Application of Jean Watson's Theory of Transpersonal Caring in Nurses Practicing in a Pain Center

The aim of this project was to determine if an educational intervention utilizing Jean Watson’s Theory of Human Caring influences nurses’ level of awareness and practice of loving kindness to self and others. Watson’s paradigm of transpersonal caring is presented as a means to provide the compassionate care needed by patients with chronic pain, who are vulnerable to the comorbidities of depression and anxiety and often have poor outcomes. This quality improvement project was implemented with five Registered Nurses working in a pain center. A two-pronged intervention was structured to begin developing a Caritas Consciousness in Session 1 by focusing on the nurse, applying Caritas #1, loving kindness, to self before applying it to others. Mindfulness, meditation and reflective journaling cultivated their personal journey for several weeks. In Session 2 the focus shifted to the needs of the patient, applying Caritas #1 and #6 with patients in chronic pain. Session 3 allowed time for discussion of ways to grow and sustain a healing environment. Self-reporting of nurses’ perceptions of their caring preand post-educational intervention was obtained via surveys. The Watson Caritas SelfRating Scale, a tool with demonstrated validity and reliability, showed an increase in each of five components of self-caring with a mean increase overall. This indicates movement in a positive direction toward the loving-kindness initiative. The Self-Rating Survey of Caring, designed and piloted for the nurses to rate self on each of the ten Caritas Processes, showed an increase for each item and a mean increase overall. A Post-Survey for Nurses showed positive ratings on all 12 statements. The educational intervention helped the nurses begin a journey which should lead to improved compassionate care. The Caritas #1 component of this project is a model which can be replicated with nurses in any setting. Focusing on one Caritas Process to meet the specific needs of a patient population can also be replicated. APPLICATION OF TRANSPERSONAL CARING IN NURSES IN A PAIN CENTER 8 I. BACKGROUND a. Introduction A comprehensive literature review search for evidence on chronic pain management was conducted utilizing the following databases: CINAHL, Cochrane, Medline, and PsycINFO within a 10-year period. Chronic pain is a major problem worldwide, with more than 1.5 billion people worldwide suffering from chronic pain and approximately 3-4.5% of the global population suffering from neuropathic pain, with incidence rate increasing in complementarity to age (The American Academy of Pain Medicine, 2011). Population level surveys indicate that between 11% and 40% of the U.S. population report some level of chronic pain, with millions suffering from daily, severe, and disabling pain according to the National Pain Strategy (NPS) written by the Interagency Pain Research Coordinating Committee (2016, p. 13). At least 116 million U.S. adults are burdened with chronic pain (Institute of Medicine, [IOM], 2011). It affects more Americans than diabetes, heart disease, and cancer combined (the Academy of Pain Medicine, 2018). Pain is recognized as an “unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage” (International Association for the Study of Pain [IASP], 2017, para. 1). Chronic pain was defined in the past as pain lasting over six months, but now as persistent or recurrent pain lasting longer than three months (Treede, 2015). The IASP Task Force of 2004 defined it as pain with no biological value that persists past normal tissue healing (Mersky & Bogduk, Eds., 2004). Chronic pain is a leading cause of disability, and high rates of depression and anxiety occur in this population (Katz et al., 2015). It is frustrating not only for the patient, but their significant others and health care providers, which often requires considerable effort and poses APPLICATION OF TRANSPERSONAL CARING IN NURSES IN A PAIN CENTER 9 challenges to effective care delivery. The patient with chronic pain patient seeks relief, and when not achieved, they experience further stress, and can become irritable, and demanding, creating a challenging and potentially taxing work environment for nurses practicing in a pain center. Nurses frequently encounter persons with chronic pain, but they may lack the knowledge needed to best help. The fact that chronic pain has multiple causes complicates the situation, as do additional issues detailed in the literature review below. To explore methods in which nurses will be better able to help patients with chronic pain, a nurse expert in pain management, also an Advanced Practice Nurse (APN) who manages an in-patient pain service at a local community hospital, agreed to serve as mentor in this project. Jean Watson’s Theory of Human Caring (2008) was selected as the theoretical basis of this project. Application of her theory in a novel way with nursing staff at the Pain Center actually became the project since the theory guided the intervention. This educational intervention was designed to help nurses deepen their understanding of Watson’s theory and learn to live it, by first embracing a Caritas Consciousness, using Caritas #1, loving kindness, in their own life, before extending it to others, and using it to help their patients with pain via transpersonal caring. The initial focus was on self-care and mindfulness practice over several weeks, which was planned and implemented. Later sessions focused on Caritas #6, using the self in all ways of being and knowing and being open to all modalities, to assist the patient in pain. This is a demonstration of Essential III: Clinical Scholarship and Analytic Methods for Evidence Based Practice (AACN, 2006). As Chism (2013) states, “DNP graduates are in a distinctive position to merge nursing science, practice, human needs, and human caring” (p. 15). A site for implementation was sought at a small community hospital. Upon phone consultation with the Director of Nursing (DON), she expressed interest in having someone work with the nursing APPLICATION OF TRANSPERSONAL CARING IN NURSES IN A PAIN CENTER 10 staff of the Pain Center to facilitate application of Watson’s theory to the clinical setting. Guidance was sought from Caring Science, Mindful Practice (Sitzman & Watson, 2014) which illustrates ways this has been done in various clinical settings, bridging the gap between the theoretical and the practical. An outline of Watson’s basic concepts was formulated to determine how to best implement Watson’s theory, using each of the Caritas Processes to improve the care of patients attending the Pain Center. The importance of mindfulness to Caritas was recognized since Caritas is the Latin word for “cherish”; to appreciate and give special, if not loving attention to. It represents compassion and generosity of spirit (Watson, 2008). Jon Kabat-Zinn (1990) states “Simply put, mindfulness is moment-to-moment awareness. It is cultivated by purposefully paying attention to things we ordinarily never give a moment’s thought to. It is a systematic approach to developing new kinds of control and wisdom in our lives” (p. 2). In a subsequent meeting with the DON, the supervisor of the outpatient surgical area, which includes the Pain Center, and the Pain Center nurse-manager, their desire to increase nurses’ literacy of Watson’s theory was voiced, as it is part of the hospital’s vision. Discrepant levels of literacy among staff throughout the hospital were reported, with most nurses at a beginning level of understanding. This helped to establish the “buy in. ” There was particular interest in self-care for the nurses, especially mindfulness. All seemed enthusiastic at the prospect of increasing nurses’ knowledge of the use of Jean Watson’s theory as the hospital strives for Magnet status. Two Caritas Processes were selected with these nurse administrators as the focus of this project: Caritas #1, using mindfulness as a way to be in “right-relationship” with self, and Caritas #6, helping nurses understand the chronic pain experience, using all ways of knowing and being, and helping with their decision-making when considering all modalities. APPLICATION OF TRANSPERSONAL CARING IN NURSES IN A PAIN CENTER 11 This meets DNP Essential II: Organizational and Systems Leadership for Quality Improvement and System Thinking, since it was designed to meet the needs of a patient population. A later planning meeting was held with the nurse-manager. A timeline was developed and shared with the nurse-manager who was scheduling the proposed sessions with the staff. An expedited Institutional Review Board approval was required for Atlantic Health, so the proposal was first presented to the DON, followed by presentation to the Nurse Research Council on May 10, 2017. Approval was received two weeks later and further planning commenced. b. Description of the Project This project is an attempt to make a positive change in a small setting by focusing on the needs of the nurses, to ultimately improve the delivery of care to patients attending a Pain Center. It was designed to highlight the importance of the care and compassion needed by these patients. Jean Watson has developed a theory of nursing, and extended it to include other disciplines, based on caring. Caritas #1 explains that in order to practice loving care and kindness to others, one must first practice loving kindness of self. Achievement of Caritas #1 and having a “Caritas Consciousness” were the goals for this project, as well as learning about the needs of the patient with chronic pain and having a readiness to employ Caritas #6. Jean Watson’s paradigm of transpersonal caring is presented as the means to an end—that is, the highest quality care for these patients. Watson states “The mode of Caritas thinking invites a total transformation of self and systems” (2008, p. 36). To move toward this aim, a Quali