% • B= assurance of human presence 8/30 26.6% • C= positive connectedness 3/30 10% • D= professional knowledge and skill 18/30 60% • E= attentiveness to the other’s experience 3/30 10%

25. Further research • Additional research required with an experimental design to broaden the understanding of the best practices assist the student in the development of caring behaviors • Further expand the students development of caring behaviors related to all psychomotor interventions

26. Congruency • Although the authors used Wolf et al. operationalized definitions • the study focused more on the skill acquisition • No mention of relationships • Poor • Did not stay focused on theoretical construct as refers to Benner and Watson as well.

27. Contributions to nursing science • Noted by the authors as” a beginning step in identifying and testing educational strategies for promoting psychomotor skill development” (MBPSFG, 2008, p.104) within the human caring and health experience). • The need to incorporate explicit instruction in caring behaviors throughout psychomotor skill development

28. References Fawcett, J. (2005). Contemporary Nursing knowledge: Analysis and evaluation of nursing models and theories, 2nd Ed., Philadelphia: F.A. Davis Company. Jesse, DE. (2010). Watson’s philosophy and theory of transpersonal caring In Nursing theorist and their works, 7th ed. (Eds.). In M.R. Alligood & A. M. Tomey, Nursing theorist and their works, 7thEd, ( pp. 91-112). Johnson, B.P. & Kelley, J.H. (2011). Theory of transpersonal caring: Jean Watson. In Julia B. George (Ed.). Nursing theories: The base for professional nursing practice, 6th Ed. (pp. 454-478). Upper Saddle River, NJ: Pearson. Minnesota Baccalaureate Psychomotor Skills Faculty Group, 2008. Journal of Nursing Education, 47(3), 98-104.