The use of family caregivers is increasing as our society ages. As society ages, so do caregivers; it is increasingly common for 65-year-old caregivers to be responsible for aged parents or spouses. These older caregivers often experience depression, caregiver burden, and frustration. Hence, there is an. urgent need for nurses to fully understand caregivers in order to assist them in times of need and help them maintain their well being.
Nursing research has provided evidence that the caregiver role is overwhelming. This body of research has identified primarily negative effects of the caregiving experience of older adults. These caregivers are considered at serious risk for developing health problems (Browning & Schwirian, 1 994; Sayles-Cross, 1993), high perceived burden (Browning & Schwirian, 1994), depression (Collins, Stommel, Wang, & Given, 1994; Wood, 1991), and social isolation (BergmanEvans, 1994). Caregiver behaviors were found to be similar to professional workers in first and second stage burnout by Ekberg, Griffith, and Foxall (1986) who termed it "spousal burnout syndrome, " Gaynor (1990) labeled the caregiver experience the "long haul" and also found evidence of spousal burnout syndrome amongst the women in her study. The caregiver career has also been described as a "fatalistic career process" (Lindgren, 1993).
Nursing has begun to study determinants of a positive caregiving experience. Mutuality, a measure of gratification and reciprocal benefits in a relationship, lessened the role strain experienced by caregivers in a study by Archbold, Stewart, Greenlick, and Harvath (1990). Smith (1994) developed and tested a model describing effective family caregiving in which length of time in caregiving, mutuality, empathetic motivation to help, income adequacy, family coping, and preparedness contributed to caregiving effectiveness outcomes. Motenko (1989) developed a measure of caregiver gratification and revealed that gratification was associated with greater well-being, and frustration with more distress. Carey, Oberst, McCubbin, and Hughes (1991) reported that caregivers who reported high family hardiness viewed caregiving as a challenging and beneficial experience.
Nurses must continue to move away from a problem-focused approach to one of identifying and studying caregiver strengths. This approach will broaden nursing's understanding of the predictors of a positive caregiving experience. This knowledge will be useful to help nurses refine their interventions and thus promote a positive caregiving experience.
Hardiness has become a popular research concept in nursing (Jennings & Staggers, 1994). Hardy individuals and families are considered resistant in the encounter with stressful life events. Given the stressful nature of the caregiving experience, hardiness poses great potential as a determinant of positive caregiving experiences. Interrelating phenomena of interest to nursing such as hardiness with concepts identified specifically by nursing theorists, such as Watson, is integral to developing nursing's body of knowledge. Therefore, the purpose of this article is to answer the following questions:
1 . How is hardiness described in the literature?
2. What are the essential elements of Jean Watson's Theory of Human Caring in Nursing?
3. How is caregiver hardiness congruent with Watson's Theory of Human Caring in Nursing?
4. What are the implications for gerontological nursing?
The concept of hardiness, as a personality characteristic, was identified in 1977 by Kabosa as "a constellation of personality characteristics that function as a resistance resource in the encounter with stressful life events" (Kabosa, Maddi, & Kahn, 1982, p. 169). The hardy personality type theorized by Kabosa builds upon existential psychology and the proposition that "persons who experience high degrees of stress without falling ill have a personality structure that differentiates them from persons who become ill under stress" (Kabosa, 1979, p. 3). Hardy individuals are considered to possess three interrelated attributes: control, commitment, and challenge (Kabosa, 1979; Kabosa, Maddi, & Kahn, 1982).
The control attribute of hardiness has three dimensions: a) decisional control, or the capability of autonomously choosing among various courses of actions to handle stress; b) cognitive control, or the ability to appraise and incorporate stressful events in an ongoing life plan and thereby deactivate their negative effects; and c) coping skill, or a greater repertoire of suitable responses to stress developed through high motivation. Hardy persons have an internal locus of control and hold the belief that they can control or influence life events (Kabosa, 1979).
Committed persons have a belief system that minimizes the perceived threat of any given stressful situation. They possess an ability to feel deeply involved in the activities of their lives and to identify with and find meaningful the events, things and persons of their environment. They do not give up easily under pressure (Kabosa, Maddi, & Kahn, 1982).
Although commitment to all areas of life is characteristic of hardy persons, commitment to self is held above all others as particularly important to health. Commitment to self is described as "an ability to recognize one's distinctive values, goals, and priorities and an appreciation of one's capacity to have purpose and make decisions that support internal balance and structure" (Kabosa, 1979, p. 4).
Hardy persons view change as a challenge and as beneficial to personal development. They are cognitively flexible and value a life filled with interesting experiences. Possessing a unique ability to seek challenge in the face of potential psychological, social, and biological threat is characteristic of a hardy person (Kabosa, 1979).
Kabosa (1979) initially studied hardiness retrospectively by comparing executives who lived stressful but healthy lives with those who became ill under comparable stress, finding hardiness significantly mitigated the illness -provoking effects of stressful life events. This study provided a basis for understanding how persons can encounter stress and remain healthy. Kabosa and other psychologists continued to study hardiness and find significant main effects of hardiness on health but measurement, reliability, and validity problems are citeJ frequently (Funk & Houston, 1987; Hull, Van Treuren &Virnelli, 1987).
During the 1980s nursing began to explore the concept of hardiness and how it might be borrowed, adapted and applied to nursing practice (Bigbee, 1985; Lee, 1983). The hardiness concept was first used and continues to be used in nursing to explore its relationship to the stressful nature of nursing and/or nursing education (Keane, Ducette, oc Adler, 1985; Lambert & Lambert, 1993) and burnout (Duquette, Kerouac, Sandhu, & Beaudet, 1994; Rich & Rich, 1987).
Theoretical and measurement ambiguity of the original hardiness concept complicated nursing research. To address these concerns, nurses built on Kabosa's hardiness concept and developed new theoretical and measurement indicators. Pollock (1986) refined Kabosa's hardiness indicators of control, commitment, and challenge to investigate the effect of hardiness on adaptation to actual and potential health problems. Pollock (1989) defined control as "the use of ego resources to appraise, interpret, and respond to health Stressors" (p. 55); commitment as "the appraisal and coping that leads to involvement in healthrelated activities for dealing with the health Stressors" (p. 55); and challenge as "reappraisal of health Stressors as potentially beneficial" (p. 55). McCubbin, McCubbin and Thompson (1987) developed the Family Hardiness Index (FHI) to assess the family as it responds to life events and hardships. Challenge, commitment, confidence, and control were identified as the attributes of family hardiness. O'Connor (1989) developed the Hardiness for Health Professional Scale (HHP Scale) to assess levels of hardiness in registered nurses. The HHP Scale measures the cognitive, affective, and behavior components of control, challenge, and commitment. Based on existential theory that recognizes humans as not only physical and emotional in nature, but also spiritual, Carson and Green (1992) proposed spiritual well-being be included as a predictor of hardiness. If an individual is spiritually well, characterized by an existential sense of a meaningful and valuable life, then hardiness would also be present.
With continued empirical examination of hardiness as a construct, nurses discovered vast significant findings (Jennings & Staggers, 1 994). Only select studies will be described to provide a flavor of the research. Pollock (1986, 1989) examined hardiness in chronically ill adults and provided initial support for the direct and indirect effects of hardiness on adaptation to chronic illness. When hardiness and depression in institutionalized elderly were studied, a significant negative correlation (r=.40, p x.001) was found (Cataldo, 1993). Carson and Green (1992) demonstrated a significant relationship (r=.247,p<.05) between spiritual well-being and hardiness in patients with AIDS. Nicholas (1993) observed older adults high in hardiness had higher perceived health status (r=.68, /K.001). These diverse findings give credence to the premise that hardiness promotes positive outcomes in the stress-illness equation. Regardless of the continued refinement and use of the hardiness construct, recent conceptual and methodological analyses of the nursing literature continue to suggest the need for further definition and refinement (Jennings & Staggers, 1994; Lindsey & Hills, 1992; Tartasky, 1993).
Watson's Carative Factors
The current trend in nursing is toward qualitative research guided by a theoretical nursing model. Surprisingly, only isolated researchers use a qualitative approach and/or are guided by a theoretical framework in the study of hardiness Qennings & Staggers, 1994). King (1989) implemented Leininger's life history protocol with an 85-year-old Australian caregiver and discovered a cultural theme that resembles hardiness. Pollock (1 993) used Roy's Adaptation Model to guide her quantitative health-related hardiness research with the chronically ill.
Hardiness is a complex concept that is existential, phenomenological, and thus difficult to define and measure (Jennings & Staggers, 1994). Future research needs to be guided by theoretical nursing frameworks to test nursing theory and provide a more relevant and meaningful exploration of hardiness. Because Watson's (1988) nursing theory is congruent with the phenomenological and existential characteristics of the hardiness construct, it will provide the framework to explore the concept.
Building on the existential-phenomenological approach, Watson (1988) describes caring as fundamental to the human science of nursing. She incorporates the values, moral ideals, and commitments of caring into a nursing paradigm "about persons-health-environment and human care processes of nursing different from the medical and natural science paradigm" (1988, p. 19). Committed to the art and science of nursing, Watson defines nursing by explaining "The knowledge, values, action, and passion are generally related to human care transactions and intersubjective personal human contact with the lived world of the experiencing person" (1988, p. 53).
Human care transactions, the moral ideal of nursing, provide a coming together and establishment of contact between persons (Watson, 1988). One's mind-body-soul engages with another's mind-body-soul in a lived moment in which the nurse affects and is affected by the other person. Two individuals are both in a process of being and becoming. Both individuals bring a unique life history and subjective reality into the transaction. Together they generate a combined phenomenal field for that given moment, where past, present, and future blend into one. They create an energy field that will influence the future and become a part of the life history of both. Allowing for the spirit of both to be present in the moment and transcend space and time, this caring occasion expands the limits of openness and has the capacity to expand the human consciousness, restore inner harmony, and potentiate healing. This human care process is a special, delicate gift to be cherished by humanity.
Where there is inner harmony, there exists a unity between mind, body, and soul; a harmony between self and others; between self and nature; between subjective reality and external reality. Harmony is health, a congruence between the self as perceived (I) and the self as experienced (me). Disharmony is subjective turmoil within a person's inner self or soul. It is an incongruence between the self as perceived and the self as experienced, between the person and the world. Disharmony can lead to illness, and illness can produce disease.
The goal of nursing is to "help persons gain a higher degree of harmony within the mind, body, and soul, which generates self-knowledge, self-reverence, self healing, and self-care processes while allowing increasing diversity" (Watson, 1989, P. 226). This goal is achieved through the human caring process, occurring in such a way that individuals can achieve mental-spiritual growth through exploring the meaning of their disharmony, suffering and turmoil. Finding meaning enhances discovery of inner power and self-control, and promotion of health and healing.
The agent of change is the individual patient. The nurse is a co-participant in change through the human care process using the 10 carative factors (Watson, 1989). These carative factors are enabling actions embedded in the human care process (Figure). The 10 carative factors become actualized in the momentto-moment human caring process in which the nurse is being with the other person. Caring occurs in different degrees. The more human caring is actualized, the more potential the caring holds for human Health goals to be met through finding meaning in one's own existence, discovering one's own inner power, and controlling and potentiating self-healing.
Hardiness, the personality characteristic composed of control, commitment, and challenge, functions as a resistance resource m the encounter with stressful life events for caregivers (Kabosa, Maddi, & Kahn, 1982, p. 169) or as a motivating factor in adaptation to illness (Pollock, 1989). This is congruent with Watson's goal of nursing. According to Watson (1988), the goal of nursing is to "help persons gain a higher degree of harmony within the mind, body, and soul, which generates self-knowledge, selfreverence, self-healing, and self-care processes while allowing increasing diversity" (Watson, 1989, p. 226).
Watson's (1989) self-knowledge, self-reverence, self-healing, and selfcare are related to control, commitment, and challenge, the three components of hardiness. Watson's (1989) concept of self-knowledge, the ability to learn about one's self through other, is reflected in the characteristics of a hardy person: a) commitment or ability to feel deeply involved and find meaning, b) cognitive ability to appraise and incorporate stressful life events into an ongoing life plan, and c) ability to seek challenge and view it as beneficial to personal development (Kabosa, 1979). Self -reverence (Watson, 1989) corresponds with commitment to self, "an ability to recognize one's distinctive values, goals and priorities and an appreciation of one's capacity to have purpose and make decisions that support internal balance and structure" (Kabosa, 1979, p. 4). Self-healing and self-care are evident in Pollock's (1989) health-related hardiness attribute definitions; control being "the use of ego resources to appraise, interpret, and respond to health Stressors" (p. 55); commitment being "appraisal and coping that leads to involvement in healthrelated activities for dealing with the health Stressors" (p. 55); and challenge being "the reappraisal of health Stressors as potentially beneficial" (p. 55).
Through transpersonal caring, nurses promote mental-spiritual evolution, discovery of inner power, and self-control which in turn potentiate harmony and transcendence regardless of the external health condition (Watson, 1988). This inner power and self control is analogous to control as described by Kabosa (1979), an internal locus of control and the ability to control or influence life events. Harmony and transcendence correlate with Carson and Green's (1992) expanded concept of hardiness. Harmony is health, a congruence between the self as perceived and the self as experienced, a unity between mind, body, and soul (Watson, 1988). "Transcendence provides opportunities to grow and become more fully human" (Watson, 1989, p. 224), "to transcend the physical world by controlling it, subduing it, changing it, or living in harmony with it" (Watson, 1989, p. 225). Based on existential theory which recognizes humans are not only physical and emotional in nature, but also spiritual, Carson and Green, (1992) proposed spiritual well-being be interjected into Kabosa's (1979) hardiness attributes as a predictor of hardiness. They hypothesized and demonstrated that if an individual is spiritually well, characterized by an existential sense of a meaningful and valuable life, then hardiness would also be present.
Promoting caregiver hardiness within Watson's (1988) theory will help guide nursing practice with older caregivers in a variety of clinical settings where nurses encounter caregivers. Theses settings might include homes, adult day care centers, retirement centers, hospices, and mental health agencies. Creative nursing care plans should focus on goals of caregiver coping and adaptation by strengthening hardiness in older caregivers. The nurse and older caregiver should collaborate for a plan of care designed to encourage a sense of commitment, control, and challenge for older caregjvers based on the needs and experiences of the caregiver using Watson's carative factors.
Commitment to themselves and their situation can be fostered in the caregivers by facilitating the caregivers to identify a vision for themselves, define their purpose in life, find meaning in the caregiver situation based on their human predicament, and celebrate caregiver successes. These increase the capacity to "make decisions that support internal balance and structure" (Kabosa, 1979, p. 4). Caregivers need to care for themselves by finding a balance between work, sleep, leisure, nutrition, and exercise. They need to give themselves permission for personal enjoyment because their caregiver role is often defined by self-sacrifice. The caregivers must find time for personal fulfillment by creating a space for themselves in the home, take vacations from their caregiving role, learn stress management techniques, have hobbies, and interact with friends. In addition, the nurse can assist caregivers to seek out persons with common challenges to establish networks. Commitment can be fostered by the nurse using a variety of Watson's carative factors (1989). Through the development of a helping-trusting relationship, the acceptance of expression of positive and negative feelings, and the use of a creative problem-solving process, the nurse will assist caregivers to feel committed to themselves and their care recipients.
Nurses can assist older caregivers to discover their inner power by encouraging decision-making. Transpersonal teaching-learning can assist caregivers to learn about their loved ones' health problems, as well as appropriate community resources. Inner power can be promoted also by encouraging older caregivers to draw faith and hope through their religion or other spiritual sources. Control and competence can be increased by teaching assertive communication strategies using role playing. Assertiveness is especially useful in improving communication with health care professionals.
Older caregivers often have ambivalent feelings regarding the care recipient. Their complex feelings may reflect love, duty, resentment, frustration, and wish to be free of responsibility. Sharing these positive and negative feelings regarding caregiving with nurses can assist caregivers with their sense of control because the ambivalent feelings cause guilt.
Control can be further increased when older caregivers develop a feeling of competence. Nurses can encourage positive self-appraisal by encouraging realistic, attainable goals. It is important for nurses to give positive feedback by focusing on the contributions made by caregivers. Caregiver hardiness can be addressed in nursing care planning through fostering transpersonal caring using Watson's (1989) cararive factors. Nurses can encourage the older caregivers to look after their own health, healing, spirituality, and health care decisions. Taking care of themselves is essential to have the inner harmony and strength to care for their loved ones.
As difficult as many caregiving situations may be, hardy caregivers rally to the challenge. Hence, hardiness can be promoted if nurses can foster caregivers' ability to see the situation as a challenge and growthproducing experience. Nurses can help caregivers identify their usual responses to change. Through discussion, caregivers can discover those responses they appraise to be beneficial. By encouraging positive selftalk, imagery, meditation, and relaxation, older caregivers will increase their inner harmony to rise to the difficult challenge of caregiving.
In summary, framing future caregiver hardiness research within Watson's (1988) theory will help build the science of nursing necessary for nurses to effectively participate in the evolution of caregiver hardiness. By doing this, nurses will promote the health, healing, and spiritual evolution of the older caregivers and the loved ones for whom they care. Nurses who bring a humanisticaltruistic value system to their practice convey kindness to older caregivers. This is necessary for the caregivers who also are "receiving through giving" (Watson, 1989, p. 228).
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Watson's Carative Factors