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versão impressa ISSN 0080-6234
Rev. esc. enferm. USP vol.47 no.2 São Paulo abr. 2013
Cuidado transpersonal en enfermería: un análisis pautado en modelo conceptual
Luciane FaveroI; Lorita Marlena Freitag PagliucaII; Maria Ribeiro LacerdaIII
INurse. Doctoral student in
nursing, Federal University of Paraná. Member of the Center for Study and
Research on Human Care Nursing (NEPECHE-UFPR). Fellow of the Center for the
Improvement of Higher Education Personnel (CAPES / DS). Curitiba, PR, Brazil. firstname.lastname@example.org
IINurse. Doctorate in nursing. Professor at the Federal University of Ceará. Researcher at the National Council for Scientific and Technological Development (CNPq). Fortaleza, CE, Brazil. email@example.com
IIINurse. PhD in Nursing. Professor at the Federal University of Paraná. CNPq Researcher. Coordinator of Research and Extension Study in Human Care Nursing. Curitiba, PR, Brazil. firstname.lastname@example.org
This theoretical study aimed to analyze the attributes, antecedents, and consequences of the transpersonal caring concept through using the Concepts Analysis Model. For this purpose, books published based on Jean Watson's theory in Portuguese and English from 1979 to 2012 were listed. Fulfilled inclusion criteria, only six literary works remained. The time of care and intention to be in relationship were the most cited antecedents. The most present attributes were intersubjectivity and relationships among those ones involved in the process. With regard to consequences, the most present element was the fact that the transpersonal caring provides restoration/reconstitution (healing). The study allowed noting tiny changes in the concept definition over the years and publications of theory. Thus, analyzing the attributes, antecedents, and consequences of concept provided its better understanding and comprehension of its importance in the Human Caring Theory proposed by American theorist.
Descriptors: Nursing care; Concept formation; Models, nursing; Nursing theory
Estudio teórico objetivando analizar los atributos, antecedentes y consecuencias del concepto de cuidado transpersonal, utilizando el Modelo de Análisis de Concepto. Se seleccionaron libros de la teórica Jean Watson, en portugués e inglés, escritos entre 1979 y 2012. Cumplidos los criterios de inclusión, se trabajó con 6 obras literarias. Los antecedentes más citados fueron el momento de cuidado y la intención de relacionarse. Los atributos más presentes fueron la inter-subjetividad y las relaciones involucradas en el proceso. Respecto a consecuencias, el hecho de que el cuidado transpersonal favorezca la restauración/reconstitución (healing) fue el elemento más expresado. Fue posible constatar ínfimas alteraciones en la definición del concepto al pasar de los años según las publicaciones de la teórica. En conclusión, analizar los atributos, antecedentes y consecuencias del concepto favoreció un mejor entendimiento de éste, y la comprensión de su importancia en la Teoría del cuidado Humano propuesta por la teórica norteamericana.
Descriptores: Atención de enfermería; Formación de concepto; Modelos de enfermería; Teoría de enfermería
Caring is the essence of nursing and this act can be considered the guiding thread of the knowledge structure of the discipline and its evolution; it is both the practice and theory based on the manner and the complexity of caring provided(1).
The effectiveness of nursing care requires its grounding in a theoretical framework, in a nursing theory, which, among other relevant information, guides the embodiment of that caring so that the targets proposed can be reached, according to the view of the theorist chosen.
Between the various existing theories of nursing, there is the Theory of Human Caring described by the theory of Jean Watson, which has contributed to the development of nursing knowledge, especially after the release of her first book in 1979, entitled, Nursing: the philosophy and science of caring.
Caring can be effectively demonstrated and practiced in a transpersonal mode, in which consciousness that goes beyond the biological, material dimension and is capable of transcending time, space and the physical body(2).
The theory understands that, in relation to caring, the nurse is not alone, she needs the other in order for this interaction of caring to occur. Therefore, a transpersonal relationship of caring connotes a special form of the caring relationship, being characterized as one in union with the other, elevating the consideration for this to be and by its being in the world. It is from the transpersonal relationship that nurse and client become just one, it is the moment in which caring is made concrete and the two beings are attuned body and soul in the relationship(3).
By means of this approximation with this previous philosophical reference, it was possible to perceive that transpersonal caring, as described by the theory, goes far beyond the caring moment experienced by the nurse and by the one receiving care. He is transposed into the life of those involved in this relationship of caring.
The American researcher, the author of the theory mentioned here, shows constant preoccupation with her work, which is justified by the improvement and incremental update that she performs in her writings, which can lead to the need for studies to monitor possible changes, in particular the concept of transpersonal caring, presented by her.
Thus, it is justified that an analysis of the concept of transpersonal caring is completed, so it can be clarified and better understood, and so that the proposed developments emerged over time can be perceived and described.
Model of Concept Analysis
Several authors in the field of nursing or other fields of knowledge have developed proposals for analysis of concepts(4).
In general, the development of the concept passes through three stages: derivation, synthesis, and analysis(4). Derivation may be understood as analogies / metaphors that provide changes in terminology or in the structure of a field, from one context to another, and thus facilitates the development of new concepts(5).
Synthesis is already used by theorists to group or order information about some event or phenomenon, and it allows the combining of isolated pieces that are as yet theoretically disconnected(5). Analysis examines the structure and function of the basic elements of a concept and allows the theoretical examination and re-examination of existing knowledge about a phenomenon as a means to improve the accuracy, update or relevance of the knowledge(5-6).
Thus, the analysis helps to distinguish and clarify the vague concepts that are prevalent in nursing; it refines ambiguous theoretical concepts, increasing the construct validation; it supports the construction of instruments or the evaluation of existing tools and contributes to the development of a standardized language to describe the practice of nursing(5-6). It should be performed when concepts require further clarification or further development, so that they can be used in the growth of theories, in the progress of practice, or in research.
Therefore, the derivation, analysis and synthesis of the concept refers to the rigorous process of clarifying the definition of the concepts used in the science. Analysis and derivation are commonly used in nursing, particularly in the context of research, to refer to the examination of concepts related to their level of development, as evidenced by internal structure, use, representativeness and relationships with other concepts, in order to explore their meaning and promote their understanding(4).
The concept analysis model(5-6) consists of the following eight steps: concept selection, delimitation of the goals or purpose of the analysis, identification of the uses of the concept; determining the defining attributes; identification of a model case; identification of additional cases (borderline, related, contrary, invented, and illegitimate); identification of the antecedents and consequences of the concept; and definition of the empirical references.
The first step, normally, is related to the field of knowledge or interest of the researcher, and the choice of concept stems from the desire for its expansion or even its clarification. The second phase seeks to determine the purpose of the analysis and helps the researcher to focus on what has been determined to achieve the expected result. The third step is characterized by the identification of multiple uses of the concept, in different areas of knowledge. The attributes or defining characteristics determined in the fourth step identify the salient features present in the existence of the concept. They facilitate the differentiation between a specific occurrence of a phenomenon and another that is similar or related(5,7).
Thus, the attributes comprise the characteristics that act as differential diagnosis elements(5-6,8), which facilitate the differentiation of specific occurrences of a phenomenon with another that is similar or related. They are the defining characteristics or salient aspects that are present in the identification of the existence of the concept(7).
The fifth phase refers to the construction of a real-world example for the use of the concept, with the ability to include all the attributes listed. In addition to this, the construction of additional cases, objectified in the sixth step, are performed with the purpose of providing examples that do not define the concept and, thereby, promote understanding of the concept that is being analyzed. For the achievement of the seventh step it is necessary to identify the antecedents which, as its name suggests, precede the existence of the concept and consequences, which are events that occur as a result of the existence of the concept.
Finally, the eighth phase refers to the empirical references, which are classes or categories of actual phenomena that, by their existence or presence, demonstrate the occurrence of the concept itself(5,7).
Thus, the proposition of analyzing the concept of transpersonal caring stems from the necessity of clarifying its meaning, especially its defining attributes, antecedent events and consequences, so that it can help to elucidate difficulties regarding its conceptualization on the part of those who study and use such form of caring in their research and / or practice of care.
Based on these aspects, this article used the following orienting question: What are the attributes, antecedents and consequences of the concept of transpersonal caring? In order to respond to this inquiry, the objective was to analyze the attributes, antecedents and consequences of the concept of transpersonal caring.
This was a theoretical study with a documentary research design and utilization of the following methodological steps of the concept analysis model(5-6): selection of the concept, delimitation of the purpose of analysis, determination of the defining attributes; identification of the antecedents and consequences of the concept under analysis, referring to steps 1, 2, 4 and 7, of a total of eight that were proposed by the authors.
We opted for these steps by understanding that they were sufficient to respond to the proposed objectives for this study, since the others that comprise the elaboration of cases only illustrate, based on the information obtained by the other phases, the attributes, antecedents and consequences of the concept. Another step that we did not use refers to the use of the concept which, given the types of works chosen for this study, could not be achieved.
The necessary descriptions were identified, the concept to be analyzed was selected, and the objective of the analysis was defined, thus passing on to the remaining steps of the study. For this, we identified the books published by the American theorist Jean Watson, according to the following inclusion criteria: literary works (books) that dealt with the Theory of Human Caring, written in English or Portuguese (Portugal and Brazil), ranging between the period of 1979 to the present day.
When considering these criteria, we identified seven books, which were acquired and submitted for consideration by an initial reading of the content. As a result of this verrification, the book published in 1979 was excluded because there was no reference to the concept of transpersonal caring in its content. Thus, the final sample of this study consisted of six books, which went through a process of being carefully and objectively read, in which information was highlighted that corresponded to the elements that referred to the attributes, antecedent events and consequences of transpersonal caring, based on questions that follow.
For the identification of attributes, we used the following questions: How does the theory define the concept? What characteristics are described relating to the transpersonal caring concept? In order to find the antecedents of the concept under analysis, we established the following question: What events contribute to the emergence and existence of the concept? And finally, so that we could verify the presence of the consequences related to the concept, we used the following question: What results after the application of the transpersonal caring concept?
As noted by the results presented, the analysis of literary works that comprised the study sample allowed the identification of the antecedents, attributes and consequences of the transpersonal caring concept, shown in Table 1.
Based on the results listed in Table 1, the antecedents, attributes or essential characteristics, and the consequences of the transpersonal caring concept that emerged, are presented.
Antecedents of transpersonal caring
Among the antecedents described in Table 1, the element most present in the publications analyzed was the caring moment (event or real occasion of caring), present in all of the selected publications.
The American theorist describes a caring moment as a thoughtful moment; an existential field, energetic; a turning point; a call to higher consciousness and profound intentionality; a choice of an authentic ethic of caring / living, which requires a new level of authenticity that can enhance the ego, restore and preserve the wholeness of being1. The author further states, in more recent work(14) that, a caring moment transcends time and space and continues as part of a larger complex pattern of life of both the nurse and the patient.
The caring moment is one in which the self of the nurse joins the self of the client (union between those involved in caring), becoming one. This union provokes permanent changes in the lives of these beings, which is able to echo into the future(10).
The Theory of Human Caring considers transpersonal caring as that which happens at the moment of caring, an occasion in which the process elements of clinical caritas are used to operationalize and support the nurse to drive the effectuation of transpersonal caring. Therefore, in order for transpersonal caring to occur, there is necessity for a caring moment to exist.
In addition to this element, a transpersonal caring relationship also depends on a moral commitment among those involved in the caring relationship; intention and will of the nurse to be in the relationship and thus affirm the subjective significance of being caring(9-11); and understanding that the human being is not just the sum of its constituent parties, but a mind-body-spirit unit(9-10).
Attributes or essential characteristics of transpersonal caring
The most described element in the publications that comprised the sample was intersubjectivity, which is present in the definition of transpersonality described by Jean Watson.
Transpersonal refers to an intersubjectivity of the human to human relationship in which the person of the nurse influences and is influenced by another person. Both are fully present in the moment and feel a bond with one another. They share a phenomenological field that becomes part of the life history, and both are co-participants in becoming the now and the future(10-11).
Thus, it is possible to see that the concept of intersubjectivity is intimately related to another element quite present in the publications analyzed, reciprocity and mutual influence between the one who provides caring and the one who is cared for.
Transpersonal caring radiates a field of caring beyond the people involved (transcends the individual), in a process that becomes part of the complex journey of life(2,9-10,15). This subjective contact has the potential to go beyond the physical-material or mental-emotional; it transcends time, space and physicality and affects those involved so that they carry for their lives the lived process (2,9-10,15).
Thus, the form of transpersonal caring is understood as the moral ideal of nursing, in which the maximum concern is with the dignity and preservation of the human being. A transpersonal caring relationship connotes a relationship of special caring, a union with another person, and considers the whole and its being in the world(10,16).
Besides these, other elements are commonly cited in the analyzed works as essential attributes of the concept under analysis. The theory affirms that transpersonal caring and the relationships of caring are scientific, professional, ethical, aesthetic, creative and personalized behaviors of giving and receiving responses between those involved(9-12). The moments of transpersonal human caring are connections that include the awareness of the nurse, intentionality, authenticity and sincerity, through the use of self, recognizing the totality of the other, noticing movements, senses, touch, sounds, words, colors and ways in which the client transmits and reflects his own condition(11).
It is, therefore, a careful experiential, contextual and metaphysical caring, based on a system of values that recognizes the power of love, faith, compassion and consciousness associated with a profound respect and admiration for the mysteries of life, named, from 2005, as caritas(10-11).
Consequences of the transpersonal caring concept
Among the elements present in this category, one that has been described in all the analyzed publications and which refers to a consequence arising from transpersonal caring, that was its capacity to provide restoration / reconstitution (healing).
As stated, transpersonal human care occurs in an I-thou relationship, and this contact is a process that transforms, creates and potentiates the healing process, a term that means recomposition, restoration and reconstitution, but that should not be construed as a cure(17) .
Therefore, transpersonal caring is a transformation in which the individual moves toward a heightened sense of being and harmony with his mind, body and spirit. Transpersonal caring liberates feelings, allows the client, the care receiver, to better assimilate the condition of his own being. Such assimilation can lead to the reorganization of the perceived I and of the experienced I(10).
Since the publication of the book, Caring science as sacred science, in 2005, an evolution occurred in the construction of the theory. The caring factors are replaced by elements of the clinical caritas process. In order to expose them, Watson enables a profound understanding of the dimensions of the process of life and of human experiences, in addition to expanding its concepts, including the sacredness of being caring and its connection to a plan that extrapolates the concrete and visual, thus having the proposition of healing and reconstitution(2,12,14-15,17-19).
According to this perception, and to use caritas and caritas processes or clinical caritas, the theory(2,14-15) affirms intentional invoking of the word love, explaining the connection between caring and love(18,20). By bringing together love and caring, one is invited to deepen the transpersonal caring. The relationship between love and caring creates an opening for internal healing of everyone(2,15,18), which, in other words, generates and potentiates processes of self-recovery, self-growth, self-control and self-recuperation.
Therefore, transpersonal caring is perceived as one that happens at the moment of caring, operationalized by the elements of the process of clinical caritas, much more than a nursing process, a view that Watson did not advocate(3). It is capable of bringing about the restoration/reconstitution between human beings involved in the process and, therefore, the caring moment becomes part of both the past and future life history of both human beings and enables new opportunities, for example, self-knowledge(10).
Transpersonal caring, understood in this dimension, enables a better understanding of oneself to better know one another, promotes the amplification of the capacity of restructuring. The care that encompasses and values the trinomial body-mind-spirit is capable of changing the focus of caring, moving the focus from cure to reconstitution and love(21).
To analyze the transpersonal caring concept based on the Walker and Avant model makes it possible to broaden one's understanding by defining attributes, antecedents and consequences, and it is possible to clarify its meaning and follow the evolution undergone with the passing of years, which was due primarily to constant updates made by the theorist, Jean Watson.
It is worth highlighting the commitment of the theorist to her beliefs and studies, which are portrayed in dozens of scientific articles and in about 15 books that address not only the Theory of Human Caring, but aspects relating to caring in nursing. This material is widely studied and has translations into the Japanese, Portuguese, French, Korean, German, Swedish, Chinese, Norwegian and Danish languages.
Therefore, this study makes it possible to notice that the concept transpersonal caring presents negligible changes in its definition with the passing of years and the publications presented by Jean Watson, because the first definition presented in the 1985 production has been maintained as its base in the publication of 2012. However, independent of the maintenance of premises contained in the concept, The Theory of Human Caring, in general, transformed and received significant changes over time, especially with regard to the expansion and reformulation of the older factors of caring, which are now being called elements of the clinical caritas process.
As a possible limitation of the study, we would point to our option to not include the case elaboration phase in the selected method, an aspect that could be investigated in future studies.
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1 Excerpted from the conference notes: Caring in nursing beyond postmodernity delivered by Jean Watson, in the International Exchange: Theoretical and Philosophical Foundations of the Practice of Caring in Nursing, November 2003, in the city of Rio de Janeiro.