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Many cities are experiencing ongoing infectious disease and overdose outbreaks among injection drug users (IDU). In particular, HIV and hepatitis C have become prevalent in many settings, where there is a heavy concentration of IDUs (Jarlais, 2010). In an effort to address this epidemic in Vancouver’s east end neighborhood, Insite opens its doors in September 2003 to become the first facility in North America to open a “medically supervised safer injecting facility, where IDUs can inject pre-obtained illicit drugs under the supervision of medical staff” (Macphee, 2006, p. 2;Shoveller, DeBeck & Montaner, 2010). In light of this facility, Jean Watson’s theory of caring is a central component into understanding the patient/nurse relationship. Watson’s theory is based on the characteristic of humanistic nursing which dictates nurses to view patients as a holistic being, instead of a physical being (Sourial, 2006). In this paper, I will explore the carative factors of Watson’s theory and apply them to the facility of Insite, in hope of understanding the therapeutic relationship that exists between Insite’s nurses and their clients.
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Insite and Injection Drug Users (IDUs)
Insite Harm Reduction Clinic (IHRC) is a health promotion facility for people to connect with health care services. Operated free of charge, IHRC supplies resources for IDUs by providing primary care and treatment for infections and diseases as well as addiction counseling and prevention education (Vancouver, 2003). Nurses at this facility monitor the status of IHRC clients during the pre-injection and post-injection phase to ensure a safe, clean and sanitary environment (Vancouver, 2003). These nurses oversee approximately 600 on site injections per day, effectively decreasing the number of injections performed in back allies of downtown Vancouver. The effect has been profound as there has been a decline in the number of accidental drug overdoses in the area. Although there have been 500 accidental drug overdoses at IHRC, none of these have resulted in death because of the nurses’ monitoring of injections (Macphee, 2006).
Jean Watson defines health as the “unity and harmony with the mind, body and soul” and the “degree of congruence between the self as perceived and the self as experienced” (Watson, 1988, p. 48). Her theory suggests that a client’s health is a subjective experience and that holistic caring is the core of nursing. Human caring is an ongoing interaction with transpersonal processes, which is the foundation for therapeutic relationships between human beings. Watson’s theory focuses on the art and science of nursing, which dictates that both the nurse and the patient seek self-actualization through transpersonal caring relationships (Wade & Kasper, 2006). For instance, nurses look beyond menial tasks and procedures to focus on a more meaningful relationship by connecting with the client and seeing them as a holistic being.
Transpersonal caring is divided through ten carative factors that distinguish human-to-human caring. The carative factors are techniques applied by nurses for use in the delivery of healthcare to the client. Each factor has a phenomenological component that is in relation to the individuals involved in the relationship (Alligood & Tomey, 2010). Transpersonal caring interventions build a deep connection with the individual to provide comfort, pain control, well-being, wholeness and healing (Gallagher-Lepak & Kubsch, 2009).
Watson’s Theory Applied to Insite
Despite comments from former health minister, Tony Clement, describing doctors and other health professionals who support IHRC as unprofessional and unethical, the facility remains open five years longer than originally planned (Federal, 2009; Vancouver, 2003). This demonstrates the caring relationship between the nurses and clients (the foundation of Watson’s theory of caring) as the nurses rallied for support and conducted research to show that IHRC was valuable to IDUs (WorkingTV, 2008). As suggested in Watson’s theory, this relationship must move beyond a simple nurse-client relationship to one involving a deeper connection built on communication, respect and trust; this has been achieved at IHRC as nurses and counselors meet with patients to discuss their current state, progress and/or future outlook (Sourial, 1996). During these discussions, nurses are providing humanistic care by being positive, present (physically and consciously) and providing active, uninterrupted participation. In actuality, the success of IHRC is highly dependent on the one-on-one communication relationship between the nurse and client, which exploits Watson’s notion that communication, is the key to building meaningful relationships (Sourial, 1996; The, 2009)
Overcoming Barriers through Watson’s Carative Factors
Essential health services provided here for thousands of vulnerable citizens, IHRC cares for those who would not likely access any care if it were not for IHRC (WorkingTV, 2008). Assisting these clients at their current state and understanding their situation through empathy, staff at IHRC are concerned for the well being of the client and are interested in helping them attain their goal. Nurses refer to and remember readmitted patients by first name – showing caring and respect to patients. They also go out of their way for patients because they not only oversee injections to ensure a clean environment but also rally for their patients’ needs when faced with community and governmental backlash (The, 2009). Together, all of the above demonstrate a humanistic-altruistic value and human needs assistance which are the first and ninth carative factors of Watson’s theory.
The third carative factor, sensitivity to self and others, is incorporated through differentiating between feelings of the client and nurses of IHRC. IHRC will see the individual as a blank state, which will allow the nurse to build a relationship that can be built on self and self with others (Watson, 1988). They do not prejudge patients because they have used drugs; rather, they practice discernment in evaluating situations and value the intrinsic goodness of self and others. Moreover, nurses understand it is not necessarily every IDUs’ wish to get clean but they continue to support IDUs efforts at healing, whatever that may mean for each patient.
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The fourth carative factor, a helping-trusting human care relationship, is present at IHRC. Many clients that have been going there to IHRC years and both staff and the owner, Darwin, does not only know them by name but also by habits such as times they usually ‘shoot up’. When these patients fail to come to IHRC, Darwin hunts the streets of Vancouver’s east side for them. Darwin and staff alike have strong connections with his clients that they care about them and trust them to make the right decisions. This does not mean staying sober per say, as much staying off the streets and sleeping on a bed (The, 2009). This is important since IDUs do not feel pressured to quit drugs; instead patients feel as if that IHRC is a sacred space of healing when they need it, and the space is offered with unconditional acceptance.
The fifth carative factor, expressing positive and negative feelings, is expressed through the one-on-one communication that occurs between the patient and a counselor. Not all talk is positive at IHRC – negative feelings exist, which is often related to the root of their addiction. Every individual that formally spoke to counselors at IHRC experienced some form of abuse at one period in their lives. For female patients, this was always in the form of sexual abuse while males experienced physical and/or sexual abuse (The, 2009). Nurses at IHRC provide a sacred space (to allow unfolding and emerging) and help them deal with their negative feelings.
Barriers in Treating IDUs at IHRC
The nurses working at IHRC are able to nurture a caring relationship between themselves and the drug-injecting patients. For me, this is admirable as I would have some barriers connecting with the patients on a spiritual level and thereby incorporating a patient’s beliefs into their care plan. However, I would try to overcome these barriers by learning about their religions and make a conscious effect to support their beliefs. This would allow me to be sensitive to their values and allow me to accept them on a basic spiritual level and see them as unique and worthy of caring. This will promote the occurrence of caring moments, ultimately leading to authentic helping-trusting caring relationships.
To conclude Watson’s theory I will protect, enhance, and preserve humanity by helping a person find meaning in illness, suffering, pain and existence. Instead of prejudicially deciding a person’s well being, I will interact with them, not just physically but as well as emotionally, spiritually and mentally (Wade & Kasper, 2006). Watson’s theory emphasizes on the basis that all human have goals of self actualization and through caring and helping another person, you can achieve a higher sense of well being within yourself (Watson, 1988).
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