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Criticisms of existing nursing theories in relation to community health nursing practice are that they focus on individuals and have been developed primarily for practice within the context of infirmity and disease, making them inadequate to guide community health nursing practice. Despite being developed for individuals, Watson's theory is proposed as a nursing framework that is philosophically congruent with contemporary global approaches to community health and health promotion.
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Watson's Philosophy, Science, and Theory of Human Caring as a Conceptual Framework
for Guiding Community Health Nursing Practice

[Communities and Systems]

Falk Rafael, Adeline R. RN, PhD
Assistant Professor; College of Nursing; University of Western Ontario; London, Ontario
Outline
Abstract
OVERVIEW OF WATSON'S THEORY OF HUMAN CARING

Preparation of the nurse

The transpersonal caring relationship

Caring processes
WATSON'S THEORY OF HUMAN CARING AS A CONCEPTUAL FRAMEWORK FOR COMMUNITY
HEALTH NURSING
REFERENCES
Appendix Community Assessment Guided by Watson's Theory

COMMUNITY IDENTITY

COMMUNITY SPIRIT

INTERNAL AND EXTERNAL ENVIRONMENTS

COMMUNITY CAPACITY TO MEET BASIC NEEDS OF MEMBERS

COMMUNITY CAPACITY TO CARE FOR ITS MOST VULNERABLE MEMBERS

COMMUNITY CAPACITY TO MEET SOCIAL NEEDS OF MEMBERS

COMMUNITY CAPACITY TO PROMOTE GROWTH AND DEVELOPMENT OF ITS MEMBERS

SUMMARY

Abstract^

Criticisms of existing nursing theories in relation to community health nursing practice are that they focus on
individuals and have been developed primarily for practice within the context of infirmity and disease, making them
inadequate to guide community health nursing practice. Despite being developed for individuals, Watson's theory is
proposed as a nursing framework that is philosophically congruent with contemporary global approaches to
community health and health promotion. An overview of her theory identifies the centrality of caring, holism, and
ecology in the theory as it has evolved over the past 20 years. Concepts developed for individualDnurse interactions
are extrapolated to the community in a discussion of the suitability of the theory to guide community health nursing
practice. A community assessment tool based on Watson's theory is provided.
Commonly, public/community health nursing scholars lament the paucity of nursing conceptual frameworks
that are useful in guiding community health nursing practice. Their concern is frequently echoed by public health
nursing practitioners who, not uncommonly, dismiss nursing theories as irrelevant to their work. Yet, at the same
time, either knowingly or unknowingly, public health nurses inform their practice with theories from other
disciplines as diverse as medicine, sociology, psychology, and even business. 1 Because many of those theories
emanate from paradigms incongruent with a nursing philosophy, it seems logical to assume that they contribute to
the increasing loss of identity and invisibility that has been reported among public health nurses. 2-5 Although the
reasons that nursing theories frequently are not perceived as useful to community health nurses and, at the same
time, those from other disciplines are enthusiastically embraced are many and complex, the limitations of existing

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Copyright © 2000 by Aspen Publishers, Inc.
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nursing theories for community health nursing practice are an important factor and bear further consideration.
Two major criticisms of existing nursing theories are that they focus on individuals, and they have been
developed primarily for practice within the context of infirmity and disease. They are, thus, inadequate for a
population-focused health promotion approach in which the focus of nursing attention moves beyond the individual
to the community, population, or group. Although considerable work has been done to extrapolate Neuman's theory
to the community, 6 and Helvie 7 recently developed a systems-based theory for community health nursing practice,
a conceptual framework that recognizes the primacy of relationship in community health nursing work and informs
an empowering approach to the health promotion of communities is lacking.
This article proposes that Watson's philosophy/science/theory of human caring, although also developed with
individuals in mind, has the potential to be such a framework because of its philosophic congruence with community
health nursing. That congruence was evident in the first publication of Watson's theory in 1979 when, remarkably
for the time, she offered a critique of the medical domination of health care and devoted a whole chapter to
nonmedical determinants of health. 8 Watson's position at the time was in keeping with those of others that began to
surface internationally at approximately the same time and formed the basis for contemporary global approaches to
health and the health promotion of communities. 1 Watson's critique, however, is grounded as much in Nightingale's
legacy and vision of nursing as it is influenced by health care critics such as Illich. As such, it offers the hope of
returning community health nursing practice to a nursing center and restoring the strong nursing identity and vision
of early community health nursing leaders such as Nightingale and Wald.
My explication of the relevance of Watson's work to community health nursing practice is grounded in my
own experiences with using Watson's theory as a practicing public health nurse, examining public health nursing
practice through research, and facilitating the learning of students who use Watson's work to guide their community
health nursing experiences. Before examining Watson's theory as a conceptual framework for community health
nursing practice, however, a brief overview of the theory itself is instructive.
OVERVIEW OF WATSON'S THEORY OF HUMAN CARING^
Watson's 8,9 theory of human caring has evolved over the last 20 years. First published in 1979 as a basic
nursing text for baccalaureate students, Watson later expanded her ideas to "elucidate the process of human caring
[and to] preserve the concept of the person in our science." 8(p ix) In her latest book, 10 Watson continues her
visionary quest to move nursing's caring-healing practices from the margins to the center of societal health and
healing practices. This work strongly reflects the influences of consciousness theory, noetic sciences, quantum
physics, transpersonal psychology, Jungian psychology, and feminist theories, among others, that have gained
prominence in her work over the past decade. 11-15

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At least three factors make Watson's theory unique among nursing theories. First, it stresses the importance of
the lived experience not only of the client, but also of the nurse. Both come together in a caring moment that
becomes part of the life history of each person. Second, the theory acknowledges the unique dimensions of
mindbody-spirit without compromising the wholeness of the person. Although some critics insist that
acknowledging dimensions of a whole is tantamount to reducing it to parts, Watson's approach may be viewed as
similar to appreciating the unique contribution of each color of a rainbow to the beauty of the whole or each musical
note to the grandeur of a symphony. Her assertion of acknowledging parts without compromising the whole is based
on the holographic paradigm that suggests the whole is in the parts. 12 Third, Watson's theory of nursing values and
explicitly acknowledges multiple ways of knowing, including empirical, aesthetic, ethical, and personal knowing.
Watson's humanistic, existential, and metaphysical conceptualization of human beings underpins her view of
both the transpersonal caring relationship that is central to her theory and her conceptualization of health-illness. She
views human beings as beings-in-the-world with dimensions of mindbodysoul that, in health, exist in harmony. 9
Conversely, illness results from conscious or subconscious disharmony and may lead to disease. Inherent in
Watson's conceptualization of human beings is the metaphysical potential for self-healing and transcendence to
higher levels of consciousness. From her perspective, the patient/client is the agent of change and is primarily
responsible for allowing healing to occur with or without external coparticipant agents of change (of which the nurse
may be one).
Watson describes her concept of soul as "spirit, or higher sense of self" 9(p45) and notes that it most closely
resembles the psychologic concept of self-actualization. Unlike Maslow's theory, however, in which the need for
self-actualization is only activated after all other needs are met, striving for actualization of one's spiritual self is for
Watson the most basic human need to which all other needs are subservient. Spirit is "greater than the physical,
mental, and emotional existence of a person at any given point in time" and is tied to a "higher degree of
consciousness, an inner strength, and a power that can expand human capacities … and cultivate a fuller access to
the intuitive and even sometimes allow uncanny, mystical, or miraculous experiences." 9(pp45-56)
The human potential for self-healing and transcendence to higher levels of consciousness informs Watson's
vision for nursing, which is "to help persons gain a higher degree of harmony" 9(p49) through a transpersonal caring
relationship. She characterizes this relationship as one of mutuality in which the whole nurse engages with the whole
client, each bringing her or his own experience and meaning to an actual caring occasion. The transpersonal caring
relationship at once recognizes the value and importance of both the client's and the nurse's subjectivity. As a result,
a number of the 10 carative factors identified in Watson's theory focus on preparation of the nurse prior to
interaction with the patient/client.

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The carative factors in Watson's theory are not linear "steps" to human caring but represent the core of
nursing (in contrast to the trim). 15 Watson described the carative factors further as "those aspects of nursing that
actually potentiate therapeutic healing processes and relationships; they affect the one caring and the one-being-
cared-for." 15(p50) Although the carative factors are the attributes of caring that characterize the transpersonal caring
relationship, 9 some more clearly focus primarily on the nurse, the relationship, or the processes of caring. Important
to note is that the 10 carative factors are based on a knowledge base, clinical competence, and healing intention. 8
Preparation of the nurse^
Watson values and attaches importance to both the nurse and the client in the transpersonal caring
relationship. Caring-healing within her caring framework begins with the preparation of the nurse as indicated in the
first three carative factors: a humanistic-altruistic system of values, faith-hope, and sensitivity of self and others.
Human caring, according to Watson, is based on human values such as "kindness, concern, and love of self
and others." 8(p10) She differentiates altruism from self-sacrifice and describes it as a fullness of being that allows the
nurse to be authentically present with clients. 16 Watson states that a humanistic-altruistic value system begins early
in life but continues to be influenced through interactions with parents, family, friends, and others, including nurse
educators. Furthermore, she asserts that such values can be developed through consciousness raising and
introspection. Watson believes that the carative factor she labels as "faith-hope" interacts with the first to enhance
caring-healing. 8 From the perspective of the nurse's belief and value systems, this involves gaining knowledge of
mindbodyspirit integration and valuing the therapeutic effects of faith-hope.
Influenced by the work of Carl Rogers, Watson asserts that a balanced sensitivity to one's self is foundational
to empathy. 8 Sensitivity to self includes reflection on one's own thoughts, feelings, and experiences in the clinical
setting and development of one's own potential. It allows the nurse to be fully present to the client, not hidden
behind professional detachment. Developing sensitivity to self involves values clarification regarding personal and
cultural beliefs and behaviors such as racism, classism, sexism, ageism, and homophobia, among others, that might
pose barriers to transpersonal caring. Finally, sensitivity to self includes an awareness of the interconnectedness of
all things and beings and of the social, historical, and political context that shapes nursing practice and nurses' vision
of what is possible. 10
The transpersonal caring relationship^
Four of Watson's carative factors focus on the transpersonal caring relationship. 9 Two, which have been
discussed from the perspective of the nurse, are also important to the client-patient relationship. Faith-hope extends
beyond the nurse's understanding of the integration of mindbodyspirit and also involves fostering faith and hope in
clients, based on the client's, and not the nurse's, belief systems. 16 Whereas sensitivity to self is clearly important in

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Copyright © 2000 by Aspen Publishers, Inc.
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the preparation of the nurse to care, sensitivity to others refers to a way of being in relation to clients and is critical
to the caring relationship. It allows for the nurse to be changed through the caring relationship and is fundamental to
facilitating authentic communication.
Two carative factors relate to interpersonal communication as the basis for the therapeutic relationship.
Establishing a helping-trusting, human care relationship is pivotal to Watson's theory and is informed by the first
three carative factors. 16 Watson states that the development of a helping-trusting relationship involves
intentionality and a consciousness directed at preserving the integrity of the person. As noted, she credits much of
her thinking on therapeutic relationships and communication to the work of Carl Rogers and identifies congruency,
empathy, and warmth as foundational to a caring relationship that facilitates the client's expression of emotions.
Congruency refers to authenticity and genuineness, empathy reflects understanding of both the content and emotion
the client is communicating, and warmth is the degree to which the nurse conveys caring to the client. 17 Gazda,
Childers, and Walters 17 note that warmth reflects respect and acceptance and is communicated extensively by
nonverbal behaviors.
Caring processes^
The remaining five carative factors address those aspects of caring that primarily involve assessing client
health priorities and needs, planning to address those priorities, contributing to meeting client health goals, and
evaluating the effectiveness of the caring processes in promoting client health and healing. These carative factors, as
do the others, occur within a context of mutuality in which both patient and nurse together decide not only what
caring processes will be used but also the role each will assume. 18
Watson identifies the creative, reflective use of problem solving as a carative factor. 16 However, she stresses
that this is not a linear, cause-and-effect approach to problem solving, but it is a creative process that allows
interaction of multiple factors and requires not only scientific knowledge but also personal or intuitive, aesthetic,
and ethical knowledge. In addition, the whole process is reflective, suggesting that evaluation is constantly occurring
and influencing the assessment, caring process, and caring relationship. Watson prefers the term "caring process" to
"intervention," because she notes the latter has a mechanistic connotation that is inconsistent with her ideas. 9
Each carative factor interrelates with the creative, reflective use of the problem-solving (nursing) process and
guides the process and content of assessment and evaluation, the nature of planning, and the direction of nursing
actions. The last three carative factors are particularly helpful in guiding content and organizing assessment of
clients and are discussed in more detail below. Watson rejects the connotations of power conveyed by diagnostic
language as well as the diagnostic process in which nurses assess and judge other human beings. 10 Instead, the
nurse and client mutually determine conclusions about client strengths, goals, and needs. This requires that the nurse

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Copyright © 2000 by Aspen Publishers, Inc.
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create an opportunity for active participation of the client in the caring process to the extent that the client is
able/willing. In this process, in contrast to a consumeristic approach, nurses actively facilitate clients' authentic self-
determination, including making their knowledge, expertise, and professional judgment available to clients for use in
making health decisions. 19 Nurses help clients express realistic health goals, facilitating clients' empowerment to
assume as much of the responsibility for health work as they are willing or able.
One of the nursing activities that the client and nurse may decide will be helpful for the client in achieving
health goals is the carative factor related to transpersonal teaching-learning. Although an understanding that the
nurse and client both teach and learn from each other is implicit in the label for this carative factor, teaching-
learning is concerned with enhancing a client's response to health concerns. 8 It is not the didactic giving of
information, but it includes an exploration of the meaning of the situation for the client. 16 Teaching-learning is
based on the tenets of teaching-learning theory and involves the acquisition of knowledge and skills that are
important in the development of self-efficacy. It often contributes to clients' empowerment by enabling them to gain
or regain some control over their health.
Action contributing to a supportive, protective, or corrective mental, physical, sociocultural, and spiritual
environment is the carative factor that has perhaps undergone the most dramatic change in emphasis over the last 20
years. Although environment was broadly conceptualized in Watson's earliest work to include mental, physical,
social, and spiritual environments, her early emphasis was much narrower than her more recent work. Discussion of
internal and external environments focused on stress, comfort, privacy, safety, and clean aesthetic surroundings. 8 In
broadening the focus of the immediate environment, Watson revisited Nightingale's model and reframed her
discussion from the perspective of Nightingale's wisdom regarding the importance of the environment in facilitating
healing. Watson has brought each of the tenets of Nightingale's 19th-century model into the 21st century by
illustrating them with contemporary and futuristic nursing actions to create healing environments. 10
In her most recent works, Watson also developed further the notion of spiritual environment. Drawing on
sources as diverse as Eastern philosophy, 12th-century mystic Hildegard von Bingen, and 20th-century artist Alex
Grey, Watson situates body within spirit within a field of consciousness that is connected and integral to all
consciousness. 10 Within this conceptualization, the nurse moves beyond creating healing environments to
becoming a healing environment through the intentional use of consciousness. 20 Watson believes consciousness
can be shared, creating new energy fields with healing potential in the process. 10 The implications she draws from
the interconnectedness of all things do not stop with human interactions but extend to issues that are critical to the
health, healing, and survival of the earth and all life on it, revealing an ecologic aspect to her theory.

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Copyright © 2000 by Aspen Publishers, Inc.
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The sociocultural environment of the patient/client is the least developed aspect of this carative factor.
Although issues traditionally associated with sociocultural concerns, for example, economic status, ethnicity,
cultural values, norms, and healing practices, are not explicitly discussed, Watson's emphasis on interconnectedness,
mutuality, and the nurse's goal to facilitate client self-determination implies their consideration. Aspects of the
social, cultural, and political environments that are discussed at length relate to a postmodern analysis of the place
and value of caring, healing, and women's voice in a patriarchal society. 10,13 Clearly this discussion, although
focused largely on the implications for nurses and nursing, also has significance for clients.
To frame her discussion of human needs assistance, Watson initially drew on the work of Maslow. She
described this carative factor as being a systematic way of attending to an individual's comfort and well-being,
including symptom management. 16 Depending on the role that the nurse and client negotiate, the nurse may
advocate for the client with other health professionals and health care agencies and may assist the client in
advocating for himself or herself. In her earlier work, Watson categorized human needs in terms of biophysical
needs such as food and fluids, elimination, and ventilation; psychophysical needs such as activity, rest, and
sexuality; psychosocial needs such as achievement and affiliation; and intrapersonal-interpersonal needs such as
self-actualization. 8 This framework for human needs, along with a systematic review of internal and external
environments and consideration of existential-phenomenological-spiritual forces, provides a useful schema for
organizing an assessment.
The allowance for existential-phenomenological-spiritual forces is perhaps the most difficult of all carative
factors to understand. Watson notes that this factor is closely related to self-actualization, but whereas self-
actualization is concerned primarily with the pursuit of life goals, this factor focuses on a person's search for
meaning in experience and purpose in life. Carative processes related to this carative factor center around being fully
present with clients and helping them explore the meaning of an experience, the means by which they transcend
life's predicaments, the meaning of life and death, and belief systems through which they find a sense of purpose.
A brief overview cannot possibly reflect the intricacies of Watson's philosophy, theory, and science of caring.
It can, however, serve as a basis for extrapolating key concepts into a framework that may be used to guide
community health nursing practice.
WATSON'S THEORY OF HUMAN CARING AS A CONCEPTUAL FRAMEWORK FOR COMMUNITY
HEALTH NURSING^

Resistance to using Watson's work to guide community health nursing practice is usually related to the
centrality of the transpersonal relationship to her theory and the question of how it can translate into nursing practice
in which communities are the focus of attention. Gadow, who significantly influenced Watson's conceptualization of

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Copyright © 2000 by Aspen Publishers, Inc.
Volume 23(2), December 2000, pp 34-49


the nurse-patient caring relationship, believes the philosophy underpinning a person-to-person relationship extends
to a person-to-community relationship (Personal communication, July 1993). Her work with Schroeder 21
explicated that relationship in a reconceptualized notion of community as partner, in which the goal of the nurse is to
enhance community self-determination. That idea of partnership is congruent with the concept of mutuality that is
central to a transpersonal caring relationship. It is equally congruent with global approaches to health articulated in
the tenets of primary health care, 22-24 the principles of health promotion, 25,26 and models of community
development and empowerment. 27-29
The centrality of relationship to effective public health nursing practice also has been documented in recent
community health nursing research. 2,30 These studies not only show the integral connection of the nurse with the
community, but they provide evidence that effective public health nursing practice cannot dichotomize the
community from the individuals within it. Although such a statement may seem self-evident to community health
nurses, external pressures on community health nursing practice have in some instances shifted nurses' practice
away from communities to individuals, 5 and in others from individuals and families to communities and
populations. 1
A holistic approach that recognizes the interconnectedness of a community's health with that of its constituent
members would not be congruent with a view of holism that denied attention to parts. Watson's theory, which
recognizes the whole in the parts, supports a focus on the wholeness of a community, aggregate, or population,
while still attending to the individuals and families within it. In extrapolating ideas such as mindbodyspirit to
community, it is not difficult to see how "body" of a community may refer to physical attributes of the environment,
the services it offers, and the demographics of a community. "Mind" might well refer to a community's cultural
norms, laws, and political structures. Community spirit may be exemplified in the community's value systems. Yet
each of these dimensions of a community are not parts that can be summed to represent the whole community any
more than the sum of mind, body, and spirit represent a whole person. Rather, consistent with the holographic
model, individual parts provide information about the whole that in themselves produce a less-detailed and coherent
projection of the whole than they do together. 31
Health, according to Watson, is unity and harmony within bodymindspirit and with the world. Likewise,
harmony within the various aspects of the community described above, as well as its relationship to the outside
world (other jurisdictions and the environment), reflects health, while disharmony is indicative of illness. Disease is
qualitatively different from illness but is more likely to occur in a state of disharmony. A community example might
be that an outbreak of disease is less likely to occur when a community is in harmony, that is, when services such as
immunization are in place to prevent anticipated diseases. "Disease" in the community extends beyond biologic

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epidemics. Community problems also may be thought of as a form of community disease. Homelessness and crime
are more likely to occur in communities that do not have an established social safety net or what might be
considered harmony of the various dimensions of a community. Watson's conceptualizing of health is consistent
with the World Health Organization (WHO) definition of health as "a positive concept emphasizing social and
personal resources, as well as physical capacities." 25
The qualitative differentiation of health and disease in Watson's theory marks a significant departure from the
dominant biomedical model. An example of the latter, the Leavell and Clark model, continues to be used widely in
public health and situates health promotion as a prepathogenic strategy. 32 One study revealed that this model had
been used widely to support the elimination of public health nursing services that were not considered to be primary
prevention because disease (such as mental illness or heart disease) was already present, and therefore health
promotion was deemed not possible. 1 Nurses in that study expressed the ethical dilemmas they faced because of
administrative directives that, in the opinions of several, amounted to patient abandonment. Most nurses, however,
did not recognize that the basis for the directives was a medical model, and the reason for their discomfort was, at
least in part, related to the incongruence of that model with their own nursing paradigm. Consciously informing
practice with a nursing theory in which health promotion can occur whether or not disease is present may strengthen
nurses' voice to advocate for services that meet expressed community health needs and enable them to resist external
pressures to eliminate those services.
Not surprising, given that Watson's conceptualization of health is consistent with WHO's definition, health-
promoting nursing practice guided by her framework also is consistent with the definition of health promotion
articulated in the Ottawa Charter 25 and affirmed most recently in the Jakarta Declaration, 26 which is "the process
of enabling people to increase control over, and to improve, their health." The centrality of empowerment to health
promotion is as clear in the WHO definition as it is in Watson's strikingly similar assertion that caring involves
"helping a person gain more self-knowledge, self-control, and readiness for self-healing." 9(p35) Health-promoting
actions identified in the Ottawa Charter, such as strengthening community actions, are consistent with this aspect of
caring. Another of the Charter's five health promotion actions, the development of personal skills, is demonstrated in
Watson's carative factor related to transpersonal teaching-learning. The other three-creating supportive
environments, building healthy public policy, and reorienting health services toward a health promotion approach-
are encompassed by the carative factor that attends to the support, protection, or correction of sociopolitical
environments.
Health promotion practices that flow logically from Watson's theory and her early attention to nonmedical
determinants of health are also supported by nursing literature. One aspect of health according to Watson 9 is

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harmony with the world or environment. It is easy to see how her theory guides the community health nurse to
examine and address social, economic, political, and other environmental determinants of health. In fact, the carative
factor relating to nursing activities that support, protect, or correct mental, physical, sociocultural, and spiritual
environments in community health nursing encompasses the social or political activism that has been advocated in
nursing literature for some time. 33-36 Broadening a nursing focus from individual determinants of health to include
sociopolitical determinants also addresses the challenges issued in nursing literature over the last decade to
reconceptualize both the environment 37,38 and health promotion to be consistent with nursing's legacy and
paradigm. 39-43
Expanding community health nursing practice to include broad determinants of health is also congruent with
contemporary global approaches to health. The Ottawa Charter identified nine prerequisites to health: peace, shelter,
education, food, income, a stable ecosystem, sustainable resources, social justice, and equity. 25 More recently, the
Jakarta Declaration added social security, social relations, the empowerment of women, and respect for human
rights to the initial nine, acknowledging poverty as the single greatest threat to health. 26 Identifying such
sociopolitical issues as prerequisites to health recognizes that although they may greatly affect the health of
individuals and communities, the supportive, corrective, or protective measures to address them must be directed
beyond the individual to societal social and political structures.
Many other of Watson's carative factors are helpful for community health nurses working within her
framework. Several factors focus on the nurse's part of the caring relationship in clarifying values and being
authentically present to clients. Understanding one's self and being sensitive to others is as important in caring for
communities as individuals. Community caring occurs within a helping-trusting relationship and is directed toward
protecting and enhancing the dignity of others.
The reflective and creative use of the problem-solving process is consistent with contemporary ideas of health
promotion because, according to the theory, it occurs within the context of a relationship of mutuality where the
community's health goals are paramount, and there is at least an opportunity for the community's active and equal
participation in the process. Watson's theory informs not only the process of assessment but also its scope and focus.
The community assessment tool proposed in the Appendix to this article reflects Watson's emphasis on
strengthening the client's resources or capacities, as well as mutuality, in planning, taking, and evaluating health
actions. As with individual clients, the nurse and client together decide on the role each will play in working toward
health goals. (It should be noted that this assessment tool was recently developed to assist students to assess
communities holistically and to make the abstract notion of broad determinants of health more concrete. At this
point, it is an untested tool.)

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Copyright © 2000 by Aspen Publishers, Inc.
Volume 23(2), December 2000, pp 34-49


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