Watsons Theory of Transpersonal Caring applied to BSN

Watson’s Theory of Transpersonal Caring applied to BSN students Seton Hall University Emerging Nursing Theory NUR 8101 Dr. Marie Foley, Ph. D, RN, CSN-NJ Jeannie Couper, MSN, RN-BC November 17, 2011

Theory of Transpersonal Caring (WTTC) (1979) Caring for the purpose of: Ë Promoting healing Ë Preserving dignity Ë Respecting the wholeness Nursing is healing art and science dedicated to the pursuit of harmonious and sacred relationships Challenges nursing: Ë To rediscover its healing traditions Ë Expanding its mission for caring relationships

Based on Nightingale's concepts Transform the professional Used by schools and hospitals- return the human element back into study and the practice of nursing Advocates for liberal art education Emphasis on philosophy and values Watson’s intent was not to be prescriptive but a paradigm Biomedical/natural science model ->postmodern/human science perspective Distinct from medicine with emphasis on disease and curing

Human Science Paradigm Concerned predominantly with the meaning of the lived experience Key elements of knowledge formation: Ë Ë human environment personal-life spirit or the human-to-human interaction Multiple ways of knowing Emphasis on “being” and cocreation of RN- pt interactions

“Ever evolving theory” Employs language to reflect on own life journey and beliefs 10 “carative factors” → “clinical caritas processes” ↑ emphasis on metaphysical and spiritual dimensions (love) “Love as an ethic” as the basis for caring-healing practices adapted from Pearson Publication

Major conceptual elements Original theory included: Ë Ë Ë transpersonal caring relationship 10 carative factors Caring occasion/moment Current dimensions which evolved/ emerged from theory: Ë Transpersonal mind/body/spirit oneness Ë Importance of caring-healing consciousness Ë Consciousness as energy Ë Phenomenal field / unitary consciousness Ë Advanced caring-healing modalities/ nursing arts Ë Ultimate form of healing and transcendence is love Ë Nurse as sacred healing environment

Nursing as Profession and Praxis Caring in Nursing: Ë Reciprocal relationship btw nurse and “others Ë Nurse is the co-participant with patient (the change agent) Ë Coparticipants in a pattern of subjectivity-inter subjectivity “Consciousness Intentionality Perceptions and lived experiences R/T caring, healing, and healthillness conditions given in a ‘caring moment’. Experiences or meanings that transcend the moment and beyond the actual experience” (Watson, 1996, p. 146). Care is never separated from the context of the unity of mind-body-spirit -nature Profession exists in order to sustain caring, healing, and health

Nursing interventions, “human care processes” Goals defined by Watson (1985/1988) Ë R/T mental spiritual growth for self and others Ë Finding meaning in one’s own existence & experiences Ë Discovering inner power & control Ë Potentiating instances of transcendence & self-healing Nurse intervenes through “a way of being” & “presence” Require a wide scope of knowledge Presuppose a knowledge base and clinical competence Require intent, a will, a relationship, & actions. “heart-centered awareness & loving/caring consciousness”

Nursing student caring behaviors during blood pressure measurement Minnesota Baccalaureate Psychomotor Skills Faculty Group (MBPSFG) Journal of Nursing Education, 2008, 47(3) Study partially funded by Kappa Phi Chapter of STTI and 6 participating nursing programs

Nursing student caring behaviors during blood pressure measurement Multi-site (6), non-experimental, descriptive study Organizing framework: Watson’s Theory of Transpersonal Caring and a combination of cognitive and connectionist learning theories teaching strategy included: Ë required reading: Caring made visible, Swanson, 1998 Ë Video tape analysis Ë Feedback Ë BP measurement taught in nursing perspective based on Watson’s theory of caring in the human health experience

Watson’s (1988 ) Theory of Transpersonal Caring caring “operationalized” Watson’s definition of caring: A moral commitment to protect human dignity & preserve humanity Caring conceptualized by Morse et al. 1990 A human trait, a moral imperative, an affect, an interpersonal relationship, and a therapeutic intervention (MBPSFG, 2008, p. 100) Moral commitment illuminated in research as interpersonal and therapeutic interactions influencing the pt’s experience and physical response. Involves intentionality Morse, Solberg, Neander, Bottoff, and Johnson (1990)

Caring in human health experiences Operationalized caring from the perspective of the nurse and patient (Morse et al, 1990) Intentionality : basis for teaching, understanding, developing , and adopting caring behaviors

Watson’s Theory of Transpersonal Caring “operationalized” (1994) Focused on five caring dimensions or categories: Ë Respectful deference to others Ë Assurance of human presence Ë Positive connectedness Ë Professional knowledge and skills Ë Attentiveness to the other’s experience Wolf, Giardino, Osborne, & Ambrose (1994)

Watson’s (1988)Transpersonal Caring Theory “operationalized” by Wolf et al. , 1994 Watson’s Carative Factors: Ë Ë Ë five caring dimensions: 1. Formation of a humanisticaltruistic system of values Ë 2. The instillation of faithhope Ë 5. Promotion and acceptance of the expression of + and feelings 7. Promotion of transpersonal teachinglearning 4. development of a helpingtrusting relationship and #5. Ë Ë Ë Respectful deference to others Assurance of human presence Positive connectedness Professional knowledge and skills Attentiveness to the other’s experience

Research Question: “Is there a change in objective and subjective caring behaviors demonstrated by baccalaureate nursing students completing blood pressure measurement when these behaviors are taught in nursing psychomotor skill curricula? ” Minnesota Baccalaureate Psychomotor Skills Faculty Group, 2008, p. 100.

The Descriptive Study Sample: Jr-level nursing students at 6 independent BSN prog Teaching strategies: Ë Ë BP measurement served as the forum for integrating caring behaviors Students viewed demonstration videotape of BP measurement based on the objective tool (Caring Behaviors During BP Measurement instrument ) Teaching included caring behaviors as an integral component of professional nurses’ role Student identification of caring and non-caring behaviors

The Descriptive Study continued Evaluation: BSN students videotaped (VT) and evaluated twice 8 weeks apart VT analysis: reviewed for evidence of caring and noncaring behaviors In response to analysis: Students discussed thoughts and feelings Specific instruction was not standardized amongst BSN programs Both tools created by the researchers

#1 Caring Behaviors During BP Measurement instrument Designed as an objective tool: Ë 30 -item procedure (behavior present; 1= yes; 0= no) Ë Total score = sum of item procedure scores (max=30) Ë Content validity established via AHA/NHLB guidelines Ë Relevant caring behaviors (CB) r/t caring dimensions Ë Evaluators: faculty as patient-role player

#2 Role Player Survey of Caring Behaviors During BP Measurement instrument Ë Ë 3 -item Liker-scale evaluating student caring behaviors A) respect B) conveyed warmth and caring C) conveyed competence Score; 1= not at all 2= some 3=much Documented the role players perception of caring during BP 5 Caring dimensions based on CBI consistent with WTTC Content validity was established using caring dimensions as described by Wolf, et al. ( 1994)

Objective Caring Behaviors During BP Measurement Caring Behavior Caring Dimension 1. Washes hands D 9. Posture reveals relaxed muscle tone 2. Cleans equipment D 3. Introduces self A, B 10. Voice congruent with patient's emotions A, B, C 4. Calls patient by preferred name A, B 11. Leans toward patient when talking 5. Explains procedure and elicits questions A, B, E 6. Provides privacy A 7. Faces client throughout procedure A 8. Maintains appropriate eye contact A A = Respectful deference to others; B = assurance of human presence; C = positive connectness; B B 12. Asks patient about comfort during procedure B, E 13. Physical contact is performed with a gentle touch C 14. Seats patient with feet flat on floor, uncrossed legs 15. Uses right arm unless unable to do so D = professional knowledge and skill; =attentiveness to the other’s experience (Wolf et al. 1994) A, D D E

Objective Caring Behaviors During BP Measurement cont. Caring Behavior Caring Dimension 16. Gently supports patient's arm at heart 23. Inflates cuff to 30 mm Hg above estimated level C, D systolic A, D 17. Measures arm for correct cuff size D 24. Deflates cuff 2 mm Hg/second A, D 18. Centers bladder of cuff over palpated 25. If mercury, keep centered at eye level D brachial artery D 26. Obtains systolic and diastolic blood pressure 19. Wraps cuff gently, snugly, 1 inch above D antecubital A, D 27. Allows 10 mm Hg before complete deflation 20. Use palpation or patient's reported D blood pressure to estimate systolic D 28. Explains findings to patient A, B, E 21. Deflates bladder, waits 15 to 30 seconds A, D 29. Completes calmly, confidently 22. Applies stethoscope correctly A = Respectful deference to others; B = assurance of human presence; C = positive connectness; D 30. Obtains accurate blood pressure D = professional knowledge and skill; E =attentiveness to the other’s experience (Wolf et al. 1994) D

Comparison of Scores of Student Caring Behaviors Before and After Role-Playing Subjective data: Score Range Mean Score SD Caring Behavior Conveyed Pretest Posttest Genuine respect 1 -3 2. 43 2. 82 0. 53 0. 39 Warmth and caring 1 -3 2. 40 2. 70 0. 58 0. 49 Competence 1 -3 2. 25 2. 68 0. 63 0. 50 Minnesota Baccalaureate Psychomotor Skills Faculty Group, 2008, p. 102

Findings and limitations ↑ in students’ subjective and objective caring behaviors Greatest gains in professional knowledge and skill caring dimensions Little to no gain in respect, presence, & attention to other’s experience caring dimensions Feedback is required in clinical settings as is facilitating understanding within the nursing disciplinary context Limitations included Ë Ë Absence of a control group Absence of standardized information, approaches to teaching and learning, and varying methods to determine role-player inter-rater reliability

Discussion and Evaluation of tool ↑ in students’ subjective and objective caring behaviors Greatest gains in professional knowledge and skill caring dimensions Little to no gain in respect, presence, & attention to other’s experience caring dimensions Caring dimensions addressed by tool: Ë A= respectful deference to others 14/30 46. 6% Ë B= assurance of human presence 8/30 26. 6% Ë C= positive connectedness 3/30 10% Ë D= professional knowledge and skill 18/30 60% Ë E= attentiveness to the other’s experience 3/30 10%

Further research Additional research required with an experimental design to broaden the understanding of the best practices assist the student in the development of caring behaviors Further expand the students development of caring behaviors related to all psychomotor interventions

Congruency Although the authors used Wolf et al. operationalized definitions Ë the study focused more on the skill acquisition Ë No mention of relationships Ë Poor Ë Did not stay focused on theoretical construct as refers to Benner and Watson as well.

Contributions to nursing science Noted by the authors as” a beginning step in identifying and testing educational strategies for promoting psychomotor skill development” (MBPSFG, 2008, p. 104) within the human caring and health experience). The need to incorporate explicit instruction in caring behaviors throughout psychomotor skill development

References Fawcett, J. (2005). Contemporary Nursing knowledge: Analysis and evaluation of nursing models and theories, 2 nd Ed. , Philadelphia: F. A. Davis Company. Jesse, DE. (2010). Watson’s philosophy and theory of transpersonal caring In Nursing theorist and their works, 7 th ed. (Eds. ). In M. R. Alligood & A. M. Tomey, Nursing theorist and their works, 7 th Ed, ( pp. 91 -112). Johnson, B. P. & Kelley, J. H. (2011). Theory of transpersonal caring: Jean Watson. In Julia B. George (Ed. ). Nursing theories: The base for professional nursing practice, 6 th Ed. (pp. 454 -478). Upper Saddle River, NJ: Pearson. Minnesota Baccalaureate Psychomotor Skills Faculty Group, 2008. Journal of Nursing Education, 47(3), 98 -104.