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A Critical Appraisal of Health Promotion in a Primary Care Clinic Utilizing Jean Watson's

Human Caring Theory: A Qualitative Study

STUDENT NAME

United States University

MSN 563: Evidenced-Based Inquiry for Scholarship and Practice

Dr. Anita Hunter

DATE
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A Critical Appraisal of Health Promotion in a Primary Care Clinic Utilizing Jean Watson's

Human Caring Theory: A Qualitative Study

The research study titled “Patents’ Experiences of the Caring Encounter in Health

Promotion Practice: A Qualitative Study in Swedish Primary Health Care” was published

in BMC Family Practice Journal in 2020 by Kristina Lundberg, Mats Jong, Meik C. Jong, and

Kristiansen L. Porskrog (Lundberg et al., 2020). This study uses Jean Watson’s Human Caring

Theory (JWHCT) framework to explore the fundamental components of a caring interaction

between patients and nurses in a primary practice setting.

Type of Study (Qualitative)

This article was a phenomenological, qualitative study that describes lived experiences

through the gathering of narrative data. Phenomenology offers perspectives from study

participants through dialogue rather than specific procedures performed (Melnyk & Finest-

Overholt, 2019).

Study Design (Thematic Analysis)

This study was a descriptive research design using thematic analysis, a method of pattern

recognition after conducting face-to-face interviews to extract themes that compile non-

numerical data sets (Roberts et al., 2019). This design was a method of capturing the patient's

experiences from an encounter with a nurse using fundamentals gathered from the

JWHCT (Lundberg et al., 2020). Initially, a deductive approach was used for content analysis to

prove JWHCT had a positive impact on health promotion practice (HPP). Subsequently, an

inductive latent content approach was used to verify patterns in the participant's answers to gain

new knowledge (DifferenceBetween, 2015).

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In Lundberg et al. (2020), researchers asked questions to determine if nurses trained to

deliver care using principles from the 10 Caritas of the JWHCT had a positive impact on the

HPP of patients suffering from cardiovascular disease (CVD). The in-person interviews were

conducted with 12 volunteer participants. Participants were required to speak and understand the

Swedish language, have one or more risk factors for CVD, have had at least one or more office

visit encounters with the nurse in the primary care clinic, be at least18 years old, and not

currently suffering from dementia. Using this study design was appropriate to explore if using

JWHCT in the HPP with patients in a primary practice setting makes a significant difference

whether or not patients related to one or more of Watson's 10 Caritas and if this had a positive

impact on their health care (Lundberg et al., 2020). 

Quality of Study

Melnyk & Finest-Overholt (2019) stated that qualitative single descriptive study's

hierarchy of evidence is at level VI. Qualitative studies are not bound by a specific sample size,

in fact, at the start of a qualitative study, the sample size is usually not determined. Sample sizes

are generally small but grow as interviews are conducted that may reveal new details that lead to

additional participants. Final sample size is determined by the researcher who begins to see

“saturation” or the same thing over-and-over again; the same concepts or themes keep surfacing

and nothing new is revealed. The purpose becomes focused on human experiences from the

people who are living those experiences, to “understand”, “explore”, or “describe” (Melnyk &

Finest-Overholt, 2019, p. 646).

Lundberge et al. (2020) stated that that organizational structures of primary practice are

not quickly changed but felt implementing JWHCT would result in positive human experiences

between patients and clinicians and result in better health outcomes. Interestingly, 50 participants
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met the inclusion criteria listed earlier, but only 12 signed the consent and participated in the

study. The invitation letter did inform the participants of the researcher's background, current job

title, and the aim of the study. The nurses who took part in the study were part of a pilot program

that trained them on how to deliver a more holistic type of care based on the 10 Caritas of

Watson's Theory; however, participants were not aware of this fact before the start of the

study (Lundberg et al., 2020).  

Lunderg et al. (2020) stated the data was collected using individual face-to-face

interviews in a neutral place. Neither patient nor interviewer knew each other before the

interview. The mean interview length was 59 minutes. An interview guide was used to capture

variations, field notes were taken, and digital audio-recordings were transcribed verbatim. All

questions were open-ended and broad in nature. A couple of the questions were, “In what ways

were your needs met?” and “In what way did the district nurse give you support and instill

confidence?” (Lundberg et al., 2020, p. 6). Broad, open-ended questions allowed for the full

expression of the participant's viewpoint and opinion.

In the Lundberg et al. (2020) study, analysis was carried out by an initial read-through by

the first and last author of the study to obtain a big picture view of the texts. First, in the

deductive phase of data analysis, a categorization matrix was generated and applied structurally

and systematically to study descriptions of the participant's experiences. The goal was to identify

traces of JWHCT theoretical background in their answers, looking for references to her 10

Caritive Factors. The categorization matrix revealed that not all 10 of the Carative Factors were

identified, so the matrix was revised twice more to only 5 Carative Factors. Finally, an inductive

latent analysis was performed to understand the material by placing meaning units, assigning
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specific codes, and then sorting them into similar groups. The inductive latent analysis revealed

seven subthemes, three themes, and one central theme (Lundberg et al., 2020). 

Results

Lundberg et al. (2020) stated that three themes emerged. First, "feeling the deepest

essence of being cared for," participants spoke about being respected, listened to, and liked being

the focus with the nurse (p.8). Second, "feeling acceptance and worth," patients spoke of being

able to absorb new information without feeling substandard and expressed how they felt more

comfortable talking about past failures (p.9). Last, "being in a supportive atmosphere that

promotes hope" (p. 10). The supportive atmosphere is directly related to patients' past

experiences with the inability to have trusting relationships. After the office encounter with a

nurse versed in caring science, they left empowered to take charge of their health and better

trusting ability (Lundberg et al., 2020). 

After identifying all the subthemes and themes, a central theme emerged, "experiencing

human dignity" (Lundberg et al., 2020, p. 11). Jean Watson wrote about how seeing people as

individual human beings with unique needs leads to a holistic approach to health care delivery

(NurseLabs, 2016), which this study set out to prove. 

Implications for Practice

Lundberg et al. (2020) said one of the main reasons to conduct this study was to find a

way to change organizational structures in primary care clinics more easily. Since JWHCT has

been successful in hospitals and teaching institutions but not studied in primary practice, the

authors wanted to see if applying the human caring principles in this environment would also

show the same success with better health outcomes. The theme that stood out to me the most was

the sense of empowerment patients felt to take charge of their health after having a caring
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encounter with the nurse (Lundberg et al., 2020). If nurses practice the JWHCT principles daily

and provide a holistic approach in their health care delivery, I feel we could have a healthier

society.

Further Research/ Evaluation

Two strengths and two limitations to this study were identified. Lundberg et al. (2020)

stated the first strength was that this was the first study that researched the effects of JWHCT

principles on patient experiences in primary care clinics in Sweden. The second strength was that

the participants had no idea the nurses took part in a pilot program that trained them in caring

science before the encounters, which meant the responses were authentic and not influenced by

possible patient expectations. Patients having access to this knowledge prior could have skewed

the data (Lundberg et al., 2020).

Two limitations were identified. Lundberg et al. (2020) stated the first limitation was that

the office visits were only studied after the nurses received human caring science training and

not before the caring principles were applied, which doesn't allow the researcher to compare the

before and after experiences of each patient encounter. Last, some patients had already had

numerous meetings with the nurse before delivering a different style of care, which may have led

to an already established caring/trusting relationship based on multiple previous visits and not

JWHCT. Therefore the data may not accurately reflect the true impact of using JWHCT in

primary practice (Lundberg et al., 2020). 

I feel there were two other limitations not referenced in the article. The demographics

didn't identify ethnicity or cultural background, leading to this study not being generalizable in

different populations. Jean Watson's Theory speaks about holistic care and spirituality directly

influenced by culture (Riegel et al., 2018). Second, four authors took part in the study, but only
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two participated in generating the transcribed interviews' broader themes. The more dialogue you

have about thematic data, the more profound thought goes into meaning and inference. 

Conclusion

Thus far in nursing, JWHCT has been vital to establishing a trusting relationship with my

patients and improving health outcomes.  I have utilized her 10 Caritas in practice and will

continue as I become a primary provider. This study set out to prove that Watson's Theory could

positively impact health outcomes in primary practice. Since I am becoming a Family Nurse

Practitioner, this study solidifies my personal goal to provide holistic care using Jean Watson’s

Theory. This study can easily be replicated in other health environments. By identifying cultural

background and ethnicity, I feel, could help this study be more generalizable and the results more

applicable if quantitative and/or mixed method research study was done with a larger population

size. The themes that emerged demonstrated Jean Watson's Theory has made and will continue

to make a positive difference in delivering health care now and into the future.
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References

DifferenceBetween. (2015, May 12). Difference between inductive and deductive research.

DifferenceBetween.com. https://www.differencebetween.com/difference-between-

inductive-and-vs-deductive-research/

Lundberg, K., Jong, M., Jong, M. C., & Porskrog Kristiansen, L. (2020). Patients’ experiences of

the caring encounter in health promotion practice: A qualitative study in Swedish primary

health care. BMC Family Practice, 21(1). https://doi.org/10.1186/s12875-020-01296-6

Melnyk, B. M., & Finest-Overholt, E. (2019). Evidence-based practice in nursing & healthcare:

A guide to best practice (4th ed.). Wolters Kluwer Health.

NurseLabs. (2016, January 5). Jean Watson: Theory of human caring. Nurseslabs.

https://nurseslabs.com/jean-watsons-philosophy-theory-transpersonal-caring/

Riegel, F., Crossetti, M., & Siqueira, D. (2018). Contributions of jean watson's theory to holistic

critical thinking of nurses. Revista Brasileira de Enfermagem, 71(4), 2072–2076.

https://doi.org/10.1590/0034-7167-2017-0065

Roberts, K., Dowell, A., & Nie, J.-B. (2019). Attempting rigour and replicability in thematic

analysis of qualitative research data; A case study of codebook development. BMC

Medical Research Methodology, 19(1). https://doi.org/10.1186/s12874-019-0707-y