The Scientific production about the Human Caring Theory : a bibliometric study

The Human Caring Theory supports and guides the nursing care with a view to a holistic and transpersonal care, bringing attention love, ethics and spirituality as an essential component of care. Therefore, this study aimed to analyze Bibliometric indicators of scientific literature concerning the Human Caring Theory disseminated in journals online, with an emphasis on characterization of publications. It is a Bibliometric study in a quantitative approach. The sample was made up of 55 articles published from 1995 to 2015. The data obtained showed that the national journals are published on Human Caring Theory, with predominance of original articles published between the years 2010 and 2011. It is concluded that the publications about the subject investigated quantitative feature listless, considering the period researched. It is suggested to conduct new studies to broaden and deepen the knowledge. The Scientific production about the Human Caring Theory: a bibliometric study


Introduction
Theory is a set of experiences, knowledge and ideas that are represented symbolically and aim to test the interrelationship between concepts to clarify a certain phenomenon [1].In the scope of Nursing, theories are based on metaparadigms, in order to base the practice of the nurse to provide care of quality, efficient and effective; paying attention to the patient and not the illness.Nursing has sought to rethink its practice and to establish itself as science and subject, developing and adopting for it some theories of Nursing, which the Theory of Human Caring proposed by Jean Watson, in 1979, deserves to be emphasized.
The Human Caring Theory supports and guides Nursing Care and brings human-centered assistance as a point of convergence of all of its actions, the integrality of body, mind and spirit in a transpersonal process [2].Therefore, it aims to provide a holistic and transpersonal care based on love, ethics, self-awareness; bringing faith and spirituality as an essential component of care.
Based on this understanding, this theory is based on human values and concerns for the well-being of the other, with emphasis on caring and compassion in providing care.The subjectivity of caregiving involves a look at human interactions, which are constantly changing, requiring preparation and critical reflection of professionals who promote moments of care [3][4].
Watson [1] points out that, by working with people in times of suffering and vulnerability, health care professionals, emphasizing nurses, are challenged to learn again and re-examine the very meaning of life and death.As this is accomplished, they engage in an authentic process in order to cultivate and sustain practices of caring for themselves and others.
In 1979, Watson developed curative factors for nursing by considering them as the center of the caring process with the goal of helping the patient to maintain and achieve his or her health, or even to obtain a dignified death.These factors were revised in 1985, introducing the Transpersonal Care paradigm, which focuses on the moral ideal, the view of the person as being more than just the sum of its parts, and Nursing as the art and science of caring, which acts in the search for a harmony between mind and body, allied to the incorporation of the spiritual dimension so neglected in the daily practice of health professionals.
In 2005, care factors were redefined for clinical caritas processes, which were understood as guidelines for care centered on love.It is composed of ten elements that seek the promotion of humanistic care, looking at the individual in all its dimensions (biopsychological, spiritual and sociocultural) and considering nurse-patient intersubjectivity [2][3][4].
The component elements of clinical caritas processes are presented by Watson followed by numbers that correspond to the proposed order, and may or may not occur in that order, they are: 1) To practice benevolence and equanimity for oneself and for another; 2) To be present, to respect and to stimulate the faith and the subjectivity of self and of the other; 3) Promote the transpersonal self and develop one's own spiritual practices; 4) Perform an authentic care based on the bond between the I-Other; 5) Be present and seek a deep connection with oneself and the other through the manifestation of positive and negative feelings; 6) Use creativity in the process of caring for knowledge through the art of care-cure; 7) Promote authentic teaching-learning experiences through the empathic care of the other; 8) Promote a healing environment; 9) Attending to being cared for in your physical, emotional, and spiritual needs with awareness of intentional touching; 10) Allowing and caring for the existential spiritual dimension and caring for one's own soul and that of the other [6].
Thus, the Human Caring Theory brings as a focus of nursing factors of care from a humanistic perspective enabling nurses to perceive the practice of care as health promotion and not as a cure for diseases [5].
Therefore, it is essential to rescue the approach of this theory in the training of health professionals, as well as in the permanence of graduation studies, considering that, in order to unite technical and relational qualities, it is necessary to provide the nurse with a full professional Holistic [7].
Given this, the relevance of Human Caring Theory to practical nursing care is irrefutable.Hence the importance of researches on the dissemination of studies developed by nurses about the theory proposed by Jean Watson, since there are few in the literature works on the scientific production emphasized in the aforesaid theory.
In view of the above, the interest in carrying out a study that had as its guiding axis the following questioning emerged: what are the bibliometric indicators about the scientific production on the Theory of Human Caring disseminated in online journals in the Nursing Area.
To this end, this research aimed to reach the following objective: To analyze bibliometric indicators of the scientific production about the Theory of Human Caring disseminated in online journals, with emphasis on the characterization of publications.

Methods
This is a bibliometric study of a quantitative nature.Bibliometrics allows analyzing and evaluating objectively the scientific production about a certain theme.For this, bibliometric indicators are used in order to statistically measure the production index and the dissemination of scientific knowledge [8].This method is used in several areas of science and has shown evident growth in the field of Nursing, since it allows emphasizing the patterns and trends of the research carried out in the area [9].
To carry out this study, the following steps were considered: Vanz and Stumpf [10]: survey of the publications and selection of the sample, collection, organization of data, treatment and presentation of results.
In the first stage there was carried out the bibliographical survey about the scientific productions on Jean Watson's Human Caring Theory.This occurred in the months of January to March of 2016, as well as the selection of the publications for the selection of the sample.To do so, a search was made in the Portal of Periodicals of the Coordination of Improvement of Higher Level Personnel (CAPES) and in the following databases: Latin American and Caribbean Literature (LILACS), Spanish Bibliographical Index of Health Sciences (IBECS), National Library of Medicine (MEDLINE)/PubMed.
In order to instrumentalize the search of the publications in these data sources, the terms "Human Care Theory", "Transpersonal Care" and "Clinical Caritas" were used because they represent descriptors related to Jean Watson's Theory.The term "Watson" combined with the Boolean operator AND and the descriptor "Nursing Theory" was also used as a search word in the summary index.
Inclusion criteria for selection of the sample were: publications in the format of a scientific article freely available in full in the online collection; Written in Portuguese, English and/or Spanish; Who used Jean Watson's Human Caring Theory as the central focus of the study or as theoretical foundation and which had been published in the time frame from January 1995 to December 2015.
Exclusion criteria include: letters to the editor, articles in duplicate, published in other languages except Portuguese, English and Spanish, and those that did not address the proposed theme.Thus, the identified publications were organized into folders according to the descriptors and location where they were found.
In the second stage, data were collected from a script prepared by the authors, which was divided into three topics: data related to the publication (name of the journal and Qualis of the periodical, country and year of publication, language in which it was published , number of descriptors); Authors (number of authors per article, most frequent authors, professional training and degree); And the methodology (geographical location, ins-titution where it was carried out, type of research, methodological approach, participant subjects, data collection technique used).
It is worth noting that no distinction was made between author and co-author.Thus, in this study was considered author all the researchers whose names appeared in the publications.Concerning the titration of the authors, it was considered the greatest title they had at the time of publication of the article.Such information was verified through the manuscript itself, as well as in the curriculum lattes of the authors.
The third step consisted in tabulating and analyzing the data.For that, the program Microsoft Office Excel ® 2010 was used to organize the information obtained from the proposed instrument and the software Statistical Package for the Social Sciences, SPSS, version 20 as a tool for obtaining frequencies and percentages of data.These were presented through graphical representations and analyzed in the light of the descriptive statistics and the relevant literature.

Results
The universe of the study consisted of 87 publications related to the researched subject, of which 55 composed the sample because they met the inclusion criteria described in the methodology.The results obtained are presented in this section considering the chosen indicators for the research.

Data referent to the journals
The sample included studies published in from January 1995 to December 2015, totaling 55 scientific articles.2010 and 2011 were the years of greatest scientific production about the subject, totaling 7 articles (12.7%) in each year, while the years 1995, 1996, 1997, 1998, 2000 and 2001 had no publication about Jean Watson's Theory of Human Caring.Figure 1 shows the distribution of articles published per year on the theme: Considering the databases where the works were identified, there was found that 27 (49.2%)were selected from the CAPES Portal, 17 (30.9%) in the LILACS database, 09 (16.3%),In the MEDLINE/Pub-Med database and 02 (3.6%) in the IBECS.
With regard to journals, 27 journals were published that published works on Human Caring Theory, among which 15 are of national origin and 12 international, as shown in Table 1.Source: research data, 2016.

% publications
According to Table 1, the largest number of publications was disseminated in the Journal of Nursing at the State University of Rio de Janeiro, which led with 10.9%, followed by the journal Text & Context-Nursing with 9.09% and By Online Brazilian Journal of Nursing and Nursing Science Quarterly with 7.27% each.
The distribution in the different strata was: A1 -7.3%, A2 -21.8%,B1 -32.7%, B2 -16.3%, B3 -3.6%, and B4 -7.3%.It is cost mentioning that 10.9% of journals are not classified in Qualis of Capes.About the language in which the studies were published, 50.9% of the studies were disseminated in Portuguese, 18% in English, 12.7% in Spanish, 12.7% were published in Portuguese and English and 5.4 % were published in the three languages (Portuguese, English and Spanish).
With regard to the descriptors, it was possible to identify 115 different terms expressed in Portuguese, English and Spanish, in which the average per article was 3.6.From these, a cloud of words, shown in Figure 2, was constructed to express the frequency of use of such words as descriptors of the sample studies.
Among the descriptors, Nursing Theory (n = 21), Nursing (n = 17) and Nursing Care (n = 19) stand out as the most frequent, corroborating with the graphic representation in Figure 1, which brings the Nursing words, theory and care as the most expressive before the sample group.

Data referent to the authors
With regard to composition of the publications, a total of 158 authors were verified.As a result of the repetition of the same author in more than one article, the exclusion of duplications was performed, resulting in a total of 120 authors, of which 117 (97.5%) had undergraduate nursing training.The other authors were from several areas of knowledge, specifically: Physics, Sociology and Social Communication, corresponding to the percentile of 0.83% each.
With regard to titration, it was found that 92 (58.2%) authors were doctors; 37 (23.4%)teachers; 10 (6.3%) specialists; 04 (2.5%) postdoctors and 12 (7.6%)did not yet hold an academic degree.It was not possible to identify the titration of 03 (1.9%) authors.It is cost mentioning that these percentiles were calculated taking into consideration the number of authors without the exclusion of the repetitions, that is, n = 158, since the maximum  titre of each author varied according to the year of publication of the manuscripts.Table 2 highpoints the distribution of the most published researchers on the Jean Watson Human Caring Theory of the selected sample.
It is shown the majority of Brazilian authors who published on the Theory of Human Caring, especially Maria Ribeiro Lacerda, who obtained the highest percentage -5,8 (n = 7) of publications on the subject.Among the international authors is the author of Theory, Jean Watson, who obtained the second highest percentage -5% (n = 6).

Data related to the methodology
When analyzing the bibliometric indicators related to the methodology of the articles that composed the sample, it was possible to verify that 24 (43.6%) were original articles, 12 (21.8%)articles of reflection, 8 (14.5%) reviews, 7 (12.7%)case studies, 3 (5.45%)reports of experience and 1 (1.8%) editorial.Of these, 51 (92.7%) adopted the qualitative approach, while 4 (7.2%)followed the quantitative approach.
Of the sample, 32 mentioned the research site, 2 did not specify where it was performed and 21 did not report, since they did not fit as the original article.Among the original articles it was observed that the vast majority, that is, 25 articles (73.5%) were of national origin, while 7 (26.4%)were international studies developed in Colombia, Costa Rica, Venezuela, Chile, the USA and Turkey.The South region (n = 10) is the one that publishes the most on the subject, especially the state of Santa Catarina, followed by the Southeast (n = 8) and Northeast (n = 6) respectively.
It is also wealth mentioning that the prevalence occurred at the hospital level (70.5%, n = 24), followed by ambulatory care units (11.76, n = 4%) and other Data collection (14.7%, n = 5), such as domicile and educational institutions.
The participants in the studies that composed the sample were the most diverse, and were categorized into patients (n = 16), nurses (n = 13), relatives (n = 10), bibliographic material (n = 08), and others = 08) such as nursing technicians, physicians, reading mediators and others.It is important to stress that each article is not limited to having only one category of participants, so a single article can present different categories, reflected in the count of (n).
Concerning the techniques and instrument for data collection of the scientific productions of the study sample, the interview technique was used in 21 (38.1%)studies, followed by the use of forms, audio visual and printed records, observation and Questionnaires totaling 7, 5, 4 and 2 articles, respectively.Other techniques and instruments were also used; however, presenting low frequency, such as the free association of ideas, test of the eight colors of Lüscher, creative-sensitive method, drawingstory technique, workshops, artistic productions and field diary.

Discussion
Analyzing the incidence of publications in the period from 1995 to 2015, there is an increase in the number of these on the Theory of Human Caring from the year 2005, having its apex in the years 2010 and 2011.The predominance of publications in the last decade Is due to the fact that the review of the factors of care and its redefinition for clinical caritas processes in 2005, as well as reflecting the growing perception about the moral, spiritual, ethical and human dimensions of the nursing care actions themselves [11].
In the period in-between, it is clear that Nursing through the Human Caring Theory has tried to create an identity of care based on humanistic actions that allow both authentic care of the other, as well as the advancement of knowledge in the field of Health, Nursing and Human experience [1].
The dissemination of the Human Caring Theory, in this context, is important both in the area of care and academic being closely linked with the means of dissemination.Thus, among the databases where the works were identified, the CAPES journal portal was highlighted when compared to other databases.This is due to the wide range of its online collection, which offers free access to more than 30,000 national and international periodicals, as well as the diversity of databases covering all areas of knowledge [12].
It was also noted that 29% of the articles that made up the sample were published in journals with Qualis A. Qualis/CAPES is an indicator of the quality of journals where only 25% of them are eligible to be included in higher-level strata (A1 and A2), which favors a more rigorous analysis process for the publication of a select group of articles of high scientific quality [13].Therefore, this percentage found in this study demonstrates the relevance of the Human Caring Theory to the scientific community, as well as the quality of the publications about it.
With regard to the distribution of authors by article, it was verified that the collective authorship stands out.Among the authors, the prevalence of academic training in nursing is clear.This result is justified since the Theory of Human Caring fits as one of the great theories specific to Nursing.Regardless of the specificity, this theory [14] brings elements of other fields of sciences, such as psychology, philosophy and sociology, which explain the interest of other professionals in the field of Health Sciences.
Concerning the authors' titration, the effective participation of doctors and masters was evidenced, a fact that was justified by the recent dissemination of graduate programs in Brazil in the last decades, which has markedly increased professional training strict sense [15].Of these, the most published on Theory of Human Caring is to the own theoretician, Jean Watson.The American nurse constantly seeks to improve her theory by making it flexible to changes in the health scenario and adaptable to practice, a fact proven by the constant updating of her publications about the theory [16].
Even though the Human Caring Theory shows itself to be important for Nursing to identify articles that the approach presents some difficulties, among which we have the non-specific descriptors that characterize the publications.As can be seen in Figure 2, the most used words as descriptors were nursing, care and nursing theory, which, although defining the area of study of the articles, does not make clear the use of the Human Caring Theory in them, making room for identification of other Nursing Theory that also make use of such descriptors.This is justified by the lack of more adequate terms indexed both in the Health Sciences Descrip-tors of the Virtual Health Library -DeCS/BVS and in the Medical Subject Headings of PubMed.This fact evidences the need to insert more adequate terms to define this theory, such as transpersonal care and clinical caritas processes, in order to facilitate the characterization and identification of studies in search databases.
Regarding the modalities of study, the original works were predominant followed by the articles of reflection.This is due to the great visibility that the journals give the original publications, since with these it is possible to obtain a new, expressive and structured knowledge using a scientific method that allows a new and extended look on the same theme [17].
Regarding the place of development of the study of the original publications, the data demonstrate the prevalence of national surveys especially performed in the hospital setting, which suggests the search for the Systematization of Nursin g Care based on a theoretical reference by the institutions of Cheers.However, it is important to emphasize that this theory is not restricted to the hospital environment.It proposes that nursing seek to preserve care in situations in which it is threatened, proposing to take care of the evolution and deepening of the human species, either individually or collectively, anywhere in order to sustain humanity [18].
Although the Human Caring Theory is a reference to be adopted by the nurses in their care, it aims to care for the patient, approaching it with fragility, sensitivity and careful attention, corroborating in this way that the patients are the category of predominant participants.The studies that composed the sample of this research.Thus, it is important to stress the importance of re-establishing and restoring those involved, starting with the care of nurses, facilitating the acceptance of their lives by establishing a relationship of help, trust, care and love, imbued with an ethical commitment" [19:685].
Watson's care is something experiential, contextual and metaphysical, grounded in moral and ethical values and governed by love, care, faith, compassion and respect.This occurs in a moment of care where the nurse and patient meet and unite and become one, a transpersonal care, which is operationalized through clinical caritas process [16].
It is with clinical caritas processes that Watson includes the sacred aspect of being cared for, establishing a connection that goes beyond the physical plane, and there is also the proposition of healing as a reconstitution in order to deepen the understanding about human experiences, the process of life And the experience of caring [16].
The clinical caritas processes, together with the theoretical assumptions of the Human Caring Theory, allow the practice of an integral care that values the self and the experiences of the caring and caregiver in a mutual teaching-learning relationship in an environment Where the physical, spiritual, emotional, and sociocultural dimensions can assist in the occurrence of insight into the promotion of care.In this sense, the care process is based on the conception that the desired changes in the health scenario must be based on its own changes as an individual and on the way in which the act of caring lives.
Regarding the approach, the quantity of qualitative articles was expressive.This is probably due to the fact that this research modality is concerned with investigating and interpreting deeper aspects, providing a detailed analysis of habits, attitudes and tendencies of behavior, from the description of the dimensionality and complexity of human relations [17].
In the qualitative approach, data collection can occur in different ways, and in the studies surveyed the interview was the one that obtained the highest percentage.This is due to the fact that it is a simple technique to be applied and low-cost, but if carried out in a methodologically correct way, it gives the researcher the production of material and deepening of the information.In addition, this technique [20] enables spontaneous reporting and description of nursing care experience and its relation and repercussion with other issues important to research, such as the health-disease process.

Conclusion
The study proves that research on the Theory of Human Caring has been developed especially in the last decade both in the international scenario and predominantly in the national, especially in the hospital setting.Thus, it is important to develop research that demonstrates the practical probability of this theory at an extra-institutional level and the adequacy of it to the care directed to the different types of patients in order to disseminate the relevance of it.
Although the publications about the research topic present a little expressive quantitative, considering the period studied, it is possible to perceive the interest of researchers in developing and disseminating studies that give more visibility to this theory in an academic environment aiming to implement it as a theoretical reference in services of improve the quality of care provided by nurses.
The bibliometric indicators evidenced the prevalence of original articles of qualitative approach that were used of interviews to collect data.Through this study it was possible to highlight a predominance of publications in periodicals of higher strata and the hegemony of authors Nurses with academic title of Doctor.
It is considered, from the findings of this study, that bibliometric research is a very imperative method, since it made it possible to highpoint relevant characteristics about the publications of the study, with emphasis on data related to the journals, authors and the investigated works.However, the research presents as a limitation, the non-inclusion of dissertations and theses on the subject, and the scarce amount of publications in the selected period of time.
As a result, it is suggested that new studies be carried out, among them bibliometric research, so that other indicators can emerge in order to raise the knowledge about the applicability of Jean Watson's Human Caring Theory.

Figure 1 :
Figure 1: Distribution of publications on Human Caring Theory regarding the year of publication (n=55).

Figure 2 :
Figure 2: Cloud of words drawn from the keywords of the publications that make up the sample of this study (n = 199).

Table 1 .
Distribution of articles about the journals and country of publication.

Table 2 .
Distribution of authors by number of articles published.