JONA’S Healthcare Law, Ethics, and Regulation / Volume 8, Number 3 / B 2006, Lippincott Williams & Wilkins, Inc.

Caring Theory as an Ethical

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Guide to Administrative and

Clinical Practices
Jean Watson, PhD, RN, AHN-BC, FAAN

A B S T R A C T
This article explores the conventional relationship between caring, economics, and
administrative practices that no longer serve patients, practitioners, or systems. A shift
toward human caring values and an ethic of authentic healing relationships is required as
systems now have to value human resources and life purposes, inner meanings, and
processes for workers and patients alike, not just economics alone. This shift requires
a professional ethos with renewed attention to practice that is ethics/values-based
and theory-guided, alongside evidence and economics. Emergent professional,
caring-theory–guided practice options are presented, which are grounded on this deeper
ethical moral and theoretical foundation for transforming the practitioners and the system.
................................................................................................................................................................

Editor’s Note: This article is
being reprinted with permission
from Nursing Administration Quar-
terly 2006;30(1):48–55. Copyright
Lippincott Williams & Wilkins.
this conflict and dissonance is a able, to be ill, to be cured, to be
separation of values of human cared for, to be healthy, and to be
caring as an underlying ethic healed.
and a moral foundation for prac-
tice. The dominant institutional ..
.. This manuscript is based on a presentation
values and commitments are in- .. at an International Health Administration
.. Conference, Nuremberg, Germany,
..

C
aring and economics, formed and guided by economics, .. November 2005.
.. From the School of Nursing, University of
and caring and admin- technology, medical science, and .. Colorado Denver and Health Sciences Center,
.. Denver.
..
istrative practices, are administrative theory, instead of .. Corresponding author: Jean Watson, PhD,
.. RN, AHN-BC, FAAN, School of Nursing,
often considered in conflict with basic considerations of what it .. University of Colorado Denver and Health
..
.. Sciences Center, Denver, CO 80262
each other. One of the reasons for means to be human, to be vulner- . (e-mail: Jean.Watson@uchsc.edu).

JONA’S Healthcare Law, Ethics, and Regulation / Volume 8, Number 3 / July–September 2006 87

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 These dominant business or economic models that
are devoid of caring have short-term solutions to patient
care needs and to the crisis of nursing shortage in the
United States and elsewhere. They focus on beds and
disease, body physical as object, technology, and prod-
ucts. In addressing the nursing shortage, they focus
on incentives such as increasing enrollments, signing
bonuses, tuition, relocation fees, etc, without address-
ing underlying dissatisfaction, for example, inability
to practice own profession; dominance of medical-
economic-technological-institutional foci over direct-care,
person-centered, human-to-human relationships and
caring-healing processes and practices. This void in caring
persists in spite of corporate rhetoric and slogans of ‘‘car-
ing institutions.’’ These dominant emphases and super-
ficial, often trivial, catch-phrases of caring are detours and
barriers to practicing and achieving the work nurses love,
and what call them into this ancient and noble profession
in the first place. The result is a hostile environment that
places dollars over human life and quality of caring-
healing experiences for patients and practitioners alike.
Thus, the lingering mood from nursing/nurses in the
field: ‘‘Nurses love their work and hate their jobs.’’
If nurses leave organizations as fast as they are hired,
money is wasted and hopedfor solutions are doomed
for failure, as are patient care and satisfaction. What
good is it to have an industrial model of treatment and
cure/physical care when patients and practitioners
alike are disenchanted and, even worse, worse off after
hospitalization than before, owing to dissatisfaction,
repeat hospitalization, medical errors, nursing recruit-
ment, retention, etc?
Numerous studies in the United States continue to
document publicly that patient deaths are tied to lack of
nurses. Recent crises related to safety concerns have
brought renewed attention to nursing and physician
practices and how to address the shortage and crises of
care in acute care hospitals.1
This dominant model has co-opted the language of
industry and business, in that, rather than referring to
the quality of caring and healing offered to whole
human beings, what the hospitals increasingly mean
is that they have the most advanced technology to
diagnose and treat malfunctioning body parts. This is
not the relational language of caring, but the language
of the market.2 For example, patients are referred to as
‘‘consumers’’ or ‘‘end users,’’ practitioners are ‘‘pro-
viders,’’ nurses are ‘‘workers’’.2 This language conjures
up an image of impersonal, functional exchange of
fees for services or goods that require no humanity
or human relationship, no authentic caring connection,
no mutuality, and no compassionate human service
ethic, philosophy, or value that guides the system.
A values-based, theory-guided approach to caring
and administration helps to make visible that a caring
model for professional nursing and system survival
would meet needs of practitioners and patients alike.
For example, as I have noted elsewhere,3
88 JONA’S Healthcare Law, Ethics, and Regulation / Volume 8, Number 3 / July–September 2006
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Any profession that loses its values becomes heartless;
any profession that becomes heartless becomes soul-
less. Any profession that becomes heartless and
soulless, becomes [Worthless].
So, a shift toward theoretical practices guided by
human caring values becomes an economic as well as
human resource for nursing and systems alike. This
shift includes the following:
 From economics to professional practice that is based
on morality-ethics-values
 From mechanical cure approaches to spiritualizing of
health and healing processes
 From rote, atheoretical professional routines of nursing
practice to more conscious, intentional caring-theory–
guided professional actions
 From artificial ‘‘hospitality’’ environments to authentic
healing environments
 From corporatization of health to public covenant for
healthy citizenry
 From industrial product line models of ‘‘managed care’’
to relationship-centered caring-healing partnerships, at
multiple levels
Such shifts acknowledge that caring is not a com-
modity to be bought and sold. Caring and economics,
however, are not mutually exclusive, in that human
caring is an essential resource. Cost-benefit and cost-
effectiveness models can and must include human
caring-healing—as a value-added resource, a founda-
tional asset, as well as a more humane model to serve
the whole.
In the dominant, but declining, model, caring-
healing and human values have become a dwindling
resource for systems and society alike. Such thinking
fails to recognize human caring-healing values, ethics,
knowledge, and practices of nurses (in particular) as
an essential albeit underutilized resource; it fails to
understand professional, theory-guided nurses as in-
tentional, conscious, knowledge workers—professional
experts in human caring and healing who can trans-
form the entire culture. It is as if, as one of my physics
colleagues said, ‘‘the health [read sick] care [read cure]
system is using only one half of its brain.’’ The other
half of the model is waiting and longing to emerge for
practitioners and the public alike.
............................................................................
Public Changes Toward
Medicine and Health
This tension in the dominant approaches to hospital
and treatment is simultaneously juxtaposed against
an accelerating public interest in complementary-
alternative medicine, and an explosion of both public
and professional interest in relationships between
spirituality and health. These changing times now
warrant, if not require, a reorientation—away from
traditional hospital structures and patterns of care/cure human spirit back into the workplace, is based on
with their routinized, industrial practices, driven by caring-healing values and theoretical-philosophical and
economics, diagnosis, and treatment of acute disease moral foundations. This orientation toward one’s pro-
and product line management. fessional work adheres to an ethic of unitary being and
becoming more human and humane; a model that
honors the inner subjective experience of patients and
Healthcare Economics and Human Caring: practitioners alike. This emerging professional nursing
Resolving Moral Conflict practice model is overtly moving beyond the separate
.........................................................................................................................................
disease focus that defines the human. It is explicitly
 Caring is not a commodity to be bought/sold moving beyond a ‘‘clinicalizing’’ and ‘‘medicalizing’’ of
 Caring and economics are not mutually exclusive the human condition, which reduces the person to
the moral status of physical object. This new turn is
 Synthesis of economics models must include caring toward a spiritualizing of human experience and re-
(cost-benefit and cost-effectiveness includes caring)
quires a return to wholeness; unity of mind, body, and
spirit; and acknowledging a human-environment en-
............................................................................ ergy field oneness, which affects, and is affected by,
the human presence, the intentionality, consciousness,
Caring—Legitimate Economic and practices of the practitioners.4
This emerging model seeks to integrate inner healing
Resource and human caring processes with healing environ-
The evolving caring-healing practice environment is ments, no longer restricted to outer curing alone;
increasingly dependent on relationships, partnerships, this perspective incorporates life-generating and life-
negotiation, coordination, new forms of communica- receiving processes of human caring and healing for the
tion patterns, and authentic connections.1 The new practitioners as well as the patients. The emerging
emphasis is on a change of consciousness, a focused model includes the transcendent as well as immanent
intentionality toward caring-healing relationships and view of human experience, attends to nonphysical
modalities, and a shift toward a spiritualizing of health phenomena as much as physical, and allows for human
versus a limited medical view alone. Thus, new stan- environment energy field dynamics and processes. This
dards, principles, guidelines, and models of excellence emerging human caring values–guided ethic for pro-
are required for advancing and sustaining professional fessional practices happens to be consistent with what
relationship-centered caring practices. the public is seeking as well as extant nursing theory.
It can be argued that these chaotic changes lead to This convergence of change is an opportunity for an
uncertainty and confusion; however, when one inter- overt turn toward advancing nursing qua nursing
prets these complexities, it is clear those dominant professional practices and processes.5–7 This turn is a
practices and patterns are under fire from within and moment in history and an occasion in time in which
without, and something else is wanting to emerge out nursing can come of age and mature in its own hope-
of the chaos. It is the responsibility of professionals ful paradigm for this era.
and administrators alike to rethink conventional in-
dustrial models and work together for transformation ............................................................................
from within. The will to make the changes necessary
for renewal and transformation are dependent on Watson’s Theory of
human dimensions and skills, which arise from the Human Caring
human spirit, offering new visions, creativity, and pos-
sibilities that result in changing patterns, relation- Recently, several hospitals in the United States have
ships, and depths of communication and culture. begun to use Watson’s Theory of Human Caring5–7 as a
These changes involve worldview shifts that transcend guide to change nursing practice—and ultimately the
professions, systems, and institutional structures. culture of hospital nursing and the hospital milieu—in
seeking or sustaining magnet status. (see Watson’s Web
............................................................................ site: www.uchsc.edu/nursing/caring).
This theory involves making explicit that human
Emerging Theoretical-ethical caring and relationship-centered caring is a founda-
Model of Caring-healing tional ethic for healing practices; it honors the unity of
the whole human being, while also attending to
These emerging possibilities, longing to actualize, now creating a healing environment. Caring-healing modal-
have to be honored; they are now arising internally ities and nursing arts are reintegrated as essentials to
within hospital and nursing systems alike. Without ensure attention to quality of life, inner healing
attending to this emergence, practitioners become experiences, subjective meaning, and caring practices,
dispirited and the nursing shortage is accelerated, not which affect patient outcomes and system successes
diminished. The emerging model, which invites the alike. The theory places human-to-human caring as

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central to the professional nursing responsibilities and
role and the moral foundation for the profession.
Preserving human dignity, relationships, and integrity
through human caring is ultimately the measure by
which patients evaluate their often ‘‘cure dominated
experience.’’8
In this model, caring is acknowledged as transper-
sonal, in that it goes beyond the ego-oriented human; it
involves the one caring as well as the one being cared
for, and is mutual, intersubjective, and reciprocal. The
‘‘caring moment’’ between the patient and nurse has a
field of its own, which is greater than either one, and
transcends both patient and nurse and becomes part of
the life history of both, as well as of some larger,
deeper, complex pattern of life.6 The caring moment
transcends the here and now and informs the life
history of both patient and nurse beyond the caring
moment. The influence can be for better or for worse,
depending on the nature of the relationship and the
nature of caring. A caring moment involves the hu-
manity of the nurse and potentiates healing. Healing
occurs when the nurse connects with the spirit of the
other; it involves listening, making one’s presence felt,
expressing emotions, as well as the instrumental acts of
treatment, medication, procedures, etc.
But the (caring) consciousness, intentionality, mood,
demeanor, and presence of the nurse affect the human-
environment energy field in the given moment, for
better or for worse.4 Thus, the focus is on the person
behind the patient and professional, as well as the
caring relationship, the human consciousness field,
generated by the nurse’s very presence.4 In the Caring
model, the practitioner’s caring-healing consciousness
is influencing and helping to shape the patient’s health
and healing experience as well as their own experience
in the moment.
The following framework of transpersonal caring-
healing highlights this model:6,7
 The whole caring-healing consciousness is contained
within a single caring moment
 Human caring and healing processes—or noncaring
consciousness—of the practitioner is communicated to
the one being cared for
 Caring consciousness transcends time, space, and
physicality—that is, caring goes beyond the given
moment, and situation, and informs the future
experiences of practitioner and patient
 Caring-healing consciousness is dominant over physical
illness and has the potential to help the patient access
the healer within, or potentiates inner healing processes
 One’s (caring) intentionality and consciousness
energetically affects the ‘‘whole field,’’ for example,
thoughts that are positive, such as love, caring, joy,
compassion, affection, and forgiveness, have a higher
frequency of energy. Likewise, thoughts that create
emotions such as anger, hatred, jealousy, and fear have
low-frequency energy and therefore lower the
frequency of the system.7 ‘‘A system of higher frequency
90 JONA’S Healthcare Law, Ethics, and Regulation / Volume 8, Number 3 / July–September 2006
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will soothe, calm, and refresh you because of the . . .
quality of . . . your system.’’7(p112)
..................................................................................
Relevant Research on the
Consequences of
Caring-noncaring
Relevant research points out the seriousness of a caring
relationship. The presence and absence of caring can
have either a positive or negative consequence. This
caring phenomenon is found to affect both patient and
practitioner. For example, Halldorsdottir’s classic re-
search9 on levels of caring found that caring relation-
ship ranged from what she called biocidic, or toxic
relationships between nurses and patients, to biogenic,
which is congruent with transpersonal caring, in that a
biogenic caring relationship is characterized by a life-
giving and life-receiving relationship between both
parties. The other levels in between these 2 extremes
were referred to as biostatic caring or life-restraining,
whereby the practitioner is cold, treating the other as
a nuisance, to biopassive, which is life-neutral and is
characterized by apathy and a detached manner. The
bioactive level was found to be the more classic nurse-
patient relationship, whereby the nurse is kind, con-
cerned, and benevolent.
However, the deepest level of a caring relationship,
the biogenic level, was related to authentic caring
connection, whereby both were affected for life-giving
experience. This biogenic level is consistent with trans-
personal caring theory and occurs within any given
caring moment.3,6,7 However, this research also highlights
the destructive, toxic, noncaring relationship. The biocidic
level of noncaring can be an act of cruelty, leading to
despair, anger, frustration, and nonhealing for both.
The research of Kristine Swanson3,10 likewise de-
tected the positive and negative outcomes of caring-
noncaring for both patients and nurses through her
comprehensive metaanalysis of 130 studies on caring.
For example, when patients experienced caring, the
following consequences were reported:
 Emotional-spiritual well-being (dignity, self-control,
personhood)
 Physical lives enhanced, lives saved, increase in safety
 Decrease in costs
 Increase in trust relationships, comfort, and family support
When patients experienced noncaring, the following
consequences were reported:
 Humiliation, fear, lack of control
 Despair, helplessness, alienation, vulnerability
 Lingering bad memories
 Decreased healing
These noncaring consequences from Swanson’s 1999
work parallel Halldorsdottir’s 1991 biocidic caring, which
is actually harmful to patient and nurse alike and has
negative outcomes for the system, including costs. These
findings are also consistent with the transpersonal caring
theory, helping to empirically validate the significance of
theory-guided caring and patient and nurse outcomes.
Swanson’s10 findings for patients were mirrored for
nurses. For example, the following consequences were
present when nurses were practicing caring:
 Emotional-spiritual sense of accomplishment,
satisfactions, purpose
 A sense of gratitude, fulfillment, wholeness, self-esteem
 Ability to live their own philosophy
 Greater respect for life, death
 Ability to be more reflective
 A love of nursing
 Desire for increased knowledge
However, just as patients were negatively affected by
noncaring, nurses who were not practicing caring
reported the following:
 Being hardened, oblivious, robot-like
 Feeling depressed, frightened
 Feeling worn down, etc
Once we awaken to the negative consequences of
conventional approaches to healthcare, or models that
do not honor caring and healing processes for the
whole person, we realize the ethical and operational
responsibilities administrators and leaders have to
transform the system within.
............................................................................
Caring and Administrative
Leadership: Responsibility of
Nurse Administrator in the
Caring Model
Nursing administrators as well as hospital managers
and administrators have a significant role to play in
transforming the medical system from one that is often
biocidic to one that is biogenic. Nyberg11 was one of the
early nursing administrators creating caring systems
leading to Magnet status, long before it was main-
stream. Having had extensive leadership roles as a
nursing administrator, who early on was guided by
caring theory, she developed a model of caring nursing
administration that served to inform the entire health-
care system. The model is outlined in her book Caring in
Nursing Administration.11 Her model incorporated the di-
versity of theories that inform caring administration in
nursing leadership. This model is depicted in Figure 1.11
If a nurse administrator were to take this model
seriously, as many nursing leaders are doing today, the
following leadership responsibilities are proposed:
 Understanding and communicating caring as philosophy
and ethic for organizational processes, structures, and
relationships
Figure 1  Nyberg (1998) Model of Caring Administration.12
 Developing skills of caring behaviors, caring presence in
formal-informal relationships with individuals and groups
 Being alert and responsive to situations for modeling,
creating, and articulating theoretical-philosophical
ethics of caring with staff, colleagues
 Providing leadership in implementing, evaluating
experimental models of caring based on theoretical-
philosophical values
 Critiquing and helping to transform conventional
practices by offering an inspired, informed, articulate
vision for creating caring-healing systems
 Promoting and supporting research on caring and
health/healing outcomes
 Pursuing relationships and data that document
relationship between and among caring practice
models, and nurse retention, patient-nurse satisfaction,
healing outcomes, and costs
 Becoming stewards of caring-economics costs, by
incorporating caring as a valuable economic resource
and caring as a foundational, ethical variable in
costbenefit ratios
 Experimenting with new demonstration projects that
showcase models of caringhealing excellence, new
professional practice models (eg, ‘‘Nightingale Units,’’
‘‘Attending Nurse Caring/Attending Caring Team
Models’’)
Responsibility of the Nurse Administrator
in Caring Model
.........................................................................................................................................
 Understand and communicate caring as a philosophy/
ethic for organizational processes and structures and
relationships
 Develop skills of caring behaviors/presence in
formal-informal relationships with individuals and groups
 Become a steward of caring-economics costs

JONA’S Healthcare Law, Ethics, and Regulation / Volume 8, Number 3 / July–September 2006 91

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 (nursing-patient-family) caring-healing needs and prac-
Nursing Administrator Responsibilities for
tices along with the integration of medical treatments
Integrating Economics and Caring
......................................................................................................................................... (and other interdisciplinary practices). The (redefined)
 Being alert and responsive to situations for modeling, Caring Attending Nurse/Team model is informed and
creating, and articulating ethics of caring to staff, guided by the ethics and theory of caring—and caring
colleagues relationships—combined with best evidence, especially
with respect to pain management of children.
 Implementing theoretical models of caring to critique
and transform nursing practices In summary, this ethical, theory-guided professional
practice model seeks to make explicit the caring
 Promoting research on caring and health/healing relationship, the knowledge, values, philosophy, the-
outcomes as well as nurse retention/satisfaction costs
ory, and therapeutics that guide advanced professional
caring-healing practices in action. Finally, the ANCM
creates a new pattern and structure for the delivery of
............................................................................ professional nursing that transforms the practitioners
themselves and conventional systems.1
The Attending Nurse Caring As a result of this initial project, the Attending
Model as an Exemplar of Caring Caring Team Model now serves as an inspired model
for other units in the hospital. Additional developmen-
Theory, and Clinical and Ethical tal project activities are underway to expand the model
Administrative Changes within the Children’s Hospital, Denver, Colo.

The Attending Nurse Caring Model (ANCM) has been ............................................................................

piloted at the Children’s Hospital, Denver, Colo.1 It was
implemented as a research and advanced professional
Other National Initiatives
practice model for actualizing caring theory and of Caring Theory–guided
evidence as a guide to advancing professional nursing Practice Models
practice. Furthermore, it allowed for more actualization
of nursing as a mature caring and healing profession, Other such models of caring theory–guided practices
not just a technical assistant to medical treatment and are underway in such systems as Denver Veterans
models of cure. The ANCM was designed to deliver Administration Hospital, Denver, Colo; McKee Banner
and oversee a program of collaborative, comprehen- Medical Center, Loveland, Colo; Elmhurst Hospital,
sive, continuous caring-healing nursing with its thera- NY; INOVA health system, Fairfax, Va; Kendall Health,
peutic practices for a group of identified patients/ Miami, Fla; Miami Baptist system, Fla; Sarasota
families on a pain-management, postsurgical unit. Memorial Hospital, Fla; Winter Haven Hospital, Fla;
The model is grounded in relationship-centered caring, Resurrection Healthcare, Chicago, Ill; Scripps Institute/
which incorporates caring theory as a philosophical- Hospital, La Jolla, Calif; University of California Irvine
ethical base that offers nurses a shared worldview Medical Center Hospital, Orange, Calif; St Joseph
and professional culture. It allows the emergence of a Hospital, Orange, Calif; University of Arkansas Chil-
collective vision, whereby shared knowledge, values, dren’s Hospital, Little Rock, Ark; and Central Baptist
goals, and advanced caring-healing arts and therapeu- Hospital, Lexington, Ky, among others. Many of these
tics extend nursing practices. This process seeks to named hospitals are already Magnet hospitals or are in
generate a new pattern and structure for care delivery the process of preparing for Magnet status, using the
and administrative practices. A culture of shared caring ethic and theory as the underlying professional
knowledge and values serves as a guide to heartfelt practice model.
caring practices that are grounded in both theory and These identified and named hospital systems serve
evidence. This model translates theory and evidence into only as some exemplars of hospitals today guided by an
advanced nursing practices. It extends and advances evolved ethic and theoretical-philosophical foundation
professional caring practices and patterns, while ex- of human caring as a means to transform practitioners
panding, supporting, and simultaneously sustaining and system alike.* Also, there are additional hospitals
independent and interdependent care goals. and care systems exploring this direction that have not
The ANCM is both discipline-specific and transdis- been named, but have communicated with the author
ciplinary in its approach and experiences; for example, about their efforts in this direction. This direction for
more recently this model has evolved to be renamed as caring theory–guided ethical practices is helping to
the Attending Caring Team Model from Attending more fully actualize nursing qua nursing in our
Nurse Caring Model, having been adopted by the full contemporary institutions, educating and transforming
interdisciplinary team of this unit.
The original ANCM parallels an Attending Physician
..........................................................................
Model, except that the ANCM makes explicit that the *I apologize if I have inadvertently omitted a hospital or system that is
professional nurse is ‘‘attending to’’ comprehensive informed by this philosophy and theory.

92 JONA’S Healthcare Law, Ethics, and Regulation / Volume 8, Number 3 / July–September 2006

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nurses, other practitioners, and systems alike. These
and many, many other nursing caring-focused admin-
istrators and practitioners, as well as all systems
seeking to transform nursing from its ethical core, from
the inside out, serve as inspirations of hope for the
future of human caring-healing, health, and the
survival of this noble and ancient profession. For more
information, see Watson’s Web site: www.uchsc.edu/
nursing/caring.
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1. Watson J, Foster R. The attending nurse caring model. J
Clin Nurs. 2003;12:360-365.
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for healing the healthcare system. Front Health Care Serv
Manage. 2003;19(2):3-21.
3. Watson J. Caring Science as Sacred Science. Philadelphia: FA
Davis; 2005.
4. Watson J. Intentionality and caring-healing consciousness.
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A practice of transpersonal nursing. J Holist Nurs Pract.
2002;16(3):12-19.
5. Watson J. Nursing: The Philosophy and Science of Caring.
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