PHILOSOPHY CREDENTIALS AND BACKGROUND OF THE THEORIST Margaret Jean Harman Watson was born in southern West Virginia

and grew up during the 1940s and 1950s in the small town of Welch, West Virginia, in the Appalachian Mountains. As the youngest of eight children, she was surrounded by an extended familycommunity environment. Previous authors: Tracey I. F. Patton, Deborah A. Barnhart, Patricia M. Bennett, Beverly D. Porter, and Rebecca S. Sloan. In addition. Ruth Neil updated the chapter in 1990. The authors wish to thank Dr. Jean Watson for her ongoing inspiration and support, along with her review of the content of this chapter for accuracy and her assistance in updating the references and bibliography. Watson attended high school in West Virginia and then the Lewis Gale School of Nursing in Roanoke, Virginia. After graduation in 1961, she married her husband, Douglas, and moved west to his native state of Colorado. Douglas, whom Watson describes not only as her physical and spiritual partner, but also as her best friend, died in 1998. She has two grown daughters, Jennifer (born in 1963) and Julie (born in 1967), and five grandchildren. She continues to live in Boulder, Colorado. After moving to Colorado, Watson continued her nursing education and, graduate studies at the University of Colorado. She earned a baccalaureate degree in nursing in 1964 at the Boulder campus, a master's degree in psychiatric-mental health nursing in 1966 at the Health Sciences campus, and a doctorate in educational psychology and counseling in 1973 at the Graduate School, Boulder campus. After Watson completed her doctoral degree, she joined the School of Nursing faculty of the University of Colora& Health Sciences Center in Denver, where she has served in both faculty and administrative positions. She has served as chairperson and assistant dean of the undergraduate program, and she was involved in early planning and implementation of the nursing Ph.D. program in Colorado, which was initiated in 1978. She .was .coordinator and director of the Ph.D. program between 1978 and 1981. In 1981 and 1982, she pursued international sabbatical studies and diverse learning experiences in New Zealand, Australia, India, Thailand, and Taiwan. Upon her return, she was appointed dean of the

University of Colorado School of Nursing and Associate Director, Nursing Practice at University Hospital from 1983 to 1990. She is currently a Distinguished Professor of Nursing and holds the Murchinson-Scoville Endowed Chair in Caring Science at the University of Colorado School of Nursing. She continues to offer her basic theory courses as part of the International Certificate Program in Caring-Healing, which can be taken for credit twice a year. Information about these courses and other selected in-resident studies with Dr. Watson can be obtained by contacting her at the Web site http://....ww2.uchsc.edu/son/ caring/content During her deanship, she was instrumental in the development of a postbaccalaureate nursing curriculum in human caring, health, and healing, which leads to a career professional clinical doctoral degree (ND). This pilot ND program was selected as a national demonstration program by the Helene Fuld Health Trust in New YOrk and was funded by the Trust and Colorado Clinical health care agencies. The program was implemented in 1990 as a partnership betWeen miring education and practice, whereby Clinical andacadernicagendms in Colorado and beyond work jointly to restructure simultaneouslt nursing eduation and nursing Oractice for the future. The Center for Hnman Caring was established in the 1980s by Watson and colleaguei at the University of Colorado; it was the nation's first interdisciplinary center with an overall commitment to develop and use knowledge of human caring and healing as the moral and scientific basis of clinical practice and nursing scholarship and as the foundation for efforts to transform the current health care system (Watson, 1986). During its existence, the center developed and sponsored numerous clinical, educational, and community scholarship activities and projects in human caring, including participation. of ..natiorial and international scholars in residence. During her career, Watson has been active in community programs, having served as an earlier founder and member of the Board of Boulder County Hospice, and she has initiated numerous collaborations with area health care facilities. The recipient of several research and advanced education federal grants and awards, Watson has also received numerous university and private grants and extramural funding for her faculty and administrative projects and scholarships in human caring. Other honors include honorary doctoral degrees from at least six universities in the United States and abroad including Assumption College in Worcester, Massachusetts, the University of

Akron, Ohio, the Univeisity of West Virginia, Goteborg University in Sweden, Luton University in London, and the University of Montreal in Quebec, Canada. Watson also received the high honor of Distinguished Professor of Nursing at the University of Colorado in 1992. In 1993, she was the recipient of the National League for Nursing (NLN) Martha E. Rogers Award, which recognizes a nurse scholar who has made significant contributions to nursing knowledge that advance the science of caring in nursing and health sciences. Between 1993 and 1996, Watson served as a member of the Executive Committee, the Governing Board, and as an officer for the NLN. She was president from 1995 to 1996. In 1997, she was given an honorary lifetime certification as a holistic nurse. In 1998, she was recognized as a Distinguished Nurse Scholar by New York University and in 1999, she was honored with the national Norman Cousins Award by the Fetzer Institute in recognition of her commitment to developing, maintaining, and practices (Watson, personal communication, August 14,, 2000). Watson's national and international work includes distinguished lectureships throughout the United States at well-known universities including Boston College, Catholic University, Ade1phi University, Columbia University Teachers College, State University of New York, and at universities and scholarly meetings in numerous foreign countries induding Canada, England, Finland, Sweden, Germany, Australia, Nova Scotia, Micronesia, Portugal, Scotland, Korea, Israel, Japan, Spain, New Zealand, Thailand, Taiwan, Denmark, Braiil, and Venezuela. Her international activities also include an International Kellogg Fellowship in Australia (1982), a Fulbright Research and Lecture Award to Sweden and other parts of Scandinavia (1991), and a lecture tour in the United Kingdom (1993). She has also been involved in international projects and received invitations in New Zealand, India, Thailand, Taiwan, Israel, Japan, Venezuela, Korea, and others. Watson is featured in several nationally distributed videotapes on nursing theory. These include "Circles of Knowledge" and "Conversations on Caring with Jean Watson and Janet Quinn" from the NLN, "Portraits of Excellence: Nursing Theorists and Their Work" from the Helene Fuld Health Trust, and "Theory in Practice" from the NLN. The
exe mplifying

relationship-centered care

latter features the Denver Nursing Project in Human Caring, a nurse-directed caring center for persons with acquired immunodeficiency syndrome (AIDS) (Watson, personal correspondence, August 14, 2000). The. Denver Nursing Project in Human Caring was a clinical (caring-theory based) demonstration project of the University of Colorado Center for Human Caring and School of Nursing and served patients from 1988 to 1996. More recent media productions include the gLN-produced videotape, "Applying the Art and Science of Human Caring, Parts I and II"; "A Meta..eflection on Nursing's Present," an audiotape proiuced by the American Holistic Nurses Association; tad "Private Psalm: A Mantra and Meditation for {ealing," a compact disc set (See the complete listing of audiovisual productions at the end of this 4.1.41AQ& 4D,d 412& Wk.) Watson's publications reflect the evolution of her theory of caring. Her writings have been geared toward educating nursing students and providing them with the ontological, ethical, and epistemological basis for their praxis and research directions. Much of her current work began with the 1979 publication that was reprinted in 1985 and has been translated into Korean and French, Nursing: The Philosophy and Science of Caring, which she says began as class notes for a course she was developing. She says the book "emerged from her quest to bring new meaning and dignity to the world of nursing and patient carecare that seemed too limited in its scope at the time, largely defined by medicine's paradigm and traditional biomedical science models" (Watson, 1997, p. 49). Nursing: Human Science and Human CareA Theory of Nursing, published in 1985 and reprinted in 1988 and 1999, was her second major work. The purpose of this book was to address some of the conceptual and philosophical problems that still existed in nursing. She hoped that others would join her as she sought to "elucidate the human. care process in nursing, preserve the concept of the person in our science, and better our contribution to society" (Watson, 1988, p. ix). This book has been translated into Chinese, German, Japanese, Korean, Swedish, Norwegian, Danish, and probably, by now, other languages (Watson, personal communication,, August 14, 2000). Postmodern Nursing and Beyond was published in 1999 and is Watson's most recent work. This work projects nursing and health care into the midtwenty-first. century. It seeks to illuminate ... a model of caring and healing practices that take medicine, nursing, and

the public beyond traditional Western medicine, beyond the 'Cure at all" costs' approach" (Watson, 1999, p. xii) and embeds caring and healing practices in a new paradigm that acknowledges the symbiotic relationship between humankind-technology-nature and the larger, expanding universe. "It offers a search for the spiritual aspects of our being and our approaches to health and healing" (Watson, 1999, p. xiv). In the dedication section of Postmodern Nursing and Beyond (Watson, 1999), which has been translated into Portuguese and Japanese, Watson described recent traumatic personal experiences that contributed to her insights as expressed in the book. One of these was an accidental injury in 1997 that resulted in the loss of her left eye despite many months of trying to save it. The other was her husband's death in 1998. Watson states that she is now "attempting to integrate these wounds into my life and work. One of thezifts through the suffering was the privilege of experiencing and receiving my own theory through the care from my husband and loving nurse friends and colleagues" (Watson, personal communication, August 31, 2000). In Watson's (1979) original Nursing: The Philosophy and Science of Caring, she referred to caring as "central to nursing" (p_ 9).. Caring 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_ One of her earliest written treatises on the caring model was presented at an American Nurses Association Division of Practice Meeting in 1979 (Watson, Burckhardt, Brown, Block, & Hester, 1979). As her work evolved, Watson posited that caring is intrinsically related to healing: "Such an ethic and ethos of caring, healing, and health comprises nursing's professional context and missionits raison d'erre to society" (Watson, 1997, p. 50). THEORETICAL SOURCES In addition to traditional nursing knowledge and the works of Nightingale and Henderson, Watson acknowledges the work of Leininger, Gadow, and Peplau as background for hers (Watson, 1985a, 1997). In her more recent work, Watson refers to that of others such as Maslow, Heidegger, Erickson, Selye, Lazarus, Whitehead, de Chardin, and Sartre. In addition, she acknowledges philosophiCal and intellectual guidance from feminist theory, quantum physics, wisdom traditions, and perennial philosophy (Watson, 1995, 1997, 1999). To develop her framework, Watson drew heavily on the sciences and the humanities, providing a

phenomenological, existential, and spiritual orientation. Watson explains that the concepts she defined to bring new meaning to nursing's paradigm were "derived from dinically inducted, empirical experiences, combined with my philosophical, intellectual and experiential background; thus my early work emerged from my own values, beliefs, and perceptions about personhood, life, health, and he a li n g . . . " (Wa t s on , 1 9 97, . p . 4 9. ). Watson attributes her emphasis on the interpersonal and transpersonal qualities of congruence, empathy, and warmth to the views of Carl Rogers and more recent writers of transpersonal psychology. Rogers described several incidents that led to the formulation of his thoughts on human behavior. One of these involved learning that "it is the client who knows what hurts and that the facilitator should allow the direction of the therapeutic process to come from the client" (Rogers, 1961, pp. 11-12). Rogers believed that "through understanding" the patient would come to accept himself, an initial step toward a positive outcome (Rogers, 1961, pp. 18-19). The therapist, motivated by a warm interest in the patient, helps by darifying and stating feelings about which the patient has been unclear: Together, the therapist and the patient understand the meaning of the patient's experience. Another crucial concept of Rogerian theory is that the therapist-patient relationship is more important to the outcome than adherence to traditional methods_ Rogers-states: In my early professional years I was asking the question, "How can I treat, or cure, or change this person?" Now I phrase the question in this Way: "How can I provide a relationship which this person may use for his own personal growth?" (Rogers, 1961, p. 33) (For additional information about Rogers, see Betz and Whitehom [1956] and Seeman [1954]). Watson points out that Rogers' phenomenological approach, with his view that nurses are not here to manipulate and control others, but rather to understand, was profoundly influential at a time when "clinicalization" (therapeutic control and manipulation of the patient) was considered the norm (Watson, personal communication, August 31, 2000). Watson believes a strong liberal arts background is also essential to the process of holistic care for patients. She believes the study of the humanities expands the mind and increases thinking skills and personal growth. Watson compares the current status of nursing with the mythological Danaides, who attempted to fill a broken jar with water, only to see water flow through the cracks. Until nursing merges theory and practice

through the combined study of the sciences and the humanities, she believes similar cracks will be evident in the scientific basis of nursing knowledge (Watson, 1981, 1997) Yalom's 11 curative factors stimulated Watson's thinking about the psychodynamic and human components that could apply to nursing and caring and, consequently, to her 10 carative factors in nursing (Watson, 1979). Although Watson still says the 10 carative factors continue to embrace the core of nursing, she is emerging toward more fluid and evolutionary language: caritas, making explicit connections between caring and love (Watson, personal correspondence, 2004). Watson's work has been called a treatise, a conceptual model, a framework, and a theory. This chapter uses the terms theory and framework interchangeably. In addition, Watson states that, both retrospectively and prospectively, her work "can be read as philosophy, ethic, or even paradigm or worldview" (Watson, 1997, p. 50).

MAJOR CONCEPTS DEFINITIONS Watson bases her theory for nursing practice on the following 10 carative factors. Each has a dynamic phenomenological component that is relative to the individuals involved in the relationship as encompassed by nursing. The first three interdependent factors serve as the "philosophical foundation for the science of caring" (Watson, 1 979, pp. 9-10). As Watson's ideas and values have evolved, she translated the 10 carative factors into caritas processes. In caritas processes, there is a decidedly spiritual dimension and overt evocation of love and caring (http://www2.uchscedu/son/ caring/content/wetasp). (See Table 7-1 (p. 104) for the original carative factors and the caritas process interpretation.) I- FORMATION OF A HUMANISTIC/kLTRUISTIC SYSTEM OF VALUES humanistic and altruistic values are learned early int life but can be influenced greatly by nurse educators. This factor can be defined as satisfaction through giving and extension of the sense of self (Watson, 1979).

2.

INSTILLATION OF FAITH-HOPE. This factor, incorporating humanistic and altruis-

tic values, facilitates the promotion of holistic nursing care and positive health within the patient population. It also describes the nurse's role in developing effective nurse-patient interrelation-. ships and in promoting wellness by helping the patient adopt healthseeking behaviors (Watson, 1979).
3.

CULTIVATION OF SENSITIVITY TO SELF AND TO OTHERS

The recognition of feelings leads to self-actualization through self-acceptance for, both the nurse and the patient. As nurses acknowledge their sensitivity and feelings, they become more genuine, authentic, and sensitive to others (Watson, 1979).
4.

DEVELOPMENT OF A HELPING-TRUST RELATIONSHIP The development of a helping-trust relationship

between the nurse and patient is crucial for trans-personal caring. A trusting relationship promotes and accepts 'the expression of both positive and negative feelings. It involves congruence, empathy, nonpossessive warmth, and effective communication. Congruence involves being real, honest, genuine, and authentic. Empathy is the ability to experience and, thereby, understand the other .. person's .perceptions and feelings and to communicate those understandings. Nonpossessive warmth is demonstrated by a moderate speaking volume, a relaxed, open posture, and facial expressions that are congruent with other communications. Effective communication has cognitive, affective, and behavior response components (Watson, 1979). S. PROMOTION AND ACCEPTANCE OF THE EXPRESSION OF POSITIVE AND NEGATIVE FEELINGS The sharing of feelings is a risk-taking experience for both nurse and patient. The nurse must be prepared for either positive or negative feelings. The nurse must recognize that intellectual and embtional understandings of a situation differ (Watson, 1979). 6.. SYSTEMATIC USE OF THE SCIENTIFIC PROBLEM-SOLVING METHOD FOR DECISION MAKING Use of the nursing process brings a scientific problem-solving approach to nursing care, dispelling the traditional image of a nurse as the doctor's haridthaiden. The nursing process is similar to the research proCess'in that iris systematic and organized (Watson, 1979).

7. PROMOTION, OF INTERPERSONAL TEACHING-LEARNING This factor is an important concept for nursing in that' it caring from curing. It allows the patient to be informed and shifts the responsibility for wellness and health to the patient. The nurse facilitates this process with teaching-learning techniques that are designed to enable patients to provide self-care, determine personal needs, and provide opportunities for their personal growth (Watson, 1979). PROVISION FOR SUPPORTIVE, PROTECTIVE, AND CORRECTIVE MENTAL, P I4YS CAL, SOCIOCULTURAL, AND SPIRITUAL ENVIRONMENT Nurses must recognize the influence that internal and external environments have on the health and illness of individuals. Concepts relevant to the internal environment include the mental and spiritual well-being and sociocultural beliefs of an individual. In addition to epidemiological variables, other external variables include comfort, privacy, safety, and clean, aesthetic surroundings (Watson, 1979).
8.

ASSISTANCE WITH GRATIFICATION OF HUMAN NEEDS

The nurse recognizes the biophysical, psychophysical, psychosocial, and intrapersonal needs of self and patient. Patients must satisfy lower-order needs before attempting to attain higher-Aarder needs. Food, elimination, and ventilation are examples of lower-order biophySical needs, whereas activity, inactivity, and sexuality are considered lower-order psychophysical needs. Achievement and affiliation are higher-order psychosocial needs. Self-actualization is a higher-order intrapersonalinterpersonal need (Watson, 1979).
9.

ALLOWANCE FOR EXISTENTIAL-PHENOMENOLOGICAL FORCES

Phenomenology describes data 'of the immediate situation that help people understand' the phenomena in question. Extste441 PsYchology is a. science of human existence that uses phenomenological analysis. Watson considers this factor difficult to understand. It is included to provide a thought-provoking experience leading to a better understanding of the self and others. Watson believes that nurses have the responsibility to go beyond the 10 carative factors and to facilitate patients' development in the area of health promotion through preventive health actions. This goal is accomplished by

teaching patients personal changes to promote health, providing situational support, teaching problem-solving methods, and recognizing coping skills and adaptation to loss (Watson, 1979). USE OF EMPIRICAL EVIDENCE Watson and her colleagues have attempted to study the concept of caring by collecting data to use in classifying caring behaviors, to describe the similarities and differences between what nurses consider care and what patients consider care, and to generate testable hypotheses around the concept of nursing care. They studied responses from registered nurses, nursing students, and patients to the same open-ended questionnaire covering a variety of aspects of (1) taking care of and (2) caring about patients. Their findings revealed a discrepancy in the values considered most important by patients, nursing students, and registered nurses. They stressed the need for further study to clarify what behaviors and values are important from each viewpoint. The study also raised a question about differences in values for persons in various situations and the question of meeting minimum care needs before the quality of care can be evaluated (Watson, 1981). Watson's research into caring incorporates empiricism, but it emphasizes methodologies that begin with nursing phenomena rather than the natural sciences (Leininger, 1979). She has used human science, empirical phenomenology, and transcendent phenomenology in her work. She has also investigated new language, such as metaphor and poetry, to communicate, convey, and elucidate hutnan caring and healing (Watson, 1987). In her inquiry and writing, she increasingly incorporates her conviction that there is a sacred relationship between humankind and the universe (Watson, 1997). Instruments for Assessing and Measuring Caring in Nursing and Health Sciences was published in 2002 to facilitate the collection of evidence and received the American Journal of Nursing Book of the Year Award. MAJOR ASSUMPTIONS In her first book, Nursing: The Philosophy and Science of Caring (1979), Watson states the major assumptions of the science of caring in nursing as follows: I. Caring can only be effectively demonstrated and practiced interpersonally.

2. Caring

consists of carative factors that result in the satisfaction of certain human caring promotes health and individual or family growth.

needs.
3. Effective 4. Caring

responses accept a person not only as he or she is now but as what he or she may

become.
5. A

caring environment, offers the development of potential while allowing the person to

choose the best action for himself or herself at a given time

6. Caring

is more l'healthogenic" than is curing. The practice of caring integrates. biophysical

knowledge with knowledge of human behavior to generate or promote health and to provide ministrations to those who are ill. A science of caring is therefore 'complementary to the science of curing.
7. The practice of caring is central to nuising. (Watson, 1979, pp. 8-9).

- Gaut identified three conditions necessary for caring. These include . "(I) an awareness. and knowledge about one's need for care; (2) an intention to act, and actions based on knowledge; (3) a positive change as a result of caring, judged solely on the basis of welfare of others" (Gaut, 1983, pp. 313-324). Watson expanded Gaut's work by adding two additional conditions, "an underlying value and moral commitment to care; and a will to care" (Watson, personal communication, August 3, 1997). In her second book, Nursing: Human Science and Human Care A Theory of Nursing, Watson states, "both nursing education and the healthcare delivery system must be based on human values and concern for the welfare of others" (Watson, 1985a, p..33). To further define the social and ethical responsibilities of nursing and to explicate the human care concepts in nursing, Watson proposes the following I I assumptions related to human care values:
1.
2.

Care and love comprise the primal and universal psychic energy. Care and love, often overlooked, are the cornerstones of humanness; nourishment of these needs fulfills humanity. The ability to sustain the caring ideal and ideology in practice will affect the development of civilization and determine nursing's contribution to society. Caring for the self is a prerequisite to caring for others.

3.

4.

5.

Historically, nursing has held a human care and caring stance in regard to people with healthillness concerns. Caring is the central unifying focus of nursing practicenthe essence of nursing. Caring, at the huMan level, has been increas-

6.

7.,

ingly deemphasized in the health care system.

8.

Technological advancements and institutional constraints have sublimated nursing's caring foundation. A significant issue for nursing today and in the future.is the preservation and advancement of human care. Only through interpersonal relationships can human care be effectively demonstrated and practiced. Nursing's social, moral, and sdentific contributions to humankind and society lie in its commitments to human care ideals in theory, practice, and research (Watson, 1988).

9.

10.

11.

(1999) seeks to describe a more fundamental ontological shift in human consciousness that evokes a return to the sacred core of humankind and its relation with the universe, connecting with a sense of the divine and inviting awe and mystery back into life and work. Such thinking holds a sense of reverence and openness for the infinite possibilities contained within an individual's inner and outer space. It offers a search for the spiritual aspects of being and approaches.to .health_andlealing:. . This ontological shift invites practitioners to embark upon the following paths:

Path of awareness, of awakening to the sacred feminine archetype-cosmology to rebalance the disorder of conventional modern medicine and the modern, cultural mindset. Path of cultivation of higher/deeper self and a higher consciousness: transpersonal self. Path of honoring the sacred within and without; open to deeper explorations of the mystery of the human body and life-healing processes: postmodern-transpersonal body. Path of acknowledging the metaphysical-spiritual level, attending to the nonphysical, spiritual dimensions of existence. Path of acknowledging quantum concepts and phenomena such as caring-healing energy, intentionality and consciousness, as paths toward expanding human existence and the evolving

human consciousness.

Path of honoring the connectedness of all; unitary consciousness; the eternal 'caring moment"; 'transpersonal caring-healing". Path of honoring the unity of mindbodyspirit; both immanence and transcendence of the human being and becoming. Path of reintegrating the caring-healing arts, as an artistry of being into healing practices: ontological competencies. Path of creating healing space: healing architecture. Path of a relational ontology, open to new epistemologies of existence.

Path of movingbeyond the modem-postmodern into the open, transpersonal space and the new thinking required for the next millennium (Watson, 1999, p. xv) THEORETICAL ASSERTIONS According to Watson, nurses are interested in understanding health, illness, and the human experience. Within the philosophy and science of caring, she tries to define an outcome of scientific activity with regard to the humanistic aspects of life. She attempts to make nursing an interrelationship of quality of life, including death, and the prolongation of life (Watson, 1979). Watson believes nursing is concerned with health-promotion, restoration, and illness prevention. Health, more than the absence of illness, is an elusive concept because it has a subjective nature (Watson, 1979). Health refers to "unity and harmony within the mind, body, and soul" and is associated with the "degree of congruence between the self as perceived and the self as experienced" (Watson, 1988, p. 48). According to Watson, caring is a nursing term representing the factors nurses use to deliver health care to patients. She states that by responding to others as unique individuals, the caring person perceives the feelings of the other and recognizes the uniqueness of the other (Watson, 1985a). Using the 10 carative factors, the nurse provides care to various patients. Each carative factor describes the caring process of how a patient attains, or maintains, health or dies a peaceful death. Conversely, Watson describes curing as a medical term referring to the elimination of disease (Watson, 1979). In her initial work, Nursing: The Philosophy and

Science of Caring, Watson (1979) describes the following basic premises of a science for nursing:
1.

Caring (and nursing) has existed in every society. Every society has had some people who have cared for others. A caring attitude is transmitted by the culture of the profession as a unique way of coping with its environment. The opportunities for nurses to obtain advanced education and engage in higher-level analyses of problems and concerns in their education and practice have allowed nursing to combine its humanistic orientation with the relevant science. There is often a discrepancy between theory and p ractice or between the scientific and artistic aspects of caring, partly because of the disjunction between scientific values and humanistic values. Expanding on her previous work, Watson (1985a) added the following components for

the context of human science theory development:

1. 2.

A philosophy of human freedom, choice, and responsibility A biology and psychology of holism (nonreducible persons interconnected with others and nature) An epistemology that allows not only for empirics but also for advancement of esthetics, ethical values, intuition, and process discovery An ontology of time and space A context of interhuman events, processes, and relationships' A scientific world view that is open As Watson's work evolved, she continued to focus more on the human care process and the

3.

4. 5. 6.

transpersonal aspects of caring-healing. The basic premises Watson stated in Nursing: Human Science and Human CareA Theory of Nursing are a reflection of the interpersonal-transpersonal-spiritual aspects of her work (Watson, 1985a). These aspects represent an integration of her beliefs and values about human life and provide the foundation for further development of her theory, as follows: i. A person's mind and emotions are windo'ss to the soul ...
2.

A person's body is confined in time and space, but the mind and soul are not confined M the physical universe ... A nurse may have access to a person's mind, emotions, and inner self indirectly through any

3.

spheremind, body or soulprovided. the physical body is not perceived or treated as separate from the mind and emotions and higher sense of self (sod])
4. 5.

The spirit, inner self, or.soul (geist) of a person exists in and for itself ... People need each other in a caring, loving way... To find solutions, it is necessary to find meanings ...

6.

The totality of experience at any given moment . constitutes a. phenomenal field ... (Watson, 1985a, pp. 50-51). Watson's evolving work continues to make it explicit that humans cannot be treated as objects and humans cannot be separated from self, other, nature, and the larger universe. The caring-healing paradigm is located within cosmology that is both metaphysical and transcendent with the co-evolving human in the universe. The context calls for a sense of reverence and sacredness with regard to life and all living things. It incorporates both art and science, as they are also being redefined, acknowledging a convergence between the two -(Watson, 1997). LOGICAL FORM The framework is presented in a logical form. It contains broad ideas and addresses many situations on the health-illness continuum. Watson's definition of caring as opposed to curing delineates nursing from medicine. This concept is helpful in classifying the body of nursing knowledge as a separate science. Since 1979 the development of the theory has been toward clarifying the person of the nurse and the person of the patient. Another emphasis has been on existentialphenomenological and spiritual factors. Watson's theory has foundational support from theorists in other disciplines, such as Rogers, Erikson, and Maslow. She is adamant in her support for nursing education that incorpOrates holistic - knowledge from many disciplines and integrates the humanities, arts, and sciences. She believes the increasingly complex requirements of the health care system and patient needs require nurses to have a broad, liberal education. The ideals, content, and theory of liberal education must be integrated into professional nursing education (Sakalys & Watson, 1986). Watson has recently incorporated dimensions of a postmodern paradigm shift throughout

her theory of transpersonal caring. Modern theoretical underpinnings have been associated with concepts such as steady-state maintenance, adaptation, linear interactions, and problem-based nursing practice: The postmodern approach moves beyond this point; the redefining of such a nursing paradigm leads to a more holistic, humanistic, open system wherein harmony, interpretation, and seif-transcendence are the emerging directions reflected in this epistemological shift. Watson (1999.) believes that nursing must be challenged to construct and coconstruct ancient and new knowledge toward an ever-evolving humanity of possibilities to further clarify nursing for a_ new. era, "The .theory evolution has - tended to place-greater emp.hasis on transpersonal_ caring, intentionality, caring consciousness, and the caring field" (Watson, personal communication, August 21, 2000). ACCEPTANCE BY THE NURSING COMMUNITY Practice Institutions that are seeking a holistic approach to nursing care are integrating many aspects of Watson's theoretical commitment to caring. For example, nursing journals concerned With the delivery of nursing care contain increasing numbers of articles that refer to Watson and incorporate the importance of caring as an essential domain of nursing (Brenner, Boyd, Thompson, Cervantez, Buerhaus, & Leininger, 1986). Watson's theory is being validated clinically in a variety of settings and with various populations. With the nursing:shortage, the emergence of magnet hospital initiatives has generated more recent interest, in the use of Watson's caring theory as context and framework for transforming nursing practice from the inside out The clinical settings have included critical care units, neonatal. intensive care units, and. pediatric and gerontological care units (BYrd,:1988; Cronin & Harrison, 1988; Miller, 1987; Ray, 19.87; SithichokeRattan, 1989; Swanson, 1991). (See Watson's Web site [htip://www2uchsc.edu/son/caring/content/j for more information about clinical agencies using this workfor example, Miami Baptist Hospital, Resur rection Health System [Chicago], Denver Veteran's Administration Hospital, and Children's Hospital [Denver], Inova Health System [Virginia], Baptist Central Hospital [Kentucky], Elmhurst Hospital [New York] Pascak Valley Hospital [New Jersey], Sarasota Memorial Hospital and Tampa Memorial Hospital [Florida], and Scripps Memorial Hospital [California], among others.)

The systems and populations have included women who have miscarried, women who have had newborns in intensive care units, and women who have been identified as socially at risk (Swanson, 1990, 1991 & 2000); patients who have had myocardial infarction (Cronin & Harrison, 1988); oncology patients (Larson, 1987); people with acquired immunodeficiency syndrome (Neil, 1990); and the elderly (Clayton, 1989). Montgomery (1993) studied healing through communication. The relationship of caring to nursing administration has also been examined (Miller, 1987; Nyberg, 1989, 1998; Ray, 1987, 1989). In 2002 Watson's book, Instruments for Assessing and Measuring Caring in Nursing and Health Science, was published. The acuity level of hospitalized individuals, the short length of hospital stays, and the increasing complexity of technology have been identified as possibly interfering with the implementation of the caring theory. However, more recently this caring theory focus is considered one of the solutions needed to address health care reform and system reform at a deep, ethical level, enabling nurses to follow their own professional practice model. New initiatives for this model are emerging under Watson's leadership as "Nightingale units," where caring-healing excellence is manifested within current institutions seeking major nursing reform at individual and environmental levels. Education Watson has been active in curriculum planning at the University of Colorado. Her framework has been taught in numerous baccalaureate nursing curricula, including Bellarmine College in Louisville, Kentucky; Assumption College in Worcester, Massachusetts; Indiana State University in Terre Haute; and Florida Atlantic University in Boca Raton. In addition, these concepts are now used widely in nursing programs in Australia, Sweden, Finland, and the United Kingdom. Critics of Watson's work have concentrated on the use of undefined terms, incomplete treatment of subject matter when describing the 10 carative factors, and a lack of attention to the pathophysiological aspect of nursing. Watson (1985a) addresses these aspects in both her first book, Nursing: The Philosophy and Science of Caring (1979, 1988), and the preface of her second book, Nursing: Human Science and Human Care A Theory of 'Nursing (1985), where she defines her intent to describe the core of nursing (those

aspects of the nurse-patient relationship resulting in a therapeutic outcome) rather than the trim of nursing (the procedures, tasks, and techniques used in practice settings). With this focus, the framework is not limited to any nursing specialty. Although she emphasizes that both the core and the trim are necessary, she believes that the trim cannot be the center of a professional model of "nursing qua nursing" (Watson, 1997, p. 50). Watson (1985a) hopes her work will help nurses develop a meaningful moral and philosophical base for practice. A study of Watson's framework leads the reader through a thought-provoking experience by emphasizing deep inner reflection and personal growth, communication skills, use of self-transpersonal growth, attention to both nurse and patient, and the human caring process that potenti:- ates human health and healing. Research Watson and colleagues are attempting to research the caring framework and to arrive at empirical data amenable to research techniques (Hester & Ray, 1987; Morse, Bottorff, Nea,nder, & Solberg, 1991; Morse, Solberg, Neander, Bottorff, & Johnson, 1990; Watson, 1985b; Watson & Lea, 1997). . However, this abstract framework is difficult to study concretely. Watson believes that a chasm often exists between the essential qualities and subject matter of nursing and the methods used for research. As with her concern for uniting the liberal arts with nursing education, she hopes that nursing research will incorporate and explore esthetic, metaphysical, empirical, and contextual methodologies (Leininger, 1979; Watson, 1987). Morse and colleagues (1990, 1991) have analyzed the caring literature for themes related to conceptual and theoretical development. They conclude that the abstractness of the concept and the clinical reality in some situations (e.g., the brief interactions With patients afforded by outpatient-or office visits) has limited the development of a knowledge base in Watson's caring theory, whether caring exists in nursing situations that have yet to develop interpersonally and whether caring is unique to nursing. Patient outcomes in caring transactions need further study. Research and practice must focus on both subjective and objective patient outcomes in determining whether caring is the essence of nursing. The development of behaviors and predictors of change is critical to further development of this work. (See Box 7-1 for

information on the use of caring instruments.) FURTH-LR0EVLOPNIENT 'Early received nursing view research format in traditionally which followed single-factor the method-

ology is compared with rigorous standards of truth, operational definitions, and observational criteria (Seeman, 1954; Watson, 1981). Watson writes about the inadequacy of this methodology for studying the multidimensional phenomena of nursing care. She proposes that as nursing advances in its doctoral programs, the process of scientific development will be used on itself. Nursing research will adopt the received view, reject it, and synthesize new ideas, which will result in a new nursing model for the next century. . Watson has identified some critical issues for future .research conditions that foster the person as an end and not a means in a highly technological society and has also identified conditions that promote caring when humanity is threatened (Watson, 1985a). This theory lends itself to creative research methodologies that assist nursing in formulating a philosophical base for professional human care concepts. CRITIQUE Clarity Watson's theory uses nontechnical, yet sophisticated, language. At times, lengthy phrases (e.g., "symbiotic relationship between humankindtechnology-nature") (Watson, 1999 p, xiv) and sentences need to be read more than once to gain meaning. Her increasing inclusion of metaphor, personal reflections, artwork, and poetry make her complex concepts more tangible and more aesthetically appealing. She continues to refine her theory and has recently revised the original carative factors which she now describes as caritas processes. The word caritas comes from a Greek word meaning "to cherish, to appreciate, to give special attention toeven loving attention to.". Table 7-1 outlines an evolution of Watson's thinking. Simplicity Watson draws on a number of disciplines to formulate her theory. To understand the theory as it is presented, the reader does best by being familiar with broad subject matter. It is viewed as complex when considering the existential-phenomenological

nature of her work, which is partly because many nurses have a limited liberal arts background and baccalaureate nursing curricula have limited integration of liberal arts. Generality The theory seeks to provide a moral and philosophical basis for nursing. The scope of the framework encompasses all aspects of the health-illness continuum. In addition, the theory addresses aspects of preventing illness and experiencing a peaceful death, thereby increasing its generality. The carative factors that Watson described have provided important guidelines (or nurse-patient interactions; however, some critics have stated that the generality is limited by the - emphasis placed on the psychosocial aspects rather than the physiological aspects of caring. Another characteristic of the theory is that it does not furnish explicit directions about what to do to achieve authentic caring-healing relationships. It is more about being than about doing and it must be internalized thoroughly by the nurse .to be actualized in practice. Nurses who want concrete guidelines may not feel secure when trying to rely on this theory alone. Empirical Precision Although the framework is difficult to study empirically, Watson draws heavily on widely accepted work from other disciplines. This solid foundation strengthens her views. Watson describes her theory as descriptive and she acknowledges the evolving nature of the theory and welcomes input by others. The theory does not lend itself to research conducted with traditional scientific methodologies. In her second book, Nursing: Human Science and Human CareA Theory of Nursing, Watson (1985a) addresses the issue of methodology. The methodologies relevant to studying transpersonal caring and developing nursing as a human science and art can be .classified as qualitative, naturalistic, or phenomenologiCal. Watson does acknowledge that a

CARATIYE FACTORS

CARITAS PROCESS

I,

"The of values"

formation

of

a "Practice and of loving-kindness within the

humanistic-altruistic

system

2.

"The instillation of faithhope" "The to others" cultivation of

equanimity

context of caring consciousness" "Being authentically present and enabling and sustaining the deep belief system and subjective lifeworld of self and one being cared for" "CultivatiOn Spiritual the ego self" "Developing and sustaining a helping trusting authentic caring relationship" "Being present to, and supportive of, the expression di positive and negative feelings as a connection with deeper spirit and self and the one-beingcared for" "Creative use of self and all ways of knowing as part of the caring process; to engage in the artistry of caring-healing practices" "Engaging in genuine teachinglearning experience that attends to unity of being and meaning attempting to stay within other's frame of reference" Of One's and owii practices

3.

sensitivity to one's self and "Development of 'a helpingtrust relationship" human became caring "development of a helpingtrusting, Web site)
5.

4.

relation" (in 2004 Watson "The promotion and

transpersonal self going beyond

acceptance of the expression of positiVe ana iregatiVe feelings"

6.

"The systematic use of the scientific problem-solving method for decision making" became "systematic use of a creative caring "The problem-solving process" promotion (in 2004 of

Watson Web site)

7.

transpersonal learning"
8.

teaching-

"The provision of supportive, protective, and (or)

corrective mental, physical, societal "The needs"

10.

"Creating healing environment nonphysical, subtle environment

and assistance of

spiritual at all levels (physical as well as with human for of energy and consciousness, beauty,

environment"
9.

gratification "The

whereby

wholeness,

comfort, dignity and peace are allowance potentiated)" "Assisting with basic needs, with an 'human care essentials', which potentiate alignment of mindbodyspirit, wholeness, and unity of being in all aspects of care" "Opening and attending to and spiritual-mysterious, intentional for caring consciousness, administering

existentialphenomenological forces" became "allowance existentialphenomenologicalspiritual forces" (in 2004 Watson Web site)

existential dimensions of one's own life-death; soul care for self and the one-beingcared for"

combination of qualitative-quantitative inquiry may also be useful. Derivable Consequences Watson's theory continues to provide a useful and important metaphysical orientation for the delivery of nursing care. Watson's theoretical concepts, such as use of self, patient-

identified needs, the caring process, and the spiritual sense of being human, may help nurses and their patients find meaning and harmony in a period of increasing complexity. Watson's rich and varied knowledge of philosophy, the arts, the human sciences, and traditional science and traditions, joined with her prolific ability to communicate, has enabled professionals in many disciplines to share and recognize her work. SUMMARY Jean Watson began developing her theory while assistant dean of the undergraduate program and it evolved in the early planning and implementation of the nursing Ph.D. program at the University of Colorado. Her first book started as class notes that emerged from teaching in an innovative, integrated curriculum. She became coordinator and director of the Ph.D. program when it was initiated in 1978 and served until 1981. While serving as Dean of the University of Colorado School of Nursing, she was instrumental in the development of a postbaccalaureate nursing curriculum in hurnan caring that leads to a career professional clinical doctoral degree (ND) that was implemented in 1990 and has been a national demonstration program. She initiated the Center for Human Caring that was the nation's first interdisciplinary center with a commitment to develop and use knowledge of human caring for practice and scholarship. She worked from Yalom's 1 1 curative factors to formulate her 10 carative factors. She modified the 10 factors slightly over time and developed the caritas processes that have a spiritual dimension and use a more fluid and evolutionary language. She added spiritual aspects. She believes that the core of nursing is those nurse-patient relationships that result in a therapeutic Putcome. Case Study A young woman has prematurely delivered her second infant. The infant had considerable difficulty and expired shortly after birth. Her husband is with her. Some friends are taking care of their 2-year-old child.The parents of the couple live a great distance away and are working. What caring practices can the nurse implement?