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Revista da Escola de Enfermagem da USP

Print version ISSN 0080-6234

Rev. esc. enferm. USP vol.48 no.spe São Paulo Aug. 2014

http://dx.doi.org/10.1590/S0080-623420140000600012 

Artigo Original

The practice of nurses caring for families of pediatric inpatients in light of Jean Watson*

La práctica del cuidado del enfermero com famílias de niños según jean watson

Maiara Rodrigues dos Santos1 

Regina Szylit Bousso2 

Patrícia Vendramim3 

Michelle Freire Baliza4 

Maira Deguer Misko5 

Lucía Silva6 

1Student of the Doctorate program, School of Nursing, University of São Paulo, São Paulo, SP, Brazil

2Free-lecturer Professor, Department of Mother-Child and Psychiatric Nursing, School of Nursing, University of São Paulo, São Paulo, SP, Brazil

3Student of the Doctorate program, Program of Graduation in Health Sciences, Federal University of São Paulo, São Paulo, SP, Brazil

3Master in Sciences, School of Nursing, University of São Paulo, São Paulo, SP, Brazil

3Student in the Post-Doctorate program, School of Nursing, University of São Paulo, São Paulo, SP, Brazil

6Student in the Post-Doctorate program, School of Nursing, University of São Paulo, São Paulo, SP, Brazil

ABSTRACT

Objective

To know the facilities and the difficulties of nurses in caring practice of hospitalized children’s families in the light of Jean Watson’s Theory of Human Caring.

Method

It was used the descriptive qualitative approach. The data collection was conducted in three stages: presentation of theoretical content; engagement with families in the light of Watson’s theory; and semi-structured interview with 12 pediatric nurses. The interviews were analysed using inductive thematic analysis, being possible to form three themes: Recognizing a framework for care; Considering the institutional context; and Challenges in family’s relationship.

Results

The theory favored reflections about self, about the institutions and about nurses’ relationship with the family of the child, normalized by a consciousness toward caring attitudes.

Conclusion

In this process, it is imperative that nurses recognize the philosophical-theoretical foundations of care to attend the child’s family in hospital.



Key words: Child, hospitalized; Nursing care; Nursing theory; Professional-family relations; Family nursing; Models, nursing

RESUMEN

Objetivo

Analizar la violencia contra los adolescentes a la luz de las categorías de género y generación.

Método

It was used the descriptive qualitative approach. The data collection was conducted in three stages: presentation of theoretical content; engagement with families in the light of Watson’s theory; and semi-structured interview with 12 pediatric nurses. The interviews were analysed using inductive thematic analysis, being possible to form three themes: Recognizing a framework for care; Considering the institutional context; and Challenges in family’s relationship.

Resultados

The theory favored reflections about self, about the institutions and about nurses’ relationship with the family of the child, normalized by a consciousness toward caring attitudes.

Conclusión

In this process, it is imperative that nurses recognize the philosophical-theoretical foundations of care to attend the child’s family in hospital.



Palabras-clave: Niño hospitalizado; Atención de enfermería; Teoría de enfermería; Relaciones profesional-familia; Enfermería de la familia; Modelos de enfermería

Introduction

Nursing theories are the basis of a body of knowledge that is structured and organized to support practice. Today, there is still a gap between theory and practice in nursing, which means theoretical models are rarely used and, because of that, theory-guided practice remains only an ideal for most institutions(1).

In recent years, theoretical framework have been reconsidered in the institutional context because of the need to meet the requirements of quality certification evaluations.

The Magnet Recognition Program® offered by the American Nurses Credentialing Center includes specific criteria for quality standards in nursing. Because of that, in countries like the U.S., there is an increase in the number of studies that adopt theoretical framework in practice(2-5). These studies suggest that bringing nurses closer to patients through care practices has positive consequences, such as increases in patient satisfaction and nurses’ work comfort, enabling improvements in the quality standards of entire institutions(1,6).

Therefore, theoretical frameworks in nursing have been recognized for their positive influence on practice.

Theoretical frameworks based on the science of care have brought improvements to: cost-effectiveness of patient care; communication and education; advancement of nursing research; and recognition and appreciation of the professionals(2-5).

In this sense, few concrete actions have been carried out in Brazilian institutions. Although many institutions have adopted theoretical models of nursing, as demanded for quality certification evaluations, the use of frameworks for nursing care practice must be further analyzed in the national literature.

Having in mind the need for more studies that concern the use of theoretical models of nursing in care, this investigation had as its objective the experience of nurses caring for families of pediatric inpatients, using as a framework Jean Watson’s Theory of Human Caring.

Jean Watson’s Theory of Human Caring

The theory developed by Watson puts care science at the starting point of nursing as a discipline, offering a foundation for the profession and care based on metaphysical, philosophical and moral paradigms, respecting the significance of humans in their individuality and mind/body/spirit wholeness(7).

Through what Watson callsclinical caritas, the interaction between science and humanism is organized as a guideline for conscious practice of nursing care(7). Clinical caritas processes are described in Chart 1.

Care must be especially focused on interpersonal relations, since the care moments are expressions of the interaction among two or more people. For Watson(7), the development of this interaction can happen in a transpersonal manner. Analysis of the transpersonal care concept focuses on the establishment of a relation that goes beyond caring for physiological necessities, aiming at a higher level and resulting in transformation of both individuals(8).

Chart 1 The 10 clinical caritas processes of Jean Watson’s Theory of Human caring 

Note: Adapted from Watson, 2008(7).

With this in mind, this study had as its objective knowing the facilities and the difficulties of nurses in caring practice of hospitalized children’s families in the light of Jean Watson’s Theory of Human Caring.

Method

This study used the descriptive qualitative approach(9) to understand what facilitates and hinders nurses’ performance when using Jean Watson’s theoretical framework with families of pediatric inpatients.

The study was carried out in three stages. The first involved presentation of theoretical content and support material. This was carried out in October 2011 by a workshop for pediatric nurses at a private hospital in the city of São Paulo.

Initially, we got a favorable decision from the research ethics committees of two institutions, one public and one private. However, when we presented the project to the nursing administrators of the public hospital, it was considered unfeasible. That is why the study was conducted only at the private institution. The study was made possible by the interest and availability of nursing administration in relation to bringing professionals closer to theoretical framework for family care.

The workshop had a duration of four hours and was offered in two periods (morning and afternoon) to reach the highest possible number of participants, making it possible to fit it in between work shifts. This strategy was chosen to connect the experiences of nurses caring for families of pediatric inpatients with the concepts of care centered in the family(10), as well as elements of the caritas process from Watson’s theory(7).

The activity was coordinated by two researcher nurses who specialized in family nursing, had no ties to the institution, and had a lot of knowledge of Watson’s theory. The workshop began as a group dynamic activity. At that time, each participant was asked to think about what care is and is not. After the reflections by the participants, the theoretical contents were presented.

A pocket handbook was offered as support material. It contained a synthesis of the concepts and theory approached in the workshop so the nurses would remember the discussed framework. The idea was to enable reflection through quick inquiries into this material regarding relations with the other and the self, within care contexts.

The second stage of the study was an invitation and efforts to motivate the nurses to constantly reconsider their caring moments with the families, looking to engage them in consciously practicing elements of Jean Watson’s theory.

In this stage, we emphasized, that according to Watson(7), interactions in nursing care are as intuitive, creative, authentic and personal as the empirical processes related to the profession’s technical knowledge. The nurses could use the pocket handbook and other materials that were made available, such as articles from national and international journals.

This stage lasted for a period of 60 days, starting with the workshop. The researchers considered this sufficient time for the nurses to experience the interactions with the families. During this stage, the researchers were available through email, telephone, meetings and visits (previously scheduled) to clear up any doubts.

After the 60 days, interviews were scheduled as the third stage of the study with those who agreed to participate. The semi-structured interviews had as their objective understanding what facilitates and hinders nurses’ practice of caring for families of pediatric inpatients, in light of Jean Watson’s Theory of Human Caring. The interviews had as their guiding questions: 1. How was your experience with caring for families of pediatric inpatients after having participated in the workshop? and 2. What facilitates or hinders the use of Watson’s Theory of Human Caring in practice with families of pediatric inpatients?

The interviews were conducted in a private room at the hospital between December 2011 and February 2012. All were recorded and transcribed. Field notes, with details of the context and non-verbal expressions, were made during the entire process. All thirteen participants in the workshop were invited to take part in the study, with the following inclusion criteria: being a registered nurse; working on the pediatric ward; having participated in the workshop; and agreeing to participate in the research through signing a Free and Informed Consent form. Only one nurse refused (no reason given).

The sample included 12 nurses; seven worked in the pediatric intensive care unit and one in a pediatric emergency room. Four nurses had administrative or management positions. The professionals had between six months and 23 years of work experience at the hospital where the study was carried out.

This research project was approved by the research ethics committee of the hospital (a private hospital located in the city of São Paulo), according to Resolution 196/96 from the Brazilian National Health Council(11).

The interviews were submitted to inductive thematic analysis(12). In this process, a theme is derived from patterns found in the data to describe and organize possible interpretations of the phenomena that are analyzed. The inductive process made it possible to create codes for the construction of three themes from the raw data generated through the interviews and field notes, aiming to answer the researched problem(12).

Results

Analysis of the interviews revealed what facilitates and hinders nurses’ practice of caring for families of pediatric inpatients through Jean Watson’s Theory of Human Caring. It was possible to create three themes, in which there were aspects that facilitated and hindered the use of this theory in practice. They were: recognizing a framework for care, considering institutional context and challenges in the relationship with families.

Recognizing a framework for care

This theme represented the nurses’ reactions to encountering theoretical frameworks for their actions. They attributed a character that was mostly intuitive to the practice of caring for families. Therefore, they did not recognize performance methods based on theories, even though the institution had established two nursing theories.

They say there is Orem and Wanda Horta. All nurses that arrive here are trained to say that. If they see it in practice, that’s another question (Nurse 4).

We always hear about caring for the family, humanized work, (...) but saying I’ve ever heard about any theory, I haven’t. (Nurse 6).

The nurses recovered a desire to look for scientific evidence as care models for their practice. In theory, the proximity of theoretical concepts and nursing practices was a highlight. However, there were problems identifying moments when it was possible to notice actions and attitudes based on the utilized theoretical model.

The funniest was to notice that you do something, but you don’t know that it is a theory, that it may be grounded in something. There is a scientific theory behind it! We do it instinctively and I didn’t know that it already was a theory, that it already existed (Nurse 5).

Theory made sense of a very simple thing. I thought they were easy words, that’s why I think it is easily assimilated in practice. Because sometimes theory is very distant from practice, maybe with concepts, a very deep philosophy. I think it is even possible to assist a cardiopulmonary arrest, based on Watson, because it is a thing with a very human essence, very common for all of us (Nurse 4).

Having approached theory, the nurses found meaning in the professional activity, being able to perform care in a manner that was coherent with their selves. Knowledge and theory made it possible to identify personal values with a moral ideal of the professional. The nurses understood that difficulties such as lack of personal identity and achievements in the performance of their professional activities could be overcome.

I don’t see problems in applying this framework. I think it would be the solution. I think that if a person, by their own accord, can’t find the meanings they look for or have lost them, they should reassess what they are doing. Or else they may also conclude that this is not what they wanted to do!(Nurse 12).

Care science and its philosophical basis have a value that is defined by the relevance of biomedical knowledge. For the nurses, adopting a framework for the profession, such as Watson’s theory, enriched care practices because of the scientific character attributed to it.

Theory deals a lot with this issue of nurses’ low self-esteem, because it is the essence of nursing care (...) People are derogatory toward this preoccupation with care and underappreciate it, believing that it is the least important! I’m talking about the nurses (...) they think what the physicians do is beautiful and they don’t find themselves. I think it (the theory) values the professional (Nurse 4).

When you talk about emotions, love, affection, anger it seems like it is not very scientific. With the framework, you feel safer and more supported, because there is something based on what is scientific (Nurse 11).

In the nurses’ view, scientific practices in care may bring security and ease for professionals, as well as for families. The theoretical foundation had the potential to guide actions through scientific support, enabling the nurses to trust their abilities, understand the families and take better care of others and of themselves.

I think the families feel safer. They feel more secure and calm (...) Also for the professional (it is better) because very frequently the families feel insecure with what we are doing. With frameworks, it is easier to work, it is not so stressful (Nurse 6).

For the nurses, one of the difficulties of using this nursing theory was the lack of opportunities to measure results in professional practice.

Because we don’t know how to measure it. (...) If the physical space is improved... it is palpable, visible. But care and the team-patient relations... That we can’t measure yet. It is hard to have a palpable instrument, in Portuguese, to try to measure it! (Nurse 3).

Considering the institutional context

This theme refers to the influence of the institution’s policies on facilitating the articulation between caring theory and professional practice. For the nurses, the mission, vision and values of the institution must be compatible with the adopted theory, as well as with the profile of the hired professionals. It is the role of nurses and administration to fit philosophy to practice, so that professionals feel supported in their necessities and decisions.

It is the role of the nurses and administration to fit philosophy to practice, so that the professionals feel supported in their necessities and decisions. You have to like the theory and the philosophy of the place where you are. I think all of this has an influence. In addition to that, if the institution believes in it, if it is a philosophy, I think it helps a lot. You get resources faster, you get support! (Nurse 11).

With support from theory and the institution, nurses have the autonomy to decide and act because, often, care cannot be conditioned to the bureaucratic rigor of protocols.

The institution must give autonomy to nurses. Sometimes you are afraid to make a decision that goes against what you have to do, but you see that, at that moment, an exception could be made. You have to feel adaptability from the administration and it is positive to give liberty, to trust professionals. If we are here to perform humanized care, it means that sometimes some decisions must be made. Decisions that, when you check the protocols, are not adequate. (Nurse 5).

Theory made concepts clear. The nurses believed that a caring theory that reinforces practices of kindness and goodness contributes to client satisfaction, facilitating aspects of the institution’s strategic management.

Theory helps to understand the clients’ necessities, who are demanding clients, and to perform better and safer care. Because if I know how to relate better, I will get fewer complaints. So I think that, thinking about strategic management, there will be a decrease in complaints; the clients’ satisfaction will flow (Nurse 4).

The requirements of the hospital accreditation assessment affected the configuration of performed care. The nurses presented themselves as engaged in performing care based on what was demanded by the institution, distancing themselves from authentic, unique and transpersonal care.

In private institutions there are continuous education and accreditation assessments all the time.

There’s what’s routine to do, it ends up turning into a mechanized thing, also. It’s prescribed! So: I’m going to do it, or else they will complain about me (Nurse 3).

Challenges in relationships with families

This theme revealed the factors recognized by the nurses that may influence care for the families of pediatric inpatients, with Watson’s theory in mind. These factors were related to the organization of work in nursing, professional motivation, and personal and cultural characteristics.

Regarding organization of work in nursing, there was an emphasis on the preoccupation with the focus on technical activities as a hindrance for connection of the caring moment theory to families and children. The accreditation evaluation process, work overloads and excessive task demands interfered in the quality of care and in the development of a humanistic system, which negatively influences the professionals’ performance.

We are filled with protocols and overloading things. The professionals are not to blame, but maybe how the styles of work are imposed on us. So you end up acting automatically, which is not good. I think that it is a loss of what is the essence of the profession, which is care (Nurse 5).

I couldn’t tell you that, after the workshop, I changed my practices. More so because we were stressed because of the evaluation and some stays that were very stressful, like, the relations with the families (Nurse 6).

Another challenge for the use of the theory is lack of motivation and engagement in caring practice. For example, lack of commitment to the profession, lack of interest in effectively helping others and lack of recognition may influence the professionals’ behavior in relation to the necessity of articulating a caring theory in practice.

It is a hindrance if I don’t believe that, if I’m not committed. I may have knowledge and structure, but if I don’t want it, I won’t do it. You have to want it, believe it, like it, be there fully (Nurse 4).

Some say: Oh, I won’t do it because I won’t get anything from it. So we see a lot of this lack of motivation in the teams (Nurse 3).

There were personal and cultural characteristics of professionals that interfered in the care of families and children in the hospital. For the nurses, having the theory as framework could bring them closer to the families, based on the recognition of the influence of the self on care relations.

I think it goes through some issues of personal order. How much do I want do expose myself, how much can I manage to do (...) there are many types of professionals (Nurse 4).

I have difficulty establishing a closer contact with the families (...). I think it is part of my personality, I was always more reserved, I have difficulties with relationships, making friends (...) Some people are very extroverted! I talk to the families, but I don’t embellish things. My difficulty is with early relations. So I thought: Let me see how I can change a little how I am with this theory! (Nurse 6).

Discussion

Emphasis on models and practices based on evidence has given rise to reasons to rethink nursing care. Changes in thinking processes were set off not only by problems with nursing resources in relation to the demands of the health system, but also by the care void among people living in society(13).

Better abilities to establish caring relations with families are necessary because of the predominance of development of technical competence by professionals(14). Cultivating caring attitudes based on theoretical framework is a way to overcome difficulties, favoring the formation of ties in care relations(2-5,15).

In this study, after understanding what facilitates and hinders nurses’ practice of caring for families of pediatric inpatients in light of Watson’s theory, the importance of a theoretical framework to guide nursing actions becomes clear. It is necessary to invest in theoretical-philosophical knowledge and support professionals in regard to self-knowledge so that new care practices will be effectively adopted(3,13,15-16).

The nurses identified knowledge that fit the profession, capable of valuing and supporting its practice. For Watson(7), this is the objective of caring science: to establish itself in nursing, as discipline and specific knowledge in the profession.

The coupling of biomedical knowledge and theoretical and philosophical knowledge of human interactions in health care is a continuous challenge, because of the complexity and dynamics of the relationship(17). Nurses can offer care with kindness, empathy, compassion and assurance, using the caritas process of Watson’s theory. Therefore, this science complements the routines and tasks in conventional care, making practice more integrated, individualized and based on human values(7).

The data in the current study reflect the suffering felt at work by professionals because of the demands imposed on them by accreditation evaluations, as well as the importance given by the nurses to feeling supported by the administration in performing care practices that are not supported by these frameworks and are not very appreciated in institutional systems.

The urgency of defining standardized models of care became stronger with the creation of organizations for hospital accreditation(2-3). Despite the need to define a framework, it is known that its acceptance among professionals is higher according to its coherence with the institution’s philosophy; because of that, great efforts must be made to facilitate this aspect(2,4).

The conventional model, focused on the administrative and economical spheres of health systems, is not adequate for the necessities of patients, nurses and institutions(3,5). Because of that, a new type of management is necessary, which values and incorporates human values and the ethics of authentic relations(3) in caring practices. The transformation of caring practices results in benefits not only to individuals, but also to institutions as a whole(3,5).

The nurses revealed that excessive tasks, lack of professional motivation and personal and cultural characteristics caused feelings of unrest when interacting with families, which resulted in hindrance of engagement. When observing such difficulties, it is evident that a sense of humanity is an inherent necessity for care that involves relationships and enables the nurses to go beyond the tasks(17-18).

Furthermore, the important of a conscience focused on care is not limited to nurses’ professional relations. It should extend to personal lives and society, as being integral to the universe(13). Difficulties inherent in personality characteristics may be addressed from the moment that nurses perceive personal obstacles as impediments to making their encounters with others more centered in authentic, creative practices, focused on helping-trusting relationship during the caring moment(7).

From these considerations, this study revealed the potential of using Jean Watson’s Theory of Human Caring in the practice of caring for families of pediatric inpatients. Going in the direction of building a culture of care involves issues that concern relations in personal and other spheres, favoring essential and fundamentally human values.

The use of theory values nurses’ work and makes it possible to open the self in human relations, recovering goodness and kindness, authentically and genuinely, from the values established to promote a care environment.

Conclusion

This study contributed to the articulation of Jean Watson’s Theory of Human Caring in nursing practice with families of pediatric inpatients with the objective of praising a caring culture. The concepts of the theory received little recognition in the nurses’ practice. The teams lacked awareness and framework to care for the families and perceived themselves far from the moral ideal that brought them to the profession. In spite of that, the nurses revealed a clear awareness of the importance of improving relations and having a basis of theoretical frameworks for nursing, recognizing the relevance of incorporating elements from Jean Watson’s theory in their practice with families.

More studies are necessary to explore the use of the theory in practice, especially in privately owned institutions, so that other contexts become better known. Said contexts may reveal what facilitates and hinders nurses’ practices of caring for families of pediatric inpatients, in light of Jean Watson’s Theory of Human Caring.

To guide a practice that has the objective of promoting meaningful interactions in care, nurses and institutions may appropriate theories that better translate their values, and guide care actions with continuous involvement and recognition of professionals, based on the necessities of institutions.

*Extracted from the dissertation "Relação de ajuda e confiança entre enfermeiros e familiares de crianças internadas", School of Nursing, University of São Paulo, 2012.

References

Tongs M, Ray J. Translating caring theory into practice: the Carolina Care Model. J Nurs Adm. 2011;41(9):374-81 [ Links ]

Watson J, Foster R. The Attending Nurse Caring Model: integrating theory, evidence and advanced caring–healing therapeutics for transforming professional practice. J Clin Nurs. 2003;12(3):360-5 [ Links ]

Watson J. Caring theory as an ethical guide to administrative and clinical practices. Nurs Adm Q. 2006;30(1):48-55 [ Links ]

Birk L. The magnetism of theory: resonance to radiance. J Nurs Adm. 2007;37(3):144-9 [ Links ]

Dyess S, Boykin A, Rigg C. Integrating caring theory with nursing practice and education: connecting with what matters. J Nurs Adm. 2010;40(11):498-503 [ Links ]

Swanson K. What’s known about caring in nursing: a literary meta-analysis. In: Hinshaw AS, Feetham S, Shavers J, editors. Handbook of clinical nursing research. Thousand Oaks: Sage; 1999. p. 31-58 [ Links ]

Watson J. Nursing: the philosophy and science of caring. Boulder: University Press of Colorado; 2008 [ Links ]

Favero L, Pagliuca LMF, Lacerda MR. Transpersonal caring in nursing: an analysis grounded in a conceptual model. Rev Esc Enferm USP [Internet]. 2013 [cited 2014 Mar 25];47(2):500-5. Available from: http://www.scielo.br/pdf/reeusp/v47n2/en_32.pdf [ Links ]

Sandelowski M. What’s in a name? Qualitative description revisited. Res Nurs Health. 2010;33(1):77-84 [ Links ]

Johnson B, Abraham M, Shelton TL. Patient- and family-centered care: partnerships for quality and safety. N C Med J. 2009;70(2):125-30 [ Links ]

Conselho Nacional de Saúde. Resolução 196, de 10 de outubro de 1996. Dispõe sobre as diretrizes e normas regulamentadoras de pesquisas envolvendo seres humanos. Bioética. 1996;4(2 Supl):15-25 [ Links ]

Boyatzis R. Transforming qualitative information: thematic analysis and code development. Thousand Oaks: Sage; 1998 [ Links ]

Watson J. Caring as the essence and science of nursing and health care. Mundo Saúde. 2009;33(2):143-9 [ Links ]

Baltor MRR, Matos APK, Wernet M, Ferreira NM, Dupas G. The perceptions of families with children having chronic diseases and their relationships with healthcare professionals. Rev Esc Enferm USP [Internet]. 2013 [cited 2014 Mar 18];47(4):808-14. Available from: http://www.scielo.br/pdf/reeusp/v47n4/en_0080-6234-reeusp-47-4-0808.pdf [ Links ]

Gomes IM, Silva DI, Lacerda MR, Mazza VA, Méier MJ, Mercês NNA. Jean Watson’s Theory of Transpersonal Caring in nursing home care to children: a reflection. Esc Anna Nery Rev Enferm. 2013;17(3):555-61 [ Links ]

Oliveira MAC. (Re)significando os projetos cuidativos da Enfermagem à luz das necessidades em saúde da população. Rev Bras Enferm. 2012;65(3):401-5 [ Links ]

Corbin J. Is caring a lost art in nursing? Int J Nurs Stud. 2008;45(2):163-5 [ Links ]

Lukose A. Developing a practice model. Nurs Sci Q. 2011;24(1):27-30 [ Links ]

Received: March 20, 2014; Accepted: July 06, 2014

Correspondence: Regina Szylit Bousso. 
Av. Dr. Enéas de Carvalho Aguiar, 419 – Cerqueira César
.CEP 05403-000 – São Paulo, SP, Brazil
. szylit@usp.br

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