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Application of Watson's Theory of Human Caring to End of Life Care in the

Burns Intensive Care Unit: A Case Report

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Case Study in Caring
Application of Watson’s Theory of Human Caring to End of Life Care in the Burns Intensive Care
Unit: A Case Report
Jonathan Bayuo, RN, Department of Nursing, Presbyterian University College–Ghana

Abstract Overview of Watson’s Theory

Care provision to severely burned patients is a challenging task that has the potential of putting The theory of caring as espoused by Watson
aside other spheres of the patient and placing emphasis on the physical injury. Thus, Watson’s contends that nursing care extends beyond
Theory of Human Caring was applied to a burned patient. Though his stay was short, it offered an human contact and focuses on the soul of the
opportunity to assess the applicability of Watson’s theory to end of life care. The theory proved patient instead. Watson’s conviction is that when
useful to end of life care in the unit but it was identified that the current nursing care strategies a nurse cares for a patient, the nurse enters into
will have to change to the primary nursing approach to enable a continuity of this application. the life space of that patient and detects his or her
condition at a spiritual level (Watson, 1988a).
Thus, the nurse connects with the patient at a
Keywords: Theory of Human Caring; burns; end life of patients and their families facing the deep spiritual level. The theory focuses on the
of life care problems associated with life-threatening illness whole patient instead of the pathology and
through the prevention and relief of suffering by treatment plan. In Watson’s view, the disease
Introduction means of early identification and impeccable might be cured, but illness would remain because
Globally, health care systems are undergoing assessment and treatment of pain and other without caring, health is not attained (Watson,
unprecedented changes in all spheres and in problems, physical, psychosocial, and spiritual, 2007). Caring is the essence of nursing and
response to increasing complexities associated and this specifies the dimensions of the patient. It connotes responsiveness between the nurse and
with patient care and changing demographics. has also been noted that the principles of the person; the nurse co-participates with the
These advances, although appropriate to palliative care include excellent communication, person. Furthermore, Watson contends that
enhance patient care, have the potential of pain and symptom management, goals of care, caring can assist the person to gain control,
undermining the core of nursing, which is to offer bereavement, and spiritual support (Mosenthal & become knowledgeable, and promote health
care that transcends the physical illness. Within Murphy, 2003). Along similar lines, at the end-of- changes.
the burn unit, this is likely to occur as greater life period, patients have been noted to possess According to Watson (2007), the major
focus remains on attenuating physiological physical, psychosocial, and spiritual needs elements of her theory are (a) the caritas
perturbations associated with burn injury. It has whereas family members have been noted to processes, (b) the transpersonal caring
been argued that nursing a severely burned have psychosocial needs that can be elicited relationship, and (c) the caring occasion or caring
patient is physically and emotionally exhausting through honest and tactful communication moment.
due to the intensive treatment modalities required (McKay, Rajacich, & Rosenbaum, 2002). Watson views the caritas processes as a
to prevent complications and restore functional guide for the core of nursing, which is in contrast
Burn as an injury threatens not only the
ability (Cronin, 2001). Thus, a greater attention is to medicine’s curative factors. Her caritas
physiological stability of the patient, but also all
paid toward the physical illness, and this leaves processes attempt to ‘‘honour the human
aspects of his or her life as well as that of the
limited room for the nurse to deliberately and dimensions of nursing’s work and the inner life
family. A burn injury occurs suddenly and leaves
sufficiently attend to other spheres of the patient. world and subjective experiences of the people
very limited time for adjustment (Coffey, Everett,
The theory of human caring by Jean Watson we serve’’ (Watson, 1997, p. 50). These caritas
Miller, & Brown, 2011). Watson (2007) has
is considered a philosophy that offers processes (Watson, 2000) include the following:
asserted that the mission of nursing involves
indispensible assistance to nurses in offering  Practice of loving kindness and equanimity
seeking to preserve humanity even when
holistic care to patients while preserving the within the context of caring consciousness
caring practices of the nursing profession. Being threatened, attending to and helping to sustain
 Being authentically present and enabling
informed by Watson’s caring theory allows nurses human dignity, unity of oneness of being, and to
and sustaining the deep belief system and
to return to our deep professional roots and hold the other in their wholeness even when they
subjective life world of self and one being
values. Caring endorses our professional identity could not feel whole themselves. Watson (2007)
cared for
within a context in which humanistic values are further argues that these are all activities that  Cultivation of one’s own spiritual practices
constantly examined and provides avenues to transcend illness, diagnosis, condition, and and transpersonal self, going beyond ego
respond to profound human dimensions of illness setting. Thus, the theory of human caring as self
and health (Watson, 2007). espoused by Watson provides an avenue to  Developing and sustaining a helping–

Although burn care aims to achieve survival render care that transcends the physical illness so trusting authentic caring relationship
outcomes with limited disability, greater mortality as to offer holistic care. As burn-injured patients  Being present to and supportive of the

has been noted to exist among patients with and families have concerns beyond the physical expression of positive and negative feelings
severe burns (Peck, 2011). Also, severely burned injury, Watson’s theory appears useful. Mckay et as a connection with deeper spirit of self and
patients face distressing symptoms that may not al. (2002) affirms this as they noted the the one being cared for
respond to traditional burn management usefulness of the theory of human caring in  Creative use of self and all ways of knowing

strategies. Thus, the tenets of palliative care have meeting the palliative care needs of cancer as part of the caring process to engage in
been noted to be useful for these patients patients who decide to die in their homes and with the artistry of caring–healing practices
although its place in trauma has received minimal their family members. It is in light of this  Engaging in genuine teaching–learning

attention (Mosenthal & Murphy, 2003). The World realization that the theory was selected to assess experience that attends to unity of being and
Health Organization (2002) has defined palliative its applicability in meeting the needs of the meaning, attempting to stay within the
care as an approach that improves the quality of severely burned patient. other’s frame of reference

142 International Journal for Human Caring


 Creating a healing environment at all levels
(physical as well as nonphysical), subtle
environment of energy and consciousness,
whereby wholeness, beauty, comfort, dignity,
and peace are potentiated
 Assisting with basic needs with an
intentional caring consciousness,
administering ‘human care essentials,’ which
potentiate alignment of mind–body–spirit,
wholeness, and unity of being in all aspects
of care, tending to both embodied spirit and
evolving spiritual emergence
 Opening and attending to spiritual,
mysterious, unknown, and existential
dimensions of all the vicissitudes of life
change, ‘‘allowing for miracle.’’ All of this is
presupposed by a knowledge base and
clinical competence.
According to Watson (1999), the
transpersonal concept is an inter-subjective,
human-to-human relationship in which the nurse
affects and is affected by the person of the other.
Both are fully present in the moment and feel a
union with the other; they share a phenomenal
field that becomes part of the life story of both.
Thus, the transpersonal caring relationship
characterizes a special kind of human care
relationship, and as such, the nurse goes beyond
objective assessment toward the patient’s
subjective and deeper meaning.
The caring moment or occasion is that period
(focal point in space and time) when the nurse
and patient come together in such a way that an
occasion for human caring is created. Both
persons with their unique phenomenal fields have
the possibility to come together in a human-to-
human transaction (Watson, 1999). The caring
occasion becomes ‘‘transpersonal’’ when ‘‘it
allows for the presence of the spirit of both—then
the event of the moment expands the limits of
openness and has the ability to expand human
capabilities’’ (Watson, 1999, pp. 116–117).
Case Report
K.K., a 22-year-old male, was admitted on
account of thermal burns affecting both upper and
lower limbs and the posterior trunk as well as
fracture of both lower limbs and, as such, could
not move them. He was a high school graduate
who loved to play football with his friends. He was
dark in complexion, stout, and the third-born male
child among six siblings. He had recently
completed high school and hoped to further his
education as well as pursue football as his
favorite game. His parents described him as a
jovial person who got along well with everyone.
His favorite meal was yam with palaver sauce. He
neither took alcohol nor smoked and loved to hunt
with his friends as well.
According to his history, he was in a tractor
with three colleagues when they were attacked by
a swarm of bees. His colleagues escaped, but he
was trapped among the bees, and as a result, his
colleagues lighted a fire to drive the bees away.
However, the fire came close to his shirt and set
his clothes on fire. He was seen at a peripheral
hospital and later referred to a tertiary health
facility for specialist management on 10/12/2016.
Upon arrival at the tertiary health facility, he was
triaged with triage early warning score of nine and
sent to the red wing of the accident emergency
department. Wounds were assessed and noted to
be characteristic of third-degree burns (40% total
burned surface area). Fluid resuscitation was
commenced based on values obtained from the
Parkland formula as well as pain management,
monitoring of vital signs, and wound care. He was
later transferred to the burn unit for continuity of
care. Continuous monitoring was ensured, but
urine output was noted to be inadequate. Blood
samples were obtained for various investigations
on 12/12/2016, and results indicated the presence
of severe hyperkalemia. Interventions were
instituted to correct this with subsequent plans to
commence hemodialysis.
Due to his inability to move his lower limbs, he
was always in bed although he wished he could
ambulate and perform activities of daily living for
himself. Occasionally, he indicated missing his
football game and was worried about whether he
would be able to walk again. Although he
appeared withdrawn and not willing to talk much
on the first day of admission, he was reassured,
and there were several interactions with his
family. On the second day, he opened up quite
well and spoke about how he felt about the injury.
He was particularly worried about not been able
to meet his personal needs, play his favorite
football game, or go hunting with his friends. He
expressed concerns regarding being confined to a
room, and relatives were only allowed to see him
during visiting hours. He was also worried about
how his friends, who attempted to rescue him
from the bee attack, felt about the entire incident.
He noted that he was aware they wanted to help
him and wanted them to know that he really
appreciated the assistance. However, his friends
were unable to visit him while on admission.
Despite these concerns, the priority of the
health team was to improve renal functioning and
correct the hyperkalemia. On 14/12/2016 at 8 AM,
he was noted to be in a state of
unresponsiveness, and the cardiac monitor
indicated asystole. Cardiopulmonary resuscitation
and other activities were instituted to correct this.
At that point, it was noted that he was at the end-
of-life phase. After resuscitation, he was put on
oxygen support and continuous monitoring
ensured. This continued until he was declared
clinically dead at 12 noon that same day.
Discussion
Burn care generally aims to achieve survival
outcomes with limited functional disability. For
Case Study in Caring
most patients with severe burns, survival
outcomes are poor, and death is inevitable in
these patients. However, the role of palliative care
in burn management is ill defined, and as such,
most severely burned patients undergo
aggressive burn management until they die
(Mosenthal & Murphy, 2003). In this regard, the
focus remains on managing the burns.
Watson (1988b) has defined a person as a
being in the world, comprising mind, body, and
soul. Watson (2007) argues that the patient is part
of himself or herself, environment, nature, and the
larger universe. Thus, caring for the burned
patient at the end-of-life period with this theory will
require attention to all these spheres through the
creation of a caring moment and application of the
clinical caritas processes (Watson, 2000).
From the day of admission, it was noted that
K.K. was severely burned and had other
comorbidities that prevented him from being able
to meet his personal care needs. Despite this,
through interactions, he shared his life story,
which enabled me to know him as a person with a
past, present, and future and not just a burned
patient—a feature that has been described as a
phenomenal field (Watson, 2000). This was
achieved by asking him, ‘‘Can you please tell me
about yourself?’’ This question enabled K.K. to
open up to me to understand what his current
condition meant to him as well as his hopes,
aspirations, and dreams. He noted that the injury
was only temporal and hoped to get better so that
he could resume his normal life in which he
enjoyed football and hunting with his friends. He
hoped that his recovery would occur soon as he
missed football a lot. The discussion with K.K.
placed me at a point that enabled me to see
things from his point of view and also to achieve
greater awareness of my goals, dreams, and
aspirations. As the discussion continued, I
realized his constant reverberation of getting well
soon. However, considering the extent of the
injury and previous professional experience with
patients with similar conditions, I realized that the
chances of speedy recovery were very thin. Thus,
I asked him what if he did not get better or stayed
longer in the hospital. This question created a
long pause before he responded that God knows
better and he would leave that to God. However,
his long pause was explored further, and that
enabled me to understand that he felt helpless
and powerless in the entire situation. Personally, I
felt like there is a limitation to what humans can
do. Although we might wish and hope for
something better, we may not possess the power
to make that happen. The discussion enabled me
to understand his life experiences. According to
Watson, the mind is the point of access to the
body and the spirit. The spirit relates to the
patient’s soul, the inner self, the essence of the
person, the spiritual self. It is the spirit that allows
the patient to transcend the here and now,
2017, Vol. 21, No. 3 143
Case Study in Caring
coexisting with past, present, and future. Thus,
assessment was not limited to the characteristics
of the burn injury, but expanded to all spheres so
as to know K.K. as a person and not just a case
to be attended to. Further to this, information was
obtained regarding his family and community as
Watson (2007) has noted that the person is
connected to his environment. As the discussions
continued, he noted that he would be glad if his
family members were made aware of the possible
outcomes of care. His wish was granted as the
possible outcomes of care were discussed with
family members. This required tactful and honest
communication as family members asked, ‘‘So
will he die?’’ and ‘‘When will he die?’’ and ‘‘Why
will he die?’’ In response, I made the family
aware that answers to these questions are difficult
to provide. They also expressed hope in God and
believed that God would grant them strength.
Furthermore, although K.K. felt sad for not
being able to meet his personal care needs, he
was informed that those would be provided by the
nursing staff. He was encouraged to verbalize his
emotions regarding his inability to handle his self-
care needs. Constant reassurance was offered as
Watson (1988a) has noted that caring must be
grounded in a set of universal human values
(kindness, concern, and love for others).
Throughout the period he was able to talk, he was
encouraged to verbalize his feelings as and when
he experienced them. This allowed him to be
present with the emotions and feelings at a
particular period. As the primary nurse, I also
noted my feelings as K.K. verbalized his feelings
and lived the moment. What I felt was empathy
toward him and encouraged him to verbalize
these feelings. However, it was ensured that
these discussions did not interfere with his rest
periods. As this continued, he was able to find
hope within himself, which made him feel better.
He also expressed faith in the existence of a
supreme being (God) and hoped that his faith
would be a source of strength to him and his
family. Throughout the period, personal hygiene
needs were met by the nursing staff, wound care
rendered, and other appropriate care required by
the patient.
On the fourth day post-admission, K.K.
became unconscious and could not verbalize his
feelings and emotions. His family became the
focal point then as they manifested anticipatory
grief, and they came face to face with the reality
of impending loss. However, due to the activities
in the intensive care unit, it is very difficult to have
enough time to allow the family to verbalize their
feelings regarding the impending loss. They were
updated from time to time about K.K.’s state until
he was declared clinically dead at 12 noon by the
attending physician. The family members were
informed and encouraged to talk about their loss
amid intermittent sobbing. This continued until
they indicated their readiness to go back home.
144 International Journal for Human Caring
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Conclusion Watson, J. (2000). Via negativa: Considering
Caring for the burn-injured patient is a caring by way of non-caring. The Australian
challenging activity, and greater focus appears to Journal of Holistic Nursing, 7(1), 4–8.
be placed on the injury with limited attention to the Watson, J. (2007). Watson’s theory of human
patient as a holistic being. However, in applying caring and subjective living experiences:
Watson’s theory of human caring in our setting, it Carative factors/caritas processes as a
was identified that the theory offered an disciplinary guide to the professional nursing
opportunity to attend to other spheres of the practice. Texto Contexto Enferm,
patient. Watson’s theory of human caring opened Florianópolis, 16, 129–135.
World Health Organization. (2002). WHO
the possibilities for greater patient and family
definition of palliative care. Retrieved from
involvement in the care delivery process. It
http://www.who.int/cancer/palliative/definition/
enabled an assessment of not only physical
en
response to the burn injury, but also an
understanding of psychosocial and spiritual
issues faced by the patient and the family as care Author Note
transcended the burn injury. Thus, as research Jonathan Bayuo is RN at the Department of
continues to establish the place of palliative care Nursing, Presbyterian University College–Ghana.
in burns, it may be useful to consider the theory of Conflict of interest: none.
human caring as providing useful insights. Correspondence regarding this article may be
However, it was noted that if this application will sent to Jonathan Bayuo, Presby University
continue, there may be a need to enhance staffing College–Ghana, Asante Akyem Campus, P. O.
levels so as to enable nurses to have sufficient Box AG 42, Agogo. Email: jbayuo88@gmail.com,
contact number: þ233209266925.
time with patients and their families.
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