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«The Journey to Integrate Watson’s Caring Theory with Clinical Practice Linda A. Ryan, PhD, RN Resurrection Medical Center Abstract This article ...»

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The Journey to Integrate Watson’s Caring Theory with Clinical


Linda A. Ryan, PhD, RN

Resurrection Medical Center


This article describes the process of integrating Jean Watson’s (1985, 1988, 1999) caring

theory with nursing practice. Strategies to transition the theory from a multihospital

system conceptual level to a departmental-specific operational level are discussed. Benefits

and barriers in implementing nursing theory within the practice setting are also revealed.

Key Words: Watson, nursing, caring, theory, integration, implementation, benefits, barriers In the spring of 2003, the notion of integrating a nursing theory with clinical practice across a multihospital healthcare system emerged. Nursing leadership within the healthcare system recognized that clinical practice would be strengthened through the integration of an established nursing theory. An established nursing theory would strengthen practice by providing structure and language to describe, explain, support, and guide the professional nursing practice (Meleis, 1997). It would openly proclaim the beliefs and values that underpin the nursing practice, and thus it would express essences of professional nursing that had formerly been unspoken. It would make explicit what was previously merely implied. Additionally, by selecting and integrating one established nursing theory across the healthcare system, the vision for and language of nursing would be unified across the various entities of the system, solidifying and strengthening the system nursing practice as an integrated whole. This notion, then, was the impetus to begin the journey to integrate nursing theory with clinical practice.

The selection of a nursing theory was the logical first step to begin this journey. It was imperative that the selected nursing theory be congruent with the mission and core values of the healthcare organization. The mission of the organization purports that the organization “…exists to witness God’s sustaining love through compassionate, family-centered care. Motivated by a reverence for life and respect for those we serve, we are committed to improving the health and well-being of our community…” (Resurrection Health Care, 2005).

The core values of the organization are represented by the acronym CARES:

Compassion, Accountability, Respect, Excellence, and Service (Resurrection Health Care, 2005). Nursing leaders who were doctorally or masters-prepared, familiar with both the organization’s mission and core values, and nursing theories were consulted and asked to recommend a congruent nursing theory. Their recommendation was to integrate Watson’s (1985, 1988, 1999) caring theory as it was most consistent with the organization’s mission and core values.

A doctorally prepared nursing leader within the organization was then given the charge to facilitate the integration of the selected nursing theory and move the theory from a conceptual level to an operational level. Over the next several months, this nursing leader developed and presented various overviews of Watson’s (1985, 1988, 1999) caring theory to key persons within the organization, including facility board of directors and vice presidents, and system nurse executives and nursing leadership representatives. The board of directors, vice presidents, and system nurse executives were briefed on the reasons behind the initiative to integrate nursing theory with nursing practice and were given a summary of Watson’s caring theory. The system nursing leadership representatives were provided a full-day workshop to familiarize themselves with nursing theoretical concepts, to explore Watson’s caring theory, to discuss the ten carative factors from Watson’s (1985) foundational work and their relevance to nursing practice, and to develop strategic action plans to integrate the theory at their individual institutions. The strategic action plans developed at the end of the workshop included such ideas as providing written invitations to staff nurses to join discussion groups that explored the relevance of the caring theory to their own work, and/or to discuss carative factors at unit meetings. The strategic action plans thus explicated specific methods that the nursing leadership groups hoped to employ at each of their respective facilities to move the nursing theory from the conceptual level to the operational level.

With this foundational work in place, the doctorally prepared nursing leader next turned her focus on guiding the integration work within her home facility. That home hospital was linked with one of the other system hospitals for this endeavor; thus the nursing leader asked for volunteers from both of those two hospitals to participate in a council whose main objective was to integrate nursing theory with practice. Nursing directors, managers, educators, and staff nurses who embraced the tenets of Watson’s (1985, 1988, 1999) theory and/or those interested in exploring nursing theory and the possibilities of this endeavor were selected as participants. This core council consisted of 20 representatives from the two hospitals and eventually came to be known as the Caring Advocates.

The initial meeting of the Caring Advocates took place in May 2003. During that meeting, the nature of the council work and the role of the participants were discussed. The nature of the council work encompassed more than the completion of delegated tasks. So too, the participant role was broader in scope than merely task achievement. The council participants were expected to be scholars who would explore and reflect upon nursing theory, and guide their fellow nurses to do the same. The participants were to serve as bridges, supporting the journey to integrate nursing theory with clinical practice. They were to be catalysts that sparked the interest in nursing theory among their nursing colleagues and risk-takers, not afraid to challenge the status quo. They also needed to be visionaries that fostered new perspectives.

During this initial session, the impact of nurses’ belief systems upon the nature of their nursing practice was also explored. The participants considered how each nurse’s beliefs regarding the core concepts of nursing—the concepts of humans, health, and the environment— influence how they approach and care for others. To graphically depict the significance of underlying belief systems, two film clips were viewed: one showing the insensitive and controlling Nurse Ratched from the classic motion picture, One Flew Over the Cuckoo’s Nest (Zaentz, Douglas, & Forman, 1975) and the other depicting the sensitive and patient-centered nurse caring for the terminally ill English scholar, Vivian Bearing, in the motion picture, Wit (Bosanquet & Nichols, 2001). The participants discussed the possible belief systems held by each nurse depicted in the film portrayals; that is, what each nurse may have believed about humans, health, and the environment and then how those beliefs influenced how they valued and cared for their patients. This discussion led to a presentation revealing Watson’s (1988) beliefs regarding humans, health, and the environment.

Watson (1988) espouses that human life is “a gift to be cherished—a process of wonder,

awe and mystery” (p. 17). Watson also holds:

…a view of the human as a valued person in and of him- or herself to be cared for, respected, nurtured, understood and assisted; in general a philosophical view of a person as a fully functional integrated self. The human is viewed as greater than, and different from, the sum of his or her parts. (p. 14) Health is seen as “…unity and harmony within the mind, body, and soul…” (Watson, 1988, p. 48). Regarding the environment, Watson purports that within the current environment of

the healthcare system:

The person is split apart and the soul is replaced with narcissism of self or denied all together. The human soul is further destroyed with a depersonalized, manmade environment, advanced technology, and robot treatment for cure, delivered by strangers in a strange environment. (p. 39) She states that the “mandate for nursing…is a demand for cherishing the wholeness of human personality” and to focus on “human relationship and transaction between persons and their environment and how that affects health and healing…” (Watson, 1988, pp. 29, 14). She calls for a balance between high-tech and high-touch in the environment, and summons the nurse to be “… a scientist, scholar, and clinician but also a humanitarian and moral agent” (p. 54) that utilizes his/her person to transform the environment into one in which healing can occur.

Watson’s (1988) beliefs were compared to the beliefs that underpin the traditional medical model of healthcare. The beliefs of the traditional medical model reduce the human to body systems, or even further to individual cells or atoms, in order to cure a disease. The participants discussed the differences between the beliefs underpinning the traditional medical model and those undergirding the nursing model of healthcare. The dialogue among the Caring Advocates highlighted the fact that the nursing model and medical model are complimentary to but different from one another and that both perspectives are valuable to the health of society.

The Caring Advocates proceeded to meet every other week for 9 months exploring each of Watson’s (1985) ten carative factors in depth. According to Watson, these ten carative factors form a structure for studying and understanding nursing as the science of caring. Those carative

factors are:

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

2. The instillation of faith-hope.

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

4. The development of a helping-trust relationship.

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

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

7. The promotion of interpersonal teaching-learning.

8. The provision for a supportive, protective, and (or) corrective mental, physical, sociocultural, and spiritual environment.

9. Assistance with the gratification of human needs.

10. The allowance for existential-phenomenological forces (pp. 9-10).

It was felt that if the Caring Advocates were to be successful in bringing the caring theory to life at the nursing unit level, they would need an extensive understanding of and appreciation for the carative factors. The participants demonstrated full dedication to this endeavor and emerged themselves in this scholarly work. They prepared for the biweekly meetings by reading about each of the carative factors from Watson’s (1985) foundational work, Nursing: The Philosophy and Science of Caring. They thoughtfully considered and discussed reflective questions to deepen their understanding of the theoretical content and they willingly explored the relevance of each carative factor to their own nursing practice. The questions utilized to facilitate

the self-reflection and group discussion included such questions as:

1. What does this carative factor mean to you?

2. Do you see this carative factor lived out in your area of practice? If not, how would your practice setting be different if this carative factor were present?

3. Give an example of a situation in which a nurse displays this carative factor.

4. Give an example of a situation in which a nurse does not display this carative factor.

Participants were also asked to bring in and present creative arts that displayed the carative factors, such as poetry, paintings, and music.

Story-telling became a central component of the biweekly dialogues. Nurses on all levels of practice—from nursing administrators, to nursing managers, to nursing educators, to staff nurses—were able to share past practice situations in which the carative factors were exemplified. The participants were also able to discuss situations in which the carative factors were not present, which further led to dialogue about how nurse-patient encounters might have been enhanced if the carative factor had been utilized. These story-telling and creative art dialogues held several benefits. They brought the caring theory to life, moving it from a conceptual level to the operational level of the practice setting. They affirmed that the stellar nursing professionals were already living out the theory. The discussions confirmed that the caring theory actually did explain, describe, guide, and support nursing practice; it gave language to the previously unspoken beliefs and perspectives of the nursing profession, so that the nursing professionals could better envision, realize, and articulate their unique role in healthcare.

Once the Caring Advocates were knowledgeable of and comfortable with Watson’s (1985, 1988, 1999) caring theory, their next goals were to share the theory with their nursing colleagues and to make the theory an integral part of nursing practice. They developed essential

strategies to accomplish these goals. The strategies were to:

1. Weave the caring theory into the existing corporate nursing philosophy.

2. Introduce the revised corporate nursing philosophy and the caring theory to fellow nursing leaders.

3. Allow the nursing leadership team to develop tactics to best integrate the caring theory within their individual units.

4. Use the caring theory as a component of recruitment and selection of new nurses.

5. Introduce the revised corporate nursing philosophy and the caring theory to newly hired nursing personnel during orientation.

6. Weave the caring theory into the nursing job descriptions and clinical ladder.

7. Incorporate the nursing theory into future educational offerings, emphasizing the holistic nursing perspective.

8. Incorporate the carative factors into the clinical documentation system.

9. Revise nursing shift-report tools to enhance communication of individual patient preferences.

10. Empirically measure the impact of the initiative to integrate the caring theory into clinical practice.

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