Introduction – Modern nursing is a rewarding, but challenging, career choice. The modern nurse’s role is not limited only to assist the doctor in procedures, however. Instead, the contemporary nursing professional takes on a partnership role with both the doctor and patient as advocate caregiver, teacher, researcher, counselor, and case manager. Under the paradigm of quality health care, modern nurses should interpret this as “quality patient care” – which comprises three important factors – sound theoretical knowledge of the latest medical procedures, information and innovations; superior communication skills that are multi-culturally based; and the ability to empathize appropriately with the patient and family to buttress the role of caregiver. The necessity for modern nurses is to be far more than ever – more of a multitasking professional with superior communication and organization skills – and even more focused on the holistic model of the patient and the manner in which they, the nurse, affects the outcome of the patient’s care experience (Brown, 2007).
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Theory into Practice – It is a given that the modern nurse will have a far greater exposure to new medical methods, pharmaceutical interactions, and techniques than many nurses of the past. In fact, “the use of clinical judgment in the provision of care to enable people to improve, maintain, or recover health, to cope with health problems, and to achieve the best possible quality of life, whatever their disease or disability, until death” is one of the definitions of modern nursing (Royal College of Nursing, 2003). In fact, with such a vast amount of clinical information needed, combined with the stress of a busy hospital, and the various insurance and legalities to be considered, many contemporary nurse managers find that it is helpful for the modern nurse to utilize a “medical checklist” to improve patient care (Hales, 2008).
In the contemporary world, it is important to note that a more holistic approach is preferable, seeing the patient as more than their disease, and advocating for that patient’s proper care and assistance when they are unable (Kozier, Erb, & Blais, 1997). One of the more critical approaches to the rubric of patient care and advocacy is the Theory of Human Caring, by Jean Watson. This book represents a needed, but dramatic, shift in the modeling of patient care, and remains controversial still. Watson’s theory formed the basis of modern nursing theory and some of the ideas she epitomizes have become part of other theories, among them Marilyn Ray’s “Theory of Bureaucratic Caring for the Nursing Practice.” Some of Watson’s material came from a previous theoretical maxim, that of the “Self-Scare Deficit” based on the book Nursing: Concepts of Practice (Orem, 1971, 2001).
Between 1949 and 1957, Orem worked for the Division of Hospital and Institutional Services of the Indiana State Board of Health. Coming out of the World War II paradigm, Orem immediately found that the health care system often perpetuated illness as opposed to helping cure disease. She believed that the quality of nursing in general hospitals should be upgraded, and to do this, she believed that the patient should take some of the overall responsibility for their care and management of their own ability to deal with illness (“Dorthea Orem,” 2010).
The reason Orem’s model is important when discussing other nursing theories is due to its seminal nature of generalized care and one of the most commonly used in actual practice. Orem’s model has three major templates: 1) Nursing is required because of the individual’s inability to perform self-care in many medical situations, 2) As adults age, they deliberately learn and master actions that help direct their survival, quality of life, and well-being, and 3) The product of nursing systems should be a nurses advocacy to help people meet their self-care requirements and avoid dependency on others (Ibid.).
The significance of these paradigms set up a value system and put responsibilities on both the nursing profession and the client. The nurse’s role is not continual care without the prospect of improvement, nor is it simply to provide medical care without explanation. Instead, the nurse’s role is a bit of a self-advocacy method (advocacy, we will see, is very important for Watson, too). The nurses’ role is to help the patient understand their care, perform care on their own, and be able to remain self-sufficient and independent as long as possible. In fact, Orem’s theory found resonance in the new ways of communicating with patients. Instead of simply providing medication or therapy, but educating the client on their own illness and care, a greater level of empowerment is reached – and a lessening of completely dependence on the health care system (Alligood and Tomey, 2005, 255-9).
One way to understand the way and importance of Orem in the modern hospital situation is to analyze the way the theory has been put into practice:
Takes into consideration the basic factors of age, developmental state, and health care systems. Provide for effective regulation of health and development state by setting forth relationships among component and self-care demands. Specify timing of nursing contact, reasons for contact; actions of nurse, client and others.
Production of Care
Specify time, place, environmental conditions, equipment, supplies, and number of personnel and stakeholders. Coordination of self-care tasks, assist client in performing of those tasks; bring about accomplishment of self-care that is satisfying to the client.
Observation/Appraisal of Care
Make judgments about quality and quantity of care; development of self-care agencies and assistance; judge nursing assistance and make adjustments to determine if operations are in accord with client condition and appropriate care.
(Bridge, Cabell, and Herring, n.d.).
Even though it was published in 1979 and revised in 2008, the book Nursing: The Philosophy and Science of Caring, remains a seminal part of new nursing scholarship/ Discussion abounds, possibly because of the implications of her theory challenge the applicability of nursing practice in the contemporary world of budget cuts and HMO’s, as to less the validity and more the practicality of Watson’s theory. There is a great deal of information on Watson’s theory, critiques, applications, and amalgamations of her theory, and the content and veracity of the information that is available is well documented and explored. 
Jean Watson views nursing as an art and a science, which has the goal of preserving the worth of humankind through the process of caring. Caring is the essence of nursing and a moral ideal: Caring…has to become a will, an intention, a commitment, and a conscious judgment that manifests itself in concrete acts. Watson herself notes that human care is both an ideal and a moral tenet, and it must, for the nurse, move beyond an individual’s frame of reference and ensure that the profession as a whole acts in tandem with a more universal attitude toward the care for all humanity (Watson, 1988, p. 32).
In addition, Watson emphasizes that all individual experience is relatively subjective, and uses the term “phenomenal field” to describe the specific frame of reference arising from the individual. This frame of reference is influenced by a myriad of cognitive stimuli, experiences that are individual and unable to uncover in the initial nurse/patient relationship. Instead, Watson stresses that one take those cognitive paradigms, move them into transpersonal care – and allow the patient to partner with the nurse – all with one goal – complete health for the individual. (Watson, 1988, p. 70). Watson (1988) defines health as harmony between mind, body and soul, and illness as a subjective disharmony between mind, body, and soul. As well, integral to Watson’s theory are the 10 carative factors that serve as a “framework for providing a structure and order for nursing phenomena” (Watson, 1997, p. 50). The 10 carative factors are as follows:
Humanistic-altruistic system of values
Sensitivity to self and others
Helping-trusting, human care relationship
Expressing positive and negative feelings
Creative problem-solving caring process
Supportive, protective, and/or corrective mental, physical, societal, and
Human needs assistance
All of this presupposes a knowledge base and clinical competence (Watson, 1988, p. 75). Watson (1988) believes that nursing must separate itself from the reductionist views of the traditional science medical paradigm and focus on movement towards a human science nursing paradigm. Watson also readily acknowledges that her theory is a work in progress, and she “invites participants to co-create the model’s further emergence” (Watson, 1997, p. 52). This is in accordance with her theory in that she believes that everything is in an unending process of becoming (Watson, 1988).
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Within the Watson theoretical construct, then, the central view for healthcare professionals is that they work diligently to emphasize “care” as more than a mere term, and take it further to engender the universal idea of comfort, attention to a patient’s needs, genuine concern. This idea, certainly historical in its constructs, has no specific chronology, rather has been a part of human nature since the first Neanderthal tribe cared for a sick individual who was unable to hunt for the tribe. It is this overwhelming “caring” that changes Watson’s theory into a practical view for modern health care systems. (Watson, 2008). This universal theory is both intellectually and emotionally attractive, and seems to embody the very principles of health care – however; it was necessary to utilize additional non-internet sources to delve deeper into Watson’s theory.
Marilyn Ray, on the other hand, looks at a slightly wider universe, in a sense the medical anthropology paradigm, and forms a model called the “Theory of Bureaucratic Caring.” While Orem emphasizes the way nursing must model care so the patient can take over some of the responsibility, and Watson primarily seems nursing care as a way to advocate the patient through the mire of modern health care, Ray’s theory emphasizes the interconnectedness of nursing within modern health care systems as a hole. Like Watson, Ray believes that nursing is part of a holistic determiner of care as opposed to the cause/effect template so prevalent in Western medicine. When nurses realize that they represent the entire breadth of medical care (social, spiritual, medical, practical, etc.), then they realize they are treating an organism, not just an imbalance. If one thinks about the contemporary world, one easily sees that changes in the political, economic, legal, and technological world necessitate a broader view of nursing care. This is the power of Ray’s work – it helps find new policies and ways of looking at the human perspective, if even through corporate or governmental policy (Ray, 1989).
If the contemporary nurse asks themselves truly what the most important part of their job would be it is difficult to delineate just one aspect. However, in the past three decades the demographic and psychographic landscape of nursing has dramatically evolved. Combined with the movement towards cultural and economic globalism, the number and proportion of international nurses practicing in the United States continues to increase (Aiken, 2007). Among the most often reported challenges for these nurses, a deficiency in communications is the top, most persistent, issue for employers (Davis and Nichols, 2002). Additionally, the communication paradigm works equally with American trained nurses and an increasingly diverse, multi-ethnic, population – most especially the need to communicate effectively with the patient’s family, many of whom have very poor English skills. However, how can communications be part of a nursing paradigm without looking at culture and the whole person – as Ray does.
What is most important for Ray is that desirable and derivable consequences occur. She challenges the medical field to think beyond their usual boxes and to envision a more holistic world. Once the nursing profession appreciates and responds to the interrelatedness of the individual, one has adopted Ray’s theory (Marriner-Tomey and Alligood, 2005, 132-4).
Conclusions- All parties in the healthcare paradigm have certain expectations of nurses: physicians are ever more reliant upon the expertise and attention to detail from nurses and expect more clinical knowledge; hospital staff see the nurse as the focal point in the wheel of patient care – the “go-to” person who is really a patient care “manager;” the patient tends to view the nurse as the lifeline of communication and empathy; the family the translator of the physician’s diagnosis and the true individual who is watching out for their loved one (Daly, et.al. 2005). Competence, then, for the modern nurse has a number of significant definitions. Certainly, all sides expect the clinical expertise to be a given, as well as continuing education and training on new technologies and treatments. The nurse is almost expected to be prescient, but if not possible, then at least exhaustive in the ability to synergistically interact with all sides of the patient-healthcare equation (Saha, p. 1280-1; Levin and Feldman, 2006).
Thus, the core concept for nurses and the professional and non-professional people they interact with, “care” is one of the fields least understood terms, enshrouded in conflicting expectations and meanings. Although its usage varies among cultures, caring is universal and timeless at the human level, transcending societies, religions, belief systems, and geographic boundaries, moving from Self to Other to the community and beyond, affecting all of life and the ability for nurses, as well as patients, to self-actualize and assist in the healing process (Watson, 2008). This universal theory is both intellectually and emotionally attractive, and seems to embody the very principles of health care. In actuality, though, the new paradigm of Nursing care; whether Watsonian or Ray or the myriad of others, must be an amalgamation of “aesthetic knowing.” For only in that manner can a modern nurse be truly successful (Slevin in Basford, pp. 197-200).
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