Guide to deliver the elements of the Clinical Caritas Process

Guía para la realización de los elementos del Proceso Clinical Caritas

Abstract

Objective:  To introduce a guide to apply the elements of the Clinical Caritas Process.

Methods:  It is a study introducing a guide developed to identify the necessary caring actions, aiming to provide transpersonal care. It was designed from a bibliographic review and discussion with peers, who apply the theory underpinning the present study.

Results:  The instrument features a layout with ten lines and two columns, decoding each structural component in its enunciation with its respective care manifestations. Additionally, it showed to be a facilitator for the use of the Human Caring Theory.

Conclusion:  It is believed that the guide can be reproduced in order to direct the practice of transpersonal care in different settings of Brazilian nursing. Moreover, it can also be used to teach this theory.

Keywords:
Nursing Theory; Nursing Care; Nursing Education

Resumo

Objetivo:  Apresentar um guia para a aplicação dos elementos do Processo Clinical Caritas.

Métodos:  Trata-se de um estudo que apresenta um guia desenvolvido com o intuito de identificar ações de cuidado necessárias para realizar o cuidado transpessoal. Foi construído após revisão bibliográfica e discussão com pares que aplicam a teoria de Jean Watson adotada no presente trabalho.

Resultados:  O instrumento apresenta-se em layout com 10 linhas e duas colunas, decodificando cada componente estrutural no seu enunciado com suas respectivas manifestações de cuidado, demonstrou ser facilitador para a utilização da Teoria do Cuidado Humano.

Conclusão:  Acredita-se que o guia, poderá ser reproduzido para orientar a prática do cuidado transpessoal na Enfermagem brasileira em diferentes cenários, e pode ser utilizado inclusive no ensino desta Teoria.

Palavras-chave:
Teoria de Enfermagem; Cuidados de Enfermagem; Educação em Enfermagem

Resumen

Objetivo:  Presentar una guía para la aplicación de los elementos del Proceso Clinical Caritas.

Métodos:  Se trata de un estudio que presenta una guía desarrollada con el objetivo de identificar acciones de cuidados necesarios para realizar la atención transpersonal. Fue elaborado después de la revisión bibliográfica y la discusión con colegas que utilizan la teoría de Jean Watson, adoptada en este trabajo.

Resultados:  El instrumento se presenta en layout con 10 líneas y dos columnas, decodificando cada componente estructural en su enunciado con sus respectivas manifestaciones de cuidado, demostró ser facilitador para la utilización de la Teoría del Cuidado Humano.

Conclusión:  Se considera que la guía podrá reproducirse para orientar la práctica del cuidado transpersonal en la Enfermería brasileña en diferentes contextos y lugares, y puede utilizarse inclusive en la enseñanza de esta Teoría.

Palabras-clave:
Teoría de Enfermería; Cuidados de Enfermería; Educación en Enfermería

INTRODUCTION

Caring is the core of nursing and this action can be understood as the basis of knowledge about this discipline. It is both the practice and theory founded on the form and diversity of care provided.¹

Aiming to enable nursing care to be effective, it must be based on theoretical frameworks, i.e. on a Nursing theory, which directs the way care is provided so that the objectives can be achieved.²

According to Meleis (2012), a Nursing theory can be defined as interrelated concepts that are connected to an organized, logical and systematic group of statements associated with significant questions about a discipline, linked and shared in a meaningful whole, explicitly aimed at explaining or predicting facts/events.³

As practical human sciences, Nursing theories enable expansion and guide care. To understand the universe of individuals, their contact with the environment and the manifestations that this relationship has in health helps to develop the clinical practice and establish what the most relevant types of care are.⁴

The Human Caring Theory described by theoretician Dr. Jean Watson is one of the several Nursing theories, which has contributed to the increase in knowledge about Nursing since 1979, when her first book was released, "Nursing: the philosophy and science of caring".⁵

However, Watson does not consider this to be a verifiable, measurable and testable theory, but rather a theory that helps professionals to consider human beings in their transcendence in the phenomenon of human experience. In other words, this theory is centered on the importance of care, on existential phenomenological assumptions and the search for an interconnection of concepts, a human science adequate for Nursing, which is transformed through connection, between the one that cares and the one cared for.⁶

The use of Watson's Theory allows a "sacred" meeting between the one that cares for and the one cared for to take place in each interaction, enabling a healing care environment to be developed, capable of supporting transpersonal care in several contexts.⁷

Thus, productive care can be evidenced and developed in a transpersonal way, when perception goes beyond the physical proportion and is capable of surpassing this moment and the cosmos.⁸

As a result, we have the essence of the Human Caring Theory and transpersonal care, which can be effective through the use of the Clinical Caritas Process elements, a process that enables its application in practice. These elements originate from the theoretician's assumptions that direct one towards the achievement of transpersonal care.^5,6 This is because Watson does not advocate the use of a Nursing process for such, leaving professionals free to make choices when using them, which can lead to questions in some situations.⁹

Thus, the Clinical Caritas Process is comprised of the following ten elements:⁹ Practicing love/kindness and equality in the context of awareness of care; Being truly present, strengthening, supporting and honoring the deep system of beliefs and the world of subjective life of the one cared for; Fostering transpersonal self and personal spiritual practices and going beyond the ego; Developing and supporting an authentic relationship of care, help and trust; Being present and supporting the expression of positive and negative feelings as a deep connection with one's own spirit and that of the one cared for; Using the self and all ways of knowledge creatively, as part of the care process, engaging in artistic practices of healing care; Being truly involved with teaching/learning experiences that serve an individual as a whole and their meanings, seeking to remain inside the other's perspective; Creating a healing environment on all levels (physical and non-physical), a subtle environment of energy and awareness, where beauty, comfort, dignity and peace are enhanced; Supporting basic needs, with the intentional awareness of care, managing "essential human care", which strengthens the mind-body-spirit alignment, the totality and unity of being in all aspects of care; and Being open to and paying attention to the spiritual mysteries and existential dimensions of life-death, caring for one's own soul and that of the one cared for.^a

Understanding that the practice of Nursing care is capable of transcending and uniting humanistic factors with scientific knowledge in accordance with world trends coherently, responsive to the health needs of patients, family and the community,¹⁰ the Jean Watson's Human Caring Theory was selected as the theoretical framework of a dissertation and thesis that dealt with the theme of home care.

The objectives of these postgraduate studies are as follows: interpreting the patients' experience with home care and validating a health care model in this area, following the assumptions of the selected theoretician, adopting Grounded Theory and research-care. In view of the need to prepare instruments to collect data from these studies, the authors identified the need to interpret the Clinical Caritas Process in such a way that it answered the following questions: What Nursing actions/attitudes are required to perform the Clinical Caritas Process? How to identify whether the process elements are present in professionals' actions? What health care action needs to be performed to provide transpersonal care?

Several studies on the theme of Clinical Caritas Process elements can be identified.^7,11-14 However, there are no studies aimed at the description, decoding and understanding of manifestations of care that each of these elements involves, thus revealing a gap of knowledge to which the present study is dedicated.

METHODS

The present study introduces a guide designed to support the actions of researchers in the application of the Clinical Caritas Process, thus putting the Human Caring Theory into practice, aiming to achieve transpersonal care as proposed by Jean Watson. This study is part of a large research project approved by the Research Ethics Committee under official opinion number 1200886. It was performed between March and December 2016 and it resulted from an ongoing dissertation and thesis, associated with the Grupo de Estudos, Pesquisa e Extensão em Cuidado Humano em Enfermagem (NEPECHE - Study, Research and Extension Group on Human Care in Nursing) of the Postgraduate Program in Nursing of the Federal University of Paraná).

A total of two stages had to be covered to perform the study in question. The first stage included delving into the theoretical framework of this study. To achieve this, an extensive bibliographical review was performed to identify the basic assumptions presented by the theoretician and the interpretations from different authors.^2,6,8,15-19

Thus, apart from the bibliographical review of the theoretical framework, the following was required to develop this instrument: studies on methodological frameworks; data collection instruments that can be used in these research projects; and studies on the Human Caring Theory written in Portuguese, English and Spanish that were published in journals, reliable websites and online annals of congresses and forums on Nursing, emphasizing the elements of the Clinical Caritas Process.

The authors of the present study participated in an international event with the presence of Dr. Jean Watson herself, when they could effectively understand the explanation about the previously mentioned process. Based on what has been described, a guide was designed to direct and identify Nursing Caritas actions, aiming to support the practice of this Theory in routine Nursing care.

The procedure following the guide design occurred through an event named "Seminar - Jean Watson's Human Caring Theory", organized by the abovementioned research group, including the participation of doctors, postgraduate program students and nurses from different institutions in the state of Paraná, Southern Brazil, experts in theoretical framework. The designed guide was presented to these professionals for improvement and validation.

RESULTS AND DISCUSSION

The guide was designed to direct and identify the main Nursing actions, aiming to execute the Clinical Caritas Process elements in such a way that these actions result in transpersonal care. Consequently, this Theory is put into practice, which was here named "Care Manifestations", according to table 1.

Table 1
Guide to execute the Clinical Caritas Process elements.

Element	Care Manifestation
Practicing love-kindness and equality in the context of awareness of care.a	-To promote relationships of affection, knowledge, training and healing possibilities between oneself and the other; -To practice equality according to need, impartiality and non-judgment; -To believe that love is essential in all situations in life; -To use appropriate visual contact and touch gently; -To develop moral care, considering the elements of culture, education and tradition; -To listen with genuine concern, to pay attention to others and to use accessible language; -To speak calmly or to be silent, completely focused on the moment of care; -To transform “tasks” into healing interactions, that is, to go beyond these tasks, taking intentionality into consideration when care is provided; -To go beyond the conventional knowing and doing (identifying clients’ actual needs, extrapolating biological care, being concerned about the one cared for and oneself while providing care); -To believe in the therapy, while being aware of when to go further, considering and believing in existential questions; -To see and understand individuals as human beings, rather than objects; -To prepare oneself professionally through training courses and specializations; -To prepare oneself spiritually: to acknowledge one’s own religious beliefs and those of the ones cared for; and not to impose, judge or discriminate; -To recognize one’s potentials and limits to provide care for individuals and professionals themselves.
Being truly present, strengthening, supporting and honoring the deep system of beliefs and the world of subjective life of the one cared for.a	-To be involved with the reality experienced and to be connected to the other in an authentic way (to be body and soul committed with care); -To be truly willing to care; -To perceive, support and incorporate values, beliefs, and what is meaningful and important for individuals in the context of care; -To create a transpersonal environment; to interact and share; to create an opportunity for silence and reflection; -To recognize one’s transcendental capacity (healing among those involved);6 -To show respect for oneself and others, to accept and respect others as they are; -To honor the integrity and dignity of oneself and all those involved;6 -To help others to believe in themselves; -To encourage individuals and families to see their capacity to continue living; -To honor the subjective world of the one cared for (to understand that each individual develops a subjective world from their previous experiences and, even if this world diverges from the professionals’ beliefs, understanding and empathy are required); -To see life as a mystery to be explored, rather than a problem to be solved.
Fostering transpersonal self and personal spiritual practices and going beyond the ego.a	-To foster spiritual practices; -To use group analysis, self-analysis and conversation group strategies; -To practice self-reflection (prayer, meditation, artistic expression), to be willing to explore one’s feelings, beliefs and values for self-development; -To offer blessings, prayers and spiritual expression as appropriate; -To develop meaningful rituals to practice gratitude, forgiveness, renunciation and compassion; -To create relationships of care that promote spiritual growth; -To connect and show true interest in others; -To encourage oneself to provide transpersonal care as a possibility of understanding oneself;8 -To accept oneself and others on the same spiritual level, as unique beings worth of respect and affection; -To be open to others with sensibility and compassion; -To be spiritually open to access intuitive experiences; -To be receptive to patients’ (the others’) needs and feelings, thus being capable of creating a relationship of greater trust.
Developing and supporting an authentic relationship of care, help and trust.a	-To work with the truth, eye contact, body expression, respectful communication (verbal and non-verbal) and smile, and to avoid mechanical speech and impersonality; -To empathize with the other; -To truly care for, comfort, soothe and touch the other; -To enable the other to choose the best moment to talk about their questions; -To call individuals by their favorite name; -To develop activities that promote healthy growth, and not to behave in an unethical, illegal, risky and seductive way; -To be present at the moment of care to explore all possibilities; -To encourage activities that increase individual freedom and independence; -To accept the moment better.
Being present and supporting the expression of positive and negative feelings as a deep connection with one’s own spirit and that of the one cared for.a	-To help others to express the positive and negative aspects of certain situations experienced; -To encourage narratives, to tell stories as a way to express one’s feelings and understanding of the moment experienced; -To encourage reflection on feelings and experiences; -To enable the relationship of transpersonal care between nurse and the other to appear, change and grow; -To allow feelings to flow among all.
Using the self and all ways of knowledge creatively, as part of the care process, engaging in artistic practices of healing care.a	-To go beyond scientific knowledge, to be creative, to use playful resources, therapeutic touch and instruments; -To help others to explore alternative ways to find new meaning in their situations; to express one’s feelings through instruments, stories, diaries and therapeutic toys; -To integrate aesthetic, ethical, empirical and personal knowledge and metaphysical ways of knowing with creative, imaginative and critical thinking to develop human care expression; -To have skills for new situations; -To use knowledge to enable environments that promote healing, using the following: intentional touch, authentic presence, movement, artistic expression, music, sound (if this is the case), joy, spontaneity, preparation, breathing, relaxation, appropriate visual contact, positive gestures, active listening; -To recognize and integrate the full awareness of one’s presence as an effective element of care.
Being truly involved with teaching/learning experiences that serve an individual as a whole and their meanings, seeking to remain inside the other’s perspective.a	-To truly engage in teaching-learning experiences, to perceive what information, guidance and learning mean to others; -To actively listen and share life experiences with others; -To accept others as they are and as far as their understanding, knowledge and availability to learn go; -To help individuals to ask questions and talk about possible doubts; -To guide according to customs, beliefs and values; -To seek to learn from others and understand their view of the world first, so as to subsequently develop actions, give training courses and provide information; -To understand the moment of guidance as a learning exchange; -To understand that the teaching situation can affect the care process.8
Creating a healing environment on all levels (physical and non-physical), a subtle environment of energy and awareness, where beauty, comfort, dignity and peace are enhanced.a	-To create a healing environment that aims: -To recognize and seek to organize the energy of the environment; -To use strategies to provide comfort, privacy, safety, a clean environment and energy exchange; -To create space for human connections that occur naturally; -To recognize healing as an inner journey; -To include a reconnection between environment and universe to bring healing;6 -To promote a relationship of respect, attention and willingness to be together, and to create a space to allow for one’s own integrity and healing; -To respect clients’ routines and rituals.
Supporting basic needs, with the intentional awareness of care, managing “essential human care”, which strengthens the mind-body-spirit alignment, the totality and unity of being in all aspects of care.a	-To satisfy individual needs identified by professionals and the ones cared for themselves; -To respect the others’ perception of the world and their specific needs; -To anticipate clients’ needs; -To understand clients’ needs; -To recognize the vulnerabilities and abilities of those cared for; -To visualize clients as integrated beings; -To be aware of the fact that touching someone does not only mean touching the physical body, but also their mind, heart and soul on some level, strengthening the mind-body-spirit alignment;6,8 -To consider the moment of care provision as an honor, a privilege, a sacred act and a life mystery, thus contributing to the strengthening of the spirit and oneself.
Being open to and paying attention to the spiritual mysteries and existential dimensions of life-death, caring for one’s own soul and that of the one cared for.a	-To know what is important for oneself and to respect what is meaningful to others; -To maintain a sacred healing space for others, respecting their time and need; -To enable miracles to have a place and meaning for oneself and others; -To embrace the unknown and develop oneself; -To understand the limitations of science; -To accept that certain events in life are inexplicable; -To believe in the healing power of faith and hope; -To seek inner strength for care; -To recognize the process of life and death; -To recognize one’s potential for metaphysics and transcendence.

Comprised by all Clinical Caritas Process elements, the guide was designed in a layout with ten lines and two columns, decoding each structural component in its enunciation with its respective manifestations of care.

This instrument was applied to 15 participants (ongoing) from the previously mentioned PhD and Master's research projects. Additionally, this guide has proved to be simple to perform activities and identify manifestations of care, especially with significant results.

The traditional methods applied to experimental sciences result in reductionist attitudes at the moment when life and health situations are interpreted. Thus, one must gain a holistic and contextualized perspective of phenomena in health care.⁸

There are several health institutions that are currently using Human Caring Theory and studies showing the efficacy and importance of investing in its use. Moreover, it has quality of knowledge and prioritizes transpersonal care to further increase the quality of service in the workplace and guarantee that all health professionals have the required skills to provide such care in a productive way.^7,20-23

Nonetheless, there is more emphasis on the international literature, where there is a presentation and use of validation scales for transpersonal care through the application of Clinical Caritas Process elements.^24,25 However, there are no instruments in Portuguese. Thus, the present instrument showed to be a facilitator for the use of the Human Caring Theory, as it is the foundation for Nursing actions. This is because Watson does not support a Nursing Process, understood as a hindering factor by certain professionals when using this Theory.²⁶

As a result, knowledge and the function of Nursing need to be progressively absorbed as the foundation of any and all theoretical and care action, as they are the ones that include and give visibility to this profession's actions.^27,28

It should be emphasized that the application of theoretical and methodological components in Nursing care is essential for its strengthening. As a result, one must continue to incorporate knowledge into new strategies based on scientific evidence and theoretical instruments, as the use is restricted to the practice of health institutions associated with complexity and difficult understanding.^28,29

Thus, the development of instruments, explanatory models and studies on Nursing theories, associated with their application to practice and adequacy to distinct experiences, is increasingly required, as this enables the theoretical basis for professional performance and helps to bring change to the modern world.³⁰

To achieve this, the guide designed helps researchers to understand the theoretician's assumptions with an emphasis on the subjective world of each human being; it focuses on the depth of the relationship between human beings and translates the moment of care. This is a research tool with the possibility of practical application, thus enabling one to understand the intersubjective, interpersonal and transpersonal relationship located in a cosmic sphere. Additionally, it directs one towards the responsibility of using the Human Caring Theory and, consequently, caring in a transpersonal way, as a deep ethical content that guides the relationship between the one caring and the one cared for.

CONCLUSIONS

Considering the objective of the present study, the results obtained help to direct Nursing care and research, based on the Human Caring Theory. Additionally, it enables each structural component of the Clinical Caritas Process elements to be decoded.

We believe this guide can be reproduced to instruct and provide resources for the practical application of transpersonal care to Brazilian Nursing in different contexts, including its use in the teaching of such Theory. As this is made available for the Nursing community, the inclusion of other experiences and contributions to its improvement are expected.

Finally, we hope to have shown the Theory and encouraged the academic world to develop new studies on the application of Clinical Caritas Process elements, in addition to these manifestations being an inspiration and promotion of new ways of doing Nursing.

• a
  See at website Watson Caring Science Institute. 10 Caritas Processes^TM [internet]. [Boulder, Colorado, EUA]: 10 Caritas Processes^TM; c 2016 [cited 2016 Aug 10]. Available from: https://www.watsoncaringscience.org/jean-bio/caring-science-theory/10-caritas-processes/

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Publication Dates

• Publication in this collection
  2017

History

• Received
  15 Mar 2017
• Accepted
  19 July 2017