According to Watson (1988), the word nurse is both noun and verb. To her, nursing consists of “knowledge, thought, values, philosophy, commitment, and action, with some degree of passion” (p. 53). Nurses are interested in understanding health, illness, and the human experience; promoting and restoring health; and preventing illness. Watson’s theory calls upon nurses to go beyond procedures, tasks, and techniques used in practice settings, coined as the trim of nursing, in contrast to the core of nursing, meaning those aspects of the nurse-patient relationship resulting in a therapeutic outcome that are included in the transpersonal caring process (Watson, 2005; 2012). Using the original and evolving 10 carative factors, the nurse provides care to various patients. Each carative factor and the clinical caritas processes describe the caring process of how a patient attains or maintains health or dies a peaceful death. Conversely, Watson has described curing as a medical term that refers to the elimination of disease (Watson, 1979). As Watson’s work evolved, she increased her focus on the human care process and the transpersonal aspects of caring-healing in a Transpersonal Caring Relationship (1999, 2005).

Watson’s evolving work continues to make explicit that humans cannot be treated as objects and that humans cannot be separated from self, other, nature, and the larger universe. The caring-healing paradigm is located within a cosmology that is both metaphysical and transcendent with the co-evolving human in the universe. She asks others to be open to possibility and to put away assumptions of self and others, to learn again, and to “see” using all of one’s senses.

Watson uses interchangeably the terms human being, person, life, personhood, and self. She views the person as “a unity of mind/body/spirit/nature” (1996, p. 147), and she says that “personhood is tied to notions that one’s soul possess a body that is not confined by objective time and space ….” (Watson, 1988, p. 45). Watson states, “I make the point to use mind, body, soul or unity within an evolving emergent world view-connectedness of all, sometimes referred to as Unitary Transformative Paradigm-Holographic thinking. It is often considered dualistic because I use the three words ‘mind, body, soul.’ I do it intentionally to connote and make explicit spirit/metaphysical—which is silent in other models” (Watson, personal communication, April 12, 1994).

Originally, Watson’s (1979) definition of health was derived from the World Health Organization as, “The positive state of physical, mental, and social well-being with the inclusion of three elements: (1) a high level of overall physical, mental, and social functioning; (2) a general adaptive-maintenance level of daily functioning; (3) the absence of illness (or the presence of efforts that lead to its absence)” (p. 220). Later, she defined health as “unity and harmony within the mind, body, and soul” associated with the “degree of congruence between the self as perceived and the self as experienced” (Watson, 1988, p. 48). Watson (1988) stated further, “illness is not necessarily disease; [instead it is a] subjective turmoil or disharmony within a person’s inner self or soul at some level of disharmony within the spheres of the person, for example, in the mind, body, and soul, either consciously or unconsciously” (p. 47). “While illness can lead to disease, illness and health are [a] phenomenon that is not necessarily viewed on a continuum. Disease processes can also result from genetic, constitutional vulnerabilities and manifest themselves when disharmony is present. Disease in turn creates more disharmony” (Watson, 1985, 1988, p. 48).

In the original ten carative factors, Watson speaks to the nurse’s role in the environment as “attending to supportive, protective, and or corrective mental, physical, societal, and spiritual environments” (Watson, 1979, p. 10). In later work, she has a much broader view of environment: “the caring science is not only for sustaining humanity, but also for sustaining the planet …. Belonging is to an infinite universal spirit world of nature and all living things; it is the primordial link of humanity and life itself, across time and space, boundaries and nationalities” (Watson, 2003, p. 305). She says that “healing spaces can be used to help others transcend illness, pain, and suffering,” emphasizing the environment and person connection: “when the nurse enters the patient’s room, a magnetic field of expectation is created” (Watson, 2003, p. 305).

Watson’s theory has been validated in outpatient, inpatient, and community health clinical settings and with various populations, including recent applications with attention to patient care essentials (Pipe, Connolly, Spahr, et al., 2012), living on a ventilator (Lindahl, 2011), and simulating care (Diener & Hobbs, 2012). Watson and Foster (2003) described an exemplary application of theory to practice; the Attending Nurse Caring Model (ANCM) is a unique pilot project in a Denver children’s hospital that is modeled after the “Attending” Physician Model. However, unlike a medical/cure model, the ANCM is concerned with the nursing care model. “It is constructed as a Nursing-Caring Science, theory-guided, evidence based, collaborative practice model for applying it to the conduct and oversight of pain management on a 37-bed, post surgical unit” (Watson & Foster, 2003, p. 363). Nurses who participate in the project learn about Watson’s caring theory, carative factors, caring consciousness, intentionality, and caring-healing practices. The mission of the ANCM is to have a continuous caring relationship with children in pain and their families. The ANCM is made visible in a caring-healing presence throughout the hospital. (See Watson’s website [http://www.watsoncaringscience.org] for examples of her theory in practice and further information about the many clinical agencies that use Watson’s work, such as Miami Baptist Hospital, Resurrection Health System [Chicago], Denver Veterans Administration Hospital and Children’s Hospital [Denver], Inova Health System [Virginia], Baptist Central Hospital [Kentucky], Elmhurst Hospital [New York], Pascak Valley Hospital [New Jersey], Sarasota Memorial Hospital and Tampa Memorial Hospital [Florida], and Scripps Memorial Hospital [California], among others.)

Watson’s theory calls for administrative practices and business models to embrace caring (Watson, 2006c), even in a health care environment of increased acuity levels of hospitalized individuals, short hospital stays, increasing complexity of technology, and rising expectations in the “task” of nursing. These challenges call for solutions that address health care system reform at a deep and ethical level, and that enable nurses to follow their own professional practice model rather than short-term solutions, such as increasing numbers of beds, sign-on bonuses, and/or relocation incentives for nurses. Many hospitals seeking Magnet status, such as Central Baptist Hospital in Lexington, Kentucky, are meeting these challenges by using Watson’s Theory of Human Caring for administrative change. Others call for sustaining a professional environment based on the definition of patient care essentials (Pipe, Connolly, Spahr, et al., 2012). This and other examples of caring administrative practices are described at her website and in her recent article, “Caring Theory as an Ethical Guide to Administrative and Clinical Practices” (Watson, 2006c).

Watson’s writings focus on educating graduate nursing students and providing them with ontological, ethical, and epistemological bases for their practice, along with research directions (Hills & Watson, 2011). Watson’s caring framework has been taught in numerous baccalaureate nursing curricula, including Bellarmine College in Louisville, Kentucky; Assumption College in Worcester, Massachusetts; Indiana State University in Terre Haute; Oklahoma City University; and Florida Atlantic University. In addition, the concepts are used in nursing programs in Australia, Japan, Brazil, Finland, Saudi Arabia, Sweden, and the United Kingdom, to name a few.

Qualitative, naturalistic, and phenomenological methods are relevant to the study of caring and to the development of nursing as a human science (Nelson & Watson, 2011; Watson, 2012). Watson suggests that a combination of qualitative-quantitative inquiry may be useful. There is a growing body of national and international research that tests, expands, and evaluates the theory (DiNapoli, Nelson, Turkel, & Watson, 2010; Nelson & Watson, 2011). Smith (2004) published a review of 40 research studies that specifically used Watson’s theory. Persky, Nelson, Watson, and Bent’s (2008) study used a quantitative approach to determine the attributes of a “Caritas nurse” as part of an effort to initiate Relationship-Based Care (RBC) at New York Presbyterian Hospital/Columbia University Medical Center. More recently, Nelson and Watson (2011) report on studies carried out in seven countries. Nelson and Watson (2011) present eight caring surveys and other research tools for caritas research, such as differences among international perceptions of caring, nurse and patient relationships, and guidelines for hospitals seeking Magnet status.

Watson uses nontechnical, sophisticated, fluid, and evolutionary language to artfully describe her concepts, such as caring-love, carative factors, and caritas. Paradoxically, abstract and simple concepts such as caring-love are difficult to practice, yet practicing and experiencing these concepts leads to greater understanding. At times, lengthy phrases and sentences are best understood if read more than once. Watson’s inclusion of metaphors, personal reflections, artwork, and poetry make her concepts more tangible and more aesthetically appealing. She has continued to refine her theory and has revised the original carative factors as caritas processes. Critics of Watson’s work have concentrated on her use of undefined or changing/shifting definitions and terms and her focus on the psychosocial rather than the pathophysiological aspects of nursing. Watson (1985) has addressed the critiques of her work in the preface of Nursing: The Philosophy and Science of Caring (1979, 1988); in the preface of Nursing: Human Science and Human Care—A Theory of Nursing (1985),and in Caring Science as Sacred Science (Watson, 2005). Table 7-1 outlines the evolution of Watson’s thinking.

The theory does not furnish explicit direction about what to do to achieve authentic caring-healing relationships. Nurses who want concrete guidelines may not feel secure when trying to use this theory alone. Some have suggested that it takes too much time to incorporate the caritas into practice, and some note that Watson’s personal growth emphasis is a quality “that while appealing to some may not appeal to others” (Drummond, 2005, p. 218).

Watson describes her theory as descriptive; she acknowledges the evolving nature of the theory and welcomes input from others (Watson, 2012). Although the theory does not lend itself easily to research conducted through traditional scientific methods, recent qualitative nursing approaches are appropriate. Recent work on measurement reviews a broad array of international studies and provides research guidelines, design recommendations, and instruments for caring research (Nelson & Watson, 2011).