Nursing assistance and Jean Watson : a reflection on empathy

Objective: To relate the empathy with the Theory of the Human Care, from Jean Watson, in the current context of Nursing. Methods: Theoretical and reflective essay that proposes a discussion about empathy and its relation with the theory of the human care. Results: It is presented the Clinical Caritas process and each element of care, in order to propose and discuss the connections with empathy in Nursing care. It is imperative to combine technical and humanistic care in the care offered, in addition to rescue the appreciation of the approach of empathy in the training of health professionals, as well as the continuation of the studies after graduation. Conclusion: This process can contribute to the reorganization of the ideas and concepts about essential advances that are necessary to the current practice of Nursing.


INTRODUCTION
Nursing as a practice is trying to establish itself as a science, since, to support assistance and strengthen the profession, is appropriates on theories to justify the practice and systemize the care.In this context, the reflections on the theoretical precepts of Nursing constitute an important aspect for the development of the profession and delimitation of its field of action 1 .
Nursing theories provide discussion and improvement of professional practice and guide the eligible care for every human being, to the extent that each of them focuses on a related perspective to one of the following main points: patient, patient-environment interaction, nurse-patient relationship, nursing therapy 2 .
On the one hand, the cartesian and biomedical model, in many instances, seems limited by not being able to offer support to the deepest needs of the human being and to attend to the spiritual concerns 3 .On the other hand, Nursing has sought possibilities for understanding and forms of care that can exceed the limits built by this line of thought, so that there is enhancement of personal, subjective and cultural conditions of those involved in the care process 4 .
Nowadays, issues involving more attentive and humanized by the professionals have been in focus.Several countries have invested in research and training for doctors and nurses to behave in a less impersonal way during the evaluation of patients, so that the strict focus on physical issues of treatment is extended to the other human dimensions [5][6][7][8][9] .
Thus, consistent with its ability to unite humanistic factors with scientific knowledge to develop the most appropriate care and in line with the global trends, the practice of nursing care, which extends beyond the biological care, is enhanced so that it is possible the attendance of several needs of the patient and family 5,8,10,11 .
Margaret Jean Watson developed the Theory of Human Care, which considers effective care through the transpersonal relationship, that is, care that transcends time, space and matter of patient and professional so that they form a single element in harmony, in addition to the punctual moment of interaction, in order to promote the renovation (healing) 1,4 .
Although the nursing care favors, many times, the physical dimension, with the execution of technical procedures, at a more advanced level of care, nursing is able to access emotional and subjective aspects in order to objectify the transpersonality through communication and empathy, which can develop and maintain the harmony and trust necessary for this process 1,4 .
The concept of empathy has several strands, however, all consider the ability to understand the feelings from another person and communicate them this experience 12 , always based on cognitive, emotional and behavioral pillars 13 .
For developing of empathetic behavior, the real will to be concerned about the suffering of others is highlighted, representing a conscious process, which aims at the improvement of interpersonal relationships through consolidating the bond and communicational skills 12 .
There are recommendations for inclusion and improvement of this content in the initial and permanent health professionals training, since empathy provides both: patient and workers satisfaction 6,12,14 .However, its theoretical and practical joints in nursing and in other areas of health care are still scarce in Brazil.
From these considerations, this article, linked to the master's project of the Professional Master's Program in Nursing, of the Instituto Israelita de Ensino e Pesquisa Albert Einstein, aims to relate empathy with the Theory of Human Care, of Jean Watson, in the current context of nursing practice.

METHODS
Theoretical and reflective essay that proposes a discussion about empathy and its relation with the Theory of Human Care of Jean Watson, in the contemporary practice of Nursing.
The theoretical essay is founded on the logic and reflective exhibition, in addition to detailed arguments, with a high degree of interpretation and personal judgment 15 .

EMPATHY AND THE THEORY OF HUMAN CARE
Watson has refined her theory constantly and, since 1979, the year of her first publication, some aspects have evolved and have been enhanced, always culminating in the valorization of dimensions beyond the concrete field, with emphasis on subjective perceptions and experiences from the other 4 .
Currently, Watson's theory is adopted in various health institutions such as hospitals, medical centers and universities with courses in the health area, in the USA and Mexico.The Watson Caring Science Institute was created by the author to disseminate the principles of the theory and assistance in the implementation and maintenance of the assumptions in the health services, as well as offering professional training, promote scientific research and events and train doctors in care who consider the sacred human dimension 16 .
According to Watson, one of the most appropriate instruments to establish and maintain important aid-trust relationship between professional and patient is empathy.From the real intention of caring, it is possible to develop an empathic relationship, when one recognizes the other as someone who lives their own exerience of being a patient and understanding and acceptance are expressed through verbal and non-verbal language 4 .Clinical Caritas is the current name of the process developed and improved by her.Initially, it was formed by Care Factors of ten precepts that aimed the expansion of only biological care, consistent with her initial theory.In 2007, then, she built the Clinical Caritas, consisting of ten elements that considers sacred the cared being (part of the universe and of the divine) and, therefore, deserves to be recognized with delicacy, sensitivity and love.The ten elements from this care are 1,2,17 :

Reflection on watson's teory and empathy
Savieto RM, Leão ER 1.To practice kindness and equanimity, even for yourself; 2. To be present and promote the belief system of the cared; 3. To cultivate own spiritual practices, deepening the individual knowledge; 4. To keep the authentic care through a help-trust relationship; 5. To support expression of positive and negative feelings; 6.Using knowledge and intuition creatively in solving problems; 7. Truly link the teaching-learning experience; 8. Providing an environment of physical, emotional and spiritual restoration; 9. To promote body, mind and spirit alignment in order to know the needs of the individual; 10.Consider the spiritual aspects and of life and death.
Several of these elements are related to empathy.Practicing kindness (element 1), prior to providing care to another, is linked to the recognition of the humanity existing in a professional, who also has emotions in its relationships.For Watson, everyone involved in the process of care should express their feelings, so that the empathetic relationship builds mutually 4 .In this way, it creates a space for horizontal relationships of care, promoting mutual respect.
In the practice, it is clear there are difficulties among many nurses to line up concepts related awareness with Nursing Theories.The adoption of more subtle elements in Theories, such as the proposal of Jean Watson, seems to incur still major difficulties, observing the precarious healthcare centers across the country.However, an exercise in establishing care practices with theories is necessary.For example, to identify deep resonance between this first element and the hospital humanization concept proposed in the Programa Nacional de Humanização Hospitalar of Humaniza SUS, as the "[...] process of transformation of the institutional culture that recognizes and values the subjective, socio-cultural and historical aspects of the social actors -users and professiona* -involved in health practices, improving" the working conditions and the quality of care [...] 18 .
Being present in the relationship (element 2) represents the foundation of empathy.It is from the focus and the attention given to the other that the empathic process begins and that makes possible the understanding of the experience of others 12 .We are present where our attention is.If to take care we are preoccupied with other issues and situations not related to others that are in front of us, we can hardly develop and demonstrate empathy.
The third element concerns to the growth practices that improve self-knowledge.The maintenance of activities that develop self-knowledge is encouraged by theorists of empathy, as it is crucial for the internal movement that provides the ability to put one in the place of another 12 .
How have we been seeing this among health professionals, in particular those of nursing?We know that it is a single track, but should we not encourage such practices since academics classes?And organizations do not also have a role to play in this sense?It is necessary to seek answers to these questions, since self-knowledge favors the individual recognition of its limits, as well as minimize inappropriate care relations projections, which may compromise the empathy.
In the fifth element of Clinical Caritas we have the incentive to the exposure of feelings, whether positive or negative.This allows initially the patient to recognize its emotions, to accept or confront them.When this occurs, the nurse is able to know the real feelings of the patient and put itself in its place 17 .For that, sensitive listening is required, in addition to the time it implies in the interactions between the nurse and the patient.Many may say that it is virtually impossible to rely on structural conditions and work organization.No doubt, are aspects which have its weight, but, on the other hand, we know that this is also a personal choice, on the way of driving assistance.Hear the other is something that requires training, in addition to the care situations 19 .
Engaging in educational interaction with the patient (element 7) represents the possibility of true connection between those involved, because the nurse that encourages and promotes patient participation in decision making, respecting even ethical precepts of the profession, highlights the process of the autonomy of those involved.The recognition of the other as someone capable to making choices is a fundamental aspect of the empathic relationship, because it is from this consideration that originates the cognitive and emotional factors of empathy 12 .
The recognition of the knowledge of other by professionals is influenced by aspects inherent to underpin the Humanistic Theories of Nursing (considering always the prior knowledge, experiences and needs of care) and by the advent of the internet.
Nowadays, information is abundant and makes the professional's role requires adjustments to live in this new environment.First, because it can determine a professional posture more vigilant, since the patient is more questioning.Second, the professional can feel "confronted" by the patient on issues that previously was just in its domain, affecting the construction and maintenance of an empathic relationship.And, finally, it requires of the professional longer time in attentive listening, to help the patient to discern and separate "the wheat from the chaff" in the flood of information accessible.Without it, all teaching-learning relationship becomes compromised, in actuality.
The eighth and ninth elements are related to promoting the balance of the environment and individuals, respectively.The empathic attitude, that welcomes and accepts the other, is able to strongly influence such aspects.The empathic behavior can either cause a change in an unfavorable environment, as attend physical, mental and emotional needs of individuals 12 .Recognize what in an environment is hostile to the other, put itself in the patient's place and choose not only technical and procedural interventions, but an attitude that will change him is at the heart of restoration and meeting the requirements set out in these elements.
About the tenth element, it is the reflection of how empathy helps in aspects of spirituality, life and death.How to put itself in Reflection on watson's teory and empathy Savieto RM, Leão ER the place of the other who is in the process of dying, if it is an experience the professional did not have experienced before?Some time ago, to attend the spiritual needs of patients in these situations practically restricted to promote the visit of a religious leader.However, advances in the area of palliative care enables the professional to go beyond distant atittudes from the real needs of the patients and, the thought assigned to Cicely Saunders, can sum up what being empathic before this scenario: I do care about the fact that you are you, caring until the last moment of your life, and we will do everything in our power, not only to help you die peacefully , but also for you to live up to the day of your death 20 .
These assumptions consider a humanistic vision of the human being, be it professional or patient, so that both can have respected their principles, strengthened their autonomy and be participants in a more sensitive and welcoming care structure.
For these reasons, it is possible to understand too, that empathy pervades the entire care process of Jean Watson, since the application of the Clinical Caritas elements is made possible by the empathetic behavior.On the other hand, when you experience the transpersonal care, the empathy is oportunized, since in order to achieve the objectives of this care is dominant to recognize the patient as a participant of the process, holder of anxieties and expectations, with a history of life.
Apart from these considerations, to accomplish the Clinical Caritas, it is essential that nurses put themselves in the patient's position and, from that, can meet the pressing needs to prioritize its assistance, without deviating to the uniquely care focused to the physical dimension, always attentive to the completeness that makes up a human being.It is, therefore, to change the focus of the cure of the disease or instrumental performance and procedures for care that provides restoration.
It is necessary to consider that nurses need to know the theoretical and philosophical assumptions and be able to participate as actors of this process of care.The definition of theories that supports assistance is able to contribute to professional strengthening, better definition of roles and providing guidance to conduct 21 .
The literature shows that, Watson's Human Care Theory in particular, is able to contribute to the autonomy of those involved and to promote an ethical and human care.On the other hand, have been raised points that may hinder the implementation, such as the absence of a formalized nursing process, institutional, political and social difficulties and even the absence of this content in vocational education 22 .
Anyway, it is important to emphasize that, even if the technical competence is the foundation for nurses, patients can identify "a good nursing care" when they receive loving attitudes, sincere explanations about actions and goodwill in moments of great anxiety 23 .
In assessing the significance of care for emergency room patients, for instance, researchers found the importance of interpersonal relationships in the perception of the environment, so that qualifying relationship were represented by patients as consisting of empathy and openness to dialogue from professionals 24 .
Listen to the concerns and show respect and compassion to patients and its families are considered very important actions to improve relationships and increase satisfaction of those involved, besides, who in the assistance as the cared, values communication skills, critical thinking and sensitivity as fundamental to nurses 8 .
Reflect on Jean Watson's theory, it shows clearly how much nursing needs to improve its practice to fill the gap of real care, fulfilling the mission of nursing profession and evolve as a science.The theoretical basis and the appreciation of humanistic aspects can strongly contribute to greater magnitude of care in Nursing and, consequently, for better recovery of patients.
The watchful eye to the care practices combined with reflection about doing contribute to the constant improvement of provided nursing care.In this way, the professional capable of understand this situation and, consequently, transform interactions with patients, certainly broadens its scope, enabling fuller attention to the needs of those who are being taken care of.
We believe that the effective presence of empathy is able to qualify the care processes, which, in turn, needs to be anchored in theoretical references consistent to the humanistic principles.Thus, it is possible to build a harmonic care context, which constantly enhances the other.

CONCLUSION
It is noteworthy the importance of this reflection to the alignment of the healthcare practice with the real needs of patients, which certainly are not fully covered by exclusive biomedical approach.Considering the complexity of human beings and their various aspects, such as physical, mental, emotional and spiritual, it is at least inconsistent, to talk about nursing care geared solely to the biological.
It should be noted the significant contribution of Jean Watson's theory to support these concepts and reinforce a more coherent nursing care, genuine and empathetic.Given the importance of empathy in health relationships, it is imperative to rescue the appreciation of its approach in the training of health professionals, as well as the continuation of studies after graduation considering that in order to have nurses able to gather technical and relational qualities it is necessary to offer them subsidies in education for a complete and holistic professional exercise.
Finally, it is understood that this reflection can contribute to the reorganization of ideas and concepts about essential improvements that prove necessary to the current practice of nursing.