CARING

The Theory of Human Caring was developed between 1975-1979, while engaged in teaching at the University of Colorado; it emerged from my own views of nursing, combined and informed by my doctoral studies in educational-clinical and social psychology. It was my initial attempt to bring meaning and focus to nursing as an emerging discipline and distinct health profession with its own unique values, knowledge and practices, with its own ethic and mission to society. The work also was influenced by my involvement with an integrated academic nursing curriculum and efforts to find common meaning and order to nursing that transcended settings, populations, specialty, subspecialty areas, and so forth.

From my emerging perspective, I tried to make explicit nursing's values, knowledge, and practices of human caring that are geared toward subjective inner healing processes and the life world of the experiencing person, requiring unique caring-healing arts and a framework called "carative factors," which complemented conventional medicine, but stood in stark contrast to "curative factors." At the same time, this emerging philosophy and theory of human caring sought to balance the cure orientation of medicine, giving nursing its unique disciplinary, scientific, and professional standing with itself and its public.

Original and Evolving Ten Carative Factors

The original 1979 work was organized around ten carative factors as a framework for providing a format and focus for nursing phenomena. While "carative factors" are still the current terminology for the "core" of nursing, providing a structure for the initial work, the term "factor" is too stagnant for my sensibilities today. I offer another concept today that is more in keeping with my own evolution and future directions for the "theory". I offer now the concept of "clinical caritas" and "caritas processes" as consistent with a more fluid and contemporary movement with these ideas and my expanding directions.

Carative factors include the following original work:

• Formation of a Humanistic-altruistic system of values;
• Instillation of faith-hope;
• Cultivation of sensitivity to one's self and to others;
• Development of a helping-trusting, human caring relationship;
• Promotion and acceptance of the expression of positive and negative feelings;
• Systematic use of a creative problem-solving caring process;
• Promotion of transpersonal teaching-learning;
• Provision for a supportive, protective, and/or corrective mental, physical, societal, and spiritual environment;
• Assistance with gratification of human needs;
• Allowance for existential-phenomenological-spiritual forces.

(For the content and description of the original carative factors, see Watson, 1979/1985, 1985/1988c, 1989; also see Fawcett, 1993 for a brief overview of the carative factors).

While some of the basic tenets of the original carative factors still hold, and indeed are used as the basis for some theory-guided practice models and research, what I am proposing here, as part of my evolution and evolution of these ideas and the theory itself, is to transpose the "carative factors" into "clinical caritas processes". For example, consider the following within the context of clinical caritas, and emerging, transpersonal caring theory.

The original carative factors served as a guide to what was referred to as the "core of nursing";, in contrast to nursing's "trim". Core pointed to those aspects of nursing that potentiate therapeutic healing processes and relationships; they affect the one caring and the one-being-cared-for. Further, the basic core was grounded in what I referred to as the philosophy, science, and art of caring. Carative is that deeper and larger dimension of nursing that goes beyond the "trim" of changing times, setting, procedures, functional tasks, specialized focus around disease, treatment and technology. While the "trim" is important and not expendable, the point is that nursing cannot be defined around its trim and what it "does" in a given setting at a given point in time. Nor can nursing's trim define and clarify its larger professional ethic and mission to society - its raison d'etre for the public. That is where nursing theory comes into play and transpersonal caring theory offers another way, that both differs from, yet complements, that which has come to be known as "modern" nursing and conventional medical-nursing frameworks.

From Carative Factors To Clinical Caritas Processes

As carative factors evolve within an expanding perspective, as my ideas and values evolve, I now offer the following translation of the original carative factors into clinical caritas processes, suggesting more open ways in which they can be considered. For example,

• Formation of humanistic-altruistic system of values, becomes: "Practice of loving-kindness and equanimity within context of caring consciousness
• Instillation of faith-hope, becomes: "Being authentically present, and enabling and sustaining the deep belief system and subjective life world of self and one-being-cared- for";
• Cultivation of sensitivity to one's self and to others, becomes: "Cultivation of one's own spiritual practices and transpersonal self, going beyond ego self";
• Development of a helping-trusting, human caring relationship, becomes: "Developing and sustaining a helping-trusting, authentic caring relationship";
• Promotion and acceptance of the expression of positive and negative feelings, becomes: "Being present to, and supportive of the expression of positive and negative feelings as a connection with deeper spirit of self and the one-being-cared-for";
• Systematic use of a creative problem-solving caring process, becomes: "creative use of self and all ways of knowing as part of the caring process; to engage in artistry of caring-healing practices";
• Promotion of transpersonal teaching-learning, becomes: "Engaging in genuine teaching-learning experience that attends to unity of being and meaning attempting to stay within other's frame of reference";
• Provision for a supportive, protective, and/or corrective mental, physical, societal, and spiritual environment, becomes: "Creating healing environment at all levels, (physical as well as non-physical, subtle environment of energy and consciousness, whereby wholeness, beauty, comfort, dignity, and peace are potentiated";
• Assistance with gratification of human needs, becomes: "assisting with basic needs, with an intentional caring consciousness, administering ‘human care essentials', which potentiate alignment of mindbodyspirit, wholeness, and unity of being in all aspects of care"; tending to both embodied spirit and evolving spiritual emergence; Allowance for existential-phenomenological-spiritual forces, becomes: "opening and attending to spiritual-mysterious, and existential dimensions of one's own life-death; soul care for self and the one-being-care-for.

What differs in the Clinical Caritas framework is that a decidedly spiritual dimension and an overt evocation of love and caring merge into a new paradigm for the next millennium. Such a perspective ironically places nursing within its most mature framework, consistent with the Nightingale model of nursing, yet to be actualized, but awaiting its evolution within a caring-healing theory. This direction, ironically while embedded in theory, goes beyond theory and becomes a converging paradigm for nursing's future.

Thus, I consider my work more a philosophical, ethical, intellectual blueprint for nursing's evolving disciplinary/professional matrix, rather than a specific theory per sé. Nevertheless, others interact with the original work at levels of concreteness or abstractness; the caring theory has been, and is being used, as a guide for educational curricula, clinical practice models, methods for research and inquiry, as well as administrative directions for nursing and health care delivery.

This work posits a value's explicit moral foundation and takes a specific position with respect to the centrality of human caring, "caritas" and love as now an ethic and ontology, as well as a critical starting point for nursing's existence, broad societal mission, and the basis for further advancement for caring-healing practices. Nevertheless, it's use and evolution are dependent upon "critical, reflective practices that must be continuously questioned and critiqued in order to remain dynamic, flexible, and endlessly self-revising and emergent" (Watson, Blueprint; 1996, p. 143).

Ironically, this work is congruent with recent reports on health care and health professional educational reform, which call for "centrality of caring-healing relationships" as the foundation for all health professional education and practice reform. I quote:

The central task of health professions education - in nursing, medicine, dentistry, public health, psychology, social work, and the allied health professions - must be to help students, faculty, and practitioners learn how to form caring, healing relationships with patients, and their communities, and with each other, and with themselves…the knowledge, skills, and values necessary for effective relationships… Developing practitioners mature as reflective learners and professionals who understand the patient as a person, recognize and deal with multiple contributions to health and illness, and understand the essential nature of healing relationships.