By: Jean Watson, PhD, RN, AHN-BC, FAAN, and Robert Browning, BA
Editor’s note: Viewpoint highlights the thoughts, opinions, and expertise of well-known nurse leaders. We welcome your comments about these thought-provoking articles.
During these past decades, nursing has increasingly advanced as a distinct caring discipline and theory-guided practice profession. Discipline-specific, theory-guided practice models, motivated in part by the American Nurses Credentialing Center’s national Magnet program, have led to improved patient care and system outcomes. These new initiatives are resulting in transformative nursing theory-guided practices and research. Magnet systems demonstrate best practices, improved work environments, and nurses less likely to be dissatisfied with their jobs.1 Thus, theory-guided, evidence-based nursing professional practice models are coming of age.
Watson’s theory of Human Caring, and the 10 Caritas Processes™ contained within the theory, is one of the prominent theories used in many of the Magnet systems. This article invites another turn on theory-guided, evidence-based practice and the theory of human caring. It introduces CaritasHeart™ methodology as a specific authentic caring theory, evidence-based approach, integrating Caring Science and Heart Science.
Caring Science/Watson’s theory of human caring
Caritas is a Latin word connecting authentic human caring with love and deeper ethical meanings, honoring the preciousness and fragility of human caring. The 10 Caritas Processes of the theory are embedded in a framework of Caring Science as sacred science.2-4
Caring Science is grounded in the ethic of “Belonging”5 to that which is greater than our “Being”; it goes beyond medical science, acknowledging the relational, life force; the philosophical, unitary field dimensions underlying all of humanity.
The 10 Caritas Processes give language to the phenomenon, theory, and practice of human caring, which nurses rarely see in the busyness of practice demands, nor appreciate for its significance. Often the institutional pressures and priorities result in rushed, scripted, and routine approaches to “caring,” often seen as an institutional slogan. In mainstream settings, there is little attention to theory-guided practice of truly authentic, human-to-human-caring.
Nevertheless, authentic human-to-human caring is core to professional theory-guided, evidenced-based practices, and caring-healing relationships affecting patient/system outcomes. However, learning, embodying, and living authentic Caritas Processes require another level of “ontological” human heart competencies/education and skill, beyond technological competencies.
CaritasHeart methodology, as a theory-guided evidence-based practice, has evolved from the foundation of Caring Science, the 10 Caritas Processes, intersecting and informed with the latest philosophical-scientific premises and evidence from Heart Science research and the Institute of HeartMath (www.heartmath.org). (See Caring Science and theory of human caring premises for more information.)
Caring Science and theory of human caring premises
The 10 Caritas Processes™3,4
The 10 Caritas Processes provide the language and structure of the theory. They name and define the otherwise largely invisible processes of authentic human caring that sustain caring for self and others. They include the following:
Caritas Process 1
Humanistic-altruistic values through cultivating personal/professional practice of loving-kindness, compassion, and equanimity with self/other
Caritas Process 2
Authentic Presence: allowing faith and hope/belief system that honors inner life world of self/other
Caritas Process 3
Sensitivity to self and others by cultivating own growth and spiritual practices, beyond ego-control
Caritas Process 4
Developing and sustaining loving, trusting, caring relationships
Caritas Process 5
Allowing for expression of positive and negative feelings; authentically listening to another person’s story
Caritas Process 6
Creatively problem solving/solution seeking through caring process; full use of artistry of self, embracing all ways of knowing/being/doing/Becoming
Caritas Process 7
Engaging in transpersonal teaching and learning within context of caring relationship; staying within the other’s frame of reference; make shift from “teaching” per se toward “coaching” models for health/wellness
Caritas Process 8
Creating a healing environment at all levels; subtle environment, attending to energetic caring healing field consciousness
Caritas Process 9
Reverentially assisting with basic needs as sacred acts; touching mind body spirit of other while sustaining human dignity
Caritas Process 10
Opening to spiritual, existential, mystery, unknowns, “allowing for miracles”
This focus and research on the heart and its relation to intelligence of feelings go back to the 1960s and 70s, with the original work by John and Beatrice Lacey related to the heart-brain connection in relation to health. “… [T]hey discovered the heart is not just a pump but an organ of great intelligence, with its own nervous system; that the heart actually ‘talks’ to the brain; the heart somehow ‘tuned’ the senses that transformed into nerve impulses that permeate the brain.”6
The heart-brain has been affirmed as one organ, not two, referred to sometimes as the “little brain” of the heart.6 More recently, the personal story of Jill Bolte Taylor, a neuroscientist with a stroke, affirms the personal and lay understanding of a higher energetic intelligence beyond the rational brain.7
The field of neurocardiology has revealed the heart as a neurological, endocrine, and immune organ, as well as a neurotransmitter of info-energy or L=Love energy.8 The heart is continually being scientifically and even spiritually affirmed as essential for sustaining our humanity, our caring, our compassion, and the deeply felt emotions that define our human essence. The heart is the source for accessing universal infinite energy of Love.2-5,9-14
Currently there is continuation of such ground-breaking heart research being undertaken by research institutes, such as the Cleveland Clinic Heart-Brain Institute, Fetzer Institute, Institute of Noetic Sciences, and Center for Spirituality and Healing at the University of Minnesota, as well as the research and methods derived from the work at the Institute of HeartMath. (See Heart Science premises for more information.)
The Institute of HeartMath teachingsResearchers and teachers at HeartMath® have translated the body of Heart Science research knowledge into personal/professional stress-reducing methods that use specific heart-focused methods. These practices focus on building skills to generate positive thoughts and emotions and shift into a specific state known as physiological coherence. This results in greater resilience, health, inner peace, and authentic care. Methods born from this research have now merged with Caring Science and the Caritas Processes of the theory to help manifest higher states of inner caring, intuition, and energetic healing field environment. OneHeartMath method includes a step-by-step process called Quick Coherence®:
- Heart- focus
- Heart-focused breathing
- Heart-feeling (reexperiencing heart feelings, such as love/gratitude, compassion, and caring)
This process aligns our inner systems, resulting in more coherent heart rhythms, positively impacting both the individual as well as the environment. Uniting this method within a Caring Science framework for practicing Caritas Processes and, likewise, uniting practice of theory of Caritas with this HeartMath method, create a synergistic methodology for potentiating health, healing, and intuition—thus, where Caring Science meets Heart Science.Caring theory practice teachings congruent with HeartMath include:
- Authentic presence” is the starting point for practicing the caring theory; it is foundational for a “caring moment4,15 and human-to-human connection. Thus, an exercise of “centering“—emptying out and breathing—has been used as a Watson teaching/practice process over the years2-4,11-13,15-19,21 to prepare nurses for authentic presence and connection. This concrete practice helps one to engage in the first Caritas Process: Cultivation of loving kindness and equanimity for self/other.
- These simple, concrete practices, emergent from the theory, are related to the nurse’s capacity to sustain humanistic-altruistic values and caring-healing, authentic caring moments.
- The research on the heart affirms that one’s heart-centered presence affects the entire field of practice and thus the authenticity of caring moments.
- The HeartMath method has specific research-based protocols that guide one through their scientifically researched concrete heart-centered practices, thus facilitating authentic presence and capacity for genuine caring that is radiating from the heart. Thus, Caring Science theory and its ethic and philosophical foundation for Caritas practices blend with the HeartMath protocols, resulting in a new methodology.
CaritasHeart methodology: From intellectual theory to authentic personal Caritas experiencesThe authors of this article discovered through their respective institutes’ collaborative teaching and research (Watson Caring Science Institute and the Institute of HeartMath) the profound connection between Caring Science and scientifically based heart-centered methods. The authors have worked together over the past 3 years educating nurses and health professionals in multiple hospitals and systems with the Caring Science/Heart Science practices. Through this process and study, the philosophical and scientific-theoretical congruencies were identified, clarified, integrated, blended, tested, and refined; the result, a blended synthesis of a specific evidence-based caring theory-guided practice method for living out theory in practice: CaritasHeart methodology.Thus, the CaritasHeart methodology now is taught in hospitals throughout the United States and other countries as a form of evidence-based caring-theory-guided Caritas practice, birthed through a synthesis of Caring Science/Heart Science.This synthesis guides and sustains the practice of loving kindness, compassion, and equanimity, the first foundational practice of Caritas Process number 1 and authentic presence. The CaritasHeart methodology unites the essence of Caring Science and Watson’s philosophy and ethic underlying Caring Theory, with a synthesis of personal/professional practices of HeartMath’s protocols, research, and science base. This integrative approach brings new meaning and practices associated with “theory-guided, evidence-based practices”—what the healthcare system ultimately stands for and progressive medical systems are striving to implement to better serve staff, patients, and communities. (See Protocols and practices of CaritasHeart™ methodology for more information.)Implications for CaritasHeart nursing practiceThe transformation of nursing and health care and the increasing use of evidence-based, theory-guided nursing practice now combine with the need for healing practices and patient/person-centered caring-healing relationships and healing environments.20, 21 The CaritasHeart methodology is one way forward. It offers new scientific, concrete approaches for staff on how to be authentically present in a caring moment in ways that are sustainable for self and others.This work also provides new insights into translational research, offering a protocol and methodology for converging and translating Caring Science and theory into exemplary professional Caritas practices consistent with national hospital Magnet initiatives and new outcomes.This evolved human-caring practice invites nurses and staff and instructs on how to skillfully live out caring-theory practices from their heart, in the moment. This work gives new meaning to theory-guided, evidence-based practices, moving from superficial meanings of theory and human caring to authentic practices that sustain and transform self and system.
Jean Watson is a distinguished professor emerita of nursing; held an endowed Chair in caring science at the University of Colorado Denver, College of Nursing and Founder of Watson Caring Science Institute. Boulder, Colorado. Robert Browning is a healthcare director and master teacher for HeartMath in Boulder Creek, California.
References1. Kelly LA, McHugh MD, Aiken LH. Nurse outcomes in Magnet® and non-Magnet® hospitals. J Nurs Adm. 2011;41(10):428-433.2. Watson J. Caring Science as Sacred Science. Philadelphia, PA: FA Davis; 2005.3. Watson J. Nursing: The Philosophy and Science of Caring. New rev ed. Boulder, CO: University Press of Colorado; 2008.4. Watson J. Human Caring Science: A Theory of Nursing. Sudbury, MA: Jones & Bartlett; 2012.5. Levinas E. Totality and Infinity. Pittsburgh, PA: Duquesne University; 2000.6. Guarneri M. The Heart Speaks. New York, NY: Touchstones: Simon & Schuster, Inc; 2006.7. Bolte Taylor J. Jill Bolte Tayler’s stroke of insight. TED. http://www.ted.com/talks/jill_bolte_taylor_s_powerful_stroke_of_insight.html. Accessed June 26, 2012.8. Pearsall P. The Heart’s Code. New York, NY: Broadway Books/Random House; 1998.9. de Chardin T. The Phenomenon of Man. New York, NY: Harper & Row; 1959.10. 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;12:360-365.11. Watson J. Love and caring: ethics of face and hand. Nurs Adm Q. 2003;27(3):197-202.12. Watson J. Caring science: Belonging before Being as ethical cosmology. Nurs Sci Q. 2005;18(4):4-5.13. Watson J. Caring theory as ethical guide to administrative and clinical practices. Nurs Adm Q. 2006;30(1):48-55.14. Kemper KJ, Shaltout HA. Non-verbal communication of compassion: measuring psychophysiologic effects. BMC Complement Altern Med. 2011;11:132.15. Watson J. Nursing: The Philosophy and Science of Caring. Boston, MA: Little Brown; 1985.16. Watson J. Nursing: Human Science and Human Care. New York, NY: National League for Nursing; 1999.17. Watson J. Postmodern Nursing and Beyond. Boulder, CO: Watson Caring Science Institute; 2011.18. Watson J. Assessing and Measuring Caring in Nursing and Health Sciences. 2nd ed. New York, NY: Springer; 2009.19. Watson J, Browning R. CaritasHeart Methodology and Practices. Unpublished working papers, 2009.20. Quinn JF. Holding sacred space: the nurse as healing environment. Holist Nurs Pract. 1992;6(4):26-35.21. Quinn JF, Smith M, Ritenbaugh C, Swanson K, Watson J. Research guidelines for assessing the impact of the healing relationship in clinical nursing. Altern Ther Health Med. 2003;9(3)(suppl):A65-A70.______________________________________________________ResourcesHeartMath. www.HeartMath.comInstitute of HeartMath. www.HeartMath.orgUniversity of Colorado College of Nursing. www.nursing.ucdenver.edu/caringWatson Caring Science Institute. www.watsoncaringscience.orgJean Watson’s Facebook page. www.Facebook.com/watsonjean
Heart Science premises
Protocols and practices of CaritasHeart™ methodology
Begin with “Centering–Authentic Presence” exercises, facilitating authentic heart-centered loving “presencing” to prepare for a “caring moment.” These include Pausing, Silencing, “emptying out” before entering a patient’s room; connecting with inner “still point”–breathing and releasing from heart-centered stillness; welling up feelings of caring, loving-kindness, and compassion in one’s consciousness and intentionality.
The next steps involve specific HeartMath exercises to engage and anchor in states of positive emotion. This method involves focusing around the area of the heart, imagining the breath flowing through the center of the chest, and activating positive heart feelings. These research-based approaches teach how to create and manifest coherence and the higher energetic caring field. This opens the heart to deep human-to-human caring feelings of gratitude, love, forgiveness, and compassion, thus experiencing and deepening the heart-centered feelings of Caritas.
The method then progresses by guiding participants through authentic personal and professional, individual and collective self-caring, decision making, and deep heart-centered listening exercises, engaged dialogue and feedback exchange.
Finally, the method asks participants to radiate the caring consciousness and heart-centered feelings to loved ones, colleagues, and all suffering in the world, as far into the universe each can imagine. The goal of radiating beyond self is to open to unitary field of universal Source for pure alignment, for renewal, to manifest a caring-healing environment; to “be/become” a healing environment of wholeness healing for self and others.
This completes the CaritasHeart methodology that integrates specific steps for theory-guided, evidence-based professional practices.
The next step is for staff to translate this method to a caring-healing modality for patients/families—for example, inviting patients to pause, fall into their heart; breath through their heart; experience heart feelings of love, gratitude, compassion, and forgiveness for self/other; and speak from their heart awareness and own inner wisdom as to what is most needed for their healing and caring this day.