The Philosophy and Science of Caring:Revised Edition The original text begins with a discussion of nursing as the Philosophy and Science of Caring. I now ponder suggesting that today, almost thirty years later, it perhaps could equally be framed as Caring: The Philosophy and Science of Nursing. Discussions and ambiguity remain as to the nature of Caring Science and its relation to nursing science. Rhetorical questions arise, such as, are there distinct differences between the two? Do they overlap? Do they intersect? Are they one and the same? These questions perhaps remain, but the present work offers a distinct position. By transposing the order of Nursing and Caring, it invites a new discourse and context. My position is this: Caring Science as a starting point for nursing as a field of study offers a distinct disciplinary foundation for the profession; it provides an ethical, moral, values- guided meta- narrative for its science and its human phenomena, its approach to caring- healing- person- nature- universe. It reintroduces spirit and sacred dimensions back into our work and life and world. It allows for a reunion between metaphysics and the material- physical world of modern science. In positing Caring Science as the disciplinary context and matrix that guides professional development and maturity, I acknowledge that there is a difference between the discipline of nursing and the profession of nursing. It is widely known that the discipline (of any field) should inform the profession. The disciplinary matrix of Caring carries the meta- paradigm, the values, the metaphysics, the philosophical- moral meta- narrative with respect to what it means to be human, honoring unity of Being, the oneness of mind- body- spirit/ universe; the discipline offers subject matter foci and a distinct perspective on the subject matter. The profession, without clarity of its disciplinary context, loses its way in the midst of the outer- worldly changes and forces for conformity to the status quo of the moment. The discipline of nursing, from my position, is/ should be grounded in Caring Science; this, in turn, informs the profession. Caring Science informs and serves as the moral- philosophical- theoretical- foundational starting point for nursing education, patient care, research, and even administrative practices. If nursing across time had been born and matured within the consciousness and clarity of a Caring Science orientation, perhaps it would be in a very different evolved place today: a place beyond the struggles with conventional biomedical- technical science that linger still, beyond the crisis in care that haunts hospitals and systems today, beyond the critical shortage of nurses and nursing that society is experiencing at this turn in history, and beyond the noncaring communities in our life and world. Our world is increasingly struggling with wars, violence, and inhumane acts— be they human- to human, human- to- environment, or human- to- nature. In spite of an evolved cosmology for all disciplines today, including physics and basic sciences and other scientific fields, we still often find ourselves locked in outdated thinking within a separatist- material- physical world ontology and an outer- worldview as our starting point. Caring Science, in contrast, has as its starting point a relational ontology that honors the fact that we are all connected and Belong to Source— the universal spirit field of infinity (Levinas 1969)— before and after the human plane of worldly experiences. Caring Science makes more explicit that unity and connectedness exist among all things in the great circle of life: change, illness, suffering, death, and rebirth. A Caring Science orientation moves humanity closer to a moral community, closer to peaceful relationships with self– other communities– nations, states, other worlds, and time. BASIC ASSUMPTIONS OF CARING SCIENCE (ADAPTED WITH MINOR MODIFICATIONS FROM WATSON 1979: 8– 9) Caring Science is the essence of nursing and the foundational disciplinary core of the profession. Caring can be most effectively demonstrated and practiced interpersonally; however, caring consciousness can be communicated beyond/ transcends time, space, and physicality (Watson 2002a). The intersubjective human- to- human processes and connections keep alive a common sense of humanity; they teach us how to be human by identifying ourselves with others, whereby the humanity of one is reflected in the other (Watson 1985: 33). Caring consists of Carative Factors/ Caritas Processes that facilitate healing, honor wholeness, and contribute to the evolution of humanity. Effective Caring promotes healing, health, individual/ family growth and a sense of wholeness, forgiveness, evolved consciousness, and inner peace that transcends the crisis and fear of disease, diagnosis, illness, traumas, life changes, and so on. Caring responses accept a person not only as he or she is now but as what he or she may become/ is Becoming. A Caring relationship is one that invites emergence of human spirit, opening to authentic potential, being authentically present, allowing the person to explore options— choosing the best action for self for “being- in- right relation” at any given point in time. Caring is more “healthogenic” than curing. Caring Science is complementary to Curing Science. The practice of Caring is central to nursing. Its social, moral, and scientific contributions lie in its professional commitment to the values, ethics, and ideals of Caring Science in theory, practice, and research. PREMISES OF CARING SCIENCE (ADAPTED FROM WATSON 2005: 218– 219) Knowledge of Caring cannot be assumed; it is an epistemic- ethical- theoretical endeavor that requires ongoing explication and development. Caring Science is grounded in a relational, ethical ontology of unity within the universe that informs the epistemology, methodology, pedagogy, and praxis of caring in nursing and related fields. Caring Science embraces epistemological pluralism, seeking to understand the intersection and underdeveloped connections between the arts and humanities and the clinical sciences. Caring Science embraces all ways of knowing/ being/ doing: ethical, intuitive, personal, empirical, aesthetic, and even spiritual/ metaphysical ways of knowing and Being. Caring Science inquiry encompasses methodological pluralism, whereby the method flows from the phenomenon of concern— diverse forms of inquiry seek to unify ontological, philosophical, ethical, and theoretical views while incorporating empirics and technology. Caring (and nursing) has existed in every society. Every society has had some people who have cared for others. A caring attitude is not transmitted from generation to generation by genes. It is transmitted by the culture of a society. The culture of nursing, in this instance the discipline and profession of nursing, has a vital social- scientific role in advancing, sustaining, and preserving human caring as a way of fulfilling its mission to society and broader humanity. WORKING DEFINITION OF CARING SCIENCE (EXTRACTED/ MODIFIED FROM WATSON 2004A; WATSON AND SMITH 2002) Caring Science is an evolving philosophical- ethical- epistemic field of study, grounded in the discipline of nursing and informed by related fields. Caring is considered as one central feature within the metaparadigm of nursing knowledge and practice. Caring Science is informed by an ethical- moral- spiritual stance that encompasses a humanitarian, human science orientation to human caring processes, phenomena, and experiences. It is located within a worldview that is non- dualistic, relational, and unified, wherein there is a connectedness to All: the universal field of Infinity: Cosmic LOVE. This worldview is sometimes referred to as A unitary transformative paradigm (Newman, Sime, and Corcoran- Perry 1991; Watson 1999) Nonlocal consciousness (Dossey 1991) Era III medicine/ nursing (Dossey 1991, 1993; Watson 1999). Caring Science within this worldview intersects with the arts and humanities and related fields of study and practice. CARING: SCIENCE- ARTS- HUMANITIES To understand nursing as a discipline and a distinct field of study is to honor it within a context of art, the humanities, and expanding views of science. As a distinct discipline, it is necessary to acknowledge that nursing and Caring reside within a humanitarian as well as a scientific matrix; thus, there is an intersection among the arts, humanities, philosophy, science, and technology. The discipline encompasses a broad worldview that honors evolving humanity and an evolving universe that is full of wonder and unknowns as well as known set expectations about our world. Just as the profession may detour at times from its disciplinary heritage, so too we often forget that an equal need exists for humanistic- aesthetic views of a similar phenomenon. Humanities and the arts seek to answer different questions than science does. It continues to be important to understand the essential characteristics they all bring and the ways in which they are similar and different and in which they also converge. For example, conventional science is concerned with order, prediction, control, methods, generalizations, detachment, objectivity, and so forth. The three classical assumptions that have shaped modern conventional science are objectivism, positivism, and reductionism (Harman 1990– 1991; Watson 2005). Science in this context cannot answer certain questions about humanity, about caring and what it means to be human. Science generally is not concerned with specific individual responses but more with prediction and generalizations about anonymous others. It cannot be expected or called upon to keep alive a sense of common humanity (Watson 1979: 4). It does not offer insights into depth of human experiences such as pain, joy, suffering, fear, forgiveness, love, and so on. Such in- depth exploration of humanity is expressed and pondered through study of philosophy, drama, the arts, film, literature, humanistic studies in the liberal arts, humanities proper, and so on. This perspective is learned through self- knowledge, self- discovery, and shared human experiences, combined with the study of human emotions and relations that mirror our shared humanity. In spite of inherent differences between science and the humanities, both fields and, in fact, all fields of study are changing, expanding, growing into new dynamic intersections between and among each other. There is a convergence between and among art, science, and spirituality; this convergence is becoming more prevalent among emerging models of mind- body- spirit medicine, so- called complementary- alternative- integrative medicine, and new understandings of the physics of science, energy medicine, spirituality and healing, and so forth. The intersections between art and science help reveal what is beyond the confines and contingencies of the visible world, to “see” that which is deeper, glimpsing the human spirit, the human soul, its beauty and loveliness, whatever its shape or form (Housden 2005: 3). As Housden put it, art helps our eyes see more than they usually do: about life in general but also about ourselves. The same can be said for the humanities, drama, and also science, opening up a new horizon of meaning and possibilities. However, art helps us “to bear witness to eternal joy, suffering, pain and struggle of our own human soul and to feel the poignant, bittersweet reality of our physical mortality” (Housden 2005: 3). In their own ways, art and science remind us that we are “both finite and infinite and everything in between” (Housden 2005: 10– 11). In considering Caring Science, art, the humanities, and the beauty of science and life itself all come into play. When one is engaged in human caring and healing, one cannot ignore the element of aesthetics and beauty and the spiritual domain of life’s journey. In Emerson’s words: “This element [beauty] I call an ultimate end. No reason can be asked or given why the soul seeks beauty. Beauty in its largest and most profound sense is one expression of the universe” (Emerson 1982: 48). In this sense, then, art transforms us and helps us to see our everyday world differently, in that arts move us into a space where we can create visions of other ways of Being/ doing/ knowing and ask what it might signify to realize them (Greene 1991). It is this engagement in art and a sense of beauty that gives rise to wonder, to questioning, and to pondering our Being. The art and science of caring- healing is emerging in mainstream medicine and nursing, as the public has a hunger for the intersection among art, science, beauty, and spiritual dimensions of the healing arts and health and also has a greater sense of self- knowledge, self- control, and well- being. As Kandinsky (1977) understood it, “the spiritual resides in art” (just as Emerson viewed nature as spirit); perhaps they are one and the same, tapping into the human spirit of humanity and the universal source of infinity in which we dwell. In any event, in nursing and caring- healing work, we draw upon healing arts in a more expanded way that integrates science, art, beauty, and spirituality. These are manifest in unlimited potential for areas such as visual arts, music, sound, aroma, dance, movement, theater, drama, storytelling, design, psycho- architecture/ sacred healing architecture, and a variety of tactile- touch and noncontact, energetic modalities. Diverse categories of healing arts are emerging. At least four types have been identified: Art intended to directly heal, using symbols, images that calm and center. Art created by artists to facilitate their own healing; for example, autobiographical art, representational art depicting incidences of treatment, illness, change. Art about specific aspects of the healing process— pain, loss, body image changes, loss, grief, death, as well as hope, change, joy, insights, and so forth. Artist- designed psycho- architecture; healing spaces/ healing architecture— this art/ architecture makes a conscious, intentional, even a technical, precise scientific effort to integrate symbol, myth, archetype, mystery, and legend into architectural and environmental themes. Such art can be considered “ontological design,” an integration of sacred geometry into architectural structures so humans can “be” and feel differently as a way of experiencing self- in- harmony, with the sacred universal field of life’s energy for healing, wholeness, alignment, and so on. (Lafo, Capasso, and Roberts 1994: 9) Caring Science seeks to combine science with the humanities and arts. Caring Science is not neutral with respect to human values, goals, subjective individual perceptions, and meanings. It is not detached from human emotions and their diverse expressions, be they culturally bound or individually revealed. The discipline of nursing— guided by a Caring Science orientation— seeks to study, research, explore, identify, describe, express, and question the relation and intersection between and among the ethical, ontological, epistemological, methodological, pedagogical, and praxis aspects of nursing, including health policies and administrative practices. Thus, a Caring Science orientation seeks congruence between and among clinical nursing science, humanities, the arts, and the human subject matter and phenomena of caring knowledge and practices. ONTOLOGICAL “COMPETENCIES”: CARING LITERACY* In moving from a discussion of art, beauty, the humanities, and science, perhaps there is more awareness of the connection between this integrated way of thinking about Caring Science and Human Artistry. Such notions translate into what I have previously referred to as “Ontological Competencies,” reframed as “Caring Literacy,” or “Caritas Literacy.” Image not available Figure 5. Hands of light and love— the basis of healing in midst of institutional darkness. Hans Neleman/ Getty Images. While the meaning of literacy is associated with the abilities to read and write, the notion of having fluency in caring at both personal and professional levels introduces new meaning to deepen our ways of attending to and cultivating how to Be- deeply Human/ humane and Be- Caring and Having a Healing presence. This form of Being is a form of human literacy, human artistry. Such literacy includes an evolved and continually evolving emotional heart intelligence, consciousness, and intentionality and level of sensitivity and efficacy, followed by a continuing lifelong process and journey of self- growth and self- awareness. Such an awakening of one’s being and abilities cultivates skills and awareness of holding, conveying, and practicing communicating thoughts of caring, loving, kindness, equanimity, and so on as part of one’s professional Being. This level of evolved Being/ Ontological presence is now ethically required for any professional engaged in caring- healing. Perhaps this requirement was and has always been present in the tradition of healing professions, but somewhere along the way professional education and practices took a detour from the very foundation of our shared humanity. A return to a focus on Ontological Competencies, within the evolved notion of Caring Literacy, seems essential to balance and carry out the pervasive technological competencies, helping to make these skills and forms of Being part of the requirements for nursing education and practice. EXAMPLES OF (ONTOLOGICAL) CARING LITERACY I have only begun to identify some of these so- called Ontological Competencies for cultivating Caring Literacy (Watson 1999). (For more exploration of these ideas within the context of Nightingale, see Watson 1999: chapter 14.) In addition, an emerging project from the International Caritas Consortium (ICC) is focused on Caring Literacy and Caritas Literacy, seeking more and more specificity in the knowledge, skills, and ways of being to manifest such literacy. A working document is found in the Addenda as well as on the Web site www.caritasconsortium.org.* In the meantime, I have identified the following general guideline dimensions as examples of “ontological competencies” that facilitate Caring Literacy. These directions have emerged from my work over the past decade or so and need to continue to unfold with more specificity— something related to the ICC project— ultimately leading to better documentation and assessment of Caring/ Caritas. I invite readers to identify the ontological- literacy processes they bring to their caring- healing practice and to continue to contribute to more specificity so these practices can be taught, documented, researched, and practiced. WATSON’S CARITAS LITERACY DIMENSIONS: A WORK IN PROGRESS Cultivate Caring consciousness and intentionality as a starting point Ability to “Center”— quiet down, pause before entering patient’s room or be still in the presence of the other Ability to “read the field” when entering into the life space or field of another Ability to Be present— Be with other as well as Do for other Accurately identify and address person by name Maintain eye contact as appropriate for person/ cultural meaning and sensitivity Ability to ground self and other for comforting, soothing, calming acts Accurately detect other’s feelings Stay within the other’s frame of reference Invite and authentically listen to the inner meaning, the subjective story of other Authentically listen/ hear behind the words Hold other with an attitude of unconditional loving- kindness, equanimity, dignity, and regard Ability to be with “silence,” waiting for other to reflect before responding to questions, allowing other’s inner thoughts to emerge Respond to the other’s feelings and mood verbally and nonverbally, with authentic affective congruence Cultivate and create meaningful caring- healing rituals: translate conventional nursing tasks into purposive healing acts For example, hand washing as purification, cleansing psychically as well as physically; use as opportunity to “center,” release, and bless patient/ situation while preparing oneself to enter into next moment Incorporate, translate, and expand nursing skills/ tasks into nursing arts/ caring- healing modalities: for example, intentional use of music- sound, touch, aroma, visual- aesthetic- beauty, energetic approaches, and so on Carry out conventional nursing tasks and procedures, such as basic needs and physical care acts, as intentional, reverential, respectful caring- healing arts Cultivate own practices for spiritual growth and evolution of higher/ deeper consciousness Others— yet to be identified (see www.caritasconsortium.org). We need to continue to explore models for cultivating Caring Literacy and skill in attending to our human presence in “Being- in- caring- healing- relationships.” These directions incorporate aspects of caring such as silence, song, music, poetry, physical and nonphysical touch, centering practices of “presencing”; the use of art, nonverbal expressive forms, spirit- energy- filled conscious affirmations; holding intentions of wholeness, calmness, healing, and so on. Within this framework of Caring Literacy, it is important to realize that the nurse is not only in the environment, able to make significant changes in ways of Being/ doing/ knowing in the physical environment, but that the nurse IS the environment (Quinn 1992; Watson 2005). Thus, the nurse is invited to engage in significant insight into the Nurse- Self as an energetic- vibrational field of consciousness and intentionality (Quinn 1992), affecting the entire environment for better or for worse. The nurse’s (caring- loving) consciousness radiates higher vibrational effects. A nurse without an informed, “literate” caring consciousness can actually be “biocidic”— that is, toxic, life destroying, and destructive to the experience of others (Halldorsdottir 1991). On the other hand, a nurse who is cultivating ontological competencies in Caring Literacy is more likely to be “biogenic”— that is, life giving and life receiving for self and other and thereby more likely to engage in and experience a transpersonal caring- healing moment. As the nurse cultivates these ontological literate abilities and sensitivities of caring, there is an invitation to open to inner healing processes that expand to infinite new possibilities. Ontological– Caring Literacy directions serve only as examples of the intersection between technological competencies and emotional- intellectual literacy of human caring skills of Being- Caring. Such exploration into the literacy of caring incorporates the ethical, philosophical, and theoretical foundations of professional caring- healing. This view of Caring Literacy serves as core knowledge that leads directly back to the original Carative Factors and the evolution toward Caritas Consciousness and Caritas Processes.