On-line version ISSN 1982-0194
Acta paul. enferm. vol.22 no.2 São Paulo 2009
Aplicación de la Teoría del Cuidado Transpersonal de Jean Watson: una década de producción brasileña
Luciane FaveroI; Marineli Joaquim MeierII; Maria Ribeiro LacerdaIII; Verônica de Azevedo MazzaIV; Luísa Canestraro KalinowskiV
IGraduate student at the Nursing Post-Graduation
course; Member of the Nucleus of Studies, Research and Extension on Nursing
Human Care NEPECHE, Universidade Federal do Paraná UFPR
Curitiba (PR), Brazil
IIDoctor, Assistant Professor at the Nursing Department; Member of the Multi-professional Group of Studies on Adult Health GEMSA, Universidade Federal do Paraná UFPR Curitiba (PR), Brazil
IIIDoctor, Assistant Professor at the Nursing Department; Coordinator of NEPECHE; Coordinator of the Nursing Post-Graduation Program, Universidade Federal do Paraná UFPR Curitiba (PR), Brazil
IVDoctor, Professor at the Nursing Department; Member of the Group of Studies on Family, Health, and Development GEFASED, Universidade Federal do Paraná UFPR Curitiba (PR), Brazil
VNursing Academic; Grant student and Member of the Nucleus of Studies, Research, and Extension on Nursing Human Care NEPECHE, Universidade Federal do Paraná Curitiba (PR), Brazil
This systematic review aimed to describe and analyze the use of Jean Watson's Theory of Human Caring in Brazilian studies in the last ten years. A literature search using MEDLINE (MEDLARS Medical Literature Analysis and Retrieval System), LILACS (Latin American and Caribbean Health Science Literature) BDENF (Nursing Database), and SciELO (Scientific Electronic Library Online) databases was conducted. A sample of 34 publications met the systematic review inclusion criteria. The results showed that 61.8% of the studies were conducted in the south of Brazil, and these studies suggested that the Theory of Human Caring could be used in the three levels of care: primary, secondary, and tertiary. The majority of publications (64.7%) used the carative factors proposed by Jean Watson in 1979. There is a need for research approaches in respect to changes occurred in the Theory of Human Caring that evolved into the clinical caritas processes. Few studies have tested these new processes. This fact makes difficulty to use them in clinical practice.
Keywords: Nursing theory; Nursing research
Esta revisión sistemática tuvo como objetivo describir y analizar la aplicación de la Teoría del Cuidado Transpersonal de Jean Watson en las investigaciones divulgadas en publicaciones de Enfermería brasileñas de los últimos diez años. El levantamiento bibliográfico abarcó 34 producciones seleccionadas en las bases de datos electrónicas MEDLINE (MEDLARS [Medical Literature Analysis and Retrieval System] On-line), LILACS (Literatura Latinoamericana y del Caribe en Ciencias de la Salud), BDENF (Base de datos de Enfermería) y SciELO (Scientific Electronic Library On-line), que después de la aplicación de los criterios de inclusión establecidos, compusieron la muestra del estudio. Los resultados señalaron que la región Sur concentra el 61,8% de las producciones referidas al tema de estudio, que ella puede ser aplicada en los niveles de atención primaria, secundaria y terciaria y que el 64,7% de las producciones utilizan los factores de cuidado propuestos por Jean Watson en 1979. Surge la necesidad de perfeccionamiento de las investigaciones respecto a la transformación ocurrida en la Teoría del Cuidado Transpersonal, con abordaje del Proceso Clinical Caritas, no obstante como son escasos los estudios referentes a esta temática, dificultan su utilización práctica.
Descriptores: Teoría de enfermería; Investigación en enfermería
The word theory is defined as an abstraction of reality, which is elaborated for a specific purpose. In the nursing area, nursing theory scholars highlight that theories contribute to a grounded basis of the practice, because they gather proposals to think over the healthcare process, evidence purposes, limits and relationships between professionals and clients, the ones who provide care and are the ones who receive it(1).
Thus, Nursing has been constructed, especially in the past three decades, considering a humanistic care basis, which searches for a meaning in the human existence. It is through the care of people and life, with a humanistic focus, that the true professional identification is possible, for the nursing essence is built upon the relationship with the other human being(2).
Since his first book was published and later on, continuing his studies, Watson proposes a care-centered philosophy and science, which constitutes the Nursing practice axis(3-7). Care is more than the conduct or tasks performance, it involves the exact comprehension of health aspects and the transpersonal relationship between nurse and client(8).
The Human Caring Theory developed by Jean Watson came up between 1975 and 1979, when the author was teaching at University of Colorado. It emerged from the results of studies accomplished by the author along her Doctorate in Clinic and Social Psychology(1,9).
Such study originated the book published in 1979, called " The Philosophy and Science of Caring" , which brought new meanings and dignity to the Nursing world and client caring(3,7).
The Human Caring Theory is focused on the concept of caring and on existential phenomenological assumptions, which goes beyond the physical body. It concerns openness and attention to the spiritual mysteries and existential dimensions of life and death; caring about your own soul and the one who is receiving care(7).
The author states that her theory is both science and art, and searches, through the concepts inter-relation, for a human science that belongs to nursing, that evolves through nurse and client interaction, aiming to reach therapeutic caring.
Back in 1985, the above mentioned theory was altered by its author, as well as the concepts used as basis of her work. The transpersonal human caring paradigm was introduced to the caring science. This paradigm focus, according to the author, on the moral ideal, the communication meaning and the inter-subjective contact upon co-participation of the self as a whole(4).
It considers the transpersonal human caring as the contact of the nurse's and client's subjective worlds, which can go beyond the physical-material and mental emotional aspects, once it reaches the highest spiritual sense of " self" , soul, and spirit(10). The transpersonal human caring occurs in an I-you relationship, and such contact is a process that transforms, generates and increases the healing* process potential.
The human values were emphasized through factors such as caring, the construction of a humanistic-altruist system, through the faith-hope and the sensibility cultivation towards the self. These factors were employed in the caring process routine, and were established in the inter-subjectivity relationship(11).
The transpersonal caring, based on the definition used, determines a respectful attitude towards what is sacred, which is the other, considering this being is connected to the universe and to the others, with no divisions or spaces, time or nationalities, which Watson, as of 2005, called Caritas and Communitas(7) in her theory.
Within such development context, the care factors, initially used in the referred theory, are replaced by the clinical caritas process elements, and by exposing them, the author amplifies her concepts, including the sacrality of the being receiving care, the human being connection with a dimension that goes beyond the concrete and visual, and the proposal of healing as a reconstitution of that being(12).
It is understood, therefore, that the clinical caritas concept approaches the other with delicacy, sensibility, giving special and careful attention. This is what the author stated when she modified the " Carative" concept and created the " Caritas" concept, through which she intended to " evoke love and care connected to an existential-spiritual dimension and to experiences and processes of the human life" (7).
Taking into account the alteration proposed in Jean Watson's Transpersonal Human Caring Theory, as of its publication in 2005, an investigation of the Brazilian Nursing researches and their adequacy to Watson's theory is considered necessary.
Therefore, the issue analyzed was: How is Jean Watson's Transpersonal Caring Theory being applied to the researches published by the Brazilian Nursing?
The objective of the present research was to describe and analyze Jean Watson's Transpersonal Caring Theory application to Brazilian Nursing researches published in the past ten years.
It is a systematic review of Nursing scientific production, based on Jean Watson's Transpersonal Caring Theory.
The systematic review uses the literature concerning a chosen theme as a source of data. This investigation provides an evidence summary related to an intervention strategy, upon systematic search methods, critical appreciation and a synthesis of the selected information(13).
First of all, after defining the question that would guide the present research, the descriptors and key words for evidence search were defined: Nursing Theory and Nursing Philosophy, and the words: transpersonal caring, human caring, and Jean Watson's caring science.
Afterwards, inclusion criteria were defined to select the literature found in the database. For this study, the criteria chosen were: Brazilian publications from the last ten years, as of 1998, studies that were not repeated in another selected database, and the ones which used Jean Watson's Transpersonal Caring Theory as a basis.
The studies were reviewed in the following databases on-line: MEDLINE (MEDLARS [Medical Literature Analysis and Retrieval System] On-line), LILACS (Literatura Latino Americana e do Caribe em Ciências da Saúde Latin American and Caribbean Literature on Health Sciences), BDENF (Base de dados de Enfermagem Nursing Database) and SciELO (Scientific Electronic Library On-line).
Based on this initial selection, 1802 productions were obtained. Their titles and abstracts were analyzed by using the selection criteria mentioned, and their methodological quality was assessed. A total of 1768 productions were excluded due to repetitions found in the databases selected, publication prior to 1998, inconsistency with the proposed subject, or usage of Jean Watson's Transpersonal Caring Theory just as a theoretical reference, without a development of the topic. Thus, 34 publications were analyzed and distributed according to their respective database, and word or descriptor selected.
Identifying the sources, 50% of the researches were selected in LILACS, 41.2% from BDENF, 8.8% from SciELO and none from MEDLINE, probably due to the fact that the inclusion criteria required only Brazilian publications written in Portuguese. The mostly used key-words were: " transpersonal caring" and " Jean Watson" , present in 41.2% and 26.5% of the productions, respectively.
The selected publications were 25 articles, five masters' dissertations and four post-graduation (lato sensu) monographies. Concerning the masters' dissertations, only the abstracts available at the thesis databases were used, considering the difficulties to find the entire articles.
At this point, with all texts, careful readings of the material were performed. A data collection form was developed and was filled out for each production in the final study sample. The form included information on the article identification, authors' background, location where the research was developed, studies outline and characteristics, methodological aspects, data analysis, results, and recommendations for the Nursing practice.
As of the comprehension and analysis of the data obtained through the selected material readings, the results described below emerged:
A total of 34 national productions were analyzed and the methodological criteria described by Sampaio and Mancini(13) were used.
The so called characterization was comprised of: publications year and origin, background of the authors involved, research development location, methodology used, subject types, and data collection methods.
Based on the research and publication year, and the location where the research was developed, it was possible to verify that most of the articles had been written and published in the year 2000 (8)**, followed by the year of 2004 (5), second year when most publications had approached the subject.
From the 25 articles selected, 15 were masters' dissertations clippings, and 3 were doctorate thesis clippings.
The Brazilian state which presented most of the publications concerning the reference theme was Paraná (10), followed by Rio de Janeiro (7). It is possible to notice, though, that the publications were restricted to the south (SC- 6, RS- 5) and southeast (SP- 1, and publications from RJ) regions, in most cases, for only 4 publications did not belong to these regions: 3 of which were from Ceará, and 1 from Brasília. One publication did not have a location characterization due to the type of methodology adopted.
With regard to authors background, most of them were doctor and professor nurses (32), followed by master and professor nurses (11). Something considered remarkable was the fact that only 2 professionals called themselves doctor, professor and researcher nurses.
In respect to the research development location, the internment units were the most mentioned (7 researches the most mentioned specialty was oncology, in 4 studies), followed by the domiciliar environment (6), and the critical and intensive care units (6). However, Jean Watson's Theory was also reported to be applied in pediatric and rehabilitation clinics, emergency rooms, universities, public health system, and in an obstetric center.
Concerning the methodological approach used to develop the researches, most of them used the qualitative approach; there were only two cases of quanti-qualitative researches. About the type of study, a variety of research types was found: phenomenological (4), descriptive (3), descriptive exploratory (3), case studies (3), experience reports (3), literature reviews (3), among others.
The studies subjects were, in the majority of cases, adult clients under Nursing care (8) and/or these clients' families (7). The Nursing team (5) and the nurses (6) were also the subjects who mostly participated in the studies.
The data collection occurred mainly through interviews (12), recordings of the subjects' speech (10), workshop participations (9), questionnaires (4), field diaries (4), participating observation (4), and non-participating observation (3).
After the productions characterization, which was the first step, it is possible to present better defined concepts and similarities among the authors and type of researches analyzed.
The most frequent concept defined by publications was Nursing (12), followed by the environment concept (11), human being (10), care (10), health/disease (7), transpersonal caring (6), family (4), and domiciliar caring (2), among others. Other important terms developed by Jean Watson appeared few times. They are: the moment of care (2), transpersonal relationship (1), human caring (4), care factors (3), clinical caritas or caritas processes (3), transpersonality (2) and transpersonal caring theory (3).
Considering the conclusions reached by the authors regarding the Transpersonal Caring Theory contribution to the researches, clients, and their families, to the professional category, and to improve the nursing care, positive results were found, and were considered as possible reasons for the Theory full or partial usage in the nursing routine.
It is necessary to understand some transformations Jean Watson's theory has gone through in the past few years, so that it is possible to analyze some considerations from the selected literature, such as, for instance, the fact that 17 studies mention ten care factors, 5 studies use part of the care factors, and only 5 studies use the clinical caritas process. This is perfectly acceptable once the research and/or publication year of 29 studies is prior to 2006. It also justifies why care factors emerge to the detriment of the clinical caritas process, even though they were overcome by Jean Watson herself.
Another point considered positive was the fact that authors considered the care factors as humanistic perspective agents, which provide growth and autonomy to the nurse, as well as a more ethical, moral and human caring.
However, productions published as of 2006 approaching the clinical caritas process (5) bring the being sacrality possibility as a process application contribution. The being sacrality concept concerns two beings (the ones who gives and the one who receives care) that are connected to the universe, with no divisions, and transcends the physical body, going beyond the material and reaching the cosmos.
Negative points were also reported by different authors in the publications analyzed regarding the Transpersonal Caring Theory. Many of them mentioned the difficulty found on the theory practical application, because Jean Watson does not defend a nursing process that systematizes the practical application of the ideals proposed by her theory.
According to some authors, the theory practical application may be difficult due to some institutional and social-politics issues that limit its practice.
Some studies state that the Brazilian graduation and post-graduation courses do not value the Transpersonal Caring Theory, or that the theory concepts are not part of the Nursing teaching in Brazil. There is also a gap between educational and professional practices, for it is necessary to adopt paradigms that are compatible with the Brazilian reality. There are other statements that affirm health service institutions are not prepared for such ideals implementation, and caregivers' capacitation is required so that they can work with this model, among other aspects found.
Through the results obtained, it is possible to notice the strict sensu post graduation programs collaboration to the Nursing knowledge production in Brazil, once most of the articles found on the theme come from such programs.
The incentive agencies consider research activities are concentrated in the public university post-graduation courses, and its professors have the main role in this process(14).
In agreement with what has been exposed and justifying the fact that the South region is where most of productions on the theme were found, it is possible to verify how important the Post-Graduation Program of the Federal University of Santa Catarina is, due to its nursing and philosophy doctorate course, besides being, for many years, a partner and an important masters graduation university in the south. Through a program called Rede de pós-graduação em Enfermagem da Região Sul (REPENSUL Nursing post-graduation network in the South region)(15), UFSC (Federal University of Santa Catarina) created poles of professor nurses for the academic masters' degree in the states of Paraná and Rio Grande do Sul, which were strongly influenced by the projects, research subjects, and intellectual development of the institution.
Moreover, Jean Watson herself visited that state a few times and assisted on the application and understanding of her theory by professor and students of the mentioned program, which use Jean Watson's theory to develop researches that may bring benefits to the Brazilian population and advances to the Nursing development in Brazil.
However, it is possible to notice researches in the area are still a privilege that only professionals attending such institutions have. A study shows that nurses develop few researches, and that researches produced for the Nursing field come, mainly, from the academy, developed by nursing professors(16).
Between the two types of researches found by this study, qualitative research prevails. Such research type uses multiple methods that are interactive and humanistic. Data collection methods are increasing and, gradually, absorb subjects' active participation and sensibility from the study participants(17).
For the qualitative research, data collection occurs through observation, interviews, audiovisual material (photographs, video tapes, art objects, films, recorded sounds and images, software), and document analysis(17).
Researches that are based on the theory proposed by Watson may be used in a wide range of locations, for the theorist herself(7) states that the care science proposes that Nursing, either individually or collectively, contributes to the humanity preservation (wherever it is) and tries to sustain care wherever it is threatened, assisting on the human species evolution and deepening, besides being its support.
Jean Watson's Transpersonal Caring Theory went through a reformulation and growth process, when the core concepts were reinforced, new concepts came up and some points were modified. Such modification occurred in 2005, when " Caring Science as Sacred Science" was published. However, only as of 2006 Brazilian researches started talking about the new focus.
The widely diffused and used care factors are replaced by the clinical caritas or caritas processes. The care moment is considered the moment when the transpersonal caring process occurs between nurse and client, where clinical caritas is applied(7, 12, 18).
May be due to this modification, considered recent, few studies approaching Jean Watson's theory new concepts were found. Many studies still demonstrate the care factors usage or partial usage, which provides, according to some research authors, innovation to the nursing practice, relationships humanization, a closer interaction between caregiver and patient, transforming them into unique beings and an overview of the process, not to generalize the individual, but to consider him/ her a unique, special being.
Such described innovation is, today, overcome by the theory advances. Nevertheless, there are some publications that, in spite of using the new perspective proposed by Jean Watson, still work with the care factors proposed in the beginning of the Human Caring Theory development.
In this new process, developed as of 2005, the ostensive evocation of a connection between love and care occurs, through an expanded paradigm, where the spiritual and existential dimensions can be linked to the human life experience processes(7).
It enables a better knowledge of oneself in order to get to know the other, amplifies the restructuring capacity. This care embodies and values the trinomial body-mind-spirit, and is able of changing the care focus, aiming, more than healing, reconstitution and love.
In order to apply the theory, there are some factors that are not related to structure or institutionally limited, such as beliefs, principles, and each person's feelings. It is known that, when applying such care method, a strong bond must be created between caregiver and patient, effort and dedication to build a transpersonal relationship are also necessary. The nurse needs to abandon pre-established concepts and be open for this new relationship, pervaded by care and faith in something that transcends the current moment.
Besides that, considered as a negative point by many authors, some researches also point to the fact the theorist does not explain the applicability of her theory, following nursing phases, such as in other nursing theories. The theorist states, though, that the transpersonal caring happens during the caring process and the clinical caritas is the application of this process(12).
The factors mentioned above, allied to the difficulties faced by the Nursing teaching and professional practice in Brazil, have been the determining factors for the little usage and for the difficulties found in the theory usage according to some authors. Nevertheless, taking such adversities into account, it is worth highlighting that the nurse's professional mission is to search for assistance quality and that the transpersonal caring is a possibility within reach(1).
This review shows that there are researches that use Jean Watson's theory in Brazil, although such production is concentrated in the country's South/Southeast regions.
Jean Watson has dedicated herself to the Nursing profession development for the past 30 years, and in spite of the recent transformation her theory went through, her purposes have always focused on the nursing care. Such process does not consider the cure a final objective, once it happens transpersonally, with the nurse's self involved with the client's self, both aiming to reach a state where mind, body, and spirit can be one, bringing the self-healing process as a result of the care, not its main objective.
The clinical caritas process emerged from the theoretical search for a nursing care that would transcend the medical diagnosis, the disease, or the scenario where it happens, not to limit the care to a physical body or the disease, but to go beyond, to transcend the material, and to achieve care plenitude.
From this discussion, it is possible to conclude there is a research improvement demand regarding the clinical caritas process and its practical application to nursing care, because there are few studies concerning the subject.
Through the Brazilian productions survey, it was possible to verify that the Nursing uses the Transpersonal Caring Theory as a practical application of Jean Watson's studies to our country, despite some authors' statements with regard to the theory teaching in some educational institutions. It is necessary, though, to assess the theory evolution, which provided two different moments for its utilization (before and after the care factors replacement by the clinical caritas process).
This discussion brings new possibilities to the Brazilian Nursing, both as a human caring reference, which meets the Public Health System guidelines, and as a model for reviews that cover other theories and their applications.
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Corresponding Author: Received article 04/09/2008 and accepted 18/10/2008 * "A term
that means recomposition, restoration and reconstitution, and should never be
understood as cure" (12).
R. Urbano Lopes, 214 - Apto. 1901 - Bloco A
Curitiba - PR - CEP. 80050-520
** The numbers in brackets refer to the number of publications that fit the criteria after analysis.
Received article 04/09/2008 and accepted 18/10/2008
* "A term
that means recomposition, restoration and reconstitution, and should never be
understood as cure" (12).