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Escola Anna Nery

Print version ISSN 1414-8145

Esc. Anna Nery vol.17 no.3 Rio de Janeiro July/Aug. 2013

http://dx.doi.org/10.1590/S1414-81452013000300021 

REFLECTION

Jean watson's theory of transpersonal caring in nursing home care to children: a reflection

Ingrid Meireles GomesI 

Daniel Ignacio da SilvaII 

Maria Ribeiro LacerdaIII  16 

Verônica de Azevedo MazzaIV  17 

Marineli Joaquim MéierV  18 

Nen Nalú Alves das MercêsVI  19 

IRN. M.Sc. in Nursing, Universidade Federal do Paraná - UFPR. Member of the Study, Research and Community Service Group in Humane Nursing Care – NEPECHE/UFPR. Curitiba-PR. Brazil. Email: inguide@gmail.com

IIRN. M.Sc. in Nursing, UFPR. Member of the Study Group on Family, Health and Development – GEFASED/UFPR. Curitiba-PR. Brazil. Email: danigcol@gmail.com

IIIRN. Ph.D. in Nursing, Universidade Federal de Santa Catarina – UFSC. Faculty, Graduate Nursing Program, UFPR. Coordinator, NEPECHE/UFPR. Curitiba-PR. Brazil. Email: lacerda@milenio.com.br

IVRN. Ph.D. in Nursing, School of Nursing, University of São Paulo – USP. Faculty, Undergraduate Program and Graduate Nursing Program, UFPR. Coordinator, GEFASED/ UFPR. Curitiba-PR. Brazil. Email: mazzas@ufpr.br

VRN. Ph.D. in Nursing, UFSC. Faculty, Undergraduate Program and Graduate Nursing Program, UFPR. Leader of the Research Group on Technology and Innovation in Health – TIS/UFPR. Curitiba-PR. Brazil. Email: mmarineli@ufpr.br

VIRN. Ph.D. in Nursing, UFSC. Faculty, Undergraduate Program and Graduate Nursing Program, UFPR. Member of NEPECHE/UFPR. Curitiba-PR. Brazil. Email: nennalu@ufpr.br


ABSTRACT

This is a reflexive essay on the potential use of Jean Watson's Theory of Transpersonal Caring in the delivery of child-oriented nursing home care, in the light of the 10 elements of the Clinical Caritas Process. This theoretical background permits the development of transpersonal home care to children, the moment when nurses need to develop self-knowledge, have theoretical-philosophical support, and use this knowledge to overcome the paradigm of objectivity and biological care.

Key words: Nursing Theory; Home Nursing; Child Health (Public Health)

RESUMO

Trata-se de um ensaio reflexivo sobre o potencial de utilização da Teoria do Cuidado Transpessoal de Jean Watson, na realização do cuidado domiciliar de enfermagem direcionado à criança, desenvolvido à luz dos 10 elementos do Processo Clinical Caritas. Este referencial teórico permite desenvolver a transpessoalidade no cuidado domiciliar da criança, momento em que o enfermeiro precisa desenvolver autoconhecimento, ter suporte teórico-filosófico e valer-se deste conhecimento, a fim de ultrapassar o paradigma da objetividade e do biologicismo.

Palavras-Chave: Teoria de Enfermagem; Assistência domiciliar; Saúde da criança

RESUMEN

Se trata de un ensayo reflexivo sobre el potencial de utilización de la Teoría del Cuidado Transpersonal de Jean Watson, en la realización del cuidado domiciliario de enfermería, direccionado al niño, desarrollado a la luz de los 10 elementos del Proceso Clinical Caritas. Este referencial teórico permite desarrollar la transpersonalidad en el cuidado domiciliario del niño, momento en que el enfermero precisa desarrollar autoconocimiento, tener soporte teórico-filosófico y valerse de este conocimiento, a fin de superar el paradigma de la objetividad y del biologicismo.

Palabras-clave: Teoría de Enfermería; Atención Domiciliaria de Salud; Salud del Niño

INTRODUCTION

In recent years, health systems have demanded new care alternatives to structure high-quality primary healthcare services. The urgent need to advance beyond the Cartesian logic is noteworthy, so that, beyond the separations, the connections that involve a human being be assessed in the accomplishment of interventions that comprise not only the physical dimension, but also individuals in their holistic existence, including even the spiritual range.

The new primary healthcare alternatives have attempted to offer clients with enhanced quality care through innovations that further holistic care, the diversification of the resources adopted and multidisciplinary articulation in different care spheres1.

One of these alternatives is home care, which is "a strategy to articulate the service system at its different levels". In addition, it is attractive not only to service managers and workers, but also to clients, due to its advantages and possibilities2 :245. Home care comprises the full range of actions accomplished at the patient's home, but which are put in practice through different categories, which are: home hospitalization, home visit and home care3.

In home care, the role of nursing is highlighted, considering that home-care nurses should have scientific-technological knowledge, interpersonal relationship skills and administrative abilities to deal with patients, relatives and the multiprofessional team, besides aptitude to conciliate scientific with popular knowledge, the technical with the emotional. Nurses' determinant role in home care is perceived, ranging from its coordination to simple patient orientations. These professionals' work at home involves planning, coordination, training and assessment, integrating health promotion and different factors related to individual and collective wellbeing and quality of life3. Hence, in this work environment, professionals have an enhanced degree of autonomy and, consequently, responsibilities.

Home care can enhance child healthcare; for example, through home visit programs that include intensive monitoring, under the responsibility of nurses in the first two years of life, which have demonstrated satisfactory results for child health promotion, family functioning and the reduction of inequities in health4.

In this context, health care is not only aimed at the biological perspective, but at stimulating the family to promote the child's healthy growth and development, preserving his/her social, affective and psychological support network, besides promoting the family's encounter with health, even in an environment of disease5.

Home nursing care to children is relevant due to the appearance of new situations in child health, such as the birth of premature infants, children with chronic conditions, among others. Under these circumstances, the family often feels stressed and in need of orientations that can show its role, so as to minimize the negative effects of the disease and help to promote its wellbeing. At home, the child can find physical, emotional and social support and overcome the feeling of separation of loss present in the hospital environment5 , 6.

These conditions require specialized care, in which the parents in many cases do not have the necessary orientation or experience. This reveals a gap that demands professional action, in which home-care nurses work through interactive, transpersonal6 care.

The idea of transpersonal care emerges in 1985, when nurse Dr. Jean Watson first reformulates her Theory of Human Caring, which she launched between 1975 and 19796. Over time, this theory has been improved. Today, the Theory of Transpersonal Caring, proposed through the Clinical Caritas process, combines care and love with a view to comprehensive and mature care delivery7.

Although this theory does not discard conventional science and modern nursing practices, it complements them, as a conscious intervention in care to enhance cure and integrity6. In their professional caring, nurses should cultivate a care awareness, which they need to develop daily in their professional and personal life7.

Considering this theory a feasible option to perceive subjects in their full range of complexity, a characteristic that is in line with the demand to overcome the predominance of the Cartesian health model, this reflexive essay is proposed. The aim is to reflect on the potential to use Jean Watson's Theory of Transpersonal Caring for home nursing care delivery to children. For this purpose, the ten elements of the Clinical Caritas Process will be used.

A ROUTE TOWARDS HOME NURSING FOR CHILDREN

This essay departs from the premise that the transpersonal care Watson proposes represents a hard but gratifying road in care practice. This care is defined as the moral ideal of Nursing, based on human values and on concern with other people's wellbeing, resulting from practice and theory8.

Care is something precious and fine, like the presence of love in caring; that gives rise to the meaning of caritas, the Latin word that symbolizes kindness, loving touch, appreciation, giving special attention9. Focused on this care, the Clinical Caritas Process, which represents a care process that goes beyond traditional and static nursing models, requires nurses' opening to spiritual issues and existential dimensions, understanding themselves and others as evolutionary beings, based on the sacral nature of the being who receives care10. To organize care in this dimension, Watson proposes 10 structural elements of the Clinical Caritas Process9.

The first is described as practicing love-kindness and equanimity, in the context of care awareness, which relates to nurses' need to go beyond the conventional knowhow and be concerned with how to be while they deliver care9. Watson affirms that professionals need to take care of themselves in order to be able to take conscious care of the other through love. In the holistic care process, a transpersonal responsiveness needs to be mobilized, awakening transpersonal caring in oneself as a form of understanding and help.

In the same element, Watson also addresses the engagement of the self/selfhood of the professional, the being who receives care and society, considering the ongoing link between man, the environment and the universe, which leads to the reconstitution of individual and collective health8.

The home environment is the individual's most intimate place; it is his/her private world; when nurses enter this environment with this concern in mind, they can stop perceiving themselves as co-participants and simply practice care with know-how. This is mainly the care when the being who receives care is the child because, besides the care focus on this being, an additional focus involves the caregiver and family members, putting an even greater strain on the professionals when delivering care that responds to all environmental demands.

This element of the Clinical Caritas Process highlights the importance of professionals' looking inwards, with a view to finding their potentials and limitations and, thus, work at home with caritas conscience. When they find this conscience, nurses will deliver childcare based on love, in the transcendental sense, as human transformation, reaching a meaning of global health, in the attempt to reduce situations of negligence, such as violence and childhood abuse6 , 9.

Childcare requires the strengthening of the intersubjectivity among nurses, children and their relatives, permitting developmental stimulation, problem prevention and health promotion. In that sense, nurses need to understand that the family has its own timeframe to advance or not in this transpersonal encounter, and needs to be sensitive to respect these people's rhythm, understanding their peculiarities6.

The second element of the Clinical Caritas Process, defined as being authentically present, honoring the profound system of beliefs and the subjective world of the human being, requires nurses' integration into the reality experienced at home and their authentic connection with the other6, creating a transpersonal responsiveness9. Therefore, they need to strengthen and sustain the system of beliefs of the beings who receives care, their world and their lives9.

Hence, the importance of preserving faith in this care process is highlighted, of respecting the other's belief, mainly because they are present in their private environment, the home. This metaphysical acknowledgement permits a deep connection with the others, using the essence of their being as a form of valuing their particular abilities and thus approximating them to health and wellbeing8.

Particularly children have a stronger belief in a wide range of things or situations, as they often have not been exposed yet to the restrictive conditions of daily objectivity. Thus, the stimulus towards credibility in their beliefs can represent a significant positive reinforcement in their search to get better, to gain health: Watson refers to this as the curative power of faith and hope9.

When considering children as transpersonal, as a system that goes beyond individual and isolated realities, one can perceive that the strengthening of the families' beliefs in home care is also important, as they are influenced by the children's needs in disease situations6 , 8.

Therefore, it is essential for nurses to manifest due respect for their faith, with a view to enhancing their interior abilities; extending the curative power of hope and faith to all stakeholders in the social condition that led to the home care demand for the children6.

In line with the first and second element presented earlier, the third element of the Clinical Caritas Process is to cultivate particular spiritual practices of the transpersonal I and go beyond one's own ego, which addresses the practitioner, that is, the professional's susceptibility and spiritual growth9.

Spirituality is considered as greater than people's physical, mental and emotional existence at a certain moment in time. It is related to a superior degree of awareness, an interior strength, and a power that can expand human abilities and cultivate further access to intuitive, mystical or miraculous experiences7.

Also, spiritual practices are considered relevant, which permit a balance with the physical and metaphysical whole, in which both nurses and the beings receiving care are constantly evolving; this evolution is possible through the link body - mind - spirit, balanced with the universe8.

One can understand the combination body - mind - spirit from a community perspective, as a construct of physical, environmental, cultural and political components, which should be considered as analogue to a complete person. Thus, nurses should focus their care on the entire community, although they take care of individuals and families inside that community11.

In this interval, one can perceive that balance is achieved more appropriately for the children who receive care when they are at home, as that does not represent just any physical space; it is the intimate environment for them and their families, with its own symbols, as a shelter for customs, secrets, affections and disaffections, representing the dynamism, integration and link among things, events and people6 , 12.

The particularities in this environment are significant, for the children, as that is place where they will receive protection from their social network, as well as for their family, with greater proximity and autonomy towards the sick child. Thus, professional, family member and child, each in its own turn and to its own extent, are able to open up and pay attention to the spiritual, beyond the physical. In these existential dimensions of life and death, care for the soul and the care being can be understood and addressed appropriately.

For this environment to truly gain the welcoming and enhancing function in health, leading to the family's autonomy to protect and take care of the child, nurses need to understand this place, so as not to turn it into an extension of the hospital, but an environment of self-recognition for the being and of evolution for themselves13.

Respect for the home, as a sacred environment, is one of the critical points for nurses to be able to be accepted by the beings who receive care: child and family. After overcoming that barrier, the professionals' holistic presence is highlighted, putting themselves in the other's place and apprehending their needs. That is what Watson explains in her fourth element of the Clinical Caritas Process, defined as the development and sustainment of an authentic relationship of care, help and confidence9.

In that sense, a perception is required from nurses that goes beyond their senses, but reflects the other, without judgments or prejudices, which is fundamental for bonding in home care. Leaving aside their own concepts makes it easier to understand the child's private world and, at the same time, permits the understanding of family members' anxiety, respecting the being's possible flaws6 , 14. This is one option to establish a relationship of help and confidence at home.

The home space furthers an environment to construct and sustain a caregiving relation of help and authentic confidence. At the same time, the nurses can manifest their true commitment to be with the family and the child, far beyond the biological dimension, towards genuine care delivery that can comfort through a calming touch and a satisfying silence6.

The fifth element is to be present and support the expression of positive and negative feelings, as a profound connection with one's own support and that of the person receiving care, related to the precise expression of feelings, whether good or bad, in the individuals' process of being, becoming and reconstituting themeselves9. This element relates to the valuation of the nurses, the children and their families' feelings, as it arouses perceptions, feelings and thoughts that are responsive to the individuals6.

In a profound connection among nurses, children and their families, achieved through the creation of an open and sincere relationship, in which both are transformed, the expression of feelings emerges as a consequence; nevertheless, this expression needs to be stimulated, as it has therapeutic effects. The persistence of negative feelings is not healthy though6; it is reflected in and minimizes the search for self-care.

Nurses are responsible for mediating among the feelings the children express. They are not expected to play a psychotherapeutic role, but a role of sensitivity, empathy, appreciation, a caritas role7. If properly stimulated, the children will eventually grant access to their feelings, which will enhance a more assertive care. Their sincerity allows the nurses to discover their true needs.

Families often express difficulties to manifest their feelings, as they maintain the focus on care for their children, due to a lack of attention to care for themselves and the biased feelings the home care arouses15. Therefore, nurses needs to maintain an attentive look, stimulate the family members' expression of personal feelings, which are often manifested through attitudes of agitation, irritation and anguish, deriving from the privation of sleep, the feeling of incapacity and the burden of care for the sick child6.

The children's expression of feelings are needs mediation, with a view to avoiding excessive affective transference towards the nurses; what matters is to achieve a relationship that, in the end, has achieved sufficient maturity to undo the affection in a mild instead of an abrupt manner6.

Transpersonal care reveals the possibility for nurses to act in this type of situation, with a view to overcoming the rupture of the bond nurse-child-relative, as this care aims for the reconstitution of the care being's self; in other words, at the end of the relationship, both the professionals and the beings who receive care end up transformed, care for and reconstituted in their own self-propelled being, prepared to continue without dependence on the previously established relation9.

This requires the application of the sixth element in the process, defined as the creative use of the I and all knowledge routes, as a part of the process of caring and engaging in artistic practices of care-reconstitution (healing)9.

This element is linked to the creative use of all ways of knowing, being and doing, as a part of the caring process in solving problems and as an instrument to seek solutions for patients, families and communities7. It is considered that care should not only be based on scientific knowledge, but should also comprise the following: common, ethical, esthetic, religious knowledge, besides the caregiver's pragmatic empirism6.

In home nursing care to children, the professionals need even more creativity: its target public is strongly influenced by play resources; in addition, the therapeutic touch can represent a significant presence, demonstrating their desire to take care of the children and their family, revealing their readiness.

In this profound interaction, the bonds among professionals, families and children and strengthened, contributing to the children's protection and stimulating their development, through actions and practices that are not only aimed at biological, but also at psychological, social and spiritual aspects.

In the elaboration of their care plan, the nurses need to acknowledge the families' potentials and limitations to take care of the children, and explore their own creativity to propose interventions aimed at facilitating the home care experience for the children, in view of each family's reality.

In that sense, the application of the seventh element is highlighted, which refers to the genuine engagement in teaching-learning experiences that fully attend to the individuals and their meanings, trying to remain within the other's reference framework9; in this context, involvement constitutes a true experience of teaching and learning, which emerges from an understanding of the interconnectiveness7.

When getting closer to the children who need care, the nurses need to use alternative forms of self-knowledge about their weaknesses and abilities. They need to acknowledge learning beyond the supply of information, facts or data; but as an exchange, permitting an essentially interpersonal subjective relation, which affects the form and context of the reconstitution process for the children and caregivers6.

Differently from the hospital's normative environment, with its rules and prescriptions, the home context represents an opportunity for the nurses to intervene, in search of the subjects' autonomy13, through health education as well as childcare actions. Its success is conditioned by a proper adaptation to the family's customs, beliefs and values though. This space permits a range of exchanges among professionals, children and their families: both teach and learn and, in the end, are transformed; thus, they are more than subjects, because they construct a joint and collective future.

In that sense, the eighth element is highlighted, which is the creation and maintenance of a healing environment, at all physical and non-physical levels, which implies a subtle environment of energy and awareness, in which completeness, beauty, comfort, dignity and peace are enhanced9, which takes form in the creation and maintenance of a healing context, in view of the correlations with the environment, the cosmos and the universe; hence, this refers to the totality through which the energetic conscience irradiates the entire field, creating a climate of intimacy for care6.

The subtleties of the home context make it extremely relevant to recognize the children as beings who receive care, in view of their family, social or environmental correlations. This allows the professional to develop attitudes focused on the subjects' true needs, understand that the children and their family members constitute a whole and act not only on the disease or prevention, but to heal these beings15.

The nurses need to understand that elements external to the healing environment influence the appropriate climate for the bonding and approximation that are essential for the development of childcare, as follows: wellbeing, trustworthiness, comfort, besides cleanliness and healthiness6.

Then, the ninth element is expressed as helping with basic needs, with intentional awareness of care, administering essential human care; this can enhance the alignment between mind, body and spirit, that is, the totality and unity of the being in all care aspects9, which consists in the delivery of essential human care, in mutual help to fellow human beings, to satisfy their demands, and with an intentional care awareness that honors the unity of spirit, mind and body7.

When offering essential human care to children, nurses need to attempt to satisfy the demands characteristic of childhood, whether these are biological, social, psychoaffective and/or spiritual. In view of these demands, the nurses need to intervene in the home context in a humane and balanced manner; attempt to be and be there, with and for the children. Therefore, they need to actively listen to the family members and offer genuine care, through the permanent practice of love and sharing, capable of constituting a reliable relationship of help and confidence with the family that takes care of the child14.

Taking care of children demands that nurses use their full range of knowledge to offer wellbeing and comfort to the children and overcome their health problem14. This action is considered in the comprehensive perspective of human beings, as opposed to the Cartesian model, which describes the human being as a machine divided in separate and reduced parts15.

The tenth element of the Clinical Caritas Process, described as giving room and responding to the spiritual mysteries and existential dimensions of life-death, taking care of one's own and the care being's soul, is the element the author finds most difficult to understand, as it addresses the presence of questions the rational mind cannot explain; nurses will be confronted with the limitations of science though; what matters is to stay open to accept even miracles in life9.

Being confronted with uncontrollable situations causes anguish and anxiety in the nurses; particularly in home care, in which situations like financial precariousness, caregivers' lack of preparation and lack of domestic infrastructure increase the degree of difficulty to put in practice holistic care delivery15. The advantages of care in this environment are even more significant though; they include self-care, emotional welcoming, economy, improvements in care and patients, care humanization and family care beyond the individual15.

Some of the advantages attributed to home care are not always scientifically understandable, in view of the difficulties that coexist, which are related to the emotional or spiritual nature and not just to the concrete. Nevertheless, they obviously exist; therefore, it is necessary to return to what Watson considered about this tenth element, in which she acknowledges that there is a lot beyond the horizon of scientific criteria; in this sense, the author refers to the miracles of life8.

Specifically in home care for children, this element represents a relevant opportunity to strengthen bonds and relations, considering that this is a situation in which the family's psycho-affective condition is often distributed and compromised by the child's situation of disease and suffering. That is the case when the subjective world of one's own and other people's internal experiences is perceived as a mystery or even as a miracle of life; human beings undergo changes in a wide range of factors, in a way that is never fully explained6 , 8 , 15.

Acknowledging life as a miracle, about which one does not have all of the answers, grants nurses greater respect for the family members' beliefs and faith. Thus, they will offer interventions based on prayer, meditation and the participation of leaders or priests of the family religion in the child's care process.

Human beings have a metaphysical potential for self-cure and transcendence to higher levels of awareness, acting as agents of change and mainly assuming the responsibility for care to take place with or without the co-participation of external agents of change11. This indicates an opportunity for nurses to act from the perspective of alternative and complementary practices in the primary healthcare context.

When this element of care is put in practice, the families will feel supported, encouraged, accompanied, strengthened and relieved; and realize that they gained further knowledge to cope with the suffering of their little loved one14. They are happy to witness that their structure is reconstructed by the hope of the child's improvement and confidence in their beliefs, deriving from the certainty of cure and the restoration of the state of health and wellbeing.

FINAL CONSIDERATIONS

The use of Jean Watson's theory of transpersonal caring is one possibility with a view to the effectiveness of home nursing care for children. Therefore, nurses need selfknowledge and theoretical-philosophical support; moreover, they need to be willing to use and apply this knowledge to make nursing practice genuine and less of a routine.

Transpersonal caring is one route Nursing can follow, although obstacles remain with a view to its implementation, especially in the primary healthcare dimension. Therefore, professionals need to learn to leave aside their judgments and prejudices and accept spirituality as a part of care, despite the prevalence of the technical-scientific approach that permeates their educational background. In that sense, it is considered fundamental for nurses to be open to new care practices, which go beyond the paradigm of objectivity and biological care, using Nursing knowledge to turn the science of their profession into their art as well.

Watson's reference framework can contribute to professional nursing practice that promotes care beyond the objective dimension, including the families' conceptions, beliefs and values in child healthcare, also respecting the spirituality of the being who receives care and of the professional, with a view to this transpersonal encounter. This process can favor nurses' actions as elements in the children's healing, through the strengthening of their and their family's capacity to seek self-cure and transcendence.

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Received: July 15, 2011; Revised: January 11, 2012; Accepted: March 06, 2012

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