Jean Watson

Introduction

Theorist was born in West Virginia, US Educated: BSN, University of Colorado, 1964, MS, University of Colorado, 1966, PhD, University of Colorado, 1973 Distinguished Professor of Nursing and endowed Chair in Caring Science at the University of Colorado Health Sciences Center. Fellow of the American Academy of Nursing. Previously, Dean of Nursing at the University Health Sciences Center and President of the National League for Nursing Undergraduate and graduate degrees in nursing and psychiatric-mental health nursing and PhD in educational psychology and counseling. She has six (6) Honorary Doctoral Degrees. Her research has been in the area of human caring and loss. In 1988, her theory was published in nursing: human science and human care.

The seven assumptions

Caring can be effectively demonstrated and practiced only interpersonally. Caring consists of carative factors that result in the satisfaction of certain human needs. Effective caring promotes health and individual or family growth. Caring responses accept person not only as he or she is now but as what he or she may become. A caring environment is one that offers the development of potential while allowing the person to choose the best action for himself or herself at a given point in time. Caring is more healthogenic than is curing. A science of caring is complementary to the science of curing. The practice of caring is central to nursing.

The ten primary carative factors 1. The formation of a humanistic- altruistic system of values. 2. The installation of faith-hope. 3. The cultivation of sensitivity to ones 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, socio-cultural and spiritual environment. 9. Assistance with the gratification of human needs. 10. The allowance for existential-phenomenological forces.

The first three carative factors form the philosophical foundation for the science of caring. The remaining seven carative factors spring from the foundation laid by these first three. 1. The formation of a humanistic- altruistic system of values

Begins developmentally at an early age with values shared with the parents. Mediated through ones own life experiences, the learning one gains and exposure to the humanities. Is perceived as necessary to the nurses own maturation which then promotes altruistic behavior towards others.

2. Faith-hope

Is essential to both the carative and the curative processes. When modern science has nothing further to offer the person, the nurse can continue to use faith-hope to provide a sense of well-being through beliefs which are meaningful to the individual.

3. Cultivation of sensitivity to ones self and to others

Explores the need of the nurse to begin to feel an emotion as it presents itself. Development of ones own feeling is needed to interact genuinely and sensitively with others. Striving to become sensitive, makes the nurse more authentic, which encourages self-growth and self-actualization, in both the nurse and those with whom the nurse interacts. The nurses promote health and higher level functioning only when they form person to person relationship.

4. Establishing a helping-trust relationship

Strongest tool is the mode of communication, which establishes rapport and caring. Characteristics needed to in the helping-trust relationship are:
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Congruence Empathy Warmth

Communication includes verbal, nonverbal and listening in a manner which connotes empathetic understanding.

5. The expression of feelings, both positive and negative

Feelings alter thoughts and behavior, and they need to be considered and allowed for in a caring relationship. Awareness of the feelings helps to understand the behavior it engenders.

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

The scientific problem- solving method is the only method that allows for control and prediction, and that permits self-correction. The science of caring should not be always neutral and objective.

7. Promotion of interpersonal teaching-learning

The caring nurse must focus on the learning process as much as the teaching process. Understanding the persons perception of the situation assist the nurse to prepare a cognitive plan.

8. Provision for a supportive, protective and /or corrective mental, physical, socio-cultural and spiritual environment

Watson divides these into eternal and internal variables, which the nurse manipulates in order to provide support and protection for the persons mental and physical well-being. The external and internal environments are interdependent. Nurse must provide comfort, privacy and safety as a part of this carative factor.

9. Assistance with the gratification of human needs

It is based on a hierarchy of need similar to that of the Maslows.

Each need is equally important for quality nursing care and the promotion of optimal health. All the needs deserve to be attended to and valued.

Watsons ordering of needs

Lower order needs (biophysical needs)

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The need for food and fluid The need for elimination The need for ventilation

Lower order needs (psychophysical needs)

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The need for activity-inactivity The need for sexuality

Higher order needs (psychosocial needs)

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The need for achievement The need for affiliation Higher order need (intrapersonal-interpersonal need) The need for self-actualization

10. Allowance for existential-phenomenological forces

Phenomenology is a way of understanding people from the way things appear to them, from their frame of reference. Existential psychology is the study of human existence using phenomenological analysis. This factor helps the nurse to reconcile and mediate the incongruity of viewing the person holistically while at the same time attending to the hierarchical ordering of needs. Thus the nurse assists the person to find the strength or courage to confront life or death.

Watsons theory and the four major concepts 1. Human being

Human being refers to .. 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. He, human is viewed as greater than and different from, the sum of his or her parts. 2. Health

Watson adds the following three elements to WHO definition of health:

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A high level of overall physical, mental and social functioning A general adaptive-maintenance level of daily functioning The absence of illness (or the presence of efforts that leads its absence)

3.

Environment/society According to Watson, caring (and nursing) has existed in every society. A caring attitude is not transmitted from generation to generation. It is transmitted by the culture of the profession as a unique way of coping with its environment. Nursing

4.

Nursing is concerned with promoting health, preventing illness, caring for the sick and restoring health. It focuses on health promotion and treatment of disease. She believes that holistic health care is central to the practice of caring in nursing. She defines nursing as.. a human science of persons and human health-illness experiences that are mediated by professional, personal, scientific, esthetic and ethical human transactions.

Watsons theory and nursing process

Nursing process contains the same steps as the scientific research process. They both try to solve a problem. Both provide a framework for decision making. Assessment

1.

Involves observation, identification and review of the problem; use of applicable knowledge in literature. Also includes conceptual knowledge for the formulation and conceptualization of framework. Includes the formulation of hypothesis; defining variables that will be examined in solving the problem.

2.

Plan It helps to determine how variables would be examined or measured; includes a conceptual approach or design for problem solving. It determines what data would be collected and how on whom. Intervention

3.

It is the direct action and implementation of the plan. It includes the collection of the data. Evaluation

4.

Analysis of the data as well as the examination of the effects of interventions based on the data. Includes the interpretation of the results, the degree to which positive outcome has occurred and whether the result can be generalized. It may also generate additional hypothesis or may even lead to the generation of a nursing theory.

Watsons work and the characteristic of a theory 1. The basic assumptions for the science of caring in nursing and the ten carative factors that form the structure for that concept is unique in Watsons theory. 2. Watsons work is logical in that the factors are based on broad assumptions which provide a supportive framework. 3. The theory is relatively simple as it does not use theories from other disciplines that are familiar to nursing. The theory is simple relatively but the fact that it de-emphasizes the pathophysiological for the psychosocial diminishes its ability to be generalizable. 4. Watsons theory is based on phenomenological studies that generally ask questions rather than state hypotheses. 5. Watsons work can be used to guide and improve practice. 6. Watsons work is supported by the theoretical work of numerous humanists, philosophers, developmentalists and psychologists. Strengths

This theory places client in the context of the family, the community and the culture. It places the client as the focus of practice rather than the technology.

Limitations

While Watson acknowledges the need for biophysical base to nursing, this area receives little attention in her writings. The ten caratiive factors primarily delineate the psychosocial needs of the person. While the carative factors have a sound foundation based on other disciplines, they need further research in nursing to demonstrate their application to practice.

Research related to Watsons theory The effectiveness of Watson's Caring Model on the quality of life and blood pressure of patients with hypertension. J Adv Nurs. 2003 Jan;41(2):130-9.

This study demonstrated a relationship between care given according to Watson's Caring model and increased quality of life of the patients with hypertension. Further, in those patients for whom the caring model was practised, there was a relationship between the Caring model and a decrease in patient's blood pressure. The Watson Caring Model is recommended as a guide to nursing patients with hypertension, as one means of decreasing blood pressure and increase in quality of life.

Martin, L. S. (1991). Using Watsons theory to explore the dimensions of adult polycystic kidney disease . ANNA Journal, 18, 403-406 . Mullaney, J. A. B. (2000). The lived experience of using Watsons actual caring occasions to treat depressed women . Journal of Holistic Nursing, 18(2), 129-142 Martin, L. S. (1991). Using Watsons theory to explore the dimensions of adult polycystic kidney disease . ANNA Journal, 18, 403-406 Conclusion

Watson provides many useful concepts for the practice of nursing. She ties together many theories commonly used in nursing education. The detailed descriptions of the carative factors can give guidance to those who wish to employ them in practice or research.

Myra Levine
About the Theorist Born in Chicago Also called as renaissance women-highly principled, remarkable and committed to patients quality of care Died in 1996 Educational Achievement Diploma in nursing:-Cook county SON, Chicago, 1944 BSN:-University of Chicago,1949 MSN:-Wayne state University, Detroit, 1962 Publication:-An Introduction to Clinical Nursing, 1969,1973 & 1989 Received honorary doctorate from Loyola University in 1992 Achievements Clinical experience in OT technique and oncology nursing Civilian nurse at the Gardiner general hospital Director of nursing at Drexel home in Chicago Clinical instructor at Bryan memorial hospital in Lincoln, Nebraska Administrative supervisor at university of Chicago Chairperson of clinical nursing at cook country SON Visiting professor at Tel Aviv university in Israel Conservational model

Goal: To promote adaptation and maintain wholeness using the principles of conservation Model guides the nurse to focus on the influences and responses at the organismic level Nurse accomplishes the goal of model through the conservation of energy, structure and personal and social integrity

Adaptation

Every individual has a unique range of adaptive responses The responses will vary by heredity, age, gender or challenges of illness experiences While the responses are same, the timing and manifestation of organismic responses will be unique for each individual pulse rate) An ongoing process of change in which patient maintains his integrity within the realities of environment Achieved through the "frugal, economic, contained and controlled use of environmental resources by individual in his or her best interest"

Wholeness Exist when the interaction or constant adaptations to the environment permits the assurance of integrity Promoted by use of conservation principle Conservation The product of adaptation "Keeping together "of the life systems or the wholeness of the individual Achieving a balance of energy supply and demand that is with in the unique biological realities of the individual Nursings paradigm Person A holistic being who constantly strives to preserve wholeness and integrity A unique individual in unity and integrity, feeling, believing, thinking and whole system of system Environment

Competes the wholeness of person Internal Homeostasis Homeorrhesis External Preconceptual Operational Conceptual Internal Environment

Homeostasis: A state of energy sparing that also provide the necessary baselines for a multitude of synchronized physiological and psychological factors A state of conservation Homeorrhesis: A stabilized flow rather than a static state Emphasis the fluidity of change within a space-time continuum Describe the pattern of adaptation, which permit the individuals body to sustain its well being with the vast changes which encroach upon it from the environment External Environment

Preconceptual: Aspect of the world that individual are able to intercept Operational: Elements that may physically affects individuals but not perceived by hem: radiation, micro-organism and pollution Conceptual: Part of person's environment including cultural patterns characterized by spiritual existence, ideas, values, beliefs and tradition

Person and environment Adaptation Organismic response Conservation Adaptation Characteristics Historicity: Adaptations are grounded in history and await the challenges to which they respond Specificity: Individual responses and their adaptive pattern varies on the base of specific genetic structure Redundancy: Safe and fail options available to the individual to ensure continued adaptation Organismic response A change in behavior of an individual during an attempt to adapt to the environment Help individual to protect and maintain their integrity They co-exist They are four types: 1. Flight or fight: An instantaneous response to real or imagined threat, most primitive response 2. Inflammatory: response intended to provide for structural integrity and the promotion of healing 3. Stress: Response developed over time and influenced by each stressful experience encountered by person 4. Perceptual: Involves gathering information from the environment and converting it in to a meaning experience Nine models of guided assessment Vitals signs Body movement and positioning Ministration of personal hygiene needs Pressure gradient system in nursing interventions Nursing determination in provision of nutritional needs Pressure gradient system in nursing Local application of heat and cold Administration of medicine Establishing an aseptic environment Assumption

The nurse creates an environment in which healing could occur A human being is more than the sum of the part Human being respond in a predictable way

Human being are unique in their responses Human being know and appraise objects ,condition and situation Human being sense, reflects, reason and understand human being action are self determined even when emotional Human being are capable of prolonging reflection through such strategists raising questions Levines work & Characteristics of theory Theories can interrelate concepts in such a way as to create a different way of looking at a particular phenomenon

The concept of illness adaptation, using interventions, and the evaluation of nursing interventions are interrelated .they are combined to look at nursing care in a different way (more comprehensive view incorporating total patient care) form previous time.

Theories must be logical in nature.

Levines idea about nursing care are organized in such a way as to b sequential and logical. they can be used to explain the consequences of nursing action

Theories should be relatively simple yet generalizable. Levines theory is easy to use . Its major elements are easily comprehensible and the relation ship have the potential for being complex but are easily manageable Certain isolated aspect of the theory are the generalizable i.e. those related to the conservational principles Theories can be the bases for hypotheses that can be tested. Levines idea can be tested Hypothesis can be derived from them . The principle of conservation are specific enough to be testable Theories contribute to and assist in increasing the general body of knowledge within the discipline through the research implemented to validate them.

Since Levines idea have not yet been widely researched ,it is hard o determine the contribution to the general body of knowledge with in the discipline

Theories can be utilized by the practitioner to guide and improve their practice.

Paula E.Crawford-gamble :-successfully applied Levines theory to the female patient undergoing surgery for the traumatic amputation of the fingers These ideas lend themselves to use in practice particularly in acute care setting

Theories must be consistent with other validated theories, laws and principles but will leave open unanswered questions that need to be investigated .

Levines ideas seem to be consistent with other theories, laws and principles particularly those from the humanities and sciences

Conservational Principle Conservation of energy Conservation of structural integrity Conservation of personal integrity Conservation of social integrity 1. Conservation of energy Refers to balancing energy input and output to avoid excessive fatigue includes adequate rest, nutrition and exercise Example: Availability of adequate rest Maintenance of adequate nutrition 2. Conservation of structural integrity Refers to maintaining or restoring the structure of body preventing physical breakdown And promoting healing Example: Assist patient in ROM exercise Maintenance of patients personal hygiene 3. Conservation of personal integrity Recognizes the individual as one who strives for recognition, respect, self awareness, selfhood and self determination Example: Recognize and protect patients space needs 4. Conservation of social integrity An individual is recognized as some one who resides with in a family, a community ,a religious group, an ethnic group, a political system and a nation Example: Position patient in bed to foster social interaction with other patients Avoid sensory deprivation Promote patients use of news paper, magazines, radio. TV Provide support and assistance to family

Health

Health is a wholeness and successful adaptation It is not merely healing of an afflicted part ,it is return to daily activities, selfhood and the ability of the individual to pursue once more his or her own interest without constraints Disease: It is unregulated and undisciplined change and must be stopped or death will ensue

Nursing "Nursing is a profession as well as an academic discipline, always practiced and studied in concert with all of the disciplines that together from the health sciences" The human interaction relying on communication ,rooted in the organic dependency of the individual human being in his relationships with other human beings Nursing involves engaging in "human interactions" Goal of Nursing To promote wholeness, realizing that every individual requires a unique and separate cluster of activities o The individual integrity is his abiding concern and it is the nurses responsibility to assist him to defend and to seek its realization o Human being make decision through prioritizing course of action o Human being must be aware and able to contemplate objects, condition and situation o Human being are agents who act deliberately to attain goal o Adaptive changes involve the whole individual o A human being has unity in his response to the environment o Every person possesses a unique adaptive ability based on ones life experience which creates a unique message o There is an order and continuity to life change is not random o A human being respond organismically in an ever changing manner o A theory of nursing must recognized the importance of detail of care for a single patient with in an empiric framework that successfully describe the requirement of the all patient o A human being is a social animal o A human being is an constant interaction with an ever changing society o Change is inevitable in life o Nursing needs existing and emerging demands of self care and dependant care o Nursing is associated with condition of regulation of exercise or development of capabilities of providing care Nursing Process o Assessment o Trophicognosis o Hypothesis o Interventions o Evaluation
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Assessment
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Collection of provocative facts through observation and interview of challenges to the internal and external environment using four conservation principles Nurses observes patient for organismic responses to illness, reads medical reports. talks to patient and family Assesses factors which challenges the individual

Trophicognosis
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Nursing diagnosis-gives provocative facts meaning A nursing care judgment arrived at through the use of the scientific process Judgment is made about patients needs for assistance

Hypothesis
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Planning Nurse proposes hypothesis about the problems and the solutions which becomes the plan of care Goal is to maintain wholeness and promoting adaptation

Interventions
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Testing the hypothesis Interventions are designed based on the conservation principles Mutually acceptable Goal is to maintain wholeness and promoting adaptation

Evaluation Observation of organismic response to interventions o It is assesses whether hypothesis is supported or not supported o If not supported, plan is revised, new hypothesis is proposed Conservational models Conservational model provides the basis for development of two theories Theory of redundancy Theory of therapeutic intention Theory of redundancy
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Untested ,speculative theory that redefined aging and everything else that has to do with human life Aging is diminished availability of redundant system necessary for effective maintenance of physical and social well being

Theory of therapeutic intention Goal: To seek a way of organizing nursing interventions out of the biological realities which the nurse has to confront o Therapeutic regimens should support the following goals: o Facilitate healing through natural response to disease o Provide support for a failing auto regulatory portion of the integrated system o Restore individual integrity and well being Theory of therapeutic intention Provide supportive measure to ensures comfort o Balance a toxic risk against the threat of disease o Manipulate diet and activity to correct metabolic imbalance and stimulate physiological process o Reinforce usual response to create a therapeutic changes Uses of the theory Critical, acute or long term care unit Neonates, infant and young children, pregnant young adult and elderly care unit o Primary health care o OT o Community setting Utility of Theory
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Nursing research o Nursing education o Nursing administration o Nursing practice Nursing research Principles of conservation have been used for data collection in various researches o Conservational model was used by Hanson et al.in their study of incidence and prevalence of pressure ulcers in hospice patient o Newport used principle of conservation of energy and social integrity for comparing the body temperature of infants who had been placed on mothers chest immediately after birth with those who were placed in warmer Nursing education
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Conservational model was used as guidelines for curriculum development It was used to develop nursing undergraduate program at Allentown college of St.Francis de sales, Pennsylvania Used in nursing education program sponsored by Kapat Holim in Israel

Nursing administration
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Taylor described an assessment guide for data collection of neurological patients which forms basis for development of comprehensive nursing care plan and thus evaluate nursing care McCall developed an assessment tool for data collection on the basis of four conservational principles to identify nursing care needs of epileptic patients Family assessment tool was designed by Lynn-Mchale and Smith for families of patient in critical care setting

Nursing practice
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Conservational model has been used for nursing practice in different settings Bayley discussed the care of a severely burned teenagers on the basis of four conservational principles and discussed patients perceptual, operational and conceptual environment Pond used conservation model for guiding the nursing care of homeless at a clinic, shelters or streets

Nursing process according to Levines model Mrs. MN, a wife of an abusive husband, underwent a radical hysterectomy. Post operatively has pain ,weight loss, nausea and inability to empty bladder .Patient has history of smoking and stays in house which is less than sanitary Assessment
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Challenges to the internal env:-weight loss, nausea, loss of reproductive ability Challenges to the external env:-abusive husband, insanitary condition in home Energy conservation:-weight loss, nausea ,pain Structural integrity:-threatened by surgical procedure, inability to pass urine Personal integrity:-not able to give birth to more children Social integrity:-Strained relationship with husband

Trophicognosis
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Inadequate nutritional status Pain

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Potential for wound and bladder infection Need to learn self catheterization Decreased self worth Potential for abuse

Hypothesis
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Nutritional consultation Teaching and return demonstration of urinary self catheterization Care of surgical wound Exploring concern regarding hysterectomy

Interventions Energy conservation

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Provide medication for pain and nausea Allowing rest period

Structural integrity
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Administrating antibiotic for wound, Teaching self catheterization

Personal integrity
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Exploring her feeling about uterus removal while respecting her privacy

Social integrity
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Assess potential abuse form husband Support to the family

Organismic response
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Controlled pain Abdominal wound healing Improved appetite ,weight gain Clean urinary self catheterization

Assistance from husband

Critiquing the theory

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She values the holistic approach to all individual, well or sick Values patients participation in nursing care Comprehensive content in depth Provides direction of nursing research , education, administration and practice Logically congruent Shows high regard to adjunctive disciplines to develop theoretical basis for nursing

Limitation
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Limited attention can be focused on health promotion and illness prevention. Nurse has the responsibility for determining the patient ability to participate in the care ,and if the perception of nurse and patient about the patient ability to participate in care dont match, this mismatch will be an area of conflict. The major limitation is the focus on individual in an illness state and on the dependency of patient.

Research Highlights
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A theory of health promotion for preterm infants based on conservational model of nursing. Nursing science quarterly,2004 Jul,17 (3)

The article describes a new middle range theory of health promotion for preterm infants based on Levines conservational model that can be used to guide neonatal nursing practice.