Caring Science, Mindful Practice : Implementing Watson's Human Caring Theory [1 ed.] 9780826171542, 9780826171535

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Caring Science, Mindful Practice 

IMPLEMENTING WATSON’S HUMAN CARING THEORY

Kathleen Sitzman Jean Watson

Caring Science, Mindful Practice

Kathleen Sitzman, PhD, RN, CNE, is professor, Undergraduate Nursing Science, at East Carolina University, Greenville, North Carolina. Previous to her current position, she held dual appointments at Weber State University in Ogden, Utah: director, Bachelor of Integrated Studies Program, and faculty in the School of Nursing. Dr. Sitzman has been a nurse since 1983 and has used her extensive experience to produce scholarly work that contributes to the nursing profession and body of knowledge on international, national, state, community, and local levels. She has been co-prinicipal investigator or prinicipal investigator on 10 research projects, several of which focused on nursing students’ perception of caring online. She has received numerous awards for her scholarship, mentorship, and teaching, including the Jean Watson Award for outstanding scholarship in caring science from the ­International Association for Human Caring (2007–2008). Dr. Sitzman has published more than 100 ­peer-reviewed articles and has co-authored two textbooks: Understanding the Work of Nurse Theorists: A Creative Beginning (2nd ed.) (2011) and Nursing History: Trends and Eras (2010). She is a member of the American Nurses Association, the National League for Nursing, Sigma Theta Tau International, and the International Association for Human Caring. Dr. Sitzman has been generous with her skills and expertise by serving on a wide variety of health-related service projects. Jean Watson, PhD, RN, AHN-BC, FAAN, is distinguished professor emerita and dean emerita of the College of Nursing at the University of Colorado, Denver. She is founder of the Center for Human Caring in Colorado, a fellow of the American Academy of Nursing, and past president of the National League for Nursing. Her current activities include founder and director of Watson Caring Science Institute, a nonprofit international foundation, committed to furthering caring science in the world. Dr. Watson has earned undergraduate and graduate degrees in nursing and psychiatric–mental health nursing with a PhD in educational psychology and counseling. She is a widely published author and recipient of several awards and honors, including an international Kellogg Fellowship in Australia, a Fulbright Research Award in Sweden, and 10 honorary doctoral degrees, including seven honorary international Doctor of Science awards from Sweden, Spain, the United Kingdom, Japan, British Columbia, and Canada. Clinical nurses and academic programs throughout the world use her published works on the philosophy and theory of human caring and the art and science of caring in nursing. Dr. Watson’s caring science/ philosophy theory is used to guide new models of caring and healing practices in diverse settings worldwide. At the University of Colorado, Dr. Watson held the title of distinguished professor of nursing, the highest honor accorded its faculty for scholarly work. In 1998–1999 she assumed that nation’s first endowed chair in caring science, based at the University of Colorado. Her work continues through the Watson Caring Science Institute, www.­watsoncaringscience.org.

Caring Science, Mindful Practice Implementing Watson’s Human Caring Theory

Kathleen Sitzman, PhD, RN, CNE Jean Watson, PhD, RN, AHN-BC, FAAN

Copyright © 2014 Springer Publishing Company, LLC All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior permission of Springer Publishing Company, LLC, or authorization through payment of the appropriate fees to the Copyright Clearance Center, Inc., 222 Rosewood Drive, Danvers, MA 01923, 978-750-8400, fax 978-646-8600, [email protected] or on the Web at www.copyright.com. Springer Publishing Company, LLC 11 West 42nd Street New York, NY 10036 www.springerpub.com Acquisitions Editor: Margaret Zuccarini Composition: diacriTech Illustrations: Lou W. Everett ISBN: 978-0-8261-7153-5 e-book ISBN: 978-0-8261-7154-2 13 14 15 16 17 / 5 4 3 2 1 The author and the publisher of this Work have made every effort to use sources believed to be reliable to provide information that is accurate and compatible with the standards generally accepted at the time of publication. The author and publisher shall not be liable for any special, consequential, or exemplary damages resulting, in whole or in part, from the readers’ use of, or reliance on, the information contained in this book. The publisher has no responsibility for the persistence or accuracy of URLs for external or third-party Internet websites referred to in this publication and does not guarantee that any content on such websites is, or will remain, accurate or appropriate. Library of Congress Cataloging-in-Publication Data Sitzman, Kathleen, author. Caring science, mindful practice : implementing Watson’s human caring theory / Kathleen Sitzman, PhD, RN, CNE, Jean Watson, PhD, RN, AHN-BC, FAAN.      pages cm   Includes bibliographical references and index.   ISBN 978-0-8261-7153-5 (alk. paper)—ISBN 978-0-8261-7154-2 (ebook)   1.  Nursing—Philosophy. 2.  Nursing models. 3.  Caring. I. Watson, Jean, 1940– author. II.  Title.   RT84.5.S528 2014  610.7301—dc23 2013021400

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Jean Watson’s work has been my professional refuge and inspiration from the very beginning of my nursing career. Her vision has given me the courage to practice fierce love and open caring no matter what environment or situation I find myself in. This stance has transformed my life and career in ways I could not have imagined at the outset. Jean, I give my love and deepest gratitude to you. I dedicate this work to my husband Rick, my mom Marge Fox, and my sister Tami Bingham. Your love and caring make me better able to love and care for all. Kathleen Sitzman

Contents

Contributors  ix Author’s Note  xi Preface  xiii Note From Contributing Nurse Artist   xv

Section I: Introduction to the Caritas and Enhancing Use Through Mindfulness  1. Use of Mindfulness to Cultivate Understanding of Watson’s Theory of Caring   3  2. Overview of Watson’s Theory (10 Caritas)   15  3. Thich Nhat Hanh’s Five Mindfulness Trainings   23  4. Entering the Stream: Understanding and Living Out Jean Watson’s Work   31

Section II: The 10 Caritas  5. The First Caritas Process: Embrace Altruistic Values and Practice Loving Kindness With Self and Others   41  6. The Second Caritas Process: Instill Faith and Hope, and Honor Others   53  7. The Third Caritas Process: Be Sensitive to Self and Others by Nurturing Individual Beliefs and Practices   63  8. The Fourth Caritas Process: Develop Helping–Trusting–Caring Relationships  73  9. The Fifth Caritas Process: Promote and Accept Positive and Negative Feelings as You Authentically Listen to Another’s Story   83 10. The Sixth Caritas Process: Use Creative Scientific Problem-Solving Methods for Caring Decision Making   93

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Contents

11. The Seventh Caritas Process: Share Teaching and Learning That Addresses Individual Needs and Comprehension Styles   105 12. The Eighth Caritas Process: Create a Healing Environment for the Physical and Spiritual Self That Respects Human Dignity   115 13. The Ninth Caritas Process: Assist with Basic Physical, Emotional, and Spiritual Human Needs   125 14. The Tenth Caritas Process: Open to Mystery and Allow Miracles to Enter   135 15. Conclusions and Suggestions for Deepening Study   145 Index  149

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Contributors

Mark D. Beck, BS, MSN, RN-BC Director, Clinical Education, Practice, Kaiser Foundation Hospital, Oakland, CA

and

Informatics,

and

Caritas

Coach,

Danilo C. Bolima, MSN, RN, NEA-BC, PCCN Critical Care Manager and Caritas Coach, Hackensack UMC Mountainside, Montclair, NJ Susan J. Caron, BA, RN-BC, CAPA, CPAN Clinical Leader/Nurse Educator and Caritas Coach, Saint Anne’s Hospital, Fall River, MA Wanda Davis, RN, BSN Clinical Nurse/Caritas Coach, Veterans Administration Medical Center, Grand Island, NE Tarron Estes, BA Conscious Dying Educator, Caritas Coach, and Watson Caring Science Institute Faculty, Boulder, CO Debby Flickinger, BA Caritas Coach, Pleasant Hill, CA Marilee Ford, RN, MA Clinical Educator and Caritas Coach, Department of Clinical Education, Practice, and Informatics, Kaiser Foundation Hospital, Santa Rosa, CA Sheryl Jacobson, RN, MS Associate Professor, BSN Program, Viterbo University, La Crosse, WI

ix

Contributors

Tamara A. King, RN Nurse Supervisor and Caritas Coach, Center for Psychiatry, Winter Haven Hospital, Winter Haven, FL .

Denise Laws, RN, MSN Manager, Med/Surg/Telemetry Services, Kaiser Foundation Hospital, Santa Rosa, CA Candace M. Leonard, RN, BSN, HNB-BC Clinical Nurse/Caritas Coach, AtlantiCare Regional Medical Center, Atlantic City, NJ Deleta M. Moore, MSN, RN Clinical/Informatics Educator and Caritas Coach, Kaiser Permanente, Kaiser Oakland ­Medical Center, Oakland, CA Mary Mullany, DNP, APRN, BC Clinical Educator and Caritas Coach, Metrowest Medical Center, Natick, MA Vivian Norman, RN, MSN, CCRN Critical Care/Telemetry Educator and Caritas Coach, St. Joseph’s Hospital, Orange, CA Joie Ogrodnick, RN, BS, CEN Clinical Nurse, Caritas Coach, Bon Secours Charity Health System, St. Anthony Community Hospital, Warwick, NY Lynn M. Priddy, BSN, RN, RN-BC Physician and Community Health Access, Caring Practice Team Chair, Wake Forest Baptist Health Medical Center, Winston-Salem, NC Anne Sagastume, BA, RN, CCRN, CNRN Clinical RN III, ICU and Caritas Coach, Adventist Hinsdale Hospital, Hinsdale, IL Nancy Swartley, RN, MSN Clinical Nurse/Caritas Coach, Einstein Medical Center, Philadelphia, PA Nancy Vitali, RN, MS Associate Professor of Nursing, Academic Division Administrator, Tulsa Community ­College, Tulsa, OK Ashley Weber, BSN, RN Clinical Nurse and Caritas Coach, Children’s Hospital Colorado, Castle Rock, CO

x

Author’s Note

It is a special privilege to support and endorse this publication, which contributes to the growing scholarship of the Caring Science Library of Springer Publishing Company–Watson Caring Science Institute Series. Further, this is a unique publication, in that it builds upon the impressive personal practices and extensive teaching experience of Dr. Kathleen Sitzman. Dr. Sitzman brings to this writing a background of mindfulness practices, guided by the writing and teachings of Thich Nhat Hanh. I consider Dr. Sitzman and Thich Nhat Hanh enlightened and informed humans who help us deepen our understanding and the meaning of a “Caring Moment,” “Authentic Presence in the Now,” “Mindfulness,” “Reflective Practice”— all foundational to living out authentic human-to-human caring for self and others and our world. In this work, Dr. Sitzman assists me in bringing my Human Caring ­Theory into embodied experiences and learning activities, which engage a first-time learner of this theory. At the same time this work invites anyone into an expanded and deepened practice and understanding of the theory; it draws upon creative learning practices of human caring through images, art, metaphors, and expressive ­symbols to reveal the theory to anyone familiar or unfamiliar with my writings. Thus, this book can serve as a guided learning text for any student, practitioner, educator, or administrator needing a graceful and inviting guide to translate and integrate the complexities of the abstract, philosophical–ethical worldview underlying the Human Caring Theory; finding ways to live out into concrete daily self-caring practices. Renewed attention and intentions are created for contemplation, reflections, and simple “pauses” to move from ego–head–fear mindsets, to love, open heart–centered compassion, accessing sources of inner knowing and interbeing in relation to all of life. While the theory addresses concepts such as “core” and “trim” to understand the difference between what is lasting and timeless about caring and what is

xi

Author’s Note

constantly impermanent and changing, such as skills, tasks, procedures, and even knowledge, Sitzman anchors these distinctions into the simple images—the simplicity of visualizing an orange and the sensuous act of peeling an orange to grasp the lasting juicy part of an orange core and what peels away with time. However, both are essential to have an orange. Other such mindful invitations are throughout the book, introducing exercises, art activities, and abstracts for each of the Caritas Processes of the theory. The abstracts are from staff nurses, nursing leaders, and new Watson Caring Science Institute Caritas coaches from across the United States, representing ­ changes in health care systems in this country—transformative changes that are happening in the field. Overall, this work brings Human Caring Theory to life through use of creativity and engagement of the heart and human spirit. It draws upon multiple ways of knowing, being, doing, becoming—“interbeing”—in-the-moment, living out human caring for self and other. This learning process parallels the caring science worldview for use of multiple emancipatory methods for teaching and learning as well as forms of inquiry to explore; to be curious, and to obtain self-knowledge and a disciplined mindful, inner practice, as the true guide to human caring. Finally this work reunites science with spirit, physical with metaphysical, profane with sacred, ordinary with extraordinary, and head with heart and soul, for a new level of human consciousness, for the evolution of the discipline of nursing. This work gives an entirely new meaning to the notion of “discipline”— inviting self-practices that radiate caring into the human heart, sustaining Onenessof-Being/Becoming with Mother Earth, our universe unfolding. I trust that those who study this theory and engage in this learning will awaken to what is calling them in their heart of hearts. I trust it will help you align self with your soul’s call, to go deeper into your personal/professional inner practices that radiate out into our work and world. May we all awaken our hearts and soul to fully learn and live out authentic human caring for a new world calling out for this paradigm of caring and healing from one world/one heart of humanity. Jean Watson, PhD, RN, AHN-BC, FAAN

xii

Preface

I have been practicing and teaching Watson’s Caritas Nursing since 1984, in hospital nursing, home health care, hospice, occupational health, and then in nursing education, administration, and research in higher education. I began studying and practicing mindfulness in the Thich Nhat Hanh tradition in 1990. Watson’s work and Nhat Hanh’s mindfulness practice form the foundations of my life and work. Nhat Hanh’s mindfulness practices are not specific to any one religious or spiritual tradition and support meaningful introspection and self-awareness. Watson has made clear that personal spiritual practices and cultivation of selfawareness form the underpinnings of genuine Caritas practice. In many years of teaching Watson’s theory to laypeople, nursing students, and nurses, I have found that mindfulness practice and Caritas practice seamlessly harmonize to support deep understanding for learners who are very knowledgeable about Watson’s work and also for those who are unfamiliar. This text is meant to provide clear and simple content to support foundational learning and direct experience related to Watson’s work, opening possibilities for exploring the complexities and promises of caring science into the future. Kathleen Sitzman, PhD, RN, CNE

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Note From Contributing Nurse Artist

When I read this book, it touched my heart and soul like no other nursing textbook has in the past. I was moved on many levels by the authors, Sitzman and Watson, and their collective ability to beautifully, scientifically, and eloquently articulate theory and mindful activities to incorporate caring for self and others within the boundaries of one textbook. This is an amazing contribution to all nurses, and I surely hope it will find its way to becoming a foundational text for all nursing students entering the profession. I cannot help but think it might set the stage for all the difference for patients in the future—like the ripple effects of the pond, described in the book…. This one book may have started as a “pebble” and yet, maybe not in my lifetime but hopefully in the future, the ripples will be felt and seen around the world. Finally an opportunity for students and nurses to glean through a choice of creative activities to apply components of caring theory to nurture one’s mind, body, and soul, which ultimately benefits each nurse’s patients, family, colleagues, and friends. As a professor emeritus at the College of Nursing, a licensed marriage and family therapist, and an artist, I thoroughly enjoy passing my joy of ­painting to ­others. Currently serving as clinical professor/coordinator of special projects at the East Carolina University College of Nursing, I primarily paint in watercolor, but have also won awards in acrylics and oils. Regardless of the medium, I prefer to paint the effect of light on my subjects en plein air. En plein air is a term from the French, ­ rovides sunshine which means literally “in the open air.” Painting en plein air also p and exercise. By offering “Traveling Studio” classes in c­ ollaboration with gallery owners, I have been able to pass my joy of painting onto others as well, many of whom are nurses.

xv

Note From Contributing Nurse Artist

I discovered painting in watercolor as a delightful way to nurture and rejuvenate my body, mind, and spirit during years of career development and caregiving. Each time I developed pneumonia as a result of “burning the candle at both ends,” I began to set aside more time for my creative expressions, which led to increased relaxation and increased immunity to prevent illness. My paintings have become another means of contributing to the well-being of patients in multiple service roles. I have incorporated art in research studies that include “Expressions of Art in Children of Divorce” and “Stepfamilies: Making It in the New Family.” Renderings have been used for imagery in those experiencing chronic illnesses, in addition to assisting those coping with various causes of grief. Contributions of my art have been given for fundraising activities for Sigma Theta Tau International, in support of student scholarships and other community organizations that support health of the population, and to East Carolina University College of Nursing’s Development Fund. My 2012 solo show “Humble Beginnings” was the invitational Inaugural Exhibition for Art as Avocation at the Laupus Library, showcasing artistic talents from the Division of Health Sciences at East Carolina University. Expressions of art provide me with much gratitude for the “good life” and beauty that surrounds each of us each day, and provides me with more energy to enjoy the most important roles of my life: wife, mother, grandmother, nurse, therapist, colleague, and friend. It is my hope that nurses will use this as a foundational textbook for practicing caring science while serving the same or other important roles in their lives. Lou W. Everett, EdD, RN, LMFT Professor Emeritus, College of Nursing East Carolina University, Greenville, NC

xvi

Section I Introduction to the Caritas and Enhancing Use Through Mindfulness

Chapter 1 Use of Mindfulness to Cultivate Understanding of Watson’s Theory of Caring

1.  Use of Mindfulness to Cultivate Understanding of Watson’s Theory of Caring

Prelude to Watson’s Theory of Human Caring and Thich Nhat Hanh's Mindfulness Practice Nurse theorists, over time, have presented various aspects of nursing practice through many different lenses, and the notion of caring is usually included in some form, either implicitly or explicitly. Most nurses and laypeople routinely associate caring with nursing. Because of this, professional caring is often vaguely assumed rather than specifically examined and purposefully enacted. Jean Watson’s Theory of Human Caring provides a foundation to carefully examine and purposefully enact caring in nursing. As a nursing student, and then a new nurse, I found that the realities of nursing education and then professional practice sometimes blunted my ability to fully and wholistically care for myself and others. Watson’s work has been a revelation and a comfort. It provides an outlet to immerse myself in the study of caring deliberatively, productively, wholistically, and completely in nursing and in life. I have been studying, practicing, and teaching Watson’s Theory of Human Caring for 27 years, since I discovered Watson’s Nursing: Human Science and Human Care: AT ­ heory of Nursing (Watson, 1985/1988). I have shared the following quote often with nursing colleagues and nursing students because it enduringly provides the basis for my understanding of Watson’s work: “Care and love are the most universal, the most tremendous and the most mysterious of cosmic forces: they comprise the primal universal psychic energy…Caring is the essence of nursing and the most central and unifying focus for nursing practice” (Watson, 1985/1988, pp. 32–33). Students and colleagues often react with wide-eyed disbelief about my straightforward assertion that there is a need to consciously, deliberately, and viscerally care and love while practicing nursing in all its forms. I entered nursing for the opportunity to care and to love, and I will do this unashamedly. Caring for and loving myself and others permeates my professional and personal life. It is a lifestyle and a commitment. Watson’s work supports this endeavor.

Why Use Mindfulness to Cultivate Understanding of Watson's Theory of Caring? In studying, practicing, and teaching Watson’s theory over the years, I have found it helpful to incorporate mindfulness practice and perspectives from Thich Nhat Hanh’s Zen Buddhist tradition (Sitzman, 2002). Nhat Hanh’s m ­ indfulness practices are not religion specific and can be cultivated within any spiritual ­ ­tradition or in the absence of spiritual tradition. Watson’s work often discusses the

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I.  Introduction to the Caritas and Enhancing Use through Mindfulness

i­mportance of cultivating personal practices, including mindfulness, to ­support caring ­comportment: This model now more explicitly acknowledges that the nurse or practitioner who is working with this theory and its underlying philosophy, needs to cultivate a daily practice for self. Practices such as centering, meditation, breathwork, yoga, prayer, connections with nature and other such forms of daily contemplation [mindfulness] are essential to the theory’s authenticity and success. In other words, if one is to work from a caring healing paradigm, one must live it out in daily life. (Watson, 1997, p. 51) Internalizing and then consistently practicing caring from within and w ­ ithout are essential in cultivating deep and lasting understanding. Another nurse theorist, Newman (1997), echoes this belief: We must study the process of our relationships with clients from within, as part of the process. We are imbedded in what we study. We cannot step outside the process. The nature of reality is not ­outside ourselves … The paradigm of nursing embraces wholeness and ­pattern. It reveals a world that is moving, evolving, transforming— a process. (Newman, 1997, p. 37) Although Nhat Hanh’s mindfulness approach evolved from a Zen Buddhist tradition, it closely parallels both Newman’s and Watson’s work: [With mindfulness] we can appreciate the wonders of life, and, at the same time, act with firm resolve to alleviate suffering [ours and the suffering of others]. Too many people distinguish between the inner world of our mind and the world outside, but these realities are not separate. They belong to the same reality. The ideas of outside and inside are helpful in everyday life [and in nursing practice], but they can become an obstacle that prevents us from experiencing ultimate reality [similar to Watson’s notion of abiding in the highest consciousness of love]. (Nhat Hanh, 1993, p. 4) Nhat Hanh offers simple yet powerful insights and mindfulness practices that will support understanding, internalization, and meaningful translation of Watson’s theory into everyday nursing practice and everyday life. They are presented in each chapter as an accompaniment to Watson’s work, and to provide examples of how to cultivate personal practices that will support caring comportment in nursing and beyond.

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1.  Use of Mindfulness to Cultivate Understanding of Watson’s Theory of Caring

Art as an Alternative Pathway for Learning Watson’s theory is multilayered and complex. In addition to engaging in ­spiritual practices to deepen understanding, art provides a hands-on approach that will help clarify underlying structures of the theory, the scaffolding upon which the Caritas Processes are placed. This approach moves away from traditional wordbased learning and toward an integrated, wholistic understanding. I have used art to teach nursing theory in general, and Watson’s theory in particular, for many years with great success (Sitzman & Eichelberger, 2010). Art, as it is used within this context, is meant to be a contemplative exercise for the learner, helping to uncover underlying theoretical structures and nonverbal understandings as they emerge in the conscious mind as a result of committed study. Art activities can facilitate deep insight and mindfulness. I have found, for Watson’s theory, that pointillism, mandalas, and photography have been the most helpful approaches for stimulating growth, insight, and learning. Brief explanation of each art form and its usefulness for studying and practicing Watson’s theory follows. Pointillism is a technique in which tiny points or dots of pure color are painstakingly applied to a canvas. Georges Seurat (1859–1891) perfected this ­ ­technique and created many iconic masterworks such as A Sunday on La Grande Jatte, 1884.

Source: Georges Seurat, A Sunday on La Grande Jatte, 1884, 1884–1886, Oil on canvas, 207.6 × 308 cm, Helen Birch Bartlett Memorial Collection, 1926, p. 224, The Art Institute of Chicago. Reprinted with permission from the Art Institute of Chicago.

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I.  Introduction to the Caritas and Enhancing Use through Mindfulness

Viewed close up, individual dots of pure color are clearly apparent. Viewed from far away, the human eye mixes the colors and creates a vibrant, multihued image in the mind’s eye. There is unity and form [in pointillism], and at the same time there is awareness of the interplay between individual points of color and the larger composition … [pointillism images] are finite works, with specific themes and bounded visual representations. However, the many points of color within each work seem to merge with the light and color in the surrounding environment to create a feeling of boundlessness. (Sitzman & Eichelberger, 2010, p. 22) Pointillism can also be found in nature, for example the night sky with stars and planets, or the sand and tiny seashells that can be found on the beach. Watson’s theory is like a pointillism image. It is made up of distinct points of knowledge development that merge to form a bounded yet ultimately boundless approach to caring in nursing. In this instance, learners are invited to take the opportunity to consider distinct points in Watson’s theory, to transform them into a purely visual representation (or points of color), and then place them within the context of a wordless pointillism image. Creating pointillism images provides opportunities for contemplation, exploration, free expression, learning, and feeling the central tenets of Watson’s theory within a realm other than the traditional word-based method that may sometimes confound understanding within a tangle of words. Mandalas serve a similar purpose.

Mandalas are manmade or natural forms in which there is a central focal point around which multiple elements are arranged. The structure of mandalas evokes clarity and beauty. The natural boundary provided by the arrangement

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1.  Use of Mindfulness to Cultivate Understanding of Watson’s Theory of Caring

of elements around the central point provides unity and offers the possibility of adding additional layers without altering the central point. Possibilities for creating mandalas are endless. I have had students who created mandalas from leaves, pine cones, paper, paint, pencils, markers, found items, trash, textiles, and edible elements. Mandalas are abundant in spiritual traditions, for example, rose windows in Christian cathedrals, sand paintings in Buddhism depicting the cycle of birth and death, tile decorations in Muslim mosques, and temple murals depicting natural cycles in the Hindu tradition. Mandalas are also abundant in nature, for example, the iris of the eye, flowers, hurricanes, spider webs, the solar system, the arrangement of branches and leaves on trees, seashells, and the human form. Envisioning caring as a central point and then arranging specific aspects of Watson’s theory around that central point will help each learner to organize understandings into unique and meaningful configurations. As learning deepens, elements may be added or rearranged until cohesive comprehension is achieved.

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I.  Introduction to the Caritas and Enhancing Use through Mindfulness

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1.  Use of Mindfulness to Cultivate Understanding of Watson’s Theory of Caring

Some learners might prefer to search for and document/take photographs of existing images to evoke elements related to Watson’s theory. This offers yet another approach for visual exploration and learning.

How This Book Is Arranged This book is arranged to provide a simple and direct method for learning about and working with Watson’s Theory of Human Caring. Overviews of Watson’s ­theory, Nhat Hanh’s mindfulness practices and perspectives, and Layers of Caring and Mindful Influence are presented in the following three chapters. The remaining chapters will present each of Watson’s 10 Caritas Processes along with project abstracts that illustrate integration of the theory into professional practice in a variety of areas. The project abstracts describe actual projects undertaken by students in the Watson Caring Institute Caritas Coach Education Program. Mindfulness insights from Thich Nhat Hanh’s tradition will provide examples of intersections between caring science and mindfulness practice. The mindfulness examples and practices presented here are not specific to one spiritual tradition and are meant to enrich and support all spiritual traditions. Art activities will also be included for learners interested in deepening understanding through the creation of contemplative art. Simple steps are provided below for the creation of each type of art.

Creating Pointillism Images Follow the steps listed below to create simple contemplative pointillism images (summarized from Sitzman & Eichelberger, 2011): 1.  Gather art supplies that include cardstock or watercolor-weight paper, acrylic or watercolor paints, and cotton-tipped swabs. You may also use markers, crayons, or colored pencils. 2.  Using a pencil, lightly outline shapes or forms on the paper to evoke the concept you are contemplating. 3.  Use the cotton-tipped swabs and paint, markers, crayons, or colored pencils to dab different colors within and around the shapes outlined in Step 2. Fill each shape with two or three different colors of dots, and also fill the surrounding space with contrasting colors. 4.  Look at the finished work close up. Notice how easy it is to see individual dots of color and how difficult it is to discern the shapes that were penciled in at the beginning. Watson’s Caritas Processes are made up of distinct conceptual/theoretical ideas, represented by the individual points of color in the pointillism image.

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I.  Introduction to the Caritas and Enhancing Use through Mindfulness

5.  Now look at the finished work from 20 feet away. Notice how individual dots of color are difficult to distinguish, and it becomes easier to see those larger shapes that were penciled in and filled with distinct colors. When the components of Watson’s Caritas Processes blend together, a transpersonal caring moment is created. The visual blending of the dots in the pointillism image represents this phenomenon. Transpersonal caring moments will be described in more detail in the following chapter.

Creating Mandala Images Mandalas have a central point of interest (the concept or idea that you are contemplating), surrounded by smaller components (supporting ideas related to the central concept) symmetrically arranged into a unified whole. Mandalas are purposefully arranged to evoke clarity, beauty, and nonverbal understanding. They have boundaries to provide a sense of unity and completeness; however, the symmetry of mandala designs easily allows for the inclusion of additional layers as ideas and understandings develop. To cultivate understanding and insight, it is important to experience the creation (or completion through coloring) of mandalas. Follow the steps listed below to create simple contemplative mandala images (summarized from Sitzman & Eichelberger, 2011): 1.  Assemble whatever tools you prefer to color with: crayons, markers, paint, colored pencils, or colored bits of paper. 2.  Go to a mandala website (there are numerous websites with free mandalas available to print), purchase a mandala coloring book, or draw your own mandala to color. Choose a design that resonates with your feelings about the concept(s) you are contemplating. 3.  Add colors to the mandala that express your feelings and understandings about the contemplative concept. 4.  It is also possible to create mandalas with found objects from trash, nature, or everyday household objects. Choose the method that is most interesting to you.

Creating Photographic Images Use a camera of any type to create photographic images that represent Watson’s work. Pointillism can be photographed because it is evident in the weave of textiles, the skins of lizards and frogs, patterns of fading and wear on articles of clothing, television screen images, the inside of pomegranates, leaves in a forest

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1.  Use of Mindfulness to Cultivate Understanding of Watson’s Theory of Caring

landscape, sand on the beach, wood grains, ceramic textures, cross-stitch pictures, and fields of grass and wildflowers. Mandalas are abundant in urban and natural surroundings. Mindfully observing the contents of a living room, components of a neighborhood park, the façades of churches, or the toys in a preschool classroom, for example, will provide many mandala forms to photograph. Other examples of mandala forms to photograph include flowers, cross-sections of oranges or other fruits and vegetables, ripples in ponds, stars, constellations, seashells, crystals, and pine cones. Write contextual descriptions of the photographs you create that clarify relationships to Watson’s work.

References Newman, M. A. (1997). Experiencing the whole. Advanced Nursing Science, 20(1), 34–39. Nhat Hanh, T. (1993). Interbeing: Fourteen guidelines for engaged Buddhism. Berkeley, CA: Parallax Press. Sitzman, K. (2002). Interbeing and mindfulness: A bridge to u ­ nderstanding Jean Watson’s Theory of Human Caring. Nursing Education Perspectives, 23(3), 118–123. Sitzman, K., & Eichelberger, L. (2011). Understanding the work of nurse theorists: A creative beginning. Sudbury, MA: Jones & Bartlett. Watson, J. (1988). Nursing: Human science and human care. New York, NY: National League for Nursing. (Original work published 1985) Watson, J. (1997). The theory of human caring: Retrospective and prospective. Nursing Science Quarterly, 10(1), 49–52.

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Chapter 2 Overview of Watson’s Theory (10 Caritas)

2.  Overview of Watson’s Theory (10 Caritas)

Introduction to Jean Watson Jean Watson, PhD, RN, AHN-BC, FAAN, distinguished professor and dean ­emerita at the University of Colorado, Denver College of Nursing and Anschutz Medical Center, held an endowed chair in caring science for 16 years. She is founder of the original Center for Human Caring in Colorado and is a Fellow of the American Academy of Nursing. She previously served as dean of nursing at the University Health Sciences Center and is a past president of the National League for Nursing. Dr. Watson earned undergraduate and graduate degrees in nursing and ­psychiatric-mental health nursing and holds her PhD in educational ­psychology and counseling. She is a widely published author and recipient of many awards and honors, including the Fetzer Institute Norman Cousins Award, in r­ ecognition of her commitment to developing, maintaining, and exemplifying r­ elationship-centered care practices; an international Kellogg Fellowship in ­Australia; and a Fulbright Research Award in Sweden. She holds 10 honorary doctoral degrees, i­ncluding seven international honorary doctorates ­ (Sweden; United Kingdom; Spain; British Columbia and Quebec, Canada; and Japan). Dr. Watson’s caring philosophy is used to guide transformative models of caring and healing practices for nurses, allied health professionals, caregivers, and patients in diverse settings worldwide. These settings include institutions for higher education, centers for education and learning, hospitals, clinics, and public agencies. At the University of Colorado, Dr. Watson held the title of distinguished professor of nursing—the highest honor accorded its faculty for scholarly work. In 1999 she assumed the Murchinson-Scoville chair in caring science, the nation’s first endowed chair in caring science, based at the University of Colorado Denver and Anschutz Medical Center. As author or coauthor of over 18 books on caring, her latest books range from empirical measurements and international research on caring, to new postmodern philosophies of caring and healing, philosophy, and science of caring, and caring science as sacred science. Her work bridges related paradigms and points toward transformative models of caring for the 21st century. Many of her books have been honored with the American Journal of Nursing Book of the Year award.

Transpersonal Caring—Caring Science Transpersonal caring relationships are the foundation of Watson’s work. Transpersonal caring occurs when the one caring connects with and embraces the spirit of the other through authentic, full attention in the here and now, and conveys a ­concern for the inner life and personal meaning of another. Transpersonal caring also seeks

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I.  Introduction to the Caritas and Enhancing Use through Mindfulness

to go beyond the self and beyond the here and now, reaching to deeper connections with spirit, and with the broader universal consciousness. Transpersonal caring relationships start with full attention in the moment, and then radiate to spiritual, limitless connections that tap into subtle healing possibilities and potentials. The degree to which a nurse is able to detect a person’s condition of being from the gross physical to the soul/spirit level is influenced by the nurse’s cultivation of conscious love and caring intentions related to the nurse as she or he enters into the life space/phenomenal field of another. Focus on the uniqueness of self and other and the uniqueness of the moment, wherein the coming together is mutual and reciprocal, each fully embodied in the moment, while paradoxically capable of transcending the moment, exemplifies the transpersonal caring relationship. The emergence of new possibilities is also a hallmark. Transpersonal caring calls for authenticity and an ability to be present to self and other in a reflective frame; the transpersonal nurse has the ability to center consciousness and intentionality on caring, healing, and wholeness, rather than on disease, illness, and pathology. An ability to be fully in the present moment, while at the same time embracing the transformative process of becoming, emerges from an awareness of impermanence and the constant metamorphic influence of ­interconnectedness. In other words, the nurse attempts to enter into and stay within the other’s frame of reference, attempting to connect with the inner life world of meaning and spirit of the other. Together, they join in a mutual search for meaning and wholeness of being/becoming to potentiate comfort measures, pain control, a sense of well-being, wholeness, and even spiritual transcendence of suffering. Every person is viewed as whole and complete, regardless of illness or disease (Watson, 1996, Blueprint: p. 153). Transpersonal caring competencies are related to cultivation of the nurse’s human competencies and ways of being/becoming (ontology). In Watson’s model, these caring competencies are as critical as technological ­curing competencies. This approach is a departure from the conventional, modern, W ­ estern ­nursing–­medicine model where technological curing competencies tend to be considered c­ritical, whereas transpersonal caring competencies tend to be considered ­helpful but not critical. Within Watson’s Model of Transpersonal ­Caring, ­introductory work with clinical Caritas is facilitated to create a foundation for ongoing c­ ultivation of transpersonal caring competencies, in addition to the acquisition of technological curing competencies. Application of transpersonal caring competencies occurs during caring moments or caring occasions, which are described in the following.

Caring Moments, Caring Occasions A caring occasion occurs whenever the nurse and another come together with their unique life histories and phenomenal fields, creating a distinct caring moment in space and time. This moment moves toward transcending space and

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2.  Overview of Watson’s Theory (10 Caritas)

time as the actual caring occasion becomes a pebble that ripples in the ­cosmic pond, becoming part of the life history of each participant, then affecting self and others in widening circles of proximity, rippling outward in all ­directions to become part of the complex web of life, time, space, and spirit (Watson, 1985/1988). A caring moment involves an action and choice by both the nurse and the other. The moment of coming together presents an opportunity to decide how to be in the moment and in the relationship and opens opportunities for choosing how to engage in the moment. If the caring moment is transpersonal, each feels a connection with the other at the spirit level, thus it transcends time and space, opening up new possibilities for healing and human connection at a deeper level than physical interaction: “… we learn from one another how to be human by identifying ourselves with others, finding their dilemmas in ourselves. What we all learn from it is self-knowledge. The self we learn about … is every self. It is universal—the human self. We learn to recognize ourselves in others … (it) keeps alive our common humanity and avoids reducing self or other to the moral status of object” (Watson, 1985/1988, pp. 59–60).

Caring (Healing) Consciousness The dynamic of transpersonal caring (healing) within a caring moment exists in the field of consciousness. The transpersonal dimensions of a caring moment are affected by the nurse’s consciousness in the caring moment, which in turn affects the field of the whole. Evolving consciousness within the individual comes to acknowledge love as the highest consciousness. Consciousness as it relates to transpersonal caring is further described by the following (Watson, 1996, p. 148): •  Caring–healing–loving consciousness is contained within a single caring

moment. •  The one caring and the one being cared for are interconnected;

the caring–healing process is connected with the other human(s) and the higher energy of the universe; the caring–healing–loving consciousness of the nurse is communicated to the one being cared for; caring–healing–loving consciousness exists through and transcends time and space and can be dominant over physical dimensions. •  Within this context, it is acknowledged that the process is relational and connected; it transcends time, space, and physicality. The process is intersubjective with transcendent possibilities that go beyond the given caring moment.

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I.  Introduction to the Caritas and Enhancing Use through Mindfulness

Caring Science Defined Caring science encompasses a humanitarian, human science orientation to human caring processes, phenomena, and experiences. Caring science includes arts and humanities as well as science. Caring science perspective acknowledges interconnectedness as the foundation of all caring interactions and activities. Transpersonal caring acknowledges unity of life and connections that move in concentric circles of caring—from individual, to others, to community, to world, to Planet Earth, to the universe, and beyond.

The Implications of Caring Theory The caring model or theory can also be considered a philosophical and moral/­ ethical foundation for professional nursing and part of the central focus for ­nursing at the disciplinary level. A model of caring includes a call for both art and s­ cience; it offers a framework that embraces and intersects with art, ­science, ­humanities, spirituality, and new dimensions of mindbodyspirit medicine and nursing evolving openly as central to human phenomena of nursing practice. Watson emphasizes that it is possible to read, study, learn about, even teach and research the caring theory; however, to truly “get it,” one has to personally ­experience it; thus the model is both an invitation and an opportunity to interact with the ideas, experiment with and grow within the philosophy, and live it in one’s personal/ professional life (Watson, 1999).

The Future of Nursing The future of nursing depends upon whether or not it matures into a distinct health, healing, and caring profession that it has always represented across time, but has yet to actualize. Nursing, thus ironically, now is challenged to stand and mature within its own paradigm, while simultaneously having to transcend it and share with others. The future already reveals that all health care ­practitioners will need to work within a shared framework of caring relationships, ­mindbodyspirit medicine, embracing healing arts, caring practices, and processes, and the spiritual dimensions of care much more completely. Thus, nursing is at its own crossroad of possibilities, among worldviews, paradigms, centuries, and eras; invited and required to build upon its heritage and latest evolution in science and t­ echnology. The nursing profession must transcend its own boundaries for a postmodern

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2.  Overview of Watson’s Theory (10 Caritas)

future yet to be known. H ­ owever, ­nursing’s future holds promises of caring and healing mysteries and models yet to unfold as opportunities for offering compassionate Caritas service await at i­ndividual, system, societal, national, and global levels for self, profession, and the broader world community. Nurses with informed Caritas Consciousness could literally t­ ransform entire systems, contributing to worldwide changes through their own practices of Being, thus “seeing” and doing things differently—­holding a different consciousness, radiating different messages, a­ ffecting the subtle energetic environment, spreading healing, wholeness, ­forgiveness, beauty, love, kindness, equanimity. In this awareness, nurses are literally becoming the Caritas field. (Watson, 2008, p. 59)

10 Caritas Processes The word “Caritas” is Latin. It means to cherish, appreciate, and give special or loving attention with charity, compassion, and generosity of spirit. Caritas is very fine and precious, and must be actively cultivated to be sustained (Watson, 2008). Over the years, Watson has developed and refined 10 Caritas Processes to guide nurses and others in applying her theoretical constructs, and cultivating caring moments and caring occasions in their own professional practices. They may also be used to form philosophical and professional practice foundations at broader levels in clinical and academic settings. The list of 10 Caritas Processes presented here will form the basis of study for the remainder of this book. They will be addressed in more detail in subsequent chapters:

1.  Sustaining humanistic–altruistic values by practice of loving kindness, compassion, and equanimity with self/others. 2.  Being authentically present, enabling faith/hope/belief system; honoring subjective inner, life-world of self/others. 3.  Being sensitive to self and others by cultivating own spiritual practices; beyond ego-self to transpersonal presence. 4.  Developing and sustaining loving, trusting–caring relationships. 5.  Allowing for expression of positive and negative feelings— authentically listening to another person’s story.

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I.  Introduction to the Caritas and Enhancing Use through Mindfulness

6.  Creatively problem-solving-“solution-seeking” through caring process; full use of self and artistry of caring–healing practices via use of all ways of knowing/being/doing/becoming. 7.  Engaging in transpersonal teaching and learning within context of caring relationship; staying within other’s frame of reference—shift toward coaching model for expanded health/wellness. 8.  Creating a healing environment at all levels; subtle environment for energetic authentic caring presence. 9.  Reverentially assisting with basic needs as sacred acts, touching mindbodyspirit of other; sustaining human dignity. 10.  Opening to spiritual, mystery, unknowns—allowing for miracles (WatsonCaringScience.org)

References Watson, J. (1985/1988). Nursing: Human science and human care. New York, NY: National League for Nursing Press. Watson, J. (1996). Watson’s theory of transpersonal caring. In P. H. Walker & B. Neuman (Eds.), Blueprint for use of nursing models: Education, research, ­practice, & administration (pp. 141–184). New York, NY: National League for Nursing Press. Watson, J. (1999). Nursing: Human science and human care: A theory of nursing. New York, NY: National League for Nursing Press. Watson, J. (2008). Nursing: The philosophy and science of caring (Rev. ed.). B ­ oulder, CO: University Press of Colorado.

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Chapter 3 Thich Nhat Hanh’s Five Mindfulness Trainings

3.  Thich Nhat Hanh’s FIVE Mindfulness Trainings

Introduction to Thich Nhat Hanh Thich Nhat Hanh is a well-known and respected Zen master. He was born in Vietnam in 1926 and began the process of becoming a monk at the age of 16. During the Vietnam War, Nhat Hanh continued his mindful and meditative life, and also chose to assist villagers suffering from the devastations of the war. In this way, Nhat Hanh helped to start the “engaged Buddhism” movement. He continues to teach mindfulness for inner transformation, meant to benefit individuals, families, groups, communities, society, the world, and beyond. After visiting the United States and Europe in 1966 on a peace mission, he was banned from returning to Vietnam. In 1982, Nhat Hanh founded Plum Village, a Buddhist community in France that still flourishes today. Along with other monks, nuns, and laypeople within Nhat Hanh’s mindfulness tradition, he continues to teach mindfulness practices to thousands of people all over the world each year, and also continues his work to alleviate hunger, and help refugees, boat people, and political prisoners in Vietnam and throughout the Third World. He has published widely on topics related to mindfulness and engaged Buddhism (www.plumvillage.org/thich-nhat-hanh.html).

Brief Overview of Mindfulness Practice “Mindfulness is the energy of being aware and awake to the present moment. It is the continuous practice of touching life deeply in every moment of daily life. To be mindful is to be truly alive, present and at one with those around you and with what you are doing. We bring our body and mind into harmony while we wash the dishes, drive the car or take our morning shower” (www.plumvillage. org/thich-nhat-hanh.html). Mindfulness is about letting go of doctrines and simply being fully present in each moment of life. Ideas about caring, understanding, and compassion are not understanding and compassion. Caring, understanding, and compassion must be seen and touched through the immediacy of mindfulness practice (Nhat Hanh, 1993). This is a simple yet profound practice with the power to cultivate deep caring and understanding. Truly dwelling in each moment sounds simple to do, yet it is a challenging endeavor because we are conditioned to park our physical body in the present, and then engage our minds and hearts in the contemplation of mental formations, that is, thoughts, feelings, past events or future plans, and worries. In doing this, we lose touch with what is happening around us in the present moment. Mindfulness practice is meant to help unify mind, body, heart, and spirit with what is happening right now rather than what has been or what may be. In doing this, we become fully available to see, understand, love, care, and enter the stream of what Watson describes as the transpersonal caring moment. There is no time-defined path of caring, love, and mindfulness;

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I.  Introduction to the Caritas and Enhancing Use through Mindfulness

caring, love, and mindfulness is the path that manifests from the moment we fully attend to the present with the understanding that we are profoundly interconnected with all that precedes and surrounds us. Nhat Hanh describes feelings and mental formations as impermanent, passing by in the sky of our mind like white clouds on a sky-blue background. It is impossible to cling to clouds and keep them from passing by; so it is the same for feelings and thoughts. Mindfulness involves compassionately acknowledging the clouds that pass by the sky of our mind and letting go of the notion that we must retain them. Letting go of the clouds, which one could never cling to in the first place, allows full awareness of the present and all it contains. In practical terms, the [human being, situation] before you becomes part of the present moment, and in this way, mindfulness creates connection and intimacy in that moment … thereby deepening the mutuality of human-to-human caring and enabling the transpersonal caring moment (Sitzman, 2002, p. 123) Mindfulness must be cultivated through conscious, deliberate, ongoing practice. The foundational practice in Nhat Hanh’s tradition is gentle, nonjudgmental attention to the breath. The breath is the thread that knits the physical/thinking dimension into the fabric of the heart/spiritual dimension. The simple act of continually bringing attention back to one’s own in-breath and out-breath serves to unify mindbodyspirit heart in the present moment. Here is a simple practice in Nhat Hanh’s tradition to bring attention to the breath: As you breathe in, you say to yourself “Breathing in, I know that I am breathing in.” And as you breathe out, say “Breathing out, I know that I am breathing out.” Just that. You recognize your in-breath as an in-breath and your out-breath as an out-breath. You don't even need to recite the whole sentence; you can use just two words: “In” and “Out.” This technique can help you keep your mind on your breath. As you practice, your breath will become peaceful and ­gentle, and your mind will also become peaceful and gentle. This is not a difficult exercise. In just a few minutes you can realize the fruit of meditation. Breathing in and out is very important, and it is enjoyable. Our ­breathing is the link between our body and mind. Sometimes our mind is thinking of one thing and our body is doing another, and the mind and body are not unified. By concentrating on our breathing, “In” and “Out,” we bring body and mind back together, and become whole again. Conscious breathing is an important bridge … when we breathe consciously we recover ourselves completely and encounter life in the present moment. (Nhat Hanh, 1991, pp. 8–9) The only way to understand mindfulness is to practice it. In its simplicity, it can be understood and utilized in varied environments and by many different

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personalities. Mindfulness can be immediately integrated into any area of nursing practice—it is as close as one deliberately observed breath. In addition to following and observing the breath, awareness of the interconnectivity of self with others is essential in both Nhat Hanh’s mindfulness tradition and Watson’s transpersonal caring. Nhat Hanh refers to this state of awareness as interbeing. Nhat Hanh and Watson both assert that everything ­influences and is inexorably connected to everything else. Nhat Hanh provides an illustrative example; that the whole of the universe can be found within a single sheet of paper: … there is a cloud floating in this sheet of paper. Without a cloud, there will be no rain; without rain, the trees cannot grow; and without trees, we cannot make paper. The cloud is essential for the paper to exist. If the cloud is not here, the sheet of paper cannot be here either. So we can say that the cloud and the paper inter-are. “Interbeing” is a word that is not in the dictionary yet, but if we combine the prefix “inter-” with the verb “to be,” we have a new verb, inter-be. If we look into this sheet of paper even more deeply, we can see the sunshine in it. Without sunshine, the forest cannot grow. In fact, nothing can grow without sunshine, and so, we know that the ­sunshine is also in this sheet of paper. The paper and the sunshine inter-are. And if we continue to look, we can see the logger who cut the tree and brought it to the mill to be transformed into paper. And we see wheat. We know that the logger cannot exist without his daily bread, and therefore the wheat that became his daily bread is also in this sheet of paper. The logger’s father and mother are in it too. When we look in this way, we see that without all of these things, this sheet of paper cannot exist … We cannot point out one thing that is not in here [this sheet of paper]—time, space, the earth, the rain, the minerals in the soil, the sunshine, the cloud, the river, the heat. Everything co-exists with this sheet of paper … As thin as this sheet of paper is, it contains everything in the universe in it. (Nhat Hanh, 1991, pp. 95–96) Nhat Hanh created five mindfulness trainings to support the cultivation of an enduring mindfulness practice and support awareness of interbeing. They are listed below (Nhat Hanh, 2007, pp. 14–15): 1.  Reverence for Life Aware of the suffering caused by the destruction of life, I am committed to cultivating the insight of interbeing and compassion and learning ways to protect the lives of people, animals, plants, and minerals. I am determined not to kill, not to let others kill, and not to support any act of killing in the world, in my thinking, or in my way of life. Seeing that harmful

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I.  Introduction to the Caritas and Enhancing Use through Mindfulness

actions arise from anger, fear, greed, and intolerance, which in turn come from dualistic and discriminative thinking, I will cultivate openness, nondiscrimination, and nonattachment to views in order to transform violence, fanaticism, and dogmatism in myself and in the world. 2.  True Happiness Aware of the suffering caused by exploitation, social injustice, stealing, and oppression, I am committed to practicing generosity in my thinking, speaking, and acting. I am determined not to steal and not to possess anything that should belong to others; and I will share my time, energy, and material resources with those who are in need. I will practice looking deeply to see that the happiness and suffering of others are not separate from my own happiness and suffering; that true happiness is not possible without understanding and compassion; and that running after wealth, fame, power, and sensual pleasures can bring much suffering and despair. I am aware that happiness depends on my mental attitude and not on external conditions, and that I can live happily in the present moment simply by remembering that I already have more than enough conditions to be happy. I am committed to practicing Right Livelihood so that I can help reduce the suffering of living beings on Earth and reverse the process of global warming. 3.  True Love Aware of the suffering caused by sexual misconduct, I am committed to cultivating responsibility and learning ways to protect the safety and integrity of individuals, couples, families, and society. Knowing that sexual desire is not love, and that sexual activity motivated by craving always harms myself as well as others, I am determined not to engage in sexual relations without true love and a deep, longterm commitment made known to my family and friends. I will do everything in my power to protect children from sexual abuse and to prevent couples and families from being broken by sexual misconduct. Seeing that body and mind are one, I am committed to learning appropriate ways to take care of my sexual energy and cultivating loving kindness, compassion, joy, and inclusiveness—which are the four basic elements of true love—for my greater happiness and the greater happiness of others. Practicing true love, we know that we will continue beautifully into the future. 4.  Loving Speech and Deep Listening Aware of the suffering caused by unmindful speech and the inability to listen to others, I am committed to cultivating loving speech and compassionate listening in order to relieve suffering and to promote reconciliation and peace in myself and among other people, ethnic and religious groups, and nations. Knowing that words can create

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happiness or suffering, I am committed to speaking truthfully and using words that inspire confidence, joy, and hope. When anger is manifesting in me, I am determined not to speak. I will practice mindful breathing and walking in order to recognize and to look deeply into my anger. I know that the roots of anger can be found in my wrong perceptions and lack of understanding of the suffering in myself and in the other person. I will speak and listen in a way that can help myself and the other person to transform suffering and see the way out of difficult situations. I am determined not to spread news that I do not know to be certain and not to utter words that can cause division or discord. I will practice Right Diligence to nourish my capacity for understanding, love, joy, and inclusiveness, and gradually transform anger, violence, and fear that lie deep in my consciousness. 5.  Nourishment and Healing Aware of the suffering caused by unmindful consumption, I am committed to cultivating good health, both physical and mental, for myself, my family, and my society by practicing mindful eating, drinking, and consuming. I will practice looking deeply into how I consume the four kinds of nutriments, namely edible foods, sense impressions, volition, and consciousness. I am determined not to gamble, or to use alcohol, drugs, or any other products which contain toxins, such as certain websites, electronic games, TV programs, films, magazines, books, and conversations. I will practice coming back to the present moment to be in touch with the refreshing, healing, and nourishing elements in me and around me, not letting regrets and sorrow drag me back into the past nor letting anxieties, fear, or craving pull me out of the present moment. I am determined not to try to cover up loneliness, anxiety, or other suffering by losing myself in consumption. I will contemplate interbeing and consume in a way that preserves peace, joy, and well-being in my body and consciousness, and in the collective body and consciousness of my family, my society, and the Earth. Integrating mindfulness trainings in the tradition of Thich Nhat Hanh with the study of Watson’s work supports an interdisciplinary approach to understanding and enacting Watson’s transpersonal caring moments within varied professional nursing environments. These environments include, but are not limited to, hospitals, long-term care, hospice, home health care, community/public health, occupational health, nursing education, professional nursing organizations, and nursing research. They are especially relevant and helpful for us as caring professionals and our daily practices and relationships with self, family, colleagues, and friends.

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References Nhat Hanh, T. (1991). Peace is every step: The path of mindfulness in everyday life. New York, NY: Bantam Books. Nhat Hanh, T. (1993). Interbeing: Fourteen guidelines for engaged Buddhism. Berkeley, CA: Parallax Press. Nhat Hanh, T. (2007). For a future to be possible. Berkeley, CA: Parallax Press. Sitzman, K. (2002). Interbeing and mindfulness: A bridge to understanding Jean Watson’s Theory of Human Caring. Nursing Education Perspectives, 23(3), 118–123.

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Chapter 4 Entering the Stream: Understanding and Living Out Jean Watson’s Work

4.  Entering the Stream: Understanding and Living Out Jean Watson’s Work

Layers of Caring and Mindful Influence: Pebbles in a Pond Model Watson’s emphasis on philosophical concepts can be translated into everyday nursing practice by acknowledging specific layers of caring and mindful influence. Envision a still blue pond, reflecting surrounding images of trees, blue sky, clouds, and mountains. This pond is the ground of being for everyday life. Imagine a person (or nurse), with the intention to care, as a pebble dropped into the pond. Caring influence from this one small pebble ripples outward from wherever it was initially dropped. Self, others, peers, leaders, local/world communities, the environment, virtual/web-based, and beyond are all eventually touched as ever-widening, holographic spheres of influence move outward from wherever the pebble was initially dropped. One caring intention and/or action affects the universe, transcending time/space/physical boundaries, similar to Nhat Hanh’s universe in a single sheet of paper described in Chapter 3. This is the essence of each transpersonal caring moment grounded in mindfulness. See Figure 4.1 for a simple visual representation:

Self Others Peers Leaders Local/world communities The environment Virtual/web based Beyond...

Figure 4.1 Pebble in a pond model.

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Transpersonal caring consists of a stream of transpersonal caring moments that radiate in all directions beyond the specific moment, through space, time, and the physical plane, to create endless possibilities of caring influence. Entering the stream, or dropping a pebble in the pond at any point, will enact caring influence in every other area. Nurses in all areas of practice have endless opportunities to care, to enter the stream of mindful caring influence. “The human care process between a nurse and another individual is a special, delicate gift to be cherished. The human care transactions provide a coming together and establishment of contact between persons; one’s mind-body-soul engages with another’s ­mind-body-soul in a lived moment. The shared moment of the present has the potential to transcend time and space and the physical, concrete world as we generally view it in the traditional nurse-patient relationship” (Watson, 1999, p. 47).

Core and Trim In working with the philosophical, metaphysical aspects of caring in Watson’s theory, it is helpful to describe the microcosm of nursing practice using a core and trim model (Watson, 1979/1985). The constant core of nursing is conscious, deliberative caring, in all its forms and iterations. This core of genuine caring transcends space and time, similarly held as foundational by caring nurses in the 1800s and caring nurses in the 21st century. The trim is comprised of nursing knowledge, technologies, skills, and activities. The trim constantly changes to reflect the time/space/place/occasion in which caring moments occur, and will look drastically different in the 21st century as compared to the 1800s. The core and trim are both necessary to nursing practice. Neither the core nor trim could exist without the other. Here I use an ordinary orange to illustrate the concepts of core and trim. Envision an orange. The core, or edible inside of the orange, is the reason for the orange’s existence, just as caring is the reason for nursing’s existence. The orange’s juicy, sweet interior provides nourishment and sustenance, and the seeds contained within it guarantee the continuation of the species. In order for nursing to continue as a profession, the core of nursing (caring) must be recognized, valued, nurtured, and consumed/integrated. The 10 Caritas previously listed at the end of Chapter 2 comprise the inside of the orange (the core of nursing). The trim, the orange’s durable, fragrant, highly visible skin, represents the ever-changing activities of nursing. The trim is essential, as it surrounds and protects the core, allowing it to grow into maturity. The core and the trim work together in different capacities to support caring nursing practice. Trim without core is hollow, empty, and holds nothing of sustenance for survival, thus, without the core, the trim would dry up and wither away to dust. An orange can only exist when both core and trim are present. Sometimes in nursing, there is such a

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4.  Entering the Stream: Understanding and Living Out Jean Watson’s Work

strong focus on the trim, that the core is forgotten or trivialized, even though the core is the very reason for the trim’s existence. Envisioning core and trim as an orange is helpful in creating a mindful perspective related to caring as the reason for nursing’s existence.

Allow miracles

Loving kindness

Basic needs

Trim includes nursing care activities that change with time and specialty areas

Authenticity

Healing environment

Sensitivity

Transpersonal teaching Creative problem solving

Love–trust– care Allow positive and negative

Figure 4.2 Core and trim orange with Caritas. An orange meditation in the Thich Nhat Hanh mindfulness tradition is provided below to support mindful contemplation of nursing’s core and trim.

Orange Meditation Hold an orange in the palm of your hand and look at it while breathing in and out, so that the orange becomes a reality. Try to be totally here, totally present, with the orange in your palm, dwelling in the present moment. See the orange tree, see the orange blossom, see the sun and the rain passing through, and see the tiny fruit form. And now the fruit has grown into a beautiful orange. Just looking and ­smiling into the orange will help you to get in touch with the wonders of life, and with the joy of caring. Sometimes it is easy to ignore the fact that the orange in the palm of your hand is a miracle, a wonder of life. There

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I.  Introduction to the Caritas and Enhancing Use through Mindfulness

are so many wonders of life inside of you and around you. When you look deeply and smile at the orange in this way, it becomes possible to see the orange in its splendor, in its miraculous nature. And suddenly you also become a miracle and you are a miracle encountering another miracle. When you look at the orange deeply, you will be able to see many wonderful things: the sun shining and the rain falling on the orange tree, the orange blossoms, the tiny fruit appearing on the branch, the color of the fruit changing from green to yellow, and then the full-grown orange. Now slowly peel the orange. Smell the wonderful scent of the orange peel. Put a section of the orange in your mouth and taste the wonderful juice. The orange tree has taken three, four, or six months to make this orange for you. Now the orange is ready, and it says ‘I am here for you.’ If you are fully present, you will hear it, and the orange will be fully present also. Being fully present while eating an orange can be a deep and delightful experience. (Nhat Hanh, 2009, pp. 153–154)

Becoming a Caritas Nurse: Value Assumptions of Caritas In the process of valuing, learning about, and translating Watson’s work in everyday nursing practice, it is necessary to cultivate understanding and internalize the foundational assumptions of this approach. The value assumptions are listed below (Watson, 1985, p. 32; Watson, 2008, pp. 41–42): •  Caring and love are the most universal, tremendous, and mysterious

cosmic forces; they comprise the primal and universal source of energy. •  Often this wisdom is overlooked, or we forget, even though we know

people need each other in loving and caring ways. •  If our humanity is to survive and if we are to evolve toward a more loving, caring, deeply human and humane, moral community and civilization, we must sustain love and caring in our life, our work, and our world. •  Since nursing is a caring profession, its ability to sustain its caring ideals, ethics, and philosophy for professional practices will affect the human development of civilization and nursing’s mission in society. •  As a beginning, we have to learn how to offer caring, love, forgiveness, compassion, and mercy to ourselves before we can offer authentic caring and love to others. •  We have to treat ourselves with loving kindness and equanimity, gentleness and dignity before we can accept, respect, and care for others within a professional caring–healing model.

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4.  Entering the Stream: Understanding and Living Out Jean Watson’s Work

•  Nursing has always held a caring stance with respect to others and their

health–illness concerns. •  Knowledgeable, informed, ethical caring is the essence of professional

nursing values, commitments, and competent actions; it is the most central and unifying source to sustain its covenant to society and ensure its survival. Preservation and advancement of caring science values, knowledge, t­heories, philosophies, ethics, and clinical practices, within a context of ­Caritas cosmology, are foundational for sustaining and advancing the discipline and profession.

References Nhat Hanh, T. (2009). Happiness. Berkeley, CA: Parallax Press. Watson, J. (1979/1985). Nursing: The philosophy and science of caring. Niwot, CO: University Press of Colorado. Watson, J. (1999). Nursing: Human science and human care: A theory of nursing. New York, NY: National League for Nursing Press. Watson, J. (2008). Nursing: The philosophy and science of caring, revised edition. ­Boulder, CO: University Press of Colorado.

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Section Ii The 10 Caritas

Chapter 5 The First Caritas Process: Embrace Altruistic Values and Practice Loving Kindness With Self and Others

5.  The First Caritas Process

Embrace Altruistic Values and Practice Loving Kindness With Self and Others … human care and caring is viewed as the moral ideal of nursing. It consists of human-to-human attempts to protect, enhance, and preserve humanity by helping a person find meaning in illness, suffering, pain, and existence; to help another to gain self-knowledge, control, and self-healing wherein a sense of inner harmony is restored regardless of the external circumstances.… (Watson, 1999, p. 54) Holding altruistic values related to nonharming and having a desire to help wherever possible is foundational to caring in nursing, as is the practice of loving kindness with others. Practicing loving kindness with Self, on the other hand, can be elusive. This is true especially where nurses are concerned because of commonly held views that nurses are (and should be) self-sacrificing. Watson addresses this directly in the first Caritas. In 2008 she wrote It is ironic that nursing education and practice require so much knowledge and skill to do the job, but very little effort is directed toward how to be while doing the real work of the job. Nurses often become pained and worn down by trying to always care, give, and be there for others without attending to the loving care needed for the self. This model invites, if not requires, nurses to attend to their selfcaring and practices that assist in their own evolution of consciousness for more fulfillment in their life and work. (Watson, 2008, p. 47) So, what exactly does loving kindness look like? Watson writes: Caring begins with being present, open to compassion, mercy, gentleness, loving kindness, and equanimity toward and with self before one can offer compassionate caring to others. It begins with a love of humanity and everything that is living: the imminent, subtle, radiant, shadow-and-light vicissitudes of experiences along the way—honoring with reverence the mystery, the unknowns, the impermanence and changes but actively, joyfully participating in all of it, the pain, the joy, and everything. (Watson, 2008, p. xvii) The subtext for a great many people reading this might be: “I am not always a hug-giving, warm-fuzzy, gentle, motherly/fatherly, affectionate type of person, and some days I can even be impatient and grumpy, so I am probably not going to do very well with this one….” This need not be of concern. Loving kindness is not a style of behavior to be consistently modeled; it is an attitude, an i­ntention,

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a stance. Loving kindness consists of varying behavioral expressions that all arise from one thing; a deeply held desire to love and to care in whatever ways are meaningful and helpful in a given moment, within a given situation. In other words, “The ideal and value of caring is clearly not just a thing out there, but is a starting point, a stance, an attitude, which has to become a will, an intention, a commitment, and a conscious judgment that manifests itself in concrete acts” (Watson, 1999, pp. 31–32). Keeping this in mind honors variation and exploration, creating openings for the development of unique caring/loving kindness identities. A nurse working in the operating room might outwardly express caring/loving kindness intent by staying near the patient, answering questions, and offering verbal support before anesthesia, and then guarding the patient’s dignity and safety during surgery. A hospice nurse might outwardly express caring/loving kindness intent by providing safe opportunities for patients and family members to openly discuss concerns and questions related to the dying process. A critical care nurse might express caring/loving kindness intent by continuously learning and becoming an expert in the skillful management of life support for her or his patients to give them the best chance of recovery. The temperament of the nurse, the temperament of the patient, and other situation-specific factors will influence what the outward expression of caring loving kindness will be, while the inner resolve of the nurse to care and to love remains constant.

One More Consideration There is something else to consider in relation to this Caritas. Altruism and loving kindness are traits commonly attributed to nurses, and this can be problematic; people tend to take for granted what they perceive to be obvious, which can lead to complacency. Additionally, the challenges of education, professional practice, and life can sometimes blunt the ability and/or desire to consciously and deliberately honor these commonly held nursing values. Pondering, defining, and redefining these traits within the context of daily experience and evolving personal wisdom will help to keep altruism and loving kindness fresh and personally meaningful. The practices listed below may be helpful in cultivating loving kindness every day: 1.  Use Thich Nhat Hanh’s Five Mindfulness Trainings listed in Chapter 3, or create a personally meaningful list of personal altruistic ideals to guide life/practice, and then mindfully revisit this list at the end of every work week. This simple routine will cultivate engaged caring/loving consciousness.

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2.  Compassionately examine personal temperament and behavioral styles, envision what loving kindness might look like in light of who you are and what feels right to you, and then try to consistently embody and demonstrate that as your personal expression of engaged caring/loving consciousness. 3.  Practice loving kindness with yourself without fail, even when things don’t go well. 4.  Practice loving kindness with all whom you encounter. 5.  Release each encounter with gratitude for what you have learned and experienced, and then move forward.

The First Caritas in Action: Caritas Coach Education Program Project Abstracts

     

* * * ENCULTURATING CARITAS PROCESS #1: PRACTICE LOVING KINDNESS Joie Ogrodnick

Introduction St. Anthony Community Hospital is a member of the Bon Secours Health System. It is a 73-bed acute care hospital in the Warwick Valley. In 2009, Jean Watson’s Theory of Human Caring was selected to guide patient care practices (Watson, 2008). The New York part of the Bon Secours Health System is called the Charity System and is comprised of acute care hospitals, long-term care facilities, assisted living facilities, and home care. Since the commitment to Dr. Watson’s theory, there has been ongoing training at the Charity System over the past 3 years. There have been many educational offerings; for example, staff meetings, education days dedicated to the Caritas Processes, and various events for self-care (winery tours, foot and tea spa, self-care days with acupressure, massage, Reiki, reflexology, aroma therapy, hand massage, and guided ­imagery). The Charity Caritas Guiding Council assists with the individual hospital teams, local Caritas teams, and newly formed Advisory Council for oversight of the Caritas coaches and Caring Advocate graduates. There will be three Caritas coaches who have completed the Caritas Coach Education Program with this cohort. Bon Secours has made tremendous progress in setting a foundation for caring science practice (Watson, 2008).

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Significance The practice of loving kindness and equanimity is a core practice in caring science (Watson, 2008). Loving kindness for self and others is foundational to the integration of Watson’s Theory of Human Caring into nursing practice (Watson, 2008). St. Anthony Community Hospital has focused on this core concept by providing education to help with enculturation and integration of caring science into the day-to-day care provided at all levels.

Purpose With a focus on the core concepts and Caritas Process 1: Practice loving kindness and equanimity for self and others to ensure that nursing staff on all l­evels— leadership, nurse managers, nursing supervisors, staff nurses, care partners, techs, and unit clerks—have the foundational education needed to integrate and articulate caring science into everything that they do. Participants were asked to define and identify what loving kindness and equanimity meant to them personally and professionally. Education at staff meetings and placards including Caritas Process #1 that fit on employee ID for quick reference were provided for each nursing staff member.

Setting and Participants All St. Anthony Community Hospital nursing areas—medical–surgical units, intensive care, emergency department, maternity and obstetrics, operating room, same-day medical and surgical center, radiology nursing, case management, and infusion therapy—were included in the project. Nursing staff at all levels—­leadership, nurse managers, nursing supervisors, staff nurses, care partners, techs, and unit clerks—were also included in the project.

Project Description/Process The project was discussed at the Caritas Council and proceeded as a four-part process with the goal of expanding it to the long-term care facilities and sister hospitals. Part I consisted of a four-question survey designed to obtain baseline staff knowledge about Caritas Process #1. Part II included creating a placard defining Caritas Process #1, in a size to be attached to ID badges for

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easy access, to remind nurses of the meaning of it. Part III is wall stenciling Practice Loving Kindness on various areas/walls of the hospital for patients, staff, families, and others to remind them about the foundation of caring science practice and what St. Anthony’s offers. Part IV will be a s­econd questionnaire with the same questions and an additional question asking each participant to define in the person’s own words what it means to practice loving kindness. The results will be compared to further enhance the development of additional strategies to acculturate caring science into nursing practice at St. Anthony’s.

Project Outcomes The project outcomes will enhance and allow a deeper personal and foundational level understanding of Caritas Process #1, and how each individual can enhance his or her own self-love, provide a caring and healing environment for the patients, families, and peers, and integrate and articulate what it means to practice ­loving kindness. It is hoped that this deeper enculturation will be reflected in staff and patient Gallup satisfaction scores and will be monitored over the course of a year to see if there is an increase in patient scores related to staff caring about them.

Project Evaluation The second questionnaire will be completed after 6 months to evaluate the project success. Education including all 10 of the Caritas Processes will be ongoing (Watson, 2008).

Future Directions This project can be easily replicated and shared with our long-term care facilities, outpatient facilities, and sister facilities. Expanding and enhancing the education on Dr. Watson’s Caritas Processes will benefit staff as they commit to practicing loving kindness and equanimity with themselves, each other, and their patients (Watson, 2008). Ongoing future educational events and self-care days will continue to expand, inspire, and enhance caring science in the day-to-day commitment to live and be the theory (Watson, 2008).

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Acknowledgments I wish to thank: Judy Lindberg, vice president of Patient Care Services at St. Anthony Community Hospital, for her support, guidance, and commitment to improving the quality of nursing care with Dr. Jean Watson’s Caritas Processes. Jo-Ann Robinson for her support and guidance to keep the Caritas Processes growing at Bon Secours Charity Health System. Marlienne Goldin, Watson Caring Science Institute faculty associate, for her support at the ICC. Jan Anderson, Watson Caring Science Institute faculty associate, for her mentoring, love, guidance, and support for the entire process. The Earl Vincent and Julia Stamski Barry Institute for Patient Centered Excellence of the Bon Secours Charity Health System for funding the Caritas Coach Education Program. Most importantly, the nursing staff at St. Anthony Community Hospital who live Dr. Watson’s theories and give loving and compassionate care to our patients and their families.

     

* * * INTEGRATING CARING SCIENCE IN A 24/7 CALL CENTER: WEAVING THE THREAD OF CARING INTO ALL AREAS OF PRACTICE Lynn M. Priddy

Introduction Physician and Community Health Access (PCHA) is a 24/7 call center with over 80 incoming phone lines, including the Physician’s Access Line (PAL) and Health On-Call (HOC). Services provided via the PAL include patient transfers and MD-to-MD patient consultations. Services provided via the HOC line include physician referral, assistance with appointment setting, health advice, and health education. Answering service and nurse triage are provided after-hours and on weekends for internal and external clinics and physician practices. Additional services provided by PCHA include daytime triage for Downtown Health Plaza; discharge callback surveys for Cardiology; CT Surgery, Gen Med, and Hospitalist services; and after-hours on-call for Employee Health Services for contaminated exposures. Wake Forest Baptist Health is a designated Watson Caring Science affiliate and a Magnet hospital. Dr. Watson’s Caring Science Theory is being

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integrated into every area of patient care. As caring science has been integrated throughout the medical center, oftentimes our staff could not see how this model could be used in our everyday practice in the call center.

Significance The significance of this project was in continuing the integration of caring science into every area of patient care, including all staff who touch our patients through the phone. It is the goal of Wake Forest Baptist Health Medical Center (WFBMC) that although “I may not see you, I still care.” Studies have shown first impressions are formed spontaneously within the first few moments of speaking based on tone and speech. We want each caller to know that he or she is important and cared for. We are here to provide care on a transpersonal level.

Purpose The purpose of this project was to show staff members how we can provide transpersonal caring using the telephone. As our only contact is through the phone, we need to exude caring in conversations with our callers. In fact, we are here to connect with people in a meaningful way.

Setting and Participants The project took place at PCHA, 6th Floor, Piedmont Plaza II. We are located off site from the main campus of the medical center. Our staff consists of 18 customer service specialists (CSS) who answer all incoming calls and put all calls into the queue system of the computer. They are the first contact our callers have with the call center. We also have 24 registered nurses (RNs) who provide triage services as well as general health information to callers. Both the CSS and RN staffs touch base with patients following their discharge from the medical center.

Project Description/Process Dr. Watson’s Theory of Caring Science has been introduced to the caregivers in the call center at our monthly shared governance meetings. Although there was some working knowledge of the Caritas Processes, it was not a part of daily practice.

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The thread of caring needs to be weaved throughout our practice and we need to understand how each of the Caritas Processes relates to our work. This author began with Caritas Process #1, Embrace Altruistic Values and Practice Loving Kindness With Self and Others. A basic overview of each process and how this process is conceptualized at WFBMC will be presented. In addition, “care of self” education has been utilized to assist with the transition to transformational caring. Love and kindness must begin with kindness toward oneself. When love moves through us, it inspires all we do. Once one has experienced a cultivated sense of loving kindness, one’s heart of compassion is open and bubbles over into one’s life circumstances. It is important for us to realize that it does not work to “put on” an overcoat of loving kindness when anger, hurt, despair, worry, and similar feelings are present. One cannot paint over a veneer of hurts; rather, one must allow the pain to emerge, whereby it is both released and absorbed into the vibrating space of energy flow. Only after those feelings have been allowed to flow can the deep wellspring of authentic Caritas emerge, radiating out from self to others and one’s field (Young, personal communication, 2006).

Project Outcome The expected outcome of this project is the understanding that the Caritas Processes can be applied to our tele-health practice and that transpersonal caring can be given through our phone calls. As Jack Kornfield writes, “In practicing loving kindness toward self and others, birth will be given to a natural compassion. The compassionate heart holds the pain and sorrow of our life and all beings with mercy and tenderness. It is the tender heart that has the power to transform the world” (Kornfield, 2002, p.102). Each month a Caritas Process will be reviewed and the thread of caring will intertwine all areas of our practice allowing our Caritas consciousness to flow out to all those we touch.

Project Evaluation PCHA caregivers have begun some self-care practices. As we grow in our knowledge of each of the Caritas Processes and how transpersonal caring is given over the telephone, it is hoped that our callers will feel the care and love we have for each of them. It is also an expected outcome that we will show transpersonal caring to those around us in our workplace. The project is ongoing. Final data are not available.

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5.  The First Caritas Process

Acknowledgments I offer my heartfelt gratitude to: Marlienne Goldin, my Caritas faculty mentor, for all her love, wisdom, and guidance. Judy McDowell and Randy Williams for their encouragement, love, mentorship, and introduction to the work of Dr. Watson. Debbie Krueger and Michelle Manning for their help and financial assistance with my poster. My coworkers at PCHA for their support. Dr. Jean Watson, last but not least, for giving us the Theory of Human Caring and her dedication to making this her life work. Namaste.

     

* * *

Mindfulness Perspective Thich Nhat Hanh has written eloquently about the need to cultivate compassion in relation to self, others, and all that surrounds us. Watson’s loving kindness parallels Nhat Hanh’s compassion. The phrase “loving kindness” could be substituted in the following passage wherever the word “compassion” appears and the meaning would remain intact: Many of us are afraid of being attacked, so we sometimes pretend to be tough and cruel to protect ourselves, even though we have compassion and understanding inside. Without compassion, we suffer a lot and make people around us suffer. With compassion, we can relate to other living beings and we can help them suffer less. If you are inhabited by the energy of compassion, you live in the safest of environments. Compassion can be expressed in your eyes, in the way you act or react, in the way you walk, sit, eat, or deal with other people. It is the best means of self-protection. It can also be contagious. It is very wonderful to sit close to someone who has compassion in his or her heart … It is our practice to cultivate compassion in our daily lives. (Nhat Hanh, 2002, pp. 33–34)

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iI.  The 10 Caritas

Contemplative Art Activity to Deepen Learning •  Envision colors, patterns, and images that evoke altruism or loving

kindness in your mind’s eye. •  Create a pointillism image or a mandala, or take a photograph that expresses what you have envisioned.

References Kornfield, J. (2002). The art of forgiveness, lovingkindness, and peace. New York, NY: Bantam. Nhat Hanh, T. (2002). Be free where you are. Berkeley, CA: Parallax Press. Watson, J. (1999). Nursing: Human science and human care: A theory of nursing. New York, NY: National League for Nursing Press. Watson, J. (2008). Nursing: The philosophy and science of caring (Rev. ed.). Boulder, CO: University Press of Colorado.

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Chapter 6 The Second Caritas Process: Instill Faith and Hope, and Honor Others

6.  The Second Caritas Process

Be Authentically Present, Instill Faith and Hope, and Honor Others Health care increasingly incorporates holistic modalities with conventional allopathic practices. These practices might include meditation, energy medicine, acupuncture, Reiki, biofeedback, homeopathy, visualization, intentional consciousness, massage, acupressure, and many other approaches. … holistic modalities are grounded in a different worldview than the Western belief system; they incorporate spiritual-religious ­dimensions and other supernatural unknowns, thus contributing all the more to the complexities and importance of honoring deep beliefs, ­perceptions, and subjective meanings … In Caritas consciousness, the nurse honors and seeks to discover what is meaningful and ­important for a particular person. The person’s beliefs are never discarded or dismissed as insignificant in the treatment and caring process. Indeed, they are encouraged, respected, and enabled as significant in ­promoting healing and wholeness regardless of medical diagnosis, situation, and cure outcomes. The nurse practicing within a C ­ aring Science context knows that the healing power of belief and hope can never be overlooked but must be incorporated into the caring ­relationship and caring practices. (Watson, 2008, pp. 65–66) Working within primarily allopathic settings, it can sometimes be easy to discount other health-related practices and belief systems. Being authentically present, instilling faith and hope, and honoring others require caring professionals to cultivate openness to, and awareness of, alternative practices and beliefs. Wellness and healing are certainly related to physical curing. Wellness and healing are also related to spiritual, emotional, and energetic dimensions. Profound states of ­wellness and healing can and do exist in people who have chronic debilitating conditions, and in hospice patients who are actively dying because physical healing is not the only dimension to consider in assessing a person’s well-being. Authentic presence, cultivation of faith and hope, and holistically honoring others open ­healing possibilities that transcend the physical.

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The Second Caritas in Action: Caritas Coach Education Program Project Abstracts *    *    * DEVELOPING AND SUSTAINING HELPING–TRUSTING RELATIONSHIPS (caritas #4) TO FOSTER NURSES’ TRUST, FAITH, AND HOPE (caritas #2) Anne Sagastume

Introduction In April 2012, Adventist Hinsdale Hospital simultaneously moved into a new building and restructured its nursing units, which resulted in significant changes in environment, role, and work groups for many employees, leading to increased job pressure, insecurity, and stress. Nurses are charged with providing compassionate, loving care to their patients while at the same time trying to cope with the uncertainty and anxiety that accompany organizational change. Jean ­Watson’s Caritas Process #4, Developing and Sustaining a Helping–Trusting Caring Relationship, is useful in addressing the fear and insecurity these nurses are experiencing. In discussing the caring relationship, Watson writes, “the Caritas Nurse affirms the subjective-spiritual significance of self and other while seeking to sustain caring in the midst of threat and despair, be it biological, institutional, or other” (2008, p. 81).

Significance The authentic caring relationship is central to the nursing profession. Caring relationships promote emotional and spiritual well-being, and lead to enhanced healing (Watson, 2008). Nurses who are in right relation in mind, body, and spirit are empowered to become “more fully human and humane, more openhearted, compassionate, sensitive, present, [and] capable” (Watson, 2008, p. 80).

Purpose The purpose of this project was to develop and sustain helping–trusting relationships among nurses experiencing stress and anxiety during organizational restructuring as a means of fostering trust, faith, hope, and healing (which reflects Caritas #2).

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Setting and Participants Adventist Hinsdale Hospital is a 100-year old, 277-bed community teaching hospital in Hinsdale, Illinois, approximately 25 miles west of Chicago. The project takes place in the 22-bed ICU. Participants are the ICU RNs, care techs, and unit secretaries.

Project Description: The Project Consists of Four Components 1.  Reinforcing the foundation of caring science for the ICU staff by publishing a “Caritas Corner” section of the monthly, in-house Critical Care Newsletter. The first “Caritas Corner” was published in the April issue of the newsletter. The articles have been published monthly and consist of reflections on the Caritas Processes and excerpts from Watson’s books. 2.  Encouraging reflection and centering as a means of sustaining Caritas relationships. In June 2012, we began a daily centering prayer/reflection between shifts. The sessions consist of a reading and prayer, with a request board available so all intentions are included. “All of us need faith and hope to carry us through the vicissitudes and slings and arrows of the human earth-plane existence” (Watson, 2008, p. 62). 3.  Developing and strengthening relationships while practicing self-care by forming a team to train for and run a 5K-meter charity race. The Team ICU Couch-to-5K program began with motivating and recruiting team members in June 2012. Training schedules and informational e-mails were sent to all ICU staff, and fellow nurses who were experienced runners were recruited to serve as coaches for new runners. The training program began in August, and the race will take place on October 14, 2012. We will run the Rotary Run Charity Classic in Hinsdale, which is sponsored by the hospital and benefits five local charities, including the Hinsdale Hospital Foundation. 4.  The fourth component will be instituted in response to a second restructuring in August 2012 because of lower-than-predicted census levels on the new units. As a result, a significant number of PCU nurses were involuntarily transferred to the medical floor, and the ICU nurses have been asked to consider transferring either to medical/surgical or to another hospital within our system. Nurses are questioning their own worth, and anxiety and stress are high. According to Watson, a Caritas relationship can be sustained by “honoring each person and her or his talents, gifts and contribution as essential to the whole”

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(Watson, 2008, p. 88). A personal letter will be sent to a number of nurses acknowledging their unique value as a nurse. Each letter will contain two pocket-sized stones with an inspirational word such as “love,” “caring,” “healing,” or “faith” engraved on it. The nurse will be asked to keep one stone and pass the other one on to a nurse she feels could use it. Nurses often do not take the time to acknowledge the excellent caring they witness in their work. By recognizing each other, staff members can build each other up from the inside, instilling faith and hope in one another. “Caring and love beget caring and love” (Watson, 2008, p. 87).

Project Outcomes 1.  The “Caritas Corner” in the newsletter has been well received by the nurses, as evidenced by colleagues’ positive comments. It will continue to be published monthly. 2.  The daily centering session is well attended. Adventist Midwest Health Public Relations did a story on our daily centering practice in the ICU, which was later published by Nursing Spectrum and the Lake Union Herald. 3.  Training for the 5K run is well under way, and nurses are already talking about training together for a triathlon next spring! 4.  Letters and pocket stones are set to go out in mid-September, 1 week before the ICU nurses’ deadline for voluntary transfer.

Project Evaluation The 5K run will take place on October 14. Following the race, nurses will be asked to complete a survey to provide feedback on their experience and to gauge interest in future endeavors. The survey will include a question on the impact of self-care on stress.

Future Directions Projects already under way include a ritual hand-washing initiative, yoga classes for nurses, and training for a sprint distance triathlon in the spring. Planning is under way to develop a care package to assist families experiencing the death of a loved one in the ICU.

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Acknowledgments Heartfelt thanks to Marlienne Goldin, Mary Beth Desmond, Linda Ryan, Marcie Calandra, Connie Blatner, Jenna Wagner, and Kris Veenbaas.

*    *    * BUILDING TRUSTING CARING RELATIONSHIPS: WALKING IN THE SHOES OF ANOTHER Deleta M. Moore

Introduction Kaiser Permanente, Northern California, has adopted Jean Watson’s Theory of Human Caring as their theoretical framework for nursing care (Watson, 2008). Dr. Watson’s theory is transforming hearts and awakening nurses across specialties to the importance of having caring relationships with each other, as well as with patients. The practitioner-to-practitioner relationship requires the same consciousness of “being present, caring and honoring the unique subjective world of the other, openly listening with intent to hear the other’s point of view, and communicating congruence and differences effectively” (Watson, 2008, p. 97). One way for nurses to achieve more heart-centered, transpersonal caring relationships is to spend some time walking in the shoes of another. Intentionality and authentic presence create openness and opportunity to share and understand each other’s feelings, fears, desires, differences, and commonalities (Watson, 2008).

Significance Learning to honor, respect, and appreciate the gifts and talents each practitioner contributes to a caring team is overshadowed by the focus on individual performances, egos, and the differences of their specialties. Often nurses feel that their work is more demanding than other specialties and not understood by their colleagues. Nurses working on different units or with different age groups often think they share little in common with their peers, and instead define themselves by their specialty. This “silo” effect causes missed opportunities to understand and connect with each other and to strengthen that one common attribute that all nurses share—the ability and passion to care. If nurses accept that their caring unites them, there will be less division between nurses across specialties and units. Having the opportunity to “walk in another’s shoes” often brings new awareness of shared connections.

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Purpose The purpose of this project is to help nurses diversified in their specialties to develop a deeper understanding and appreciation of their caring connections despite their different work settings by spending time on each other’s units. The project is designed to foster discovery that nurse colleagues do share a common goal/bond of purpose and to build a more cohesive caring team. This, in turn, creates healing work environments through the practice of the 10 Caritas Processes as a universal mode of being, instead of being divided by their work with different patient populations (Watson, 2008). Ultimately, valuing each nurse specialist’s diversity, and the creation of a caring working team, offer the best patient care by sharing collective wisdom and universal values of caring.

Setting and Participants The setting for this project is the clinical education practice and informatics (CEPI) department at the Kaiser Oakland Medical Center, which is composed of a team of 13 nurse specialists and educators. The team was introduced to the project at the department staff meeting. Participants were selected based upon their specialty and availability, with six volunteering to participate in the first group. To date, two clinical nurse specialists (CNSs) from NICU and ICU, two clinical nurse educators from medical/surgical and post–anesthesia care units (PACU), and two educators from NICU and ICU were paired. Each participant had a unique opportunity to experience the work environment of his or her peer and to bring a new ­awareness of what they share in common.

Project Description/Process After being introduced to the project, participants from the CEPI department who volunteered were paired with a colleague with similar credentials, but who worked with different patient populations to lessen confusion with role delineation and function. Two CNS participants who worked in NICU and ICU were paired, as were the two educators who work in Med–Surg and PACU, and two educators who work in NICU and ICU. Each participant spent a minimum of 6 hours in the peer’s unit, open to experiencing each other’s environment. Participants were encouraged to explore differences, but also to uncover their commonalities during their time together. Other CEPI department team members will be encouraged to schedule shared time together. The participants will meet together to discuss the experience, how their perception of each other’s work environment and responsibilities has changed, and what commonalities they each share as nurses.

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Project Outcomes The intended outcome is to build better trusting caring relationships among team members. It is anticipated that members will discover through this experience what they share in common as nurses instead of focusing on their differences. Based on the first group’s feedback, the experience increased their understanding of each other’s nursing, along with discovering that being in an unfamiliar work environment creates discomfort of fear and anxiety. One educator stated, “The OR may be different from my area and does make me a little nervous, but there are many things that are the same, such as the importance of effective communication, being flexible, and caring about our patients and their safety.” After the experience, participants report a better appreciation for the work of their colleagues that diminishes the focus on differences and increases the understanding of their ­commonalities of caring as nurses.

Project Evaluation A partial evaluation confirms that an awakening has occurred among members of the CEPI department. Authentic relationships have been strengthened by a growing understanding of what individuals share in common as opposed to their ­differences, which can divide and isolate a team from connecting and understanding each other. It is projected that as the whole team is able to have the opportunity to “walk in another’s shoes,” a new awareness of shared connections will increase team cohesiveness.

Future Directions After all members of the CEPI department have completed the experiential sharing, it is hoped that this project will extend to the nursing units so that nurses will have an opportunity to spend time with a peer on a different shift to decrease the perception that caring on different shifts is different.

Acknowledgments I would like to thank and acknowledge Dr. Lynne Wagner, as my faculty mentor and dear friend. Also, a special thanks to the CEPI department for their participation, especially the following nurses: Jacqueline Werner, Lenese Ross, Dorothy Hutchinson, Stephen Ingerson, Kathleen Gray, Linda Linehan, and my director, Mark Beck.

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*    *    *

Mindfulness Perspective If you look at [someone] with the eyes of a meditator, you will see in him or her all generations of their ancestors. You will be very ­respectful to them and to your own body because you will see their body and your body as the sacred home of all our ancestors … You will also see that our bodies are the source of all future generations. (Nhat Hanh, 2002b, p. 15) This mindfulness perspective relates to Watson’s call to be authentically present and to honor self and others. In deeply recognizing that each person consists of all who have come before, and that they in turn form the foundation of present and future generations, it becomes possible to comprehend the tremendous i­ mportance of fully and authentically honoring each life as an integral part of the cosmic whole.

Contemplative Art Activity to Deepen Learning •  Envision colors, patterns, and images that evoke authentic presence, faith,

hope, and/or honoring self and others in your mind’s eye. •  Create a pointillism image or a mandala, or take a photograph that

expresses what you have envisioned.

References Nhat Hanh, T. (2002). No death, no fear: Comforting wisdom for life. New York, NY: Riverhead Books. Watson, J. (2008). Nursing: The philosophy and science of caring (Rev. ed.). B ­ oulder, CO: University Press of Colorado.

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Chapter 7 The Third Caritas Process: Be Sensitive to Self and Others by Nurturing Individual Beliefs and Practices

7.  The Third Caritas Process

Be Sensitive to Self and Others by Nurturing Individual Beliefs and Practices This factor/process is a lifelong journey and a big order for professional practice. Here I teach what I continually need to learn. This journey is a process of evolving and honoring one’s own inner needs, listening to the still, small voice inside, connecting with our deepest source for awakening into our being and becoming … without attending to and cultivating one’s own spiritual growth, insight, mindfulness, and spiritual dimension of life, it is very difficult to be sensitive to self and other. Without this lifelong process and journey, we can become hardened and brittle and can close down our compassion and caring for self and other. (Watson, 2008, p. 67) This Caritas Process makes clear that professionally mature caring–healing comportment is dependent upon personal cultivation of deep knowing and doing. Adopting consistent spiritual practices helps to move us beyond the worldly dimension into subtle sources of inner wisdom and truth. “We have thoughts; we have feelings; we have a body; but we are more than our thoughts, our feelings, and our body. We are embodied spirit. Or, as Teilhard de Chardin reminded us, we are spiritual beings having an earthly experience” (Watson, 2008, p. 69). Spiritual practice can mean a number of things depending on the individual. The key, regardless of the type of spiritual practice, is cultivation of mindful, loving, deep, patient, compassionate curiosity in relation to self, others, and everything else. Engaging in curiosity rather than drawing immediate conclusions opens possibilities and cultivates understandings and increased levels of compassion that would not have been possible otherwise. Here is an example of how cultivating curiosity might unfold: A coworker tells you that she dislikes the unit manager. You say little and walk away. You happen to truly like and respect the unit manager and initially feel anger and defensiveness, but you let that go and decide to cultivate curiosity. Over the next few weeks, you quietly observe (with unfettered curiosity) interactions between the unit manager and coworker who made the negative remarks. You find that the coworker bites her lip nervously and fidgets whenever she talks to the unit manager. The coworker also comments repeatedly that she is afraid that she will make a mistake and the unit manager will be harsh because she is so much more experienced than the coworker. You make a conscious effort to mentor and support the coworker. You draw her into nonthreatening conversations with the unit manager so that she can become more familiar with the unit manager as a person. After a few weeks, the coworker seems more at ease and mentions that she is beginning to like the unit manager after all. Cultivating curiosity provides calm,

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clear openings to ­positive possibilities in challenging situations. Consistent, mindful, compassion-based spiritual practice supports the cultivation of curiosity and is the foundation for caring, compassion, and genuine connection.

The Third Caritas in Action: Caritas Coach Education Program Project Abstracts

     

* * * HEALING HANDS, CARING HEARTS Tamara A. King

Introduction Winter Haven Hospital is a caring–healing hospital. Evidence of Jean Watson’s caring science can be felt throughout the organization. From patient care to the business meetings, the standards of Jean’s caring theory bring meaning into every moment shared with patient and employee alike. The “Healing Hands, Caring Hearts” project involves the creation of an “energetic Caritas field” through a simple act of caring for the hands of those who care for others, touching their hearts through a meaningful life-giving and life-receiving, caring–healing process. As each caring moment is experienced, the hope is that the Caritas field would continue to grow, causing more positive energy to flow into our surroundings; opening up greater possibilities of mystery and miracles to occur.

Significance Education, encouragement, and personal enlightenment are all beneficial in cultivating a caring consciousness. But to truly impact a person’s understanding of the human phenomenon associated with caring, one must experience a “caring moment” for one’s self. It is when “caring” touches us on a personal level that we then give it value. As Caritas coaches, how can we better nurture the art of caring in our organization than to honor all those who care for others by caring for the caregivers? All employees give through their hands and their hearts. My hope is that they would receive in the same way, through their hands and their hearts.

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Purpose The purpose of this project is to heighten heartfelt Caritas thinking throughout the organization with the understanding that we create the healing environment for our patients. We make a difference by just being who we are. We are the environment.

Setting and Participants To be able to reach out to all areas of our organization, it is my intention to visit both direct and nondirect patient care areas. It is my sincere belief that Winter Haven Hospital as a whole is a haven of healing. I believe that every person employed at our hospital has the potential to impact another person’s life in a positive way. My hope is to share this caring experience with not only the main campus of Winter Haven Hospital and our business campus, Gil Jones, but also include our mother/baby hospital, Regency, and our outpatient behavioral health (CBH) center, as well.

Project Description/Process The project involves creating an energetic field of Caritas through a simple practice of caring for another that is “biogenically” meaningful—life giving and life receiving. As part of the preparation for this practice, I set my intentionality and consciousness for caring and healing by taking a quiet moment to center, be still within myself and let go of that which I cannot control, to gain an inner state of balance that allows feelings to flow freely. I am mindful of Kornfield’s expression of loving kindness: “Loving kindness gives birth to a natural compassion. The compassionate heart holds the pain and sorrow of our life and of all beings with mercy and tenderness. It is the tender heart that has the power to transform the world” (Kornfield, 2002, p. 102). I have contacted the department manager ahead of time so that a dedicated space will have been already decided; a quiet room with a door that can close, an electrical outlet to plug in a candle warmer for aroma therapy/dim lighting and a place to plug in a CD player to subtly play soft music, pillows for comfort, and two chairs. The plan is to meet with each employee in this dedicated space and offer them a few minutes of quiet time to relax and unwind during their busy day, offering hand massages to those who would like them, reading the field, being open and sensitive to what is taking place, and meeting the needs of those who share this moment with me by drawing upon all possible ways of knowing. As a visual representation of our connection, a blanket covers my lap and the lap of the person I am caring for. At the end of each caring session,

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a simple card containing one single question will be given to each employee. The question is minuscule yet monumental: “With your heart and your hands, who will you care for next?”

Project Outcomes The projected outcome is that each “caring moment” be healing or beneficial in some way to the giver and the receiver. Through this gift of caring, I will make a difference in the moment that affects the universal field that surrounds us, realizing that if one person benefits, then we all benefit. The continued flow of positive energy throughout the organization expands our caring consciousness and transcends conventional outcomes.

Project Evaluation I will take note of all expressed comments/responses, favorable or otherwise; keeping in confidence the names of those who share their thoughts and feelings. Once leaving an area that I have visited, I will ask the department manager to assist with gathering feedback from their staff.

Future Directions This project is grand in design but despite the huge undertaking, I take on the challenge with an earnest heart … happy to go wherever it leads me. I am certain that my labor of love will result in a greater field of universal love and only good can come from that.

Acknowledgments First and foremost, thank you, Jean Watson, for caring enough to share with all of humanity that love heals. I would also like to thank: Lance Anastasio; I am so very proud to work for a chief executive officer who truly understands and honors the value of caring. Mary Jo Schreiber, for your deep unwavering faith in our organization and in every nurse employed at Winter Haven Hospital. Your confidence in me has been career changing. Kaye Hixon, your ever-steady encouragement and constant support ground me. Your grace never ceases to amaze me.

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* * * DEVELOPMENT OF NURSING STUDENTS’ CARING THROUGH ­REFLECTIVE PRACTICE Sheryl Jacobson

Introduction Ask beginning nursing students why they chose the nursing profession and many will state “because I want to help people, I want to care for them.” Ask advanced students what they are doing in nursing school and they will talk about the ­technical skills, the exams, the clinical simulations. Often nursing education focuses on the perfection of skills and tasks, the “doing” rather than the “being.” Yet it is apparent in numerous studies that what patients (and students) want is a competent nurse who also cares. Frequently students value technical skills more than the development of human caring behaviors, undervaluing the importance of the intentional use of self to promote health and healing. In part, this is because nurse educators do not give voice to caring science and multiple ways of ­knowing how to care for self and others. As more and more evidence accumulates to ­support the need for human caring in our health care systems alongside our technical skills, nurse educators have a responsibility to honor this way of being and help facilitate nursing students’ growth into caring practice.

Significance In her Theory of Human Caring, Dr. Jean Watson speaks to the importance of ­honoring multiple ways of knowing—scientific, aesthetic, ethical, intuitive, ­personal, cultural, and spiritual (Watson, 2008). Likewise, Carper (1978) has identified four fundamental patterns of knowing—empirics, aesthetics, personal knowledge, and ethics. Nursing education tends to emphasize empirical knowing, with less attention given to other ways of gaining knowledge and wisdom. The use of reflection is one methodology to help students develop personal, aesthetic, and ethical knowing. According to Herbst, Swengros, and Kinney (2010), “Teaching human caring involves cognitive and psychomotor prompts that elicit an affective response. Transformation can occur because all three learning domains are then engaged. It is the personal, internal learning prompted by the cognitive, and psychomotor knowledge that leads to affective growth and transformation” (p. E7). By developing the practice of reflection using a variety of teaching pedagogies, students can

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learn the conceptual underpinnings of caring science. In this way, students can incorporate multiple ways of knowing into their professional practice.

Purpose The purpose of this project was to engage nursing students in the development of reflective practice in order to recognize multiple ways of knowing, to learn core concepts of the Theory of Human Caring, and to develop an intentional consciousness of caring behaviors that will direct their nursing practice.

Setting and Participants This project involved 25 undergraduate baccalaureate degree-seeking nursing students in their senior year at a small university in western Wisconsin.

Project Description/Process This project involved a multifaceted approach to developing an understanding of Human Caring Theory among a group of nursing students. A variety of teaching methodologies was implemented to help students use reflective practice to gain personal, aesthetic, ethical, and empirical knowledge. Methodologies included: •  Development of a video presentation, based on a patient’s lived hospital

experience, depicting caring versus noncaring behaviors. Students were asked to engage in group discussion about the behaviors they observed. Following the classroom experience, students were asked to reflect back on a personal or professional experience they have had with caring and with noncaring behaviors. They were asked to write about the experience, or to submit an artistic expression (picture, poem, song) describing what the experience meant to them, how they were affected by it, and how they will use it in their nursing practice. •  Incorporation of a measurement tool for nursing students to self-assess their caring behaviors during a clinical experience at a homeless shelter. The tool is then used as a guide during postconference. •  Identification and documentation of caring interventions into an electronic medical record, following a simulated home-care visit. •  Revision of a journal assignment asking students to consider how the environment affects healing and the influence the nurse has on that environment.

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Project Outcome It is hypothesized that, after students have participated in this project, they will better recognize the power of caring behaviors to promote healing and well-being and will be able to continue to practice such behaviors.

Project Evaluation Qualitative evaluation conducted thus far indicates students identify the importance of being present, authentic caring relationships and attending to basic human needs as critical areas of caring consciousness.

Future Directions To date, the video presentation has been incorporated as a teaching methodology. Other methodologies will be implemented in a serial manner.

Acknowledgments I offer my heartfelt gratitude to Silvana Richardson, my dean and colleague, for encouraging me to begin my Caritas work and then sharing the journey with me; to Anne Foss-Durant, my Caritas faculty mentor for offering her wisdom and guidance in understanding and developing my Caritas being; and to Viterbo University for giving me generous gifts of time and financial support in order to accomplish my dream of becoming a Caritas nurse. To Dr. Jean Watson, I honor you for the giving of your life work, and yourself, to the development of the Theory of Human Caring.

     

* * *

Mindfulness Perspective In this Caritas, Watson emphasizes sensitivity to self and others, with the understanding that in order to be sensitive to others, one must first extend compassion and sensitivity to self. Nhat Hanh echoes this thought: “Self-understanding and self-love provide the foundation for understanding and loving another person. This is the first step: going home to ourselves, taking care of ourselves, understanding ourselves, accepting ourselves, and being compassionate to ourselves”

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(2007, p. 117). Since we are unavoidably connected to others, self-love and compassion will naturally flow to others.

Contemplative Art Activity to Deepen Learning •  Envision colors, patterns, and images that express self-love. •  Create a pointillism image or a mandala, or take a photograph that

expresses what you have envisioned.

References Carper, B. (1978). Fundamental patterns of knowing in nursing. Advances in Nursing Science, 1(1), 13–23. Herbst, A. M., Swengros, D. I., & Kinney, G. (2010). How to teach human caring: Nurse educator role in transformational learning for a large healthcare system. Journal for Nurses in Staff Development, 26(4), E6–E11. Kornfield, J. (2002) The art of forgiveness, loving, kindness, and peace. New York, NY: Bantam. Nhat Hanh, T. (2007). The art of power. New York, NY: HarperCollins. Watson, J. (2008). Nursing: The philosophy and science of caring (Rev. ed.). Boulder, CO: University Press of Colorado.

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Chapter 8 The Fourth Caritas Process: Develop Helping–Trusting– Caring Relationships

8.  The Fourth Caritas Process

Develop Helping–Trusting–Caring Relationships Helping–trusting–caring relationships are central to Caritas consciousness and require authenticity and genuineness of human connection. “Authentic caring relationship building is concerned with deepening our humanity; it is about processes of being-becoming more humane, compassionate, aware, and awake to our own and others’ human dilemma. It is about human presence, authentic listening and hearing, being present for another in the moment” (Watson, 2008, p. 72). Genuine presence and simple attentiveness to self and other in the moment facilitate trust and allow for helping and healing to take place. Each of our thoughts and choices carries spirit energy into our lives and those of others. Our intentions, presence, and level of awareness make a continuous difference in our lives and the lives of everyone around us. Calmness, mindfulness, caring, and love beget ­calmness, mindfulness, caring, and love. Acting out of love and compassion begets healing for self and others simultaneously and on multiple levels (Watson, 2005). Caring in this way is marked by being grounded in the present moment, and diminished perceived separation between the person caring and the person being cared for, shifting the focus from “you and me” to “we and us.” Here is one example of how everyday practice of this Caritas might look; ­several years ago, I did a small research study about effective nursing ­interventions I had observed an occupational health nurse doing at a local hospital. This nurse assessed the workstations of hospital employees to see if improvements could be made to avoid medical conditions related to poorly designed workstations. This nurse had an unusually high success rate related to compliance and decreased pain and injury and I wanted to see what she did when she interacted with ­clients. I wondered if caring behaviors had something to do with her success. I suspected I might see a warm, friendly, conversational approach because, at this time in my career, I equated caring with this type of behavior and believed that if it did not exist, then true caring could not occur. I was wrong. Results of this study showed that, in this case, clients expressed that they felt cared for and inclined toward following prescribed interventions because the nurse paid focused and ­in-the-moment attention to them through mirroring, eye contact, and verbal validation of the presenting concern(s). The average time required for these caring exchanges was 24 minutes. The results were notable in that this nurse did not ever touch the client directly, nor did she engage in any conversational banter during any of the observed interventions. She did not display personal warmth or a high level of friendliness. The primary features of every observed exchange were mindfulness, immediacy, and a palpable sense of being wholly attentive and firmly present for each client in that moment (Sitzman, 2001). There was a strong sense of “I am here for you, right now, in this moment, and I will do my best as we work through this together.” I learned something very valuable after completing that study and it has guided and informed my subsequent professional life: ­caring, love, and trust are best sustained through intention, presence, ­ attentiveness,

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immediacy, and mindfulness. Friendliness, warmth, and maternal affection may be components of transpersonal caring moments, but they are not necessities. This point can be particularly helpful to remember when working with people who do not respond well to warmth, affection, or friendliness.

The Fourth Caritas in Action: Caritas Coach Education Program Project Abstracts

     

* * * CARITAS SUMMITS INSPIRE HIGHER CONSCIOUSNESS IN PRACTICE ON A MEDICAL TELEMETRY UNIT Vivian Norman

Introduction Jean Watson’s Theory of Human Caring was adopted at St. Joseph Hospital, Orange, California, in 2005 and shortly thereafter the hospital made a strategic goal of Sacred Encounters. The staff was educated at the time throughout the hospital to this loving–caring vision; however, nurses no longer remembered fully the tenets of the Watson theory or pondered distinctions between transpersonal caring moments and Sacred Encounters. The Caritas coach educators at St. Joseph ­Hospital sojourned with the staff using a teaching–learning process guided by Watson’s Caritas Processes, which had two parts: Caritas educational sessions on a weekly basis, and Caritas summits. This project reports on the Caritas summits.

Significance Caritas coaching is a very different model than conventional teaching–learning approaches whereby one with authority and knowledge imparts information and content to another—often with limited comprehension of the context, meaning, and relationship with respect to the other’s inner strivings, hopes, deep longings, and needs (Watson, 2008, p. 127). An intensive immersion program was offered to give the nurses the experience of living and feeling Caritas to assist in the integration of Jean Watson’s theory into nursing practice and into St. Joseph’s nursing practice language.

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Setting and Participants St. Joseph Hospital is a 525-bed community hospital located in Orange County, California, which achieved Magnet status in 2006. Participants in this project are the members of the medical telemetry unit staff, consisting of 1 manager, 4 clinical coordinators, 41 registered nurses (RNs), and 38 unlicensed assistive personnel (telemetry techs, nursing assistants, unit secretaries).

Project Description/Process The initial education on the medical telemetry unit included 10 luncheon s­ essions, one Caritas Process per week with interactive exercises. The weekly ­Caritas ­sessions are described in Kim Rossillo’s (Cohort 4) project abstract. F ­ ollowing these weekly sessions, three 4-hour Caritas summits were held. Agenda for the summits included: 1.  Reflection, centering exercise 2.  PowerPoint presentation on the Theory of Human Caring, with photographs taken at St. Joseph Hospital by the Clinical Practice Council, alignment of the St. Joseph Hospital core values with the Theory of Human Caring 3.  10 stations, with exercises for each Caritas Process 4.  Closing, circle, reflection, and a Whoosh! The exercises for the 10 Caritas Processes enhanced the previous ones that the staff participated in during the weekly sessions. The intention for the exercises for the summit was integration and called for creative emergence and higher level of consciousness in practice: 1. Take pictures of staff—heart hands and think of sayings to put onto the pictures for posting over the sinks, as a centering reminder, and write positive affirmations for fellow staff members 2. Finger labyrinths, while listing to meditative CD 3. Create a work of art with collaborative involvement 4. Sharing of a transpersonal caring moment 5. Read a script based on a clinical narrative from a telemetry staff RN 6. Blindfolded and silent, participants are to arrange themselves in order of assigned numbers 7. Teaching/learning with participants taking turns in leading and following in dance 8. Group determination of three most important things for patients, families, and staff and make an action plan to implement on the unit 9. Seeing life from your patient’s perspective: simulate low vision, poststroke, elderly patient to do basic tasks 10. Write a description of a miracle from the selected picture

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As a gift for participation, each participant received a bag with positive affirmations and a painted worry stone, a bag of popcorn, bookmark of the Caritas, and handout.

Project Outcomes The project led to a Caritas Coach Teaching–Learning Model for renewal of loving-caring nursing practice with a higher consciousness outcome. Greater ­ ease in use and understanding of Jean Watson’s Theory of Human Caring on the ­medical telemetry unit was reported with a plan to implement intensive education-­summit/integration in all of the rest of the departments.

Project Evaluation As required for any course offering contact hours, participants completed a course evaluation, which was overwhelmingly positive. In addition, they were asked to complete the Caring Nurse–Patient Interaction Scale (CNPI-23) for nurses, to assess how competent or at ease they felt about the caring attitudes and behaviors. (Used with permission of Sylvie Cossette.) This administration of the CNPI-23 is given as a program evaluation at the completion of the Caritas education. Our plan is to repeat the CNPI-23 in 3 to 4 months, following institutional review board approval, to assess the nurses’ actual application and implementation of the caring attitudes and behaviors.

Future Directions Intensive education–integration, unit by unit, throughout St. Joseph Hospital, making the educational experiences in each unit unique to meet that unit’s needs. For instance, examples will need to be focused on specific patient–nurse interactions for diverse areas such as labor and delivery and the emergency department.

Acknowledgments I wish to acknowledge my partner in the Caritas coach journey, Kim Rossillo, RN, BSN, manager of the medical telemetry unit, for her generosity of spirit and l­ oving kindness. Special appreciation for my Caritas coach, Lois Kelley, faculty a­ ssociate

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of the Watson Caring Science Institute, and all of the other faculty at WCSI. I wish to thank Katie S ­ kelton, vice president of Patient Care Services, and Patti Aube, executive director of Education and Nursing Research, for their vision, encouragement, and support (including funding) to enable us to be part of the Caritas coach program. And most of all, I want to acknowledge and offer a heartfelt thank you to Jean Watson, for having the idea that Caritas matters and that we can change the world, one nurse at a time.

     

* * * INTEGRATION OF CARING BEHAVIORS ON AN EDUCATIONAL TEAM Marilee Ford

Introduction At many hospitals in the country, a constantly changing work environment ­creates ongoing stress for the clinical education team. According to Kaiser Permanente’s Mind Body Medicine Health Education Program, one of the “4 Cs of Stress ­Hardiness” is Caring/Connection (Kaiser, 2001). Enhancing caring and ­connection among members of a clinical education team can support stress hardiness. But caring for others must follow caring for self. As stated by Dr. Jean Watson, “­Teaching-learning in the practice of Caritas results in self-knowledge, self-care, self-­control, and even self-healing possibilities” (Watson, 2008, p. 126). One of the ways in which caring for the self can be awakened is through the use of mindfulness and creative processes, which expand our awareness of self and create caring connection to group members (Sitzman, 2002).

Significance Clinical educators are a unique group of professionals working in the hospital environment. While they usually do not provide direct patient care, they are in a position to influence caring behaviors on the part of both direct and indirect patient caregivers. Clinical educators have the opportunity to create transformational learning experiences that can reconnect nurses and caregivers with their passion for caring. However, if the clinical education team is continually stressed, the energy needed to create transformational learning events is necessarily limited. Creating stress hardiness through providing opportunities for caring and connection can pave the way for more creative, transformational educational programs that will benefit the educator team, staff, and patients.

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Purpose The purpose of this project is: 1.  To facilitate an experiential encounter with the 10 Caritas Processes through the use of nonjudgmental creative work and mindfulness practices. 2.  To support development of caring and connection to increase stress hardiness. 3.  To increase educator’s comfort levels with the abstract, more transformational qualities of caring science in a safe environment. 4.  To evaluate the effectiveness of this type of education for creating caring and connection through the use of the Peer Group Caring Interaction Scale described below.

Setting and Participants The setting of this project is Kaiser Permanente Santa Rosa, with the anticipated five participants drawn from members of the clinical education, practice, and informatics team.

Project Description/Process This project consists of offering four classes to a group of clinical educators. The 1-hour sessions will incorporate mindfulness practices, and each session will explore a different aspect of the 10 Caritas Processes using creative process, which may include, but not be limited to, collage, poetry, music, and other art media. The c­ reative processes will focus on building caring and connection among group m ­ embers. The use of transformation as an educational tool will be introduced to support ­educators in being more comfortable with incorporating the abstract qualities of caring s­ cience in their own educational practice (Herbst, Sengros, & Kinney, 2010).

Project Outcomes The desired outcome is for class members to express a shift in their sense of caring and connection with one another, as evidenced by their scores on the Peer Group Caring Interaction Scale described in the following. But even more ­important

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would be the creation of a safe environment in which clinical educators can explore their personal struggles with caring science principles as a prelude to authentic incorporation of these principles in future educational efforts.

Project Evaluation Increased caring behaviors among participants will be evaluated using the Peer Group Caring Interaction Scale. This scale is based upon a peer group rating instrument originally designed for nursing students (Watson, 2009), revised with the permission of the author, Dr. Linda Hughes, in August 2012. In addition, anecdotal evaluations will be conducted through feedback at the end of each session.

Future Directions Educators can become increasingly comfortable with integrating caring science principles in their educational efforts because they have an understanding of Caritas “from the inside out.” Their practice can be increasingly satisfying because they incorporate regular self-care practices and mindfulness in their educational activities.

Acknowledgments The author wishes to acknowledge the ongoing support of Marialena Murphy, m ­ entor extraordinaire; Gwen Kinney for needed reality checks; Anita Catlin for research advice and support; Sandra Stewart for support at Kaiser Santa Rosa; and Rob H ­ endricksen for putting up with many weekends lost in the world of caring science.

     

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Mindfulness Perspective Thich Nhat Hanh echoes Watson’s call to mindfully and carefully attend to one’s own thoughts and actions in each moment as a way of extending compassion to self, other, world, and beyond. He also affirms the transformative power of this practice: When we live in the present moment and walk, breathe, and take care of ourselves [and others] our mindfulness increases each day. ­Mindfulness means we know what’s going on … In this ­present moment I care that

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my thinking … reflects understanding and c­ ompassion. This kind of ­thinking can nourish and transform me, bringing joy and happiness to me and people around me. In this very moment, I care that my speech … ­ communicates ­understanding and compassion … that can restore communication and offer ­confidence and reconciliation. At this very moment, I care about my physical action. My Physical action should be able to translate my ­understanding and compassion … I want to invest one ­hundred percent of myself into the present moment. (Nhat Hanh, 2007, pp. 131–132)

Contemplative Art Activity to Deepen Learning •  Envision colors, patterns, and images that evoke loving–trusting–caring

relationships. •  Create a pointillism image or a mandala, or take a photograph that expresses what you have envisioned.

References Herbst, A., Sengros, D., & Kinney, G. (2010). How to teach human caring: Nurse educator role in transformation learning for a large healthcare system. ­Journal for Nurses in Staff Development, 26(4), E6–E11. Kaiser Permanente. Regional Health Education. (2001, revised 2003). Mind body medicine: An integrated approach to health and healing. Nhat Hanh, T. (2007). The art of power. New York, NY: HarperCollins. Sitzman, K. L. (2001). Effective ergonomic teaching for positive client outcomes. AAOHN Journal, 49(7), 329–335. Sitzman, K. L. (2002). Interbeing and mindfulness: A bridge to understanding Jean Watson’s theory of human caring. Nursing Education Perspective, 23(3), 118–123. Watson, J. (2005). Caring science as sacred science. Philadelphia, PA: F. A. Davis. Watson, J. (2008). Nursing: The philosophy and science of caring (Rev. ed.). Boulder, Colorado, CO: University Press of Colorado. Watson, J. (2009). Assessing and measuring caring in nursing and health sciences. New York, NY: Springer Publishing Company.

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Chapter 9 The Fifth Caritas Process: Promote and Accept Positive and Negative Feelings as You Authentically Listen to Another’s Story

9.  The Fifth Caritas Process

Promote and Accept Positive and Negative Feelings as You Authentically Listen to Another’s Story There is no right or wrong to feelings; they just are. It is how we accept, honor, and respond to our feelings that makes the difference in our emotional and cognitive life world. Once we are able to honor our feelings, to give ourselves permission to feel, we are made more aware of the feelings … Eventually we understand that feelings are universal, that there is no such thing as a good or a bad feeling. Everyone has feelings. That realization alone may free the person, allowing for equanimity, forgiveness, and gentleness toward self. Feelings come and go, but we realize that we are not our feelings. Then one is free to respond to the situation more clearly, more appropriately, even with a sense of loving kindness and compassion. Thus, the expression of feelings is a healing act in itself. The process of being with another in a nonjudgmental way as that individual expresses his or her feelings generates a mutual trust and understanding. This process serves as a core foundation that sustains the authenticity of a caring relationship and affirms the shared humanity of both individuals in that moment. (Watson, 2008, pp. 103–104) Nurses share some of life’s most pivotal, transformative moments with ­others. These moments stir the need for expression of a wide range of feelings and emotions among patients and their families, among nurses and patients, and among nurses and coworkers. Although it can be deeply challenging to witness, feel, and participate in negative expressions, Watson asks us to mindfully flow in the moment and grasp the simple realization that feelings are universal and ­impermanent. This one realization has the power to diffuse negativity and redefine it as a productive process that can create movement toward u ­ nderstanding, resolution, and deep appreciation for life experience. We are not our feelings, and others, whether they are patients, families, coworkers, or administrators, are not their feelings either. Expression of feelings is most beneficial and therapeutic if viewed in this light. Sometimes it can be challenging to keep this in perspective as it is easy to get attached to emotions as if they are something substantial, unchanging, and enduring. Over the years, I have personally used and taught this simple visualization as a reminder of the impermanent nature of feelings: Close your eyes and envision the blue sky. Your calm, unperturbed core essence is the blue sky. Breathe in the fresh, cool sparkling air in the clear blue sky that is the true “you.” Now envision a few puffy white clouds drifting by in the sky of

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your mind. Reach out to grasp a cloud. Its cool mist floats between your fingers and your hand comes up empty. Clouds represent the many feelings that pass by your blue core essence. Clouds look solid and substantial, but if you reach out to hold onto a cloud, it is impossible to grasp it. It is the same with feelings. They continually go by in the calm blue sky of your mind, impermanent, always moving, changing, dissipating, and reforming. Acknowledge the flow of clouds. Feel the cool dampness as they roll by. Appreciate each cloud for what can be learned from its passing without trying to fruitlessly hang on to any one cloud. Whether it is negative or positive, none are permanent or graspable. This approach allows for freedom to experience emotions, to grow and learn from them, without the stress of ­trying to hang on to or keep something that was never meant to be permanent. Using this visualization for self and in relation to others helps to keep the expression of ­positive and negative feelings within perspective.

The Fifth Caritas in Action: Caritas Coach Education Program Project Abstracts

     

* * * TRANSFORMING OUR PRACTICE: CARING PRESENCE AND ­COMPUTERIZED DOCUMENTATION Mary Mullany

Introduction The introduction of computerized clinical documentation in the psychiatric ­service at Metrowest Medical Center has been received by nurses as both a “blessing” and a “curse.” As integration of technology into clinical practice continues to evolve, it is important to understand how this has influenced nursing practice from the nurses’ lived experience. Understanding the challenges and opportunities of computerized clinical documentation through the nurses’ eyes sets the stage for the professional nurses, with leadership support, to begin steps to transform the environment and provide the authentic caring presence that is the essence of nursing practice.

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Significance With the enhanced focus on computerized documentation, nurses are describing a change in their practice from a patient-centered model of caring to one that has shifted to a more task-oriented model of care, with focus on computer documentation. Nurses describe spending more time with the computer than with their patients, missing the human contact and face-to-face connection. The use of computerized documentation does not allow the patient’s story to unfold; the story becomes a checklist, missing the meaning behind the words. Having an authentic caring presence cannot be lost due to the computerized documentation system. Sustaining a caring healing environment is imperative for both patients and staff in the psychiatric milieu. This project will focus on improving the staff’s capacity to integrate the core concepts of caring science while completing computerized documentation (Watson, 2008).

Purpose The purpose of this project is to conduct a qualitative survey to better understand the experiences of the nurses and their perception of patient care as they work toward integration of technology in the psychiatric milieu. The goal of the project is to reestablish the core value of psychiatric nursing: interpersonal relationships.

Setting and Participants The setting for this project is within the psychiatric service in a community hospital. A representative sample of nurses from the three inpatient units (child, adult, and geriatric) will be interviewed. The sample includes male and female nurses, with varying years of experience in nursing and educational backgrounds. Using a questionnaire, each nurse will be asked to share his or her experience and ­perception of clinical computerized documentation and the impact on the way he or she practices. The questions are: 1.  Describe how the introduction of computerized documentation has influenced practice. 2.  Has computerized documentation influenced positively or negatively authentic caring presence with your patients? Describe. 3.  What changes would you suggest to support a caring–healing environment?

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Project Description/Process This project lays the foundation for facilitating change within each psychiatric unit to better integrate technology with human caring that is the essence of nursing practice. The interviews will serve several purposes: to understand the experience of the nurses and to engage them in transforming their practice ensuring the integration of caring science. The information from the nurses will also provide valuable information for nursing leadership, identifying creative, innovative ideas for seamless integration of computer technology into the patient care environment. This project will provide a venue for nurses, the primary stakeholders, with an opportunity and a voice in defining their own professional practice.

Project Outcomes The data from the surveys will be shared with all staff and nursing leadership within the psychiatric service with the intention of using it as a means to understand the practice changes needed to integrate caring science and the use of computers to ensure patient-centered care as a core value in psychiatric patient care experience (Watson, 2008). Caritas Processes for computer documentation were built into the original platform but are currently not utilized as intended (Watson, 2008). Nurses report they mindlessly click boxes without an authentic caring intention as the design intended. The information gathered from this project is meant to serve to guide the next steps to increase Caritas literacy (Watson, 2008).

Project Evaluation The themes from the staff nurse interviews will be prioritized by staff, educators, and nursing leadership in late September. Each unit will be asked to identify one practice change to implement. A successful practice will be replicated on a larger scale throughout the department. Postimplementation staff nurse interviews will be conducted in 6 months to determine whether the changes implemented had a positive effect.

Future Directions This project will create an environment where bedside nurses have input into their professional practice, providing a venue that is grounded in caring science as the moral–ethical foundation for all practice decisions. With leadership support and

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the creativity and innovation of staff nurses, we will reshape the milieu into a caring–healing environment for patients and nurses. We will establish a “culture of caring” within a professional practice (Watson, 2008).

Acknowledgments I want to thank the dedicated group of caring nurses in the behavioral medicine department at Metrowest Medical Center. Their struggles with the integration of computerized documentation are reflective of their desire to be an authentic caring presence with patients and each other. Their energy and desire to find new ways of maintain a caring presence are impressive. Esther Kearn-Frolich, thank you for your patience, wisdom, and guidance on this Caritas journey.

     

* * * THE 7 WEST BEAR HUG BLOG: A REFLECTIVE CARITAS TOOL FOR ­PEDIATRIC ONCOLOGY NURSES Ashley Weber

Introduction As with any modern day unit I have seen signs of burnout among my peers. I care about these incredible people and feel compelled to do something to celebrate and honor the incredible work they do and reflect on their experiences within the framework of Jean Watson’s Caritas Processes (Watson, 2008).

Significance Nurses are “searching for the way to care in a society that refuses to value c­ aring, and a way to serve without being subservient” (Watson, 1999, p. 35). There is a phenomenon labeled by Muff (1988, as cited in Watson, 1999) as ­“Nightengalism” in which nurses are undervaluing themselves and overvaluing others. When nurses fall into this destructive vortex, we see vast numbers of nurses who become burned out and suffer from compassion fatigue (Potter et al., 2010). According to the Clinical Journal of Oncology Nursing (2010): “Cancer care providers tend to empathize with patients’ losses, resulting in a personal sense of futility or failure in their care” (p. 35). However, Perry (2008) learned that exemplary oncology nurses were able to avoid compassion fatigue by creating moments of connection and making those moments matter (Potter et al., 2010).

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This project is offered as a way to support the nurses and the special moments they create as they take care of this incredibly delicate patient population and honor and celebrate their unique and equally delicate humanity.

Purpose The intention of this project is to use a blog as a place to celebrate successes and unpack the hardships that are experienced as a pediatric oncology nurse using the Caritas Processes and Jean Watson’s caring theory as a frame of reference and a source of inspiration for the staff nurses (Watson, 2008).

Setting and Participants The participants will be the nursing staff of the Center for Cancer and Blood Disorders inpatient unit, approximately 100 nurses. This is a project that can be accessed from home or work, through the Internet. A printed copy will also be made available in a notebook that will be kept on the 7-West Inpatient Unit, the Center for Cancer and Blood Disorders.

Project Description/Process The blog will highlight personal stories from the staff, framing them in Watson’s Caritas Processes (Watson, 2008). The blog will be updated on a monthly basis. Staff will be invited and encouraged to leave comments on each post and submit their own entries in visual, musical, or written format.

Project Outcomes It is projected that the blog will provide an avenue for nurses to tell their positive and negative stories in reflective practice as a method to celebrate their successes. The blog will be a place in which they can celebrate their accomplishments as well as understand and unpack their experiences within the Caritas Processes.

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Project Evaluation The number of readers will be evaluated on a monthly basis with the goal of increasing readership by 2% at the end of 6 months. Contributions to the blog by staff members will also be tracked.

Future Directions It is my hope that as nurses become more familiar with the blog, they will become more inspired and begin to post their own thoughts and feelings so it becomes more interactive.

Acknowledgments I would like to acknowledge my husband who is an Aurora police officer and is my true hero; my incredible children who are my endless source of inspiration to make this world a better place; and my incredible mom who has taught me to be the compassionate person I am today. I would also like to acknowledge Children’s Hospital Colorado, the Caritas Committee, Jammie Reichel, Kelly Johnson, and Terri Woodward for their support and encouragement along my journey to become a Caritas coach.

     

* * *

Mindfulness Perspective As in Watson’s Caritas practices, Nhat Hanh’s mindfulness tradition acknowledges interconnectivity of past, present, self, and other. The two also stress selfunderstanding and compassion in facilitating healing, resolution, and positive change. In specifically addressing the expression of negative feelings, Thich Nhat Hanh has this to say: Anger is rooted in … lack of understanding … and of causes, deepseated as well as immediate, that brought about the unpleasant state of affairs. Anger is rooted in desire, pride, agitation, and suspicion. The primary roots of anger are [internal]. Our environment and other

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­ eople are only secondary … we should [try to see that anger has a p combination of deep-seated and immediate reasons]. For instance, someone who speaks badly to us may have been spoken to in exactly the same way just the day before, or by his alcoholic father when he was a child … what is most important is that we first take care of the seeds of negativity in ourselves. Then if someone needs to be helped … we will do so out of compassion. (Nhat Hanh, 1991, pp. 63–64)

Contemplative Art Activity to Deepen Learning •  Envision how you might use colors, patterns, and images to tell a story

about an instance when you listened to another person’s expressions of either positive or negative feelings. •  Create a pointillism image or a mandala, or take a photograph that expresses what you have envisioned.

References Muff, J. (1988). Of images and ideals: A look at socialization and sexism in ­nursing. In A. H. Jones (Ed.), Images of nursing: Perspectives from history, art and l­ iterature. Philadelphia, PA: University of Pennsylvania Press. Nhat Hanh, T. (1991). Peace is every step: The path of mindfulness in everyday life. New York: Bantam Books. Perry, B. (2008). Why exemplary oncology nurses seem to avoid compassion fatigue. Canadian Oncology Nursing Journal, 18(2), 87–99. Potter, P., Deshields, T., Divanbeigi, J., Berger, J., Cipriano, D., Norris, L., & Olsen, S. (2010). Compassion fatigue and burnout: Prevalence among oncology nurses. Clinical Journal of Oncology Nursing, 14(5), 56–62. Watson, J. (1999). Postmodern nursing and beyond. Edinburgh, Scotland: Churchill ­Livingstone/Harcourt-Brace. Watson, J. (2008). Nursing: The philosophy and science of caring (Rev. ed.). ­Boulder, CO: University Press of Colorado.

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Chapter 10 The Sixth Caritas Process: Use Creative Scientific Problem-Solving Methods for Caring Decision Making

10.  The Sixth Caritas Process

Use Creative Scientific Problem-Solving Methods for Caring Decision Making For effective and enduring exploration and problem solving to occur, it is important to … focus on gaining insight into, attending to, knowing, experiencing, judging: using all ways of knowing … Each form of evidence may yield different forms of knowledge pertaining to certain situations and objects of analysis; inner or outer phenomena … it is important to remind ourselves … that “evidence” takes many forms and that there is a difference between data and information, knowledge, understanding, and wisdom. (Watson, 2008, pp. 111–112) To deeply understand any phenomenon requires observation from many vantage points and then synthesis of all forms of evidence into a cohesive, holistic picture of the event of interest. Only then is it possible to derive and promote lasting, effective treatment and support. Vantage points for gathering knowledge include counting the number of a certain occurrence through direct observation, talking about it with others who have observed it, and asking someone to describe her or his own direct experience of it. Nurses routinely engage in these forms of inquiry and knowledge development at the bedside, in nursing school, and in formal research situations; all are integral in promoting deep understanding and informed caring. The “Caritas in Action” examples contained in each chapter of this book represent examples of nurses who have engaged in creative scientific problem-solving methods for caring decision making, creating Caritas-driven projects to address specific needs and concerns.

     

* * *

The Sixth Caritas in Action: Caritas Coach Education Program Project Abstracts THE CARITAS PROCESS: DAILY HUDDLE TO DECREASE FALLS AND ONE-TO-ONE OBSERVATION IN CRITICAL CARE Danilo C. Bolima

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Introduction Patient safety has risen to the forefront of health care and patient falls have become a major public health concern. Furthermore, patient falls are the most common adverse event reported in acute care facilities (Halm & Quigley, 2011). Despite numerous efforts, current literature indicates that hospital falls and injurious falls have not identified consistent evidence for effective preventive interventions (Halm & Quigley, 2011). Particularly, constant observations in acute care have not been found to be effective and there is no evidence to support the contention that one-to-one observation can prevent the incidence of falls in an acute care setting (Salamon & Lennon, 2003). The use of one-to-one observations initially offered an easy alternative to the use of restraints, but was found to be an inefficient use of health care personnel and poses an enormous financial strain to health care organizations (Salamon & Lennon, 2003).

Significance The incidence of falls and the use of one-to-one observation continue to increase despite multiple efforts. Using the Caritas Processes (e.g., Caritas Process #6; Creative Use of Self and All Ways of Knowing as Part of the Caring Process; Engage in the Artistry of Caritas Nursing), hospital administrators and staff must think creatively to solve problems related to patient safety such as reducing falls and at the same time appropriately use hospital resources such as constant observation (Watson, 2008). By allowing the expression of positive and negative feelings (Caritas Process #5: Being Present to, and Supportive of, the Expression of Positive and Negative Feelings) during the safety huddle, this author strongly believes that it is possible to create a caring environment while maintaining safety and reducing cost without negatively affecting patient ­outcomes ­(Watson, 2008).

Purpose The purpose of this project is to determine the impact of the Caritas Processes in decreasing the incidence of falls while decreasing the use of one-to-one patient observation in a critical care setting, through the use of daily safety huddle ­(Cooper, 2004).

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Setting and Participants The setting of this project is Hackensack UMC Mountainside, a 365-bed c­ ommunity hospital located in Glen Ridge, New Jersey. This project started on June 1, 2012, in the critical care setting (MICU, SICU, and step-down telemetry) where this author is currently the nurse manager of the department.

Project Process A morning huddle attended by the clinical coordinators, registered nurses (RNs), care partners, and unit secretaries will be conducted at the beginning of the shift to discuss issues related to safety such as risk for falls, restraints, one-to-one constant observation, pressure ulcers, prevention of infections bundle (VAPS, CLABSI, CAUTI), and so on. A huddle will be conducted before the initiation of a oneto-one observation to determine its appropriate use and a daily huddle will be conducted thereafter to determine if one-to-one observation is still clinically indicated. In the case of a fall, a postfall huddle will be conducted to determine appropriate intervention and to provide necessary adjustment with recommendations to prevent another occurrence of fall.

Project Outcomes The incidence of falls in critical care is expected to drop and the use of ­one-to-one observation will decrease. Another expected outcome of this project is that it will foster teamwork and enhance engagement among staff with regard to patient safety. It is expected that with constant awareness on safety, staff will escalate issues, concerns, and problems that may arise without hesitation.

Project Evaluation Patient safety will continue to be front and center on the list of hospital priorities. Analysis shows that the fall rates within the critical care departments continue to decline compared to the prior month before the start of the project. The number of patient watch/constant observation related to confusion, altered mental status, and risk for fall continue to decline. The only appropriate reasons for a one-to-one constant ­observation are when patients are at risk for elopement, harming others or self ­(suicide).

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Future Directions This project is at its beginning stage. However, with continued awareness and engagement of staff to creatively seek solutions through the caring process, the incidence of falls and the inappropriate use of constant observation are expected to decline. The safety huddle will serve as the forum to express ideas and suggestions to improve the care while enhancing patient safety. This author will continue to monitor the outcomes of this project. This project will undergo transformation and change as it progresses. This author will continue to elicit suggestions and recommendations from staff to improve the current process. Another safety indicator that is of interest to the author is to determine whether the safety huddle actually decreases the incidence of infection b ­ undles in the ICU.

Acknowledgments I wish to acknowledge Bonnie Michaels, our VP/CNO, for her unwavering support, and the nurses and staff at Hackensack UMC Mountainside for their ­vigilance in ensuring patient safety in order to create a healing environment for our patients and their families.

     

* * * End-of-Life Caritas Caregiver Certificate Pilot Tarron Estes

Introduction Why increase end-of-life caring literacy and validate the roles of nonmedical caregivers?

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End-of-Life Caring Literacy Caregivers encompass uncountable numbers of an often poorly educated ­workforce who take care of our loved ones when we cannot. These caregivers live in our communities. They become a part of our homes and families. Increasing caring literacy for these nonmedical caring professionals is a way to give back. It provides a career path that not only stabilizes caregivers in the fundamental science and stages of dying, but it may increase spiritual awareness, loving kindness to self and other, and overall sense of well-being as well. Increasing end-of-life literacy may positively influence the patient’s experience of care, decreasing pain and suffering in our communities. It may expand our understanding of “do no harm.” In our time of deepest vulnerability, frailty, and dependence, caring literacy protects all of us.

Significance Validating Roles of Caregivers: By validating the work of nonmedical caring ­professionals as end-of-life Caritas caregivers, we confirm the worth and value of caregivers who dive into the turbulent, complex waters surrounding the stages of life, illness, and death for all of us. When we bring human caring sciences to our home caregivers—the foreign laborers, single mothers, family members, volunteers who keep vigil at the bedside of those who are dying, those who midwife us to the other side—we invest in our own good death and we give legitimacy, an honored role to nonmedical caring professionals. We validate and honor one of the oldest caring professions on earth.

Let’s Talk About It Conversational Confidence: Death is an un-discussable—one of our culture’s top taboos. This end-of-life caring literacy program invites us to explore our hopes and fears about dying in advance of the onset of death. Exploring our relationship to death may increase self-knowledge. It may break down barriers between ourselves and others when we most need comfort, communion, trust, and safety. When we explore our feelings and thoughts about death, we learn more about our lives now. We come in direct contact with our spiritual beliefs, our life’s purpose, our unfinished business, what our bodies need or want, how we influence and are influenced by our environment and our relationships. We build a

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f­ oundation of confidence upon which we may then talk about life and death with others. By becoming confident in our ability to talk about death, we may have more influence on how we live and how we die. We might reduce harsh, costly interventions that threaten what we value most. We may reduce emotional and financial stress of our families, health care systems, and nation. We might place our awareness and attention on our loved ones or on our spiritual life versus living at any cost. We may be more available to life’s blessings, mysteries, miracles, and unexplainable events.

Purpose The purpose of the project is to educate caregivers in end-of-life care, self-care, reflection, and heart-centered healing practices in the form of 3-day trainings that increase caring literacy, enhance life, and validate their challenging roles as ­nonmedical caring professionals. Through these educational events, we may direct caregiver awareness toward the sacred transformative portal surrounding death and improve quality of life for caregivers and clients along the way.

Setting and Participants The End-of-Life Caritas Caregiver Certificate takes place within pilot study groups such as senior communities, home care agencies, and hospices. Trainings will be conducted on-site or off-site as appropriate to a percentage of the caregivers participating in the program in the pilot community. Participants will be chosen as potential program coaches and will be the core group of the pilot study. They will be chosen based on high functioning innate caring skills, leadership qualities, patient load, and/or promising characteristics for future coach/trainers.

Project Description/Process My affiliation with Jean Watson and the board of WCSI led to the acceptance of the proposal to conduct the pilot study using (to-be-determined pilot community), ElderSpa Innovations’ end-of-life education and WCSI’s Caritas Coaching Processes to create the End-of-Life Caritas Caregiver Certificate for nonmedical caregivers. Our team and network will include Tarron Estes, Jim D’Alfonso, and Terri Woodward of WCSI, staff and administration staff of appointed pilot group. The study in its entirety will last over a period of 9 months. It will include an initial visioning and caregiver engagement process, a training manual, and could

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develop a quality improvement baseline for pilot’s clients, allowing community to formally introduce new caring services and caring behaviors derived from the pilot study outcomes, concluding in initiatives called “Best of Life Care.”

Project Outcomes 1.  Utilize 10 Caritas healing factors for developing loving care and presence for self and others 2.  Learn to use Vision Mapping for end of life to: •  Become aware of one’s own physical, emotional, and spiritual needs as a caregiver •  Gain conversational skill and confidence •  Promote and accept all client/family feelings surrounding end of life 3.  Utilize Jean Watson’ Caritas meditation CD to stabilize in heart-centered healing presence 4.  Utilize Peter Fenner’s “Pure Listening” practice to establish neutral “open” awareness 5.  Utilize ElderSpa Innovations’ multimedia DVDs, “Why Prepare for Death” and “Introduction to Staff Training” to sensitize emotional/ energetic healing field and healing environment 6.  Learn and actualize ElderSpa’s 10 end-of-life principles •  Reduce fear, pain, and suffering •  Offer emotional and spiritual support •  Provide safe forums for clients, caregivers, and families to talk about the dying process •  Reduce burnout and emotional fatigue of caregivers of the dying •  Demystify stages of dying •  Acknowledge mysteries and unexplained events surrounding death •  Learn how to be with intense emotions of clients and families •  Hold others’ religious and spiritual beliefs without them affecting your own •  Be a conduit for a “conscious death” •  Practice bedside vigils so no one dies alone

Project Evaluation The certificate training may include pre- and post-surveys for caregiver and client satisfaction to ensure quality improvement using the Caring Factor Scale, Scoring the Caring Assessment, and ElderSpa Innovations’ employee interest/skill/satisfaction survey. The results of this survey were available in May 2011.

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Future Directions Using the End-of-Life Caritas Caregiver Certificate Pilot with the Veterans Administration may lead to future work.

     

* * *

Mindfulness Perspective Nhat Hanh’s teachings about learning from the past and taking care of the future directly apply to problem solving, scientific observation, research, and evidencebased practice in nursing and health care. Again, he proposes awareness of interconnectivity and mindfulness to facilitate deep observation, learning, and problem solving; Mindfulness means to establish yourself in the present moment. But that does not mean you don't have the right to scrutinize and learn from the past or plan for the future. If you are really grounded in the present moment and the future becomes the object of your mindfulness, you can look deeply at the future to see what you can do in the present moment for such a future to become possible. We say that the best way of taking care of the future is to take care of the present, because the future is made of the present … When we bring past events to the present moment and make them the object of our mindfulness, it teaches us a lot … With the practice of mindfulness, we have new eyes, and we can learn many things from the past. (Nhat Hanh, 2002, p. 60)

Contemplative Art Activity to Deepen Learning •  Envision colors, patterns, and images that evoke creative problem

solving. •  Create a pointillism image or a mandala, or take a photograph that

expresses what you have envisioned.

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References Cooper, R. L. (2004). Huddle up: Creating and sustaining a culture of service excellence. USA: Xlibris Corporation. Halm, M. A., & Quigley, P. A. (2011). Reducing falls and fall-related injuries in acutely and critically ill patients. American Journal of Critical Care, 20(6), 480–484. doi:10.4037/ajcc2011606 Nhat Hanh, T. (2002). Be free where you are. Berkeley, CA: Parallax Press. Salamon, L., & Lennon, M. (2003). Decreasing companion usage without negatively affecting patient outcomes: A performance improvement project. MEDSURG Nursing, 12(4), 230–237. Watson, J. (2008). Nursing: The philosophy and science of caring (Rev. ed.). B ­ oulder, CO: University Press of Colorado.

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Chapter 11 The Seventh Caritas Process: Share Teaching and Learning That Addresses Individual Needs and Comprehension Styles

11.  The Seventh Caritas Process

Share Teaching and Learning That Addresses Individual Needs and Comprehension Styles Learning is more than receiving information, facts, or data. It involves a meaningful, trusting relationship that is intersubjective … there is an honoring of the whole person. The content as well as [readiness to receive] information are critical variables. The meaning the ­content has for the person—intellectually, symbolically, and culturally as well as literally—affects his or her ability to receive and process the ­information. The process of genuine teaching becomes ­transpersonal, in that the experience, the relationship, and the meaning and ­significance of the experience affect both parties within the teaching encounter. Thus, the relationship lives on beyond the context of the teaching, informing the life and behavior and actions that flow from the experience. (Watson, 2008, pp. 125–126) Teaching is much more than presenting relevant content and urging the learner to wisely apply the information to whatever situation he or she is in. Even if the learner clearly and urgently needs to learn and apply vitally important ­information, he or she may or may not do so due to other factors besides need. I am reminded of an ­experience I had many years ago as a newly graduated nurse on the ­rehabilitation unit of a large urban hospital. I had been assigned to do headto-toe assessments on two quadriplegic patients, roommates, who had been in the hospital many times before. Both struggled with constipation, and this was why they were both hospitalized. As I leaned over the bed of one, checking skin condition, I heard the familiar voice and footsteps of the hospital nutritionist. The patient in the other bed heard it too, and loudly exclaimed, “Hey, here comes the nutritionist. Watch out. She’s on her high-fiber-high-horse again! I had a bran muffin on my breakfast tray this morning even though I specifically asked for white toast. I will not eat sawdust!” The roommate loudly affirmed agreement. Shortly thereafter, the ­nutritionist entered with dietary education materials that included high-fiber information and announced she was there to provide them both with some dietary tips that might help to avoid future hospitalizations. The roommates both turned toward their television sets and pretended she wasn’t there. This experience c­ larified for me the importance of context, individual needs and learning styles, and sensitivity to learner interest and readiness. If learners are not interested in the content as it is initially organized, then asking what the learner is interested in, and then rearranging the content or taking a different approach, are often helpful. Sensitivity to intellectual, symbolic, and cultural meanings related to content and health concerns is key.

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The Seventh Caritas In Action: Caritas Coach Education ­Program Project Abstracts

     

* * * ENGAGING FACULTY IN CRITICAL CARING DIALOGUE Nancy Vitali

Introduction Tulsa Community College (TCC) Nursing Program is undergoing a curriculum change. This change is incorporating the recommendations of several sources: National League for Nursing, Institute of Medicine, Quality and Safety Education for Nurses, the Technology Informatics Guiding Education Reform Initiative, the Oklahoma Board of Nursing, a growing cadre of doctorally prepared nursing faculty, and this faculty member, who brings a perspective of Dr. Jean Watson’s Theory of Human Caring and Caring Science from her studies at the University of Colorado and the Watson Caring Science Institute.

Significance Recent statistics tracking has revealed that the eight-semester completion rate for students in the TCC Nursing Program is less than 60%, which has generated concern, confusion, and a host of other responses among the program faculty and administration (Gerow, 2011). A survey of all the undergraduate students, using the Organizational Climate for Caring Questionnaire (OCCQ) (Hughes, 1993, in Watson, 2009) tool, has revealed that many nursing students do not perceive the ­presence of a caring environment in the program. Faculty have expressed frustration that efforts aimed at retention, such as the work of the Learning Enhancement Committee, established in 2000, and several Faculty Innovation Grant-funded projects, have not been effective in improving student success rates. This in turn has decreased faculty morale. A faculty member’s doctoral dissertation study found that students who failed even one clinical course felt devalued, felt traumatized, and experienced severe disruptions of self-concept (Gerow, 2011). It is now clear that faculty need time to collaboratively explore and discover new approaches to curriculum.

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Purpose The purpose of the project includes: (1) to engage faculty and ­stakeholders in critical caring dialogue regarding nursing, the education ­process, caring, pedagogy, and/or any topic the group feels is pertinent, lifegiving, or essential to the development of a new curriculum that would infuse a healing–learning teaching environment, and (2) to encourage faculty members’ and students’ development, expression of voice, and personal growth, which will in turn have a positive (caring) impact on the culture of the TCC Nursing Program and student success.

Setting and Participants The project took place at bimonthly faculty meetings during the spring semester of 2012, and will continue over time. These meetings were held on two campuses of a five-campus community college with particular attention to creating a warm, welcoming aesthetic and comfortable setting of artwork, seating, and food. There have been 25 participants to date, including 23 faculty and 2 other stakeholders.

Project Description/Process Participants were invited 2 weeks prior to each meeting via an e-mail flyer. A ­follow-up flyer asking participants to bring a personal narrative related to their nursing practice was sent a week later. The project process has been guided by activities suggested by Hills and Watson (2011), by this writer’s experience as a team-building facilitator and a licensed HeartMath® ­instructor, and by ­Watson Caring Science Institute (WCSI) in collaboration with my WCSI faculty-mentor. Dr. Gerow’s dissertation (2011) advocated narrative pedagogy as a means for connecting with and promoting healing in RNs who had failed a clinical nursing course during their nursing education. This project consists of convening a faculty discussion group with the goals of (1) centering via HeartMath Quick Coherence®, (2) engaging in narrative pedagogy, and (3) a “critical caring dialogue” (Hills & Watson, 2011) with faculty and stakeholders in developing the new nursing curriculum. Participants shared stories from their lives as nurses or other key experiences and engaged in deep listening. Through these exchanges, faculty will begin to dialogue about how to bring narrative into the learning environment. Hills and Watson (2011) encourage the evolution from the Tylerian (Behavioral) Model of Education toward a “Caring–Human Science Curriculum.” Our transpersonal, emotional, heart-centered presence will propel our program toward a culture of Caritas, coherence, and communitas.

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Project Outcome It is hypothesized that faculty sharing stories and practicing authentic empathic listening in an aesthetically pleasing, emotionally safe environment will cause a shift in awareness in which they will (1) honor their own subjective experiences and extend that learning opportunity in creative ways to their students, and (2) initiate a shift in the culture of the program to a more caring, empowering one that promotes increased student and faculty satisfaction and collaborative ­teaching–learning, as reflected in the OCCQ (Hughes, 1993) scores.

Project Evaluation The OCCQ will be repeated in approximately 1 year. Since it may be impossible to determine which interventions impact climate, a brief survey will be distributed to collect faculty feedback on the efficacy of the group. After the second meeting, a faculty member left a phone message stating, Thank you for facilitating such a wonderful workshop today… I hope it was rewarding for you because it was rewarding for us, and we appreciate your time and effort … you brought so many good things to the table for the support of faculty. Synchronicity of events focused on caring is also an evaluation point: Dr. Gerow’s dissertation presentation and announcing the forming of this group, and support of a new acting associate dean are harmonious occurrences.

Future Directions This discussion group will continue to meet every 2 to 3 weeks throughout the planning of the new curriculum, or beyond if that is the desire of the group.

Acknowledgments I would like to extend my heartfelt gratitude to Lynne Wagner, my WCSI Caritas mentor; to Lisa Gerow, my longtime teaching partner and devotee of Caritas; to Tulsa Community College Foundation for funding the Faculty Innovation Grant

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program of which this project is a part; to Linda Hughes, who generously granted permission to use her tool, the OCCQ; to Amy Whitehouse, whose ­beautiful ­painting is part of the project; and to Dr. Jean Watson, whose spirit and work have been an inspiration and motivation for myself and thousands of other nurses around the world.

     

* * * “HEAD OVER HEELS” MIDDLE SCHOOL–AFTERSCHOOL PROGRAM WITH NATURE AND ART: PATHWAYS TO CONSCIOUSNESS AND GROWTH GROUNDED IN CARING SCIENCE Debby Flickinger

Introduction The “Head Over Heels” project is the creation of a wholistic afterschool p ­ rogram for middle-school–age children. The program is grounded in caring science ­(Watson, 2008) and will consist of both didactic and experiential learning to reignite a new appreciation for the world we live in, our mother earth, and nature that surrounds us every day. The core concepts of caring science will provide the foundation for the curriculum development creating a loving learning environment where each child will experience loving kindness for self and others ­(Watson,  2008).

Significance Our children are our promise for a bright future for generations to come. Humankind is living in a toxic environment with little respect for self, nature, and each other. Research has provided evidence that afterschool programs strengthen schools, families, and communities. When families become more involved with schools, the students in those schools do better both academically and in personal development. The creation of afterschool programs has spurred such changes in communities across the country. Currently there is a lack of wholistic afterschool programs offered at community public schools. I have been profoundly moved by my intensive study of the Human Caring Theory and it is my belief that through introducing the core concepts of caring science with a wholistic approach to learning, the children will be touched in a new way, which may have a lifelong impact (Watson, 2008).

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Setting and Participants The afterschool “Head Over Heels” Program will be piloted at a community ­public middle school. The “Head Over Heads” Program will be a 6-week program ­conducted for 2 hours every Wednesday. On a voluntary basis, 10 children from ages 10 to 14, grades 6 to 8, from the middle school will be selected to participate. The plan is to meet initially with one community-based public middle school principal and school student counselor, requesting permission to conduct a “pilot” of the “Head Over Heels” Program. It will be conducted with the children who are already attending an afterschool program. Upon completion of the 6-week program, each child will receive a “Head Over Heels” Certificate of Completion during a small special acknowledgment of successful completion ceremony. In addition to requesting permission, it is intended to also ask for a student volunteer who will help facilitate the next “Head Over Heels” Program.

Project Description The “Head Over Heels” is a 6-week program, 2 hours every week. This afterschool curriculum will incorporate spiritual, eco therapy, and principles for children. It will consist of experiential “caring” activities for children, such as guided imagery, appreciation of nature through art and nature walks, caring for mother earth, activities to appreciate classical music, activities to practice gratitude, and forgiveness, as well as learning to journal as a daily practice. Each week a new concept in caring science is introduced through a fun, interactive experiential activity, using a wholistic approach with appreciation for mother earth and nature.

Project Outcomes The intent of this program is, through the 6-week process, to improve each child’s understanding of the importance of respecting nature and caring for themselves. As they experience new ways to appreciate self, others, nature, and mother earth, they too will be changed by adopting “caring” attitudes and living with respect for self, others, and mother earth.

Project Evaluation The plan was to conduct preimplementation interviews of a minimum of five children from ages 10 to 13, to survey their opinions of valuable curriculum content.

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Interviews were completed with elite participants and children through phone and in-person visits. The children ranged from 7 to 13 years of age and were located in the Contra Costa County area. Pre- and post-program surveys are being created for the 10 participants as a program evaluation tool.

Future Directions Once this “Head Over Heels” Program is successful, the intent is to meet with different Northern California school districts to move this project forward as an established afterschool program. Because this afterschool program is a unique combination of wholistic and caring science experiential activities for children, the children will have a profound experience, one which will touch each young life in a way they will acquire a lifelong practice of loving kindness of self, others, caring for humanity, and our mother earth. Antibullying programs are being implemented in schools across the country to help deal with the escalating problem of children tormenting and ostracizing other children through the act of bullying. Not only are the children who are on the receiving end experiencing lifelong psychological affects, the child or children who bully other children are also experiencing an extreme amount of emotional and psychological pain. The bullies DO NOT feel good about themselves and what they do! A viable future direction for the “Head Over Heels” afterschool program is to integrate it with these antibullying programs. The experiential wholistic activities of loving kindness, gratitude, forgiveness, and appreciation of self, others, and mother earth will have a lasting impact on these young hearts. Through teaching the core concepts of caring science with a wholistic approach in the a­ fterschool programs, these children will be touched in life-changing, life-giving ways.

     

* * *

Mindfulness Perspective In relation to teaching and learning, Nhat Hanh provides the imagery of a field with many kinds of seeds sown in it to represent the mind. Teaching encounters provide opportunities for more seeds to be sown, in our own minds and in the minds of those we teach. Mindfully watering (encouraging, supporting, and informing) seeds of compassion, health, mindfulness, and love will nurture self and others. Our mind is a field in which every kind of seed is sown—seeds of compassion, joy, and hope, seeds of sorrow, fear, difficulties. Every day our thoughts, words, and deeds plant new seeds in the field of our consciousness, and what these seeds generate becomes the ­substance of our life.

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There are both wholesome and unwholesome seeds in our mind-field, sown by ourselves and our parents, schooling, ancestors, and ­society. The practice of mindfulness helps us identify all the seeds in our ­consciousness and with that knowledge we can choose to water only the ones that are most beneficial. (Nhat Hanh, 2006, p. 25)

Contemplative Art Activity to Deepen Learning •  Envision colors, patterns, and images that evoke meaningful teaching/

learning moments. •  Create a pointillism image or a mandala, or take a photograph that

expresses what you have envisioned.

References Gerow, L. (2011). The experience of nursing student failure and success: A phenomenological inquiry (Doctoral dissertation). University of Kansas School of ­Nursing: Kansas City, KS. Hills, M., & Watson, J. (2011). Creating a caring science curriculum: An emancipatory pedagogy for nursing. New York, NY: Springer Publishing Company. Hughes, L. (1993). Peer Group Caring Interaction Scale and Organizational Climate for Caring Questionnaire (pp. 149–161). In J. Watson (2009), Assessing and measuring caring in nursing and health sciences (2nd ed.). New York, NY: Springer Publishing Company. Nhat Hanh, T. (2006). Understanding our mind. Berkely, CA: Parallax Press. Watson, J. (2008). Nursing: The philosophy and science of caring (Rev. ed.). Boulder, CO: University Press of Colorado. Watson, J. (2009). Assessing and measuring caring in nursing and health sciences (2nd ed.). New York, NY: Springer Publishing Company.

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Chapter 12 The Eighth Caritas Process: Create a Healing Environment for the Physical and Spiritual Self That Respects Human Dignity

12.  The Eighth Caritas Process

Create a Healing Environment for the Physical and Spiritual Self That Respects Human Dignity Healing environments exist externally and internally, personally and collectively. Environments that promote healing and dignity tend to consist of elements that include, for example, cleanliness, safety, traditional healing modalities, alternative healing modalities, collaboration/cooperation, beauty, kindness, orderliness, privacy, honesty, and holism. Overall, true caring and healing evolve from considering each thought, word, and action sacred, with an understanding of the interconnectedness of all. Feelings of being above certain people/actions/situations dissolve when viewed in light of Watson’s transpersonal caring. Nursing from premodern times onward has been associated with … bedmaking, and all the positive and negative connotations associated with those words … one may look at a bed and see it as an object, and bedmaking as a technical procedure, usually one relegated to an assistant … another way for nursing to consider the bed, whether the nurse deals with bedmaking or not, is to view bedmaking as a ­metaphor for any nursing art or caring act. Consider the “Zen of ­Bedmaking.” By this I mean that “bed” stands as a vehicle for an expanded consciousness of all; the bed and all its meanings contain the absolute universe … Rather than seeing the bed as tangential or trivial, one may look at bed and see it as a sacred space. (Watson, 1999, pp. 237–238) Every act, every interpersonal interaction no matter how small or trivial, represents opportunities to promote dignified healing/caring environments. This applies to interactions with patients and their significant others, coworkers, supervisors, and others. Here is an example of how this Caritas might unfold; I worked for many years in a home health care agency that focused on care of indigent and low socioeconomic status clients. I visited many people who had pets for desperately needed love and companionship; however, they struggled to purchase pet food during the period of time that they received home-care services due to the fact that they were unable to work or go out to collect discarded food to feed to their pets. When I visited these clients, I would make a point of bringing a small bag of pet food to last until my next visit and quietly leaving it behind when I left. I did not want clients to feel like they had to thank me or acknowledge this as I wanted to support dignity in the situation. I was usually able to obtain donations from local businesses for this purpose. Upon my return, I would discreetly look at the pet food bowl to see if there were remnants of the food I had previously brought to ensure that I was on the right track. In this small way, I would try to help clients

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with pets, who were struggling financially, to maintain a healing, dignified, loving environment. After many years of doing this, I ran into one of my old clients at a grocery store. I hardly recognized her. She was smiling, healthy, well-dressed, and had a cart full of groceries. This is what she said: “During the time you took care of me, the only spiritual, physical, and emotional connection I had in the world was my cat. I wanted to heal only so that I could take care of my cat. I was so grateful for the cat food you brought each week. It allowed me to have enough to eat. Before you came, I bought cat food first and used whatever money I had left to feed myself. Sometimes it wasn’t much and I would have to go hungry. I couldn’t say thank you then because I was too embarrassed, but I am saying it now. My life is good now and I am okay. Can I buy a couple of bags of pet food for you to give to someone else?” I accepted her offer. There was dignity in quietly giving/ accepting food for a cherished pet during a time of need, and there was dignity in paying it forward years later.

The Eighth Caritas in Action: Caritas Coach Education Program Project Abstracts

     

* * * CREATION OF A SELF-CARE SANCTUARY Wanda Davis

Introduction In October 2011, the Veterans Administration (VA) formally embraced Watson’s Theory of Human Caring (Watson, 2008). Today the VA is a Watson Caring Science Institute (WCSI) affiliate. Nebraska/Western Iowa senior leadership has invited nursing to bring a consciousness and a remembrance of why they became nurses to help align beliefs and behaviors with the caring science framework (Watson, 2008). Strong organizational support has enhanced efforts to promote healing and caring for staff.

Significance The daily demands that challenge VA caregivers may contribute to staff burnout and call-ins. A quiet, reflective space where staff can practice self-care, and where they can stop, pause, and reflect in the midst of their stressful tour of duty will

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help them deliver focused, present, and compassionate care to our veterans and their families, care that is based in the principles of caring science.

Purpose The purpose of this project is to create a self-care sanctuary for centering and healing for VA nursing and all multidisciplinary staff. This sanctuary and healing space is designed to enable staff to renew their energy and caring intentions, and to continue to provide a healing environment for the veterans.

Setting and Participants This ongoing project is being conducted on a 42-bed rehabilitation, skilled care, respite care, and hospice unit at the VA Medical Center in Grand Island, Nebraska. All personnel on this campus are invited to utilize the self-care sanctuary. The Community Living Center, where the sanctuary will be located, has nursing staff who cover all three shifts, management personnel, and ancillary staff, all of whom will benefit.

Project Description The project is embraced by administration and funding is available. A master plan has been developed and the project will be implemented as soon as the room is available. The goal is to make the environment comfortable and inviting for all health care providers who want to practice self-care rituals. The plan is to tie the self-care sanctuary closely to a sister facility in Omaha. The Omaha VA self-care sanctuary was developed by their Caritas coach last year. The Grand Island facility will be sharing the name and will be using the same paint/color schemes and decorating ideas. The nurse practitioner on the team developing the self-care sanctuary is eager to use aromatherapy in the sanctuary. There are also plans for a recliner with massage options, music, end table and/or coffee table, a bookcase, rug, and other items to help make the room warm and inviting.

Projected Outcome The self-care sanctuary will be completed quickly once the physical room is available. All hospital staff will have access to the room. The first projected outcome is that the staff will discover the potential and actual benefits of caring for self. The

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secondary outcome is that staff who utilize the room and practice self-care will be better able to provide compassionate care to veterans and their families and will better honor their dignity to promote healing. Promoting and applying the caring values in practice is not only essential to the nurses’ own health, but is also fundamental for finding meaning in their intentional caring work and providing caring leadership within the health care culture (Watson, 2008).

Projected Evaluation A survey/questionnaire will be given to those who utilize the sanctuary. The ­survey results will be evaluated to help determine whether the sanctuary was physically calming and how the space created changes in staff healing presence for the veterans and their families.

Future Directions The self-care sanctuary will be presented as an example of “Caring for Self to Care for Veterans.” Having a space to re-center will allow staff to return to the veterans more focused, present, and compassionate in caring for our veterans.

Acknowledgments I would like to extend a heartfelt and personal thank you to: Lisa Cantrell, MSN, BSN, community living center nurse manager, for her assistance at every level of moving the project forward. Peggy Gound, DNP, APRN, BC-Nursing Research, for her support, guidance, and funding. Elizabeth Yearwood, program specialist, Extended Care and Rehabilitation, for support and funds. Linda Ryan, PhD, RN, coordinator of the Introduction to Human Caring Program, and my mentor. The staff of the CLC for their willingness to accept and support the project.

     

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THE USE OF A MEDITATION ROOM TO DECREASE THE STRESS OF THE EMERGENCY ROOM NURSE Candace M. Leonard

Introduction AtlantiCare adopted Jean Watson’s Theory of Human Caring, and we are always striving to provide optimum wellness for all whom we touch (Watson, 2008). I felt our emergency room (ER) nurses could improve the health and well-being of our patient by improving their own mind, body, and spirit by providing a sacred space, a meditation room for our nurses to re-group, renew, and replenish themselves. If we take care of ourselves, as Jean Watson teaches us in self-care, we will be able to create the healing environment necessary to promote wellness in our patient community. A sacred space for the nurses will help the nurse to BE the healer our patients so need for their own minds, bodies, and spirits (Watson, 2005).

Significance Jean Watson’s theory teaches the nurse to BE the healing environment, to provide loving kindness, to be present (Watson, 1999). In order to be the healer, we must be healed. We need to take care of ourselves so we can provide our patients with a healing environment. Patients are the center of everything at AtlantiCare.

Purpose The purpose of this project is to provide a meditation room where the ER staff can go and heal their inner soul, breathe in new life, meditate for 5 or 10 minutes, and enjoy the benefits. Our study will be to determine whether meditation will be effective in reducing stress of the ER team and increase patient satisfaction.

Setting and Participants The setting is a stretcher storage room in our city emergency room. The participants are our staff in the ER, doctors, nurses, techs, secretary, registrars, EVS, pharmacists, security, manager, and educators. We enjoy it so much we want to invite everyone!

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Project Description/Process We were provided with a stretcher storage room and made it what our ER nurses now call the Zen Den. (We took a vote for name.) It is a peaceful retreat with recliners (from our AtlantiCare attic), soft music, beautiful quotes (Happiness dwells in the Soul), flickering candles, and sweet scents. As soon as you open the door you can feel the peace and tranquility. Our facilities department painted it a soft color of brown. Our room is just steps away from our busy ER, but it takes you to a quiet place of inner healing and peacefulness. There is a heart dish, which holds Jean Watson Caritas cards. Nurses enjoy reading the Caritas meanings. We have a journal where people have written positive experiences in the room. We also have laminated index cards beautifully decorated by our secretary and registrar which say “take 5” or “take 10.” When we see that a coworker is a bit stressed, we can hand them a card, tell them we will take care of their patients, and send them for some inner healing. We have had positive feedback from this already! We held a beautiful dedication for our room where staff, administration, family, and friends all came and shared with us. Our retired chaplain, John, returned to say a few prayers with us and bless our room, truly a beautiful scene!

Project Outcome We have had nothing but positive results and positive feedback about our healing space. Some of the nurses and doctors use it every work day, some during shift and some after work for 10 or 15 minutes. It is our hope that all our staff will take the time for their inner self to renew and refresh their minds, bodies, and spirits. Our projected outcome is staff will feel honored to have their own healing space where they will leave with the positive energy to be authentically present for their patients, increasing patient satisfaction and allowing healing to begin.

Project Evaluation/Future Directions We are planning a research project (awaiting approval) to evaluate how taking care of the mind, body, and spirit not only increases staff satisfaction but increases patient satisfaction. When we heal ourselves, we can help our patients with their healing process (Watson theory).

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Acknowledgments I would like to extend my grateful heartfelt thanks to: Sandra Dietrich, my director, for believing in me! For making my dream come true! This was truly an instance of Caritas Process 10: Believe in Miracles! Mary Stapleton, my manager, for not only finding our space but for standing by me through this and her excitement when it was complete! Kate Patrizzi, our educator, for dealing with my persistent nagging and being happy with the consequences. Even taking a meditation course! Doug Baker, my coworker, who was beside me through this whole journey, our persistence paid off! All my coworkers who have supported me on this journey and are now really enjoying our room! AtlantiCare Facilities Department for painting our room and hanging all of our wall décor. Joe Leonard, my husband, who has supported and continues to support me on my journey of Caritas; I love you. My children, who have taken frantic calls from me: How does this sound, or what happened to the computer. Ann Szapor, our AVP of Nursing, thrilled I spent the conference with you in Boulder. Thrilled you believed in our room! Anne Foss-Durant, for being my mentor and helping me develop and continue to develop into a caring Caritas coach! And, of course, Jean Watson, who taught us that our sacred work of caring, in its simple and profound forms of knowing–being–doing, is the ultimate manifestation of infinite love of healing in the world (Watson, 2008). As nurses, we have been given the greatest gift, compassion, and Jean Watson has opened our eyes and our hearts and our minds to this. Blessings to you all!

     

* * *

Mindfulness Perspective Like Watson, Nhat Hanh reminds us of the importance of each action, thought, and word in conveying and sustaining a healing environment for self and others. Nhat Hanh suggests breathing, deep listening, and deep looking to cultivate healing environments: If we suffer too much, we may be crushed and unable to help … To develop compassion in ourselves, we need to practice mindful breathing, deep listening, and deep looking … Compassion contains deep concern

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… You look and listen deeply [to be able to touch the pain]. You are in deep communication … and that alone brings some relief. One compassionate word, action, or thought can reduce another person’s suffering … One word can give comfort and confidence … one action can save a person’s life … One thought can do the same because thoughts always lead to words and actions. With compassion in our heart, every thought, word, and deed can bring about a miracle. (Nhat Hanh, 1997, pp. 5–6)

Contemplative Art Activity to Deepen Learning •  Envision colors, patterns, and images that evoke a healing environment. •  Create a pointillism image or a mandala, or take a photograph that

expresses what you have envisioned.

References Nhat Hanh, T. (1997). Teachings on love. Berkeley, CA: Parallax Press. Watson, J. (1999). Postmodern nursing and beyond. London: CPI Anthony Rowe. Watson, J. (2005). Caring science as sacred science. Philadelphia, PA: F. A. Davis. Watson, J. (2008). Nursing: The philosophy and science of caring (Rev. ed.). Boulder, CO: University Press of Colorado.

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Chapter 13 The Ninth Caritas Process: Assist With Basic Physical, Emotional, and Spiritual Human Needs

13.  The Ninth Caritas Process

Assist With Basic Physical, Emotional, and Spiritual Human Needs Nurses have the honored position of entering another’s private ­physical environmental surroundings as well as having access to one’s sacred body-physical-personal private space. Nurses enter this space when carrying out acts, processes, and functions of caring for another that the person/family often conducts in the privacy and intimacy of their own homes. But when another is vulnerable, injured, incapacitated, ill, weak, frail, suffering, confused, and dependent, Caritas Nurses—in a spirit of loving kindness, with an intentional consciousness of dignity and honoring other … administer to another … The Caritas Nurse is aware of this perspective in assisting another with basic needs, at whatever level of need is presenting. The nurse responds to these needs as a privilege, an honor, and a sacred act in assisting this person. The Caritas Nurse appreciates that in this one act, he or she is connecting with and contributing both to the spirit of that person and to oneself. (Watson, 2008, pp. 146–147) This Caritas asks that we see the sacred in the mundane, in the things that people must do to care for their physical, emotional, and spiritual bodies. Each of us is made of many elements, and Caritas nurses are called to honor those elements. Nurses help others manage predicaments related to the fact that human spirits reside in human bodies, and human bodies fail, wear out, and eventually die. The simple act of acknowledging this predicament and considering it a privilege to assist others with basic physical, emotional, and spiritual needs cultivates healing and wisdom in both the cared-for and care-giver. Here is an example of how this Caritas unfolded on a typical hospital unit. I worked for several years on a women and newborn unit in a large urban hospital. We had care teams that consisted of one registered nurse, one licensed practical nurse, and one or two nurse’s aides. We would work in these groups to care for women and their newborn babies. Each time I came to work, I would hope that a particular nurse’s aide would be on my team because she was so wonderful to work with. She always made sure that every water pitcher was filled with fresh, cold water, commenting frequently that “… the human body is mostly made of water, so let’s make sure it’s good water!” She worked to ensure that all of the beds were clean and beautifully made, commenting that “… nice beds make good nests for the ailing soul.” She offered each patient attentiveness, patience, kindness, and respect, saying “I treat people like I would want someone to treat my grandma.” When she held and rocked the newborns, she would talk to each one, saying things like, “I am so lucky to be one of your first friends! Let me whisper some wisdom in your ear. I know you don’t know the words, but you’ll get the idea: Your life is sacred. There is only one of you in the whole universe. Imagine that! Love this new

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life you have been given. Love others and yourself. Love is the most important thing. Remember that!” She meant every word and tried to share these thoughts with every newborn she cared for. She treated every moment and human being as precious. This one nurse’s aide raised the level of care for the entire unit simply by making it clear to all that each caring act was sacred. It reminded the rest of us to do the same. Patients, families, and coworkers alike were grateful for her wisdom and caring presence.

The Ninth Caritas in Action: Caritas Coach Education Program Project Abstracts

     

* * * CARITAS CONSCIOUSNESS INTENTIONALITY AND CARING–HEALING MODALITIES FOR PAIN RELIEF Nancy Swartley

Introduction Managing acute pain related to acute postoperative or traumatic injury presents challenges for both patient and nurse. At times, patients fail to report pain and nurses do not properly assess pain, or look for alternative approaches to pharmacologic modalities for pain relief. The practice environment of a medical–surgical unit specializing in the care of orthopedic and trauma patients is fast-paced, multidisciplinary, and often a stressful area to work. Registered nurses are frequently frustrated by an inability to effectively manage pain, resulting in feelings of inadequacy when focusing on developing and sustaining a helping–trusting–caring relationship (Watson, 2008) with patients.

Significance Watson (2008) reminds us that a transpersonal caring relationship is foundational to becoming aware of another’s frame of reference in order “to attend to what is most important for the person behind the patient and the procedure” (p. 79). Recognizing the experience and meaning of pain from the patient’s point of view allows the registered nurse to provide pain relief while creating a caring moment between nurses and patient. Moving from pain relief as a task to pain relief as a caring moment requires the nurse to expand Caritas consciousness beyond the “­personal

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ego” to “open the intelligent heart and hear what is emerging and presenting itself in the now-moment” (Watson, 2008, p. 79). Research has shown that caring–healing modalities provide effective pain relief and improve the patient experience.

Purpose The purpose of this project is twofold. First, to provide experiential education to help registered nurses develop Caritas consciousness and second, to introduce the caring–healing modalities of music, aromatherapy, hand/back massage, relaxation, and breathing as alternative methods of pain relief to the existing pharmacologic pain regimen.

Setting and Participants The setting is a 32-bed medical–surgical unit within Einstein Medical Center, an acute care hospital in an urban setting. The professional practice model is based on Watson’s Theory of Human Caring and the care delivery model is primary care. Seven registered nurses who have been integrating caring theory into ­practice were invited to participate in a pilot project using caring–healing modalities as part of patient’s pain relief.

Project Description/Process Caritas education has been an ongoing process on the unit for the past 2 years. Although the registered nurses are able to speak to the 10 Caritas Processes, the concept of Caritas consciousness is not as easy to understand. The nurse manager, clinical nurse manager, and the unit Caritas nurse began working with the participants to recognize and nurture their individual Caritas consciousness. The purpose of the education was to have the registered nurses understand how they are the caring–healing environment when they enter the patient’s room. Experiential education related to authentic presence, authentic listening, intentionality, transpersonal caring moments, and centering before entering a patient’s room was provided. The registered nurses involved in the project were given lanyards with the 10 Caritas Processes to use as a ritual for centering before entering a patient’s room. Education related to the caring–healing modalities is being provided to the participants so they understand the science behind the art of nursing. Once the education is completed, the actual project will begin. Patients will be given a ­decorative card and invited to choose from caring–healing modalities including

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music, aromatherapy, massage, relaxation, and breathing techniques as an alternative to the traditional pharmacologic modalities. Patients will be assessed for pain relief and pharmacologic pain relief provided if needed.

Project Outcomes The intent is to develop a comprehensive pain relief program incorporating both traditional pharmacologic and nontraditional caring–healing modalities for pain reduction and/or complete pain relief. It is anticipated that as nurses practice Caritas consciousness, integration of the theory into practice will expand and RN engagement will improve and that the introduction of caring–healing modalities for pain relief will improve the patient experience as a whole and specifically in terms of pain relief.

Project Evaluation Informal feedback from the registered nurses has been positive. The experiential learning activities are helping them understand the concepts of Caritas consciousness and “being the caring–healing environment” and they are using the lanyards to center. A formal survey for patients will be developed to measure pain relief with the caring–healing modalities, and response to pain management will be monitored via patient satisfaction data.

Future Directions To expand the program to other units in the hospital and to have the registered nurses involved in the pilot program certified in holistic nursing.

Acknowledgments I would like to thank my mentor, Gwen Kinney, for her support and u ­ nwavering faith in me during my journey to become a Caritas coach. She is a true Caritas nurse and I am grateful for the loving kindness shown to me. I also want to thank Marian Turkel, RN, PhD, NEA-BC, director, Professional Nursing Practice and Research at Einstein Medical Center, for helping me to develop my Caritas consciousness and providing me with constant guidance and support. Thank you to my clinical director, Theresa Stine, RN, MSN, for her support of caring science

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and of my personal journey. To my clinical manager, Gina Daniel, I am deeply grateful for her unquestioning support, for embracing this project, and for her belief in me. I give a very special thanks to the participants as they grow in their intentionality as Caritas nurses: Andee Tompkins, Andrea Schneider, Jesse Dogan, Thao Nguyen, Laura Talarowski, Anita Leva, and Susan Eluwa. Finally, I want to thank Jean Watson for her visionary nursing leadership, her caring heart, and her willingness to share herself with the world.

     

* * * THE “CARING LIGHT” CREATING CARING CONSCIOUSNESS Susan J. Caron

Introduction In 2009, Saint Anne’s Hospital’s department of nursing adopted Dr. Jean ­Watson as their nursing theorist, embarking on a journey to integrate the Theory of Human Caring into nursing practice. Dr. Watson’s caring science aligns with the hospital’s mission, core values, and philosophy of nursing care. This project ­introduces caring science to the day surgery/postanesthesia care unit (PACU)/ preadmission testing staff, stressing the importance of being before doing. Guiding and assisting staff to honor both spiritual and physical self, discovering this awareness, ­integrating into practice, and creating a culture of caring within the department.

Significance In order to bring human caring science to the practice setting and the patient, the caring (Caritas) professional must cultivate a caring consciousness (awareness) through practicing loving kindness to self and others, allowing for the expression of both positive and negative feelings, and create a healing environment.

Purpose The purpose of this project is to guide and assist staff with their personal journey in discovering the connection of spiritual self to physical self by becoming aware of the correlation between spiritual energy centers (chakras) and the corresponding Caritas Processes. This will provide staff the opportunity to focus on a c­ aring

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method to integrate into their practice. Embodying caring science will allow a more meaningful relationship with patients, a deeper appreciation of their practice, and create a biogenic practice environment. As a result, the staff will discover individually and collectively their “caring light” within.

Setting and Participants The setting is a 152-bed community hospital. Current participants are entire staff including clinical leaders, nurses, certified nursing technicians, and patient care technicians in the day surgery (17-bed unit)/PACU (8-bed unit)/preadmission testing departments.

Project Description/Process The project focuses educating staff on aligning three of the 10 Caritas Processes with the corresponding chakra and energy color. Caritas Process #1 “Practice of loving kindness and equanimity with self and others” = heart chakra = green; Caritas Process #5 “Allowing expression of positive and negative feeling; listen to another’s story” = solar plexus chakra = yellow; and Caritas Process #8 “Creating a healing environment, potentiating wholeness, beauty, comfort, dignity, and peace” = root chakra = red. The three chakras combined create a “caring light.” Traditionally and c­ ulturally these three colors are understood as a “stoplight”—green = go, yellow = caution, and red = stop. Without caring consciousness, the meaning is external (doing) and potentially fear based. With the infusion of caring consciousness, the meaning changes to a “caring light,” internal (being) and love based. The “caring light” focuses on the strengths of each chakra and gives the opportunity to move beyond the fears of each chakra. Caring checks are initiated by a clinical leader or charge nurse every 2 hours to determine chakra color of the unit. Dependent on the “color” of the unit, the staff and leaders will initiate activity and intention to ­promote caring consciousness. The foundation of this project is to continually practice in the strength of each chakra moving toward a biogenic environment. The knowledge of fear-based characteristics within each chakra provides opportunity for staff to work individually and collectively to move beyond fear into love through the practice of caring science. Activities provided to educate and support staff include: Caritas Process #1 = Introduction of HeartMath, centering techniques including meditation and breath work, HeartMath quotes sent daily to staff, publication of “Caring Moments” booklet created for staff;

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Caritas Process #5 = Encourage staff to express feelings, through questionnaire individually and collectively meeting with clinical leaders, provide safe space for staff to express feelings, and creating “Kumbaya” (named by staff) bucket used to symbolically purge toxic feelings and emotions, and through increasing Caritas consciousness determine caring and noncaring behaviors by staff, with commitment to practice caring behaviors only; and Caritas Process #8 = Education provided to staff including Halldorsdottir Model: Biocidic to biogenic caring, gifted to staff by clinical leaders— Florence Nightingale’s Notes on Nursing—reminder of the foundation (root) of our profession: dim lighting and music in the PACU, and healing and inspiring phrases placed throughout units.

Project Outcomes The project hypothesis is that the staff will able to recognize the value of first being then doing, and aligning the spiritual and physical. This consciousness will create a caring environment that sustains caring science in the preadmission testing, day surgery, and PACU, utilizing the “caring light.”

Project Evaluation Formal qualitative evaluation will occur in 6 months. Nursing staff will be provided a questionnaire to share their experience with the “caring light.”

Future Directions This project will serve as a template in developing a nursing care delivery model engrained in caring science and may also be utilized in other departments ­throughout the hospital.

Acknowledgments The author wishes to acknowledge the contributions and support of: Dominican Sisters of the Presentation, who founded Saint Anne’s Hospital in 1906, for creating and sustaining a culture of caring.

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Carole Billington, vice president and chief nursing officer, for her mentorship and continued encouragement and support. The entire staff of day surgery, PACU, and preadmission testing, for their continued commitment and enthusiasm, and the exceptional care they provide to our patients.

     

* * *

Mindfulness Perspective We are not just physical beings having a spiritual experience: rather we are spiritual beings having a physical experience. (Teilhard de Chardin, 1881–1955) Watson encourages cultivation of awareness and deep respect for the s­ acredness of life and all that it encompasses. Nhat Hanh’s perspective is similar, in that honoring the sacredness of everything helps remove barriers to truly seeing that everything arises from everything else—purity and defilement are two sides of the same coin since there cannot be one without the other: Life is always changing. Each thing relies on every other thing for its very existence. If our mind is calm and clear, using the toilet can be as sacred as lighting incense. To accept life is to accept both birth and death, gain and loss, joy and sorrow, defilement and purity … when we see things as they are, we do not discriminate between seeming opposites such as these. Everything “inter-is.” (Nhat Hanh, 1990, p. 9)

Contemplative Art Activity to Deepen Learning •  Envision colors, patterns, and images that evoke the sacredness of

assisting with basic human needs. •  Create a pointillism image or a mandala, or take a photograph that expresses what you have envisioned.

References Nhat Hanh, T. (1990). Present moment wonderful moment: Mindfulness verses for daily living. Berkeley, CA: Parallax Press. Watson, J. (2008). Nursing: The philosophy and science of caring (Rev. ed.). B ­ oulder, CO: University Press of Colorado.

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Chapter 14 The Tenth Caritas Process: Open to Mystery and Allow Miracles to Enter

14.  The Tenth Caritas Process

Open to Mystery and Allow Miracles to Enter All I am trying to say is that our rational minds and modern ­science do not have all the answers to life and death and all the human conditions we face; thus, we have to be open to unknowns we cannot control, even allowing for what we may consider a “miracle” to enter our life and work. This process also acknowledges that the subjective world of the inner-life experiences of self and other is ultimately a phenomenon, an ineffable mystery, affected by many, many factors that cannot be fully explained. (Watson, 2008, p. 191) Consideration of and openness to this dimension of nursing may be the most fulfilling aspect of practice. Explanatory notions of this aspect of nursing not only are best understood from an existentialspiritual-phenomenological lens but perhaps are only understood from this higher plane of seeing the world. (Watson, 2008, p. 195) This Caritas acknowledges the mystery surrounding life itself. It challenges Caritas nurses to cultivate awareness of this mystery, and to allow/facilitate others in expressing their mystical experiences without reservation. Here is an example of this Caritas in practice. Because I was a hospice nurse for many years, I attended many deaths. Oftentimes when death was near, patients would start talking to dead relatives as if they were in the room. Family members in attendance would usually respond with awe and affirm that, somehow, in some way, even though no one could see the dead relatives except the dying patient, they probably were present in the room to welcome the patient into whatever realm followed death. I made a point to engage in the conversation, facilitate sharing, and acknowledge the reality/importance of the experience for the patient and family.

The Tenth Caritas in Action: Caritas Coach Education Program Project Abstracts

     

* * * CARITAS CANDLE PROJECT Denise Laws

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Introduction This project addresses the identified issue of creating Caritas moments with patients. Jean Watson emphasized the importance of Caritas consciousness and the authenticity and genuineness of human connection. Authenticity is an important ingredient for a caring moment and begins the transpersonal dimensions of a caring–healing relationship with another (Watson, 2008).

Significance According to Jean Watson “The Caritas connection may occur through intentional yet authentic acts, movements, gestures, facial expressions, procedures, information giving, touch, voice, tone of voice … that communicate caring to the other ... The Caritas nurse is not expected to have a caring moment with every patient, but Caritas consciousness is held as a professional ideal to guide one’s moral, ethical commitment and intentionality with each person” (Watson, 2008, p. 82). This project focuses on Caritas Process #8, creating a healing environment for the physical and spiritual self, which respects human dignity.

Purpose The purpose of this project was to create a formalized process to assist the nurse to create a caring moment with a patient.

Setting and Participants Kaiser Foundation Hospital in Santa Rosa, California, was the setting for this project. The project was a focus of the medical/surgical department. Participants from this project crossed disciplines and included nurses, assistant managers, the chaplain, patient care technicians, a unit assistant, and the manager of the volunteer department. Approximately eight patients/families have participated in the ­Caritas candle project to date.

Project Description Shannon Norman, a staff nurse, proposed an idea for helping to create a caring moment with patients through use of a flameless candle and a group process. Her idea was to set aside a time in which staff and the patient and their family (if the

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patient desired) would meet and focus on a prayer, a meditation, a circle of silence, or even song, depending on the patient’s wishes. A flameless candle would be presented to the patient at the end of the gathering. Candles are also significant in Jean Watson’s work (2008). Jean Watson has a candle that she takes wherever she speaks. She uses the candle to represent the light of nursing around the world. This project uses the flameless candle to represent the love and light of the health care delivery staff caring for our patients. Participants in the project group met several times to create a binder to keep on the units so that, if the staff wanted to create a Caritas candle moment with a patient, they would have the necessary tools. The binder contains prayers, poems, and stories from other Caritas candle moments. Staff from our group presented information on the Caritas candle project at the September medical/surgical unit council meeting.

Project Outcome Each unit in the hospital will have a Caritas candle binder as well as candles and will understand the concept of creating a Caritas moment with patients. This will strengthen the staff’s awareness of the importance of the human-tohuman connection and also address potential spiritual or emotional needs of patients. The long-term goal is to share this process with community members of Santa Rosa by asking our patients to place the candles on the windowsill of their hospital room. As the community drives by the hospital, they will see the candles in the windows and be asked to send good intentions to one who may be suffering. Not every patient in the hospital will receive a candle. Staff will be ­empowered to select patients for this process. Staff may choose to select a patient who is ­struggling with a new diagnosis, or perhaps celebrating good news from a physician related to their illness.

Project Evaluation At the last meeting of the Caritas candle project team, members discussed how the project was going so far and gathered stories that nurses wrote about their experiences with their patients/families. The stories were very moving and a common theme woven throughout each of them focused on the positive changes in the patient’s behavior after the caring moment was experienced and the increased connection felt by the staff to the patient. Members of the nursing staff have verbalized how the process deepened their connection with the participating patients and families and made care delivery easier.

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The Caritas candle project team would like to add an evaluation for the nurse to complete after the process is complete. The group discussed including a ­question asking the nurse to reflect on their experience.

Future Directions Once the binders are complete, the Caritas candle project team would like to ­submit the process to the regional Kaiser Caring website to share among other facilities. There is also consideration of writing a journal article on the experience.

Acknowledgments I would first like to thank the CNO/COO at Kaiser Santa Rosa, Susan Janvrin, RN, MSN, as well as my director, Chris Sanford, RN, BSN, for giving me the opportunity to become a Caritas coach. I would like to send my gratitude and love to my Caritas coach mentor, Marialena Murphy, MSHSA, RN, CNOR, and my fellow Santa Rosa Caritas coach students, Marilee Ford, RN, and Amy Casey, RN. I would also like to recognize all of the staff at Kaiser Santa Rosa who worked on this project and a special recognition to Shannon Norman, RN, for bringing her idea forward! Most of all I want to thank Jean Watson for her inspiring Science of Human Caring Theory and her love and light that shine throughout the world!

*    *    * TRANSFORMING NURSING LANGUAGE THROUGH STORYTELLING: DISCOVERING AWE AND WONDER THROUGH CARING MOMENTS Mark D. Beck

Introduction The current language of nursing practice is informed by the empirical medical model to the exclusion of other ways of knowing, being, and doing. Nurses have forgotten that they are responsible for, first and foremost: spirit-to-spirit and ­caring healing relationships for self, patients and families, in Kaiser Foundation Hospital East Bay and the health care community. Establishing language centered on caring intentions and moments is always a challenge, especially for nurses whose conceptual thinking is molded by an empirical medical model, traditional performance measurements, and the absence of professional standards for ­creating

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healing relationships. Storytelling caring moments offers nurses an opportunity to remember what they value most, heart-centered, transpersonal, holistic, and integrative care filled with moments of awe and wonder. Storytelling allows the nurse to awaken to caring moments, experience transformation, and co-create a culture where caring science language becomes the new natural language of nursing in all nursing situations.

Significance Environments where nursing remembers its roots in all ways of knowing and infuses caring science language as the natural language of nursing will be healing to the nurse and other colleagues and will promote healing for the patients, the organization, and thus the universe.

Purpose The purpose of this project is to introduce caring science language into the Nurse Practice Committee as part of the work of the committee.

Setting and Participants The Nurse Practice Committee is the working group of staff nurses from all the units of the medical center that addresses nursing practice in policy. The participants are comprised of staff nurses from all specialties and units, and the ­clinical nurse specialists from the Clinical Education, Practice and Informatics (CEPI) department. The director of the CEPI department is the chair of the committee. This committee meets monthly.

Project Description/Process The meeting structure was reformatted to include a centering moment conducted by a member of the CEPI department to set the tone for the meeting. As a requirement for participation, staff members were asked to bring a caring moment story to share at the closing of the meeting. There was discussion of how the story affected others in the committee and what Caritas Processes were exhibited in the story.

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Project Outcomes The intended outcomes are to increase the Caritas consciousness, and the awe and wonder of nursing within the informal network within the Nurse Practice Committee; to help them again see the beauty of nursing with a language to describe it; and to compile a list of creative language patterns for transforming the old medical model language into a new nursing caring–healing language.

Project Evaluation The projected evaluation process is to evaluate the use of caring science language by members of the committee in the sharing of caring moment stories, in their concomitant discussions. The expectation is that caring science language will increase and infiltrate into daily work as evidenced by their stories and use of ­caring ­science language.

Future Directions The future direction will be to have this restructured time serve as a model for other meetings within the Patient Care Services division. In addition, an evolving covenant of “What the new nursing caring–healing language looks like” might be developed system-wide with integration into nursing documentation, “performance-presence” evaluation, article, or presentation at a conference.

*    *    *

Mindfulness Perspective Watson and Nhat Hanh both acknowledge that each life is a miracle, simultaneously encompassing and existing within the cosmos: Dear friends, you are nothing less than a miracle. There may be times when you feel that you are worthless. But you are nothing less than a miracle. The fact that you are here—alive and capable of breathing in and out—is ample proof that you are a miracle. One string bean contains the whole cosmos in it: sunshine, rain, the whole Earth, time space, and consciousness. You [and everyone who receives your care] contain[s] the whole cosmos. (Nhat Hanh, 2002, pp. 11–12)

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Each life is a miracle, and all of us together are a collective miracle. This is the greatest mystery, and at the same time, the greatest reality of all. Acknowledging and living within the flow of this understanding opens up vast possibilities for developing insight, wisdom, and joy, even in the face of great challenges.

Contemplative Art Activity to Deepen Learning •  Envision colors, patterns, and images that evoke mystery and miracles. •  Create a pointillism image or a mandala, or take a photograph that

expresses what you have envisioned.

References Nhat Hanh, T. (2002). Be free where you are. Berkeley, CA: Parallax Press. Watson, J. (2008). Nursing: The philosophy and science of caring (Rev. ed.). B ­ oulder, CO: University Press of Colorado.

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Chapter 15 Conclusions and Suggestions for Deepening Study

15.  Conclusions and Suggestions for Deepening Study

Caritas Consciousness Touchstones for Cultivating Love Watson created a tool (copyrighted 2002) to help Caritas nurses practice conscious intention for cultivating love and transpersonal caring moments throughout the workday. Many Caritas nurses carry these touchstones in their pockets at work, and refer to them right before the work shift begins, in the middle of the work shift, at the end of the work shift, and at the closing of the day. If used daily, these touchstones support building and maintaining a foundation for the practice of Watson’s 10 Caritas practices.

Touchstones Setting Intentionality and Consciousness for Caring and Healing (Watson, © 2002): Caring in the Beginning •  Begin the day with silent gratitude; set your intentions to be open to give and receive all that you are here to give and receive this day; intend to bring your full self, in the day-to-day moments of this day; cultivating a loving, caring consciousness toward yourself and all others who enter your path. Caring in the Middle •  Take quiet moments to “center,” to empty out, to be still with yourself before entering a patient’s room or when entering a meeting; cultivate a loving–caring consciousness toward each person and each situation you encounter throughout the day; make an effort “to see” who the spirit-filled person is behind the patient/colleague. •  Return to these loving-centered intentions again and again throughout the day, helping yourself to remember why you are here. •  In the middle of stressful moments, remember to breathe; ask for guidance when unsure, confused, and frightened; forgive and bless each situation. •  Let go of that which you cannot control. Caring in the End •  At the end of the day, fold these intentions into your heart; commit yourself to cultivating a loving–caring practice for yourself. •  Use whatever has presented itself to you this day as lessons to teach you to grow more deeply into your own humanity and inner wisdom.

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•  At the end of the day, offer gratitude for all that has entered the sacred

circle of your life and work this day. •  Bless, release, and dedicate the day to a higher, deeper order of the

great sacred circle of life. Caring Continuing •  Create your own intentions and your own authentic practices to prepare your Caritas consciousness; find your individual spiritual path toward cultivating caring consciousness and meaningful experiences in your life and work and the world.

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Index

Adventist Hinsdale Hospital, 56–59 afterschool program, 111–113 altruistic values, and practice loving kindness with self, 43–52 antibullying programs, 113 art for learning mandalas, 8–9, 12 photographs, 11–13 pointillism, 7–8, 11–12 Bon Secours Health System, 45 breathing, 26–27, 123 breathing in, breathing out, 26 caregivers, validating roles of, 99 caring consciousness, 19 caring light creating, 131–134 caring decision making, scientific problem-solving methods for, 95–102 caring–healing hospital, 66 caring–healing–loving consciousness, 19 caring–healing modalities, for pain relief, 128–131 caring influence, layers of, 33–34 caring light, creating caring consciousness, 131–134 caring model. See caring theory caring moments, 18–19 Caring Nurse–Patient Interaction Scale (CNPI-23), 78 caring occasion, 18–19 caring science, defined, 20

caring science practice, 45–47 in 24/7 call center, 48–51 caring theory, implications of, 20 Caritas core and trim orange with, 35 cosmology, 37 value assumptions of, 36–37 Caritas candle project, 137–140 Caritas Coach Education Program project, 11 building trusting caring relationships, 59–61 caring behaviors on educational team, 79–81 caring–healing modalities for pain relief, 128–131 caring light creating caring consciousness, 131–134 Caritas candle project, 137–140 computerized clinical documentation, 86–89 creation of self-care sanctuary, 118–120 end-of-life caring literacy, 98–102 engaging faculty in critical caring dialogue, 108–111 Head Over Heels project, 111–113 healing hands, caring hearts, 66–68 instill faith and hope, and honor others, 56–59 integration of caring science, 48–51 medical telemetry unit, 76–79 meditation room, use of, 120–123 nursing language through storytelling, transforming, 140–142

Index

nursing students’ caring through reflective practice, 69–71 one-to-one observation in critical care, 95–98 practice loving kindness, 45–48 reflective Caritas tool for pediatric oncology nurses, 89–91 Caritas coaches, 45, 66 Caritas consciousness, 75, 128–131 Caritas Consciousness Touchstones, 147 Caritas nurse, becoming, 36–37 Caritas Process, 7, 10, 12, 21–22, 45, 47, 49, 50 assisting with basic human needs, 127–134 creating healing environment, 117–124 embrace altruistic values and practice loving kindness, 41–52 expression of positive and negative feelings, 85–92 helping–trusting–caring relationships, 75–82 instill faith and hope, and honor others, 55–62 nurturing individual beliefs and practices, sensitive to self and others by, 65–72 open to mystery and allow miracles to enter, 137–143 scientific problem-solving methods for caring decision making, 95–102 share teaching and learning, 107–114 Caritas summits agenda for, 77 in medical telemetry unit, 76–79 CEPI department. See Clinical Education, Practice and Informatics department Charity Caritas Guiding Council, 45 Charity System, 45 Clinical Education, Practice and Informatics (CEPI) department, 60, 61, 141 clinical education team, 79 Coach Teaching–Learning Model, 78 compassion, 51 computerized clinical documentation, 86–89 consciousness caring, 19, 128–131, 147–148 caring light creating, 131–134 core and trim model, 34–35

150

course evaluation, 78 creative processes, 79, 80 critical care, one-to-one observation in, 95–98 critical caring dialogue, engaging faculty in, 108–111 CSS. See customer service specialists cultivating curiosity, 65 cultivating love, consciousness touchstones for, 147–148 cultivating personal practices, 6 customer service specialists (CSS), 49 deep listening, 28–29, 123 deep looking, 123 educational team, caring behaviors on, 79–81 emergency room nurse, decreasing stress of, 120–123 emotional human needs, 127–134 end-of-life caring literacy, 98–102 engaged Buddhism movement, 25 engaging faculty in critical caring dialogue, 108–111 expression of positive and negative feelings, 85–92 faith, fostering nurses’, 56–59 feelings, 26, 85–92 Head Over Heels project, 111–113 healing, 19, 55, 128–131 consciousness for, 147–148 environment creating, 117–124 meditation room, use of, 120–123 self-care sanctuary, creation of, 118–120 mindfulness trainings, 27–29 Health On-Call (HOC), 48 helping–trusting–caring relationships, 75–82 helping–trusting relationships, 56–59 hope, fostering nurses’, 56–59 human caring, Watson’s theory of. See Watson’s Theory of Human Caring human dignity, 117–124 human needs, assisting, 127–134

Index

integrating caring science in 24/7 call center, 48–51 Jean Watson’s Theory of Human Caring, 33–37, 45, 46, 59, 76 Kaiser Foundation Hospital, 138 Kaiser Oakland Medical Center, 60 Kaiser Permanente, 59 learning art as alternative pathway for mandalas, 8–9, 12 photographs, 11, 12 pointillism, 7–8, 11–12 share, 107–114 loving kindness cultivating, 44–45 integrating caring science, 48–51 practice of, 45–48 with self, practicing, 43–52 loving speech, mindfulness trainings, 28–29 mandala images, 8–9 creating, 12 photograph and, 13 medical telemetry unit, 76–79 meditation room, use of, 120–123 mental formations, 26 Metrowest Medical Center, 86 middle school–afterschool program, 111–113 Mind Body Medicine Health Education Program, 79 mindful influence, layers of, 33–34 mindfulness trainings loving speech and deep listening, 28–29 nourishment and healing, 29 reverence for life, 27–28 true happiness, 28 true love, 28 negative feelings, promoting and accepting, 85–86 Nhat Hanh, Thich, 25, 91–92 nonmedical caregivers, 98–102 nourishment, mindfulness trainings, 29

Nurse Practice Committee, 141, 142 nurse’s consciousness in caring moment, 19 nursing, future of, 20–21 nursing students’ caring, development of, 69–71 one-to-one observation, in critical care, 95–98 orange meditation, 35–36 Organizational Climate for Caring Questionnaire (OCCQ), 108, 110 pain relief, caring–healing modalities for, 128–131 PAL. See Physician’s Access Line PCHA. See Physician and Community Health Access pediatric oncology nurses, reflective Caritas tool for, 89–91 Peer Group Caring Interaction Scale, 80, 81 personal practices, cultivating, 6 photographic images, 11–13 physical, emotional, and spiritual human needs, 127–134 Physician and Community Health Access (PCHA), 48–50 Physician’s Access Line (PAL), 48 pivotal moments, 85 pointillism images, 7–8 creating, 11–12 photograph, 12 pond model, pebble in, 33–34 positive feelings, promoting and accepting, 85–86 postanesthesia care unit (PACU), 131 present moment, 25 reverence for life, 27–28 scientific problem-solving methods, for caring decision making, 95–102 self-care sanctuary, creation of, 118–120 silo effect, 59 spiritual human needs, 127–134 St. Anthony Community Hospital, 45–48 St. Joseph Hospital, 77–79

151

Index

teaching and learning, 107 engaging faculty in critical caring dialogue, 108–111 Head Over Heels project, 111–113 mindfulness perspective, 113–114 10 Caritas Processes, 21–22 Thich Nhat Hanh’s mindfulness practice, 5–6, 11, 25–29 touchstones, for cultivating love, 147–148 transformative models of caring, 17 transformative moments, 85 transpersonal caring, 17–18, 34, 117, 128 dynamic of, 19 moments, 25–26, 29 trim model, 34–35 true happiness, mindfulness trainings, 28 true love, mindfulness trainings, 28 trust, fostering nurses’, 56–59 trusting caring relationships, building, 59–61 Tulsa Community College (TCC) Nursing Program, 108

152

Veterans Administration (VA), 118 Wake Forest Baptist Health Medical Center (WFBMC), 49, 50 Watson, Jean, 17 Watson Caring Science Institute (WCSI), 118 Watson’s Theory of Human Caring, 5 art for learning, 7–11 mindfulness to cultivate understanding, 5–6 wellness, 55 Western nursing–medicine model, 18 WFBMC. See Wake Forest Baptist Health Medical Center Winter Haven Hospital, 66–68 Zen Buddhist tradition, 6