Jean Watson's Theory of Human Caring in Nursing Practice

Theoretical Background

One of the complexities of 21st-century medicine is the evolution of nursing care theories in combination with a changing set of needs and expectations among the stakeholder population. Nurses must be advocates and communicators, but must balance these roles alongside an overall philosophy of ethics while remaining mindful of budgets and the financial realities of medical institutions. These issues comprise a three-part template for nursing: respect for patient value and individuality, education of patients, and recognition of the realities of contemporary medicine. In many ways, modern technology has also advanced further than societal wisdom, particularly when confronting the issue of death. The modern nurse's role is to create a nurse-patient culture that encourages individuals to take responsibility for their healthcare and, in partnership with the nurse, to be actively involved in their recovery. The modern complexities of healthcare, when combined, point toward a multidimensional template — one incorporating at least psychology, biology, and philosophy (Beckstead and Beckstead, 2004).

Ethics and multidimensionality provide a way for the nurse to advocate for the patient. This is, of course, a gray area at times — certain drugs or tests may have initial negative or painful effects but, in the long run, provide relief to the patient. While the nursing code of ethics echoes the Hippocratic Oath of "do no harm," the greater or long-term benefit to the patient may, at times, override brief discomfort in order to heal. For the modern nurse, theory is not an end in itself but part of the destination — part of a toolbox of techniques drawn from experience and alternative perspectives. We live in a global society, and as such, "the usage and development of [divergent] nursing theories should be a top priority" — but only if those theories are used in a practical manner befitting patient advocacy and clinical knowledge (Dudley-Brown, 1997, p. 82).

More than just focusing on what can be done medically, the concept of ethics within modern nursing has a duality: just because something can be done medically does not mean it should be, and — more importantly — someone must ensure that those moral decisions are being made, or at least considered and discussed. Quality care is expected, and patient advocacy has always been part of this paradigm. This is not a new approach to nursing, but rather one with a long historical tradition dating back to the Civil War era and the ideals of Florence Nightingale, continuing through the interpersonal advocacy model of Hildegard Peplau, and finding its fullest contemporary expression in the work of Jean Watson.

Focus of the Model

Based on a number of theories — including those of Jean Watson — modern nursing carries an overall responsibility for advocacy and care. More often than not, nurses act as the moral agents within the healthcare system because they serve as the primary locus of communication among the physician, the patient, and the family. The modern nurse leader must act with moral courage and conviction, since "nursing leaders are responsible for creating cultures that support acts of courage in nursing… [because] these acts have the potential to increase nurse retention, promote patient comfort, relieve patient suffering, and enhance the reputation of the organization" (Edmonson, 2010).

There is, therefore, a clear expectation for APN and RN professionals. Within the culture of the healthcare industry, the moral development of the work group often shapes the way decisions are evaluated and made. For this reason, the modern nurse requires a toolbox of ethics and morals that can be applied at the right time and under the right circumstances. This influence does not need to be coercive; rather, it should take the form of servant leadership — inspiring others and leading by example. This leadership style acknowledges competition and conflict, which is not inherently negative because it surfaces alternative viewpoints that might otherwise remain unexamined. Research findings show that moral identity contributes to leadership acumen, and vice versa. The expectations embedded in a leader's role within an organization will shape the manner in which moral and ethical paradigms are used to make decisions (Mayer, 2012, pp. 165–6).

Overview of Watson's Model and Carative Factors

A critical theoretical approach to patient advocacy, Jean Watson's Theory of Human Caring represents a dramatic paradigm shift and has been a source of considerable controversy since its introduction in 1979 with Nursing: The Philosophy and Science of Caring (revised 2008). To Jean Watson, nursing is both an art and a science, with the overall goal of preserving the worth of humankind through the process of caring. The core of nursing is caring — and it must be more than a theoretical precept: "Caring… has to become a will, an intention, a commitment, and a conscious judgment that manifests itself in concrete acts. Human care, as a moral ideal, also transcends the act and goes beyond the act of an individual nurse and produces collective acts of the nursing profession that have important consequences for human civilization" (Watson, 1988, p. 32).

The caring experience is part of the human experience. Because humans are unique, Watson advocates a push toward transpersonal caring, finding that both nurse and client must participate in the responsibility and pursuit of complete healing (Watson, 1988, p. 70). Her concept of health is markedly Eastern in orientation — harmony between mind, body, and soul — with illness representing disharmony among those three dimensions. Integral to Watson's theory are the ten carative factors that serve as a "framework for providing structure and order for nursing phenomena" (Watson, 1997, p. 50). Watson's ten carative factors are:

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

Offshoots and Related Leadership Theories

Numerous leadership theories have developed over the past half century — some specific to healthcare, but most applicable to any organization, requiring only some refinement to address the particular life-and-death challenges of medicine. Most nursing theorists — Watson, Leininger, Peplau, and others — emphasize servant and/or ethical leadership, focusing on character, civility, and community. "Leadership and management development therefore focuses on the enhancement of the personal attributes, qualities… knowledge and skills of individuals" (Edmonstone, 2011). Ethics and morals are culturally influenced, yet several moral and ethical values transcend time and geography. Much of ethical leadership thinking centers on the basic premises of utilitarianism and deontology — asking whether the needs of the many outweigh the needs of the few, and whether the means to an end matters as much as the end result. The true ethical leader seeks fundamental changes within their purview to ensure that justice and equality are part of the operating paradigm, developing a culture in which ethical practices become the norm (Mayer et al., 2012).

Watson's theoretical basis is a logical offshoot of Peplau's work, combining care, advocacy, and communication as central to patient needs. Peplau's most influential contribution to nursing literature was her 1952 publication Interpersonal Relations in Nursing. In this text, Peplau argued that the foundation for any nursing theory must be the client-nurse relationship. While this seems quite logical today, around World War II it was both reactionary and controversial, given the prevailing emphasis on the doctor-nurse relationship. Peplau believed that the partnership between nurse and patient was essential to healing. The nurse, she argued, should do far more than follow physician orders — instead actively listening to patients, communicating their needs up the chain of command, and advocating for their well-being. The ratio of patients to doctors, she reasoned, gave professional nurses a critical responsibility in this advocacy role:

"The authority and direction for designing nursing functions derive from situations in which professional workers collaborate to bring about health improvement. Any problem to be faced by an individual or a community suggests what is needed for its solution; health workers assess problematic situations and cooperate with individuals and communities in getting needed help… Nurses participate in delineating the many roles they can helpfully fulfill, in relation to people and to the functions of other workers in particular situations — physicians, dentists, dietitians, physiotherapists, social workers, psychologists, occupational therapists, and others" (Peplau, 2004, p. 7).

Overall, Peplau's theory can be understood through seven major roles that form the basis of the nurse-client relationship and underpin Watson's applications. In the Stranger role, the nurse meets and gets to know the patient — asking about life situations, building trust, and establishing rapport — allowing the patient to feel important and to be seen as more than a chart full of data. As a Resource, the nurse answers questions, interprets medical tests and jargon, and demystifies procedures, thereby reducing patient anxiety. The Educator role involves providing medical instruction on procedures, medications, and lifestyle changes, ensuring the patient takes an active part in their own recovery. As a Counselor, the nurse helps the patient understand and cope with diagnosis and discomfort, offering guidance, encouragement, and referrals for extended counseling or spiritual care as needed. In the Surrogate role, the nurse advocates on behalf of patients who may be shy, frightened, or unfamiliar with hospital procedures. The Leadership role involves helping patients assume responsibility for their treatment and guiding them toward optimal health through example. Finally, as an Expert, the nurse draws on clinical skills, equipment knowledge, and technical competence within all of the above roles (Peplau et al., 1988).