Jean Watson notes, "the science of nursing, the human care process and human-tohuman transactions...become increasingly important in the rapidly growing, complex technological health care system" (1985). Her Theory of Human Caring postulates that nursing science is a "human science" that must deal with the entire person: body, mind, and spirit. Simply providing physical care does not necessarily promote healing. In fact, "individuals who will never be cured may... be healed" (1994).
More simply put, healing can occur when nurses interact with their patients on a human level. "The caring-healing consciousness of the nurse, combined with intentional, expressive caring arts /acts can thus potentiate healing and wholeness" (Quinn, 1989). A nurse's "conscious intentionality," or conscious effort to "be with" the patient and not just "do for" him or her fosters "transpersonal encounters" in which both the nurse and patient fully participate. Such human exchanges promote healing in not only the patient, but in the nurse as well (Watson, 1985).
True healing comes from a place deep within us. According to Glickstein (1995), this place is "the laughing spirit," where "universal perspective and selfawareness" dwell. Glickstein believes that one way to access this place is through Laughing Spirit Listening Circles, group sessions in which there are no discussion leaders or session agendas. Instead, members are allowed to tell their own stories in a place that lets them safely and fully express themselves in true dialogue. These Circles are communication formats in which people have the opportunity to be fully heard. Circles can also be an approach to community according to Glickstein. Listening is defined, in this context, as receiving another's experience.
After studying with Watson and participating in one of Glickstein's Circles, this author was convinced that Glickstein's format naturally embodied Watson's theory and that fliese two approaches could be successfully combined in a project with the elderly. The challenge was to apply Watson's theory, to test whether it could be operationalized in this typical caregiving setting. Following a conversation with Glickstein, who confirmed that this had not yet been applied to an elderly population, this author was presented with an opportunity to bring the concept of a "Listening Circle" to a local retirement community to see if it might benefit the residents.
As the American population ages, we find that many of our older adults - healthy or not - do not need a "cure." For all of them, however, caring must be present whether or not traditional treatments are taking place. "This approach to helping is very different from the achievementoriented one that aims to cure disease and eliminate problems" (Montgomery, 1992). The Circle format seemed like an excellent opportunity to test Watson's theory and to study the subjective experience of the client in an encounter where there is little or no "doing" - just "being" - on the part of the caregiver.
A privately held nursing care center offers a full continuum of care, including a retirement community, a nursing home, and an infirmary. The retirement center houses 120 elderly residents. Ongoing activities offered include music, art, dance, "cocktail hours," and religious studies.
Six residents of the retirement community, ages 83 to 95, were invited to participate in this pilot project by the center's activities director. All of them agreed to the 5-hour commitment (four sessions, 1.25 hour per week) without hesitation. The women had lived in the community between two months and ten years. Half of them were college educated. One was visually impaired and used a walking cane, one was hearing impaired, and the remainder suffered no major disabilities. Some of the Circle members were acquainted previously; in fact, two of them shared a table at meals. Others had never met.
Two 37-year-old volunteers (a graduate student in sociology and a nurse) acted as facilitators for the Listening Circle based on Watson's Science of Human Caring (1994). According to Glickstein's (1995) format, each Laughing Spirit Listening Circle should begin with a warm-up round, during which every participant shares a one-minute story and then receives positive feedback from the group. Following that, each member of the Circle shares a longer story (about three minutes) and again receives positive feedback. The feedback was to be related to one's own experience of Other (the storyteller) as this woman spoke and one's own experience of Self while listening. The flow of the conversation should come naturally, without direction from any one member of the Circle. The stories shared did not in any way need to be connected to one another, they were to arise spontaneously from each participant.
The Listening Circle met for four sessions, held on consecutive Mondays in January and February. All six residents and both volunteers attended all four sessions. The sessions were not recorded in any way. The volunteers provided initial guidelines for the structure of the Circle and suggested to the other participants that their "stories" could consist of past events, fantasies, ideas, night or daydreams, thoughts, feelings or anything else they wished to share. The volunteers then modeled the behavior, sharing their own stories, participating as group members ramer than "leaders." After the final session, the participants were asked for their comments and evaluation.
In this particular group, it became apparent that Glickstein's (1995) format would only loosely be followed. The warm-up round seemed unnecessary, perhaps because some of the women knew each other and all of them shared a common environment. The Circle quickly became a place where participants felt comfortable sharing their own stories and thoughts. Every member of the Circle told at least one story during each session, which lasted five to seven minutes. Most of the women, however, appeared uncomfortable receiving positive feedback from others. The subject would be changed quickly, or attention diverted away from self and to another woman in the group. When asked about this observation, they stated that this "total attention" was not something they were used to, and even though it felt good, they weren't sure what to do with this feedback. One woman, a retired librarian, called this positive feedback "reciprocal altruism" (carative factor #1). Inadvertently, these women were having discussions on their own about Watson's Carative Factors!
The women came to each session prepared to tell a particular story, as though they had been anticipating the Listening Circle all week. Typically, these stories described incidents from the distant past, at least 40 years ago. After the first story was told, those that followed were loosely associated with the first one. For example, in one session a woman shared her memories of the day Pearl Harbor was attacked; the others then shared their memories of the same day. In another session, one woman told about her recent decision to move into the retirement home without her husband, who was very ill and living in a rest home; the rest of that Circle focused on issues of transition and loss.
When asked to share "the best thing" about the Listening Circle following the fourth session, the participants described it as a "restful, peaceful, quiet place to come and be listened to," and "very neighborly and civilized." They commented that the stories they heard revived some of their own memories that had been forgotten for years, and that this was a very sweet experience. These women stated that they appreciated having someone "just listen" to them and they enjoyed getting to know each other more intimately. There was a lot of laughter in the group, and a lot of comforting silence and eye contact as well as physical reaching out to one another by patting each other's hand or leg. These gestures were strikingly soothing and "regulating" to the members of the Circle, as evidenced by their relaxed postures, slowing of respiratory rate, and nodding affirmatively with their heads.
Though each week's discussion was quite different, several themes emerged during the 4-week period. The role of women became a part of nearly every discussion; women in military combat, motherhood, and women in the workplace were discussed. Also, coping with transition and loss seemed to be a large part of this group's experience. In fact, they seemed to gain strength and hope from telling their own stories of coping and from listening to those of others. Their postures changed as they spoke, sitting more upright, reaching out physically to the woman who was speaking.
Although most of the stories shared within the Listening Circle were profoundly serious, laughter did frequently emerge. It arose naturally as the women told their stories, from the perspective of experience. This laughter was deep, affirming, throaty, spontaneous, and cleansing, and was often followed by misty eyes. The laughter was in response to their own stories and stories/ideas shared by other participants.
The main theme that emerged in this Circle was that "hospitality" (which the participants defined as "reaching out to others, one person at a time") had allowed them to be connected to others. These experiences, which they shared in the Listening Circle, had been experiences of significance to them. This business of "hospitality" - reaching out to others, being connected, being available to oneself and others were the touchstones of their lives. The participants went on to say that their experience in this Listening Circle was an example of this same hospitality.
In the closing session, participants were invited to evaluate their experiences. Participants were asked to consider how others might benefit (or not) from participating in future sessions similar to this and how the process might be modified to increase its value for others. All agreed that this was an enjoyable experience, that it had surprised them, that they had not really understood what they were agreeing to, a "Laughing Spirit Listening Circle"? They had never heard of such a thing, but participated because they were more curious than anything. One participant suggested that potential members would be more interested in becoming involved if the group had a name. Collectively, they then decided to call their group 7WWOW" or "Wild and Wise Older Women." They also thought the "Listening Circle" title was appropriate since "conversation group" or similar titles might frighten away shy people.
Spontaneously, several group members then moved to the issue of not feeling connected in the retirement community. They felt that "hospitality" did not happen in this setting with any frequency and that the hospitality that did happen usually came from other residents. The women focused on the issue of feeling isolated, and offered suggestions about how to create a greater sense of community at the facility, also commenting that many afternoons at the center are long and empty and need filling. They suggested that regular events such as weekly floor meetings or inter-floor parties would help.
The women emphasized that many people living in the retirement center are shy and /or forgetful, and that these people need encouragement and reminders to attend activities. They suggested that floor committees or representatives contact new, shy, or forgetful people about the activities. They also felt that the staff should take more initiative in reaching out to these residents. The group members felt that it was especially difficult to get to know each other at the retirement center. Perhaps a buddy system might help, and a welcoming chairperson or committee would be valuable as a "get to know you" gesture.
Group members shared their perception that it is particularly difficult for new residents to make friends in the retirement community. The participants began to give examples of what "caring" felt like. One woman shared that a welcome note slid under her door by another had made a lasting impression. This happened on her second day of arrival at the retirement center. Why had there not been a staff person who welcomed her? Another woman told about a resident who sat in front of the elevator in her wheelchair: "The woman looked into my eyes, her face smiled and lit up; she put her arms out to greet me, and said 'Welcome to your new home/ We embraced, and I knew I would be all right here." This resident noted that this was the only heartfelt welcome she received upon moving into the center, and it came from a resident - not from a staff member. The group agreed that hospitality and open hearts formed the essence of the Laughing Spirit Listening Circle and "wouldn't it be nice if some of the staff could be like this...it's because you two are volunteers, that's why you are so kind..." chorused the women.
During these Listening Circle sessions, the volunteers were often struck - in fact, silenced - by the simplicity and power of the stories these women had to tell. The women were strong believers in community and church, had made profound connections during their lifetimes and through these connections had contributed to the world over time. For example, two of the women brought soldiers' wives into their homes during World War II to help relieve their loneliness. Another participant began years ago to assemble scrapbooks for children in Third World countries so these children could see some of the wonders of the U.S. This project continues today by this 95-year-old woman.
"In a caring encounter, the caregiver and the client experience union or merger, but this union occurs beyond the ego, at the level of something greater, something which might be called spirit. This greater force or spirit can be understood as a common humanity, the fundamental sacredness and unity of all life..." (Watson, 1985).
The volunteers were deeply touched by the intimate connections, the reaching out behaviors that created community, and the "good deeds" of these participants. Both volunteers discussed feeling quite touched at the deep human need to reach out and help others, and in doing so, being helped, back then when these events took place, but also, in the moment, when these stories were retold and listened to with "conscious intentionahty." Both volunteers also found it difficult to articulate the experience and felt that this experience related to carative factor #10. Both volunteers expressed a "quieting effect," a slowing down of the external world and a timelessness about the experience. This caring-centered involvement with these elderly women produced what this author refers to as connectedness, also known as "spiritual transcendence." This "spiritual transcendence...experiencing oneself in relationship as a part of a force greater than oneself" (Montgomery, 1992) seemed the best way to define the experience.
Despite their success at making such connections over a lifetime, these women all found it difficult to do so in the environment of the retirement center. Their suggestions for ways to involve the elderly make it clear that personalized, sincere interactions mean the most to them. These women were delighted at the chance to get to know each other better, but also noted the missed "presence" of staff in their day-to-day lives. If Watson's carative factors had been in action as guiding principles for nursing care in this particular setting, these women would not be lamenting about the lack of caring available by staff.
Jean Watson's "Carative Factors"*
Integrating Watson's "carative factors" (Table) into nursing encounters with others may be a little difficult, and, in fact, may at times seem antithetical to our training. So often, technological processes are at the center of nursing, with caring on the fringe. However, with well older adults, and perhaps, with all those cared for in health settings, caring should be at the center of our relationships. Otherwise, humans are related to as objects, ramer than as humans.
The carative factors are valuable reminders of the steps we must take if we are to give others what they really need from us as caregivers. For example, participating in the Listening Circle helped this author crystallize that when feelings are expressed, a response is not always needed to validate them (carative factor #5). Even when the most poignant stories were told, empathy was not helpful or appropriate. The women did not focus on the pain in their stories. This author wanted to focus on the pain, although did not because of the format of the group and in fact learned, through listening, that it was not the focal point of a story. The women gained strength by speaking of coping, by sharing how they had self-managed these daunting obstacles in their lives. The participants stated that the volunteers' simple presence, the listening of their stories and the witnessing of their experiences created a healingcaring environment. In essence, these women felt "cared for."
The two volunteers learned that in order to teach the members of this Listening Circle about the power of listening, there had to be a willingness to learn from them as well (carative factor #7). This required an ability to tolerate one's own anxiety regarding the ambiguity of the group's structure (leaderless) and the anxiety that emerged for the volunteers because the focus was not on "doing". The volunteers had to make a strong effort not to be too directive, to instead go with the flow, allow whatever topics /issues to emerge on their own without trying to control the outcome of the group.
The main goal in this pilot project was to practice "conscience intentionality," to be truly present and authentic with these women without being too directive or empathetic, to "be" and not "do." The volunteers wanted relationships with the women to be symmetrical, not hierarchical. This would be demonstrated by listening not only to the stories told, but to truly listen to what emerged in the process of their storytelling. All eight members of this group felt that caring was present in the experience.
This author found that Watson's Theory of Human Caring works. The women stated the Circle experience was a "great success" and "simply delightful" and said "hospitality" was the way to be healthy and "get old with grace." The hospitality expressed in the group reminded them of what was sorely lacking in the retirement community. The sense of being cared for in the Circle experience also resulted in the women feeling safe enough to talk out loud about some missing aspects of caring in their facility. The experience of being listened to, witnessing, and sharing in community all seemed to be aspects of the aesthetics of caring.
This author found it revealing that, in the end, these women provided for the volunteers what we were hoping to provide for them, an experience of caring. Both volunteers felt they had had a "transpersonal experience." Indirectly, the participants talked about Watson's theory by telling stories about how they were greeted by other residents when they entered the retirement community. Their experience had taught them that people need to connect to one another and that healing occurs through reaching out to others. Ministering to the spirit, through listening (receiving the other person's experience), is indeed caring, transpersonal (larger than "me and you"), and healing.
- Glickstein, L. (1995). Unpublished raw data. Berkeley, CA: Center for Transformational Speaking.
- Montgomery, CL. (1992). The spiritual connection: Nurses' perceptions of the experience. In D.A. Gaut (Ed.), The presence of caring in nursing (pp. 39-52). New York, NY: National League for Nursing.
- Quinn, J.F. (1989). On healing, wholeness, and the haelan effect. Nursing & Health Care, 10(10), 553-556.
- Watson, J. (1985). Nursing: Human science and human care. A theory of nursing. Norwalk, CT: Appleton-Century-Crofts.
- Watson, J. (1994). Applying the art and science of human caring, New York, NY: National League for Nursing.
Jean Watson's "Carative Factors"*