In the 1980s, Watson and colleagues established the Center for Human Caring at the University of Colorado, the nation’s first interdisciplinary center committed to using human caring knowledge that forms the moral and scientific basis for clinical practice, scholarship, and administration and leadership (Watson, 1986). During the center’s existence, Watson and others sponsored clinical, educational, and community scholarship activities and projects in human caring. These activities involved national and international scholars in residence, as well as international connections with colleagues around the world, such as Australia, Brazil, Canada, Korea, Japan, New Zealand, United Kingdom, Scandinavia, Thailand, and Venezuela, among others. Activities such as these continue at the University of Colorado’s International Certificate Program in Caring-Healing, where Watson offers her theory courses for doctoral students. Her first book, Nursing: The Philosophy and Science of Caring (1979), was developed from her notes for an undergraduate course taught at the University of Colorado. Yalom’s 11 curative factors stimulated Watson’s thinking about her 10 carative factors, described as the organizing framework for her book (Watson, 1979), “central to nursing” (p. 9), and a moral ideal. Watson’s early work embraced the 10 carative factors, but her ideas have evolved to include “caritas” that make explicit connections between caring and love (Watson, personal correspondence, 2004). Her first book was reprinted in 1985 and subsequently was translated into Korean and French. Her second book, Nursing: Human Science and Human Care—A Theory of Nursing, published in 1985 and reprinted in 1988 and 1999, addressed some conceptual and philosophical problems in nursing. Watson (1985) hopes her work will help nurses develop a meaningful moral and philosophical base for practice, and that others will join her to “elucidate the human care process in nursing, preserve the concept of the person in our science, and better our contribution to society” (Watson, 1988, p. ix). Her second book has been translated into Chinese, German, Japanese, Korean, Swedish, Norwegian, Danish, and probably other languages by now. Her third book, Postmodern Nursing and Beyond (1999), was presented as a model to bring nursing practice into the twenty-first century. Watson describes two personal life-altering events that contributed to her writing. In 1997, she experienced an accidental injury that resulted in the loss of her left eye. Soon after, in 1998, her husband died. Watson states that she is “attempting to integrate these wounds into my life and work. One of the gifts through the suffering was the privilege of experiencing and receiving my own theory through the care from my husband and loving nurse friends and colleagues” (Watson, personal communication, August 31, 2000). This third book has been translated into Portuguese and Japanese. Instruments for Assessing and Measuring Caring in Nursing and Health Sciences (2002) is a collection of 21 instruments used to assess and measure caring. This text received the American Journal of Nursing Book of the Year Award. Her fifth and latest book, Caring Science as Sacred Science (2005), describes her personal journey to enhance understanding about caring science, spiritual practice, the concept and practice of care, and caring-healing work. This book leads the reader through thought-provoking experiences and the sacredness of nursing by emphasizing deep inner reflection and personal growth, communication skills, use of self-transpersonal growth, and attention to both caring science and healing through forgiveness, gratitude, and surrender. It received AJN’s 2005 Book of the Year Award. Watson’s work has been called a philosophy, blueprint, ethic, paradigm, worldview, treatise, conceptual model, framework, and theory (Watson, 1996). This chapter uses the terms theory and framework interchangeably. To develop her theory, Watson (1988) defines theory as “an imaginative grouping of knowledge, ideas, and experience that are represented symbolically and seek to illuminate a given phenomenon” (p. 1). She states further, “It (Human Science) is a theory because it helps me ‘to see’ more broadly (clearly)” (p. 1). Watson draws heavily on the sciences and the humanities, providing a phenomenological, existential, and spiritual orientation. She acknowledges philosophical and intellectual guidance from feminist theory, metaphysics, phenomenology, quantum physics, wisdom traditions, perennial philosophy, and Buddhism (Watson, 1995, 1997, 1999, 2005). In addition to traditional nursing knowledge, she cites as background for her theory nursing philosophies and theorists, including Nightingale, Henderson, Leininger, Peplau, Rogers, and Newman, and the work of Gadow, a nursing philosopher and healthcare ethicist (Watson, 1985, 1997, 2005). She describes a close connection with “Nightingale’s sense of ‘calling,’ guided by a deep sense of commitment and a covenantal ethic of human service” (Watson, 2007a). Watson reports that she was influenced in her earlier work by Western and Eastern worldviews and by philosophers such as Carl Rogers, Maslow, Heidegger, Erickson, Kierkegaard, Selye, Lazarus, Rumi, Whitehead, de Chardin, Sartre, and Thich Naht Hanh (Watson, 1996). Watson attributes her emphasis on the interpersonal and transpersonal qualities of congruence, empathy, and warmth to the views of Carl Rogers and more recent writers of transpersonal psychology. Watson points out that Carl Rogers’ phenomenological approach, with his view that nurses are not here to manipulate and control others but rather to understand, was profoundly influential at a time when “clinicalization” (therapeutic control and manipulation of the patient) was considered the norm (Watson, personal communication, August 31, 2000). In her latest book, Caring Science as Sacred Science, Watson (2005) describes the wisdom of French philosopher, Emmanuael Levinas (1969), and Danish philosopher, Knud Løgstrup (1995), which is foundational to her work. Watson explains that concepts, defined as building blocks of theory (Watson, 1988), bring new meaning to the paradigm of nursing and were “derived from clinically inducted, empirical experiences, combined with my philosophical, intellectual and experiential background; thus my early work emerged from my own values, beliefs, and perceptions about personhood, life, health, and healing …” (Watson, 1997, p. 49). Watson’s main concepts include the 10 carative factors (see box below or Table 7-1), and transpersonal healing and transpersonal caring relationship, caring moment, caring occasion, caring healing modalities, caring consciousness, caring consciousness energy, and phenomenal file/unitary consciousness. Watson expanded the carative factors to a closely related concept, caritas, a Latin word that means to “cherish, to appreciate, to give special attention, if not loving attention.” As carative factors evolved within an expanding perspective, and as her ideas and values evolved, Watson offered a translation of the original carative factors into clinical caritas processes that suggested open ways in which they could be considered (Table 7-1). Table 7-1 Carative Factors and Caritas Process From Watson, J. (1979). Nursing: The philosophy and science of caring (pp. 9-10). Boston: Little, Brown & Co. (for original carative factors); and Watson, J. (2004). Theory of human caring (website). Denver, CO: Jean Watson/University of Colorado School of Nursing. Retrieved January 25, 2008, from: http://hschealth.uchsc.edu/son/faculty/jw_evolution.htm (for caritas processes and revised carative factors). Watson (1999) describes a “Transpersonal Caring Relationship” as foundational to her theory; it is a “special kind of human care relationship—a union with another person—high regard for the whole person and their being-in-the-world” (p. 63). Watson’s research into caring incorporates empiricism, but it emphasizes methods that begin with nursing phenomena rather than with the natural sciences (Leininger, 1979). She has used human science, empirical phenomenology, and transcendent phenomenology in her work. She has investigated new languages, such as metaphor and poetry, to communicate, convey, and elucidate human caring and healing (Watson, 1987, 2005). In her inquiry and writing, she increasingly incorporates her conviction that a sacred relationship exists between humankind and the universe (Watson, 1997, 2005). Watson calls for joining of science with humanities so that nurses will have a strong liberal arts background and will understand other cultures as a requisite for using Caring Science and a mind-body-spiritual framework. She believes that study of the humanities expands the mind and enhances thinking skills and personal growth. Watson compares the current status of nursing with the mythological Danaides, who attempted to fill a broken jar with water, only to see water flow through the cracks. Until nursing merges theory and practice through the combined study of the sciences and the humanities, Watson believes that similar cracks will be evident in the scientific basis of nursing knowledge (Watson, 1981, 1997). 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. Her 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; Watson, 2007). Using the original and evolving 10 carative factors, the nurse provides care to various patients. Each carative factor and, more recently, the clinical caritas processes describe the caring process of how a patient attains or maintains health or dies a peaceful death. Conversely, Watson describes curing as a medical term that refers to the elimination of disease (Watson, 1979). As Watson’s work has evolved, she has 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 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. The context calls for a “sense of reverence and sacredness with regard to life and all living things. It incorporates both art and science, as they are also being redefined, acknowledging a convergence between the two” (Watson, 2007, para. 14). 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 describes 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” it is 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 her later work, she describes that “healing spaces can be used to help others transcend illness, pain, and suffering,” and she emphasizes that environment and person are connected: “when the nurse enters the patient’s room, a magnetic field of expectation is created” (Watson, 2003, p. 200). She also has a broad 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). Watson’s theory has foundational support from theorists in other disciplines, such as Rogers, Erikson, and Maslow. She is adamant in her support for nursing education that incorporates holistic knowledge from many disciplines and integrates the humanities, arts, and sciences. She believes that the increasingly complex requirements of the healthcare system and patient needs require nurses to have a broad, liberal education. The ideals, content, and theory of liberal education must be integrated into professional nursing education (Sakalys & Watson, 1986). Watson recently has incorporated dimensions of a postmodern paradigm shift throughout her theory of transpersonal caring. Modern theoretical underpinnings have been associated with concepts such as steady-state maintenance, adaptation, linear interaction, and problem-based nursing practice. The postmodern approach moves beyond this point; the redefining of such a nursing paradigm leads to a more holistic, humanistic, open system, wherein harmony, interpretation, and self-transcendence are the emerging directions reflected in this epistemological shift. Watson (1999) believes that nursing must be challenged to construct and co-construct ancient and new knowledge toward an ever-evolving humanity of possibilities to further clarify nursing for a new era. “The theory evolution has tended to place greater emphasis on transpersonal caring, intentionality, caring consciousness, and the caring field” (Watson, personal communication, August 21, 2000).
Watson’s Philosophy and Theory of Transpersonal Caring
CREDENTIALS AND BACKGROUND OF THE THEORIST
THEORETICAL SOURCES
Carative Factors
Caritas Process
1. “The formation of a humanistic-altruistic system of values”
“Practice of loving-kindness and equanimity within the context of caring consciousness”
2. “The instillation of faith-hope”
“Being authentically present and enabling and sustaining the deep belief system and subjective life-world of self and one being cared for”
3. “The cultivation of sensitivity to one’s self and to others”
“Cultivation of one’s own spiritual practices and transpersonal self going beyond the ego self”
4. “Development of a helping-trust relationship” became “development of a helping-trusting, human caring relation” (in 2004 Watson website)
“Developing and sustaining a helping trusting authentic caring relationship”
5. “The promotion and acceptance of the expression of positive and negative feelings”
“Being present to, and supportive of, the expression of positive and negative feelings as a connection with deeper spirit and self and the one-being-cared for”
6. “The systematic use of the scientific problem solving method for decision making” became “systematic use of a creative problem solving caring process” (in 2004 Watson website)
“Creative use of self and all ways of knowing as part of the caring process; to engage in the artistry of caring-healing practices”
7. “The promotion of transpersonal teaching-learning”
“Engaging in genuine teaching-learning experience that attends to unity of being and meaning, attempting to stay within others’ frame of reference”
8. “The provision of supportive, protective, and (or) corrective mental, physical, societal, and spiritual environment”
“Creating healing environment at all levels (physical as well as nonphysical, subtle environment of energy and consciousness, whereby wholeness, beauty, comfort, dignity, and peace are potentiated)”
9. “The assistance with gratification of human needs”
“Assisting with basic needs, with an intentional caring consciousness, administering ‘human care essentials,’ which potentiate alignment of mind body spirit, wholeness, and unity of being in all aspects of care”
10. “The allowance for existential-phenomenological forces” became “allowance for existential-phenomenological-spiritual forces” (in 2004 Watson website)
“Opening and attending to spiritual-mysterious and existential dimensions of one’s own life-death; soul care for self and the one-being-cared for”
USE OF EMPIRICAL EVIDENCE
MAJOR ASSUMPTIONS
Moral commitment, intentionality, and caritas consciousness by the nurse protect, enhance, and potentiate human dignity, wholeness, and healing, thereby allowing a person to create or co-create his/her own meaning for existence.
Continuous growth for developing and maturing within a transpersonal caring model is ongoing. The notion of health professionals as wounded healers is acknowledged as part of the necessary growth and compassion called forth within this theory/philosophy (Watson, 2006b).
THEORETICAL ASSERTIONS
Nursing
Personhood (Human Being)
Health
Environment
LOGICAL FORM
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