This paper examines Dr. Jean Watson's Theory of Caring in nursing, tracing its philosophical foundations in European ethics and exploring its core components: carative factors, the transpersonal caring relationship, and the caring occasion. The paper reviews scholarly perspectives on cultural competency as an expression of caring, outlines Watson's evolution from carative factors to Caritas processes, and analyzes the theory's strengths and limitations as a middle-range nursing theory. It also addresses practical barriers to implementing the caring model in fast-paced clinical environments and describes how nursing advocates have worked to integrate Watson's theory into institutional practice and culture.
The theoretical foundation of Dr. Jean Watson's Nursing Theory — often referred to simply as the Theory of Caring — is expressed most directly by Watson herself:
"This outer world of medicine and hospitalized orientations to ethical dilemmas and humane human practices has seemingly stripped nursing of its heart and soul as well as its language, knowledge, and voice. Yet, the irony is that the Self of nurses, the Self of systems and even society can no longer survive. This is the time, if nursing is to survive, to bring forth its voice, heart and soul and informed moral actions to attend to sustaining and flourishing of human caring work in our world. This is a moment whereby nursing can locate itself in a Caring Science and allow its ethic of Belonging, Caring (and Love) to be the starting point for its science." (Watson, 2005b, p. 2)
Dr. Watson's work entitled "Love and Caring: Ethics of Face and Hand: An Invitation to Return to the Heart and Soul of Nursing and our Deep Humanity" draws on ancient poetry and wisdom traditions, integrating the philosophical views of Levinas and Løgstrup. This theory is informed by contemporary European philosophies. Watson states that "the metaphysics, metaphors and meanings associated with 'ethics of face,' the 'infinity of the human soul,' and 'holding another's life in our hands' are tied to a deeply ethical foundation for the timeless practice of love and caring, as a means to sustain not only our shared humanity but the profession of nursing itself."
Watson argues that as nursing has progressed — accumulating more knowledge and information — it has simultaneously lost its connection to the timeless wisdom of applied nursing: the art of caring for and administering that care to the whole person in order to help them heal or regain their health.
In exploring Watson's Theory of Caring, the work of Rexroth and Davidbizar (2003) is relevant. These authors observe that the United States is an increasingly multicultural and pluralistic society due to the growing numbers of ethnic minorities in its population. Many of today's healthcare professionals lack the cultural competency required to meet contemporary healthcare needs. As Rexroth and Davidbizar (2003) state: "All healthcare providers, and particularly nurses and nurse practitioners (NPs) who are on the front lines of patient care, must be skilled in providing culturally appropriate and competent care."
During the 1990s, cultural diversity was added to nursing curricula; however, many nurses currently in the workforce received their education before these curricular changes were made. This has resulted in a significant knowledge deficit in the area of cultural competency among non-ethnic nurses across the nation (Rexroth and Davidbizar, 2003). These authors identify the following common characteristics found across ethnic minority healthcare delivery settings:
(1) Limited number of healthcare facilities and equipment; (2) language barriers; (3) inadequate numbers of healthcare providers for ethnic minorities; (4) lack of health insurance coverage in the ethnic minority population; and (5) lack of knowledge and understanding of cultural diversity, along with increased potential for cultural bias by healthcare providers (Rexroth and Davidbizar, 2003).
The nurse practitioner must become comfortable treating and communicating with culturally diverse patients. Rexroth and Davidbizar (2003) argue this is best accomplished by "becoming culturally sensitive." Such cultural sensitivity will be perceived by the patient as caring on the part of the nurse practitioner, and "exemplifies the transcendence of cultural diversity and the interpersonal bond of trust which is an end product of the caring." Dr. Jean Watson states that "human caring involves a transpersonal relationship between the nurse and her patient. This is a special kind of human care relationship — a union with a high regard for the whole person and their being in the world" (p. 63; cited in Rexroth and Davidbizar, 2003).
Roxie L. Foster, Associate Professor of Nursing, writes that "Caring theory has deep roots in philosophy and ethics and, in recent years, has become more closely aligned with Rogerian science of unitary human beings (Watson and Smith, 2002)." Foster also notes that in a meta-analysis of 130 studies conducted between 1980 and 1996, "Swanson (1999) chronicled consequences of caring for patients and nurses. Patients indicated positive emotional-spiritual outcomes, physical outcomes, and social outcomes" (Foster, 2006).
Watson proposes several updated reasons related to her theoretical notions of transpersonal caring. She states that "each thought and each choice that is made" in nursing practice "carries spirit energy into our lives" and the lives of others. She further asserts that our "consciousness, our intentionality, our presence makes a difference for better or for worse," and that "calmness and mindfulness in a caring moment beget calmness and mindfulness." Watson adds that "caring and love beget caring and love," that "caring and compassionate acts of love beget healing for self and others," and finally that "transpersonal caring becomes transformative, liberating us to live and practice love and caring in our ordinary lives in non-ordinary ways" (Watson, n.d.).
In these statements, Watson conveys that the choices nurses make infuse their own lives and the lives of those they encounter with spiritual energy — energy that may be either positive or negative. She teaches that when caring and love are given, reciprocal caring and love are experienced in return. Caring for others has the capacity to transform the nurse and free them to express love and caring in both small, seemingly inconsequential ways and in larger, extraordinary ways. Communication conducted "with compassion and an open heart" — in a manner of respect and patient listening, with full attention given to the individual — represents, for Watson, "a healing gift of self." Watson also emphasizes that nurses must learn "to be still" and "center" themselves. With responsibilities and workloads making the nurse's role more critical than ever in a healthcare environment that can be dehumanizing to patients, caring remains the "core of nursing," and Watson's caring theory can be seen as indispensable to preserving it — allowing nurses to return to their "deep professional roots and values," which represent "the archetype of an ideal nurse."
Watson (2001) identifies three primary elements within her theory: (a) carative factors; (b) the transpersonal caring relationship; and (c) the caring occasion/caring moment (Chantal, n.d.).
Carative is a term coined by Dr. Watson in contrast to curative in conventional medicine. Carative factors are those which "attempt to honor the human dimensions of nursing work and the inner life world and subjective experiences of the people we serve" (Watson, 1997b, p. 50). The ten carative factors are:
(1) Humanistic-altruistic system of values; (2) faith-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-learning; (8) supportive, protective, and/or corrective mental, physical, societal, and spiritual environment; (9) human needs assistance; and (10) existential-phenomenological-spiritual forces (Watson, 1988b, p. 75).
In her work "Caring Science: Belonging Before Being as Ethical Cosmology," Watson presents her views on nursing ethics from the perspective of caring science. She observes that mainstream ethical discourse is dominated by two dualities: the first deals with "rational decision-making, related to public, headline-level biomedical-technical ethical dilemmas," while the second addresses "more intimate, private, relational, contextual human-meaning ethical decisions." Watson argues that in reality, both perspectives are necessary, and that used together they render a "more balanced, integrated view" (Watson, 2005).
Within this both/and model, Watson states that "an expanding model emerges that is especially relevant for nursing and the increasingly acknowledged relational caring-context in which nursing dwells" (Watson, 2005). Here Watson draws on the philosophy of Levinas (1969/2000) — a European philosophical framework with "notions of totality and infinity" — which reminds one of one's sense of belonging to the "infinite universal field of consciousness of Spirit/energy/Source." It is at this point that Watson locates the starting place of ethics, arguing that "belonging becomes an ethic in itself and guides how we sustain our being in the world." Watson also highlights Palmer's concept of epistemology as ethics: an epistemology informed by cosmology that has the power to either "form or deform the human soul" and, by extension, the nurse's "way of being/becoming more human and humane" (Palmer, 1993; as cited in Watson, 2005).
As Watson's theory evolved, the carative factors were replaced by what she terms Caritas processes, in which "one can observe a greater spiritual dimension" (Chantal, n.d.). Caritas "originates from the Greek vocabulary, meaning to cherish and to give special loving attention" (Ibid). Watson's Caritas processes are as follows:
• Practice of loving kindness and equanimity within the context of caring consciousness.
• Being authentically present, and enabling and sustaining the deep belief system and subjective life world of self and the one-being-cared-for.
• Cultivation of one's own spiritual practices and transpersonal self, going beyond the ego self, and opening to others with sensitivity and compassion.
• Developing and sustaining a helping-trusting, authentic caring relationship.
• Being present to, and supportive of, the expression of positive and negative feelings as a connection with the deeper spirit of self and the one-being-cared-for.
• Creative use of self and all ways of knowing as part of the caring process; engaging in the artistry of caring-healing practices.
• Engaging in genuine teaching-learning experiences that attend to unity of being and meaning, attempting to stay within others' frames of reference.
• Creating a healing environment at all levels — physical as well as non-physical — a subtle environment of energy and consciousness in which wholeness, beauty, comfort, dignity, and peace are fostered.
• Assisting with basic needs with an intentional caring consciousness, administering "human care essentials" that foster alignment of mind-body-spirit, wholeness, and unity of being in all aspects of care; tending to both the embodied spirit and evolving spiritual emergence.
• Opening and attending to the spiritual-mysterious and existential dimensions of one's own life-death; soul care for self and the one-being-cared-for (Watson, 2001, p. 347).
The application of Watson's Caring in Nursing Model may be enacted through interaction with the patient by asking pertinent questions that engage the patient while conveying that the nurse genuinely cares about them as a whole person. Examples of such questions include: "Tell me about your health." "What is it like to be in your situation?" "Tell me how you perceive yourself in this situation." "What meaning are you giving to this situation?" "Tell me about your health priorities." "Tell me about the harmony you wish to reach." These questions may be used to assess the patient's own perspective on their healthcare (Chantal, n.d.).
Nursing theories have been presented in several different conceptual forms, defined by Jacqueline Fawcett in Contemporary Nursing Knowledge: Analysis and Evaluation of Nursing Models and Theories as: (1) grand theories and (2) middle-range theories. Watson's theory is classified by Fawcett (2005) as a middle-range theory.
One limitation of Watson's theory, as noted by Fawcett (2005), is its failure to acknowledge that although the term caring appears in several conceptualizations of the nursing discipline, "it is not a dominant theme in every conceptualization and, therefore, does not represent a discipline-wide viewpoint (Wilson, 1994). Indeed caring reflects a particular view of nursing and a particular kind of nursing (Eriksson, 1989)." Furthermore, caring "cannot be generalized across national and cultural boundaries (Mandelbaum, 1991)" (Fawcett, 2005). Fawcett also references Rogers (1994b), who states: "Caring is doing, it is practice. Caring is a way of using knowledge."
"Theory evaluated as unique middle-range model"
"Implementation challenges and integration strategies"
What was discovered by the Caring Advocates was the precise factor in nursing that Dr. Jean Watson attempts to relate in her works — and that was the "spirit" of nursing. The "spirit" of nursing is elusive when definition is sought; however, that integral component of healthcare provision that nursing contributes makes the difference in the experiential relationship that exists between the nurse and the patient in the healthcare setting.
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