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Introduction

The aim of this paper is to analyse Watson's Theory of Human Caring for its usefulness and

worth in education, practice, and research. The reason for undertaking this analysis is to

evaluate if Watson’s theory would be useful for nursing in those countries where such

theories were not an established part of the nursing curriculum. Furthermore, in some Eastern

European countries their political past or cultural influences led to an unquestioned adoption

of the biomedical model. As their political culture changes many social structures have had to

be revisited, and for nursing this has meant the introduction of theoretical teaching, practice

and reasoning.

Watson describes caring as essential in nursing, which itself is described as a human science

and art. She points to a transpersonal caring relationship and a specific type of professional

and human-to-human contact. Her theory stresses the humanity of nursing and can therefore

be very useful for nurses (Pajnkihar, 2003). Watson’s Theory of Human Caring can also

greatly support and enhance nursing education, research, and practice. This is especially the

case where undergraduate and postgraduate nursing has not been underpinned well enough by

nursing or caring theories, or if such theories have not been part of the nursing tradition.

Yancey (2015) described situations where there was more of a focus on conventional forms of

evidence, methods and procedures. This could have consequences for the nursing discipline.

Watson maintained that nursing is caught in an ontological, moral, ethical-philosophical

quandary. She asserted that the whole person is reduced to the status of an object, which is at

odds with nursing’s philosophy, values, heritage, theories, and professional viewpoints. Such

a trend can lead to patients’ dissatisfaction with care (Watson, 2012).

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Dissatisfaction with the care received, where the person feels like an object, is a major threat

to health care quality; hence caring in practice, in research and education need to be

addressed. It is important to reverse this so-called non-caring trend (Watson, 2009). This can

be particularly challenging in health care systems that face low nurse staffing levels and

where an emphasis is placed more on diagnostics and therapeutics than on the psychological,

spiritual and social aspects of care.

While the biomedical model remains a dominant approach to nursing throughout the world,

nursing models are slowly adopted. More task oriented models, such as Henderson's and

Orem's, have been widely utilised (McKenna, Pajnkihar and Murphy, 2014). However, given

the increasing complexity of nursing care, Watson's Theory of Human Caring has the capacity

to incorporate the complexity of modern nursing and provide the foundation for contemporary

nursing practice. In order to successfully implement a theory into practice, it is crucial that

there is a thorough understanding of the theory.

Overview of the theory’s major conceptual elements

Watson’s Theory of Human Caring describes the ‘heart’ of contemporary nursing as person-

centred transpersonal caring, meaning a wholeness of mind, body and soul. Watson (2015)

developed the theory between 1975 and 1979 based on her views of nursing, combined and

informed by her doctoral studies in educational, clinical and social psychology. Her early

work evolved dynamically from her original writings of 1979, 1985, 1999 to a more updated

view of caritas and caring science as sacred science.

As the theory evolved, Watson adapted terminology, knowing that this would contribute to a

readers’ better understanding of the theory and its conceptual elements. ‘Human Care’ was

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first defined as a ‘dynamic human-to-human transaction’ (Watson, 1999, p.27). More

recently, ‘Human Care’ has been changed to ‘human caring,’ referring to ‘deeper human-to-

human involvement and connection of one to another’ (Watson, 2012, p.4,xi). In her early

work she used the term ‘carative’ as an antonym to ‘curative’; this was to distinguish nursing

from medicine (Watson, 1985). More recently, the term ‘carative’ has evolved into ‘caritas’.

‘Caritas’ comes from Latin, meaning “to cherish and appreciate, giving special attention to, or

loving” (Watson, 2015, p.323).

To aid the reader’s understanding of the theory, Watson’s major conceptual elements are

listed and described briefly:

Relational caring is an ethical-moral-philosophical values-guided foundation.

The transpersonal caring moment is in the caritas field.

Caring as consciousness is an energy-intentionality-heart-centered human presence.

Caring-healing modalities.

Ten carative factors, now transposed to caritas processes of love-heart-centered-

caring/compassion (Watson, 2008; Watson, 2012).

Caring is “the moral ideal of nursing whereby the end is protection, enhancement, and

preservation of human dignity” (Watson, 1999, p.29). Watson described the most important

human values as life, the spiritual dimensions of life, and the internal power of human beings.

The theory conceptualises caring as an interpersonal happening between two persons with

transpersonal dimensions (Watson, 1999).

It is important to understand the relationship between caring and non-caring. A caring person

is responsive to a person as a unique individual (Watson, 2012). A caring nurse-patient

relationship can be viewed as life sustaining (as kind, concerned, benevolent and responsive)

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or even life giving and life receiving for both nurse and patient (Halldorsdottir, 1991, in

Watson 2012). In contrast, a non-caring person is insensitive to another person as a unique

individual (Watson, 2012). As a consequence, a nurse-patient relationship can be life

destroying (leading to anger, despair and decreased well-being), life restraining (the patient

experiences the nurse as cold and treatment as a nuisance) and life neutral (the nurse is

apathetic and detached, just doing the job) (Halldorsdottir, 1991, in Watson 2012).

One particular type of caring is transpersonal caring, which is an essential component of the

theory. Both patient and nurse engage in a transpersonal caring relationship, in which an event

becomes an actual caring occasion. This involves two persons coming together with their own

unique life histories. The participants create a unique phenomenal field that transcends time

and space and results in healing through self-awareness and self-discovery (Watson, 1999).

An actual caring occasion ultimately leads to the discovery of self (Cohen, 1991; Pajnkihar,

2003).

The whole caring consciousness of the nurse is contained within a single caring moment or

occasion and extends into the universe beyond that actual physical moment (Watson, 2015).

For developing and sustaining a trusting relationship and caring moment, consciousness,

intentionality and authentic presence are needed. “The more individual and authentic presence

the feelings are that the nurse conveys, the more strongly does the caring process affect the

recipient” (Watson, 2012, p.81).

Caring-healing modalities are interventions – nursing therapeutics – that are related to the

human-caring healing process (Watson, 2012). The carative factors are modalities that can be

employed to support and enhance the experience of the actual caring occasion. These carative

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factors were redefined from the parent field of nursing to the new field of caring science with

its explicit ethic and worldview (Watson, 2008) and are now renamed and extended into the

caritas processes. Watson described the caritas processes as:

1. Cultivating the practice of loving-kindness and equanimity towards the self and others

as foundational to caritas consciousness.

2. Being authentically present; enabling, sustaining and honouring the faith, hope and the

deep belief system and the inner-subjective life world of the self and of the other.

3. Cultivating one’s own spiritual practices and transpersonal self, going beyond the ego-

self.

4. Developing and sustaining a helping-trusting, caring relationship.

5. Being present to, and supportive of, the expression of positive and negative feelings.

6. Creatively use the self and all ways of knowing as part of the caring process; engaging

in the artistry of caritas nursing.

7. Engaging in genuine teaching-learning experiences that attend to the unity of being

and subjective meaning; attempting to stay within the other’s frame of reference.

8. Creating a healing environment at all levels.

9. Administering sacred nursing acts of caring-healing by tending to basic human needs.

10. Opening and attending to the spiritual or mysterious and existential unknowns of life

and death (Watson, 2008).

Caritas processes facilitate healing, honour, wholeness and contribute to the evolution of

humanity (Watson, 2008).

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Theory analysis and evaluation

The analysis and evaluation of Watson’s theory were undertaken using Fawcett’s criteria for

theory analysis (Fawcett, 2005) and the approach to theory analysis and evaluation described

by McKenna et al. (2014).

Through theory analysis we determined the scope of the theory, the theory context and theory

content. The scope of a theory refers to its level of abstraction (i.e. if it is a grand theory, a

mid-range theory or a practice theory) (Fawcett, 2005; McKenna et al., 2014). A theory’s

context includes descriptions of the metaparadigm’s concepts and propositions, its philosophy

of science and the philosophical claims underpinning the theory (McKenna et al., 2014). A

theory’s content includes the descriptions of its phenomena, concepts and propositions

(Fawcett, 2005).

For theory evaluation we employed the criteria described by McKenna et al. (2014): clarity,

simplicity and complexity, importance and significance, adequacy, testability and acceptance.

Theory analysis

Scope: level of abstraction

Watson argued that her theory is not a ‘hard scientific theory’ but is still a theory (Watson,

2012, p.4). Her theory has been referred to as a framework, a theory (Patton et al., 1998), a

conceptual model (Morris, 1996) and a philosophy (Marriner Tomey, 1998). It has also been

referred to as a mid-range theory (Fawcett, 2005).

It has also been said to be deductive in origin (Pajnkihar, 2003). However, it can also be

classified as retroductive, because it draws on the work of different authors and its own

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research in practice and education. It can be argued that some of the concepts, propositions

and assumptions are very abstract and that the theory may be disadvantaged by attempting to

cover all the specific and general phenomena in health and illness. Such a broad perspective is

not normally associated with a mid-range theory; rather it has a better fit with being a grand

theory. For the purpose for this paper, we did not differentiate between conceptual models and

theories. McKenna et al. (2014) claimed that “theory exists at different stages of development

and a conceptual model is a stage of development on the way to becoming a theory” (p.106).

Context: Metaparadigm concepts and propositions

According to Fawcett, nursing’s metaparadigm or worldview is composed of the four

concepts of nursing, health, person and environment (Fawcett, 2005). Watson’s metaparadigm

concepts can be seen in Figure 1. This emanated from our theory analysis in an attempt to

gain a better understanding of the complexity of the metaparadigm’s concepts and their

relationships. Dotted lines in Figure 1 depicting nursing, health, person and environment

indicate that there is openness between each of these metaparadigm concepts, the basic

concepts, and the interactions between all parts of the theory.

Please insert Figure 1 here.

Watson sees nursing as a science, art and moral ideal (Watson, 2012). Science is defined as

“a human science of persons and human health–illness experiences that are mediated by

professional, personal, scientific, aesthetic, and ethical human care transactions” (Watson,

1988, p.54), though Watson explicitly acknowledged all patterns of knowing. In nursing we

draw upon the healing arts (Watson, 2008) and the art of caring begins when the nurse joins

with others with a certain feeling of caring and compassion (Watson, 2012, p. 80). Watson

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believed that caring is essential to the nursing profession (Pajnkihar, 2003). She viewed

caring as the “moral ideal of nursing”, consisting of “transpersonal human-to-human attempts

to protect, enhance, and preserve humanity and human dignity, integrity and wholeness. It

does this by helping a person find meaning in illness, suffering, pain, and existence and

helping another gain self-knowledge, self-control, self-caring, and self-healing. Within this, a

sense of inner harmony is restored, regardless of the external circumstances” (Watson, 2012,

p.65). Communication and the release of human feelings through the co-participation of one’s

entire self is viewed as art, which allows humanity to move towards greater harmony, spiritual

evolution and the omega point of perfection (Watson, 2012, p.83). The theory’s description of

art is different from that of other theories as it emphasises a deep understanding of self and a

transpersonal human to human relationships for sustaining inner harmony of mind, body and

especially the soul.

As nursing is clearly and consistently described as having the characteristics of caring, there

have been calls for replacing the metaparadigm concept of nursing (McKenna, 1997).

Similarly, Leininger recognized the importance of caring. She proposed that the term nursing

has to be replaced, as care and caring are the central and unifying focus for nursing and the

core of nursing (Cohen, 1991; Leininger, 1991).

In the theory, the person is viewed as “a being in the world” and is the locus of human

existence (Watson, 1999, p.54), or more recently is seen as “a spiritual being-in-the world”.

“The person exists as a living, growing gestalt and is viewed as whole and complete with

unity of mind-body-spirit. A person is an experiencing and perceiving spiritual being”

(Watson, 2012, p.67). Here the person represents both the nurse and the patient. The theory

focuses on caring of an individual, not only on the caring for the patient. Self-care is an

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important aspect as transpersonal caring starts with caring for the self (Watson, 2012). Self-

care includes perceived competence of caring and caring behaviour towards the self (Nelson

& Watson, 2012). The nurse should nurture self-care. For example, “hand washing is for

infection control, but also may be a meaningful ritual of self-caring, energetically cleansing,

blessing, and releasing the last situation or encounter, and being open to the next situation” or

“intentionally pausing and breathing, preparing self to be present before entering the patient’s

room” (Watson, 2009, pp.474-475). This may conflict with the traditional views of the

professional nurse (Watson, 2012). Watson described an individual with a special focus on

the spiritual aspect and emphasises the caring of the individual and nurse in a transpersonal

caring relationship.

The theory sees health as “unity and harmony within the mind, body, and soul” (Watson,

1999, p.48). It is associated with “the degree of congruence between the self as perceived and

the self as experienced” (Watson, 1999, p.48). A person becomes ill when there is disharmony

within the mind, body and soul. Here, “illness is not necessarily disease” (Watson, 1999,

p.48), rather, it is a turmoil of conscious or unconscious disharmony within a person. Disease

can be a consequence of illness and also results from genetic and constitutional vulnerabilities

(Watson, 2012). The emphasis is on harmony and integrity of human beings and the

exploitation of inner strength and energy in health and the healing process.

In her early work Watson did not explicitly define environment, but it was specifically used

in the ten carative factors (Pajnkihar, 2003), now caritas processes. In particular she highlights

the promotion of a “supportive, protective, and/or corrective mental, physical, societal, and

spiritual environment” (Watson, 1999, p.75; Watson, 2005, p.3). Nurses must recognise the

influence of internal and external environments on the health and illness of individuals and

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also the need to support, protect (Pajnkihar, 2003) and correct individuals. The emphasis is on

knowing the impact of the environment on people’s daily lives. Most recently, Watson has

started to see nurses as not only persons in the environment, but as the environment: “Nurse is

the environment” (Quinn, 1992, in Watson, 2012, p.26). The nurse and patient are becoming

the caring-healing environment (physical and non-physical) and the Caritas environment is

seen as a unified field of Love (Watson, 2008).

While Watson described the spiritual environment within the clinical environment (Rafael,

2000), there was less explanation for what spirituality means in one’s everyday life. It raises

the question as to what extent can spirituality be achieved in this productivity-focused world.

In simple terms, the goal of nursing is to obtain a higher degree of harmony through a

transpersonal caring relationship, where nurses and patients are co-participants. Pajnkihar

(2003) claims as co-participants in the caring process, nurses need to be focused on mental-

spiritual growth and the discovery of inner power and self-control.

From this section, it can be seen that Watson’s description of the metaparadigm’s concepts

and propositions is coherent and interactive and the terminology she uses is consistent with

the basic concepts of the theory.

Context: Philosophy of science and philosophical claims

Watson views nursing as a moral ideal whose central point is caring. She has acknowledged

that her work has drawn on the ideas of Rogers, Hegel, Marcel, Whitehead, Kierkegaard, and

Eastern philosophy. In addition, she has been influenced by Gadow, describing her orientation

as “pheno-menological-existential” (Watson, 1999, p.x) and spiritual. This has been further

influenced by the work of others, such as Erikson, Heidegger, Maslow, Selye and Lazarus, as

well as the traditional nursing conceptualisations of Nightingale, Henderson, Leininger,

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Krueter and Hall (Watson, 1988), and later, the philosophers Levinas and Løgstrup (Watson,

2005). Furthermore, her work was shaped by that of Eriksson (Nelson & Watson, 2012), who

first introduced the word ‘Caritas’ in caring science, defining it as love and charity, the

motive for all caring (Eriksson, 2002).

Watson perceives human caring science as being based on an epistemology that can include

metaphysics as well as aesthetics, the humanities, art, and empirics as part of clinical sciences

(Watson, 2012, p.4), as well as ontology. The philosophical position is clear, suggesting that it

is essential that nurses have a broad knowledge, understanding and acceptance of these

different philosophies, especially Eastern philosophy (Pajnkihar, 2003). Watson’s caring

science and philosophy of science are an appropriate philosophy for the development of

nursing. It shows it to be an art and a science, with the corresponding methodology and

methods for applying the theory in research, education and practice.

The assumptions related to human care and the values of human caring in nursing listed at the

beginning of this paper can be found in Watson’s early work (Watson, 1979; Watson, 1985).

As the theory evolved, these were extended and are now slightly modified (Watson, 2005;

Watson, 2008) and can be considered to be of a ‘philosophical nature’ (Fawcett, 2005, p.555).

In addition, she also described other considerations on how to frame a caring science

(Watson, 2005, pp.28-29). Assumptions about caring, nursing and transpersonal caring

relationships are very clearly listed and described by Fawcett (2005, pp. 555-558). Readers

are encouraged to read Watson’s publications and Fawcett’s analysis for a deeper and more

thorough understanding of the theory’s philosophical underpinnings and assumptions.

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Content

Phenomena

Watson developed the theory around the phenomena of human health-illness experience and

human-to-human caring and healing experiences (Watson, 2012).

Concepts

On reading the analyses and evaluations of Watson’s theory by different authors, it can be

seen that there are inconsistencies in the determination of the theory’s central concepts. We

agree with Fawcett (2005), who established that the central concepts of Watson’s theory are

the transpersonal caring relationship, caring moments/caring occasions, caring (healing)

consciousness and caritas processes. The concept of a transpersonal caring relationship has

three dimensions: self, the phenomenal field, and intersubjectivity. The concepts of the caring

moment/caring occasion and caring (healing) consciousness are unidimensional.

Although a number of new concepts and terms are introduced; the ten caritas processes must

be addressed by nurses (Wills, 2007). As alluded to above, they evolved as a more meaningful

concept from the carative factors. They are intended to offer a greater fluidity of language so

as to gain a deeper and more comprehensive understanding of nursing (Watson, 2008). The

carative factors differ from the caritas process in their spiritual dimension and evocation of

love and caring (Watson, 2015). However, one could argue that the caritas processes are more

abstract and more focused on spirituality and mystery, creating a comprehension difficult for

clinical nurses to grasp.

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Propositions

Fawcett (2005, p.565) listed and described propositions that link the theory’s concepts. For a

clear presentation of the theory’s concepts and propositions a diagram based on Fawcett’s

description of the propositions and theory’s analysis has been developed and can be seen in

Figure 2.

Please insert Figure 2 here.

Figure 2 shows that the propositions are adequately linked. Fawcett (2005) claimed that a

proposition that links the four concepts of transpersonal caring relationship, the caring

moment/caring occasion, caring (healing) consciousness and caritas processes are

conspicuous by their absence. We can see from the Figure 2 that the caring (healing)

consciousness reflects values, developed philosophy, ways of knowing, etc. and is a way of

being. This is a prerequisite to developing/sustaining transpersonal relationships, which is the

actualization of the caritas processes. This leads to caring moments, and indeed invites or

allows caring moments.

Theory evaluation

Clarity

The concepts in Watson’s theory are abstract and in our opinion do not achieve full clarity

and consistency. While the language is clear and artful, the terminology needs to be more

consistent. The propositions and assumptions are clearly listed but they also remain abstract.

As pointed out above the scope of the theory reflects what is expected in a grand theory, one

that is global and abstract. Nursing students and hard pressed clinical nurses may not take the

time go understand the theory and may be dismayed with it and its unfamiliar language.

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Pajnkihar claimed (2003) that this is especially the case if they are not familiar with eastern

philosophy and do not have a liberal arts background. However, we could argue that this is

not the problem of the theory or of nursing students and practising nurses, rather it may

represent an inability of nurse educators to inculcate the theory to students.

We believe that our Figures 1 and 2 can contribute to a better clarity and understanding; one

can argue that with further refinement, the theory can be more elegant and more attractive to

the end user. However, we would not assume that our Figures can encapsulate Watson’s

theory in a single diagram.

Simplicity and complexity

It would be difficult to claim that the theory met the criterion for simplicity. In an effort to

refine and update the theory, Watson introduced new terminology. Fawcett (2005) asserted

that the theory has “progressed from elegance in its simplicity and relative economy of words

to a more complex and verbose work” (p.568). The explanation of the phenomenon, concepts

and especially the number of propositions make it difficult for Watson's theory to achieve the

‘simplicity’ criterion. The comprehensibility of abstract grand theories is difficult in

environments or countries that lack a long tradition in academic education and nursing

theories.

As the core elements of a theory, concepts seek to describe a particular phenomenon and often

have features of complexity. The relationships between concepts are illustrated in Figure 2.

The explanation of the relationships between the concepts uses relatively simple language, but

nonetheless, these relationships are complex in their nature. For students and clinical nurses,

the theory’s complexity is heightened by the existential-phenomenological nature of Watson’s

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work (Pajnkihar, 2003). However, it could be argued that the advantage of the theory’s

complexity is that it covers a wide range of phenomena in nursing science and art.

Importance and significance

When understood, embraced and applied, Watson’s theory does bring benefits to patients and

nurses. Nurses who are guided by it are concerned with the individual/family/group responses

to health and illness situations and thus with the goal of allowing caring and healing to take

place (Bernick, 2004, p.134). In a technological care delivery system, caring is often the

exception rather than the rule and traditionally there has been a shift in focus from caring to

curing (Cook & Cullen, 2003). Today’s crises in relation to quality and safety concerns have

renewed the attention to caring by health care professionals. The increased demand for

efficiency is set within an outdated industrial mind-set. It has led to increasingly distanced

relationships between health professionals and patients and a culture that has lost its way. The

results of a non-caring culture are quality and safety violations and increased medical errors

(Watson, 2009, p.468). Watson’s theory takes into account the individual’s active role and the

experiences of both persons (the nurse and the patient) being involved in the process of care.

It views the human being as a whole person in health treatment, incorporating all the different

ways of knowing (Rafael, 2000).

Watson tried to bridge the gap between theory and practice, believing that professional

nursing care is developed through a combined study of the sciences and the humanities and

culminates in a human care process between nurse and patient that transcends time and space

and has spiritual dimensions (Pajnkihar, 2003; Watson, 1998; Watson, 1999). The theory

brings a very useful metaphysical, philosophical and spiritual dimension to nursing (Cohen,

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1991). Furthermore, it is philosophically congruent with contemporary global approaches to

community health care and health promotion (Rafael, 2000).

The theory can be used to guide practice, research, education and administration (Jesse,

2010). It stands among the family of important nursing theories, because it stresses the

importance of the lived experience of the client and the nurse and it acknowledges the unique

dimensions of mind-body-spirit without compromising the wholeness of the person (Rafael,

2000). It emphasises the importance of the internal power of human beings, the spiritual

dimensions, love, and the universe in elegant transpersonal relationships. In addition, Rafael

(2000) claimed that the theory explicitly acknowledges multiple ways of knowing, including

empirical, aesthetic, ethical and personal knowledge.

While Watson’s theory is one of the caring theories, it is also ‘a unique grand caring theory’.

It has a significant and explicit theoretical, research and philosophical message to the nursing

profession on caring and nursing science. The uniqueness of the theory is shown in the

description of professional and personal values. Its basic concepts are linked with a mystery,

love, and the universe, which gives it a unique place among the theories.

Watson’s theory has the potential to be important for situations where the biomedical model

has historically strongly underpinned nursing education and practice. As a caring theory, it is

significant because it influences the development of nursing as a discipline and specifically as

a caring science.

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Adequacy

The theory is adequate regarding scope, content and context and is adequate for practice,

education and research. By emphasising the primary characteristics of nursing such as caring

and love, it is adequate for all areas in nursing. However, there is a need for some additional

research.

Watson’s work “presents an extensive, well-organised argument for the philosophical

assumptions of the model” (Morris, 1996, p.299). Nonetheless, the relationship between

human care and the transpersonal care relationship could be further clarified (Morris, 1996).

Accordingly, the development of a knowledge base in the theory has been limited by the

abstract nature of the concepts and the clinical reality. If caring is to exists in nursing

situations, caring has yet to develop interpersonal care, and if caring is unique to nursing,

patient outcomes when caring transactions have taken place need further study (Morse et al.,

1991; Pajnkihar, 2003).

The researchers who have investigated Watson’s theory have employed a variety of

methodologies, leading to the caritas processes beginning to meet the criterion of empirical

adequacy for mid-range theory concepts. Nonetheless, it has been pointed out that the

outcomes of a transpersonal caring relationship and the effects of the clinical caritas processes

have not yet been fully investigated empirically and additional research is needed (Fawcett,

2005). Watson has started to identify and develop caritas literacies (competencies) in order to

observe or measure behaviours that reflect each of the caritas processes. This is an ongoing

project undertaken by the International Caritas Consortium (Watson, 2008).

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Testability

The theory is testable to some extent. The methodologies for studying caring in nursing can

be qualitative, naturalistic and phenomenological, and an equal combination of the

quantitative and qualitative approaches is useful (Patton et al., 1998; Watson, 1988; Watson,

2005). Watson provided research guidelines, design recommendations and a table of potential

instruments for caring research (Jesse, 2010). There are more than 25 instruments with

demonstrated validity and reliability to assess empirically how to measure the concepts of

Watson’s theory (Nelson & Watson, 2012). Nelson & Watson (2009) exposed some claims it

is impossible to measure the impact of caring and love. If this is true, we must negate the

science developed on stress, coping, quality of life and all other abstract dimensions of the

human experience (Nelson & Watson, 2009). It should be emphasised that most of the

existing instruments are designed to measure carative factors. It is crucial that empirical

indicators for other concepts should also be developed, as well as tools to test relationships

between them (Fawcett, 2005). Watson’s theory has also been used as the theoretical

framework in various research projects. Fawcett (2005) listed more than 50 studies that have

been guided by the theory. The whole theory is, in our opinion, not possible to test; however,

the propositions, outlined in Figure 2, may be tested.

Acceptance

An analysis showed that sustained levels of work and an international interest in research

related to the Theory of Human Caring exists (Smith, 2004). This can be used by any

profession and in any setting as it transcends cultural and global differences (Rexroth &

Davidhizar, 2003). Worldwide, there are numerous examples of the use of Watson’s theory in

education, practice, administration and research. It is appropriate for general and specific

clinical areas where nurses wish to emphasise caring and put the patient into the centre of the

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caring experience. However, time is needed for such a complex theory to come to life in

education and in practice, especially where nurses have a dearth of information and

knowledge about it, where English is not the first language or in countries where nursing

theories are not commonplace.

Nursing practice

Watson’s theory can be applied to various populations and to different clinical settings

(Fawcett, 2005). For example, it can be used for the management of patients with

hypertension in outpatient settings (Erci et al., 2003), women with infertility (Arslan-Özkan,

Okumuş, & Buldukoğlu, 2014) and women with depression (Mullaney, 2000). It also

demonstrated its usefulness in teaching health promotion to a group of preadolescent children

(Sessana, 2003).

Research

Globally, Watson’s theory has been used as a research framework in many different studies.

For example, it was used to research the relationship between caring and patient safety

(Pajnkihar et al., 2014) and the relationships between the caring culture, safety culture and

patient safety outcomes (Pajnkihar et al., 2016). The International Watson Caritas

Comparative Database and the Watson Caritas Patient Score (WCPS) developed an

instrument with five critical caring questions to assess caring practices and patient

satisfaction. This represents multi-site clinical research in systems using Watson’s theory.

Watson Caritas Patient Score (WCPS) is also being used in multi-site clinical research. It uses

Watson’s Theory of Human Caring and Caring Science as a theoretical foundation for

advancing professional practice by measuring clinical indicators of caring in relation to

patient outcomes (Watson Caring Science Institute, 2016).

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Education

The theory has been used in numerous baccalaureate nursing curricula in the USA and in

many other countries, such as the United Kingdom (Patton et al., 1998) and in the Middle

East (Suliman, Welmann, Omer, & Thomas, 2009). It has also been used to underpin doctoral

nursing programmes in the USA and Canada (Morris, 1996). The Caritas Coach Education

Program (six-month certificate program of study) and the Doctorate Program in Caring

Science are informed by Watson’s work. They are provided by the Watson Caring Science

Institute, the International Caritas Consortium and the University of Colorado.

Nursing administration

Watson’s theory was also used as a framework for the application of caring to the human

resource management process in nursing (Minaar, 2002). Another example is the use of the

theory in a computerized clinical documentation system in eight hospital organizations. For

this, extensive clinical documentation upgrades were made as there was no language available

that was specific enough in existing documentation (Rosenberg, 2006).

Discussion and conclusion

Watson’s theory has had an important impact on the development of a unique core knowledge

for nursing as a discipline. It can be argued that the theory is an artful description of

phenomena that informs nursing education, research and practice. It contributes to nursing

philosophy and nurses’ perception and understanding of patients as whole persons.

There is no doubt that holistic care empowers nurses in caring partnerships with individuals.

It also helps nurses to achieve freedom and autonomy in the context of professional

21

responsibilities and obligations (Pajnkihar, 2003). Because it clearly differentiates nursing

from other health care disciplines such as medicine, the theory has had an important impact

on the development of a unique core of knowledge for nursing practice and science. However,

it will take some time and many champions before Watson’s ideas and terminology will be as

omnipresent in everyday practice as are those of the biomedical model. Adaptation and

application of the theory is, in our opinion, difficult in situations where nursing practice was

unduly influenced by the biomedical model and where nursing academic education does not

have a long tradition that would support the research, analysis and evaluation of nursing

theories before implementing them into practice. The problem is not the theory, but the

nurses’ prior level of knowledge and the inability of some nurse educators to impart the

theory. Yancey (2015) claimed that nurse educators should give nursing students a theoretical

foundation and nursing education programs should be founded in nursing theoretical

perspectives. Without a solid foundation in nursing theories, nursing students will enter

practice, form a professional identity and decide about their practice without having a clear

understanding of the phenomena of nursing.

We agree that nursing education should provide support for theory based education, but in

some countries, especially in eastern and south-eastern European countries, nursing education

does not well enough provide such core knowledge and skills for choosing an appropriate

theory, of for analysing, evaluating, testing and applying theories in nursing. According to

Pajnkihar (2003) Watson’s theory would first need to be incorporated into the nursing

curriculum for a period.

Watson’s theory has great potential for the development of science and the theoretical core of

knowledge for supporting safe, efficient and especially humane patient care and for presenting

22

a new dimension that exposes the core and essence of nursing. Furthermore, Pajnkihar (2003)

asserted that Watson’s theory offers the knowledge that nurses need to promote and maintain

a vision, perspectives, and values, and argued that caring is essential to nursing, or as Watson

maintained, it is a moral ideal.

Watson’s theory offers great benefits to nursing in many countries in the development of

transpersonal caring relationships and an emphasis on the individual’s mind, body and soul.

Incorporating nursing theory in undergraduate and graduate curricula will help students to

conceptualize caring, create values and beliefs about the caring philosophy and understand

what it means to be a caring nurse. Learning Watson’s theory encourages nursing students to

practise humane caring. Teaching undergraduate students to sit down with patients, hold their

hand, maintain eye contact, and provide reassurance are simple examples of Watson’s theory

in action (Likose, 2011). Nursing students can see how Watson’s theory focuses on respecting

the integrity, dignity and the wholeness of human beings. In addition, the caritas processes

can guide nursing students in applying theoretical concepts, cultivating caring moments and

caring in practice (Sitzman & Watson, 2014). However, cultivating a caring practice during

basic nurse education is in our opinion not enough; it should also be a core element in the

continuous professional development of practising nurses.

Further research is needed in order to operationalize all its concepts and to test its

propositions. The successful application of Watson’s theory will require collaboration and

coordinated action between theorists and university educators with nursing managers and

clinical nurses. The importance of the support of patients should not be underestimated, as

Watson’s theory places them central to the essence of caring.

23

Declaration of Conflicting Interests: The author declared no potential conflicts of interest

with respect to the research, authorship, and/or publication of this editorial.

Funding: The author received no financial support for the research, authorship, and/or

publication of this editorial.

24

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