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Facilities Adopt Caring Theory Principles

Monday February 15, 2010
From the International Caritas Consortium Gathering in Charleston, S.C., April 23-24, 2009
From the International Caritas Consortium Gathering in Charleston, S.C., April 23-24, 2009
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When nurses and nursing students first encounter the Theory of Human Caring, they often are baffled or overwhelmed by the words and phrases used by its author, nursing theorist Jean Watson, RN, PhD, AHN-bc, FAAN, a professor at the University of Colorado, Denver College of Nursing. Caritas processes? Transpersonal caring? Ontological caring competencies?

A peek at Watson’s Web site (watsoncaringscience.org) may only add to the confusion. She talks of Love with a capital L, sells singing bowls (a type of standing bell used in meditation), and promotes a Million Nurses Caring Field Project that she says will radiate “a field of Worldwide Energetic Caring Consciousness for Global Healing and Health for all.”

But when nursing leaders and staff nurses describe how they use Watson’s theory in their clinical practices, her ideas are at once familiar, and as musical to most nurses’ ears as the sound of a singing bowl: listening to patients; seeing the person behind the disease; paying attention to what they are doing at the moment rather than the million tasks yet to do; showing respect for colleagues; learning to take care of themselves.

Nurses who practice Watson’s theory say it’s a reminder that their primary purpose as healthcare professionals is not to read vital signs, fill out forms, or insert IVs, but to help real, living people heal.


Jean Watson, RN
Giving Words to an Ethic

Watson estimates some 100 hospitals have adopted her caring theory as their practice guide in one way or another, most within the last five years. About 20 of these work directly with her on an ongoing basis, attending her International Caritas Consortium meetings held in facilities around the country. Some are using the theory primarily in their nursing departments, others are implementing it hospitalwide.

“This is not something new,” says Randy Williams, RN, MSN, MBA, professional practice coordinator at Wake Forest University Baptist Medical Center in North Carolina, which has adopted Watson’s theory as its clinical practice guide. “It’s just giving words to things we do every day.”

Watson’s theory has evolved since the late 1970s when she first developed it in response to what she saw as an increasing gap between the science of medicine, with its emphasis on technology, diagnosis, and curing disease, and the art of healing, which emphasized humanity, looking at an entire person, and the personal relationship between the caregiver and the patient.

The Theory of Human Caring consists of 10 basic ideas Watson calls the caritas processes. (Caritas is Latin for charity or altruistic love.) These include directions to “practice loving kindness,” “develop helping-trusting-caring relationships,” “use creative scientific problem-solving methods for caring decision making,” and to be “open to mystery and allow miracles to enter.”

“It goes beyond patient-centered care,” Watson says. “It goes to the heart of the human-to-human connection.” She considers it more of an ethic than a theory. “Everybody translates it in their own way.”

As more hospitals apply for Magnet status or look for ways to guide their healthcare delivery, an increasing number of nursing departments are adopting nursing theories — including Watson’s — to help define and recognize what nurses do.

Measure of Kindness

Watson is looking at creating a way to measure results of how her theory is put into practice and perhaps designing a system of affiliation or accreditation through her Caring Science Institute. She has created a caring assessment tool for patients to rate their experience based on statements such as: “My caregivers consistently provide care to me with loving kindness.” Some hospitals are working on pilot projects, collecting data not only on patient satisfaction, but also on how nurses take care of themselves and how they see themselves as being treated by colleagues.

Nursing leaders at many of the hospitals that are implementing Watson’s theory say their nursing committees chose it because it reflects what they were already practicing. “A theory gives grounding on why you should do what you are doing,” says Williams. “We wanted to create a caring, compassionate, healing environment.”

Ellen Gruwell, RN, MSN, a staff labor-and-delivery nurse at St. Joseph’s Hospital of Orange in California, says Watson’s theory complements the hospital’s own core values of dignity, service, excellence and justice. Nurses are encouraged to take time with their patients, to connect with them in emotional and spiritual ways, she says. “We’re given the license to do that. That is a part of who we are.”

“Her theory speaks very well to the bedside nurse,” says Anne Foss-Durant, RN, NP, MBA, chief nursing officer at Kaiser Medical Center in Antioch, Calif., where the Theory of Human Caring has guided nursing practice since the hospital opened two years ago. In recent years, healthcare has become so complex many nurses feel they are too busy or stressed to remember why they got into nursing in the first place, she says. Watson talks about comfort, compassion, and self-care to nurses who feel their jobs have been reduced to filling out forms and passing meds, she says.

The caring theory gives nurses a voice, a language, and a hearkening back to nursing school, where many of them eagerly studied and wrote about Watson, she says. It focuses on “centering” and “being in the moment,” turning basic practices such as hand-washing into rituals that nurses can use to pull themselves together and be present for the patient in the room.

Walking the Talk

Besides direct patient care, some hospitals are incorporating Watson’s theory into their education, hiring, job descriptions and staff programs. Some have created meditation rooms where nurses and other staff members can go when they need a moment of quiet reflection. Some use “caritas coaches,” who help nurses learn, remember and interpret the 10 parts of Watson’s theory.

Many hospitals encourage nurses to tell stories of how they practiced some part of Watson’s theory. For instance, Williams says, one nurse at Wake Forest recently talked about a patient who spoke harshly to her because he wasn’t being discharged as quickly as he wanted to be. Instead of getting upset, she responded courteously and offered to walk him out of the hospital after he was discharged. As they walked, the patient began crying and apologized, saying his wife had died recently and he was worried about making his daughter wait when she picked him up. The nurse reassured him she was there for him. “She was creating a caring, healing environment — that environment being herself — so the patient could heal,” Williams says.

At Winter Haven (Fla.) Hospital, some nurses have established nondenominational prayer circles (which began as “moment of silence circles”) and created and displayed posters demonstrating various caritas processes. They light candles, strike singing bowls and share “caring moments” at the start of meetings. “We’re known in this area as the Jean Watson hospital,” says Mary Jo Schreiber, RN, MSN, chief nursing officer at Winter Haven.

At John C. Lincoln North Mountain Hospital in Phoenix, quarterly volunteer gatherings called “circle of light” offer tea and homemade pastries, followed by a reflection session in which participants talk about what brought them into nursing or healthcare and special moments they’ve had with patients. “It’s amazing how sharing those stories creates such a connection among the people in the group,” says Barbara B. Brewer, RN, MALS, MBA, PhD, director of professional practice at Lincoln. “It’s my goal to help them remember why [they went into healthcare] and to re-energize them.”

Skeptics’ Questions

Not everyone immediately embraces the caring theory, nursing leaders say. Some have trouble with the language or wonder how they will ever find time to practice it. A few think it means they should be so emotionally involved with patients that they can’t make objective decisions about care. Some are suspicious of a theory that seems to value touchy-feely rituals above technical competency.

Many of these are misinterpretations, say nurses familiar with Watson’s work. Caring does not mean a nurse can be incompetent — just the opposite, they say. A nurse who cares makes sure patients do not suffer from medical errors or other mistakes. When Watson talks about loving patients, she’s referring to a universal love of humanity and seeing them as people, Williams says. Part of Watson’s theory emphasizes self care, meaning nurses should not let feelings for patients intrude on time they need for themselves or their families.

As for the most common nursing concern — lack of time — Foss-Durant notes that when nurses really listen to patients, they usually spend less time running to a room to answer a call buzzer. “If you’re able to make that connection with the patient, you’re going to become more efficient because you’re not guessing what the patient needs,” she says. “If you focus on what the patient needs at the moment, everything else will fall into place.”

Watson’s theory may not work for every facility or even for every nurse, nursing leaders say. But, they add, having a prevailing nursing care theory to guide practice, whether from Watson or another theorist, can help a facility, particularly in tough economic times or when morale is low.

Schreiber recalls a period at Winter Haven during the height of the nursing shortage when nearly 40% of the hospital’s nursing positions were vacant. Some wondered whether the hospital’s caring culture could survive, she says, but having Watson’s theory in place reminded staff and administrators of their higher goals. “You need the framework to remember who you are and why you are there,” she says. “This caring theory is embedded in the DNA of Winter Haven Hospital.”

Cathryn Domrose is a staff writer for Nurse.com.


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