JEAN WATSON AND SUSAN B. FRAMPTON
This chapter does the following:
* Explores the role of human caring in creating optimal human interactions in health care environments
* Describes the Relationship-Centered Care/Caring model and how this supports a patient-centered approach to healing partnerships
Note: This chapter draws heavily on two previous works: J. Watson, Nursing: The Philosophy and Science of Caring (2nd ed.), Boulder: University Press of Colorado, 2008; and L. Gilpin, "The Importance of Human Interactions," in Putting Patients First (1st ed.), San Francisco: Jossey Bass, 2003.
* Describes tools and techniques employed at Planetree affiliates that foster optimal healing relationships
INTRODUCTION
When Angelica Thieriot, the founder of Planetree, was confronted with an acute illness that required hospitalization, she felt it was more frightening to be hospitalized than to face a life-threatening health crisis. "First do no harm" is the golden rule of health care. Yet many patients leave hospitals, as Thieriot did, feeling abused, traumatized, and dehumanized. In an attempt to alleviate physical suffering, many health care environments seem to create-or at least exacerbate-emotional suffering. Planetree's goal has always been to change the way patients experience hospitals and other health care settings. This experience is fundamentally rooted in the interactions and relationships between patients, families, and health caregivers.
Clinical care and health care practices are grounded in human communication, human interactions, and relationships. At the same time, approaches to system solutions are often disconnected from relationships and caring. "The current dilemmas in health care are often located within a framework that emphasizes the outer forces of economics, staffing shortages, and technological-medical issues, or system/institutional needs" (Watson, 2004b, p. 249). This disconnection between the current focus in addressing health care issues (read that as sick care) conflicts with and greatly differs from the deeply human-to-human caring relationships and human-to-human connections that give meaning and purpose to nurses, patients, all other health practitioners, and systems alike.
In spite of, or because of, the dissonance between and among the diverse external forces affecting health care and the human caring relational dimensions, it becomes mandatory to recognize and acknowledge that any authentic solution to health problems has to arise from a deeply human discourse-a discourse that philosophically and theoretically underpins and guides health and healing for professional-disciplinary practices and system changes. The Planetree model of care provides a framework for shifting the discourse toward more humane and caring practices for practitioners and systems.
Whereas the health care system excels at measuring and improving the "what" and the "why" of medical care, patients themselves are more concerned with the "how" and "by whom." In a technological era that values the objectivity of science, little regard has been given to the subjective experience of patients. Subjectivity is often relegated to the realm of patient satisfaction and referred to as soft science. Although patient satisfaction is viewed as vital to the hospital's financial health, it is rarely perceived as having an effect on the health outcomes of those who receive care. New medications, procedures, and other advances in medical care are often studied extensively, whereas the manner in which these advances are delivered is intentionally factored out. As Leland Kaiser points out, "If it doesn't matter how the care is delivered, why do pharmaceutical companies conduct double-blind studies?" (personal interview, April 11, 2001).
What underlies many of the issues raised in focus groups and satisfaction surveys with patients and caregivers alike is an area that medical science finds difficult to define, much less to quantify. It involves the vague and elusive but vital area of human interactions. How do we communicate caring? How do we ensure that patients feel respected? How do we encourage patients to ask questions? How do we honor patients' dignity when dignity may be defined differently by each patient?
When a nurse or other caregiver enters a patient's room to give a medication, deliver a meal, or complete any task, what really takes place? Medical science would have us believe that completing the task alone is enough. Quality is seen as a measure of how skillfully and efficiently each task is performed. But from the patient's perspective, every task is more than the delivery of medical services. It is an opportunity for a caring human interaction and forms the basis for a healing partnership between patient and caregiver.
These relationships are central to attending to the humane, ethical considerations that affect subjective human experiences, perceptions, and meanings related to hospitalization or treatment regimes (Shattell, 2002). Whether the relationships are caring or not has consequences for both patients and practitioners, especially nurses (Halldorsdottir, 1991; Swanson, 1999).
These relationships and their impact on the care experience are captured in the shift from externally generated problem solutions to inner-oriented, ontological, human-caring relational changes, at several levels (Tresolini and Pew-Fetzer Task Force, 1994):
* Practitioner-to-patient relationship
* Practitioner-to-practitioner relationship
* Practitioner-to-community relationship
* Practitioner-to-self relationship
Each of these levels is informed and affected by one's understanding and exploration of human caring as the ethical and philosophical foundation for professional practice, as well as an action component. Caring relationships at all levels affect health and healing outcomes and become the basis for understanding the critical nature of patient communications, for developing human (caring-ontological) competencies, and for cultivating relationship-centered caring at all levels of one's life and work.
RELATIONSHIP-CENTERED CARE/CARING
Planetree has always believed that the way care is delivered is as important as the care itself, and the Relationship-Centered Care (RCC) model focuses its full attention on this issue. RCC emerged from the original Pew-Fetzer Task Force, an interdisciplinary project that sought to advance all health professional education beyond the conventional biomedical, technical orientation and toward an expanded model for healing. This focus acknowledged that relationships are critical to the care provided by all health practitioners, regardless of discipline or subspecialty and holds a central place in education and practice (Tresolini and Pew-Fetzer Task Force, 1994, p. 11). Further, this term conveys the importance of human-to-human interaction, of human-to-human caring and connections, as the foundation of any therapeutic or healing activity. Relationship-centered care/caring likewise locates health care within a context of multiple and diverse relationships, which put into action "a paradigm of health that integrates caring, healing, and community" (Tresolini and Pew-Fetzer Task Force, 1994, p. 19).
This philosophy brings forth deeply human connections and opens up the subjective/intersubjective world and the relational connections between and among all aspects of one's life and one's interactions. This model therefore does not and cannot stand outside in some detached, abstract construction of practitioner-patient-community relationships. Rather, this model invites the full self of practitioner to engage in the full self of the patient, whereby the subjective world of both are brought closer together (Tresolini and Pew-Fetzer Task Force, 1994, p. 22) through a human-to-human intersubjective caring connection (Watson, 1999).
Concepts and Consequences of Caring/Noncaring
The caring literature in nursing science studies has identified concepts and outcomes related to constructs such as empathy, compassion, communication, hope, trust, respect, faith, love, patient-centeredness, and relationship-centeredness (Quinn and others, 2003). The work of Swanson (1999) in particular has relevance to the significance of caring and its effects, for better or worse, depending on the presence of caring in practice models. For example, her 1999 work synthesized 130 database articles, chapters, and books on caring, published between 1980 and 1996. These studies included both empirical and theoretical-interpretive studies. Swanson summarized and categorized her findings into five levels:
* Capacity for caring (characteristics of caring persons)
* Concerns and commitments (beliefs and values that underlie nursing)
* Conditions (what affects, enhances, or inhibits the presence and practice of caring)
* Caring actions (what caring means to nurses and clients and what it looks like)
* Caring consequences (outcomes of caring-for both patients and nurses)
The overall summary of Swanson's findings related to consequences of caring for both patient and nurse has implications for all health professionals, as captured in Figures 1.1 and 1.2.
As illustrated in these figures, one's stance toward and practice of caring at the individual and system level can for better or for worse either facilitate healing or create distress for both parties. Thus, caring and one's relationship can be constructive or destructive, healing or nonhealing.
Halldorsdottir's research is considered a timeless study of this caring/ noncaring relationship continuum (Halldorsdottir, 1991). Through her research, she identified five levels, or types, of caring relationships. These ranged from Type 1, which she named biocidic (toxic, life-destroying, leading to anger, despair, and decreased well-being), to Type 5, biogenic (life-giving and life-sustaining). The biogenic is of course the ideal kind of caring, which allows for an authentic human-to-human connection that is gratifying for both patient and nurse. As Halldorsdottir put it:
This Biogenic mode involves loving benevolence, responsiveness, generosity, mercy and compassion. A truly life-giving presence offers the other interconnectedness and fosters spiritual freedom. It involves being open to persons and giving life to the very heart of man as person, creating a relationship of openness and receptivity yet always keeping a creative distance of respect and compassion. The truly life-giving or biogenic presence restores well being and human dignity. It is a transforming personal presence that deeply changes one. For the recipient there is experienced an inrush of compassion, often like a current [1991, p. 44].
Figure 1.3 identifies the five types and the continuum of caring/ noncaring.
The biogenic caring relationship is considered congruent with transpersonal caring and Watson's caring moment (Watson, 1985, 1999; Quinn and others, 2003), in that the relationship is affecting both patient and nurse in a way that paradoxically transcends the moment, while both being fully present in the moment.
As Quinn and others (2003, p. A69) remind us from another point of view, these models of caring and their effect and consequences can be supported by the "enormous literature in psychoneuroimmunology, social support, love, and systems and chaos theories.... For example, social support has been shown to affect health status, as has love. The ... (caring) relationship might be viewed as a type of critical social support and a particular kind of love, offered in moments of intense disequilibrium and vulnerability" toward healing. As supported by both Swanson and Halldorsdottir's work, caring has consequences, which can either be life-giving or life-draining, healthy as well as destructive for both.
A conscious, informed, intentional approach to better our understanding of caring and relationship is necessary for true professional practices if we are to assume ethical as well as empirical-practical responsibility for sustaining caring at the individual, system, and societal levels.
It is through relationships and caring that health professionals and nurses in particular are to sustain caring and healing practices through the formal cultivation of such relational caring competencies, moving closer to biogenic-transpersonal caring. At the same time, it has to be acknowledged that "the biggest 'psychosocial' problem facing us may be the need for our own personal transformation-to understand and promote change within ourselves" (Tresolini and Pew-Fetzer Task Force, 1994, p. 24).
Practitioner-to-Self Relationship
The practitioner-to-self relationship is grounded in self-awareness, self-reflection, and specific lifelong practices, which cultivate a caring consciousness, loving-kindness, and equanimity toward self. Cultivating a loving, caring relationship with self generates such feelings toward others. This is referred to as caritas (Watson, 2008), drawing upon the Latin association, which makes a connection between caring and love, reminding us that caring is something precious and fragile and has to be cultivated. One of Watson's original core carative factors (1979, p. 9) for a caring model was "cultivation of sensitivity to one's self and others," which in turn helps "develop a helping-trusting human caring relationship" and instills faith, hope, and trust.
In this framework of starting with self and one's relationship with self, we acknowledge, "To be human is to feel.... but all too often people allow themselves to think their thoughts, but not to feel their feelings" (Watson, 1979, p. 16). Further, we rarely build in a self-responsibility to pay attention to our feelings to the extent that we are able to cultivate skill in witnessing and reflecting on our own behavior, reactions, moods, and emotions. We rarely are taught about honoring our emotions, witnessing them, becoming familiar with them. Through this process of attending to and reflecting on our emotions, we are allowing them to pass through us, to be released or channeled, rather than holding and freezing the emotions. It is in lack of self-awareness and through fighting our emotions, holding onto them, justifying them, and so on, that our feelings torture or control us with internal psychic fights. Conversely, when we cultivate an emotional awareness and even an emotional intelligence of self-acceptance, self-love, and patience, we are learning how to generate an inner peace and calm for self, thereby becoming a healing presence for self and others.
It is through this beginning point of attending to our self-awareness that we cultivate our spiritual growth and our ability to witness our dynamic changing feelings. We also learn that our feelings often control us. We learn to see how often we freeze and set our emotions, creating more discomfort for our self and others. In contrast, when we honor our relationship with our self in kind, caring, loving ways, we learn that our feelings give us insight into our shared human condition. We learn in this model that we all have emotions and feelings, but we are not our emotions and feelings (Watson, 1999).
The development of self-growth and sensitivity to self evolves from emotional work and emotional insights. This effort requires the nurturing of judgment, taste, values, and sensitivity in human relationships in general. The development of feelings of caring and compassion can expand and deepen through the study of the humanities: arts, aesthetics, drama, film, and literature, as well as through diverse life experiences with persons with different values, cultures, belief systems, and geographical and national settings, which can cultivate compassion and understanding that take us beyond our limited perceptions and set opinions about judging others. The recognition and development of such understanding generates knowledge and wisdom, which leads to self-growth; self-acceptance; and the practices of patience, loving-kindness, equanimity, and forgiveness toward self first, then toward others.
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Excerpted from Putting Patients First Copyright © 2009 by Susan B. Frampton. Excerpted by permission.
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