Today, in health care systems, considering the requirement behind applying high-level care standards and methods, high-quality care is expected to be taken into account as a major objective (1-3). In this regard, the most significant element that helps health care providers fulfill their commitment to their clients is knowledge (4, 5). Therefore, the development of different care approaches such as palliative care in clinical practice requires sufficient knowledge. Adequate knowledge in every profession originates from the theories of that profession. Such theories supply a framework for practice in different areas and help health care providers provide standardized and systematic care (5, 6). In addition to facilitating the standardized care provision, employing such theories can be an important step in promoting a profession. Accordingly, theories should be viewed as the basic structure and the building block of the body of knowledge in any profession. Over the past 3 decades, special attention has been paid to human-centered care, and one of the theories that focus on the humanistic approach is Watson’s human caring theory (7). Concerning that, the elements of this theory can be used in a variety of areas appropriate for health care. One of the health care provision areas, especially in nursing in dealing with chronic diseases such as cancer, is palliative care. Given the properties of these areas of health care, Watson’s human caring theory can be employed in this respect. However, applying this theory in Palliative care has not been repeatedly used in the clinical field. Therefore, this paper addresses the use of this theory in palliative care.
1.1. Background in Human Caring Theory and Palliative Care
Watson assumes that health care should be provided based on human values, which emphasize the human components of care (caregiver and care given) and momentary confrontation between them (8). According to Watson, care is desirable ethics that ultimately leads to the maintenance and promotion of human dignity and the goal behind caring is to help the individuals achieve a higher level of harmony between mind, body, and soul, which indicates health (9). This goal is gained through “human-to-human” care processes and interactions and under the influence of such care, self-healing, and self-control flourishes (10). Watson defines a human being as a valuable person for being cared for, respected, fostered, understood, and helped. The key concepts employed by Watson in his theory cover the following: Transpersonal caring; this concept is considered the guiding principle of ethical, spiritual, and philosophical values. Clinical caritas processes; Caritas shows charity and compassion, generosity, and benevolence of the soul. Caring moment; the correlation between the two persons occurs at one moment and at a point, and at that moment, they get the opportunity to decide how to act. Caring consciousness; in care consciousness, the nurse seeks to discover the significance behind giving meaning and importance to a certain person. Caring-healing modalities; nursing interventions have been proposed as “modalities” of care-healing in this theory. These interventions are related to the full partnership of the nurse with the patient.
Palliative care is an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness through the prevention and relief of suffering. Palliative care focuses on comfort and compassionate care for persons, whose life-limiting illness is no longer responding to curative treatments. Through an interdisciplinary team of palliative care focuses on the uniqueness of each individual and satisfies the physical, psychological, social, cultural, and spiritual needs of patients (11).
Due to the erosion and vulnerability of patients with life-threatening diseases, especially cancer, attention to the patients and their family as a human is one of the basic principles of palliative care, and Watson’s theory of human caring is based on this principle. Although the theory of human caring can be used in other areas of health care, its use in the field of palliative care, especially in countries that are in the early stages of organizing palliative care, according to its philosophical principles can provide a common language in the patient care. Although palliative care and human caring theory have several concepts, in an in-depth look at both models it can be inferred that human caring theory and palliative care practice can be linked through two major concepts (human uniqueness and transpersonal relationship). Because these two concepts have been the dominant concepts of both models, which show their existential philosophy, other concepts have been centered around these concepts.
2.1. Human Uniqueness
The theory emphasizes that everyone is unique and specifically present in the current situation. As a unique person, each individual has a particular vision that can see, hear, feel, understand, and experience the world, and bring meanings to that world. Through this vision, the individuals get the ability to experience their true self, which in turn allows the individuals to experience their perspective and become aware of themselves in the world because they establish their relationships with others (9, 10). One of the main aspects of the human caring theory concerning human uniqueness is their intrinsic capacity and the freedom to react to the conditions they confront. Through this self-reflection, the individuals can think about past experiences and employ them to better understand themselves (12). In the context of palliative care, this self-reflection and self-awareness by the patient and the health care provider can help them understand the meanings of life-threatening illness, its induced problems, and the end of life. Also, paying attention to the intrinsic capacity of the individual and patient-centeredness in palliative care using the humanistic perspective can potentially bestow a new meaning to the individual’s life and create a sense of well-being in them (13). Recognizing and being aware of the unique personal traits facilitates caring for patients, who require palliative care regarding their requests and concerns (14). Although the inherent capacity and freedom including the patients receiving palliative care, this issue encompasses the nurses providing service (15, 16). One of the angles of selection capacity in palliative care is though the patients requiring palliative care forcefully find themselves on the path to receive palliative care, the issue as free choice and autonomy are of the main elements of care ethics for the patients and palliative care is considered in all health care services. On the one hand, health care providers voluntarily enter the palliative care field according to their health care system laws; in this case, this type of selection and professional commitment of the health care providers introduce them as palliative care specialist and provide an opportunity for their growth in a new direction.
In the human caring theory, health is considered one of the indicators of quality of life or death; it considered through the potential of the individuals for being good and better and nursing merely emphasizes people’s well-being and is responsible for helping people at the right time (12). In palliative care, though death is viewed as a natural process in human evolution when it appears in reality, it creates a feeling of pain and affliction, which is usually difficult to accept (17). Under such circumstances, caring the patients with life-threatening diseases must always accompany with the interests of the patients, maintaining independence, and the ability to make decisions.
One of the aspects to consider the uniqueness of humans in palliative care is spirituality, in which the palliative care providers are looking for and maintaining the meaning and goal in the patient’s life. The present research pursues the goal to promote the patient’s life and can work as a key factor in the patient's adaptation to the disease, recovery, and existential integration (18). Although the issue known as spirituality in Watson’s theory has not been stressed separately, Caritas sub-concepts as reinforcing factors of care indicate special attention to the patient and imply the patient’s uniqueness that is also focused on when communicating with the patient. Thus, considering that spatiality is paying attention to the uniqueness of the patient as a human being stressed by Watson’s theory and palliative care and this emphasis in communicating between the care provider and the patient has been demonstrated with such concepts as transferring faith and hope, presence, empowerment, and creating peace in the patient (2, 19-21).
2.2. Transpersonal Relationship
In Watson’s theory, although the person’s individuality is respected, they must be in contact with other people within time and place. As stated by the concepts, humanistic caring goes beyond one-sided relationships (12) and in the field of palliative care, patients share their care needs with their relatives and health care providers (22). Palliative care is relevant via granting value to ethics and a set of experienced feelings expressed by humans. The central value of care ethics is human dignity, with an emphasis on the relationship between the patients and the health care providers. In line with this relationship, Watson assumes that in clinical Caritas processes, care combined with love is a moral ideal for nursing that ultimately preserves and enhances human dignity (12). Through redefining Caritas processes, Watson has granted it the potential as an implementable model so that the clinical love process is provided, using this model as a useful and comprehensive framework in caring for the patients to thoroughly and quickly identify the patient’s psychological and spiritual needs. On the one hand, the clinical love aspects of the theory can be applied as a model, the philosophy of ethical codes for changing oneself, and/or one’s performance in palliative care. Creating a transpersonal relationship considering Caritas processes is the main route to maintain human dignity as a moral value. To maintain human dignity as a moral value in palliative care is of the significant patient-oriented concepts (23, 24) and one of its aspects is to pay attention to the patient’s needs. Therefore, the interpersonal transaction promotes a supportive system that helps the patient act as active as possible and feel that his needs have been met (25). One of the dimensions to focus on the patient’s needs in providing palliative care is to relieve various physical and mental suffering of the patient (11, 26). Moreover, relieving the patient’s pain and suffering is an aspect of important ethical considerations in patient-oriented care provision. Aligned with the above issue, Watson mentioned some methods of care/healing, such as using music and touch that are applied concerning others as a vulnerable and/or hurt whole and with their interaction and cooperation to lower the patient’s suffering and in palliative care also employing different care methods like music therapy, yoga, and psychological support are observed for alleviating the patient’s suffering (27-30). When the palliative care providers respond to the individual needs, a targeted transaction occurs between the individual and the nurse. This transaction is intersubjective and takes place in a specific condition, time, and place (12). In this process, the health care providers are accessible and present along the patients; such presence is considered a strong intervention in palliative care (31). In Palliative Care process, the health care providers are present at all stages of the process and participate in supporting the patients and their families to deal with a variety of problems they are facing. This partnership not only includes pain management, respiratory failure, anxiety, depression, and other disorders but also encompasses sharing care decisions about care for the patients and their families (32). Care providers constantly evaluate the patient’s abilities and needs and stimulate their maximum participation in the empowerment plan. Therefore, caring is a guiding activity nurturing the individual’s human potential. This potential is represented by the concept of “well-being” within the limits of a person’s current and future living status. “Well-being” is one of the critical issues in palliative care pointed out by the studies on this topic (21, 33-35). The concept of “well-being” also reflects the meaning in life, which is related to factors such as human relationships (patients to care providers), health status, activities and social relationships, contexts of care, and culture (36, 37), The main source of meaning in life is human relationships (37).
Human care includes the real and legitimate presence and live and valid dialogue between the health care provider and the patient, and this real presence is part of the concept of the environment in caring. This environment supplies an atmosphere facilitating communication at the individual and collective levels and is not confined to the measures of the physical domain (12). In this regard, the palliative care framework requires the health care provider and the patients to be together and at the time and place of this connection coverage, which results in creating an appropriate harmony and balance and helps satisfy the patient’s needs. For example, the presence and availability of health care providers for patients with cancer receiving palliative care are one of the main domains of establishing an emotional bond with the patient; this strategy is one of the inseparable parts of care and the experiences of palliative care providers also emphasize this issue (38). Communication is essential to help the patients discover controlling feelings and allowing their active participation in care decisions. By creating this caring relationship, the care providers and the patients feel secure and their trusting each other increases (39). From this perspective, when providing palliative care, the health care provider must avoid performing exclusive actions and adapt to the needs of the individuals to provide the best quality of life in the disease experience. In this transaction, trust- and support-based relationship is created with the patient receiving palliative care, which will ultimately lead to the patient’s comfort (40). The main element of creating peace and comfort in palliative care is self-esteem and the quality of life improvement (39). Thus, palliative care providers should possess the potential to understand the world of the patients, provide comprehensive care, and focus on the demands of the patient and their family. Besides, when the palliative care providers are empathetic and reliable, they can understand the stress and suffering of the patient and their family and support them in dealing with life-threatening conditions, the issue which is mentioned in other studies (41, 42). Decent relationships are influenced by factors such as the individual values, beliefs, feelings, experiences, and the person’s inclination to communicate with others (43); considering these factors can be effective in establishing close communication and fulfilling and deeper intersubjective transaction. Of course, the ability of the health care provider and the patient to pay attention to the above factors will increase their potential to understand each other and transact with each other.
Although Watson’s human caring theory describes the phenomenon of health care provider-patient relationships, its use in palliative care is limited. For instance, the major theory concepts are defined in abstract conditions, whose application is difficult in clinical practice. Therefore, it is necessary to define the central concepts objectively and operationally and be employed in the clinical practice. Another concern is born due to the theory emphasizing the intersubjective nature of the health care provider-patient relationship. This emphasis involves consciousness and choice to respond to the needs that both of them are difficult to provide care for the patients lacking the power to choose. In other words, the patients in their end of life may be deprived of two factors, namely, knowledge and choice, in which the intersubjective transaction will be impaired; however, such a relationship must be developed between the nurse and the patient’s family. Also, the human caring process and the time it takes to establish a reliable and mutual relationship with the patient may not be possible for compulsory care settings, where there is a brief clinical encounter. Therefore, it is essential to build care environment structures applying human caring theory in palliative care in such a manner that a reliable care relationship is created between the nurses, doctors, and patients. In various societies, a variety of health care settings such as nursing homes, community-based care centers, home care, and all clinical settings have been considered for building the proper structure and mentioned in various studies (44-46).
The aspects of suffering associated with life-threatening diseases imply the need to develop scientific and human care, which enable health care teams to provide effective responses to the problems experienced by the patients and their families. The human caring approach is congruent with the palliative care values and goals. In this regard, the health care provider and the patient consider their views the basis of their relationship. Palliative care specialists must understand that every human being is an exclusive entity with their past and their own experience and has lived in their way. This caring approach shields the health care provider against prejudgments. Therefore, they can go beyond their prejudices to accept the patients.
Watson’s Theory is a theory of care and guidance for providing human care regarding the patient’s dignity in a variety of areas including palliative care. Besides. Watson’s theory is a general framework that can be used in different conditions and places and analyzes the patient in their cultural context, family, and society that allows the health care provider to get adapted and provide unique care. Using the core theory concepts can provide a common language for all health care providers in care and intervention planning in palliative care. In these clinical care plans of palliative care, the humanistic relationship framework and strategies such as paying attention to the spiritual aspects of the patient’s life, meeting the patient’s needs through purposeful care, effective presence, and practice of love and kindness can be used to provide services to patients. Palliative care performance is more than a human caring relationship so that specialized management practices of symptoms, interventions to relieve mental suffering, and using different practical strategies should be presented based on universal theories and evidence gained from the studies-derived results.
In addition to utilizing the concepts of Watson’s theory in the palliative care field, one of the aspects, which pave the way to apply such concepts, is the training area of palliative care to the health care provider. Employing concepts like a transpersonal relationship, spirituality, and reliving the patient’s suffering, Caritas processes can be employed as an appropriate basis for palliative care training topics and content for the health care provider.
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