SITZMAN, KATHLEEN L.
This article proposes using Thich Naht Hanh's concept of interbeing and the practice of mindfulness as a bridge to understanding Jean Watson's theory of human caring. An explanation and comparison of both approaches are provided in narrative and table form. Simple mindfulness practices of nonjudgmental attention to thoughts and awareness of breath are described to provide a starting point for teaching and action. A deeper understanding of interbeing and the theory of human caring, and how they relate to one another, is possible through the practice of mindfulness. Creative utilization of this alternative teaching approach may enhance student understanding of complex principles when teaching Watson's theory.
FIGURE Nursing theories reflect nursing development through time. From Florence Nightingale's Notes on Nursing (1) to Jean Watson's theory of human caring (2), theories are the foundation of nursing thought, teaching, and practice. However, over the course of my career, I have heard many colleagues refer to nursing theories as superfluous and irrelevant to daily practice.
| Figure. No caption available. |
I recently shared a passage from Watson's theory of human caring with a colleague: "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" (3, pp. 32-33). During the conversation that followed, my colleague asked, "Do you actually think about this stuff during your workday?" I explained that I think about it daily - it is who I am and how I view the world. I explained that living "care" as a lifestyle meant caring for myself as well as others - not the traditional objectivist view of providing care.
Since Watson's theory exists without a specific roadmap for how to understand it, or effectively teach it to others, I found myself describing methods I had used that allowed me to grasp the concepts. It occurred to me that I might never have appreciated the deep significance of this theory for nursing practice had I not first studied mindfulness in the Zen Buddhist tradition. Watson alludes to the concept of mindfulness in her writings: "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 [mindfulness]. Practices such as centering, meditation, breathwork, yoga, prayer, connections with nature and other such forms of daily contemplation 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" (4, p. 51).
Sadly, I realized that without a common bridge to understanding this complex theory, my colleague and I might never connect and meaningfully discuss this issue. I wondered if nurse educators could provide tools to students to enable them to more comfortably explore and discuss the hard-to-define aspects of nursing - those things that are mutual and simultaneously happening on several levels at once but are difficult to understand in linear, Western terms, and that may be explored and described in the Zen tradition.
The Challenge of Wholism Nursing practice, as it is taught today, is based on the assumption that it is best to treat the "whole" client. A widely accepted concept of wholistic nursing includes providing care to both the tangible and intangible aspects of human existence: mind, body, and spirit (5). Watson's theory of human caring creates a balanced perspective in nursing education and practice by providing a framework for addressing the mind-body-spirit of nurse and client simultaneously during interactions.
Changes in the health care system have led to the view that nursing care consists primarily of technical tasks that may be measured in objective, monetary terms. This is an error. The core identity of nursing is a combination of technical tasks, multilevel interaction with the patient, and self-reflection and growth on the part of the nurse. While Nightingale addressed the technical tasks associated with the care of the sick, she also discussed attending to their psychological, social, and emotional well-being as important in the overall scheme of care (1).
In her theory, Watson describes the basis or core of nursing as "those aspects of nursing that actually potentiate therapeutic healing processes and relationships; they affect the one caring and the-one-being-cared-for" (4, p. 50). She uses the term trim to describe the tasks associated with nursing care and clarifies their importance in nursing practice: "'Trim' referred to the practice setting, the procedures, the functional tasks, the specialized clinical focus of disease, technology and techniques surrounding the diverse orientations and preoccupations of nursing. The 'trim,' however, is in no way expendable. It is just that it cannot be the center of a professional model of nursing [the 'core'] (4, p. 50).
Nurse theorist Rosemarie Rizzo Parse supports this interpretation. "The tasks and procedures that nurses perform are different in every setting and change as new technologies are invented and new disciplines established. These tasks and procedures are not the core of nursing practice; the core lies in the knowledge that guides the nurse-person process" (6, p. 143).
Traditional linear nursing process as it is widely taught and practiced and Western thinking styles are not easily adapted to Watson's theory of human caring. Thus, exploring a Zen method of understanding may be helpful in shifting perception and deepening understanding of this theory.
Interbeing and Caring/Approaching the Challenge of Wholism Watson's theory has evolved since it was introduced in 1979. The concepts of core and trim are no longer discreet but have become a fluid whole of nursing practice. In 1997, Watson wrote, "The transpersonal caring relationship and authentic presencing translate into ontological caring competencies of the nurse, which intersect with technological medical competencies" (4, p. 50). At this point in the theory's development, the concept of interbeing becomes a powerful tool for understanding and applying the theory.
Thich Naht Hanh, a prominent contemporary Zen master, has created the term interbeing to describe the intersecting and merging of ideas such as "core" and "trim." Interbeing acknowledges that all existence is interdependent and interconnected. "Contemplation on interdependence is a deep looking into all dharmas in order to pierce through their real nature, in order to see them as part of the great body of reality and in order to see that the great body of reality is indivisible. It cannot be cut into pieces with separate existences of their own..." (7, pp. 46-47). Dharmas are described as the components that make up sentient existence and are categorized as bodily and physical forms, feelings, perceptions, mental functionings, and consciousness (7).
This concept of interconnectedness is elemental to wholistic nursing practice, where the whole patient is addressed with regard to mind, body, and spirit. Watson's theory sheds light on this unified reality as it relates to nursing and describes a nondualistic approach to practice.
Empirics Are Part of the Nursing Whole, Not the Whole of Nursing In our efforts to gain respect and validity in the dualistic medical community, the professional nursing community has tended to trivialize wholistic nursing care while embracing empiricism as our core purpose. This emphasis is evident in educational practices as described by many contemporary nurse educators. A corporate trainer who conducts classes for nurses concerning use of intuition in the work setting made this observation: "It became clear that their intuitive side had long been active, yet had been suppressed through rigorous analytical education" (8, p. 157).
The preeminence of empiricism is further evident in the research setting. Results have numeric values and statistical significance attached to them, and it is assumed that the best form of research is that which can be strictly controlled, measured, quantified, and presented as valid. Nurse theorist Margaret Newman agrees: "Nursing claims to be a discipline dedicated to understanding and relating to the health of the whole person, not just the pathology that often brings the person to the attention of health care professionals. The preponderance of nursing research, however, fails to focus on this commitment. In an effort to be scientific, we have allowed our vision to be blurred by the pragmatic demands of objectivity and control. In an attempt to be predictive, we have divided the person into parts" (9, p. 34).
In 1978, Barbara Carper discussed her observation that empiricism is so strongly emphasized in nursing research, "one is almost led to believe that the only valid and reliable knowledge is that which is empirical, factual, objectively descriptive and generalizable" (10, p. 16). Nurse scholars Peggy Chinn and Mae Kramer agree: "The majority of formal knowledge development efforts have focused on empiric knowledge development" (11, p. 14).
Is empiricism the "whole" of nursing? Many nurse scholars do not think so. Carper describes personal knowledge as an important nonempirical component of "knowing" in effective wholistic nursing practice. Personal knowledge, as described by Carper, is quite similar to interbeing and mindfulness. "It is concerned with the kind of knowing that promotes wholeness and integrity in the personal encounter, the achievement of engagement rather than detachment" (10, p. 20).
Chinn and Kramer propose that shifting knowledge development and education to include personal knowing (interbeing and mindfulness) will bring the profession to an integrated position of wholeness and effective practice. "By shifting to a balance in the development of all the fundamental knowledge patterns, a sense of purpose can develop that is grounded in the whole of knowing that shapes and directs nursing practice" (11, p. 16).
The profession of nursing exists because nurses have a desire to engage their lives in attending to both the tangible and intangible realms of human existence as related to birth, illness/wellness, suffering, and death. Dismissing, or overvaluing, any single aspect of nursing practice will undermine the existence of nursing as a distinct profession with valuable contributions to make to an already depersonalized, under-cared-for society.
For nursing to maintain a unique presence, we must embrace a caring continuum that encompasses traditional scientific methods of inquiry as well as qualitative, experiential, and metaphysical inquiry (5). In this way, we will build a valuable body of knowledge that honors the total nursing experience, without diminishing the importance of ethereal phenomena that nurses know exist, but are hesitant to fully acknowledge out of fear of being dismissed and trivialized within nursing ranks and by other professional groups.
Mindfulness as a Solution for Wholistic Integration To appreciate and work within wholistic paradigms, nurses require specific formal preparation and support within nursing education. Simple mindfulness techniques could provide this preparation. Just as training in statistics and scientific method is important for positivistic inquiry and understanding, training in introspection and spirituality is important for naturalistic inquiry and understanding.
While in nursing school, I received adequate instruction in positivistic methods, scant instruction in naturalistic methods, and no instruction in methods associated with alternate ways of knowing and experiencing nursing. While practicing as a nurse in varied disciplines, I often had questions about nursing that could not be adequately addressed using an empirical, positivistic approach. How could I fully engage in nursing practice on all levels of human existence?
Being unexposed to nursing theory that could support my desire to view caring relationships in a naturalistic, wholistic way, I turned my attention to spiritual education in the hope that I could better understand the many dimensions of nursing work. My commitment to wholistic nursing led to exploring frameworks that acknowledged wholeness and interconnectedness.
Zen mindfulness and interbeing best described my deeply held understanding of existence. The practical tools given for cultivating mindfulness were directly applicable to my life and work. Moreover, I found that practicing mindfulness enhanced my empathic and intuitive skills and dramatically improved my physiologic assessment skills, thereby reinforcing my belief that personal knowing and empirical phenomenon are inexorably interconnected.
When I discovered Watson's theory of human caring after years of what I refer to as "mindfulness nursing," I knew this theory described my experience and provided a conceptual framework conducive to further exploration and valid research. I believe nurses would more often attempt to study nursing phenomena based on Watson's theory if they were presented with tools that could provide a bridge to understanding and implementing the theory. Because the concept of interbeing strongly resembles Watson's theory, and because mindfulness techniques create a path to understanding interbeing, mindfulness techniques may be used to aid in the understanding of the theory of human caring.
Similarities Between Interbeing and the Theory of Human Caring Mindfulness is simple to explain and applicable to all areas of life. Thus, it is a valuable practice that is useful in varied environments with diverse personalities. The simplicity of the practice itself, while easy to explain, is challenging to fully understand. The only way to comprehend mindfulness is to practice it.
I have taught mindfulness techniques to clients, students, and colleagues with success across diverse populations. Zen mindfulness is not a religion but a practice, designed to enrich and deepen a person's spiritual experience and understanding based on one's own cultural and spiritual identity. Naht Hanh writes: "[realization and mindfulness] means not to dwell or be caught in a world of doctrines or ideas, but to bring and express our insights into real life. Ideas about understanding and compassion are not understanding and compassion. Understanding and compassion must be real in our lives. They must be seen and touched through the immediacy of mindfulness practice" (12, p. 5).
Similarities between the theory of human caring and Nhat Hanh's mindfulness and interbeing are outlined in Table 1. When Watson's and Nhat Hanh's different descriptive styles are taken into account, entries for numbers 1, 2, 3, 6, 7, and 8 are essentially the same. Number 4 shows a slight difference, with Watson "seeking" transpersonal connection and Nhat Hanh "acknowledging" it. (It is helpful to clarify that in the Zen tradition, the idea of seeking is often replaced with the idea of acknowledging since Zen asserts that one need not seek what is already present.)
| TABLE 1. COMPARISON OF JEAN WATSON'S THEORY OF HUMAN CARING and Thich Naht Hanh's Concepts of Mindfulness and Interbeing |
Number 5 shows a subtle difference between Watson and Nhat Hanh, again because of the Zen focus. Terms like promoting and accepting indicate acting on a phenomenon that does not require anything more than acknowledgement. The terms embracing and acknowledging are often used in Zen to replace terms that evince urgency or transformative effort. Entries for number 9 reflect the same concept, with Nhat Hanh's addition of the basic Zen belief that suffering is inevitable in human existence. This addition is small but significant. For example, a caregiver's attitudes about suffering may depend on an assessment of suffering as an inevitable aspect of the human condition or an anomaly of the human condition.
Number 10 entries differ. Nhat Hanh accepts the notion of effortless coexistence of observable and unobservable phenomenon as part of the same reality, while Watson is simply open to that notion. All told, although their descriptive styles differ, the basic tenets that Nhat Hanh and Watson propose correspond closely, with immediacy and the interconnection of sentient existence providing the basis for both.
Envisioning Interbeing In melding the concepts of the theory of human caring and interbeing, I envision the patient as an ocean. The water is made up of the physical, mental, emotional, psychological, spiritual, and social aspects of the patient. The different aspects flow freely in, around, and through one another, just as water molecules do. Some of the waves are realities of existence that require nursing care, some are not.
The nurse is a gentle wind above the surface that mingles in, around, and through the ocean, responding where intervention is necessary with the understanding that a wave cannot exist without an ocean and wind, and an ocean cannot exist without producing waves. The waves, as part of the natural and ceaseless movement of existence, eventually return to the vastness and peace of the ocean. Our job is to interact with skill, peace, and compassion, and provide whatever intervention we can to calm the waves.
This vision can be shifted to represent human embodiment as well, with each wave representing the manifestation of a human being. A wave may be considered discreet in one sense, since each is discernable during its manifestation, just as a human being is a discreet entity during its embodied existence. A wave, or human being, may also be viewed in the context of complete and unavoidable connection to the ocean, or all of existence, with the ocean representing all of existence.
In describing human existence as a wave, it is possible to envision preexistence as the calm, deep, blue-green ocean. Embodiment, or manifestation, begins as a ripple and continues as a rolling wave that eventually crests and then returns to the ocean. During manifestation, or embodiment, the wave is continually, unavoidably connected to the ocean and all other calm pools, ripples, waves, and crests. The wave (human being) will eventually return, through death - represented by the completely resolved crest - to the vastness and peace of the ocean where all of existence resides.
Envisioning and Engaging in Mindfulness Practice Based on similarities highlighted in Table 1, it is conceivable that mindfulness techniques could encourage understanding and implementation of Watson's theory just as they have, for centuries, aided in the understanding and implementation of Zen. The techniques for cultivating mindfulness are simple but not easy to do. If used with commitment on a daily basis, then deeper appreciation, understanding, and connection to the interdependency of existence will emerge.
Naht Hanh has a suggestion for beginning mindfulness practice: "For beginners, I recommend the method of pure recognition: recognition without judgment. Feelings, whether of compassion or irritation, should be welcomed, recognized and treated on an absolutely equal basis; because both are ourselves" (7, p. 61). 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 across 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 client before you becomes part of the present moment, and in this way, mindfulness creates connection and intimacy in that moment between client and caregiver, thereby deepening the caring exchange.
Another suggestion for beginning practitioners is to have them follow and gently observe their own breath. James Forrest wrote, "Breathing. It comes to many as astonishing news that something as simple as attention to breathing has a central part to play in mindfulness meditation and prayer. It is like a mystery novelist's idea of hiding the diamonds in the fishbowl: too obvious to notice" (7, p. 106). To be mindful is to be presently aware of what is going on in our bodies, our feelings, our minds, and the world. While practicing mindfulness, do not be concerned with distinguishing "good" thoughts from "bad," thus creating conflict within oneself. To acknowledge thoughts as they pass is enough. Only the present moment is real and available to us.
According to the concepts of interbeing and the theory of human caring, there is no time-defined path of caring. Caring is the path that manifests itself from the moment as we attend to self and patient within the context of whatever surrounds us. Newman alluded to these concepts in this way: "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" (9, p. 37).
Conclusion The simplicity of mindfulness practice lends itself to use in varied environments. If practiced regularly, mindfulness is a powerful means to transforming perceptions from fragmented snatches of time and experience to a wholistic, nondualistic flowing awareness of the web of existence that we, our students, and our clients inhabit: "[With mindfulness] we can appreciate the wonders of life, and, at the same time, act with firm resolve to alleviate suffering. 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 inside and outside are helpful in everyday life, but they can become an obstacle that prevents us from experiencing ultimate reality" (12, p. 4).
Watson's theory of human caring exists within this nondualistic web and can be understood, taught, and implemented effectively from the experiential perspective supported by mindfulness practice. Wholistic care is widely recognized as a cornerstone of nursing practice. "The paradigm of nursing embraces wholeness" (9, p. 37). It would be helpful to provide nurses and nursing students with traditional, as well as nontraditional, practices and tools that could enhance their grasp of the profession's wholistic paradigm. We would thereby encourage scholarly exploration of the aspects of nursing we all know exist, but are sometimes hesitant to embrace and acknowledge.
1. Nightingale, F. (1859). Notes on nursing: What it is and what it is not. London: Harrison and Sons. [Context Link]
2. Watson, J. (1995). The philosophy and science of caring (rev.). Boulder, CO: Colorado Associated University Press. [Context Link]
3. Watson, J. (1988). Nursing: Human science and human care. New York: National League for Nursing. [Context Link]
4. Watson, J. (1997). The theory of human caring: Retrospective and prospective. Nursing Science Quarterly, 10(1), 49-52. Article Linker Bibliographic Links Library Holdings [Context Link]
5. Watson, J. (1999). Postmodern nursing and beyond. London: Harcourt Brace. [Context Link]
6. Parse, R. R. (1995). Again: What is nursing? Nursing Science Quarterly, 8, 4. [Context Link]
7. Naht Hanh, T. (1976). The miracle of mindfulness. Boston: Beacon Press. [Context Link]
8. Rosanoff, N. (1999). Intuition comes of age: Workplace applications of intuitive skill for occupational and environmental health nurses. American Association for Occupational Health Nursing Journal, 47, 156-162. [Context Link]
9. Newman, M.A. (1997). Experiencing the whole. Advanced Nursing Science, 20(1), 34-39. Ovid Full Text Article Linker Bibliographic Links Library Holdings [Context Link]
10. Carper, B. (1978). Fundamental patterns of knowing in nursing. Advances in Nursing Science, 1(1), 13-23. Article Linker Bibliographic Links Library Holdings [Context Link]
11. Chinn, P., & Kramer, M. K. (1999). Theory and nursing: Integrated knowledge development (5th ed.). St. Louis: Mosby. [Context Link]
12. Naht Hanh, T. (1993). Interbeing: Fourteen guidelines for engaged Buddhism. Berkeley, CA: Parallax Press. [Context Link]
Key Words: Theory of Human Caring; Jean Watson; Thich Naht Hanh; Nursing Theory; Ways of Knowing; Zen Buddhism
