Running head: JEAN WATSON 1

Human Caring Theory

Rachel H. Rose

Bethel College

JEAN WATSON 2

Theory of Human Caring

The Theory of Human Caring is a grand nursing theory (McEwen and Wills, 2014, p.

182). It is an interactive process based explanatory theory. It is descriptive in style and

philosophical, cosmological, and metaphysical in scope (Watson, 2012, p. 46-49). The theory

includes spiritual dimensions (McEwen and Wills, 2014, p. 182) and emphasizes the unique

process of entering an intentional relationship with the person receiving care (Watson, 2006, p.

296).

Jean Watson

Nursing theorist Jean Watson developed the Theory of Human Caring. It has been

refined over time with the first major publication in 1979 and a major revision in 2008 (McEwen

and Wills, 2014, p. 183). Dr. Watson’s formal education includes a Bachelor of Science in

Nursing, Master of Science in Psychiatric-Mental Health, and a Doctorate in Educational

Psychology and Counseling. She is an author and an international speaker. She previously

served as Dean of the School of Nursing at the University of Colorado and is founder and

director of the Center for Human Caring (Watson, 2006, p. 295).

Nursing’s Metaparadigm as Expressed in the Theory of Human Caring

The THC defines three of the four components of Nursing’s Metaparadigm. Human

being is defined as a valued person in and of oneself to be cared for, respected, nurtured,

understood, and assisted; a fully functional integrated self; greater than and different from the

sum of the parts.  Health is described as a high level of overall physical, mental, and social

functioning; an adaptive and maintaining level of functioning; and the absence of illness, or the

presence of activities that sustain the absence of illness or effects of illness. “Nursing is a science

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of persons and health-illness experience that are mediated by professional, personal, scientific,

and ethical care interactions” (McEwen & Wills, 2014, p. 185). Environment is not defined in

THC. Implied in the theory are multiple dimensions of environment including inner

environment of each person, the unique environment created within the caring moment, the work

environment, the community, and the global, ecological environment.

Major Elements

Watson’s Theory of Human Caring (THC) incorporates several major elements. These

three are key: carative factors with clinical caritas processes, transpersonal caring relationship,

and transpersonal caring moment/occasion. Most central of which are the ten carative factors

with the clinical caritas processes which are descriptions of elements of the practice of caring as

guided by this theory. Transpersonal caring relationship is the form of connection co-created

with the person being cared for within the caring moment/occasion. The relationship of these

elements is illustrated in a model in appendix A.

Carative Factors and Clinical Caritas Processes

In Watson’s 1979 work and it’s 1985 revision she lists ten caritive factors. She uses the

term “caritive” to intentionally contrast her approach to medicine’s curative approach. In her

major revision/expansion in 2008, she has developed correlating clinical caritas processes

(Watson, 2012, p. 47). Table1deliniates each of these (Watson, 2012, p. 47):

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Caritive Factors Clinical Caritas Processes

1. “The formation of a humanistic-altruistic system of values”

“Practice of loving-kindness and equanimity within the context of caring consciousness”

2. “The instillation of faith-hope”“Being authentically present and enabling and sustaining the deep belief system and subjective life-world of self and one being cared for”

3. “The cultivation of sensitivity to one’s self and to others”

“Cultivation of one’s own spiritual practices and transpersonal self, going beyond the ego self”

4. “Development of a helping-trust relationship”

“Developing and sustaining a helping trusting authentic caring relationship”

5. “The promotion and acceptance of the expression of positive and negative feelings”

“Being present to, and supportive of, the expression of positive and negative feelings as a connection with deeper spirit and self and the one-being-cared for”

6. “The systematic use of the scientific problem solving method for decision making”

“Creative use of self and all ways of knowing as part of the caring process; to engage in the artistry of caring-healing practices”

7. “The promotion of transpersonal teaching-learning”

“Engaging in genuine teaching-learning experience that attends to unity of being and meaning, attempting to stay within others’ frame of reference”

8. “The provision of supportive, protective, and (or) corrective mental, physical, societal, and spiritual environment”

“Creating healing environment at all levels (physical as well as nonphysical, subtle environment of energy and consciousness, whereby wholeness, beauty, comfort, dignity, and peace are potentiated)”

9. “The assistance with gratification of human needs”

“Assisting with basic needs, with an intentional caring consciousness, administering ‘human care essentials,’ which potentiate alignment of mind body spirit, wholeness, and unity of being in all aspects of care”

10. “The allowance for existential-phenomenological forces” became “allowance for

“Opening and attending to spiritual-mysterious and existential dimensions of one’s own life-death; soul care for self and the one-being-cared for”

The core concepts of nursing practice found in the carative factors are developed into

more descriptive and action oriented processes (Watson, 2006, p. 298). For example,

“expressing positive and negative feelings” is developed into “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” (Watson, 2012, p. 47). Notice that beyond description and action she

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also includes purpose or rational. The processes do not replace the factors. In her writings,

Watson intentionally lists both the factors and the processes thus guiding us in a progression of

understanding that reflects Watson’s own journey of development.

Transpersonal Caring Relationship

There are many components to the transpersonal caring relationship as presented in the

theory. Within this relationship, the nurse is called to be present to the one-being-cared-for in an

authentic way, attempting to create connection between the inner self of the nurse and that of

person (Watson, 2006, p. 299). This begins with concern and caring for the whole person. This

relationship goes beyond ego and action and time to become transpersonal, allowing for greater

healing possibilities and potentials (Watson, 2006, p. 299).

The Nurse within the Transpersonal Caring Relationship

According to THC, to be effective, the nurse must employ a high level of consciousness

regarding care and intentional focus toward the connection with the one-being-cared-for. The

transpersonal caring relationship requires of the nurse: awareness of his/her own uniqueness, a

reflective frame of mind, and a willingness to be changed by the relationship (Watson, 2006, pp.

298-300). “The nurse’s will and consciousness affirm the subjective-spiritual significance of the

person while seeking to sustain caring in the midst of threat and despair – biological, institutional

or otherwise” (Watson, 2005, pp. 6-7).

It is of profound importance to recognize the process aspect of the nurse competencies

required to enter this level of nursing care using the THC framework. It is an underlying

principle of the theory that to develop these competencies requires inner work to develop a

moral, ethical, loving, realistic, and open view of self in order to properly see, accept and serve

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the other (Watson, 2005). The concept of “becoming” is woven through Watson’s writings as a

valued end for both nurse and person-being-cared-for (Watson, 2005).

THC principles of Transpersonal Caring share concepts with Unitary Science nursing

theory’s view of the nurse patient relationship. Martha Rogers developed Unitary Science.

Rogers’ concepts correlating with the Watson concepts include pan dimensionality and

transcending time, space and physicality, infinity-- transformative world view and universal field

of consciousness connecting with infinity, and integrality-- mutual human-environment field

process and mutuality of caring relationship (Watson, 2005, p. 8). Watson acknowledges this

overlap and describes it as trans-theoretical dimensions of her own theory (Watson, 2005, p. 7).

Transpersonal Caring Moment

In THC, the transpersonal caring moment is a coming together of the uniqueness,

wholeness, and unique history of both the nurse and the person. The encounter then transcends

each person and time and space to become something greater than the sum of the parts. It

becomes a dynamic phenomenon filled with potential to change the moment, the participants,

and the future trajectory of each (Watson, 2012, pp 71-72).

Watson describes an ideal transpersonal caring moment as being spirit-to-spirit (Watson,

2012, p. 56). In her writings, she uses the terms spirit, soul, and energy field in similar ways,

often using soul, spirit and geist interchangeably. In this use of spirit, her writings suggest a

coming together of the inner selves- not dependent upon the physical realm, of both nurse and

other. This coming together involves both choice and action.

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Each person chooses to open or offer oneself in some way to the encounter. The way the

nurse chooses to enter the caring moment can increase his or her ability to promote health and

support the patient’s choice to enter openly to the occasion.

The nurse seeks to “see” who is that spirit-filled person behind the disease, the

diagnosis, even the behavior we may not like. Thus, honoring the whole person

helps to promote more self-knowledge, self-reverence, self-caring, self-control

and self-healing for both nurse and patient. (Watson, 2012, p. 69)

One significant aspect of transpersonal caring in the caring moment is the role that

subjectivity plays. The subjectivity of each participant is a necessary part of the connection

(Watson, 2012, p, 72). Each one brings his or her subjective values and perspectives into the

exchange. It is a more common view among nurses that the patient’s subjective self is honored

and accepted but the nurse, while supporting the patient, tries to keep her subjective-self separate

from the encounter. Watson reveals that if the nurse is unwilling to share her perspectives and

views (therapeutically and appropriately) and unwilling to approach the patient subjectively--

unwilling to be transformed-- then neither the patient nor the nurse is being honored as a whole

person.

THC Applied to Research

C.A. Walker (1996) provides a study comparing the use of Parse’s Theory of Human

Becoming and Watson’s THC in practice. It reviewed both theories and then focused on their

most relevant aspects to practice. Theoretic premises identified for application to the case study

include specificity of the felt expression between nurse and client, clarity of feelings transmitted,

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and the client’s perception of genuiness and sincerity in the nurse (Walker, 1996, p. 994).

Walker (1996) posits that “to the extent that an actual caring occasion reflects these ideals the

client will experience the caring more completely and the imperative to care will be more fully

realized” (p. 994).

Assessment strategies, nursing diagnoses and interventions were developed based on both

theories and applied to a client case involving psychosocial concerns. One nursing diagnosis

utilizing THC developed for this case was “Languaging, connecting-separating: Expressing

ambivalence about own contribution to marital conflict related to recent separation from spouse

and children” (Walker, 1996, p. 995). The interventions developed by Walker (1996)based on

THC are listed in table 2 paired with a supporting carative factor (Walker, 1996, p. 995)

(Watson, 2012, p. 47).

Table 2: Walker’s Interventions paired with Carative Factors

-Establish trusting nurse client relationship using accurate reflection of feelings and attentive listening.

4. “Development of a helping-trust relationship”

-Engender verbalization of ambivalences with nonjudgmental acceptance of aired emotional content.

5. “The promotion and acceptance of the expression of positive and negative feelings”

-Support and maintain clients-person’s self-esteem.

3. “The cultivation of sensitivity to one’s self and to others”

-Encourage client-person to acknowledge and act according to her life situation and its possibilities.

6. “The systematic use of the scientific problem solving method for decision making”

-Discern Client-person’s wishes about continuance of amiable relationship with her estranged spouse.

6. “The systematic use of the scientific problem solving method for decision making”

-Coax client to voice her dreams for the future. 2. “The instillation of faith-hope”

Walker (1996) goes on to describe the case scenario over several weeks of care and

describe outcomes. The formation of a helping-trust relationship and acceptance of the

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expression of feelings is credited with the client’s progress (Walker, 1996, p. 995). Client-

person could express openly not only her current issues but feelings from past disrupted

relationship with parents which allowed her to recognize patterns in her own behavior which

could begin to be addressed and which afforded her a new perspective on both her and her

husband’s behaviors. She has been able to blame less and focus on her own decisions-- past,

present and future. She recognizes the end of her marriage as a loss and, while in the midst it, is

able to grieve.

A study was done using THC to develop a plan of care for a patient fighting

gastrointestinal cancer who was recently told it had become terminal (Childs, 2006, p. 284). The

author highlights the importance of using nursing theory as a guide when situations involve the

values of both patient and nurse while developing practical aspects of care (Childs, 2006, p.

284). Childs (2006) writes with a perspective compatible with Watson’s, “whereas there is a

scientific basis for the practice of nursing, it is the ‘body mind and spirit’ of the caregiver and

care receiver that has the greatest impact on the outcome of care” (Child, 2006, p. 284). In the

two primary goals of supporting the patient in decision making and supporting nutrition intake, a

holistic approach is taken based on THC carative factors. The author emphasizes that the benefit

of using THC was to provide clarity and framework for the nurses in a case that was

physiologically complex as well as psycho-social-spiritually complex.

Discussion

Watson’s theory provides the field of nursing science with guidance toward a moral ideal

related to nursing (Watson, 2012, p. 83). Foundational and philosophical principles are drawn

from existential philosophy, psychology, and traditional nursing philosophy. The breadth of her

background sources and her vision for clarifying nursing’s own science inform her theory

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development and provide us with insight for defining nursing practice and our individual

practice. The well-focused carative factors and caritas processes are immediately applicable for

practice while being constructed in a way that calls the nurse to continuously develop caring

skills. The description given of the transpersonal relationship requires much of the nurse.

Watson would say that this provides the ideal and that the individual personal development of

each nurse is as essential to nursing as other caring activities. She would say that the process of

becoming is intrinsic to the use of the theory (Watson, 2012, pp. 70-71).

Requirements of the Nurse in Human Caring

The level of higher order functioning required of the nurse is so great that this theory may

not be approachable to some. Understanding the theory’s language considering the various

knowledge fields used in its development requires a level of philosophical and language

adeptness not always present. Some of these requirements from Watson’s (2012) book Human

Caring Science are:

Human caring requires knowledge of human caring-healing consciousness,

presence and processes, and caring competencies/literacy to balance and

complement the medical/technological competencies and skills. Caring requires

knowledge and understanding of individual needs; knowledge of how to respond

to others’ needs; knowledge of our strengths and limitations; knowledge of who

the other person is, his or her strengths and limitations and the meaning of the

situation for him or her; and knowledge of how to comfort and offer compassion

and authentic presence; and to hold another in his or her wholeness, while he or

she is vulnerable, hurt, wounded and suffering. Human caring also requires

enabling actions, that is, actions that allow another to seek creative solution to life

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situation, to grow, evolve and transcend the here and now, actions that are related

to general and specific knowledge and practices of caring and healing. The caring

healing modalities related to the human caring process require a consciousness, an

intentionality, a will, a mutual relating, and actions. (p. 89)

The spiritual maturity and personal maturity required to operate at the level called for

requires more than education and more than working as a nurse. Granted, there is great

advantage for attaining these things, but the requirements are so great they may be a barrier to

applying the theory without focused instruction, mentoring and commitment to the THC process.

For the Nurse Educator

A visionary nurse educator may be inspired by the holistic and spiritual aspects of THC,

impressed by its well documented borrowed and nursing theoretical foundations, moved by the

high moral and ethical call it represents and both convicted and comforted by its position that we

all approach caring relationships as vulnerable and evolving human beings. That nurse educator

may be challenged to develop teaching strategies that not only provide knowledge about the

theory but impart ways of learning about self, caring for self, being open and genuine, loving self

and other, and being self-evaluative so that the student can be a continuous learner as well as

care giver.

Christian Faith Juxtaposed with THC

If a Christian, the nurse may be forced to evaluate closely the metaphysics underlying the

foundations of this theory. Christianity teaches so many of the caring concepts represented in the

THC caritas processes. The theory would speak powerfully to those passionately committed to

living out one’s faith convictions in the service of others in the field of nursing. Watson’s use of

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language such as energy-field, spirit, geist, and soul may need some clarification and delineation.

The grand concept and assumption in the THC of “unitary consciousness” is not the Christian

worldview. While it could be viewed that within Christian teaching there is evidence for a

universal connectedness, it is not the same. The Christian notion of connectedness stems from

all of creation being from a common source and all human kind being made in the image of God.

It progresses to each believer having a call to love and serve fellow humans individually and

globally and to care for the earth. Unitary consciousness can refer to a phenomenon of

spontaneous co-consciousness. In Christianity consciousness is an aspect of self that can be

developed, but all that we become conscious of that we have not ourselves perceived is

considered to have been revealed to us. This, not by our own doing or the universes doing, but

by a higher and uniquely omniscient God. Writing about the metaphysical foundation of caring

science as sacred science, Watson (2005) states “these dimensions are revealed as Sovereign

Expressions of Life” (p. 56). The meaning of sovereignty and the difference between soul and

spirit are very specific in Christian teaching, requiring careful examination of one’s own

understanding of faith teaching to properly place this theory into personal use.

THC Viewed Through the Filter of Perinatal Bereavement

In perinatal bereavement, nursing necessarily operates in the metaphysical realm.

Patients face life and death, confrontation of belief system, loss of chosen role, spiritual crisis,

marital crisis, questions of adequacy, depth of parental love and great emotional suffering. The

simultaneous depth and subtlety of this suffering can be draining at best and overwhelming for

many nurses. It is an absolute necessity to have a framework to approach care for such a patient.

Watson’s theory offers guidance that most practice theories and even some middle-range theories

cannot.

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Watson’s Theory of Human Caring has included spiritual concepts from its inception. At

the heart of this theory is the transpersonal relationship within the transpersonal caring moment.

It is only from within this phenomenon that the caritas processes are applied. For the grieving

mother, simple expression of feelings is inadequate and difficult. Engendering faith-hope is

painful, conflicted and not always possible in the first few days. Pain medication and reaching

criteria for discharge does not address the primary concerns. Only from within the caring

relationship does the patient feel safe enough to even face her feelings. Merely doing so

promotes healing later as she must wrestle with her feelings of loss but does so more freely

having chosen to be vulnerable with a trusted nurse.

THC validates the reality of the central role of relationship in the perinatal loss setting. It

helps the nurse to know what her focus should be even though the patient may not exhibit

progress in a shift or hospital stay. Concepts associated with the transpersonal relationship such

as inter-subjectivity and bringing the whole self into the encounter are concepts rarely delineated

in daily practice. The theory allows us to carry with us a guide to approach care (caritas

processes) and encouragement from an invisible collegiality with the voice of the theory which

supports us in entering the transpersonal caring moment. It supports us in the necessary

reflection and self-care required to do such intimate work.

Conclusion

Theory of Human Caring provides a useful and broadly applicable tool in its caritas

processes. “Caritas comes from the Greek word meaning to cherish and appreciate, giving

special attention to, or loving. It connotes something that is very fine, that indeed is precious”

(Watson, 2006, p. 297.) The choice of this word reveals the underlying essence of the

transpersonal caring relationship within the transpersonal caring moment. These represent a high

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call to enter our patients’ world with our entire being ready to receive the other person as a

whole, without judgement. This is an appropriate aspiration for all nurses. The grandness of this

theory is both an asset and a detractor. The borrowed and created underpinnings, described in

detail by the theorist are a study in the nature of nursing practice, science, and philosophy. The

language and the breadth and depth of concepts in the THC, taken in its entirety, may be

cumbersome to some learners and some types of research.

THC is most applicable to research as a framework for examining such concepts as ethics

and moral practice, and in defining nursing. Applied to direct nursing practice it is especially

appropriate for multifaceted patient assessment and care that include psychological and spiritual

dimensions. Overall the Theory of Human Caring is best understood as concepts that not only

shape care but guide the nurse in his or her own process of human development and professional

development.

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References

Cara, Chantal, (2007). A Pragmatic view of Jean Watson’s Caring Theory. Doctoral Work.

http://www.watsoncaringscience.org/files/PDF/Pragmatic_View.pdf

Child, A. (2006). The complex gastrointestinal patient and Jean Watson’s theory of caring in

nutrition support. Gastroenterology Nursing, 29(4) 283-288.

http://downloads.lww.com/wolterskluwer_vitalstream_com/sample-content/

9780781784542_dudek/samples/sga_1042895x_2006_29_4_283.pdf

McEwen, M. & Wills, E. (2014). Theoretical basis for nursing (4th edition). Philadelphia, PA:

Wolters Kluwer Health/ Lippincott Williams & Wilkins.

Walker, C. (1996). Coalescing the theories of two nurse visionaries: Parse and Watson. Journal

of Advanced Nursing, 24(5), 988-996. doi:10.1111/j.1365-2648.1996.tb02935.x

Watson, Jean (2005). Caring science as sacred science. Philadelphia, PA: F.A. Davis Company.

Watson, J. (2006). Jean Watson’s Theory of Human Caring. In M. Parker (Ed.), Nursing

Theories & Nursing Practice (pp. 295-302). Philadelphia, PA: F.A. Davis Company

Watson, Jean (2012). Human caring science: a theory of nursing. Sudbury MA: Jones & Bartlett

Learning.

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Appendix A: Model of relationship of major components

Carative Factors and

Caritas Processes

Transpersonal caring moment/Caring occasion—

A multifaceted unique phenomenon

created in and by the encounter

Nurse

phenomenal field including life experience, expertise, Intent toward moral ideal

Person-being-cared-for

Phenomenal Field including life experience and need for care

Co-Created

Transpersonal

Relationship