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Nursing
Theories third edition

& Nursing
Practice
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Nursing
Theories third edition

& Nursing
Practice Marilyn E. Parker, PhD, RN, FAAN
Marlaine C. Smith, PhD, RN, AH N-BC, FAAN
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F. A. Davis Company
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Copyright 2010 by F. A. Davis Company

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Library of Congress Cataloging-in-Publication Data

Nursing theories and nursing practice / [edited by] Marilyn E. Parker, Marlaine Cappelli Smith. 3rd ed.
p. ; cm.
Includes bibliographical references and index.
ISBN-13: 978-0-8036-2168-8
ISBN-10: 0-8036-2168-X
1. NursingPhilosophy. 2. Nursing. I. Parker, Marilyn E. II. Smith, Marlaine Cappelli.
[DNLM: 1. Nursing TheoryBiography. 2. NursesBiography. WY 86 N9737 2010]
RT84.5.N8793 2010
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Preface to the Third Edition

This book offers the perspective that nursing nursing theories and their use in nursing prac-
is a professional discipline with a body of tice and scholarship. In addition, and in
knowledge that guides its practice. Nursing response to calls from practicing nurses, this
theories are an important part of this body of book is intended for use by those who desire
knowledge, and regardless of complexity or to enrich their practice by the study of nursing
abstraction, reflect nursing and should be used theories and related illustrations of nursing
by nurses to frame their thinking, action, and practice. The contributing authors describe
being in the world. As guides, nursing theo- development processes and perspectives on
ries are practical in nature and facilitate com- the work, giving us a variety of views for the
munication with those we serve as well as twenty-first century and beyond. Each chapter
with colleagues, students, and others practic- of the book includes both descriptions of a
ing in health-related services. Our hope is particular theory and an illustration of use of
that this book illuminates for the reader the the theory in nursing practice. Each chapter
interrelationship between nursing theories offers a glimpse into the theory and how it
and nursing practice, and that this will focus might be used in practice. We anticipate that
practice more meaningfully and make a dif- this will lead to deeper study of the theory by
ference in the health and quality of life of consulting published books and articles by the
people who are recipients of nursing care. theorists and those working closely with the
This very special book is intended to honor theory in practice or research.
the work of nursing theorists and nurses who The first section of the book provides an
use these theories in their day-to-day practice, overview of nursing theory and a focus for
by reflecting and presenting the unique con- thinking about evaluating and choosing
tributions of eminent nursing thinkers. Our nursing theory for use in nursing practice.
foremost nursing theorists have written for Section II introduces the work of early nurs-
this book, or their work has been described by ing scholars whose ideas provided a founda-
nurses who have thorough knowledge of the tion for theory development. The nursing
theorists work and who have a deep respect conceptual models and grand theories were
for the theorist as person, nurse, and scholar. clustered into three sections. Section III
Indeed, to the extent possible, contributing includes those that have been classified
authors have been selected by theorists to within the interactive-integrative paradigm,
write about their work. Seven additional while the fourth section includes those in the
grand or middle range theories and the con- unitary-transformative paradigm. We sepa-
ceptualizations of an early nursing scholar rated the grand theories that focus on caring
have been added to this edition of the book. within Section V. The final section includes
This expansion reflects the growth in nursing a selection of middle range theories.
theory development especially at the middle An outline at the beginning of each chap-
range; it was not possible to include all exist- ter provides a map for the contents. Major
ing middle range theories in this volume. points are highlighted in each chapter. Since
This book is intended to assist nursing stu- this book focuses on the relationship of
dents in undergraduate, masters, and doctoral nursing theory to nursing practice we invited
nursing programs to explore and appreciate the authors to share a practice exemplar. The

v
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vi Preface

research methods and key research findings have joined in preparing this book and to find
related to the theories have been placed on the new friends and colleagues as contributing
books website under Additional Chapter authors.
Content at http://davisplus.fadavis.com. We Nursing Theories and Nursing Practice, now
recognize the value of research in expanding in the third edition, has roots in a series
nursing theory and in serving as a foundation of nursing theory conferences held in
for theory; however, this decision allowed us South Florida beginning in 1989 and ending
to focus the book more explicitly on theory when efforts to cope with the aftermath of
and its relationship to practice. Having said Hurricane Andrew interrupted the energy
this, readers will notice that not all the theo- and resources needed for planning and offer-
rists chose to provide a practice exemplar, and ing the Fifth South Florida Nursing Theory
some authors insisted on including research Conference. Many of the theorists in this
related to the theory in their chapters. Two book addressed audiences of mostly practic-
chapters, 8 and 18, were not updated from the ing nurses at these conferences. Two books
second edition. stimulated by those conferences and pub-
The books website features materials that lished by the National League for Nursing
will enrich the teaching and learning of these are Nursing Theories in Practice (1990) and
nursing theories. Materials that will be help- Patterns of Nursing Theories in Practice
ful for teaching and learning about nursing (1993).
theories are included as online resources. For For me (Marilyn), even deeper roots of this
example, there are case studies and activities book are found early in my nursing career,
that facilitate student learning; powerpoint when I seriously considered leaving nursing
presentations are included in both instructor for the study of pharmacy. In my fatigue and
and student websites. We have cited online frustration, mixed with youthful hope and
resources, more extensive bibliographies and desire for more education, I could not answer
have included biographies of chapter contri- the question What is nursing? and could not
butors. The ancillary materials for students distinguish the work of nursing from other
and faculty have been prepared for this book tasks I did every day. Why should I continue
by Dr. Shirley Gordon and a group of doctor- this work? Why should I seek degrees in a
al students from Florida Atlantic University. field that I could not define? After reflecting
We are so grateful to Dr. Gordon for her on these questions and using them to examine
creativity and leadership and to the doctoral my nursing, I could find no one who would
students for their thoughtful contributions to consider the questions with me. I remember
this project. being asked, Why would you ask that ques-
For the latest and best thinking of some of tion? You are a nurse; you must surely know
nursings finest scholars, all nurses who read what nursing is. Such responses, along with
and use this book will be grateful. For the a drive for serious consideration of my ques-
continuing commitment of these scholars to tions, led me to the library. I clearly remember
our discipline and practice of nursing, we are reading several descriptions of nursing that, I
all thankful. Continuing to learn and share thought, could have just as well have been
what you love keeps the work and the love about social work or physical therapy. I then
alive, nurtures the commitment, and offers found nursing defined and explained in a
both fun and frustration along the way. This book about education of practical nurses writ-
has been illustrated in the enthusiasm for this ten by Dorothea Orem. During the weeks
book shared by many nursing theorists and that followed, as I did my work of nursing in
contributing authors who have worked to cre- the hospital, I explored Orems ideas about
ate this book and by those who have added why people need nursing, nursings purposes,
their efforts to make it live. For us, it is a joy and what nurses do. I found a fit of her ideas,
to renew friendships with colleagues who as I understood them, with my practice, and
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Preface vii

I learned that I could go even further to which is now humanbecoming. I conducted


explain and design nursing according to these several studies based on Rogers conceptual sys-
ways of thinking about nursing. I discovered tem and Parses theory. At theory conferences
that nursing shared some knowledge and I was fortunate to dialogue with Virginia
practices with other services, such as pharma- Henderson, Hildegard Peplau, Imogene King
cy and medicine, and I began to distinguish and Madeleine Leininger. In 1988 I accepted
nursing from these related fields of practice. I a faculty position at the University of
decided to stay in nursing and made plans to Colorado when Jean Watson was Dean. The
study and work with Dorothea Orem. In School of Nursing was guided by a caring
addition to learning about nursing theory philosophy and framework and I embraced
and its meaning in all we do, I learned caring as a central focus of the discipline of
from Dorothea that nursing is a unique disci- nursing. I had studied Newmans theory of
pline of knowledge and professional practice. Health as Expanding Consciousness and was
In many ways, my earliest questions about intrigued by it, so for my sabbatical I decided
nursing have guided my subsequent study and to study it further as well as learn more about
work. Most of what I have done in nursing the unitary appreciative inquiry process that
has been a continuation of my initial experi- Richard Cowling was developing.
ence of the interrelations of all aspects of We both have been fortunate to hold
nursing scholarship, including the scholarship faculty appointments in universities where
that is nursing practice. Over the years, I have nursing theory has been valued, and we
been privileged to work with many nursing are fortunate today to hold positions at the
scholars, some of whom are featured in this Christine E. Lynn College of Nursing at
book. My love for nursing and my respect for Florida Atlantic University where faculty and
our discipline and practice have deepened, students ground their teaching scholarship
and knowing now that these values are so and practice on caring theories, including
often shared is a singular joy. Nursing as Caring, developed by Dean Anne
Marlaines interest in nursing theory had Boykin and a previous faculty member at the
similar origins to Marilyns. As a nurse pursu- College, Savina Schoenhofer. Many faculty
ing an interdisciplinary masters degree in colleagues and students continue to help us
public health I recognized that while all the study nursing and have contributed to this
other public health disciplines had some book in ways we would never have adequate
unique perspective to share, public health words to acknowledge. We are grateful to our
nursing seemed to lack a clear identity. In knowledgeable colleagues who reviewed and
search of the identity of nursing I pursued a offered helpful suggestions for chapters of this
second masters in nursing. At that time nurs- book, and we sincerely thank those who con-
ing theory was beginning to garner attention, tributed to the book as chapter authors. It is
and I learned about it from my teachers and also our good fortune that many nursing the-
mentors Sr. Rosemary Donley, Dr. Rosemarie orists and other nursing scholars live in or
Parse and Dr. Mary Jane Smith. This discov- willingly visit our lovely state of Florida. Since
ery was the answer I was seeking, and it both the first edition of this book was published we
expanded and focused my thinking about have lost several nursing theorists. Their work
nursing. The question of What is nursing? continues through those refining, modifying,
was answered for me by these theories and I testing and expanding the theories. The disci-
couldnt get enough! It led to my decision to pline of nursing is expanding with more
pursue my PhD in Nursing at New York research and practice in existing theories and
University where I studied with Martha the introduction of new theories. This is espe-
Rogers. During this same time I taught at cially important at a time when nursing theory
Duquesne University with Rosemarie Parse can provide what is missing and needed most
and learned more about Man-Living-Health, in health care today.
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viii Preface

All three editions of this book have been husband, Terry Worden, for his abiding love
nurtured by Joanne DaCunha, an expert nurse and for always being willing to help, and her
and editor for F. A. Davis Company, who has niece, Cherie Parker, who represents many
shepherded this project and others because nurses who love nursing practice and scholar-
of her love of nursing. We are both grateful ship and thus inspire the work of this book.
for her wisdom, kindness, patience and Marlaine acknowledges her husband Brian
understanding of nursing. We give special for his love and support, and her children
thanks to Kimberly DePaul and Maria Price Kirsten, Alicia and Brady for their under-
of F. A. Davis, for their gentle and wise edito- standing, and gives special recognition to her
rial assistance, attention to detail, and creative parents, Deno and Rose Cappelli, for instill-
ideas during the development of the project ing in her the love of learning, the value of
and to Berta Steiner who so carefully directed hard work, and the importance of caring for
the books production. Marilyn thanks her others.

M ARILYN E. PARKER M ARLAINE C. S MITH


W EST PALM B EACH , F LORIDA B OCA R ATON , F LORIDA
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Nursing Theorists

Charlotte D. Barry, PhD, RN, NCSN Betty Neuman, PhD, RN, PLC, FAAN
Associate Professor of Nursing Beverly, Ohio
Florida Atlantic University Margaret Newman*
Boca Raton, Florida
Dorothea E. Orem
Anne Boykin, PhD, RN
Dean and Professor Ida Jean Orlando (Pelletier)*
Florida Atlantic University Marilyn E. Parker, PhD, RN, FAAN
Boca Raton, Florida Clinical Professor
Barbara Montgomery Dossey, University of Kansas
PhD, RN, AHN-BC, FAAN
Kansas City, Kansas
International Co-Director Rosemarie Rizzo Parse, PhD, FAAN
Nightingale Initiative for Global Health Distinguished Professor Emeritus
Santa Fe, New Mexico Loyola University Chicago
Joanne R. Duffy, PhD, RN, FAAN Chicago, Illinois
Professor Josephine Paterson*
Indiana University Hildegard Peplau
Indianapolis, Indiana
Marilyn Anne Ray, PhD, RN, CTN
Helen L. Erickson* Professor Emeritus
Lydia Hall Florida Atlantic University
Virginia Henderson Boca Raton, Florida

Dorothy Johnson Pamela G. Reed, PhD, RN, FAAN


Professor
Imogene King University of Arizona
Katharine Kolcaba, PhD, RN Tucson, Arizona
Associate Professor Emeritus Martha E. Rogers
The University of Akron
Akron, Ohio Sister Callista Roy, PhD, RN, FAAN
Professor and Nurse Theorist
Madeleine M. Leininger* Boston College
Myra Levine Chestnut Hill, Massachusetts
Patricia Liehr, PhD, RN Savina O. Schoenhofer, PhD, RN
Professor and Associate Dean for Nursing Research Professor of Nursing
and Scholarship Alcorn State University
Florida Atlantic University Natchez, Mississippi
Boca Raton, Florida Marlaine C. Smith, PhD, RN, AHN-BC, FAAN
Rozzano C. Locsin, PhD, RN Helen K. Persson Eminent Scholar and Associate Dean
Professor Florida Atlantic University
Florida Atlantic University Boca Raton, Florida
Boca Raton, Florida

ix
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x Nursing Theorists

Mary Jane Smith, PhD, RN Evelyn Tomlin*


Professor and Associate Dean Joyce Travelbee
West Virginia University
Morgantown, West Virginia Jean Watson, PhD, RN, AHN-BC, FAAN
Distinguished Professor of Nursing
Mary Ann Swain, PhD University of Colorado at DenverAnschutz Campus
Provost and Vice President for Academic Affairs Aurora, Colorado
Binghamton University
Binghamton, New York Ernestine Wiedenbach

Kristen M. Swanson, PhD, RN, FAAN Loretta Zderad*


Professor and Dean *Retired
University of North Carolina Deceased
Chapel Hill, North Carolina
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Contributors

Patricia Deal Aylward, MSN, RN, CNS Marcia Dombro, EdD, RN


Assistant Professor Chairperson
Santa Fe Community College Miami-Dade College
Gainesville, Florida Miami, Florida

Elizabeth Ann Manhart Barrett, PhD, RN, FAAN Lynne M. Dunphy, PhD, APRN-BC
Professor Professor
City University of New York Routhier Endowed Chair for Practice
New York, New York University of Rhode Island
Kingston, Rhode Island

Nettie Birnbach
Laureen M. Fleck, DNS, FNP-BC, CDE
Family Nurse Practitioner
Florida Atlantic University
Boca Raton, Florida

Howard Karl Butcher, PhD, RN, PMHCNS-BC


Associate Professor
University of Iowa
Iowa City, Iowa
xi
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xii Contributors

Maureen A. Frey, PhD, RN Bonnie Holaday, RN, DNS


Research Associate Professor
Wayne State University Clemson University
Detroit, Michigan Clemson, South Carolina

Theresa Gesse, PhD, RN Mary B. Killeen, PhD, RN, NEA-BC


Professor Consultant
University of Miami Evidence Based Practice Nurse Consultants, LLC
Miami, Florida Howell, Michigan

Shirley C. Gordon, PhD, RN Susan Kleiman, PhD, RN, CS, NPP


Associate Professor Founder
Florida Atlantic University International Institute for Human Centered Caring
Boca Raton, Florida Riverdale, New York

Donna L. Hartweg, PhD, RN Kaitlin A. Laubham


Director Nursing Student
Illinois Wesleyan University University of Kentucky
Bloomington, Illinois Lexington, Kentucky
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Contributors xiii

Danielle Linden, MSN, ARNP-BC, ARNP Ann R. Peden, ARNP, CS, DSN
Nurse Practitioner Professor
Coral Springs, Florida University of Kentucky
Lexington, Kentucky

Violet M. Malinski, PhD, RN


Associate Professor Margaret Dexheimer Pharris,
Hunter-Bellevue School of Nursing PhD, RN, MPH, FAAN
New York, New York Associate Professor
College of St. Catherine
St. Paul, Minnesota

Marilyn R. McFarland,
PhD, RN, CTN, FNP-BC
Maude Rittman, PhD, RN
Associate Professor Associate Chief of Nursing Service for Research
University of Michigan at Flint Gainesville Veterans Administration Medical Center
Flint, Michigan Gainesville, Florida

Linda G. Payne, MSN, RN, BC, CARN-AP Karen Moore Schaefer, PhD, RN
PhD Student and Teaching Assistant Associate Chair
Florida Atlantic University Temple University
Boca Raton, Florida Philadelphia, Pennsylvania
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xiv Contributors

Christina L. Sieloff, PhD, RN, CNA-BC Autumn Wells


Associate Professor Nurse Research Intern
Montana State University University of Kentucky
Billings, Montana Lexington, Kentucky

Jacqueline Staal, MSN, ARNP, FNP-BC Kelly N. White, MSN, FNP-BC


PhD Student PhD Student
Florida Atlantic University Florida Atlantic University
Boca Raton, Florida Boca Raton, Florida

Theris A. Touhy, DNP, GCNS-BC Terri Kaye Woodward,


Professor MSN, RN, CNS, AHN-BC, HTCP
Florida Atlantic University Founder
Boca Raton, Florida Cocreative Wellness
Denver, Colorado

Marian C. Turkel, PhD, RN


Director of Professional Nursing Practice Lin Zhan, PhD, RN, FAAN
Albert Einstein Healthcare Network Dean and Professor
Philadelphia, Pennsylvania Massachusetts College of Pharmacy and Health
Sciences
Boston, Massachusetts
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Reviewers

Geraldine Allen, RN, DSN, FNP Carole-Lynne Le Navenec, PhD, RN


MSN Program Director Associate Professor
Troy University University of Calgary
Selma, Alabama Calgary, Alberta, Canada
Cathryn J. Baack, PhD, RN, CPNP Margherite Matteis, PhD, RN, PMHCNS-BC
Assistant Professor Associate Professor
MedCentral College of Nursing Regis College
Mansfield, Ohio Weston, Massachusetts
Mary Baumberger-Henry, PhD, RN Victoria Menzies, PhD, APRN-BC
Associate Professor Assistant Professor
Widener University School of Nursing Florida International University
Chester, Pennsylvania Miami, Florida
Beverly M. Brown, EdD, MSN, APRN/GCNS, BC Carel Mountain, MSN, RN
Assistant Professor Nursing Faculty
Tennessee State University Shasta College
Nashville, Tennessee Redding, California
Nancy Hinzman, MSN, RN Carla Mueller, PhD, RN
Associate Professor of Nursing Professor
College of Mount St. Joseph University of St. Francis
Cincinnati, Ohio Fort Wayne, Indiana
Marlene Huff, PhD, MSN Barbara R. Norwood, MSN, EdD, RN
Associate Professor Associate Professor
University of Akron University of Tennessee at Chattanooga
Akron, Ohio Chattanooga, Tennessee
Kathleen Ann Kalb, PhD, RN Lauren E. OHare, EdD, RN
Associate Professor of Nursing Chair
The College of St. Catherine Wagner College
St. Paul, Minnesota Staten Island, New York
Barbara Kearney, PhD, RN Nelma B. Shearer, PhD, RN
Assistant Professor Associate Professor
Murray State University Arizona State University
Murray, Kentucky Phoenix, Arizona
Norma Krumwiede, EdD, RN Christina L. Sieloff, PhD, RN, CNA-BC
Professor Associate Professor
Minnesota State University Montana State University
Mankato, Minnesota Billings, Montana
Judy Kuhns-Hastings, PhD, APRN-BC, FNP Pamela Wessling, MSN, ARNP, NP-C
Associate Professor of Nursing Assistant Professor
University of Maine Barry University
Orono, Maine Miami Shores, Florida
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Contents

Section I An Introduction to Nursing Theory 1


Chapter 1 Nursing Theory and the Discipline of Nursing 3
M ARLAINE C. S MITH AND M ARILYN E. PARKER

Chapter 2 A Guide for the Study of Theories for Practice 16


M ARILYN E. PARKER AND M ARLAINE C. S MITH

Chapter 3 Choosing, Evaluating and Implementing Nursing


Theories for Practice 20
M ARILYN E. PARKER AND M ARLAINE C. S MITH

Section II Evolution of Nursing Theory 33


Chapter 4 Florence Nightingales Legacy of Caring and Its
Applications 35
LYNNE M. D UNPH Y

Chapter 5 Twentieth-Century Nursing: Ernestine Wiedenbach,


Virginia Henderson, and Lydia Halls Contributions to
Nursing Theory and Their Use in Practice 54
S HIRLE Y C. G ORDON , T HERIS A. T OUH Y, T HERESA
G ESSE , M ARCIA D OMBRO , AND N ET TIE B IRNBACH

Chapter 6 Nurse-Patient Relationship Theories: Hildegard Peplau,


Joyce Travelbee, and Ida Jean Orlando 67
A NN R. P EDEN , K AITLIN A. L AUBHAM ,
AU TUMN W ELLS , J ACQUELINE S TAAL , AND
M AUDE R IT TMAN

Section III Conceptual Models/Grand Theories in the Interactive/


Integrative Paradigm 81
Chapter 7 Myra Levines Conservation Model 83
K AREN M OORE S CHAEFER

Chapter 8 Dorothy Johnsons Behavioral System Model and Its


Applications 104
B ONNIE H OLADAY

Chapter 9 Dorothea Orems Self-Care Deficit Theory 121


D ONNA L. H ART WEG AND L AUREEN M. F LECK

Chapter 10 Imogene Kings Theory of Goal Attainment 146


I MOGENE K ING , C HRISTINA LEIBOLD S IELOFF,
M ARY B. K ILLEEN , AND M AUREEN F RE Y
xvii
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xviii Contents

Chapter 11 Sister Callista Roys Adaptation Model 167


C ALLISTA R OY AND LIN Z HAN

Chapter 12 Betty Neumans Systems Model 182


PATRICIA D EAL AYLWARD

Chapter 13 Helen Erickson, Evelyn Tomlin, and Mary Ann Swains


Theory of Modeling and Role Modeling 202
H ELEN L. E RICKSON

Chapter 14 Barbara Dosseys Theory of Integral Nursing 224


B ARBARA M ONTGOMERY D OSSE Y

Section IV Conceptual Models/Grand Theories in the


Unitary-Transformative Paradigm 251
Chapter 15 Martha E. Rogers Science of Unitary Human Beings 253
H OWARD K ARL B U TCHER AND

V IOLET M. M ALINSKI

Chapter 16 Rosemarie Rizzo Parses Humanbecoming


School of Thought 277
R OSEMARIE R IZZO PARSE

Chapter 17 Margaret Newmans Theory of Health as Expanding


Consciousness 290
M ARGARET D EXHEIMER P HARRIS

Section V Caring Theories 315


Chapter 18 Madeleine Leiningers Theory of Culture Care
Diversity and Universality 317
M ADELEINE M. LEININGER AND

M ARILYN R. M C FARLAND

Chapter 19 Josephine Paterson and Loretta Zderads Humanistic


Nursing Theory 337
S USAN K LEIMAN

Chapter 20 Jean Watsons Theory of Human Caring 351


J EAN WATSON AND T ERRI K AYE W OODWARD

Chapter 21 Anne Boykin and Savina O. Schoenhofers Nursing as


Caring Theory 370
A NNE B OYKIN , S AVINA O. S CHOENHOFER ,
AND D ANIELLE L INDEN

Section VI Middle-Range Theories 387


Chapter 22 Katharine Kolcabas Comfort Theory 389
K ATHARINE KOLCABA

Chapter 23 Joanne Duffys Quality Caring Model 402


J OANNE R. D UFFY
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Contents xix

Chapter 24 Pamela Reeds Theory of Self-transcendence 417


PAMELA G. R EED

Chapter 25 Kristen Swansons Theory of Caring 428


K RISTEN M. S WANSON

Chapter 26 Mary Jane Smith and Patricia Liehrs Story Theory 439
M ARY J ANE S MITH AND PATRICIA LIEHR

Chapter 27 The Community Nursing Practice Model 451


M ARILYN E. PARKER AND C HARLOT TE D. B ARRY

Chapter 28 Rozzano Locsins Technological Competency as


Caring and the Practice of Knowing Persons in Nursing 460
R OZZANO C. L OCSIN

Chapter 29 Marilyn Anne Rays Theory of Bureaucratic Caring 472


M ARILYN A NNE R AY AND M ARIAN C. T URKEL

Chapter 30 Marlaine Smiths Theory of Unitary Caring 495


M ARLAINE C. S MITH

Index 505
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Section
I
An Introduction to
Nursing Theory
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Section

I An Introduction to Nursing Theory

In this first section of the book we, the editors, have written three chapters that will introduce
the reader to the purpose of nursing theory and how to study, analyze, and evaluate it for use
in nursing practice. If you are new to the idea of theory in nursing, the chapters in this section
will orient you to what theory is, how it fits into the context of nursing as a professional disci-
pline, and how to approach its study and evaluation. If you have studied nursing theory in the
past, we hope the chapters will provide you with additional knowledge and insight as you con-
tinue your study. We assert that nursing is a professional discipline focused on the study of
human health and healing through caring. Nursing practice is based on the knowledge of nursing,
which consists of its philosophies, theories, concepts, principles, research findings, and practice
wisdom. Theories are patterns that guide the thinking about being, and doing of nursing. All
nurses are guided by some implicit or explicit theory, or pattern of thinking, as they care for
their patients. Too often, this pattern of thinking is implicit, and is colored by the lens of dis-
eases, diagnoses, and treatments. This does not reflect practice from the disciplinary perspec-
tive of nursing. The major reason for nursing theory is to improve nursing practice, and there-
fore the health and quality of life of those we serve. The first chapter in this section focuses on
nursing theory and how it fits within the context of nursing as a professional discipline. We
examine the relationship of nursing theory to the characteristics of a discipline. Youll learn new
words that describe parts of the knowledge structure of the discipline of nursing, and well spec-
ulate about the future of nursing theory as nursing, health care, and our global society change.
Chapter 2 is a guide to help you study the theories in this book. We hope youll use this guide
as you read and think about nursing theory for use in practice. Nurses embrace theories
because they fit with their values and ways of thinking. They choose theories to guide their prac-
tice when the theories help them to create a practice that is meaningful to them. Chapter 3
focuses on the selection, evaluation, and implementation of theory for practice. Students often
get the assignment of evaluating or critiquing a nursing theory. Evaluation is coming to some
judgment about value or worth based on criteria. Various sets of criteria exist for you to use in
theory evaluation. We introduce some that you can explore further. Finally, we offer reflections
on the process of implementing theory-guided practice models.

2
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Chapter
1
Nursing Theory and
the Discipline of Nursing
M ARLAINE C. S MITH AND
M ARILYN E. PARKER

The Discipline of Nursing What is nursing? At first glance, the question


Definitions of Nursing Theory may appear to be one with an obvious answer,
The Purpose of Theory in but when it is posed to nurses, many define
a Professional Discipline nursing by providing a litany of functions and
The Structure of Knowledge in the activities. Some answer with the elements of
Discipline of Nursing the nursing process: nurses assess, plan,
Nursing Theory and the Future implement, and evaluate the patient. Others
Summary might answer that nurses coordinate a
References patients care.
Defining nursing in terms of the nursing
process, or by functions or activities per-
formed is problematic. The phases of the
nursing process are the same as those that
delineate the solution of any problem we
encounter, from a broken computer to a fail-
ing vegetable garden. We assess the situation
to determine what is going on and then iden-
tify the problem; we plan what to do about it,
implement our plan, and then evaluate if it
Marilyn E. Parker Marlaine C. Smith
works. The nursing process does nothing to
define nursing.
Defining ourselves by tasks presents other
problems. What nurses do, that is, the func-
tions associated with practice, differs based
on the setting. For example, nurses might
start IVs, administer medications, and per-
form treatments in an acute care setting. In a
community-based clinic, nurses might teach
a young mother the principles of infant
feeding or place phone calls to connect a child
with special needs to community resources.
Multiple professionals and non-professionals
perform the same tasks as nurses, and persons
with the ability and authority to perform cer-
tain tasks change based on time and setting.
For example, both physicians and nurses may
listen to breath sounds and recognize the pres-
ence of rales. Both nurses and social workers

3
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4 S E C T I O N I An Introduction to Nursing Theory

might do discharge planning. Both nurses and that both reflect and illuminate its distinct
family members might change dressings, perspective. The discipline of nursing is
monitor vital signs, and administer medica- formed by a community of scholars, includ-
tions, so defining nursing based solely on ing nurses in all nursing venues, who share
functions or activities performed is not useful. a commitment to values, knowledge, and
To answer the question What is nurs- processes to guide the thought and work of
ing? we must formulate nursings unique the discipline.
perspective as a field of study or discipline. The classic work of King and Brownell
Florence Nightingale is credited as the (1976) is consistent with the thinking of
founder of modern Nursing, the one who nursing scholars (Donaldson & Crowley,
articulated its distinctive focus. In her book 1978; Meleis, 1977) about the discipline
Notes on Nursing: What It Is and What It of nursing. These authors have elaborated
Is Not (Nightingale, 1859/1992), she differ- attributes that characterize all disciplines.
entiated nursing from medicine, stating that The attributes of King and Brownell provide
they were two distinct practices. She defined a framework that contextualizes nursing theory
nursing as putting the person in the best within the discipline of nursing. Each of the
condition for nature to act, insisting that the attributes of disciplines is described in the
focus of nursing was on health and the nat- text that follows.
ural healing process, and not on disease and
reparation. For her, creating an environment Expression of Human Imagination
that provided the conditions for natural Members of any discipline imagine and cre-
healing to occur was the focus of nursing. ate structures that offer descriptions and
Her beginning conceptualizations were the explanations of the phenomena that are of
seeds for the theoretical development of concern to that discipline. These structures
nursing as a professional discipline. are the theories of that discipline. Nursing
In this chapter, we situate the under- theory is dependent on the imagination of
standing of nursing theory within the con- nurses in practice, administration, research,
text of the discipline of nursing. We define and teaching, as they create and apply theo-
the discipline of nursing and theory, describe ries to improve nursing practice and ulti-
the purpose of theory for the discipline of mately the lives of those we serve. To remain
nursing, identify the structure of the disci- dynamic and useful, our discipline requires
pline of nursing, and speculate on the future openness to new ideas and innovative
place of nursing theory in the discipline. approaches that grow out of members reflec-
tions and insights.

The Discipline of Nursing Domain


Every discipline has a unique focus that A professional discipline must be clearly
directs the inquiry within it and distin- defined by a statement of its domainthe
guishes it from other fields of study (Smith, boundaries or focus of that discipline. The
2008, p. 1). Nursing knowledge guides its domain of nursing includes the phenomena of
professional practice; therefore, it is classi- interest, problems to be addressed, main con-
fied as a professional discipline. Donaldson tent and methods used, and roles required of
and Crowley (1978) stated that a discipline the disciplines members (Kim, 1997; Meleis,
offers a unique perspective, a distinct way 1997). The processes and practices claimed by
of viewing...phenomena, which ultimately members of the disciplinary community grow
defines the limits and nature of its inquiry out of these domain statements. Nightingale
(p. 113). Any discipline includes networks of provided some direction for the domain of the
philosophies, theories, concepts, approaches discipline of nursing. While the disciplinary
to inquiry, research findings, and practices focus has been debated, there is some degree
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C H A P T E R 1 Nursing Theory and the Discipline of Nursing 5

of consensus. Donaldson and Crowley (1978, 1978; Watson, 1985); and humanuniverse
p. 113) identified the following as the domain health interrelationships (Parse, 1998). A
of the discipline of nursing: widely accepted focus statement for the disci-
pline was published by Newman, Sime, and
1. Concern with principles and laws that
Corcoran-Perry (1991) as Nursing is the
govern the life processes, well-being, and
study of caring in the human health experi-
optimum functioning of human beings,
ence (p. 3). A consensus statement of philo-
sick or well
sophical unity in the discipline was published
2. Concern with the patterning of human
by Roy and Jones (2007). Statements include:
behavior in interactions with the environ-
ment in critical life situations The human being is characterized by
3. Concern with the processes by which posi- wholeness, complexity, and consciousness.
tive changes in health status are affected The essence of nursing involves the nurses
true presence in the process of human-to-
Fawcett (1984) described the metapara-
human engagement.
digm as a way to distinguish nursing from
Nursing theory expresses the values and
other disciplines. The metaparadigm is very
beliefs of the discipline, creating a structure
general and is intended to reflect agreement
to organize knowledge and illuminate nurs-
among members of the discipline about the
ing practice.
field of nursing. This is the most abstract
The essence of nursing practice is the
level of nursing knowledge and closely
nursepatient relationship.
mirrors beliefs held about nursing. By virtue
of being nurses, all nurses have some aware- In 2008, Newman, Smith, Dexheimer-
ness of nursings metaparadigm. However, Pharris, and Jones revisited the disciplinary
because the term may not be familiar, focus asserting that relationship was central
it offers no direct guidance for research and to the discipline, and the convergence of
practice (Kim, 1997; Walker & Avant, seven conceptshealth, consciousness, caring,
1995). The metaparadigm consists of four mutual process, presence, patterning, and
concepts: persons, environment, health, and meaningspecified relationship in the pro-
nursing. According to Fawcett, nursing is the fessional discipline of nursing. Willis, Grace,
study of the interrelationship among these and Roy (2008) posited that the central uni-
four concepts. fying focus for the discipline is facilitating
Modifications and alternative concepts humanization, meaning, choice, quality of
for this framework have been explored life, and healing in living and dying (p. E28).
throughout the discipline (Fawcett, 2000). Finally, Litchfield and Jondorsdottir (2008)
For example, nursing scholars have suggested defined the discipline as the study of human-
that caring replace nursing in the meta- ness in the health circumstance. Smith
paradigm (Stevenson & Tripp-Reimer, 1989). (1994) defined the domain of the discipline
Kim (1987, 1997) set forth four domains: of nursing as the study of human health and
client, clientnurse encounters, practice, and healing through caring (p. 50). For Smith,
environment. In recent years, increasing nursing knowledge focuses on wholeness of
attention has been directed to the nature of human life and experience and the processes
nursings relationship with the environment that support relationship, integration, and
(Kleffel, 1996; Schuster & Brown, 1994). transformation (p. 3). Nursing conceptual
Others have defined nursing as the study models, grand theories, middle-range theo-
of: the health or wholeness of human ries, and practice theories explicate the phe-
beings as they interact with their environ- nomena within the domain of nursing. In
ment (Donaldson & Crowley, 1978, p. 113); addition, the focus of the nursing discipline
the life process of unitary human beings is a clear statement of social mandate and
(Rogers, 1970); care or caring (Leininger, service used to direct the study and practice
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6 S E C T I O N I An Introduction to Nursing Theory

of nursing (Newman, Sime, & Corcoran- nursing knowledge and practice. Confer-
Perry, 1991). ences and forums on every aspect of nursing
held throughout the world are part of this
Syntactical and Conceptual network. Nursing organizations and soci-
Structures eties also provide critical communication
Syntactical and conceptual structures are links. Nursing theories are part of this her-
essential to any discipline and are inherent in itage of literature, and those working with
nursing theories. The conceptual structure these theories present their work at confer-
delineates the proper concerns of nursing, ences, societies, and other communication
guides what is to be studied, and clarifies networks of the nursing discipline.
accepted ways of knowing and using content
of the discipline. This structure is grounded in Tradition
the focus of the discipline. The conceptual The tradition and history of the discipline is
structure relates concepts within nursing theo- evident in the study of nursing over time.
ries. The syntactical structures help nurses and There is recognition that theories most use-
other professionals to understand the talents, ful today often have threads of connection
skills, and abilities that must be developed with ideas originating in the past. For exam-
within the community. This structure directs ple, many theorists have acknowledged the
descriptions of data needed from research, as influence of Florence Nightingale, and have
well as evidence required to demonstrate the acclaimed her leadership in influencing
impact on nursing practice. In addition, these nursing theories of today. In addition, nurs-
structures guide nursings use of knowledge in ing has a rich heritage of practice. Nursings
research and practice approaches developed by practical experience and knowledge have
related disciplines. It is only by being thor- been shared and transformed as the content
oughly grounded in the disciplines concepts, of the discipline and are evident in many
substance, and modes of inquiry that the nursing theories (Gray & Pratt, 1991).
boundaries of the discipline can be understood
and possibilities for creativity across discipli-
Values and Beliefs
nary borders can be created and explored.
Nursing has distinctive views of persons and
Specialized Language and Symbols strong commitments to compassionate and
As nursing theory has evolved, so has the knowledgeable care of persons through nurs-
need for concepts, language, and forms of data ing. Fundamental nursing values and beliefs
that reflect new ways of thinking and know- include a holistic view of person, the dignity
ing specific to nursing. The complex concepts and uniqueness of persons and the call to care.
used in nursing scholarship and practice There are both shared and differing values
require language that can be specific and and beliefs within the discipline. The meta-
understood. The language of nursing theory paradigm reflects the shared beliefs while the
facilitates communication among members of paradigms reflect the differences.
the discipline. Expert knowledge of the disci-
pline is often required for full understanding Systems of Education
of the meaning of these theoretical terms. A distinguishing mark of any discipline is the
education of future and current members of
Heritage of Literature and Networks the community. Nursing is recognized as a
of Communication professional discipline within institutions of
This attribute calls attention to the array of higher education because it has an identifiable
books, periodicals, artifacts, and aesthetic body of knowledge that is studied, advanced,
expressions, as well as audio, visual, and and used to underpin its practice. Students of
electronic media that have developed over any professional discipline study its theories
centuries to communicate the nature of and learn its methods of inquiry and practice.
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C H A P T E R 1 Nursing Theory and the Discipline of Nursing 7

Nursing theories, by setting directions for the interconnected sets of confirmed hypotheses.
substance and methods of inquiry for the dis- Barnum (1998, p. 1) later offers a more open
cipline, should provide the basis for nursing definition of theory as a construct that
education and the framework for organizing accounts for or organizes some phenomenon,
nursing curricula. and simply states that a nursing theory
describes or explains nursing.
Definitions of theory emphasize its various
Definitions of Nursing aspects. Those developed in recent years are
Theory more open and conform to a broader concep-
A theory, as a general term, is a notion or an idea tion of science. The following definitions of
that explains experience, interprets observation, theory are consistent with general ideas of
describes relationships, and projects outcomes. theory in nursing practice, education, admin-
Parsons (1949), often quoted by nursing theo- istration, or research:
rists, wrote that theories help us know what we
Theory is a set of concepts, definitions, and
know and decide what we need to know. Theo-
propositions that project a systematic view
ries are mental patterns or frameworks created
of phenomena by designating specific inter-
to help understand and create meaning from
relationships among concepts for purposes
our experience, organize and articulate our
of describing, explaining, predicting, and/or
knowing, and ask questions leading to new
controlling phenomena (Chinn & Jacobs,
insights. As such, theories are not discovered in
1987, p. 71).
nature, but are human inventions.
Theory is a creative and rigorous structur-
Theories are organizing structures of our
ing of ideas that projects a tentative, pur-
reflections, observations, projections, and infer-
poseful, and systematic view of phenomena
ences. Many describe theories as lenses because
(Chinn & Kramer, 2004, p. 268).
they color and shape what is seen. The same
Nursing theory is a conceptualization of
phenomena will be seen differently depending
some aspect of reality (invented or discov-
on the theoretical perspective assumed. For
ered) that pertains to nursing. The concep-
these reasons, theory and related terms have
tualization is articulated for the purpose of
been defined and described in a number of ways
describing, explaining, predicting, or pre-
according to individual experience and what is
scribing nursing care (Meleis, 1997, p. 12).
useful at the time. Theories, as reflections of
Nursing theory is an inductively and/or
understanding, guide our actions, help us set
deductively derived collage of coherent, cre-
forth desired outcomes, and give evidence of
ative, and focused nursing phenomena that
what has been achieved. A theory, by tradition-
frame, give meaning to, and help explain
al definition, is an organized, coherent set of
specific and selective aspects of nursing
concepts and their relationships to each other
research and practice (Silva, 1997, p. 55).
that offers descriptions, explanations, and pre-
A theory is an imaginative grouping of
dictions about phenomena.
knowledge, ideas, and experience that
Early writers on nursing theory brought
are represented symbolically and seek to
definitions of theory from other disciplines to
illuminate a given phenomenon. (Watson,
direct future work within nursing. Dickoff
1985, p. 1).
and James (1968, p. 198) define theory as a
conceptual system or framework invented
for some purpose. Ellis (1968, p. 217) The Purpose of Theory in a
defined theory as a coherent set of hypothet-
ical, conceptual, and pragmatic principles Professional Discipline
forming a general frame of reference for a All professional disciplines have a body of
field of inquiry. McKay (1969, p. 394) assert- knowledge consisting of theories, research,
ed that theories are the capstone of scientific and methods of inquiry and practice. They
work, and that the term refers to logically organize knowledge, guide practice, enhance
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8 S E C T I O N I An Introduction to Nursing Theory

the care of patients, and guide inquiry to that theory provides nurses with different
advance science. Nursing theories address the ways of looking at and assessing phenomena,
phenomena of interest to nursing, including rationale for their practice, and criteria for
the focus of nursing; the person, group, or evaluating outcomes. Many of the theories in
population nursed; the nurse; the relationship this book have been used to guide nursing
of nurse and nursed; and the hoped-for goal or practice, stimulate creative thinking, facilitate
purposes of nursing. Based on strongly held communication, and clarify purposes and
values and beliefs about nursing, and within processes in practice. The practicing nurse has
contexts of various worldviews, theories are an ethical responsibility to use the disciplines
patterns that guide the thinking about, being, theoretical knowledge base, just as it is the
and doing of nursing. nurse scholars ethical responsibility to devel-
They provide structures for making sense op the knowledge base specific to nursing
of the complexities of reality for both practice practice (Cody, 1997, 2003).
and research. Theory-based research is need- At the empirical level of theory, abstract
ed in order to explain and predict nursing concepts are operationalized, or made con-
outcomes essential to the delivery of nursing crete, for practice and research (Fawcett, 2000;
care that is both humane and cost-effective Smith & Liehr, 2008). Empirical indicators
(Gioiella, 1996). Some conceptual structure provide specific examples of how the theory is
either implicitly or explicitly directs all avenues experienced in reality; they are important for
of nursing, including nursing education and bringing theoretical knowledge to the practice
administration. Nursing theories provide con- level. These indicators include procedures,
cepts and designs that define the place of tools, and instruments to determine the
nursing in health care. Through theories, impact of nursing practice and are essential to
nurses are offered perspectives for relating research and management of outcomes of
with professionals from other disciplines who practice ( Jennings & Staggers, 1998). The
join with nurses to provide human services. resulting data form the basis for improving the
Nursing has great expectations of its theories. quality of nursing care and influencing health-
At the same time, theories must provide care policy. Empirical indicators, grounded
structure and substance to ground the practice carefully in nursing concepts, provide clear
and scholarship of nursing and must also be demonstration of the utility of nursing theory
flexible and dynamic to keep pace with the in practice, research, administration, and other
growth and changes in the discipline and nursing endeavors (Allison & McLaughlin-
practice of nursing. Renpenning, 1999; Hart & Foster, 1998).
The major reason for structuring and Meeting the challenges of systems of care
advancing nursing knowledge is for the sake delivery and interdisciplinary work demands
of nursing practice. The primary purpose of practice from a theoretical perspective. Nurs-
nursing theories is to further the development ings disciplinary focus is essential within an
and understanding of nursing practice. interdisciplinary environment (Allison &
Because nursing theory exists to improve McLaughlin-Renpenning, 1999); otherwise
practice, the test of nursing theory is a test of its unique contribution to the interdiscipli-
its usefulness in professional practice (Colley, nary team is unclear. Nursing actions reflect
2003; Fitzpatrick, 1997). The work of nursing nursing concepts and thought. Careful, reflec-
theory is moving from academia into the tive, and critical thinking are the hallmarks of
realm of nursing practice. Chapters in the expert nursing, and nursing theories should
remaining sections of this book highlight undergird these processes. Appreciation and
the use of nursing theories in nursing practice. use of nursing theory offer opportunity for
Nursing practice is both the source and successful collaboration with colleagues from
goal of nursing theory. From the viewpoint of other disciplines, and provide definition for
practice, Gray and Forsstrom (1991) suggest nursings overall contribution to health care.
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C H A P T E R 1 Nursing Theory and the Discipline of Nursing 9

Nurses must know what they are doing, why and extending in order to guide nursing
they are doing it, what the range of outcomes endeavors and to reflect development within
of nursing may be, and indicators for docu- nursing. Although there is diversity of opin-
menting nursings impact. These nursing the- ion among nurses about terms used to
oretical frameworks serve as powerful guides describe the levels of theory, the following
for articulating, reporting, and recording discussion of theoretical development in
nursing thought and action. nursing is offered as a context for further
One of the assertions referred to most often understanding nursing theory.
in the nursing theory literature is that theory is
given birth in nursing practice and, after Paradigm
examination and refinement through research, Paradigm is the next level of the disciplinary
must be returned to practice (Dickoff, James, structure of nursing. The notion of paradigm
& Wiedenbach, 1968). Nursing theory is can be useful as a basis for understanding
stimulated by questions and curiosities arising nursing knowledge. Paradigm is a global, gen-
from nursing practice. Development of nurs- eral framework made up of assumptions about
ing knowledge is a result of theory-based aspects of the discipline held by members to
nursing inquiry. The circle continues as data, be essential in development of the discipline.
conclusions, and recommendations of nursing The concept of paradigm comes from the
research are evaluated and developed for use work of Kuhn (1970, 1977), who used the
in practice. Nursing theory must be seen as term to describe models that guide scientific
practical and useful to practice, and the activity and knowledge development in disci-
insights of practice must in turn continue to plines. Because paradigms are broad, shared
enrich nursing theory. perspectives held by members of the disci-
pline, they are often called worldviews.
Kuhn set forth the view that science does not
The Structure of Knowledge always evolve as a smooth, regular, continuing
in the Discipline of Nursing path of knowledge development over time,
Theories are part of the knowledge structure but that periodically there are times of revolu-
of any discipline. The domain of inquiry, tion when traditional thought is challenged
metaparadigm, or focus of the discipline is by new ideas, and paradigm shifts occur.
the foundation of the structure. The knowl- Kuhns ideas provide a way for us to think
edge of the discipline is related to its gener- about the development of science. Before any
al domain or focus. For example, knowledge discipline engages in the development of theo-
of biology relates to the study of living ry and research to advance its knowledge, it is
things; psychology is the study of the mind; in a pre-paradigmatic period of development.
sociology is the study of social structures and Typically, this is followed by a period of time
behaviors. Nursings domain was discussed when a single paradigm emerges to guide
earlier and relates to the focus statement or knowledge development. Research activities
metaparadigm. Other levels of the knowl- initiated around this paradigm advance its the-
edge structure include paradigms, conceptu- ories. This is a time during which knowledge
al models or grand theories, middle-range advances at a regular pace. At times, a new par-
theories, practice theories, and research and adigm can emerge to challenge the worldview
practice traditions. These levels of nursing of the existing paradigm. It can be revolution-
knowledge are interrelated; each level of ary, overthrowing the previous paradigm, or
development is influenced by work at other multiple paradigms can coexist in a discipline,
levels. Theoretical work in nursing must be providing different worldviews that guide the
dynamic; that is, it must be continually in scientific development of the discipline.
process and useful for the purposes and work Kuhns work has meaning for nursing and
of the discipline. It must be open to adapting other scientific disciplines because of his
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10 S E C T I O N I An Introduction to Nursing Theory

recognition that science is the work of a com- Change is characterized by fluctuating rhythms
munity of scholars in the context of society. of organizationdisorganization toward more
Paradigms and worldviews of nursing are complex organization. Health is a reflection
subtle and powerful, reflecting different values of this continuous change. Fawcett (1995,
and beliefs about the nature of human beings, 2000) provides another model for the nursing
humanenvironment relationships, health, paradigms: reaction, reciprocal interaction,
and caring. Kuhns (1970, 1977) description and simultaneous action. In the reaction par-
of scientific development is particularly rele- adigm, humans are the sum of their parts,
vant to nursing today as new perspectives are reaction is causal, and stability is valued. In
being articulated, some traditional views are the reciprocal interaction worldview, the parts
being strengthened, and some views are tak- are seen within the context of a larger whole,
ing their places as part of our history. As we there is a reciprocal nature to the relationship
continue to move away from the historical with the environment, and change is based on
conception of nursing as a part of biomedical multiple factors. Finally, the simultaneous
science, developments in the nursing disci- action worldview includes a belief that humans
pline are directed by at least two paradigms or are known by pattern and are in an open ever-
worldviews outside of the medical model. changing process with the environment.
These are described below. Change is unpredictable and evolving toward
Several nursing scholars have named the greater complexity (Smith, 2008, pp. 45).
existing paradigms in the discipline of nursing Theories are clustered within these para-
(Fawcett, 1995; Newman et al. 1991; Parse, digms. There will be many theories that share
1987); each is slightly different. Parse (1987) the worldview established by a particular par-
described two paradigms: the totality and the adigm. Nursing is in a phase whereby multi-
simultaneity. The totality paradigm reflects a ple paradigms coexist.
worldview that humans are integrated beings
with biological, psychological, sociocultural, Grand Theories and Conceptual
and spiritual dimensions. Humans adapt to Models
their environments, and health and illness are Grand theories and conceptual models are at
states on a continuum. In the simultaneity the next level in the structure of the disci-
paradigm, humans are unitary, irreducible, pline. They are less abstract than the focus of
and in continuous mutual process with the the discipline and paradigms, but more
environment (Rogers, 1970, 1992). Health abstract than middle-range theories. Concep-
is subjectively defined and reflects a process of tual models and grand theories focus on the
becoming or evolving. Three paradigms in phenomena of concern to the discipline such
nursing were identified by Newman and her as persons as adaptive systems, self-care
colleagues (Newman et al., 1991): particulate deficits, unitary human beings, human
deterministic, interactiveintegrative, and becoming, or health as expanding conscious-
unitarytransformative. From the perspective ness. The grand theories, or conceptual mod-
of the particulatedeterministic paradigm, els, are composed of concepts and relational
humans are known through parts; health is statements. Relational statements upon which
the absence of disease; and predictability and the theories are built are called assumptions
control are essential for its management. In and often reflect the foundational philoso-
the interactiveintegrative paradigm, humans phies of the conceptual model/grand theory.
are viewed as systems with interrelated These philosophies are statements of endur-
dimensions interacting with the environment, ing values and beliefs; they may be practical
and change is probabilistic. The worldview of guides for the conduct of nurses applying the
the unitarytransformative paradigm describes theory and can be used to determine the com-
humans as patterned, self-organizing fields patibility of the model/theory with personal,
within larger patterned, self-organizing fields. professional, organizational, and societal beliefs
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C H A P T E R 1 Nursing Theory and the Discipline of Nursing 11

and values. Fawcett (2000) differentiates con- theories that are directly related to grand theo-
ceptual models and grand theories. For her, ries of nursing (Ducharme, Ricard, Duquette,
conceptual models, also called conceptual Levesque, & Lachance, 1998; Dunn, 2004;
frameworks or conceptual systems, are sets of Olson & Hanchett, 1997). Reports of nursing
general concepts and propositions that pro- theory developed at this level include implica-
vide perspectives on the major concepts of the tions for instrument development, theory test-
metaparadigm: person, environment, health, ing through research, and nursing practice
and nursing. Fawcett (1993, 2000) points out strategies.
that direction for research must be described
as part of the conceptual model in order to Practice Level Theories
guide development and testing of nursing Practice level theories have the most limited
theories. We do not differentiate between scope and level of abstraction and are devel-
conceptual models and grand theories and use oped for use within a specific range of nursing
the terms interchangeably. situations. Theories developed at this level
have a more direct impact on nursing practice
Middle-Range Theories than do more abstract theories. Nursing prac-
Middle-range theories comprise the next tice theories provide frameworks for nursing
level in the structure of the discipline. Robert interventions/activities and suggest outcomes
Merton (1968) described this level of theory and/or the impact of nursing practice. Nurs-
in the field of sociology stating that they are ing actions may be described or developed as
theories broad enough to be useful in complex nursing practice theories. Ideally, nursing
situations and appropriate for empirical test- practice theories are interrelated with con-
ing. Nursing scholars proposed using this cepts from middle-range theories or devel-
level of theory because of the difficulty in oped under the framework of grand theories.
testing grand theory ( Jacox, 1974). Middle- Theory developed at this level has been called
range theories are more narrow in scope than prescriptive theory (Crowley, 1968; Dickoff,
grand theories and offer an effective bridge James, & Wiedenbach, 1968), situation-
between grand theories and the description specific theory (Meleis, 1997), and micro the-
and explanation of specific nursing phenome- ory (Chinn & Kramer, 2004). The day-to-day
na. They present concepts and propositions at experience of nurses is a major source of nurs-
a lower level of abstraction and hold great ing practice theory.
promise for increasing theory-based research The depth and complexity of nursing prac-
and nursing practice strategies (Smith and tice may be fully appreciated as nursing phe-
Liehr, 2008). Several middle-range theories nomena and relations among aspects of par-
are included in this book. Middle-range ticular nursing situations are described and
theories may have their foundations in a par- explained. Dialogue with expert nurses in
ticular paradigmatic perspective or may be practice can be fruitful for discovery and
derived from a grand theory or conceptual development of practice theory. Research
model. The literature presents a growing findings on various nursing problems offer
number of middle-range theories. This level data to develop nursing practice theories.
of theory is expanding most rapidly in the dis- Nursing practice theory has been articulated
cipline, and represents some of the most excit- using multiple ways of knowing through
ing work published in nursing today. Some of reflective practice ( Johns & Freshwater, 1998).
these new theories are synthesized from The process includes quiet reflection on prac-
knowledge from related disciplines and trans- tice, remembering and noting features of
formed through a nursing lens (Eakes, Burke, nursing situations, attending to ones own
& Hainsworth, 1998; Lenz, Suppe, Gift, feelings, reevaluating the experience, and
Pugh, & Milligan, 1995; Polk, 1997). The integrating new knowing with other experi-
literature also offers middle-range nursing ence (Gray & Forsstrom, 1991). The LIGHT
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12 S E C T I O N I An Introduction to Nursing Theory

model (Andersen & Smereck, 1989) and the working on developing and implementing
attendant nurse caring model (Watson & practice models based on grand theories/
Foster, 2003) are examples of the develop- conceptual models.
ment of practice level theories. There have been changes in the teaching
and learning of nursing theory that are trou-
Associated Research and Practice bling. Many baccalaureate programs have
Traditions very little nursing theory included in their
Research traditions are the associated meth- curricula. Similarly, some graduate programs
ods, procedures, and empirical indicators are eliminating or decreasing their emphasis
that guide inquiry related to the theory. on nursing theory. This alarming trend
For example, the theories of health as deserves our attention. If nursing is to
expanding consciousness, human becoming, continue to thrive, and to make a difference
and cultural care diversity and universality in the lives of people, our practitioners and
have specific associated research methods. researchers need to practice and expand
Other theories have specific tools that have knowledge within the structure of the disci-
been developed to measure constructs relat- pline. As practice becomes more interdisci-
ed to the theories. The practice tradition of plinary, the focus of nursing becomes even
the theory consists of the activities, proto- more important. If nurses do not learn and
cols, processes, tools, and practice wisdom practice based on the knowledge of their
emerging from the theory. Several concep- discipline, they may be co-opted into the
tual models/grand theories have specific practice of another discipline. Even worse,
associated practice methods. another discipline could emerge that will
assume practices associated with the disci-
pline of nursing. For example, health coach-
Nursing Theory and the ing is emerging as an area of practice
Future focused on providing people with help as
Nursing theory is essential to the continuing they make health-related changes in their
evolution of the discipline of nursing. Several lives. However, this is the practice of
trends are evident in the development and nursing, as articulated by many nursing
use of nursing theory. First, there seems to theories.
be more agreement on the focus of the dis- On a positive note, nursing theories are
cipline of nursing that provides a meaning- being embraced by health care organizations to
ful direction for our study and inquiry. This structure nursing practice. For example, organ-
disciplinary dialogue has extended beyond izations embarking on the journey toward
the confines of Fawcetts metaparadigm and magnet status (www.nursecredentialing.org/
explicates the importance of caring and rela- magnet) are required to identify a theoretical
tionship as central to the discipline of nurs- perspective that guides nursing practice and
ing (Newman, Smith, Dexheimer-Pharris, many are choosing existing nursing models.
& Jones, 2008; Roy & Jones, 2007; Willis, This work has great potential to refine and
Grace, & Roy, 2008). The development of extend nursing theories.
new grand theories and conceptual models The use of nursing theory in research is
has decreased. Dosseys (2008) theory of inconsistent at best. Often, outcomes research
integral nursing, included in this book, is is not contextualized within any theoretical
the only new theory at this level that has perspective; however, reviewers of proposals
been developed in nearly 20 years. Instead, for most funding agencies request theoretical
the growth in theory development is at the frameworks, and scoring criteria give points
middle range and practice levels. There has for having one. This encourages theoretical
been a significant increase in middle-range thinking and organizing findings within a
theories, and many practice scholars are broader perspective. Nurses often use theories
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C H A P T E R 1 Nursing Theory and the Discipline of Nursing 13

from other disciplines instead of their own aesthetics. These authors expect a continu-
and this expands the knowledge of another ing emphasis on unifying theory and prac-
discipline. tice that will contribute to the validation of
We are hopeful about the growth, contin- the nursing discipline. Theorists will work
uing development, and expanded use of in groups to develop knowledge in an area of
nursing theory. We hope that there will be concern to nursing, and these phenomena
continued growth in the development of all of interest, rather than the name of the
levels of nursing theory. The students of all author, will define the theory (Meleis,
professional disciplines study the theories of 1992). Newman (2003) calls for a future
their disciplines in their courses of study. We in which we transcend competition and
must continue to include the study of nurs- boundaries that have been constructed
ing theories within our baccalaureate, mas- between nursing theories and instead appre-
ters, and doctoral programs. Baccalaureate ciate the links among theories, thus moving
students need to understand the foundations toward a fuller, more inclusive, and richer
for the discipline, our historical develop- understanding of nursing knowledge.
ment, and the place of nursing theory in its Nursings philosophies and theories must
history and future. They should learn about increasingly reflect nursings values for under-
conceptual models and grand theories. standing, respect, and commitment to health
Didactic and practice courses should reflect beliefs and practices of cultures throughout
theoretical values and concepts so that stu- the world. It is important to question to
dents learn to practice nursing from a theo- what extent theories developed and used
retical perspective. Middle-range theories in one major culture are appropriate for use
should be included in the study of particular in other cultures. To what extent must nurs-
phenomena such as self-transcendence, ing theory be relevant in multicultural
sorrow, and uncertainty. As they prepare to contexts? Despite efforts of many interna-
become practice leaders of the discipline, tional scholarly societies, how relevant are
Doctor of Nursing Practice students should American nursing theories for the global
learn to develop and test nursing theory- community? Can nursing theories inform us
guided models. PhD students will learn to about how to stand with and learn from
develop and extend nursing theories in their peoples of the world? Can we learn from
research. New and expanded nursing spe- nursing theory how to come to know those
cialties, such as nursing informatics, call for we nurse, how to be with them, to truly
development and use of nursing theory listen and hear? Can these questions be rec-
(Effken, 2003). New, more open, and inclu- ognized as appropriate for scholarly work
sive ways to theorize about nursing will be and practice for graduate students in nurs-
developed. These new ways will acknowl- ing? Will these issues offer direction for
edge the history and traditions of nursing, studies of doctoral students? If so, nursing
but will move nursing forward into new theory will offer new ways to inform nurses
realms of thinking and being. Reed (1995) for humane leadership in national and global
notes the ground shifting with the reform- health policy. Perspectives of various time
ing of philosophies of nursing science and and worlds in relation to present nursing
calls for a more open philosophy, grounded concerns were described by Schoenhofer
in nursings values, which connects science, (1994). Abdellah (McAuliffe, 1998) pro-
philosophy, and practice. Gray and Pratt posed an international electronic think tank
(1991, p. 454) project that nursing scholars for nurses around the globe to dialogue
will continue to develop theories at all levels about nursing theory. Such opportunities
of abstraction and that theories will be could lead nurses to truly listen, learn, and
increasingly interdependent with other dis- adapt theoretical perspectives to accommo-
ciplines such as politics, economics, and date cultural variations.
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14 S E C T I O N I An Introduction to Nursing Theory

Summary
This chapter focused on the place of nursing This may be seen as ambiguous or as full of
theory within the discipline of nursing. The possibilities. Continuing students of the disci-
relationship and importance of nursing theory pline are required to study and know the basis
to the characteristics of a professional discipline for their contributions to nursing and to those
were reviewed. A variety of definitions of the- we serve, while at the same time, be open to
ory was offered, and the structure of knowledge new ways of thinking, knowing, and being in
in the discipline was outlined. Finally, we nursing. Exploring structures of nursing knowl-
reviewed trends and speculated about the future edge and understanding the nature of nursing
of nursing theory development and application. as a professional discipline, provide a frame of
One challenge of nursing theory is the perspec- reference to clarify nursing theory. The wise
tive that theory is always in the process of study and use of nursing theory is an essential
developing, and that, at the same time, it is use- companion through the unfolding of this new
ful for the purposes and work of the discipline. millennium.

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Andersen, M. D., & Smereck, G. A. D. (1989). Effken, J. A. (2003). An organizing framework for
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Chinn, P., & Jacobs, M. (1987). Theory and nursing: A Fawcett, J. (1993). Analysis and evaluation of nursing
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Chinn, P., & Kramer, M. (2004). Integrated knowledge Fawcett, J. (1984). The metaparadigm of nursing:
development in nursing. St. Louis, MO: C. V. Mosby. Current status and future refinements. Image:
Cody, W. K. (1997). Of tombstones, milestones, and Journal of Nursing Scholarship, 16, 8487.
gemstones: A retrospective and prospective on nurs- Fawcett, J. (1995). Analysis and evaluation of conceptual
ing theory. Nursing Science Quarterly, 10(1), 35. models of nursing (3rd ed.). Philadelphia: F. A. Davis.
Cody, W. K. (2003). Nursing theory as a guide to Fawcett, J. (2000). Analysis and evaluation of contempo-
practice. Nursing Science Quarterly, 16(3), 225231. rary nursing knowledge: Nursing models and nursing
Colley, S. (2003). Nursing theory: Its importance to theories. Philadelphia: F. A. Davis.
practice. Nursing Standard, 17(56), 3337. Fitzpatrick, J. (1997). Nursing theory and metatheory.
Crowley, D. (1968). Perspectives of pure science. In: I. King & J. Fawcett (Eds.), The language of
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Dickoff, J., & James, P. (1968). A theory of theories: Center Nursing Press.
A position paper. Nursing Research, 17(3), 197203. Gioiella, E. C. (1996). The importance of theory-guided
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Dossey, B. (2008). Theory of integral nursing. Advances R. Pratt (Eds.), Towards a discipline of nursing.
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Chapter
2
A Guide for the Study of
Theories for Practice
M ARILYN E. PARKER AND
M ARLAINE C. S MITH

Study of Theory for Nursing Practice Nursing is a professional discipline, a field of


A Guide for Study of Nursing study, focused on human health and healing
Theory for Use in Practice through caring (Smith, 1994). The knowledge
Summary base of the discipline consists of diverse com-
References ponents such as nursing science, art, philoso-
phy, and ethics. Nursing science comprises the
conceptual models, theories, and research
findings specific to the discipline. As in other
sciences such as biology, psychology, or sociol-
ogy, the study of nursing science requires a
disciplined approach. This chapter offers a
guide to this disciplined approach in the form
of a set of questions that facilitate reflection,
exploration, and a deeper study of the select-
ed nursing theories.
Marilyn E. Parker Marlaine C. Smith
As you read the chapters in this book, the
questions in the guide can facilitate your
study. These chapters offer a marvelous
beginning on the journey of studying nursing
theories, which we hope will ignite interest in
deeper exploration of some of the theories
through reading the books written by the the-
orists and other published articles related to
the use of the theories in practice and
research. This books online resources can
provide additional materials as you continue
your exploration. The questions in this guide
can lead you toward this deeper study of the
selected nursing theories.
Rapid and dramatic changes are affecting
nurses everywhere. Health care delivery sys-
tems are in crisis and in need of real change.
Hospitals continue to be the largest employers
of nurses, and some hospitals are recognizing
the need to develop nursing theory-guided
practice models. A criterion for hospitals
seeking magnet hospital designation by
the American Nurses Credentialing Center

16
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C H A P T E R 2 A Guide for the Study of Theories for Practice 17

(www.nursecredentialing.org/magnet) includes of the setting of nursing practice, nurses may


the selection of a theoretical model for practice. choose to study nursing theories together in
The list of questions in this chapter can be use- order to design and articulate theory-guided
ful to nurses as they select theories to guide practice.
practice. The study of nursing theory precedes the
Increasingly, nurses are practicing in activities of analysis and evaluation. The eval-
diverse settings and often develop organized uation of a theory involves preparation, judg-
nursing practices through which accessible ment, and justification (Smith, 2008). In the
health care to communities can be provided. preparation phase, the student of the theory
Community members may be active partici- spends time coming to know it by reading and
pants in selecting, designing, and evaluating reflecting on it. The best approach involves
the nursing they receive. In these situations, it intellectual empathy, curiosity, honesty, and
is important for nurses to identify with com- responsibility (Smith, 2008). Through reading
munities the approach to nursing that is most and dwelling with the theory, the student tries
consistent with the communitys values. The to understand it from the point of view of the
questions in this chapter can be helpful in the theorist. Curiosity leads to raising questions in
mutual exploration of theoretical approaches the quest for greater understanding. It involves
to practice. imagining ways the theory might work in
In the current health care environment, practice, as well as the challenges it might
interdisciplinary practice is frequently the norm. present. Honesty involves knowing oneself
This does not mean that practicing from a and being true to ones own values and beliefs
nursing theoretical base is any less important. in the process of understanding. Some theories
Interdisciplinary practice means that each dis- may resonate with deeply held values; others
cipline brings its own lens or perspective to the may conflict with them. It is important to
patients situation. Nursings lens is essential for listen to these inner messages of comfort/
a complete picture of the persons health and discomfort, for they will be important in the
the goals of caring and healing. The nursing selection of theories for practice. Each mem-
theory selected will provide this lens, and the ber of a professional discipline has a responsi-
questions in this chapter can assist nurses in bility to take the time and effort to understand
selecting the theory/theories that will guide the theories of that discipline. In nursing,
their unique contribution to the interdiscipli- there is an even greater responsibility to
nary team. understand and be true to those that are
Theories and practices from a variety selected to guide nursing practice.
of disciplines inform the practice of nursing. Responses to questions offered and points
The scope of nursing practice is continually summarized in the guides may be found in
being expanded to include additional nursing literature, as well as in audiovisual
knowledge and skills from related disci- and electronic resources. Primary source
plines, such as medicine and psychology. material, including the writing of nurses who
Again, this does not diminish the need for are recognized authorities in specific nursing
practice based on a nursing theory, and these theories and the use of nursing theory, should
guiding questions help to differentiate the be used.
knowledge and practice of nursing from
those of other disciplines.
Groups of nurses working together as col-
Study of Theory for Nursing
leagues to provide care often realize that they Practice
share the same values and beliefs about nurs- Four main questions have been developed
ing. The study of nursing theories can clarify and refined to facilitate study of nursing
the purposes of nursing and facilitate building theories for use in nursing practice (Parker,
a cohesive practice to meet them. Regardless 1993). They focus on concepts within the
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18 S E C T I O N I An Introduction to Nursing Theory

theories, as well as on points of interest and How can nursing situations be described?
general information about each theory. This What are attributes of the one
guide was developed for use by practicing nursed?
nurses and students in undergraduate and What are characteristics of the
graduate nursing education programs. Many nurse?
nurses and students have used these ques- How can interactions of the nurse
tions and have contributed to their continu- and the recipient of nursing be
ing development. The guide may be used described?
to study most of the nursing theories devel- Are there environmental require-
oped at all levels. ments for the practice of nursing?
2. What is the context of the theory
development?
A Guide for Study of Nursing Who is the nursing theorist as person
Theory for Use in Practice and as nurse?
Why did the theorist develop the
1. How is nursing conceptualized in the
theory?
theory?
What is the background of the
Is the focus of nursing stated?
theorist as a nursing scholar?
What does the nurse attend to
What are central values and beliefs
when practicing nursing?
set forth by the theorist?
What guides nursing observations,
What are major theoretical influences on
reflections, decisions, and actions?
this theory?
What does the nurse think about
What nursing models and theories
when considering nursing?
influenced this theory?
What are illustrations of use of
What are the relationships
the theory to guide practice?
between this theory and other
What is the purpose of nursing?
theories?
What do nurses do when they are
What nursing-related theories
practicing nursing based on the
and philosophies influenced this
theory?
theory?
What are exemplars of nursing
What were major external influences on
assessments, designs, plans, and
development of the theory?
evaluations?
What were the social, economic,
What indicators give evidence of
and political influences that
quality and quantity of nursing
shaped the theory?
practice?
What images of nurses and
Is the richness and complexity of
nursing influenced the theory
nursing practice evident?
development?
What are the boundaries or limits for
What was the status of nursing as
nursing?
a discipline and profession at the
How is nursing distinguished from
time of its development?
other health-related services?
3. Who are authoritative sources for
How is nursing related to other
information about development,
disciplines and services?
evaluation, and use of this theory?
What is the place of nursing in
Who are nursing authorities who speak
interdisciplinary practice?
about, write about, and use the theory?
What is the range of nursing
What are the professional attrib-
situations in which the theory is
utes of these persons?
useful?
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C H A P T E R 2 A Guide for the Study of Theories for Practice 19

What are the attributes of authori- How does published nursing


ties, and how does one become one? scholarship reflect the significance
Which other nurses should be of the theory?
considered authorities? What is the experience of nurses who
What major resources are authoritative report consistent use of the theory?
sources on the theory? What is the range of reports from
What books, articles, audiovisual practice?
and electronic media exist to elu- Has nursing research led to fur-
cidate the theory? ther theoretical formulations?
What nursing societies share and Has the theory been used to
support work of the theory? develop new nursing practices?
What service and academic pro- Has the theory influenced the design
grams are authoritative sources for of methods of nursing inquiry?
practicing and teaching the theory? What has been the influence of
the theory on nursing and health
4. How can the overall significance of
policy?
the nursing theory be described?
What are projected influences of the
What is the importance of the nursing
theory on nursings future?
theory over time?
How has the theory influenced the
What are exemplars of the theorys
community of scholars?
use that structure and guide indi-
In what ways has nursing as a pro-
vidual practice?
fessional practice been strengthened
How has the theory been used to
by the theory?
guide programs of nursing educa-
What future possibilities for nurs-
tion?
ing are open because of this theory?
How has the theory been used to
What will be the continuing social
guide nursing administration and
value of the theory?
organizations?

Summary
This chapter contains a guide designed for ning to a deeper understanding of nursing
the study of nursing theory for use in prac- theory. The study of nursing theory precedes
tice. As members of the professional disci- its analysis and evaluation. Students should
pline of nursing, the serious study of the approach the study of nursing theory with
theories of nursing is essential. The imple- intellectual empathy, curiosity, honesty, and
mentation of theory-guided practice models responsibility. This guide is composed of
is important for nursing practice in all four main questions to foster reflection and
settings. The guide presented in this chapter facilitate the study of nursing theory for
can lead students on a journey from a begin- practice.

References

Smith, M. C. (2008). Evaluation of middle range


Parker, M. (1993). Patterns of nursing theories in practice.
theories for the discipline of nursing. In: M. J. Smith
New York: National League for Nursing.
& P. Liehr (Eds.), Middle range theory for nursing
Smith, M. C. (1994). Arriving at a philosophy of nursing:
(2nd ed., pp. 293306). New York: Springer.
Discovering? Constructing? Evolving? In: J. Kikuchi
& H. Simmons (Eds.), Developing a philosophy of
nursing (pp. 4360). Thousand Oaks, CA: Sage.
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Chapter
3
Choosing, Evaluating and
Implementing Nursing
Theories for Practice
M ARILYN E. PARKER AND
M ARLAINE C. S MITH

Significance of Nursing Theory The primary purpose of nursing theory is to


for Practice improve nursing practice, and therefore, the
Responses to Questions from Practicing health and quality of life of persons, families,
Nurses About Using Nursing Theory and communities served. Nursing theories pro-
Choosing a Nursing Theory to Study vide coherent ways of viewing and approaching
A Reflective Exercise for Choosing a the care of persons in their environment.
Nursing Theory for Practice
When a theoretical model is used to organize
Evaluation of Nursing Theory
care in any setting, it strengthens the nursing
Implementing Theory-Guided Practice
focus of care and provides consistency to the
Summary
communication and activities related to nurs-
References
ing care. The development of nursing theories
and theory-guided practice models advances
the discipline and professional practice of
nursing.
One of the most urgent issues facing the
discipline of nursing is the artificial separa-
tion of nursing theory and practice. Nursing
can no longer afford to see these dimensions
as disconnected territories, belonging to
either scholars or practitioners. The examina-
Marilyn E. Parker Marlaine C. Smith tion and use of nursing theories are essential
for closing the gap between nursing theory
and nursing practice. Nurses in practice have
a responsibility to study and value nursing
theories, just as nursing theory scholars must
understand and appreciate the day-to-day
practice of nurses. Nursing theory informs
and guides the practice of nursing, and nurs-
ing practice informs and guides the process of
developing theory.
The theories of any professional discipline
are useless if they have no impact on practice.
Just as psychotherapists, educators, and econ-
omists base their approaches and decisions on
particular theories, so should the practice of
nursing be guided by selected nursing theories.

20
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C H A P T E R 3 Choosing, Evaluating and Implementing Nursing Theories 21

When practicing nurses and nurse scholars these theories, and implementing theory in
work together, both the discipline and practice practice. The chapter begins with responses
of nursing benefit, and nursing service to our to the questions: Why study nursing theory?
clients is enhanced. There are many examples What do the practicing nurses gain from
throughout the book of how nursing theories nursing theory? Methods of analysis and
have been, or can be, used to guide nursing evaluation of nursing theory set forth in the
practice. Many of the nursing theorists in this literature are presented. Finally, steps in
book developed or refined their theories based implementing nursing theory in practice are
on dialogue with nurses who shared descrip- described.
tions of their practice. This kind of work must
continue for nursing theories to be relevant
and meaningful to the discipline.
Significance of Nursing
The need to bridge the gap between nurs- Theory for Practice
ing theory and practice is highlighted by con- Nursing practice is essential for developing,
sidering the following brief encounter during testing, and refining nursing theory. The
a question-and-answer period at a conference. development of many nursing theories has
A nurse in practice, reflecting her experience, been enhanced by reflection and dialogue
asked a nurse theorist, What is the meaning about actual nursing situations. The every-
of this theory to my practice? Im in the real day practice of nursing enriches nursing the-
world! I want to connectbut how can con- ories. When nurses think about nursing,
nections be made between your ideas and my they consider the content and structure of
reality? The nurse theorist responded by the discipline of nursing. Even if nurses do
describing the essential values and assump- not conceptualize them theoretically, their
tions of her theory. The nurse said, Yes, I values and perspectives are often consistent
know what you are talking about. I just didnt with particular nursing theories. Making these
know I knew it, and I need help to use it in values and perspectives explicit through the
my practice (Parker, 1993, p. 4). To remain use of a nursing theory results in a more schol-
current in the discipline, all nurses must join arly, professional practice.
in community to advance nursing knowledge Creative nursing practice is the direct
in practice and must accept their obligations result of ongoing theory-based thinking,
to engage in the continuing study of nursing decision-making, and action. Nursing prac-
theories. Today, agencies that employ nurses tice must continue to contribute to thinking
are increasingly receiving recognition when and theorizing in nursing, just as nursing
they adopt a nursing theory as a guiding theory must be used to advance practice.
framework for nursing practice. This decision Nursing practice and nursing theory
provides an excellent opportunity for nurses often reflect the same abiding values and
in practice and in administration to study, beliefs. Nurses in practice are guided by
implement, and evaluate nursing theories for their values and beliefs, as well as by knowl-
use in practice. Communicating the outcomes edge. These values, beliefs, and knowledge
of this process with the community of schol- often are reflected in the literature about
ars advancing the theories is a useful way to nursings metaparadigm, philosophies, and
initiate dialogue among nurses and to form theories. In addition, nursing theorists and
new bridges between the theory and practice nurses in practice think about and work
of nursing. with the same phenomena, including the
The purpose of this chapter is to describe person nursed, the actions and relationships
the processes leading to implementation of in the nursing situation, and the context of
nursing theory-guided practice models. These nursing. It is no wonder that nurses often
processes include choosing possible theories sense a connection and familiarity with
for use in practice, analyzing and evaluating many of the concepts in nursing theories.
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22 S E C T I O N I An Introduction to Nursing Theory

They often say, I knew this, but didnt have for nursing differently, and they create nurs-
the words for it. This is another value of ing responses that are more holistic and
nursing theory. It provides a vehicle for us to client-focused. These nurses learn to reframe
share and communicate the important con- their thinking about nursing knowledge and
cepts within nursing practice. practice and are then able to bring knowledge
It is not possible to practice without some from other disciplines within the context of
theoretical frame of reference. The question is their practicenot to direct their practice.
what frame of reference is being used in prac- Nurses who practice from a nursing theo-
tice. As stated in Chapter 1, theories are ways retical base see beyond immediate facts and
to organize our thinking about the complexi- delivery systems; they can integrate other
ties of any situation. Theories are lenses that we health sciences and technologies as the back-
select that will color the way that we view reality. ground or context and not the essence of their
In the case of nursing, the theories we choose practice. Nurses who study nursing theory
to use will frame the way we think about a par- realize that although no group actually owns
ticular person and his/her health situation. It ideas, professional disciplines do claim a
will inform the ways that we approach the per- unique perspective that defines their practice.
son, how we relate, and what we do. Many In the same way, no group actually owns the
nurses practice according to ideas and direc- technologies of practice, though disciplines
tions from other disciplines, such as medicine, do claim them for their practice. For example,
psychology, and public health. If your approach before World War II, nurses rarely took blood
to a person is framed by his or her medical pressure readings and did not give intramus-
diagnosis, you are influenced by the medical cular injections. This was not because nurses
model that focuses your attention on diagnosis, lacked the skill, but because they did not
treatment, and cure. If you are thinking about claim the use of these techniques to facilitate
disease prevention as you work with a commu- their nursing. Such a realization can also lead
nity group, you are influenced by public health to understanding that the things nurses do
theory and approaches. While we use this that are often called nursing are not nursing at
knowledge in practice, nursing theory focuses all. The skills and technologies used by nurs-
us on the distinctive perspective of the disci- es, such as taking blood pressure readings,
pline which is more than and different from giving injections, and auscultating heart
these approaches. sounds, are actually activities that are part of
Historically, nursing practice has been the context, but not the essence, of nursing
deeply rooted in the medical model and this practice. Nursing theories provide an organiz-
model continues today. The depth and scope ing framework that directs nurses to the
of the practice of nurses who follow notions essence of their purpose and places the use of
about nursing held by other disciplines are knowledge from other disciplines in their
limited to practices understood and accepted proper perspective.
by those disciplines. Nurses who learn to If nursing theory is to be usefulor
practice from nursing perspectives are awak- practicalit must be brought into practice.
ened to the challenges and opportunities of At the same time, nurses can be guided by
practicing nursing more fully and with a nursing theory in a full range of nursing situ-
greater sense of autonomy, respect, and satis- ations. Nursing theory can change nursing
faction for themselves. Hopefully, they also practice: It provides direction for new ways of
provide different and more expansive oppor- being present with clients, helps nurses realize
tunities for health and healing for those they ways of expressing caring, and provides
serve. Nurses who practice from a nursing approaches to understanding needs for nurs-
perspective approach clients and families in ing and designing care to address these needs.
ways unique to nursing. They ask questions, The chapters of this book affirm the use of
receive and process information about needs nursing theory in practice and the study and
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C H A P T E R 3 Choosing, Evaluating and Implementing Nursing Theories 23

assessment of theory to ultimately use in Will those from other disciplines be able to
practice. understand, facilitating cooperation?
Will my work meet the expectations of
those I serve? Will other nurses find my
Responses to Questions from work helpful and challenging?
Practicing Nurses About Conceptual models and grand theories are
Using Nursing Theory not specific to any nursing specialty. Theories
in any discipline introduce new terminology
Study of nursing theory may either precede that are not part of general language. For
or follow selection of a nursing theory for use example, the id, ego, and superego are familiar
in nursing practice. Analysis and evaluation terms in a particular psychological theory, but
of nursing theory follow the study of a nurs- were unknown at the time of the theorys
ing theory. These activities are demanding introduction. The language of the theory facil-
and deserve the full commitment of nurses itates thinking differently through naming
who undertake the work. Because it is under- new concepts or ideas. Members of disciplines
stood that the study of nursing theory is not do share specific language that may be less
a simple, short-term endeavor, nurses often familiar to members outside the discipline. In
question doing such work. The following interprofessional communication, new terms
questions about studying and using nursing can be defined and explained to facilitate com-
theory have been collected from many con- munication as needed. Nursings unique per-
versations with nurses about nursing theory. spective needs to be represented clearly within
These queries also identify specific issues that the interprofessional team. The diversity of
are important to nurses who consider the each disciplines perspective is important to
study of nursing theory. provide the best care possible for patients.
People deserve and expect high-quality care.
My Nursing Practice
Nursing theory has the potential to bring to
Does this theory reflect nursing practice as I
bear the importance of relationship and caring
know it? Can it be understood in relation to
in the process of health and healing; the inter-
my nursing practice? Will it support what I
relationship of the environment and health; an
believe to be excellent nursing practice?
understanding of the wholeness of persons in
Conceptual models and grand theories can
their life situations; and an appreciation of the
guide practice in any setting and situation.
persons experiences, values, and choices in
Middle-range theories address circum-
care. These are essential contributions to a
scribed phenomena in nursing that are
multidisciplinary perspective.
directly related to practice. These levels of
theory can enrich perspectives on practice
My Personal Interests, Abilities, and Experiences
and should foster an excellent professional
Is the study of nursing theories consistent
level of practice.
with my talents, interests, and goals? Is this
Is the theory specific to my area of nursing?
something I want to do?
Can the language of the theory help me
Will I be stimulated by thinking about and
explain, plan, and evaluate my nursing?
trying to use this theory? Will my study of
Will I be able to use the terms to commu-
nursing be enhanced by use of this theory?
nicate with others?
What will it be like to think about nursing
Can this theory be considered in relation to
theory in nursing practice?
a wide range of nursing situations? How
Will my work with nursing theory be
does it relate to more general views of
worth the effort?
nursing people in other settings?
Will my study and use of this theory support The study of nursing theory does take an
nursing in my interdisciplinary setting? investment in time and attention. It is a
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24 S E C T I O N I An Introduction to Nursing Theory

responsibility of a professional nurse who theory grow out of research findings or out
engages in a scholarly level of practice. Learn- of practice issues and concerns?
ing about nursing theory is a conceptual activ- Does the theory reflect the latest thinking
ity that can be challenging and intellectually in nursing? Has the theory kept pace with
stimulating. We need nurses who will invest in the times in nursing? Is this a nursing the-
these activities so that knowledgeable theory- ory for the future?
guided practice is the norm in all health care
Approaching the study of nursing theory
settings.
with openness, curiosity, imagination, and
Resources and Support skepticism is important. The search for the
Will this be useful to me outside the support that the theory makes a difference is
classroom? part of the evaluation of any theory. Theo-
What resources will I need to understand ries must have pragmatic value, that is, they
fully the terms of the theory? need to generate research questions and pro-
Will I be able to find the support I need to vide models that can be applied in practice.
study and use the theory in my practice? Theory-guided practice models should be
evaluated to support that the theory makes a
The purpose of nursing theory goes
difference in the lives of persons. You will
beyond its study within courses. Nursing
find examples of how the theory has been
theory becomes alive when the ideas are
used in research and practice in the nursing
brought to practice. The usefulness of theory
literature. In some cases, especially with
in practice is one way that we judge its value
newly formed theories, this evidence may be
and worth. It is helpful to read about the
unavailable. In these situations, imagine the
theory from primary sources or the most
potential related to application of the theory.
notable scholars and practitioners who have
Theories have heuristic value in that they
studied the theory. Nurses interested in par-
can lead to new ways of thinking about situ-
ticular theories can join listservs where issues
ations. Consider the heuristic value of the
related to the theory are discussed. Many of
theory as you read it. The theory should
the theory groups have formed professional
ignite your passion about nursing.
societies and hold conferences that support
lifelong learning and growing with those
applying the theory in practice, administra- Choosing a Nursing Theory
tion, research, and education. to Study
The Theorist, Evidence, and Opinion It is important to give adequate attention to
Who is the author of this theory? What selection of theories. Results of this decision
background of nursing education and expe- will have lasting influences on nursing prac-
rience does the theorist bring to this work? tice. It is not unusual for nurses who begin to
Is the author an authoritative nursing work with nursing theory to realize their
scholar? practice is changing and that their future
How is the theorists background of nurs- efforts in the discipline and practice of nurs-
ing education and experience brought to ing are markedly altered.
this work? There is always some measure of hope
What is the evidence that use of the theory mixed with anxiety as nurses seriously explore
may lead to improved nursing care? Has the nursing theory for the first time. Individual
theory been useful to guide nursing organi- nurses who practice with a group of col-
zations and administrations? What about leagues often wonder how to select and study
influencing nursing and health care policy? nursing theories. Nurses and nursing students
What is the evidence that this nursing the- in courses considering nursing theory have
ory has led to nursing research, including similar questions. Nurses in new practice set-
questions and methods of inquiry? Did the tings designed and developed by nurses have
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C H A P T E R 3 Choosing, Evaluating and Implementing Nursing Theories 25

the same concerns about getting started as do How do my personal and nursing values
nurses in hospital organizations who want connect with what is important to society?
more from their practice.
Reflect on an instance of nursing in which
The following exercise is grounded in the
you interacted with a person, family, or com-
belief that the study and use of nursing theo-
munity for nursing purposes. This can be a
ry in nursing practice must have roots in the
situation from your current practice or may be
practice of the nurses involved. Moreover, the
from your nursing in years past. Consider the
nursing theory used by particular nurses must
purpose or hoped-for outcome.
reflect elements of practice that are essential
to those nurses, while at the same time bring- Nursing Situations
ing focus and freshness to that practice. This Who was this person, family or community?
exercise calls on the nurse to think about the How did I come to know him or them as
major components of nursing and bring forth unique?
the values and beliefs most important to nurs- What were the needs for nursing the
es. In these ways, the exercise begins to paral- person, family or community?
lel knowledge development reflected in the Who was I as a person in the nursing
nursing metaparadigm (focus of the disci- situation?
pline) and nursing philosophies described in Who was I as a nurse in the situation?
Chapter 1. From this point on, the nurse is What was the relationship between the
guided to connect nursing theory and nursing person, family or community and myself?
practice in the context of nursing situations. What nursing actions emerged in the
context of the relationship?
What other nursing responses might have
A Reflective Exercise for been possible?
What was the environment of the nursing
Choosing a Nursing Theory situation?
for Practice What about the environment was important
Select a comfortable, private, and quiet place to the needs for nursing and to my nursing
to reflect and write. Relax by taking some responses?
deep, slow breaths. Think about the reasons
Nursing can change when we consciously
you went into nursing in the first place. Bring
connect values and beliefs to nursing situa-
your nursing practice into focus. Consider
tions. Consider that values and beliefs are the
your practice today. Continue to reflect and,
basis for our nursing. Briefly describe the con-
while avoiding distractions, make notes to
nections of your values and beliefs with your
record your thoughts and feelings. When you
chosen nursing situation.
have been thinking for a time and have taken
the opportunity to reflect on your practice, Connecting Values and the Nursing Situation
proceed with the following questions. Con- How are my values and beliefs reflected in
tinue to reflect and to make notes as you any nursing situation?
consider each one. Are my values and beliefs in conflict or
frustrated in this situation?
Enduring Values
Do my values come to life in the nursing
What are the enduring values and beliefs
situation?
that brought me to nursing?
What beliefs and values keep me in nursing
today? Verifying Awareness
What are those values that I hold most and Appreciation
dear? In reflecting and writing about values and
What are the ties of these values to my situations of nursing that are important to
personal values? us, we often come to a fuller awareness and
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26 S E C T I O N I An Introduction to Nursing Theory

appreciation of nursing. Make notes about sociology, epidemiology, etc. Nursing theory
your insights. You might consider these ini- is within the pattern of empirical knowing.
tial notes the beginning of a journal in which The theoretical framework for practice inte-
you record your study of nursing theories grates the concepts, principles, laws, and facts
and their use in nursing practice. This is a essential for practice.
valuable way to follow your progress and is a Personal knowing is about striving to
source of nursing questions for future study. know the self and to actualize authentic rela-
You may want to share this process and tionships between the nurse and the one
experience with your colleagues. These are nursed. Using this pattern of knowing in
ways to clarify and verify views about nurs- nursing, the client is not seen as an object,
ing and to seek and offer support for nursing but as a person moving toward fulfillment of
values and situations that are critical to your potential (Carper, 1978). The nurse is recog-
practice. If you are doing this exercise in a nized as continuously learning and growing
group, share your essential values and beliefs as a person and practitioner. Reflecting on a
with your colleagues. person as a client and a person as a nurse in
the nursing situation can enhance under-
Multiple Ways of Knowing and standing of nursing practice and the central-
Reflecting on Nursing Theory ity of relationships in nursing. These insights
Multiple ways of knowing are used in theory- are useful for choosing and studying nursing
guided nursing practice. Carper (1978) theory. Knowing the self is essential in
studied the nursing literature and described selecting nursing theory to guide practice.
four essential patterns of knowing in nurs- Ultimately, the choice of theoretical perspec-
ing. Using the Phenix (1964) model of tive reflects personal values and beliefs.
realms of meaning, Carper described per- Ethical knowing is increasingly important
sonal, empirical, ethical, and esthetic ways to the study and practice of nursing today.
of knowing in nursing. Chinn and Kramer According to Carper (1978), ethics in nursing
(2007) use Carpers patterns of knowing is the moral component guiding choices with-
and a fifth pattern, called emancipatory in the complexity of health care. Ethical
knowing, to develop an integrated frame- knowing informs us of what is right, what is
work for nursing knowledge development. our obligation, and what the nurse ought to
Additional patterns of knowing in nursing do in any situation. Ethical knowing is essen-
have been explored and described, and the tial in every action of the nurse in day-to-day
initial four patterns have been the focus of nursing.
much consideration in nursing (Boykin, Esthetic knowing is described by Carper
Parker, & Schoenhofer, 1994; Leight, 2002; (1978) as the art of nursing; it is the creative
Munhall, 1993; Parker, 2002; Pierson, 1999; and imaginative use of nursing knowledge in
Ruth-Sahd, 2003; Thompson, 1999; White, practice (Rogers, 1988). Although nursing is
1995). often referred to as art, this aspect of nursing
Each of Carpers patterns of knowing and may not be as highly valued as the science and
its relationship to theory-guided practice is ethics of nursing. Each nurse is an artist,
articulated below. expressing and interpreting the guiding theo-
Empirical knowing is the most familiar of ry uniquely in his or her practice. Reflecting
the ways of knowing in nursing. Empirical on the experience of nursing is primary in
knowing is how we come to know the understanding esthetic knowing. Through
science of nursing and other disciplines that such reflection, the nurse understands that
are used in nursing practice. This includes nursing practice has in fact been created,
knowing the actual theories, concepts, prin- that each instance of nursing is unique, and
ciples, and research findings from nursing, that outcomes of nursing cannot be precisely
pathophysiology, pharmacology, psychology, predicted. Besides the art of nursing, knowing
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C H A P T E R 3 Choosing, Evaluating and Implementing Nursing Theories 27

through artistic forms is part of esthetic The whole theory must be studied. Parts of
knowing. Often human experiences and rela- the theory without the whole will not be fully
tionships can best be appreciated and under- meaningful and may lead to misunderstanding.
stood through art forms such as stories, paint- Before selecting a guide for theory evalua-
ings, music, or poetry. Some assert that tion, consider the level and scope of the theory.
esthetic knowing allows for understanding Is the theory a conceptual model or grand
the wholeness of experience. Examples of this nursing theory? A middle-range nursing theory?
most complete knowing are frequent in nurs- A practice theory? Not all aspects of theory
ing situations in which even momentary con- described in an evaluation guide will be evident
nection and genuine presence between the in all levels of theory. Whall (2004) recognizes
nurse and the person, family or community is this in offering particular guides for analysis
realized. and evaluation that vary according to three
The notes describing your experience will types of nursing theory: models, middle-range
help in selecting a nursing theory to study and theories, and practice theories. Fawcetts
consider for guiding practice. You will want to (2004) criteria for analysis and evaluation per-
answer these questions: tain to conceptual models and grand theories.
Smiths (2008) criteria specifically address the
Using Insights to Choose Theory
evaluation of middle-range theories.
What nursing theory seems consistent
Theory analysis and evaluation may be
with the values and beliefs that guide my
thought of as one process or as a two-step
practice?
sequence. It may be helpful to think of
What theories are consistent with my
analysis of theory as necessary for in-depth
personal values and beliefs?
study of a nursing theory and evaluation of
What do I hope to achieve from the use of
theory as the assessment of a theorys signif-
nursing theory?
icance, structure, and utility. Guides for
Given my reflection on a nursing situation,
theory evaluation are intended as tools to
how can I use theory to support this
inform us about theories and to encourage
description of my practice?
further development, refinement, and use of
How can I use nursing theory to improve
theory. There are no guides for theory analy-
my practice for myself and for my patients?
sis and evaluation that are adequate and
appropriate for every nursing theory.
Evaluation of Nursing Theory Johnson (1974) wrote about three basic
Evaluation of nursing theory follows its criteria to guide evaluation of nursing theory.
study and analysis, and is the process of These have continued in use over time and
making a determination about its value, offer direction for guides in use today. These
worth, and significance (Smith, 2008). There criteria state that the theory should:
are many sets of criteria for evaluating con-
Define the congruence of nursing practice
ceptual models and grand theories (Chinn &
with societal expectations of nursing deci-
Kramer, 2007; Fawcett, 2004; Fitzpatrick &
sions and actions
Whall, 2004; Parse, 1987; Stevens, 1998).
Clarify the social significance of nursing, or
Smith (2008) has published criteria for eval-
the impact of nursing on persons receiving
uating middle-range theories. After reading
nursing
and studying the primary sources of the the-
Describe social utility, or usefulness of the
ory, the research and practice applications of
theory in practice, research, and education.
the theory, and other critiques and evalua-
tions of the theory; it is important for the The following are summaries of the most
evaluator to come to his or her own judg- frequently used guides for theory evaluation.
ments supported by logical analysis and These guides are components of the entire
examples from the theory. work about nursing theory of the individual
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28 S E C T I O N I An Introduction to Nursing Theory

nursing scholar and offer various interesting The questions for evaluation of grand and
approaches to theory evaluation. Each guide middle-range theories (Fawcett, 2000, p. 501)
should be studied in more detail than is address:
offered in this introduction and should be
Significance
examined in context of the whole work of the
Internal consistency
individual nurse scholar.
Parsimony
The approach to theory evaluation set forth
Testability
by Chinn and Kramer (2007) is to use guide-
Empirical adequacy
lines for describing nursing theory that are
Pragmatic adequacy
based on their definition of theory as a creative
and rigorous structuring of ideas that projects a Meleis (2004) states that the structural and
tentative, purposeful, and systematic view of functional components of a theory should be
phenomena (p. 58). The guidelines set forth studied before evaluation. The structural
questions that clarify the facts about aspects of components are assumptions, concepts, and
theory: purpose, concepts, definitions, relation- propositions of the theory. Functional compo-
ships and structure, and assumptions. These nents include descriptions of the following:
authors suggest that the next step in the evalu- focus, client, nursing, health, nurseclient
ation process is critical reflection about whether interactions, environment, nursing problems,
and how the nursing theory works. Questions and interventions. After studying these
are posed to guide this reflection: dimensions of the theory, critical examination
of these elements may take place, as summa-
How clear is this theory?
rized here:
How simple is this theory?
How general is this theory? Relations between structure and function of
How accessible is this theory? the theory, including clarity, consistency,
How important is this theory? and simplicity
Diagram of theory to elucidate the theory
Fawcett (2000) developed two different by creating a visual representation
frameworks for the analysis and evaluation of Contagiousness, or adoption of the theory by
conceptual models and theories. The questions a wide variety of students, researchers, and
for analysis of conceptual models (Fawcett, practitioners, as reflected in the literature
2000, p. 63) address: Usefulness in practice, education, research,
Origins of the nursing model and administration
Unique focus of the nursing model External components of personal, profes-
Content of the nursing model sional, social values, and significance
The questions for evaluation of conceptual Smith (2008) developed a framework for
models (Fawcett, 2000, p. 63) address: the evaluation of middle-range theories and
includes the following criteria:
Explication of origins
Comprehensiveness of content Substantive foundation relates to meaning or
Logical congruence how the theory corresponds to existing
Generation of theory knowledge in the discipline. The questions
Credibility of nursing model for evaluation ask about its fit with the dis-
ciplinary focus of nursing; its specification
The framework for analysis of grand and
of assumptions; its substantive meaning of
middle-range theories (Fawcett, 2000, p. 501)
a phenomenon; and its origins in practice
includes:
and/or research.
Theory scope Structural integrity relates to the structure or
Theory context internal organization of the theory. Ques-
Theory content tions for evaluation ask about the clarity
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C H A P T E R 3 Choosing, Evaluating and Implementing Nursing Theories 29

of definitions of concepts, the consistency Selecting the theory or model to be used in


of level of abstraction, the simplicity of practice. The entire nursing staff should be ful-
the theory, and the logical represention ly involved and invested in the process of
of relationships among concepts. deciding on the theoretical model that will
Functional adequacy refers to the ability of guide practice. This can be done is several
the theory to be used in practice and ways. An organizations governance structure
research. Questions are related to its can be used to develop the most appropriate
applicability to practice and client groups, selection process. As stated previously, the
the identification of empirical indicators, selection of a nursing theory or model is based
the presence of published examples of on values. Some nursing organizations have
practice and research using the theory used their mission, values, and vision state-
and the evolution of the theory through ments as a blueprint that helps them select
inquiry (p. 299). nursing theories that are most consistent with
these values. Another approach is to survey all
nurses about the practice models they would
Implementing Theory- like to see implemented. The top three or four
Guided Practice can then be studied by the nursing staff in
Every nurse should develop a practice that is greater detail so that the staff can make an
guided by nursing theory. Most conceptual informed decision. Staff development can be
models or grand theories have actual practice involved in planning educational offerings
methods or processes that can be adopted. related to the models. A process of voting or
The scope and generality of middle-range gaining consensus can be used for the final
theories makes them less appropriate to guide selection.
nursing practice within a unit or hospital. Launching the initiative. Once the model
Instead, they can be used to understand and has been selected, the leaders (formal and
respond to phenomena that are encountered informal) begin to plan for its implementa-
in nursing situations. For example, Boykin tion. This involves creating a timeline, plan-
and Schoenhofers Nursing as Caring theory ning the phases and stages of implementation
has been adopted as a practice model by sev- including activities, and using all methods of
eral hospitals. Reeds middle-range theory of communication to be sure that all are
self-transcendence can be used to guide a nurse informed of these plans. Unit champions,
who is leading a support group for women with informal leaders who are enthusiastic and
breast cancer. Hospital units or entire nursing positive about the initiative, can be key to
departments may adopt a model that guides the building excitement for the intiative. A
nursing practice within their unit or organiza- structure to lead and manage the implemen-
tion. The following are suggestions that can tation is essential. Consultants who are
facilitate this process of adoption and imple- experts in the theory itself or who have expe-
mentation of theory-guided practice within rience in implementing the theory-guided
units or organizations: practice model can be very helpful. For exam-
Gaining administrative support. Organiza- ple, Watsons Caring Science Consortium
tional leaders need to support the initiative to consists of hospitals who have experience
begin the process of implementing nursing implementing the theory in practice. New
theory-guided practice. While the impetus to hospitals can join the consortiuim for consul-
begin this initiative might not originate in tation and support as they launch initiatives.
formal leadership, the organizational leaders Watson herself often serves as a consultant to
and managers need to be on board. If it is to hospitals adopting her caring theory. A kick-
succeed, the implementation of a model for off event, such as an inspirational presenta-
practice requires the support of administra- tion, can build excitement and visibility for
tion at the highest levels. the initiative.
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30 S E C T I O N I An Introduction to Nursing Theory

Creating a plan for evaluation. It is important prevent slippage and cement new behaviors.
to build in a systematic plan for evaluation of Staff need opportunities to dialogue about
the new model from the beginning. An evalua- their experiences: what is working and what is
tion study should be designed to track process not. They need the freedom to develop new
and outcome indicators. Consultation from an ways of implementing the model so that their
evaluation researcher is essential. For example, scholarship and creativity flourishes.
outcomes of nurse satisfaction, patient satisfac- Periodic feedback on outcomes and oppor-
tion, nurse retention, and core measures might tunities for re-energizing is essential. Planned
be considered as outcomes to be measured change involves anticipating the ebb and flow
before and after the implementation of the of enthusiasm. In the stressful health care
model. Focus groups might be held at intervals environment it is important to find opportu-
to identify nurses experiences and attitudes nities to provide feedback on how the project
related to implementation of the model. is going, to reward and celebrate the success-
Consistent and constant support and educa- es, and to fan any dying embers of enthusiasm
tion. As the model is implemented, a process for the project. This can be accomplished
to support continuing learning and growth through inviting study champions to attend
with the theory needs to be in place. The regional or national conferences, bringing in
nurses implementing the model will have speakers, or holding recognition events.
questions and suggestions, so resident experts Re-visioning of the theory-guided practice
should be available for this education and model based on feedback. Any theory-guided
support. Those working with the model will practice model will become richer through its
grow in their expertise, and their experiences testing in practice. The nurses working with
need to be recorded and shared with the com- the model will help to modify and revise the
munity of scholars advancing the theory in model based on evaluation data. This re-
practice. Ways to foster staying on track must visioning should be done in partnership with
be developed. Some hospitals have created theorists and other practice scholars working
unit bulletin boards, newsletters, or signage to with the model.

Summary
This chapter focused on the important con- need to be present in a chosen theory. Eval-
nection between nursing theory and nursing uation of nursing theory is a judgment of its
practice and the processes of choosing, eval- value or worth. Several models of theory
uating, and implementing theory for prac- evaluation are available for use. Implement-
tice. The selection of a nursing theory for ing a theory-based practice model in a
practice is based on values and beliefs, and a health care setting can be challenging and
reflective process can help to identify the rewarding. Suggestions for successful imple-
most important qualities of practice that mentation were offered.

References

Boykin, A., Parker, M., & Schoenhofer, S. (1994). Chinn, P., & Kramer, M. (2004). Integrated knowledge
Aesthetic knowing grounded in an explicit concep- development in nursing (6th ed.). St. Louis, MO:
tion of nursing. Nursing Science Quarterly, 7(4), C. V. Mosby.
158161. Chinn, P., & Kramer, M. (2007). Integrated knowledge
Carper, B. A. (1978). Fundamental patterns of knowing development in nursing (7th ed.). St. Louis, MO:
in nursing. Advances in Nursing Science, 1(1), 1323. C. V. Mosby.
Chinn, P., & Jacobs, M. (1987). Theory and nursing: A Fawcett, J. (2000). Analysis and evaluation of contempo-
systematic approach. St. Louis, MO: C. V. Mosby. rary nursing knowledge. Philadelphia: F. A. Davis.
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C H A P T E R 3 Choosing, Evaluating and Implementing Nursing Theories 31

Fawcett, J. (2004). Analysis and evaluation of contempo- Rogers, M. E. (1988). Nursing science and art: A
rary nursing knowledge. Philadelphia: F. A. Davis. prospective. Nursing Science Quarterly, 1(3), 99102.
Fitzpatrick, J., & Whall, A. (2004). Conceptual models of Ruth-Sahd, L. A. (2003). Intuition: A critical way of
nursing. Stamford, CT: Appleton & Lange. knowing in a multicultural nursing curriculum.
Johnson, D. (1974). Development of theory: A requisite Nursing Education Perspectives, 24(3), 129134.
for nursing as a primary health profession. Nursing Silva, M. (1997). Philosophy, theory, and research in
Research, 23(5), 372377. nursing: A linguistic journey to nursing practice. In:
Leight, S. B. (2002). Starry night: Using story to inform I. King & J. Fawcett (Eds.), The language of nursing
aesthetic knowing in womens health nursing. theory and metatheory. Indianapolis, IN: Center
Journal of Advanced Nursing, 37(1), 108114. Nursing Press.
Meleis, A. (1997). Theoretical nursing: Development and Smith, M. C. (2008). Evaluation of middle range theo-
progress. Philadelphia: Lippincott. ries for the discipline of nursing. In: M. J. Smith &
Meleis, A. (2004). Theoretical nursing: Development and P. R. Liehr (Eds.), Middle range theory for nursing
progress. Philadelphia: Lippincott. (pp. 293306). New York: Springer.
Munhall, P. (1993). Unknowing: Toward another Stevens, B. (1998). Nursing theory: Analysis, application,
pattern of knowing in nursing. Nursing Outlook, evaluation. Boston: Little, Brown.
41, 125128. Thompson, C. (1999). A conceptual treadmill: The
Parker, M. (1993). Patterns of nursing theories in practice. need for middle ground in clinical decision making
New York: National League for Nursing. theory in nursing. Journal of Advanced Nursing,
Parker, M. E. (2002). Aesthetic ways in day-to-day 30(5), 12221229.
nursing. In: D. Freshwater (Ed.), Therapeutic nursing: Whall, A. (2004). The structure of nursing knowledge:
Improving patient care through self-awareness and Analysis and evaluation of practice, middle-range,
reflection (pp. 100120). Thousand Oaks, CA: Sage. and grand theory. In: J. Fitzpatrick & A. Whall
Parse, R. R. (1987). Nursing science: Major paradigms, (Eds.), Conceptual models of nursing: Analysis and
theories and critiques. Philadelphia: W. B. Saunders. application (4th ed., pp. 520). Stamford, CT:
Phenix, P. H. (1964). Realms of meaning. New York: Appleton & Lange.
McGraw-Hill. White, J. (1995). Patterns of knowing: Review, critique
Pierson, W. (1999). Considering the nature of intersub- and update. Advances in Nursing Science, 17(4),
jectivity within professional nursing. Journal of 7386.
Advanced Nursing, 30(2), 294302.
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Section
II
Evolution of Nursing
Theory
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Section

II Conceptual Influences on the Evolution of Nursing Theory

The second section of the book has three chapters that describe conceptual influences on the
development of nursing theory. Thomas Kuhn calls the stage of scientific development before
formal theories are structured as the pre-paradigm stage. These scholars were working in this
stage of our development, planting the seeds that grew into nursing theories. Nursing theorists
today have stood on the shoulders of these giants, building on their brilliant conceptualiza-
tions of the nature of nursing and the nursepatient relationship. In Chapter 4 Dr. Lynne Dunphy,
a noted historian and Nightingale scholar, illuminates the core ideas from Nightingales work
that have been essential foundations for the development of nursing theories. Although
Nightingale did not develop a theory of nursing, she did provide a direction for the develop-
ment of the profession and discipline. She believed in the natural or inherent healing ability of
human beings, and that the goal of nursing was to facilitate the emergence of health and heal-
ing through attending to the personenvironment relationship. She said that the goal of nurs-
ing was to put the patient in the best condition for nature to act, and she identified five envi-
ronmental components essential to health. Nightingale saw nursing and medicine as separate
fields, and emphasized the importance of systematic inquiry. Her spiritual nature and vision of
nursing as an art continue to influence practice today. In Chapter 5, Dr. Shirley Gordon and her
contributors summarized the work of Ernestine Wiedenbach, Virginia Henderson, and Lydia
Hall. Wiedenbach emphasized the importance of reverence for life, respect for dignity, autono-
my, worth, and uniqueness of each person, and a commitment to act on these values as the
essence of a personal philosophy of nursing. Henderson described nursing as getting into the
skin of the patient so that nurses would be able to provide the strength, will, or knowledge that
was needed by the patient to heal or maintain health. Lydia Hall is an inspiration to all who envi-
sion nursing as an autonomous discipline and practice. She created a model of nursing consist-
ing of The Core, The Cure, and The Care, and implemented that model in the Loeb Center for
Nursing and Rehabilitation. Physicians referred their patients to the Center, and nurses admit-
ted the patients for nursing care. Nurses worked independently with patients to foster learning,
growth, and healing. Chapter 6, written by a group of authors, focused on three nursing lead-
ers who described the nursepatient relationship: Hildegard Peplau, Ida Jean Orlando, and
Joyce Travelbee. A psychiatric nurse, Peplau viewed the purpose of nursing as helping the
patient gain the intellectual and interpersonal competencies necessary to heal. She articulated
stages of the nursepatient relationship, a framework for anxiety and nursing interventions to
decrease anxiety. Travelbee emphasized the human-to-human relationship between nurse and
person nursed, and spoke of the purpose of nursing as assisting the person(s) to prevent or
cope with the experience of illness and suffering. Orlando described attributes of the
nursepatient relationship. She valued that relationship as central to the practice of nursing, and
was the first to describe nursing process as identifying needs and responding to those needs.

34
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Chapter
4
Florence Nightingales
Legacy of Caring and
Its Applications
LYNNE M. H EKTOR D UNPH Y

Introducing the Theorist Introducing the Theorist


Early Life and Education Florence Nightingale, the acknowledged founder
Spirituality of modern nursing, remains a compelling
War and transformative figure. Not a year goes by
Introducing the Theory in which new scholarship on Nightingale
The Medical Milieu does not emerge. Florence Nightingale and
The Feminist Context of the Health of the Raj was published in 2003
Nightingales Caring documenting Nightingales 40-year long
Ideas About Nursing interest and involvement in Indian affairs, a
Nightingales Legacy for previously not well explored area of scholar-
21st Century Nursing Practice
ship (Gourley, 2003). In 2004 a new biography
Summary
of Nightingale, Nightingales: The Extraordinary
References
Upbringing and Curious Life of Miss Florence
Nightingale by Gillian Gill, was published. In
2008, yet another new biography, entitled
Florence Nightingale: The Making of an Icon,
by Mark Bostridge, was published. Lynn
McDonalds prodigious, ambitious, and long
overdue Collected Works of Florence Nightingale
has seen the publication of 10 out of a pro-
jected 16 volumes as of this writing. In 2005
the American Nurses Association published
Florence Nightingale Florence Nightingale Today: Healing, Leader-
ship, Global Action, an ambitious casting of
Nightingale as 21st century nursings inspira-
tion and savior. At the time you are perusing
this chapter, it will be a century since the
death of Florence Nightingale in 1910, and
almost 200 hundred years since her birth on
May 12 in 1820.
Nightingale transformed a calling from
God and an intense spirituality into a new
social role for women: that of nurse. Her caring
was a public one. Work your true work, she
wrote, and you will find God within you
(Woodham-Smith, 1983, p. 74). A reflection
on this statement appears in a well-known

35
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36 S E C T I O N II Evolution of Nursing Theory

quote from Notes on Nursing (1859/1992): Nightingales were on an extended European


Nature [i.e., the manifestation of God] alone tour, begun in 1818 shortly after their mar-
cures . . . what nursing has to do . . . is put the riage. This was a common journey for those of
patient in the best condition for nature to act their class and wealth. Their first daughter,
upon him (Macrae, 1995, p. 10). Although Parthenope, had been born in the city of that
Nightingale never defined human care or car- name in the previous year.
ing in Notes on Nursing, there is no doubt that A legacy of humanism, liberal thinking,
her life in nursing exemplified and personified and love of speculative thought was
an ethos of caring. Jean Watson (1992, p. 83), bequeathed to Nightingale by her father. His
in the 1992 commemorative edition of Notes views on the education of women were far
on Nursing, observed, Although Nightingales ahead of his time. W. E. N., as her father,
feminine-based caring-healing model has William, was called, undertook the education
transcended time and is prophetic for this cen- of both his daughters. Florence and her sister
turys health reform, the model is yet to truly studied music; grammar; composition; mod-
come of age in nursing or the health care sys- ern languages; classical Greek and Latin;
tem. In a reflective essay, Boykin and Dunphy constitutional history and Roman, Italian,
(2002) extended this thinking and related German, and Turkish history; and mathemat-
Nightingales life, rooted in compassion and ics (Barritt, 1973).
caring, as an exemplar of justice-making From an early age, Florence exhibited
(p. 14). Justice-making is understood as a man- independence of thought and action. The
ifestation of compassion and caring, for it is sketch (Fig. 4-1) of W. E. N. and his daugh-
our actions that bring about justice (p. 16). ters was done by Nightingales beloved aunt,
This chapter reiterates Nightingales life from
the years 1820 to 1860, delineating the form-
ative influences on her thinking and providing
historical context for her ideas about nursing
as we recall them today. Part of what follows
is a well-known tale; yet it remains a tale that
is irresistible, casting an age-old spell on
the reader, like the flickering shadow of
Nightingale and her famous lamp in the dark
and dreary halls of the Barrack Hospital,
Scutari, on the outskirts of Constantinople,
circa 1854 to 1856. It is a tale that carries even
more relevance for nursing practice today.

Early Life and Education


A profession, a trade, a necessary occupation, some-
thing to fill and employ all my faculties, I have
always felt essential to me, I have always longed
for, consciously or not. . . . The first thought I can
remember, and the last, was nursing work. . . .
F LORENCE N IGHTINGALE , CITED IN
C OOK (1913, P. 106)
Figure 4 1 A sketch of W. E. N. and his daugh-
ters by one of his wife Fannys sisters, Julia Smith.
Nightingale was born in 1820 in Florence, (From Woodham-Smith, p. 9, with permission of Sir Henry
Italythe city she was named for. The Verney, Bart.)
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C H A P T E R 4 Florence Nightingales Legacy of Caring 37

Julia Smith. It is Parthenope, the older sister, After 6 months at Harley Street, Nightingale
who clutches her fathers hand and Florence wrote in a letter to her father: I am
who, as described by her aunt, independent- in the hey-day of my power (Nightingale,
ly stumps along by herself (Woodham- cited in Woodham-Smith, 1983, p. 77).
Smith, 1983, p. 7). By October 1854, larger horizons beckoned.
Travel also played a part in Nightingales
education. Eighteen years after Florences birth, Spirituality
the Nightingales and both daughters made an
extended tour of France, Italy, and Switzerland
Today I am 30the age Christ began his Mission.
between the years of 1837 and 1838 and later
Now no more childish things, no more vain things,
Egypt and Greece (Sattin, 1987). From there,
no more love, no more marriage. Now, Lord let me
Nightingale visited Germany, making her first
think only of Thy will, what Thou willest me to
acquaintance with Kaiserswerth, a Protestant
do. O, Lord, Thy will, Thy will. . . .
religious community that contained the Institu-
tion for the Training of Deaconesses, with a FLORENCE NIGHTINGALE, PRIVATE
hospital school, penitentiary, and orphanage. A NOTE , 1850, CITED IN W OODHAM -S MITH
Protestant pastor, Theodore Fleidner, and his (1983, P. 130)
young wife had established this community in
1836, in part to provide training for women By all accounts, Nightingale was an intense
deaconesses (Protestant nuns) who wished and serious child, always concerned with the
to nurse. Nightingale was to return there in poor and the ill, mature far beyond her years.
1851 against much family opposition to stay A few months before her 17th birthday,
from July through October, participating in a Nightingale recorded in a personal note dated
period of nurses training (Cook, Vol. I, 1913; February 7, 1837, that she had been called to
Woodham-Smith, 1983). Gods service. What that service was to be
Life at Kaiserswerth was spartan. The was unknown at that point in time. This was
trainees were up at 5 A.M., ate bread and gru- to be the first of four such experiences that
el, and then worked on the hospital wards Nightingale documented.
until noon. Then they had a 10-minute break The fundamental nature of her religious
for broth with vegetables. Three P.M. saw convictions made her service to God, through
another 10-minute break for tea and bread. service to humankind, a driving force in her
They worked until 7 P.M., had some broth, life. She wrote: The kingdom of Heaven is
and then Bible lessons until bed. What the within; but we must make it without
Kaiserswerth training lacked in expertise it (Nightingale, private note, cited in Woodham-
made up for in a spirit of reverence and dedi- Smith, 1983).
cation. Florence wrote, The world here fills It would take 16 long and torturous years,
my life with interest and strengthens me in from 1837 to 1853, for Nightingale to actual-
body and mind (Huxley, 1975, p. 24). ize her calling to the role of nurse. This was a
In 1852, Nightingale visited Ireland, revolutionary choice for a woman of her social
touring hospitals and keeping notes on vari- standing and position, and her desire to nurse
ous institutions along the way. Nightingale met with vigorous family opposition for many
took two trips to Paris in 1853, hospital years. Along the way, she turned down pro-
training again was the goal, this time with posals of marriage, potentially, in her mothers
the sisters of St. Vincent de Paul, an order of view, brilliant matches, such as that of
nursing nuns. In August 1853, she accepted Richard Monckton Milnes. However, her
her first official nursing post as superin- need to serve God and to demonstrate her
tendent of an Establishment for Gentle- caring through meaningful activity proved
women in Distressed Circumstances during stronger. She did not think that she could be
Illness, located at 1 Harley Street, London. married and also do Gods will.
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38 S E C T I O N II Evolution of Nursing Theory

Calabria and Macrae (1994) note that for forever in her mind certain truths. In the
Nightingale there was no conflict between Crimea, she was drawn closer to those suffer-
science and spirituality; actually, in her view, ing injustice. It was in the Barracks Hospital
science is necessary for the development of a of Scutari that Nightingale acted justly and
mature concept of God. The development of responded to a call for nursing from the pro-
science allows for the concept of one perfect longed cries of the British soldiers (Boykin &
God Who regulates the universe through uni- Dunphy, 2002, p. 17).
versal laws as opposed to random happenings.
Nightingale referred to these laws, or the War
organizing principles of the universe, as
Thoughts of God (Macrae, 1995, p. 9). As
I stand at the altar of those murdered men and
part of Gods plan of evolution, it was the
while I live I fight their cause.
responsibility of human beings to discover the
laws inherent in the universe and apply them N IGHTINGALE , CITED IN
to achieve well-being. In Notes on Nursing W OODHAM -S MITH (1983)
(1860/1969, p. 25), she wrote:
Nightingale had powerful friends and had
God lays down certain physical laws. Upon his
gained prominence through her study of hos-
carrying out such laws depends our responsibility
pitals and health matters during her travels.
(that much abused word). . . . Yet we seem to be
When Great Britain became involved in the
continually expecting that He will work a miracle
Crimean War in 1854, Nightingale was
i.e. break his own laws expressly to relieve us of
ensconced in her first official nursing post at
responsibility.
1 Harley Street. Britain had joined France
Influenced by the Unitarian ideas of her and Turkey to ward off an aggressive Russian
father and her extended family, as well as by advance in the Crimea (Fig. 4-2). A success-
the more traditional Anglican Church she ful advance of Russia through Turkey could
attended, Nightingale remained for her entire threaten the peace and stability of the Euro-
life a searcher of religious truth, studying a pean continent.
variety of religions and reading widely. She The first actual battle of the war, the
was a devout believer in God. Nightingale Battle of Alma, was fought in September
wrote: I believe that there is a Perfect Being, 1854. It was written of that battle that it was
of whose thought the universe in eternity is a glorious and bloody victory. The best com-
the incarnation (Calabria & Macrae, 1994, munication technology of the times, the tele-
p. 20). Dossey (1998) recasts Nightingale in graph, was to have an effect on what was to
the mode of religious mystic. However, to follow. In prior wars, news from the battle-
Nightingale, mystical union with God was fields trickled home slowly. However, the tele-
not an end in itself but was the source of graph enabled war correspondents to transmit
strength and guidance for doing ones work in reports home with rapid speed. The horror of
life. For Nightingale, service to God was serv- the battlefields was relayed to a concerned cit-
ice to humanity (Calabria & Macrae, 1994, izenry. Descriptions of wounded men, disease,
p. xviii). and illness abounded. Who was to care for
In Nightingales view, nursing should be a these men? The French had the Sisters of
search for the truth; it should be a discovery of Charity to care for their sick and wounded.
Gods laws of healing and their proper appli- What were the British to do? (Goldie, 1987;
cation. This is what she was referring to in Woodham-Smith, 1983).
Notes on Nursing when she wrote about the The minister of war was Sidney Herbert,
Laws of Health, as yet unidentified. It was the Lord Herbert of Lea, who was the husband
Crimean War that provided the stage for her of Liz Herbert; both were close friends
to actualize these foundational beliefs, rooting of Nightingale. Herbert had an innovative
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C H A P T E R 4 Florence Nightingales Legacy of Caring 39

Figure 4 2 The Crimea and the Black Sea, 18541856. (Designed by Manuel Lopez Parras in Huxley, E. [1975].
Florence Nightingale, p. 998. G. P. Putnams Sons, New York.)

solution: appoint Miss Nightingale and charge more than rose to the occasion. In a passionate
her to head a contingent of nurses to the letter to Nightingale, requesting her to accept
Crimea to provide help and organization to this post, Herbert wrote:
the deteriorating battlefield situation. It was a
Your own personal qualities, your knowledge and
brave move on the part of Herbert. Medicine
your power of administration, and among greater
and war were exclusively male domains. To
things, your rank and position in society, give you
send a woman into these hitherto uncharted
advantages in such a work that no other person
waters was risky at best. But, as is well known,
possesses. (Dolan, 1971, p. 2)
Nightingale was no ordinary woman, and she
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40 S E C T I O N II Evolution of Nursing Theory

At the same time, such that their letters actu- (with the laundry farmed out to the soldiers
ally crossed, Nightingale wrote to Herbert, offer- wives), it was accomplished under Nightingales
ing her services. Accompanied by 38 handpicked eagle eye: She insisted on the huge wooden
nurses who had no formal training, she arrived tubs in the wards being emptied, standing
on November 4, 1854 to take charge and did [obstinately] by the side of each one, sometimes
not return to England until August 1856. for an hour at a time, never scolding, never rais-
Biographer Woodham-Smith and Nightingales ing her voice, until the orderlies gave way and
own correspondence, as cited in a number of the tub was emptied (Cook, 1913; Summers,
sources (Cook, 1913; Goldie, 1987; Huxley, 1988; Woodham-Smith, 1983).
1975; Summers, 1988; Vicinus & Nergaard, Nightingale set up her own extra diet
1990), paint the most vivid picture of the expe- kitchen. Small portions, helpings of such
riences that Nightingale sustained there, expe- things as arrowroot, port wine, lemonade, rice
riences that cemented her views on disease and pudding, jelly, and beef tea, whose purpose
contagion, as well as her commitment to an was to tempt and revive the appetite, were
environmental approach to health and illness: provided to the men. It was therefore a logical
sequence from cooking to feeding, from
The filth became indescribable. The men in the cor-
administering food to administering medi-
ridors lay on unwashed floors crawling with vermin.
cines. Because no antidote to infection existed
As the Rev. Sidney Osborne knelt to take down
at this time, the provisionby Nightingale
dying messages, his paper became thickly covered
and her nursesof cleanliness, order, encour-
with lice. There were no pillows, no blankets; the
agement to eat, feeding, clean bed linen, clean
men lay, with their heads on their boots, wrapped
bodies, and clean wards, was essential to
in the blanket or greatcoat stiff with blood and filth
recovery (Summers, 1988).
which had been their sole covering for more than
Mortality rates at the Barrack Hospital in
a week . . . [S]he [Miss Nightingale] estimated . . . .
Scutari fell. In February, at Nightingales
there were more than 1000 men suffering from
insistence, the prime minister had sent to the
acute diarrhea and only 20 chamber pots. . . .
Crimea a sanitary commission to investigate
[T]here was liquid filth which floated over the floor
the high mortality rates. Beginning their work
an inch deep. Huge wooden tubs stood in the halls
in March, they described the conditions at the
and corridors for the men to use. In this filth lay the
Barrack Hospital as murderous. Setting to
mens foodMiss Nightingale saw the skinned car-
work immediately, they opened the channel
cass of a sheep lie in a ward all night . . . the stench
through which the water supplying the hospi-
from the hospital could be smelled outside the
tal flowed, where a dead horse was found. The
walls (Woodham-Smith, 1983).
commission cleared 556 handcarts and large
On her arrival in the Crimea, the immedi- baskets full of rubbish 24 dead animals and
ate priority of Nightingale and her small band 2 dead horses buried. In addition, they
of nurses was not in the sphere of medical or flushed and cleansed sewers, limewashed
surgical nursing as currently known; rather, walls, tore out shelves that harbored rats,
their order of business was domestic manage- and got rid of vermin. The commission,
ment. This is evidenced in the following Nightingale said, saved the British Army.
exchange between Nightingale and one of her Miss Nightingales anticontagionism was
party as they approached Constantinople: Oh, sealed as the mortality rates began showing
Miss Nightingale, when we land dont let there dramatic declines (Rosenberg, 1979).
be any red-tape delays, let us get straight to Figure 4-3 illustrates Nightingales own
nursing the poor fellows! Nightingales reply: hand-drawn coxcombs (as they were referred
The strongest will be wanted at the wash tub to), as Nightingale, always aware of the neces-
(Cook, 1913; Dolan, 1971). sity of documenting outcomes of care, kept
Although the bulk of this work continued to copious records of all sorts (Cook, 1913;
be done by orderlies after Nightingales arrival Rosenberg, 1979; Woodham-Smith, 1983).
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C H A P T E R 4 Florence Nightingales Legacy of Caring 41

Diagram Representing the Mortality in the Hospitals


at Scutari and Kulali from Oct. 1st 1854 to Sept. 30th 1855
observed, alone with a little lamp in her hand,
May 20 to June 9
making her solitary rounds (Kalisch & Kalisch,
June 10 to June 30
Apr. 29 to May 19 48 per
100
52 per
22
per
1987, p. 46).
100 July 1 to Sept. 30, 1855
Apr. 8 to Apr. 28 107 per 100
100
22 per 100 In April 1855, after having been in Scutari
1854
Mar. 18 to Apr.7 144 per 100 22 per 100
Oct. 1 to Oct.10
for 6 months, Florence wrote to her mother,
Commencement of Sanitary Improvements
315 per 100
85 per 100
[A]m in sympathy with God, fulfilling the
Oct. 15 to Nov. 11
Feb. 25 to Mar. 17
155 per 100 purpose I came into the world for (Woodham-
427 per 100 179 per 100
Smith, 1983, p. 97). Henry Wadsworth
Nov. 12 to Dec. 9
321 per 100
Longfellow authored Santa Filomena to
Dec. 10 to Jan. 6, 1855
Feb. 1 to Feb. 28 commemorate Miss Nightingale.
Jan. 7 to Jan. 31
Lo! In That House of Misery
Figure 4 3 Diagram by Florence Nightingale
showing declining mortality rates. (From Cohen, I. B. A lady with a lamp I see
[1981]. Florence Nightingale: The passionate statistician. Pass through the glimmering gloom
Scientific American, 250(3), 128137.) And flit from room to room
And slow as if in a dream of bliss
The speechless sufferer turns to kiss
Florence Nightingale possessed moral
Her shadow as it falls
authority, so firm because it was grounded in
Upon the darkening walls
caring and was in a larger mission that came
As if a door in heaven should be
from her spirituality. For Miss Nightingale,
Opened and then closed suddenly
spirituality was a much broader, more unify-
The vision came and went
ing concept than that of religion. Her spiritu-
The light shone and was spent.
ality involved the sense of a presence higher
A lady with a lamp shall stand
than humanity, the divine intelligence that
In the great history of the land
creates, sustains, and organizes the universe,
A noble type of good
and an awareness of our inner connection to
Heroic womanhood
this higher reality. Through this inner con-
(Longfellow, cited in Dolan, 1971, p. 5).
nection flows creative endeavors and insight,
a sense of purpose and direction. For Miss Miss Nightingale slipped home quietly,
Nightingale, spirituality was intrinsic to arriving at Lea Hurst in Derbyshire on
human nature and was the deepest, most August 7, 1856, after 22 months in the
potent resource for healing. In Suggestions for Crimea and after sustained illness from
Thought (Calabria & Macrae, 1994, p. 58), which she was never to recover, after cease-
Nightingale wrote that human consciousness less work and after witnessing suffering,
is tending to become what Gods consciousness death, and despair that would haunt her for
isto become One with the consciousness of the remainder of her life. Her hair was
God. This progression of consciousness to shorn; she was pale and drawn (Fig. 4-4).
unity with the divine was an evolutionary view She took her family by surprise. The next
and not typical of either the Anglican or Uni- morning, a peal of the village church bells
tarian views of the time (Calabria & Macrae, and a prayer of Thanksgiving were, her sis-
1994; Macrae, 1995; Rosenberg, 1979; Slater, ter wrote, all the innocent greeting except
1994; Welch, 1986; Widerquist, 1992). for those provided by the spoils of war that
There were 4 miles of beds in the Barrack had proceeded hera one-legged sailor boy,
Hospital at Scutari, a suburb of Constantinople. a small Russian orphan, and a large puppy
A letter to the London Times dated February 24, found in some rocks near Balaclava. All
1855, reported the following: When all the England was ringing with her name, but she
medical officers have retired for the night had left her heart on the battlefields of the
and silence and darkness have settled upon Crimea and in the graveyards of Scutari
those miles of prostrate sick, she may be (Huxley, 1975, p. 147).
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42 S E C T I O N II Evolution of Nursing Theory

The Medical Milieu


To gain a better understanding of Nightingales
ideas on nursing, one must enter the particu-
lar world of 19th-century medicine and its
views on health and disease. Considerable
new medical knowledge had been gained by
1800. Gross anatomy was well known; chem-
istry promised to shed light on various body
processes. Vaccination against smallpox exist-
ed. There were some established drugs in the
pharmacopoeia: cinchona bark, digitalis, and
mercury. Certain major diseases, such as lep-
rosy and the bubonic plague, had almost
disappeared. The crude death rate in western
Europe was falling, largely related to decreas-
ing infant mortality as a result of improve-
ment in hygiene and standard of living
(Ackernecht, 1982; Shyrock, 1959).
Yet, in 1800, physicians still had only the
vaguest notion of diagnosis. Speculative
philosophies continued to dominate medical
thought, although inroads continued to be made
that eventually gave way to a new outlook on the
nature of disease: from belief in general states
Figure 4 4 A rare photograph of Florence common to all illnesses to an understanding of
taken on her return from the Crimea. Although disease-specificity symptoms. It was this shift in
greatly weakened by her illness, she refused to thoughta paradigm shift of the first order
accept her friends advice to rest, and pressed
on relentlessly with her plans to reform the that gave us the triumph of 20th-century
army medical services. (From Huxley, E. [1975]. medicine, with all its attendant glories and con-
Florence Nightingale, p. 139, G. P. Putnams Sons, current sterility.
New York.) The 18th century was host to two major
traditions or paradigms in the healing arts:
one based on empirics or experience, trial
Introducing the Theory and error, with an emphasis on curative reme-
dies; the other based on Hippocratic notions
and learning. Evidence of both these trends
In watching disease, both in private homes
persisted into the 19th century and can be
and public hospitals, the thing which strikes
found in Nightingales philosophy.
the experienced observer most forcefully is this,
Consistent with the philosophical nature
that the symptoms or the sufferings generally
of her superior education (Barritt, 1973),
considered to be inevitable and incident to the
Nightingale, like many of the physicians of
disease are very often not symptoms of the dis-
her time, continued to emphatically disavow
ease at all, but of something quite different
the reality of specific states of disease. She
of the want of fresh air, or light, or of warmth,
insisted on a view of sickness as an adjective,
or of quiet, or of cleanliness, or of punctuality
not a substantive noun. Sickness was not an
and care in the administration of diet, of each
entity somehow separable from the body.
or of all of these.
Consistent with her more holistic view, sick-
F LORENCE N IGHTINGALE , N OTES ON ness was an aspect or quality of the body as a
N URSING (1860/1969, P. 8) whole. Some physicians, as she phrased it,
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C H A P T E R 4 Florence Nightingales Legacy of Caring 43

taught that diseases were like cats and dogs, What was at issue was the specificity of the
distinct species necessarily descended from contaminating substance. Nightingale, and
other cats and dogs. She found such views the anti-contagionists, endorsed the position
misleading (Nightingale, 1860/1969). that a sufficiently intense level of atmos-
At this point in time, in the mid-19th pheric contamination could induce both
century, there were two competing theories endemic and epidemic ills in the crowded
regarding the nature and origin of disease. hospital wards [with particular configura-
One view was known as contagionism, tions of environmental circumstances deter-
postulating that some diseases were commu- mining which] (Rosenberg, 1979).
nicable, spread via commerce and population Anti-contagionism reached its peak before
migration. A strategic consequence of this the political revolutions of 1848; the resulting
explanatory model was quarantine, and its wave of conservatism and reaction brought
attendant bureaucracy aimed at shutting contagionism back into dominance, where it
down commerce and trade to keep disease remained until its reformulation into the
away from noninfected areas. To the new and germ theory in the 1870s. Leaders of the
rapidly emerging merchant classes, quaran- contagionists were primarily high-ranking
tine represented government interference military physicians, politically united. These
and control (Ackernecht, 1982; Arnstein, divergent worldviews accounted in some part
1988). for Nightingales clashes with the military
The second school of thought on the physicians she encountered during the
nature and origin of disease, of which Crimean War.
Nightingale was an ardent champion, was Given the intellectual and social milieu in
known as anti-contagionism. It postulated which Nightingale was raised and educated,
that disease resulted from local environmen- her stance on contagionism seems preor-
tal sources and arose out of miasmas dained and logically consistent (Rosenberg,
clouds of rotting filth and matter, activated 1979). Likewise, the eclectic religious philos-
by a variety of things such as meteorologic ophy she evolved contained attributes of the
conditions (note the similarity to elements of philosophy of Unitarianism with the fervor
water, fire, air, and earth on humors); the filth of Evangelicalism, all based on an organic
must be eliminated from local areas to prevent view of humans as part of nature. The treat-
the spread of disease. Commerce and infect- ment of disease and dysfunction was insepa-
ed individuals were left alone (Rosenberg, rable from the nature of man as a whole, and
1979). likewise, the environment. And all were
William Farr, another Nightingale associ- linked to God.
ate and avid anti-contagionist, was Britains The emphasis on atmosphere (or envi-
statistical superintendent of the General ronment) in the Nightingale model is consis-
Register Office. Farr categorized epidemic tent with the views of the anti-contagionists
and infectious diseases as zygomatic, mean- of her time. This worldview was reinforced by
ing pertaining to or caused by the process Nightingales Crimean experiences, as well as
of fermentation. The debate as to whether her liberal and progressive political thought.
fermentation was a chemical process or a In addition, she viewed all ideas as being dis-
vitalistic one had been raging for some tilled through a distinctly moral lens (Rosen-
time (Swazey & Reed, 1978). The familiari- berg, 1979). As such, Nightingale was typical
ty of the process of fermentation helps to of a number of her generations intellectuals.
explain its appeal. Anyone who had seen These thinkers struggled to come to grips
bread rise could immediately grasp how a with an increasingly complex and changing
minute amount of some contaminating sub- world order and frequently combined a lan-
stance could in turn pollute the entire guage of two disparate realms of authority:
atmosphere, the very air that was breathed. the moral realm and the emerging scientific
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44 S E C T I O N II Evolution of Nursing Theory

paradigm that has assumed dominance in the and Nightingales development of a suitable
20th century. Traditional religious and moral occupation for women, that of nursing, was
assumptions were garbed in a mantle of a significant historical development and a
scientific objectivity, often spurious at best, major contribution by Nightingale to womens
but more in keeping with the increasingly plight in the 19th century. However, in other
rationalized and bureaucratic society accom- ways, her views on women and the question of
panying the growth of science. womens rights were quite mixed.
Notes on Nursing: What It Is and What It Is
Not (1859/1969) was written not as a manual
The Feminist Context of to teach nurses to nurse, but rather to help all
Nightingales Caring women to learn how to nurse.
Nightingale believed all women required
I have an intellectual nature which requires this knowledge in order to take proper care of
satisfaction and that would find it in him. their families during times of sickness and to
I have a passionate nature which requires satis- promote healthspecifically what Nightingale
faction and that would find it in him. I have a referred to as the health of houses, that is,
moral, an active nature which requires satisfac- the health of the environment, which she
tion and that would not find it in his life. espoused. Nursing, to her, was clearly situated
within the context of female duty.
F LORENCE N IGHTINGALE , PRIVATE In Ordered to Care: The Dilemma of American
NOTE , 1849, CITED IN W OODHAM -S MITH Nursing (1987, p. 43), historian Susan Reverby
(1983, P. 51) traces contemporary conflicts within the nurs-
ing profession back to Nightingale herself. She
Florence Nightingale wrote the following asserts that Nightingales ideas about female
tortured note upon her final refusal of Richard duty and authority, along with her views on dis-
Monckton Milness proposal of marriage: ease causality, brought about an independent
I know I could not bear his life, she wrote, fieldthat of nursingthat was separate, and
that to be nailed to a continuation, an exag- in the view of Nightingale, equal, if not superi-
geration of my present life without hope of or, to that of medicine. But this field was dom-
another would be intolerable to methat inated by a female hierarchy and insisted on
voluntarily to put it out of my power ever to both deference and loyalty to the physicians
be able to seize the chance of forming for authority. Reverby sums it up as follows:
myself a true and rich life would seem to be Although Nightingale sought to free women
like suicide (Nightingale, personal note cited from the bonds of familial demand, in her nurs-
in Woodham-Smith, 1983, p. 52). For Miss ing model she rebound them in a new context.
Nightingale there was no compromise. Does the record support this evidence?
Marriage and pursuit of her mission were Was Nightingale a champion for womens
not compatible. She chose the mission, a clear rights or a regressive force? As noted earlier,
repudiation of the mores of her time, which the answer is far from clear.
were rooted in the time-honored role of fam- The shelter for all moral and spiritual val-
ily and female duty. ues, threatened by the crass commercialism
The census of 1851 revealed that there that was flourishing in the land, as well as the
were 365,159 excess women in England, spirit of critical inquiry that accompanied this
meaning women who were not married. age of expanding scientific progress, was
These women were viewed as redundant, agreed upon: the home. All considered this to
as described in an essay about the census be a sacred place, a Temple (Houghton,
entitled, Why Are Women Redundant? 1957, p. 343). And who was the head of
(Widerquist, 1992, p. 52). Many of these this home? Woman. Although the Victorian
women had no acceptable means of support, family was patriarchal in nature, in that
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C H A P T E R 4 Florence Nightingales Legacy of Caring 45

women had virtually no economic and/or outside of the home for other women, certain
legal rights, they nonetheless yielded a major other occupationsthat of doctor, for example
moral authority (Arnstein, 1988; Houghton, she viewed with hostility and as inappropriate
1957; Perkins, 1987). for women. Why should these women not be
There was hostility on the part of men as nurses or nurse midwives, a far superior calling
well as some women toward womens emanci- in Nightingales view than that of a medicine
pation. Many intelligent womenfor exam- man (Monteiro, 1984)?
ple, Beatrice Webb, George Eliot, and, at Welch (1990) termed Nightingale a
times, Nightingale herselfviewed their gen- Christian feminist on the eve of her depar-
ders emancipation with apprehension. In ture to the Crimea. She returned even more
Nightingales case, the best word might be skeptical of women. Writing to her close
ambivalence. There was a fear of weakening friend Mary Clarke Mohl, she described
womens moral influence, coarsening the fem- women whom she worked with in the Crimea
inine nature itself. as being incompetent and incapable of inde-
This stance is best equated with cultural pendent thought (Welch, 1990; Woodham-
feminism, defined as a belief in inherent gender Smith, 1983). According to Palmer (1977), by
differences. Women, in contrast to men, are this time in her life, the concerns of the
viewed as morally superior, the holders of fam- British people and the demands of service to
ily values and continuity; they are refined, del- God took precedence over any concern she
icate, and in need of protection. This school of had ever had about womens rights.
thought, important in the 19th century, used In other words, Nightingale, despite the
arguments for womens suffrage such as the clear freedom in which she lived her own life,
following: [W]omen must make themselves nonetheless genderized the nursing role, leav-
felt in the public sphere because their moral ing it rooted in 19th-century morality.
perspective would improve corrupt masculine Nightingale is seen constantly trying to
politics. In the case of Nightingale, these improve the existing order and to work with-
cultural feminist attitudes made her impatient in that order; she was above all a reformer,
with the idea of women seeking rights and seeking to improve the existing order, not to
activities just because men valued these enti- change the terrain radically.
ties (Bunting & Campbell, 1990, p. 21). In Nightingales mind, the specific scien-
Nightingale had chafed at the limitations tific activity of nursinghygienewas the
and restrictions placed on women, especially central element in health care, without which
wealthy women with nothing to do: What medicine and surgery would be ineffective:
these [women] suffereven physicallyfrom
The Life and Death, recovery or invaliding of
the want of such work no one can tell. The
patients generally depends not on any great and
accumulation of nervous energy, which has
isolated act, but on the unremitting and thorough
had nothing to do during the day, makes them
performance of every minutes practical duty.
feel every night, when they go to bed, as if they
(Nightingale, 1860/1969)
were going mad. . . . Despite these vivid
words, authored by Nightingale (1852/1979) This practical duty was the work of
in the fiery polemic Cassandra, which was women, and the conception of the proper divi-
used as a rallying cry in many feminist circles, sion of labor resting upon work demands inter-
her view of the solution was measured. Her nal to each respective science, nursing and
own resolution, painfully arrived at, was to medicine, obscured the professional inequality.
break from her family and actualize her caring The later successes of medical science height-
mission, that of nurse. One of the many results ened this inequity. The scientific grounding
of this was that a useful occupation for other espoused by Nightingale for nursing was
women to pursue was founded. Although ephemeral at best, as later 19th-century discov-
Nightingale approved of this occupation eries proved much of her analysis wrong,
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46 S E C T I O N II Evolution of Nursing Theory

although nonetheless powerful. Much of her the myth of Victorian womanhood, particu-
strength was in her rhetoric; if not always log- larly that of a woman alone and in command
ically consistent, it certainly was morally reso- (Auerbach, 1982, pp. 120121).
nant (Rosenberg, 1979). Nightingales clearly chosen spinsterhood
Despite exceptional anomalies, such as repudiated the Victorian family. Her unmarried
women physicians, what Nightingale effec- life provides a vision of a powerful life lived
tively accomplished was a genderization of on her own terms. This is not the spinsterhood
the division of labor in health care: male of conventionone to be pitied, one of broken
physicians and female nurses. This appears to heartsbut a radically new image. She is freed
be a division that Nightingale supported. from the trivia of family complaints and scorns
Because this natural division of labor was the feminist collectivity; yet in this seemingly
rooted in the family, womens work outside solitary life, she finds union not with one man
the home ought to resemble domestic tasks but with all men, personified by the British
and complement the male principle with the soldier.
female. Thus, nursing was left on the shift- Lytton Stracheys well-known evocation
ing sands of a soon-outmoded science; the of Nightingale, iconoclastic and bold, is per-
main focus of its authority grounded in an haps closest to the decidedly masculine
equally shaky moral sphere, also subject to imagery she selected to describe herself, as
change and devaluation in an increasingly evidenced in this imaginary speech to her
secularized, rationalized, and technological mother written in 1852:
20th century.
Well, my dear, you dont imagine with my talents,
Nightingale failed to provide institutional-
and my European reputation and my beautiful
ized nursing with an autonomous future, on
letters and all that, Im going to stay dangling
an equal parity with medicine. She did, how-
around my mothers drawing room all my life! . . .
ever, succeed in providing womens work in
[Y]ou must look upon me as your vagabond son . .
the public sphere, establishing for numerous
. I shant cost you nearly as much as a son would
women an identity and source of employ-
have done, or had I married. You must consider me
ment. Although that public identity grew out
married or a son. (Woodham-Smith, 1983, p. 66)
of womens domestic and nurturing roles in
the family, the conditions of a modern society
required public as well as private forms of Ideas About Nursing
care. It is questionable whether more could
have been achieved at that point in time
Every day sanitary knowledge, or the knowl-
(King, 1988).
edge of nursing, or in other words, of how to put
A woman, Queen Victoria, presided over
the constitution in such a state as that it will
the age: Ironically, Queen Victoria, that
have no disease, or that it can recover from
panoply of family happiness and stubborn
disease, takes a higher place.
adversary of female independence, could not
help but shed her aura upon single women. F LORENCE N IGHTINGALE , N OTES ON
The queens early and lengthy widowhood, N URSING (1860/1969), P REFACE
her relentlessly spreading figure and com-
mensurately increasing empire, her obstinate Evelyn R. Barritt, professor of nursing
longevity which engorged generations of men and Nightingale scholar, suggested that
and the collective shocks of history, lent an nursing became a science when Nightingale
epic quality to the lives of solitary women identified the laws of nursing, also referred
(Auerbach, 1982, pp. 120121). Both to as the laws of health, or nature (Barritt,
Nightingale and the queen saw themselves as 1973; Nightingale, 1860/1969). The remain-
working through men, yet their lives added der of all nursing theory may be viewed as
new, unexpected, and powerful dimensions to mere branches and acorns, all fruit of the
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C H A P T E R 4 Florence Nightingales Legacy of Caring 47

roots of Nightingales ideas. Early writings most prominent Women Methodologists


of Nightingale, compiled in Notes on identified in The Women Founders of the
Nursing: What It Is and What It Is Not Social Sciences (McDonald, 1994). McDonald
(1860/1969), provided the earliest systemat- notes that Nightingale was firmly commit-
ic perspective for defining nursing. Accord- ted to . . . a determined, probabilistic social
ing to Nightingale, analysis and application science and goes on to state that: Indeed,
of universal laws would promote well- she [Nightingale] described the laws of
being and relieve the suffering of humanity. social science as Gods laws for the right
This was the goal of nursing. operation of the world (p. 186). Nightingale
As noted by the caring theorist Madeline was convinced of the necessity for evaluative
Leininger, Nightingale never defined human statistics to underpin rational approaches
care or caring in Nightingales Notes on Nursing to public administrations. Consistently she
(1859/1992, p. 31), and she goes on to wonder used the presentation of statistical data to
if Nightingale considered components of care prove her case that the costs of disease,
such as comfort, support, nurturance, and crime, and excess mortality was greater than
many other care constructs and characteristics the cost of sanitary improvements. In later
and how they would influence the reparative life, Nightingale endeavored to establish a
process. Although Nightingales conceptual- chair or readership at Oxford University to
izations of nursing, hygiene, the laws of health, teach Quetelets statistical approaches and
and the environment never explicitly identify probability theory. In todays world, this
the construct of caring, an underlying ethos of would translate to a commitment to evidence-
care and commitment to others echoes in her based practice as justification for nursings
words and, most importantly, resides in her value.
actions and the drama of her life. Karen Dennis and Patricia Prescott (1985)
Nightingale did not theorize in the way to note that including Nightingale among the
which we are accustomed today. Patricia nurse theorists has been a recent develop-
Winstead-Fry (1993), in a review of the ment. They make the case that nurses today
1992 commemorative edition of Nightingales continue to incorporate in their practice the
Notes on Nursing (1859/1992, p. 161), states: insight, foresight, and, most important, the
Given that theory is the interrelationship of clinical acumen of Nightingales more than
concepts which form a system of proposi- century and a half vision of nursing. As part of
tions that can be tested and used for predict- a larger study, they collected a large base of
ing practice, Nightingale was not a theorist. descriptions from both nurses and physicians
None of her major biographers present her as describing good nursing practice. More than
a theorist. She was a consummate politician 300 individual interviews were subjected to
and health care reformer. And our emerging content analysis; categories were named
21st century has never been more in need of inductively and validated by four members of
nurses who are consummate politicians and the project staff, separately.
health care reformers. Her words and ideas, Noting no marked differences in the
contextualized in the earlier portion of this descriptions obtained from either the nurses
chapter, ring differently than those of the or physicians, the authors report that despite
other nursing theorists you will study in their independent derivation, the categories
this book. However, her underlying ideas that emerged during the study bore a strik-
continue to be relevant and, some would ing resemblance to nursing practice as
argue, prescient. described by Nightingale: prevention of
Lynn McDonald, Canadian professor of illness and promotion of health, observation
sociology and editor of the Collected Works of of the sick, and attention to the physical envi-
Florence Nightingale, a 16-volume work still ronment. Also referred to by Nightingale
in progress, places Nightingale among the as the health of houses, this physical
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48 S E C T I O N II Evolution of Nursing Theory

environment included ventilation of both the her model of nursing: religion, science, war,
patients rooms and the larger environment and feminism, all of which are discussed in
of the house: light, cleanliness, and the tak- this chapter.
ing of food; attention to the interpersonal The assumptions in the following section
milieu, which included variety; and not were identified by Victoria Fondriest and Joan
indulging in superficialities with the sick or Osborne (1994).
giving them false encouragement.
Nightingales Assumptions
The authors note that the words change
1. Nursing is separate from medicine.
but the concepts do not (Dennis & Prescott,
2. Nurses should be trained.
1985, p. 80). In keeping with the tradition
3. The environment is important to the
established by Nightingale, they note that
health of the patient.
nurses continue to foster an interpersonal
4. The disease process is not important to
milieu that focuses on the person, while
nursing.
manipulating and mediating the environment
5. Nursing should support the environment
to put the patient in the best condition
to assist the patient in healing.
for nature to act upon him (Nightingale,
6. Research should be utilized through
1860/1969, p. 133).
observation and empirics to define the
Afaf I. Meleis (1997), nurse scholar, does
nursing discipline.
not compare Nightingale to contemporary
7. Nursing is both an empirical science and
nurse theorists; nonetheless, she refers to
an art.
her frequently. Meleis states that it was
8. Nursings concern is with the person in
Nightingales conceptualization of environ-
the environment.
ment as the focus of nursing activity and her
9. The person is interacting with the
de-emphasis of pathology, emphasizing
environment.
instead the laws of health (which she said
10. Sickness and wellness are governed by
were yet to be identified), that were the
the same laws of health.
earliest differentiation of nursing and medi-
11. The nurse should be observant and
cine. Meleis (1997, pp. 114116) describes
confidential.
Nightingales concept of nursing as includ-
ing the proper use of fresh air, light, The goal of nursing as described by
warmth, cleanliness, quiet, and the proper Nightingale is assisting the patient in his or
selection and administration of diet, all with her retention of vital powers by meeting his
the least expense of vital power to the or her needs, and thus, putting the patient in
patient. These ideas clearly had evolved the best condition for nature to act upon
from Nightingales observations and experi- (Nightingale, 1860/1969). This must not be
ences. The art of observation was identified interpreted as a passive state, but rather one
as an important nursing function in the that reflects the patients capacity for self-
Nightingale model. And this observation healing facilitated by nurses ability to create
was what should form the basis for nursing an environment conducive to health. The
ideas. Meleis speculates on how differently focus of this nursing activity was the proper
the theoretical base of nursing might have use of fresh air, light, warmth, cleanliness,
evolved if we had continued to consider quiet, proper selection and administration of
extant nursing practice as a source of ideas. diet, monitoring the patients expenditure of
Pamela Reed and Tamara Zurakowski energy, and observing. This activity was
(1983/1989, p. 33) call the Nightingale mod- directed toward the environment and the
el visionary. They state: At the core of all patient (see Nightingales Assumptions).
theory development activities in nursing today Health was viewed as an additive process,
is the tradition of Florence Nightingale. They the result of environmental, physical, and
also suggest four major factors that influenced psychological factors, not just the absence of
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C H A P T E R 4 Florence Nightingales Legacy of Caring 49

disease. Disease was the reparative process of Consistent with this caring base is
the body to correct a problem and could pro- Nightingales views on nursing as an art and a
vide an opportunity for spiritual growth. The science. Again, this was a reflection of the mar-
laws of health, as defined by Nightingale, riage, essential to Nightingales underlying
were those to do with keeping the person, and worldview, of science and spirituality. On the
the population, healthy. They were dependent surface, these might appear to be odd bedfel-
on proper environmental control, for example, lows; however, this marriage flows directly
sanitation. The environment was what the from Nightingales underlying religious and
nurse manipulated; it included the physical philosophic views, which were operational-
elements external to the patient. ized in her nursing practice. Nightingale was
Nightingale isolated five environmental an empiricist, valuing the science of obser-
components essential to an individuals health: vation with the intent of using that knowl-
clean air, pure water, efficient drainage, clean- edge to better the life of humankind. The
liness, and light. application of that knowledge required an
The patient is at the center of the Nightin- artists skill, far greater than that of the
gale model, which incorporates a holistic view painter or sculptor:
of the person as someone with psychological,
Nursing is an art; and if it is to be made an art, it
intellectual, and spiritual components. This is
requires as exclusive a devotion, as hard a prepara-
evidenced in her acknowledgment of the
tion, as any painters or sculptors work; for what is
importance of variety. For example, she
the having to do with dead canvas or cold marble,
wrote of the degree . . . to which the nerves
compared with having to do with the living bodythe
of the sick suffer from seeing the same walls,
Temple of Gods spirit? It is one of the Fine Arts; I had
the same ceiling, the same surroundings
almost said, the finest of the Fine Arts. (Florence
(Nightingale, 1860/1969). Likewise, her chapter
Nightingale, cited in Donahue, 1985, p. 469)
on chattering hopes and advice illustrates an
astute grasp of human nature and of interper- Nightingales ideas about nursing health,
sonal relationships. She remarked upon the the environment, and the person were
spiritual component of disease and illness, and grounded in experience; she regarded ones
she felt they could present an opportunity for sense observations as the only reliable means
spiritual growth. In this, all persons were of obtaining and verifying knowledge. Theory
viewed as equal. must be reformulated if inconsistent with
A nurse was defined as any woman who had empirical evidence. This experiential knowl-
charge of the personal health of somebody, edge was then to be transformed into empiri-
whether well, as in caring for babies and cally based generalizations, an inductive
children, or sick, as an invalid (Nightingale, process, to arrive at, for example, the laws of
1860/1969). It was assumed that all women, at health. Regardless of Nightingales commit-
one time or another in their lives, would nurse. ment to empiricism and experiential knowl-
Thus, all women needed to know the laws edge, her early education and religious experi-
of health. Nursing proper, or sick nursing, ence also shaped this emerging knowledge
was both an art and a science and required (Hektor, 1992).
organized, formal education to care for those According to Nightingales model, nursing
suffering from disease. Above all, nursing was contributes to the ability of persons to maintain
service to God in relief of man; it was a call- and restore health directly or indirectly through
ing and Gods work (Barritt, 1973). Nursing managing the environment. The person has a
activities served as an art form through which key role in his or her own health, and this health
spiritual development might occur (Reed & is a function of the interaction between person,
Zurakowski, 1983/1989). All nursing actions nurse, and environment. However, neither the
were guided by the nurses caring, which was person nor the environment is discussed as
guided by underlying ideas about God. influencing the nurse (Fig. 4-5).
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50 S E C T I O N II Evolution of Nursing Theory

Although it is difficult to describe the


Observation
interrelationship of the concepts in the
Personal Cleanliness Nightingale model, Figure 4-6 is a schema
Petty Management
that attempts to delineate this. Note the
prominence of observation on the outer
Light circle (important to all nursing functions) and
Health of Houses the interrelationship of the specifics of the
interventions, such as bed and bedding and
Cleanliness of Rooms cleanliness of rooms and walls, that go into
Ventilation and Warming making up the health of houses (Fondriest
& Osborne, 1994).
Bed and Bedding

Taking Food
Nightingales Legacy for 21st
What Food?
Century Nursing Practice
Noise
Order Philip and Beatrice Kalisch (1987, p. 26)
of Chattering Hopes
Significance and Advices
described the popular and glorified images
that arose out of the portrayals of Florence
Variety
Nightingale during and after the Crimean
Figure 4 5 Perspective on Nightingales 13 canons. Warthat of nurse as self-sacrificing, refined,
(Illustration developed by V. Fondriest, RN, BSN, and virginal, and an angel of mercy, a far less
J. Osborne, RN, C BSN in October 1994.) threatening image than one of educated and

"Nursing"
Observation

Management

Ventilation & Warming


"Environment"

Health of Houses (Pure Air, Water & Light)

Bed &
Bedding Taking Food
Light,
Noise & Cleanliness
Variety of Rooms &
Walls

What Food ?
Chattering
Personal
Hopes &
Cleanliness
Advices

Figure 4 6 Nightingales model of nursing and the environment. (Illustration developed by V. Fondriest, RN,
BSN, and J. Osborne, RN, C BSN.)
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C H A P T E R 4 Florence Nightingales Legacy of Caring 51

skilled professional nurses. They attribute of the functions into which she had been
nurses low pay to the perception of nursing forced in the Crimea. Her caring encom-
as a calling, a way of life for devoted passed a broadened spherethat of the
women with private means, such as Florence British Army and, indeed, the entire British
Nightingale (Kalisch & Kalisch, 1987, Commonwealth.
p. 20). Well over 100 years later, the amount Themes in contemporary nursing practice
of scholarship on Nightingale provides focusing on evidence-based practice and cur-
a more realistic portrait of a complex and ricula championing cultures of safety and
brilliant woman. To quote Auerbach (1982) quality are all found in the life and works
and Strachey (1918), she was a demon, a of Florence Nightingale. I would venture to
rebel . . . say that almost all contemporary nursing
Florence Nightingales legacy of caring practice settings echo some aspect of the
and the activism it implies is carried on ideasand idealsof Nightingale. Themes
in nursing today. There is a resurgence and of Nightingale, the environmentalist, are crit-
inclusion of concepts of spirituality in ical to nursing practice for the individual,
current nursing practice and a delineation the community, and global health. An exem-
of nursings caring base that in essence plar of practice personifying Nightingales
began with the nursing life of Florence approach and practice would be a larger-than-
Nightingale. Nightingales caring, as demon- life nurse hero/heroine championing current
strated in this chapter, extended beyond the health care reform by designing health care
individual patient, beyond the individual systems that are truly responsive to the needs of
person. She herself said that the specific the populace and that extend cross-culturally
business of nursing was the least important and globally.

Summary
The unique aspects of Florence Nightingales of caring in an unjust health care system that
personality and social position, combined does not value caring. Let us look again to
with historical circumstances, laid the Florence Nightingale for inspiration, for she
groundwork for the evolution of the modern remains a role model par excellence on the
discipline of nursing. Are the challenges and transformation of values of caring into an
obstacles that we face today any more daunt- activism that could potentially transform our
ing than what confronted Nightingale when current health care system into a more
she arrived in the Crimea in 1854? Nursing humanistic and just one. Her activism situates
for Florence Nightingale was what we might her in the context of justice-making. Justice-
call today her centering force. It allowed her making is understood as a manifestation of
to express her spiritual values as well as compassion and caring, for it is actions that
enabled her to fulfill her needs for leadership bring about justice (Boykin & Dunphy, 2002,
and authority. As historian Susan Reverby p. 16). Florence Nightingales legacy of con-
noted, today we are challenged with the necting caring with activism can then truly be
dilemma of how to practice our integral values said to continue.

References

Ackernecht, E. (1982). A short history of medicine. Auerbach, N. (1982). Women and the demon: The life of a Vic-
Baltimore: Johns Hopkins University Press. torian myth. Cambridge, MA: Harvard University Press.
Arnstein, W. (1988). Britain: Yesterday and today. Barritt, E. R. (1973). Florence Nightingales values and
Lexington, MA: D. C. Heath. modern nursing education. Nursing Forum, 12, 747.
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Boykin, A., & Dunphy, L. M. (2002). Justice-making: Nightingale, F. (1852/1979). Cassandra, with an intro-
Nursings call. Policy, Politics, & Nursing Practice, 3, duction by Myra Stark. Westbury, NY: Feminist
1419. Press.
Bunting, S., & Campbell, J. (1990). Feminism and Nightingale, F. (1859). Notes on nursing: What it is and
nursing: An historical perspective. Advances in what it is not. London: Harrison & Sons.
Nursing Science, 12, 1124. Nightingale, F. (1859/1992). Notes on nursing:
Calabria, M., & Macrae, J. (Eds.). (1994). Suggestions Commemorative edition with commentaries by
for thought by Florence Nightingale: Selections contemporary nursing leaders. Philadelphia: J. B.
and commentaries. Philadelphia: University of Lippincott.
Pennsylvania Press. Nightingale, F. (1860). Suggestions for thought to searchers
Cohen, I. B. (1981). Florence Nightingale: The after religious truths (vols. 23). London: George
passionate statistician. Scientific American, 250(3), E. Eyre & William Spottiswoode.
128137. Nightingale, F. (1860/1969). Notes on nursing: What it is
Cook, E. T. (1913). The life of Florence Nightingale and what it is not. New York: Dover.
(vols. 12). London: Macmillan. Palmer, I. S. (1977). Florence Nightingale: Reformer,
Dennis, K. E., & Prescott, P. A. (1985). Florence reactionary, research. Nursing Research, 26, 8489.
Nightingale: Yesterday, today and tomorrow. Perkins, J. (1987). Women and marriage in nineteenth
Advances in Nursing Science, 7(2), 6681. century England. Chicago: Lyceum Books.
Dolan, J. (1971). The grace of the great lady. Chicago: Quinn, V., & Prest, J. (Eds.). (1981). Dear Miss
Medical Heritage Society. Nightingale: A selection of Benjamin Jowetts letters to
Donahue, P. (1985). Nursing: The finest art. St. Louis, Florence Nightingale, 18601893. Oxford: Clarendon
MO: C. V. Mosby. Press.
Dossey, B. (1998). Florence Nightingale: A 19th Reed, P. G., & Zurakowski, T. L. (1983/1989).
century mystic. Journal of Holistic Nursing, 16(2), Nightingale: A visionary model for nursing. In:
111164. J. Fitzpatrick & A. Whall (Eds.), Conceptual models
Fondriest, V., & Osborne, J. (1994). A theorist before of nursing: Analysis and application. Bowie, MD:
her time? Presentation, NGR 5110, Nursing Robert J. Brady.
Theory and Advanced Practice Nursing, School Reverby, S. M. (1987). Ordered to care: The dilemma
of Nursing, Florida International University, of American nursing (18651945). New York:
N. Miami, FL. Cambridge University Press.
Goldie, S. (1987). I have done my duty: Florence Nightingale Rosenberg, C. (1979). Healing and history. New York:
in the Crimean War, 18541856. Iowa City: University Science History Publications.
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Gourley, J. (2003). Florence Nightingale and the health Egypt: A journey on the Nile, 18491850. New York:
of the Raj. Cornwall, UK: MPG Books. Weidenfeld & Nicolson.
Hektor, L. M. (1992). Nursing, science, and gender: Shyrock, R. (1959). The history of nursing. Philadelphia:
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Houghton, W. (1957). The Victorian frame of mind. cal influences on Florence Nightingale, an
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Kalisch, P. A., & Kalisch, B. J. (1987). The changing Manning, Florence Nightingale, Dr. Arnold, General
image of the nurse. Menlo Park, CA: Addison- Gordon. London: Chatto & Windus.
Wesley. Summers, A. (1988). Angels and citizens: British women
King, M. G. (1988). Gender: A hidden issue in nursings as military nurses, 18541914. London: Routledge &
professionalizing reform movement. Boston: Boston Kegan Paul.
University School of Nursing. In Strategies for Theory Swazey, J., & Reed, K. (1978). Louis Pasteur: Science
Development V, March 1012. and the application of science. In J. Swazey & K.
Macrae, J. (1995). Nightingales spiritual philosophy and Reed (Eds.), Todays medicine, tomorrows science.
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Nursing Scholarship, 27, 810. NIH 78244. Washington, DC: U.S. Government
Meleis, A. I. (1997). Theoretical nursing: Development Printing Office.
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Monteiro, L. (1984). On separate roads: Florence Florence Nightingale: Selected letters. Cambridge,
Nightingale and Elizabeth Blackwell. Signs: Journal MA: Harvard University Press.
of Women in Culture & Society, 9, 520533. Watson, J. (1992). Commentary. In Notes on nursing:
Newman, M. A. (1972). Nursings theoretical evolution. What it is and what it is not (pp. 8085). Commemo-
Nursing Outlook, 20, 449453. rative edition. Philadelphia: J. B. Lippincott.
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Welch, M. (1986). Nineteenth-century philosophic Winstead-Fry, P. (1993). Book review: Notes on


influences on Nightingales concept of the person. nursing: What it is and what it is not. Commemora-
Journal of Nursing History, 1(2), 311. tive edition. Nursing Science Quarterly, 6(3),
Welch, M. (1990). Florence Nightingale: The social 161162.
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Widerquist, J. G. (1992). The spirituality of Florence
Nightingale. Nursing Research, 41, 4955.
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Chapter
5
Twentieth-Century Nursing:
Ernestine Wiedenbach,
Virginia Henderson, and Lydia
Halls Contributions to Nursing
Theory and Their Use
in Practice
S HIRLE Y C. G ORDON , T HERIS A.
T OUH Y, T HERESA G ESSE , M ARCIA
D OMBRO , AND N ET TIE B IRNBACH

Introducing the Theorists Introducing the Theorists


Overview of 20th-Century Nursing: Ernestine Wiedenbach, Virginia Henderson,
Wiedenbach, Henderson, and Halls and Lydia Hall are three of the most important
Conceptualizations of Nursing
influences on nursing theory development of
Practice Applications
the 20th century. Indeed, their work continues
Practice Exemplars
to ground nursing thought in the new century.
Summary
The work of each of these nurse scholars was
References
based on nursing practice, and today some of
this work might be referred to as practice the-
ories. Concepts and terms they first used are
heard today around the globe.
This chapter provides a brief overview of
three important 20th-century nursing theo-
rists. The content of this chapter is partially
based on work from scholars who have stud-
ied or worked with these theorists and who
wrote chapters for the first and/or second
Ernestine Wiedenbach Virginia Henderson editions of Nursing Theories and Nursing
Practice (Gesse, Dombro, Gordon, & Rittman,
2006; Gordon, 2001; Touhy & Birnbach,
2006). For a wealth of additional information
on these nurses, scholars, researchers, thinkers,
writers, practitioners, and educators, please
consult the reference and bibliography sec-
tions at the end of this chapter.

Ernestine Wiedenbach
Wiedenbach was born in 1900 in Germany to
Lydia Hall an American mother and a German father
who emigrated to the United States when

54
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C H A P T E R 5 20th-Century Nursing: Wiedenbach, Henderson, and Hall 55

Ernestine was a child. She received a bachelor admired Goodrichs intellectual abilities and
of arts degree from Wellesley College in 1922 stated: Whenever she visited our unit, she
and graduated from Johns Hopkins School of lifted our sights above techniques and rou-
Nursing in 1925 (Nickel, Gesse, & MacLaren, tine (Henderson, 1991, p. 11). Henderson
1992). After completing a master of arts at credited Goodrich with inspiring her with the
Columbia Univeristy in 1934, she became a ethical significance of nursing (Henderson,
professional writer for the American Journal of 1991, p. 10).
Nursing and played a critical role in the As a member of society during a war,
recruitment of nursing students and military Henderson considered it a privilege to care
nurses during World War II. At age 45, for sick and wounded soldiers (Henderson,
she began her studies in nurse-midwifery. 1960). This wartime experience forever
Wiedenbachs roles as practitioner, teacher, influenced her ethical understanding of
author, and theorist were consolidated as nursing and her appreciation of the impor-
a member of the Yale University School tance and complexity of the nursepatient
of Nursing, where Yale colleagues William relationship.
Dickoff and Patricia James encouraged her She continued to explore the nature of
development of prescriptive theory (Dickoff, nursing as her student experiences exposed
James, & Wiedenbach, 1968). Even after her her to different ways of being in relationships
retirement in 1966, she and her lifelong with patients and their families. For instance,
friend Caroline Falls offered informal semi- a pediatric experience as a student at Boston
nars in Miami, always reminding students Floating Hospital introduced Henderson
and faculty of the need for clarity of purpose, to patient-centered care in which nurses were
based on reality. She even continued to use assigned to patients instead of tasks, and warm,
her gift for writing to transcribe books for the nursepatient relationships were encouraged
blind, including a Lamaze childbirth manual, (Henderson, 1991). After a summer spent
which she prepared on her Braille typewriter. with the Henry Street Visiting Nurse Agency
Ernestine Wiedenbach died in April 1998 at in New York City, Henderson began to appre-
the age of 98. ciate the importance of getting to know the
patients and their environments. She enjoyed
the less formal visiting nurse approach to
Virginia Henderson patient care and became skeptical of the
Born in Kansas City, Missouri, in 1897, ability of hospital regimes to alter patients
Virginia Avenel Henderson was the fifth of unhealthy ways of living upon returning home
eight children. With two of her brothers (Henderson, 1991). She entered Teachers
serving in the armed forces during World College at Columbia University, earning her
War I, and in anticipation of a critical short- baccalaureate degree in 1932 and her masters
age of nurses, Virginia Henderson entered degree in 1934. She continued at Teachers
the Army School of Nursing at Walter Reed College as an instructor and associate profes-
Army Hospital. It was there that she began to sor of nursing for the next 20 years.
question the regimentalization of patient care Virginia Henderson presented her defini-
and the concept of nursing as ancillary to tion of the nature of nursing in an era when
medicine (Henderson, 1991). She described few nurses had ventured into describing the
her introduction to nursing as a series of complex phenomena of modern nursing.
almost unrelated procedures, beginning with Henderson wrote about nursing the way she
an unoccupied bed and progressing to aspira- lived it: focusing on what nurses do, how
tion of body cavities (Henderson, 1991, nurses function, and on nursings unique
p. 9). It was also at Walter Reed Army role in health care. Her works are beauti-
Hospital that she met Annie W. Goodrich, fully written in jargon-free, everyday lan-
the dean of the School of Nursing. Henderson guage. Her search for a definition of nursing
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56 S E C T I O N II Evolution of Nursing Theory

ultimately influenced the practice and educa- Nurse Service of New York from 1941 to
tion of nursing around the world. Her pio- 1947 and was a member of the nursing faculty
neer work in the area of identifying and at Fordham Hospital School of Nursing from
structuring nursing knowledge has provided 1947 to 1950. Hall was subsequently appoint-
the foundation for nursing scholarship for ed to a faculty position at Teachers College,
generations to come. where she developed and implemented a pro-
Henderson has been heralded as the great- gram in nursing consultation and joined a
est advocate for nursing libraries worldwide. community of nurse leaders. At the same
Of all her contributions to nursing, Virginia time, she was involved in research activities
Hendersons work on the identification and for the U.S. Health Service. Active in nurs-
control of nursing literature is perhaps her ings professional organizations, Hall also
greatest. In the 1950s, there was an increasing provided volunteer service to the New York
interest on the part of the profession to estab- City Board of Education, Youth Aid, and
lish a research basis for the nursing practice. It other community associations (Birnbach,
was also recognized that the body of nursing 1988).
knowledge was unstructured and therefore Halls model, which she designed and put
inaccessible to practicing nurses and educa- into place in the Loeb Center for Nursing
tors. After the completion of her revised text and Rehabilitation at Montefiore Medical
in 1955, Henderson moved to Yale University Center in Bronx, New York, was her most
and began what would become a distin- significant contribution to nursing practice.
guished career in library science research. Opened in 1963, the Loeb Center was the
Henderson encouraged nurses to become culmination of five years of planning and
active in the work of classifying nursing liter- construction under Halls direction. The
ature. In 1990, the Sigma Theta Tau Interna- circumstances that brought Hall and the
tional Library was named in her honor. Loeb Center together date back to 1947,
Henderson insisted that if the library was when Dr. Martin Cherkasky was named
to bear her name, the electronic networking director of the new hospital-based home care
system would have to advance the work of division of Montefiore Medical Center in
staff nurses by providing them with current, Bronx, New York. At that time, Hall was
jargon-free information wherever they were employed by the Visiting Nurse Service at its
based (McBride, 1997). Bronx office and had frequent contact with
the Montefiore home care program. Hall
Lydia Hall and Cherkasky shared congruent philoso-
Visionary, risk taker, and consummate profes- phies regarding health care and the delivery
sional, Lydia Hall touched all who knew her of quality service, which served as the foun-
in a special way. Born in 1906, she inspired dation for a long-standing professional rela-
commitment and dedication through her tionship (Birnbach, 1988).
unique conceptual framework for nursing In 1950, Cherkasky was appointed director
practice that viewed professional nursing as of the Montefiore Medical Center. During
the key to the care and rehabilitation of the early years of his tenure, existing tradi-
patients. tional convalescent homes fell into disfavor.
A 1927 graduate of the York Hospital Convalescent treatment was undergoing rapid
School of Nursing in Pennsylvania, Hall held change owing largely to medical advances,
various nursing positions during the early new pharmaceuticals, and technological
years of her career. In the mid-1930s, developments. One of the homes that closed
she enrolled at Teachers College, Columbia as a result of the emerging trends was the
University, where she earned a Bachelor of Solomon and Betty Loeb Memorial Home
Science degree in 1937, and a Master of Arts in Westchester County, New York. Cherkasky
degree in 1942. She worked with the Visiting and Hall collaborated in convincing the board
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C H A P T E R 5 20th-Century Nursing: Wiedenbach, Henderson, and Hall 57

of the Loeb Home to join with Montefiore in and the excitement she generated, Hall was
founding the Loeb Center for Nursing and indeed a force for change. At a time when
Rehabilitation. Using the proceeds from the task-oriented team nursing was the preferred
sale of the Loeb Home, plans for the Loeb practice model in most institutions, she imple-
Center construction proceeded over a 5-year mented a professional patient-centered frame-
period, from 1957 to 1962. The Loeb Center work whereby patients received a standard of
was separately administered, with its own care unequaled anywhere else. At the Loeb
board of trustees that interrelated with the Center, Lydia Hall created an environment in
Montefiore board, giving Hall considerable which nurses were empowered, in which
autonomy in developing the centers policies patients needs were met through a continuum
and procedures. of care, and in which, according to Genrose
For example, under Halls direction, nurses Alfano, nursing was raised to a high therapeu-
selected patients for the Loeb Center based on tic level (personal communication, January 27,
a nursing assessment of an individual patients 1999).
potential for rehabilitation. Qualified profes-
sional nurses provided direct care to patients
and coordinated needed services. Hall fre- Overview of 20th-Century
quently described the center as a halfway Nursing: Wiedenbach,
house on the road home (Hall, 1963, p. 2),
where the nurse worked with the patients as Henderson, and Halls
active participants in achieving desired out- Conceptualizations of
comes. Over time, the effectiveness of Halls Nursing
practice model was validated by the significant
Virginia Henderson, sometimes known as the
decline in the number of readmissions among
modern day Florence Nightingale, developed
former Loeb patients as compared with those
the definition of nursing that is most well
who received other types of posthospital care
known internationally. Ernestine Wiedenbach
(Montefiore cuts, 1966).
gave us new ways to think about nursing prac-
In 1967, Hall received the Teachers College
tice and nursing scholarship, introducing us to
Nursing Alumni Award for distinguished
the ideas of (1) nursing as a professional prac-
achievement in nursing practice. She shared
tice discipline and (2) nursing practice theory.
her innovative ideas about the nursing practice
Lydia Hall challenged us to think in new ways
with numerous audiences around the country
about the key role of professional nursing in
and contributed articles to nursing journals. In
the care and rehabilitation of patients. Each
those articles, she referred to nurses using
of these nurses helped us focus on the patient,
feminine pronouns. Because gender-neutral
instead of on the tasks to be done, and to plan
language was not yet an accepted style, and
care to meet needs of the person. Each of
women comprised 96 percent of the nursing
these women emphasized caring based on the
workforce, the feminine pronoun was used
perspective of the individual being cared for
almost exclusively.
through observing, communicating, design-
Hall died of heart disease on February 27,
ing, and reporting. Each was concerned with
1969, at Queens Hospital in New York. In
the unique aspects of nursing practice and
1984, she was inducted into the American
scholarship and with the essential question of
Nurses Association Hall of Fame. Following
What is nursing?
Halls death, her legacy was kept alive at the
Loeb Center until 1984, under the capable
leadership of her friend and colleague Genrose Wiedenbachs Conceptualizations
Alfano. of Nursing
Remembered by her colleagues for her pas- Initial work on Wiedenbachs prescriptive
sion for nursing, her flamboyant personality, theory is presented in her article in the
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58 S E C T I O N II Evolution of Nursing Theory

American Journal of Nursing (1963) and her for what she does and for the outcomes of
book, Meeting the Realities in Clinical Teaching her action. Nursing action, then, is deliber-
(1969). ate action that is mutually understood
Her explanation of prescriptive theory is and agreed upon and that is both patient-
that Account must be taken of the motivat- directed and nurse-directed (Wiedenbach,
ing factors that influence the nurse not only 1970, p. 5).
in doing what she does, but also in doing it 3. The realities are the aspects of the immedi-
the way she does it with the realities that ate nursing situation that influence the
exist in the situation in which she is func- results the nurse achieves through what
tioning (Wiedenbach, 1970, p. 2). Three she does (Wiedenbach, 1970, p. 3). These
ingredients essential to the prescriptive include the physical, psychological, emo-
theory are: tional, and spiritual factors in which nurs-
ing action occurs. Within the situation are
1. The nurses central purpose in nursing is the these components:
nurses professional commitment. For
The agent, who is the nurse supplying
Wiedenbach, the central purpose in nurs-
the nursing action
ing is to motivate the individual and/or
The recipient, or the patient receiving
facilitate his efforts to overcome the obsta-
this action or on whose behalf the action
cles that may interfere with his ability to
is taken
respond capably to the demands made of
The framework, comprised of situational
him by the realities in his situation
factors that affect the nurses ability to
(Wiedenbach, 1970, p. 4). She emphasized
achieve nursing results
that the nurses goals are grounded in the
The goal, or the end to be attained
nurses philosophy, those beliefs and
through nursing activity on behalf of the
values that shape her attitude toward life,
patient
toward fellow human beings and toward
The means, the actions and devices
herself. The three concepts that epitomize
through which the nurse is enabled to
the essence of such a philosophy are:
reach the goal
(1) reverence for the gift of life; (2) respect
for the dignity, autonomy, worth, and
individuality of each human being; and
Hendersons Definition of Nursing
(3) resolution to act dynamically in relation
and Components of Basic Nursing
to ones beliefs (Wiedenbach, 1970, p. 4). Care
She recognized that nurses have different While working on the 1955 revision of the
values and various commitments to nurs- Textbook of the Principles and Practice of Nursing,
ing and that to formulate ones purpose Henderson focused on the need to be clear
in nursing is a soul-searching experi- about the function of nurses. She opened the
ence. She encouraged each nurse to first chapter with the following question:
undergo this experience and be willing What is nursing and what is the function of
and ready to present your central purpose the nurse? (Harmer & Henderson, 1955, p. 1).
in nursing for examination and discus- Henderson believed this question was funda-
sion when appropriate (Wiedenbach, mental to anyone choosing to pursue the
1970, p. 5). study and practice of nursing.
2. The prescription indicates the broad general
action that the nurse deems appropriate to Definition of Nursing
fulfillment of her central purpose. The nurse Her often-quoted definition of nursing first
will have thought through the kind of appeared in the fifth edition of Textbook of
results to be sought and will take action to the Principles and Practice of Nursing
obtain these results, accepting accountability (Harmer & Henderson, 1955, p. 4):
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C H A P T E R 5 20th-Century Nursing: Wiedenbach, Henderson, and Hall 59

Nursing is primarily assisting the individual (sick or 14. Learn, discover, or satisfy the curiosity that
well) in the performance of those activities con- leads to normal development and health
tributing to health or its recovery (or to a peaceful and use the available health facilities.
death), that he would perform unaided if he had
the necessary strength, will, or knowledge. It is like- Halls Care, Cure, and Core Model
wise the unique contribution of nursing to help Hall enumerated three aspects of the person
people be independent of such assistance as soon as patient: the person, the body, and the
as possible. disease. She envisioned these aspects as over-
lapping circles of care, core, and cure that
In presenting her definition of nursing,
influence each other.
Henderson hoped to encourage others to
Everyone in the health professions either
develop their own working concept of nursing
neglects or takes into consideration any or all
and nursings unique function in society. She
of these, but each profession, to be a profes-
believed the definitions of the day were too
sion, must have an exclusive area of expertness
general and failed to differentiate nurses from
with which it practices, creates new practices,
other members of the health team, which led
new theories, and introduces newcomers to its
to the following questions: What is nursing
practice (Hall, 1965, p. 4).
that is not also medicine, physical therapy,
Hall believed that medicines responsibility
social work, etc.? and What is the unique
was the areas of pathology and treatment. The
function of the nurse? (Harmer & Henderson,
area of person, which, according to Hall, had
1955, p. 4).
been sadly neglected, belongs to a number of
Based on Hendersons definition, and
professions, including psychiatry, social work,
after coining the term basic nursing care,
and the ministry, among others. She saw nurs-
Henderson identified 14 components of basic
ings expertise as the area of body as body, and
nursing care that reflect needs pertaining to
also as influenced by the other two areas. Hall
personal hygiene and healthful living, includ-
clearly stated that the focus of nursing is the
ing helping the patient carry out the physi-
provision of intimate bodily care. She reflected
cians therapeutic plan (Henderson, 1960;
that the public has long recognized this as
1966, pp. 1617):
belonging exclusively to nursing (Hall, 1958,
1. Breathe normally. 1964, 1965). To be expert, the nurse must
2. Eat and drink adequately. know how to modify the care depending on
3. Eliminate bodily wastes. the pathology and treatment while consider-
4. Move and maintain desirable postures. ing the patients unique needs and personality.
5. Sleep and rest. Based on her view of the person as patient,
6. Select suitable clothesdress and undress. Hall conceptualized nursing as having three
7. Maintain body temperature within aspects, and she delineated the area that is the
normal range by adjusting clothing and specific domain of nursing and those areas
modifying the environment. that are shared with other professions (Hall,
8. Keep the body clean and well groomed 1955, 1958, 1964, 1965) (Fig. 5-1). Hall
and protect the integument. believed that this model reflected the nature
9. Avoid dangers in the environment and of nursing as a professional interpersonal
avoid injuring others. process. She visualized each of the three over-
10. Communicate with others in expressing lapping circles as an aspect of the nursing
emotions, needs, fears, or opinions. process related to the patient, to the support-
11. Worship according to ones faith. ing sciences and to the underlying philosoph-
12. Work in such a way that there is a sense ical dynamics (Hall, 1958, p. 1). The circles
of accomplishment. overlap and change in size as the patient pro-
13. Play or participate in various forms of gresses through a medical crisis to the rehabil-
recreation. itative phase of the illness. In the acute care
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60 S E C T I O N II Evolution of Nursing Theory

To make the distinction between a trade and a pro-


fession, let me say that the laying on of hands to
The Person wash around a body is an activity, it is a trade; but if
Social Sciences you look behind the activity for the rationale and
Therapeutic use of self
aspects of nursing intent, look beyond it for the opportunities that the
"The Core" activity opens up for something more enriching in
growth, learning and healing production on the part
of the patientyou have got a profession. Our intent
The Disease
Pathological and when we lay hands on the patient in bodily care is
The Body
Natural and biological therapeutic sciences to comfort. While the patient is being comforted, he
sciences Seeing the patient and
family through the feels close to the comforting one. At this time, his
Intimate bodily care
aspects of nursing medical care person talks out and acts out those things that con-
"The Care" aspects of nursing
"The Cure"
cern himgood, bad, and indifferent. If nothing
more is done with these, what the patient gets is
ventilation or catharsis, if you will. This may bring
Figure 5 1 Care, core, and cure model. (From Hall, relief of anxiety and tension but not necessarily
L. [1964, February]. Nursing: What is it? The Canadian learning. If the individual who is in the comforting
Nurse, 60[2], 151. Reproduced with permission from The
role has in her preparation all of the sciences whose
Canadian Nurse.)
principles she can offer a teaching-learning experi-
ence around his concerns, the ones that are most
phase, the cure circle is the largest. During the effective in teaching and learning, then the com-
evaluation and follow-up phase, the care circle forter proceeds to something beyondto what I call
is predominant. Halls framework for nursing nurturersomeone who fosters learning, some-
has been described as the Care, Core, and Cure one who fosters growing up emotionally, someone
Model (Chinn & Jacobs, 1987; Marriner- who even fosters healing (Hall, 1969, p. 86).
Tomey, Peskoe, K & Gumm, S. 1989; Stevens-
Barnum, 1990).
Cure
Care The second area of the nursing process is
Hall suggested that the part of nursing shared with medicine and is labeled the
that is concerned with intimate bodily care cure. Hall (1958) asserted that this medical
(e.g., bathing, feeding, toileting, positioning, aspect of nursing may be viewed as the nurse
moving, dressing, undressing, and maintain- assisting the doctor by assuming medical
ing a healthful environment) belongs exclu- tasks/functions or viewed as the nurse helping
sively to nursing. Nursing is required when the patient through his or her medical, surgi-
people are not able to undertake these activ- cal, and rehabilitative care in the role of com-
ities for themselves. This aspect provided forter and nurturer. Hall felt that the nursing
the opportunity for closeness and required profession was assuming more and more of
seeing the process as an interpersonal rela- the medical aspects of care while at the same
tionship (Hall, 1958). Hall labeled this time relinquishing the nurturing process of
aspect care and identified knowledge in nursing to less well-prepared persons.
the natural and biological sciences as foun-
dational to practice. The intent of bodily Interestingly enough, physicians do not have practical
care is to comfort the patient. Through this doctors. They dont need them . . . they have nurses.
comforting, the patient as a person, as well Interesting, too, is the fact that most nurses show
as his or her body, responds to the physical by their delegation of nurturing to others, that they
care. Hall cautioned against viewing inti- prefer being second class doctors to being first
mate bodily care as a task that can be per- class nurses. This is the prerogative of any nurse.
formed by anyone: If she feels better in this role, why not? One good
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C H A P T E R 5 20th-Century Nursing: Wiedenbach, Henderson, and Hall 61

reason why not for more and more nurses is that explain my nursing stuff to get the patient to do
with this increasing trend, patients receive from pro- what we want him to do, or how can I understand
fessional nurses second class doctoring; and from my patient so that I can handle him better. Instead
practical nurses, second class nursing. Some nurses her goals are linked up with what is the problem?
would like the public to get first class nursing. Seeing and how can I help the patient understand him-
the patient through [his or her] medical care without self? as he participates in problem facing and solv-
giving up the nurturing will keep the unique opportu- ing. In this way, the nurse recognizes that the pow-
nity that personal closeness provides to further [the] er to heal lies in the patient and not in the nurse,
patients growth and rehabilitation. (Hall, 1958, p. 3) unless she is healing herself. She takes satisfaction
and pride in her ability to help the patient tap this
source of power in his continuous growth and
Core development. She becomes comfortable working
The third area that nursing shares with all of cooperatively and consistently with members of
the helping professions is that of using rela- other professions, as she meshes her contributions
tionships for therapeutic effectthe core. with theirs in a concerted program of care and
This area emphasizes the social, emotional, rehabilitation. (Hall, 1958, p. 5)
spiritual, and intellectual needs of the patient
Hall believed that the role of professional
in relation to family, institution, community,
nursing was enacted through the provision of
and the world (Hall, 1955, 1958, 1965).
care that facilitates the interpersonal process
Knowledge that is foundational to the core is
and invites the patient to learn to reach the
based on the social sciences and on therapeu-
core of his difficulties while seeing him
tic use of self. Through the closeness offered
through the cure that is possible. Through the
by the provision of intimate bodily care, the
professional nursing process, the patient has
patient will feel comfortable enough to
the opportunity to see the illness as a learning
explore with the nurse who he is, where he is,
experience from which he may emerge even
where he wants to go, and will take or refuse
healthier than before his illness (Hall, 1965).
help in getting therethe patient will make
amazingly more rapid progress toward recov-
ery and rehabilitation (Hall, 1958, p. 3). Hall Practice Applications
believed that through this process, the patient
would emerge as a whole person.
The practice of clinical nursing is goal directed,
Knowledge and skills the nurse needs to
deliberately carried out, and patient centered.
use self therapeutically include knowing self
and learning interpersonal skills. The goals of W IEDENBACH (1964, P. 23)
the interpersonal process are to help patients
to understand themselves as they participate Wiedenbach
in problem focusing and problem solving. Figure 5-2 represents a spherical model that
Hall discussed the importance of nursing with depicts the experiencing individual as the
the patient as opposed to nursing at, to, or for central focus (Wiedenbach, 1964). This model
the patient. Hall reflected on the value of the and detailed charts were later edited and pub-
therapeutic use of self by the professional lished in Clinical Nursing: A Helping Art
nurse when she stated: (Wiedenbach, 1964).
In a paper entitled A Concept of Dynamic
The nurse who knows self by the same token can
Nursing Wiedenbach (1962, p. 7), described
love and trust the patient enough to work with him
the model as follows:
professionally, rather than for him technically, or at
him vocationally. In its broadest sense, Practice of Dynamic Nursing
Her goals cease being tied up with where can may be envisioned as a set of concentric circles,
I throw my nursing stuff around, or how can I with the experiencing individual in the circle at its
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62 S E C T I O N II Evolution of Nursing Theory

activities related to basic nursing care. Relating


EARCH
RES the conceptualization of basic care components
NURS
N
IN
G with the unique functions of nursing provided
IO BORAT A
AT L L A
I O the initial groundwork for introducing the
CO N ADM

D
N
UC

concept of independent nursing practice. In

M
O IN
TI

IN
ED

I
her 1966 publication, The Nature of Nursing,

IST
A

ST
NURSING

Henderson stated: It is my contention that the


NTIFI

RATION

RATION
TION

EXPERI ENCI NG nurse is, and should be legally, an independent

CO-OR
I NDI VI DUAL
IDE

practitioner and able to make independent

AD
UC
TION

judgments as long as he, or she, is not diagnos-

VAN
R

DI
VA
T

LIDATION S
ICA

N ing, prescribing treatment for disease, or mak-

C
AT

ED
N
S

N
L

U CO IO
ing a prognosis, for these are the physicians
UB

R N N

ST
UD S I N O
TI
P

Y G ORGANIZ
A
functions (Henderson, 1966, p. 22).
Furthermore, Henderson believed that
functions pertaining to patient care could
Figure 5 2 Professional nursing practice focus be categorized as nursing and non-nursing.
and components. (Reprinted with permission from the She believed that limiting nursing activities
Wiedenbach Reading Room [1962], Yale University School to nursing care was a useful method of
of Nursing.)
conserving professional nurse power (Harmer
& Henderson, 1955). She defined non-nursing
functions as those that are not a service to
core. Direct service, with its three components,
the person (mind and body) (Harmer &
identification of the individuals experienced need
Henderson, 1955). For Henderson, exam-
for help, ministration of help needed, and validation
ples of non-nursing functions included
that the help provided fulfilled its purpose, fills the
ordering supplies, cleaning and sterilizing
circle adjacent to the core. The next circle holds the
equipment, and serving food (Harmer &
essential concomitants of direct service: coordina-
Henderson, 1955).
tion, i.e., charting, recording, reporting, and confer-
At the same time, Henderson was not in
ring; consultation, i.e., conferencing, and seeking
favor of the practice of assigning patients to
help or advice; and collaboration, i.e., giving assis-
lesser trained workers on the basis of complex-
tance or cooperation with members of other profes-
ity level. For Henderson, all nursing care is
sional or nonprofessional groups concerned with
essentially complex because it involves constant
the individuals welfare. The content of the fourth
adaptation of procedures to the needs of the
circle represents activities which are essential to the
individual (Harmer & Henderson, 1955, p. 9).
ultimate well-being of the experiencing individual,
As the authority on basic nursing care,
but only indirectly related to him: nursing education,
Henderson believed that the nurse has the
nursing administration, and nursing organizations.
responsibility to assess the needs of the indi-
The outermost circle comprises research in nursing,
vidual patient, help individuals meet their
publication, and advanced study, the key ways to
health needs, and/or provide an environment
progress in every area of practice.
in which the individual can perform activities
Wiedenbachs nursing practice application unaided. It is the nurses role, according to
of her prescriptive theory was evident in her Henderson, to get inside the patients skin
practice examples. These often related to gen- and supplement his strength, will or knowl-
eral basic nursing procedures and to materni- edge according to his needs (Harmer &
ty nursing practice. Henderson, 1955, p. 5). Conceptualizing the
nurse as a substitute for the patients lack of
Henderson necessary will, strength, or knowledge to
Based on the assumption that nursing has attain good health and to complete or make
a unique function, Henderson believed that the patient whole, highlights the complexity
nursing independently initiates and controls and uniqueness of nursing.
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C H A P T E R 5 20th-Century Nursing: Wiedenbach, Henderson, and Hall 63

Based on the success of Textbook of the among doctors, nurses, and other health-
Principles and Practice of Nursing (fifth edition), care workers.
Henderson was asked by the International
Council of Nurses (ICN) to prepare a short Hall
essay that could be used as a guide for nursing In 1963, Lydia Hall was able to actualize her
in any part of the world. Despite Hendersons vision of nursing through the creation of the
belief that it was difficult to promote a univer- Loeb Center for Nursing and Rehabilitation at
sal definition of nursing, Basic Principles of Montefiore Medical Center. The centers
Nursing Care (Henderson, 1960) became an major orientation was rehabilitation and subse-
international sensation. To date, it has been quent discharge to home or to a long-term care
published in 29 languages and is referred to institution, if further care was needed. Doctors
as the 20th-century equivalent of Florence referred patients to the center, and a profes-
Nightingales Notes on Nursing. After visiting sional nurse made admission decisions. Crite-
countries worldwide, Henderson concluded ria for admission were based on the patients
that nursing varied from country to country need for rehabilitation nursing. What made
and that rigorous attempts to define it have the Loeb Center unique was the model of pro-
been unsuccessful, leaving the nature of fessional nursing that was implemented under
nursing largely an unanswered question Lydia Halls guidance. The centers guiding
(Henderson, 1991). philosophy was Halls belief that during the
Hendersons definition of nursing has rehabilitation phase of an illness experience,
had a lasting influence on the way nursing professional nurses were the best prepared to
is practiced around the globe. She was one foster the rehabilitation process, decrease com-
of the first nurses to articulate that nursing plications and recurrences, and promote health
had a unique function yielding a valuable and prevent new illnesses.
contribution to the health care of individu- Hall saw these outcomes being accom-
als. In writing reflections on the nature of plished by the special and unique way nurses
nursing, Henderson (1966) states that her work with patients in a close interpersonal
concept of nursing anticipates universally process with the goal of fostering learning,
available health care and a partnership growth, and healing.

Practice Exemplars
Wiedenbach
The focus of practice is the experiencing indi- discharge, and this to her was evidence of
vidual, i.e., the individual for whom the nurse onset of hemorrhage. This terrified her and
is caring, and the way he and only he per- made her afraid to move. Her sister, she
ceived his condition or situation. For exam- added, had hemorrhaged and almost lost her
ple, a mother had a red vaginal discharge on life the day after she had her baby two years
her first postpartum day. The doctor had rec- ago. The nurse expressed her understanding
ognized it as lochi, a normal concomitant of of the mothers fear, but then encouraged her
the phenomenon of involution, and had left to compare her current experience with that
an order for her to be up and move about. of her sister. When the mother tried to do
Instead of trying to get up, the mother this, she recognized gross differences, and
remained, immobile in her bed. The nurse accepted the nurses explanation of the origin
who wanted to help her out of bed expressed of the discharge. The mother then voiced her
surprise at the mothers unwillingness to get relief, and validated it by getting out of bed
up when she seemed to be progressing so without further encouragement (Wieden-
well. The mother explained that she had a red bach, 1962, pp. 67).
Continued
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64 S E C T I O N II Evolution of Nursing Theory

Practice Exemplar cont.


Wiedenbach considered nursing a practical dure, and she assured Mr. G. that she would
phenomenon that involved action. She be assessing his position throughout the
believed that this was necessary to understand procedure.
the theory that underlies the nurses way of
nursing. This involved knowing what the Hall
nurse wanted to accomplish, how she went Hall envisioned that outcomes were accom-
about accomplishing it, and in what context plished by the special and unique way nurses
she did what she did (Wiedenbach, 1970, work with patients in a close interpersonal
p. 1058). process with the goal of fostering learning,
growth, and healing. Her work at the Loeb
Henderson Center serves as an administative exemplar of
Hendersons definition of nursing and 14 the application of her theory. At the Loeb
components of basic nursing care can be Center, nursing was the chief therapy, with
useful in guiding the assessment and care of medicine and the other disciplines ancillary
patients preparing for surgical procedures. to nursing. In this new model of organization
For example, in assessing Mr. Gs preopera- of nursing services, nursing was in charge of
tive vital signs, the nurse noticed he seemed the total health program for the patient and
anxious. The nurse encouraged Mr. G. to was responsible for integrating all aspects of
express his concerns about the surgery. care. Only registered professional nurses were
Mr. G. told the nurse that he had a fear hired. The 80-bed unit was staffed with
of not being able to control his body and 44 professional nurses employed around
that he felt general anesthesia represented the clock. Professional nurses gave direct
the extreme limit of loss of bodily control. patient care and teaching and were responsi-
The nurse recognized this concern as being ble for eight patients and their families.
directly related to Hendersons fourth com- Senior staff nurses were available on each
ponent of basic nursing care: Move and ward as resources and mentors for staff
maintain desirable postures. The nurse nurses. For every two professional nurses
explained to Mr. G. that her role was to there was one nonprofessional worker called
perform those acts he would do for himself a messenger-attendant. The messenger-
if he was not under the influence of anes- attendants did not provide hands-on care to
thesia (Gillette, 1996, p. 267) and that she the patients. Instead, they performed such
would be responsible for maintaining his tasks as getting linen and supplies, thus free-
body in a comfortable and dignified posi- ing the nurse to nurse the patient (Hall,
tion. She explained how he would need to 1969). In addition, there were four ward sec-
be positioned during the surgical procedure, retaries. Morning and evening shifts were
what part of his body would be exposed, and staffed at the same ratio. Night-shift staffing
how long the procedure was expected to was less; however, Hall (1965) noted that
take. Mr. G. also told the nurse about an there were enough nurses at night to make
experience he had following an earlier sur- rounds every hour and to nurse those patients
gical procedure in which he experienced who are awake around the concerns that may
pain in his right shoulder. Mr. G. expressed be keeping them awake (p. 2). In most insti-
concern that being in one position too long tutions of that time, the number of nurses was
during the surgery would damage his shoul- decreased during the evening and night shifts
der and result in waking up with shoulder because it was felt that larger numbers of
pain again. Together they discussed posi- nurses were needed during the day to get the
tions that would be most comfortable for work done. Hall took exception to the idea
his shoulder during the upcoming proce- that nursing service was organized around
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C H A P T E R 5 20th-Century Nursing: Wiedenbach, Henderson, and Hall 65

work to be done rather than the needs of the a form entitled Patients Progress Notes.
patients. These notes included the patients reaction
The patient was the center of care at to care, his concerns and feelings, his under-
Loeb and actively participated in all care standing of the problems, the goals he has
decisions. Families were free to visit at any identified, and how he sees his progress
hour of the day or night. Rather than strict toward those goals. Patients were also
adherence to institutional routines and encouraged to keep their own notes to share
schedules, patients at the Loeb Center were with their caregivers.
encouraged to maintain their own usual Staff conferences were held at least twice
patterns of daily activities, thus promoting weekly as forums to discuss concerns, prob-
independence and an easier transition to lems, or questions. A collaborative practice
home. There was no chart section labeled model between physicians and nurses evolved,
Doctors Orders. Hall believed that to and the shared knowledge of the two profes-
order a patient to do something violated the sions led to more effective team planning
right of the patient to participate in his or (Isler, 1964). The nursing stories published by
her treatment plan. Instead, nurses shared nurses who worked at Loeb describe nursing
the treatment plan with the patient and situations that demonstrate the effect of pro-
helped him or her to discuss his or her con- fessional nursing on patient outcomes. In
cerns and become an active learner in the addition, they reflect the satisfaction derived
rehabilitation process. In addition, there from practicing in a truly professional role
were no doctors progress notes or nursing (Alfano, 1971; Bowar, 1971; Bowar-Ferres,
notes. Instead, all charting was done on 1975; Englert, 1971).

Summary
Among other theorists featured in Section II about, practiced, and researched, both in the
of this book, Wiedenbach, Henderson, and United States and other countries around the
Hall introduced nursing theory to us in world. Perhaps most importantly, each of
the mid-20th century. Each of these nurses these scholars stated and responded to the
reflected on her nursing practice and explored question What is nursing? Their responses
nursepatient interactions using nursing helped all who followed to understand that
practice as the basis for their thought and the one nursed is a person, not an object, and
for their published scholarship. These nurse that the relationship of nurse and patient is
scholars defined the ways nursing is thought valuable to all.

References

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Barron, M. A. (1966). The effects varied nursing Bowar, S. (1971). Enabling professional practice through
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Birnbach, N. (1988). Lydia Eloise Hall, 19061969. In: Bowar-Ferres, S. (1975). Loeb Center and its philosophy
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M. R. (2006). Twentieth-Century nursing: Marriner-Tomey (Ed.), Nursing theorists and their
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and their applications. In: M. Parker (Ed.), Nursing McBride, A. B. (Narrator). (1997). Celebrating Virginia
theories and nursing practice (2nd ed., pp. 7078). Henderson (video). Available from Center for
Philadelphia: F. A. Davis. Nursing Press, 550 West North Street, Indianapolis,
Gillette, V. A. (1996). Applying nursing theory to IN 46202.
perioperative nursing practice. AORN, 64(2), Montefiore cuts readmissions 80%. (1966, February 23).
261270. The New York Times.
Gordon, S. C. (2001). Virginia Avenel Henderson Nickel, S., Gesse, T., & MacLaren, A. (1992). Her pro-
definition of nursing. In: M. Parker (Ed.), Nursing fessional legacy. Journal of Nurse Midwifery, 3, 161.
theories and nursing practice (pp. 143149). Stevens-Barnum, B. J. (1990). Nursing theory analysis,
Philadelphia: F. A. Davis. application, evaluation (3rd ed.). Glenview, IL: Scott,
Gowan, N. I., & Morris, M. (1964). Nurses responses Foresman/Little Brown.
to expressed patient needs. Nursing Research, 13(1), Touhy, T., & Birnbach, N. (2006). Lydia Hall: The
6871. Care, Core, and Cure Model and its applications.
Hall, L. E. (1955). Quality of nursing care. Manuscript In: M. Parker (Ed.), Nursing theories and nursing
of an address before a meeting of the Department practice (2nd ed., pp. 113124). Philadelphia:
of Baccalaureate and Higher Degree Programs of F. A. Davis.
the New Jersey League for Nursing, February 7, Tryson, P. A. (1963). An experiment of the effect of
1955, at Seton Hall University, Newark, New Jersey. patients participation in planning the administration of
Montefiore Medical Center Archives, Bronx, a nursing procedure. Nursing Research, 12(4), 262265.
New York. Wiedenbach, E. (1962). A concept of dynamic nursing:
Hall, L. E. (1958). Nursing: What is it? Manuscript. Mon- Philosophy, purpose, practice and process. Paper present-
tefiore Medical Center Archives, Bronx, New York. ed at the Conference on Maternal and Child
Hall, L. E. (1963, March). Summary of project report: Nursing, Pittsburgh, PA. Archives, Yale University
Loeb Center for Nursing and Rehabilitation. Unpub- School of Nursing, New Haven, CT.
lished report. Montefiore Medical Center Archives, Wiedenbach, E. (1963). The helping art of nursing.
Bronx, New York. American Journal of Nursing, 63(11), 5457.
Hall, L. E. (1964). Nursingwhat is it? Canadian Nurse, Wiedenbach, E. (1964). Clinical nursing: A helping art.
60, 150154. New York: Springer.
Hall, L. E. (1965). Another view of nursing care and Wiedenbach, E. (1969). Meeting the realities in clinical
quality. Address delivered at Catholic University, teaching. New York: Springer.
Washington, DC. Unpublished report. Montefiore Wiedenbach, E. (1970). A systematic inquiry: Application
Medical Center Archives, Bronx, New York. of theory to nursing practice. Paper presented at Duke
University, Durham, NC (authors personal files).
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Chapter
6
NursePatient Relationship
Theories: Hildegard Peplau,
Joyce Travelbee, and
Ida Jean Orlando
A NN R. P EDEN , K AITLIN A. L AUBHAM ,
AU TUMN W ELLS , J ACQUELINE S TAAL ,
AND M AUDE R IT TMAN

Hildegard Peplaus
Part One Joyce Travelbees
Part Two

NursePatient Relationship Human-to-Human Relationship


Development and Its Model and Its Applications
Applications Introducing the Theorist
Overview of Travelbees
Introducing the Theorist Human-to-Human Relationship
Overview of Peplaus NursePatient Model Theory
Relationship Theory Practice Applications
Practice Applications References
Practice Exemplar
References
Ida Jean Orlandos
Part Three

Dynamic NursePatient
Relationship
Introducing the Theorist
Overview of Orlandos Theory of the
Dynamic NursePatient Relationship
Practice Applications
References
Hiledegard Peplau Joyce Travelbee

Ida Jean Orlando


67
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68 S E C T I O N II Evolution of Nursing Theory

The nursepatient relationship was a signifi- was one of her teachers at Bennington. An
cant focus of early conceptualizations of nurs- experience while working in the Health Ser-
ing. Hildegard Peplau, Joyce Travelbee, and vice piqued Peplaus interest in psychiatric
Ida Jean Orlando were three early nursing nursing. A young student with symptoms of
scholars who explicated the nature of this schizophrenia came to the clinic seeking help.
relationship. Their work situated the focus of Peplau did not know what to do for her. The
nursing from performance of tasks to engage- student left Bennington to receive treatment
ment in a therapeutic relationship designed to and returned to complete her education.
facilitate health and healing. Each of these Observing the successful recovery of this
conceptualizations will be described in Parts young woman was a positive experience for
One, Two, and Three of the chapter. Peplau.
On graduation from Bennington, Peplau
joined the Army Nurse Corps. She was
assigned to the School of Military Neuropsy-
Part One Peplaus NursePatient Relationship chiatry in England. This experience intro-
duced her to the psychiatric problems of
Introducing the Theorist soldiers at war and allowed her to work with
Hildegard Peplau was an outstanding leader many great psychiatrists. After the war,
and pioneer in psychiatric nursing whose Peplau attended Columbia University on the
career spanned seven decades. A review of the GI Bill and earned her masters degree in
events in her life also serves as an introduction psychiatricmental health nursing.
to the history of modern psychiatric nursing. After her graduation in 1948, Peplau was
With the publication of Interpersonal Rela- invited to remain at Columbia and teach in
tions in Nursing in 1952, Peplau provided a their masters program. She immediately
framework for the practice of psychiatric searched the library for books to use with
nursing that would result in a paradigm shift students, but found very few. At that time, the
in this field of nursing. Before this, patients psychiatric nurse was viewed as a companion to
were viewed as objects to be observed. Peplau patients, someone who would play games and
taught that patients were not objects, but were take walks, but talk about nothing substantial.
subjects, and that psychiatric nurses must par- In fact, nurses were instructed not to talk to
ticipate with the patients, engaging in the patients about their problems, thoughts, or
nursepatient relationship. This was a revolu- feelings. Peplau began teaching at Columbia,
tionary idea. Although Interpersonal Relations knowing that she wanted to change the educa-
in Nursing was not well received when it was tion and practice of psychiatric nursing. There
first published in 1952, later the books influ- was no direction for what to include in gradu-
ence was widespread, and it was reprinted in ate nursing programs. She took educational
1988 and has been translated into at least experiences from psychiatry and psychology
six languages. and adapted them to her conceptualization of
Hildegard Peplau entered nursing for nursing. Peplau described this as a time of
practical reasons, seeing it as a way to leave innovation or nothing.
home and have an occupation. As she adapt- Her goal was to prepare nurse psychother-
ed to nursing school, she made the conscious apists, referring to this training as talking to
decision that if she was going to be a nurse, patients (Peplau, 1960, 1962). She arranged
then she would be a good one (Peplau, 1998). clinical experiences for her students at Brook-
Peplau served as the college head nurse lyn State Hospital, the only hospital in the
and later as executive officer of the Health New York City area that would take them. At
Service at Bennington College, Vermont. the hospital, students were assigned to back
While working there, she began taking courses wards, working with the most chronic and
that would lead to a Bachelor of Arts degree severely ill patients. Each student met twice
in interpersonal psychology. Dr. Eric Fromm weekly with the same patient, for a session
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C H A P T E R 6 NursePatient Relationship: Peplau, Travelbee, and Orlando 69

lasting 1 hour. According to Peplau, the nurses Peplau actively contributed to the American
resisted this practice tremendously and Nurses Association (ANA) by serving on var-
thought it was an awful thing to do (Peplau, ious committees and task forces. She was the
1998). Using carbon paper, verbatim notes only person who had been both the executive
were taken during the session. Students then director and president of ANA. Peplau served
met individually with Peplau to go over the on the ANA committee that wrote the Social
interaction in detail. Through this process, Policy Statement. For the first time in nurs-
both Peplau and her students began to learn ings history, nursing had a phenomenological
what was helpful and what was harmful in the focushuman responses.
interaction. Peplau held 11 honorary degrees. In 1994,
In 1955, Peplau left Columbia to teach at she was inducted into the American Academy
Rutgers, where she began the Clinical Nurse of Nursings Living Legends Hall of Fame. She
Specialist program in psychiatricmental was named one of the 50 great Americans by
health nursing. The students were prepared Marquis Whos Who in 1995. In 1997, Peplau
as nurse psychotherapists, developing expert- received the Christiane Reiman Prize. In 1998,
ise in individual, group, and family therapies. she was inducted into the ANA Hall of Fame.
Peplau required of her students unflinching Internationally, Peplau was an advisor to
self-scrutiny, examining their own verbal the World Health Organization (WHO); she
and nonverbal communication and its effects was a member of their First Nursing Advisory
on the nursepatient relationship. Students Committee and contributed to WHOs first
were encouraged to ask, What message am paper on psychiatric nursing. She served as a
I sending? consultant to the Pan-American Health
In 1956, Peplau began spending her sum- Association and she served two terms on the
mers touring the country, offering week-long International Council of Nurses Board of
clinical workshops in state hospitals. This Directors. Even after her retirement, she con-
activity was instrumental in teaching inter- tinued to mentor nurses in many countries.
personal theory and the importance of the Hildegard Peplau died in March 1999 at
nursepatient relationship to psychiatric her home in Sherman Oaks, California.
nurses. The workshops also provided a forum
from which Peplau could promote advanced
education for psychiatric nurses. Her belief Overview of Peplaus
that psychiatric nurses must have advanced
degrees encouraged large numbers of psychi-
NursePatient Relationship
atric nurses to seek masters degrees and even- Theory
tual certification as psychiatricmental health Peplau (1952) defined nursing as a signifi-
clinical specialists. cant, therapeutic, interpersonal process that
During her career as a nursing educator, a is an educative instrument, a maturing force,
total of 100 students had the opportunity to that aims to promote foreward movement
study with Peplau. These students have of personality in the direction of creative,
become leaders in psychiatric nursing. Many constructive, productive, personal, and com-
went on to earn doctoral degrees, becoming munity living (p. 16). Peplau was the first
psychoanalysts, writing prolifically in the field nursing theorist to identify the nursepatient
of psychiatric nursing, and entering and influ- relationship as being central to all nursing
encing the academic world. Their influence care. In fact, nursing cannot occur if there is
has resulted in the integration of the no relationship, or connection, between the
nursepatient relationship and the concept of patient and the nurse. Her work, while writ-
anxiety into the culture of nursing. In 1974, ten for all nursing specialties, provides spe-
Peplau retired from Rutgers, which allowed cific guidelines for the psychiatric nurse.
her more time to devote to the larger profes- The nurse brings to the relationship pro-
sion of nursing. Throughout her career, fessional expertise which includes clinical
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70 S E C T I O N II Evolution of Nursing Theory

knowledge. Peplau valued knowledge, believ- quality and outcome of nursing care (Peplau,
ing that the psychiatric nurse must possess 1992, p. 14). An essential component of this
extensive knowledge about the potential relationship is the continuing process of the
problems that emerge during a nursepatient nurse becoming more self-aware. This occurs
interaction. The nurse must understand psy- via supervision.
chiatric illnesses and their treatments (Peplau, Peplau (1989a) recommended that nurses
1987). The nurse interacts with the patients as participate in weekly supervision meetings
both a resource person and a teacher (Peplau, with an expert nurse clinician. The focus of
1952). Through education and supervision, the supervisory meetings is on the nurses
the nurse develops the knowledge base interactions with patients. The primary pur-
required to select the most appropriate nurs- pose is to review observations and interper-
ing intervention. In order to fully engage in sonal patterns that the nurse has made or
the nursepatient relationship, the nurse must used. The goal is always to develop the
possess intellectual, interpersonal, and social nurses skills as an expert in interpersonal
skills. These are the same skills often dimin- relations. Peplau (1989a) emphasized the
ished or lacking in psychiatric patients. For slow but sure growth of nurses (p. 166) as
nurses to promote growth in patients, they they developed their competencies in work-
must themselves use these skills competently ing with patients. Not only are patient prob-
(Peplau, 1987). lems reviewed but treatment options and the
There are four components of the nurse nurses own pattern of responding to the
patient relationship: two individuals (nurse patient are explored. If an interaction
and patient), professional expertise, and patient between a nurse and a patient has not gone
need (Peplau, 1992). The goal of the nurse well, the nurses response is to examine
patient relationship is to further the personal his/her own behaviors first. Asking ques-
development of the patient (Peplau, 1960). tions such as, Did my own anxiety interfere
Nurse and patient meet as strangers who with this interaction? or Is there some-
interact differently than friends would. The thing in my experiences that influenced how
role of stranger implies respect and positive I interacted with this patient? leads to con-
interest in the patient as an individual. tinual growth and development as a skilled
The nurse accepts the patients as they are clinician. This process also assures the deliv-
and interacts with them as emotionally able ery of quality care in psychiatric settings.
strangers and relating on this basis until evi- Supervision continues to be an important
dence shows otherwise (Peplau, 1952, p. 44). aspect in advanced practice psychiatric nurs-
Peplau valued therapeutic communication as ing and is a requirement for certification as
a key component of nursepatient interac- a psychiatric clinical specialist or nurse prac-
tions. She advised strongly against the use of titioner. Supervision is essential as the nurse
social chit-chat. In fact, she would view this assumes the role of counselor. In this role,
as wasting valuable time with your patient. the nurse assists the patient to integrate the
Every interaction must focus on being thera- thoughts and feelings associated with the
peutic. Even something as simple as sharing illness into the patients own life experiences
a meal with psychiatric patients can be a ther- (Lakeman, 1999).
apeutic encounter. The nursepatient relationship is objective
The nursepatient relationship, viewed as and its focus is on the needs of the patient. To
growth-promoting with forward movement, focus on the patients needs, the nurse must be
is enhanced when nurses are aware of how a skilled listener and able to respond in ways
their own behavior affects the patient. The that foster the patients growth and return to
behavior of the nurse-as-a-person interact- health. Active listening facilitates the nurse
ing with the patient-as-a person has significant patient relationship. As Peplau wrote in 1960,
impact on the patients well-being and the nursing is an opportunity to further the
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C H A P T E R 6 NursePatient Relationship: Peplau, Travelbee, and Orlando 71

patients learning about himself (sic), the Relations Theory (1952). This time-limited
focus in the nurse-patient relationship will be relationship is interpersonal in nature and has
upon the patient his (sic) needs, difficulties, a starting point, proceeds through identifiable
lack in interpersonal competence, interest in phases, and ends. Initially, Peplau included
living (Peplau, 1960, p. 966). Within the four phases in the relationship: orientation,
nursepatient relationship, the nurse works identification, exploitation, and resolution
to create a mood that encourages clients to (Peplau, 1952). In 1991, Forchuk, a Canadian
reflect, to restructure perceptions and views of researcher who has tested and refined some of
situations as needed, to get in touch with their Peplaus work, proposed three phases: orienta-
feelings, and to connect interpersonally with tion, working, and resolution (Peplau, 1992).
other people (Peplau, 1988, p. 10). While the Forchuks recommendation of a three-phase
nurse-patient relationship is time-limited in nursepatient relationship resolves the lack of
both duration and frequency, the aim is to cre- easy differentiation between the identification
ate an interpersonally intimate encounter, how- and exploitation stages. These two phases
ever brief, as if two whole persons are involved were collapsed into the working phase. By
in a purposive, enduring relationship; this renaming theses two phases the working
requires discipline and skill on the part of the phase, a more accurate reflection of what
nurse (p. 11). Peplau continued to emphasize actually occurs in this important aspect of
that nurses must possess well-developed the nursepatient relationship is provided.
intellectual competencies, and disciplined Although the nursepatient relationship is
attention to the work at hand (p. 13). time limited in nature, much of this relation-
Communication, both verbal and non- ship is spent working.
verbal, is an essential component of the
nursepatient relationship. However, in Orientation Phase
Peplaus view, verbal communication is The relationship begins with the orientation
required in order for the nurse-patient rela- phase (Peplau, 1952). This phase is particu-
tionship to develop. She writes, anything larly important because it sets the stage for
clients act out with nurses will most proba- the development of the relationship. During
bly not be talked about, and that which the orientation period, the nurse and
is not discussed cannot be understood patients relationship is still new and unfa-
(Peplau, 1989a, p. 197). One objective of the miliar. Nurse and patient get to know each
nursepatient relationship is to talk about other as people; their expectations and roles
the problem or need that has resulted in the are understood. During this first phase,
patient interacting with the nurse. Peplau the patient expresses a felt need and seeks
provided descriptions of phrases commonly professional assistance from the nurse. In
used by patients that require clarification on reaction to this need, the nurse helps the
the part of the nurse. These included refer- individual by recognizing and assessing his
ring to they, using the phrase, you know, or her situation. It is during the assessment
and overgeneralizing responses to situations. that the patients needs are evaluated by the
The nurse clarifies who they are, responds patient and nurse working together as a
that she/he does not know and needs further team. Through this process, trust develops
information, and assists patients to be more between the patient and the nurse. Also, the
specific as they describe their experiences parameters for the relationship are clarified.
(Forchuk, 1993). Based on the assessment information, nurs-
ing diagnoses; goals; and outcomes for the
Phases of the NursePatient patient are created. Nursing interventions
Relationship are implemented and the evaluations of the
Peplau introduced the phases of the nurse patients goals are also incorporated (Peplau,
patient relationship in her Interpersonal 1992).
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72 S E C T I O N II Evolution of Nursing Theory

Working Phase is one measure of the success of...all the other


The working phase incorporates identifica- phases (Lloyd et al., 2007, p. 50).
tion and exploitation. The focus of the work-
ing phase is twofold: first is the patient, who
exploits resources to improve health; second
Practice Applications
is the nurse, who enacts the roles of resource Almost all of the research that has tested
person, counselor, surrogate, and teacher in Peplaus nursepatient relationship has been
facilitating...development toward well-being conducted by Forchuk (1994, 1995) and col-
(Fitzpatrick & Wallace, 2005, p. 460). This leagues (Forchuk & Brown, 1989; Forchuk,
phase of the relationship is meant to be flex- Westwell, Martin, Azzapardi, Kosterewa-
ible, so that the patient is able to function Tolman, & Hus, 2000; Forchuk, Jewell,
dependently, independently, or interdepend- Schofield, Sircelj, & Vallendor, 1998). Much of
ently with the nurse, based on...developmental Forchuks work has focused on the orientation
capacity, level of anxiety, self-awareness, and phase. Forchuk and Brown emphasized the
needs (Fitzpatrick, 2005, p. 460). A balance importance of being able to identify the orien-
between independence and dependence must tation phase and not rush movement into the
exist here, and it is the nurse who must aid working phase. To assist in this, Forchuk and
the patient in its development (Lakeman, Brown (1989) developed a one-page instru-
1999). ment, the Relationship Form, which they have
During the exploitation phase of the work- used to determine the current phase of the rela-
ing phase, the client assumes an active role in tionship and overall progression from phase to
the health team by taking advantage of avail- phase. For additional information, please visit
able services and determining the degree to DavisPlus at http://davisplus.fadavis.com.
which they are used (Erci, 2008). Within this Peplau first wrote about the nursepatient
phase, the client begins to develop responsi- relationship in 1952. She hoped that through
bility and independence, becoming better able this work nurses would change how they inter-
to face new challenges in the future (Erci, acted with their patients. She wanted nurses to
2008). Peplau writes that Exploiting what a do with clients rather than do to (Forchuk,
situation offers gives rise to new differentia- 1993). The majority of the work that has tested
tions of the problem and the development Peplaus nursepatient relationship has been
and improvement of skill in interpersonal conducted with individuals with severe mental
relations (Peplau, 1992, pp. 4142). illness, many of them in psychiatric hospitals. In
these studies, patients did move through the
Resolution Phase phases of the nursepatient relationship. As
The resolution phase is the last phase and psychiatric nurses have changed the location of
involves the patients continual movement their practice from hospital to community, they
from dependence to independence, based on have carried Peplaus work to this new arena.
both a distancing from the nurse and a Unfortunately, there has been limited testing of
strengthening of individuals ability to manage the nursepatient relationship in community
care (Peplau, 1952). According to Peplau, reso- settings. Parrish, Peden, and Staten (2008)
lution can take place only when the patient explored strategies used by advanced practice
has gained the ability to be free from nursing psychiatric nurses treating individuals with
assistance and act independently (Lloyd, depression. All the participants in this study
Hancock, & Campbell, 2007). At this point, practiced in community settings. When
old needs are abandoned and new goals are describing the strategies used, the nurse
adopted (Lakeman, 1999). The completion of patient relationship was the primary vehicle by
the resolution phase results in the mutual ter- which strategies were delivered. These strate-
mination of the nursepatient relationship and gies included active listening, partnering with
involves planning for future sources of support the client, and a holistic view of the client. This
(Peplau, 1952). Completion of this final phase work supports the integration of Peplaus
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C H A P T E R 6 NursePatient Relationship: Peplau, Travelbee, and Orlando 73

nursepatient relationship into the work of the the last 10 years; however, the nursepatient
psychiatric nurse. relationship continues to be the vehicle by
However, more studies are needed that which psychiatric nursing care is delivered.
focus on the use of the nursepatient relation- Further studies must examine the progression
ship in community settings. The delivery of the phases of the nursepatient relationship
of psychiatric care has radically changed in in the managed care environment in psychiatry.

Practice Exemplar
Karen Thomas is a 49-year-old married guarded as she alludes to marital infidelity on
woman who has a scheduled appointment the part of her husband. Interspersed
with an advanced practice psychiatric nurse throughout the conversation are statements
(APPN). She appears anxious and uncomfort- about her dislike of medications. The APPN
able in the encounter with the APPN. In an then begins to ask more pointed assessment
effort to help Ms. Thomas feel more comfort- questions related to depressive symptoms. Ms.
able, the APPN offers her a glass of water or Thomas shares that she has very poor sleep,
cup of coffee. Ms. Thomas announces that she cannot concentrate, is isolating herself, has
has not eaten all day and would like some- difficulties making decisions, and feels hope-
thing to drink. The APPN provides a cup of less about her future. At this point, Ms.
water and several crackers for Ms. Thomas to Thomas also shares that she had never taken
eat. Once they are both seated, the APPN the antidepressant prescribed for her. By shar-
asks Ms. Thomas about the reason for the ing this, Ms. Thomas indicates the beginning
appointment (what brought her here today). of a trusting relationship with the APPN.
Ms. Thomas replies that she does not know; Once the initial assessment is complete, a pre-
her husband made the appointment for her. In liminary diagnosis is determined, and client
order to more fully understand the reason for and nurse are ready to move into the working
her husband making the appointment, the phase.
APPN asks Ms. Thomas to tell her what The working phase is initiated with prob-
aspects of her behavior were viewed by her lem identification. For Ms. Thomas, the pri-
husband as calling for attention. Once again, mary problem is major depression with a
Ms. Thomas shares that she does not know. secondary problem, partner-relational issues.
Continuing to focus on getting acquainted The APPN, acting as a resource person, pro-
and enhancing Ms. Thomass comfort in this vides education about the illness, major depres-
beginning relationship, the APPN asks Ms. sion. Included is information about the biolog-
Thomas to tell her about herself. Ms. Thomas ical causes of the illness, genetic predisposition,
shares that she has been depressed in the past and explanations about the symptoms. A
and was treated by a psychiatric nurse practi- partnership is formed as the APPN and
tioner who prescribed an antidepressant med- Ms. Thomas discuss treatment options. While
ication. Becoming tearful, she also shares that Ms. Thomas shares that she does not like
she has left her husband several days ago and to take medications, she agrees to an appoint-
has moved in with her oldest son, stating that ment with a psychiatric nurse practitioner who
she just needs some time to think. For the will conduct a medication evaluation. That
next 15 minutes, Ms. Thomas talks about her appointment is scheduled later in the week.
marriage, her love for her husband, and her Ms. Thomas also shares that she really wants to
lack of trust in him. She also shares symptoms talk about her relationship with her husband
of depression that are present. Ms. Thomas and come to some decision about the future of
speaks tangentially and is a poor historian their marriage. Marital counseling is men-
when recalling events in the marriage that tioned as a possible treatment option, but the
have caused her pain. Her responses are APPN suggests that this be delayed until
Continued
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74 S E C T I O N II Evolution of Nursing Theory

Practice Exemplar cont.


Ms. Thomass depressive symptoms have At the next session, Ms. Thomas is notice-
decreased. The first session ends with both ably improved. She states that she is sleeping,
client and nurse committed to working to she is not crying as much, she is concentrat-
decrease Ms. Thomass depressive symptoms. ing better, and she is feeling more hopeful
Ms. Thomas is reminded about her appoint- about her marriage. She also shares that she
ment for a medication evaluation and a second and her husband have met for dinner several
therapy appointment is made with the APPN. times and that he is willing to come with her
At the second visit, Ms. Thomas reports for marital counseling. However, she shares
that she has started taking an antidepressant that she is not yet ready for this, preferring to
but as of yet has not seen any relief of her spend time focusing on her own mental
symptoms. The APPN provides information health. Over the course of several months,
about the usual length of time required for Ms. Thomas and the APPN meet. In these
results to occur. While Ms. Thomas does sessions, Ms. Thomas explores her childhood,
not see noticeable results from the medica- talks about the recent death of her mother,
tion, the APPN shares that Ms. Thomas decides to begin a new exercise program, and
looks more relaxed and seems less anxious. reconnects with childhood friends. Through
Ms. Thomas states that she would like to this work, Ms. Thomas grows more secure in
spend this session talking about her relation- who she is and in how she wants to live. Dur-
ship with her husband. She describes what ing this same time period, she continues to
was once a very happy marriage. The APPN meet her husband regularly for dinner, and
listens, asks for clarification when needed, sometimes, a movie.
and encourages Ms. Thomas to share her At their final session, Ms. Thomas shares
perceptions of her marriage. The APPN asks that she is ready to go with her husband to
Ms. Thomas again to talk about what might marital counseling. As a result of antidepres-
have caused her husband to call and make sant medication and therapy, the problem
the therapy appointment for her. Ms. Thomas of major depression has been resolved. How-
shares that her husband does not want their ever, the focus of this last session returns
marriage to end; however, she is not sure yet to depression. This is done in order to help
about their future. Her perception is that Ms. Thomas recognize the early symptoms
her husband thinks she is the one with the of depression in order to prevent a relapse.
problem and once she is fixed that their Ms. Thomas shares that her first symptoms
marriage will return to its former state were not sleeping well and withdrawing from
of happiness. The session ends with the friends and family. The APPN emphasizes
APPN asking Ms. Thomas to focus on her the importance of monitoring this and calling
own physical and mental health. Possible for an appointment if these early symptoms
interventions include beginning an exercise occur. The focus now is on the secondary
program, practicing stress reduction strate- problem of partner-relationship issues. With
gies, and reconnecting with individuals who this, the APPN makes a referral to a marital
have been supportive in the past. and family therapist.

References

Beck, A. T., Ward, C. H., Mendelson, M., Mock, L., Recipients perspectives. Journal of Psychiatric and
& Erbaugh, J. (1961). An inventory for measuring Mental Health Nursing, 13, 347355.
depression. Archives of General Psychiatry, 4, Erci, B. (2008). Nursing theories applied to vulnerable
561571. populations: Examples from Turkey. In: M. de
Coatsworth-Puspoky, Forchuk, C., & Ward-Griffin, C. Chesney & B. A. Anderson, (Eds.), Caring for
(2006). Nurse-client processes in mental health: the vulnerable: Perspectives in nursing theory,
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practice and research (2nd ed., pp. 45-60). Sudbury, OToole, A., & Welt, S. R. (1989). Interpersonal theory in
MA: Jones and Bartlett. nursing practice: Selected works of Hildegard Peplau.
Fitzpatrick, J. J., & Wallace, M. (2005). Encyclopedia of New York: Springer.
nursing research. New York: Springer. Parrish, E., Peden, A. R., & Staten, R. R. (2008).
Forchuk, C. (1993). Hildegard E. Peplau: Interpersonal Strategies used by advanced practice psychiatric
nursing. Newbury Park, CA: Sage. nurses in treating adults with depression. Perspectives
Forchuk, C. (1994). The orientation phase of the nurse- in Psychiatric Care, 44, 232240.
client relationship: Testing Peplaus theory. Journal Peplau, H. E. (1952). Interpersonal relations in nursing.
of Advanced Nursing, 20(3), 532537. New York: G. P. Putnams Sons. (English edition
Forchuk, C. (1995). Development of nurse-client reissued as a paperback in 1988 by Macmillan
relationship: What helps? Journal of the American Education, London.)
Psychiatric Nurses Association, 1, 146151. Peplau, H. E. (1960). Talking with patients. American
Forchuk, C., & Brown, B. (1989). Establishing a nurse Journal of Nursing, 60, 964967.
client relationship. Journal of Psychosocial Nursing, Peplau, H. E. (1962). The crux of psychiatric nursing.
27(2), 3034. American Journal of Nursing, 62, 5054.
Forchuk, C., Jewell, J., Schofield, R., Sircelj, M., & Peplau, H. E. (1987). Tomorrows world. Nursing Times,
Valledor, T. (1998). From hospital to community: 83, 2933.
Bridging therapeutic relationships. Journal of Peplau, H. E. (1988). The art and science of nursing:
Psychiatric and Mental Health Nursing, 5, 197202. Similarities, differences and relations. Nursing Science
Forchuk, C., Westwell, J., Martin, A., Azzapardi, W. Quarterly, 1, 815.
B., Kosterewa-Tolman, D., & Hux, M. (1998). Fac- Peplau, H. E. (1989a). Clinical supervision of staff
tors influencing movement of chronic psychiatric nurses. In: A. OToole, & S. R. Welt (Eds.), Inter-
patients from the orientation to the working phase personal theory in nursing practice: Selected works of
of the nurse-client relationship on an inpatient Hildegard Peplau (pp. 164167). New York:
unit. Perspectives in Psychiatric Care, 34, 3644. Springer.
Forchuk, C., Westwell, J., Martin, M., Bamber- Peplau, H. E. (1989b). Therapeutic nursepatient
Azzaparadi, W., Kosterewa-Tolman, D., & Hux, interactions. In: A. OToole & S. R. Welt (Eds.),
M. (2000). The developing nurse-client relationship: Interpersonal theory in nursing practice: Selected works
Nurses perspectives. Journal of the American of Hildegard Peplau (pp. 192204). New York:
Psychiatric Nurses Association, 6, 310. Springer.
Lakeman, R. (1999). Remembering Hildegard Peplau. Peplau, H. E. (1992). Interpersonal relations: A theoret-
Vision, 5(8), 2931. ical framework for application in nursing practice.
Lloyd, H., Hancock, H., & Campbell, S. (2007). Nursing Science Quarterly, 5(1), 1318.
Principles of care. London: Blackwell. Peplau, H. E. (1998). Life of an angel: Interview with
Morrison, E. G. (1992). Inpatient practice: An integrat- Hildegard Peplau (1998). Hatherleigh Co. Audiotape
ed framework. Journal of Psychosocial Nursing and available from the American Psychiatric Nurses
Mental Health Services, 30(1), 2629. Association. www.apna.org/items.htm

Part Two Travelbees Human-to-Human University, and obtained her Master of Sci-
Relationship Model ence in Nursing degree from Yale University
(Meleis, 1997). She taught psychiatric and
mental health nursing and was a professor of
Introducing the Theorist nursing at Louisiana State University, New
Joyce Travelbee (19261973) was a nurse edu- Orleans, an instructor in the Department of
cator and psychiatric nurse practitioner and Nursing Education at New York University, a
was enrolled in doctoral study at the time of professor in the University of Mississippi
her death at age 47 (OBrien, 2008). She is School of Nursing in Jackson, and a professor
best known for her human-to-human rela- at the Hotel Dieu School of Nursing in
tionship model, a mid-range theory based New Orleans, Louisiana (Meleis, 1997;
on the nursing process. Travelbee graduated Travelbee, 1971). Her human-to-human rela-
from the diploma nursing program at Charity tionship model was based on the work of
Hospital in New Orleans, received her Bach- nurse theorists Hildegard Peplau and Ida Jean
elor of Science degree from Louisiana State Orlando (Tomey & Alligood, 2006).
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76 S E C T I O N II Evolution of Nursing Theory

Overview of Travelbees tasks without an emotional investment in the


nursepatient relationship, the ill persons
Human-to-Human physical needs are met. However, the ill per-
Relationship Model Theory son recognizes the lack of caring in the trans-
Caring, in the human-to-human relationship action and is left alone to suffer with the
model, involves the dynamic, reciprocal, symptoms of illness. Dehumanization occurs
interpersonal connection between the nurse when the ill person is left alone to find mean-
and patient, developed through communica- ing in his illness experience.
tion and the mutual commitment to perceive Questions such as why me? or why my
self and other as unique and valued. Through loved one? may be asked by many ill persons
the therapeutic use of self and the integration and their family members. By inquiring into
of evidence-based knowledge, the nurse the individuals perception of his illness and
provides quality patient care that can foster how he has derived meaning from his illness
the patients trust and confidence in the nurse experience, the nurse can assess his coping
(Travelbee, 1971). The meaning of the illness ability and provide nursing interventions to
experience becomes self-actualizing for the prevent suffering and despair. Hope and
patient as the nurse helps the patient find motivation are important nursing tasks in
meaning in the experience. The human-to- caring for an ill person in despair. However,
human relationship refers to an experience or the nurse cannot give hope to another per-
series of experiences between the human son; she can, however, strive to provide some
being who is nurse and an ill person, culmi- ways and means for an ill person to experience
nating in the nurse meeting the ill persons hope (Travelbee, 1971, p. 83).
unique needs (Travelbee, 1971, pp. 1617). All human beings endure suffering, though
The term patient is not used in Travelbees the experience of suffering differs from one
model, as patient refers to a label or catego- individual to another (Travelbee, 1971).
ry of people, rather than a unique individual According to Meleis (1997), a persons atti-
in need of nursing care. The purpose of nurs- tude toward suffering ultimately determines
ing, according to Travelbee (1971), is to assist how effectively he copes with illness (p. 361).
an individual, family or community to prevent If the patients needs are not met in his suffer-
or cope with the experience of illness and suf- ing, he may develop despairful not-caring,
fering and, if necessary, to find meaning in in which he does not care if he dies or recov-
these experiences (p. 16). Simply caring ers, or apathetic indifference, in which he
about an individual is not sufficient for pro- has lost the will to live (Travelbee, 1971,
viding quality care, but rather the integration pp. 180181). Hope helps the suffering per-
of a broad knowledge base with the therapeu- son to cope, and it is an assumption of Trav-
tic use of self is needed. elbees (1971) that the role of the nurse...(is)
Transcendence of the traditional titles of to assist the ill person (to) experience hope in
nurse and patient is necessary to prevent order to cope with the stress of illness and
dehumanization of the ill person. With the suffering (p. 77).
rapid expansion of health technology, com- To relieve the patients suffering and to
bined with financial constraints leading to foster hope, the nurse provides care based on
restructuring of nursepatient ratios, compet- the individuals unique needs. Nursing care,
ing demands are placed on the nurses time according to Travelbee (1971), is delivered
and attention. An emotional detachment through five stages: observation, interpretation,
between the nurse and ill person is created decision-making, action (or nursing interven-
when the nurse views the ill person as the cat- tion), and appraisal (or evaluation). The nurs-
egory of patient, rather than as a unique ing intervention is designed to achieve the pur-
individual with his own understanding of the pose of nursing and is communicated to the
illness experience. By performing nursing patient. The goals of communication in the
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C H A P T E R 6 NursePatient Relationship: Peplau, Travelbee, and Orlando 77

nursing process are to know (the) person, (to) the phase of emerging identities, a bond
ascertain and meet the nursing needs of ill per- begins to form between nurse and person as
sons, and (to) fulfill the purpose of nursing each individual begins to appreciate the
(Travelbee, 1971, p. 96). uniqueness of the other (Travelbee, 1971,
In the observation stage of nursing care, p. 132). The bond is created and shaped
the nurse does not observe signs of illness, through each nurseperson interaction and is
but rather collects sensory data in order to facilitated by the therapeutic use of self, com-
identify a problem or need (Travelbee, 1971, bined with nursing knowledge. The nurse
p. 99). The nurse validates her interpretation must recognize how she perceives the person,
of the problem or need with the ill person and in order to create a foundation of empathy.
decides whether or not to act upon her inter- In the phase of empathy, the nurse begins to
pretation. A nursing intervention is developed see the individual beyond outward behavior
in alignment with the purpose of nursing, and and sense accurately anothers inner experience
requires the nurse to assist ill persons to find at a given point in time (Travelbee, 1971,
meaning in the experience of illness, suffer- p. 136). Empathy enables the nurse to predict
ing, and pain (Travelbee, 1971, p. 158). How- what the person is experiencing and requires
ever, the nurse may not assume she under- acceptance, as empathy involves the intellec-
stands the meaning of the illness experience tual and...emotional comprehension of another
to the ill person without first inquiring into person (Travelbee, 1964). Empathy is the pre-
this meaning. To do so would communicate to cursor to sympathy, or the desire, almost an
the ill person that his or her experience is not urge, to help or aid an individual in order to
of value to the nurse, resulting in dehuman- relieve his distress (Travelbee, 1964). Sympa-
ization. The nurse evaluates the outcomes of thy is not pity, but rather a demonstration to
her nursing intervention based on objectives the person that he is not carrying the burden of
developed before the phase of appraisal. illness alone. Trust develops between the nurse
In meeting the ill persons needs through and person in the phase of sympathy, and the
the human-to-human relationship, the nurse persons distress is diminished.
employs a disciplined intellectual approach or Rapport, according to Meleis (1997) is
a logical approach consistent with nursing both the goal and the process of the human-
standards and clinical practice guidelines in to-human relationship (p. 367). Travelbee
order to identify, manage, and evaluate the ill (1971) defines rapport as a process, a hap-
persons problem (Travelbee, 1971). Each pening, and experience, or series of experi-
stage in the nursing process may be employed ences, undergone simultaneously by nurse and
without the establishment of a human-to- the recipient of her care (p. 150). Rapport
human relationship. An acute medical need is composed of a cluster of interrelated
may be met, but the patients deeper spiritual thoughts and feelings: interest in and concern
and emotional needs are neglected. These for, others; empathy, compassion, and sympa-
spiritual and emotional needs are addressed thy; a non-judgmental attitude, and respect
in the human-to-human relationship in the for each individual as a unique human being
progression through five phases: the original (Travelbee, 1963). Through the establishment
encounter, emerging identities, empathy, sym- of rapport, the nurse is able to foster a mean-
pathy, and rapport. ingful relationship with the ill person during
In the phase of the original encounter, the multiple points of contact in the care
nurse and ill person form judgments about setting. Rapport is not established in every
each other that will guide and shape future nurseperson encounter; however, emotional
nurseperson interactions. Past experiences, involvement is required from the nurse. To
the media, and stereotypes may influence ones establish this emotional bond with ones
perception of another, blocking the develop- patient, the nurse must first ensure her own
ment of a human-to-human relationship. In emotional needs are met.
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78 S E C T I O N II Evolution of Nursing Theory

Practice Applications encounter. Support group members discussed


the similarities and differences in their work
Cook (1989) used Travelbees nursing con- perceptions during the phase of emerging
cepts to design a support group for nurses identities. Empathy and trust developed as
facing organizational restructuring at a nurses became more accepting and nonjudg-
New York hospital. The purpose of the sup- mental of each others perceptions, culminat-
port group was to help nurses develop more ing in the establishment of rapport as group
meaningful perceptions of their roles during members were able to recapture the mean-
a nursing shortage created during a finan- ing of nursing (Cook, 1989).
cial crisis that resulted in a restructuring Cook (1989) found that nurses who had
of patient care delivery and nurse/patient threatened to quit earlier had remained in the
ratios. Group morale was low in the begin- system by the end of the support group. Nurse
ning, and nurses were frustrated with higher productivity had increased over time, and the
nurse/patient ratios. The support group met number of sick days taken by the nurses had
over 2 weeks, and the group intervention was diminished over the 6-month period after
designed by incorporating Hoff s theory on program cessation. Nurses regained a sense of
crisis intervention with Travelbees phases of meaning of their work and reported increased
observation and communication. Travelbees job satisfaction after completion of the pro-
human-to-human relationship was used to gram. Travelbees ideas hold potential as an
guide supportive discussions and problem- effective nursing intervention for improving
solving as nurses struggled to regain a sense nurse retention rates. However, further
of meaning and purpose related to their pro- research is necessary, as the exact number of
fessional identity. nurses recruited into the support group and
Participants shared their perceptions of the actual number of nurses who completed
their work environment during the initial the program are unknown.

References

Cook, L. (1989). Nurses in crisis: A support group Tomey, A. M., & Alligood, M. R. (2006). Nursing theorists
based on Travelbees nursing theory. Nursing and and their work (6th ed.). St. Louis, MO: Mosby Elsevier.
Health Care, 10(4), 203205. Travelbee, J. (1963). What do we mean by rapport?
Meleis, A. I. (1997). Theoretical nursing: Development & American Journal of Nursing, 63(2), 7072.
progress (3rd ed.). New York: Lippincott. Travelbee, J. (1964). Whats wrong with sympathy?
OBrien, M. E. (2008). Spirituality in nursing: Stand- American Journal of Nursing, 64(1), 6871.
ing on holy ground (3rd ed.). Boston: Jones and Travelbee, J. (1971). Interpersonal aspects of nursing
Bartlett. (2nd ed.). Philadelphia: F. A. Davis.

Part Three Orlandos Theory of the Dynamic she completed a masters degree in nursing
NursePatient Relationship from Columbia University. Orlandos early
nursing practice experience included obstet-
rics, medicine, and emergency room nursing.
Introducing the Theorist Her first book, The Dynamic NursePatient
Ida Jean Orlando was born in 1926 in Relationship: Function, Process and Principles
New York. Her nursing education began at (1961), was based on her research and blended
New York Medical College School of Nursing nursing practice, psychiatricmental health
where she received a diploma in nursing. In nursing, and nursing education. It was pub-
1951, she received a bachelor of science degree lished when she was director of the graduate
in public health nursing from St. Johns Uni- program in mental health and psychiatric
versity in Brooklyn, New York, and in 1954 nursing at Yale University School of Nursing.
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C H A P T E R 6 NursePatient Relationship: Peplau, Travelbee, and Orlando 79

Orlandos theoretical work is both practice the nurse and the patient. Patients experi-
and research based and was funded by the ence distress when they cannot cope with
National Institute of Mental Health to unmet needs. Nurses use direct and indi-
improve education of nurses about concepts rect observations of patient behavior to
and interpersonal relationships. The method discover distress and meaning.
of her study was qualitative and inductive, 3. Nursepatient interactions are unique, com-
using naturalistic inquiry methods. As a con- plex, and dynamic processes. Nurses help
sultant at McLean Hospital in Belmont, patients express and understand the mean-
Massachusetts, Orlando continued to study ing of behavior. The basis for nursing
nursing practice and developed a training pro- action is the distress experienced and
gram and nursing service department based expressed by the patient.
on her theory. From evaluation of this pro- 4. Professional nurses function in an inde-
gram, she published her second book, The pendent role from physicians and other
Discipline and Teaching of Nursing Process health-care providers.
(Orlando, 1972; Rittman, 1991).

Practice Applications
Overview of Orlandos
Orlandos theoretical work was based on
Theory of the Dynamic analysis of thousands of nursepatient inter-
NursePatient Relationship actions to describe major attributes of the
relationship. Based on this work, her later
Nursing is responsive to individuals who suffer or book provided direction for understanding
anticipate a sense of helplessness; it is focused on and using the nursing process (Orlando,
the process of care in an immediate experience; it 1972). This has been known as the first theory
is concerned with providing direct assistance to of nursing process and has been widely used
individuals in whatever setting they are found for in nursing education and practice in the Unit-
the purpose of avoiding, relieving, diminishing or ed States and across the globe. Orlando con-
curing the individuals sense of helplessness. sidered her overall work to be a theoretical
(Orlando, 1972) framework for the practice of professional
nursing, emphasizing the essentiality of the
The essence of Orlandos theory, the
nursepatient relationship. Orlandos theoret-
Dynamic NursePatient Relationship, reflects
ical work reveals and bears witness to the
her beliefs that practice should be based on
essence of nursing as a practice discipline.
needs of the patient and that communication
Although there is little evidence in the
with the patient is essential to understanding
literature that Orlandos theory has been
needs and providing effective nursing care.
directly used in nursing practice, it is highly
Following is an overview of the major compo-
probable that nurses familiar with her writing
nents of Orlandos work.
used her work to guide or more fully under-
1. The nursing process includes identifying the stand their practice. During the 1960s, several
needs of patients, responses of the nurse, studies were published that explored nursing
and nursing action. The nursing process, practice issues. These works focused on
as envisioned and practiced by Orlando, is patients complaints of pain (Barron, 1966;
not the linear model often taught today, Bochnak, 1963), incidence of postoperative
but is more reflexive and circular, and vomiting (Dumas & Leonard, 1963), patient
occurs during encounters with patients. admission processes (Elms & Leonard, 1966),
2. Understanding the meaning of patient nurses responses to expressed patient needs
behavior is influenced by the nurses per- (Gowan & Morris, 1964), and the effects of
ceptions, thoughts, and feelings. It may be patient assistance with planning nursing pro-
validated through communication between cedure administration (Tryson, 1963).
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80 S E C T I O N II Evolution of Nursing Theory

The most important contribution of society at large. Orlandos theory can serve as
Orlandos theoretical work is what it says a philosophy as well as a theory, because it is
about the values underpinning nursing prac- the foundation upon which our profession
tice. Inherent in this theory is a strong state- has been built. With all of the benefits that
ment: What transpires between the patient modern technology and modern health care
and the nurse is of the highest value. The true bringand there are manywe need to pause
worth of her nursing theory is that it clearly and ask the question What is at risk in health
states what nursing is or should be today. care today? The answer to that question may
Regardless of the changes in the health care lead to reconsideration of the value of Orlan-
system, the human transaction between the dos theory as perhaps the critical link for
nurse and the patient in any setting holds the enhancing relationships between nursing and
greatest value, not only for nursing, but also for patient today (Rittman, 1991).

References

Orlando, I. J. (1961/1990). The dynamic nurse-patient


Barron, M. A. (1966). The effects varied nursing
relationship: Function, process and principles. New York:
approaches have on patients complaints of pain.
National League for Nursing (reprinted from 1961
Nursing Research, 15(1), 9091.
edition). New York: G. P. Putnams Sons.
Bochnak, M. A. (1963). The effect of an automatic and
Orlando, I. J. (1972). The discipline and teaching of
deliberative process of nursing activity on the relief
nursing process: An evaluative study. New York:
of patients pain: A clinical experiment. Nursing
G. P. Putnams Sons.
Research, 12(3), 191193.
Rittman, M. R. (1991). Ida Jean Orlando (Pelletier)
Dumas, R. G., & Leonard, R. C. (1963). The effect of
the dynamic nursepatient relationship. In: M. Parker
nursing on the incidence of post-operative vomiting.
(Ed.), Nursing theories and nursing practice (pp.
Nursing Research, 12(1), 1215.
125130). Philadelphia: F. A. Davis.
Elms, R. R., & Leonard, R. C. (1966). The effects of
Tryson, P. A. (1963). An experiment of the effect of
nursing approaches during admission. Nursing
patients participation in planning the administration
Research, 15(1), 3948.
of a nursing procedure. Nursing Research, 12(4),
Gowan, N. I., & Morris, M. (1964). Nurses responses
262265.
to expressed patient needs. Nursing Research, 13(1),
6871.
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Section
III
Conceptual Models/Grand
Theories in the
Interactive/Integrative
Paradigm
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Section

III Conceptual Models/Grand Theories in


the Interactive/Integrative Paradigm
Section III includes eight chapters on the conceptual models or grand theories situated in the inter-
activeintegrative nursing paradigm. These chapters are written by either the theorist or an author
designated as an authority on the theory by the theorist or the community of scholars advancing
that theory. Theories in the interactiveintegrative paradigm view persons (families, groups, com-
munities) as integrated wholes or integrated systems interacting with the larger environmental sys-
tem. The integrated dimensions of the person (family, group, community) are influenced by envi-
ronmental factors leading to some change that impacts health or well-being. The subjectivity of the
person and the multidimensional nature of any outcome are considered. Most of the theories are
based explicitly on a systems perspective. Levines Conservation Model, described in Chapter 7,
focuses on promotion of adaptation and maintaining integrity of the system in interaction with the
environment. The goal of nursing is to promote health or integrity as the person is confronted with
challenges or life situations. According to Levine, energy conservation in the midst of organismic
response to stress is essential for integrity. In Chapter 8, Johnsons Behavioral Systems Model is
described. It includes principles of wholeness and order, stabilization, reorganization, hierarchic
interaction, and dialectic contradiction. The person is viewed as a compilation of subsystems.
According to Johnson, the goal of nursing is to restore, maintain, or attain behavioral system bal-
ance and stability at the highest possible level. Chapter 9 features Orems Self-Care Deficit Nursing
Theory, a conceptual model with three interrelated theories associated with it: Theory of Nursing
Systems, Theory of Self-Care Deficit, and the Theory of Self-Care. According to Orem, when
requirements for self-care exceed capacity for self-care, self-care deficits occur. Nursing systems are
designed to address these self-care deficits. Kings Theory of Goal Attainment presented in Chap-
ter 10 offers a view that the goal of nursing is to help persons maintain health or regain health.
This is accomplished through a transaction or setting a goal with the patient. In Chapter 11,
Sr. Callista Roy and her colleague, Dr. Lin Zhan, describe the Roy Adaptation Model and its appli-
cations. In this model, the person is viewed as a holistic adaptive system with coping processes to
maintain adaptation and promote personenvironment transformations. The adaptive system can
be integrated, compensatory, or compromised depending on the level of adaptation. Nurses pro-
mote coping and adaptation within health and illness. Patricia Deal Aylward authored Chapter 12
on Neumans Systems Model. The model includes the clientclient system with a basic structure
protected from stressors by lines of defense and resistance. The concern of nursing is to keep the
client stable by assessing the actual or potential effects of stressors and assisting client adjustments
for optimal wellness. In Chapter 13, Erickson, Tomlin, and Swains Modeling and Role Modeling
Theory is presented by Helen Erickson. Modeling and Role Modeling Theory provides a guide for
the practice or process of nursing. The theory integrates a holistic philosophy with concepts from
a variety of theoretical perspectives such as adaptation, need status, and developmental task res-
olution. The final chapter in this section is Dosseys Theory of Integral Nursing, a relatively new
grand theory that posits an integral worldview and bodymindspirit connectedness. The theory
is informed by a variety of ideas including Nightingales tenets, holism, multidimensionality, spiral
dynamics, chaos theory, and complexity. It includes the major concepts of healing, the metapara-
82 digm of nursing, patterns of knowing, and Wilbers integral theory and Wilbers all quadrants, all
levels, all lines.
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Chapter
7
Myra Levines
Conservation Model
K AREN M OORE S CHAEFER

Introducing the Theorist Introducing the Theorist


Overview of the Model Myra Levine has been called a Renaissance
Applications to Practice womanhighly principled, remarkable, and
Practice Exemplar committed to what happens to the patients
Summary quality of life (Loyola University, 1992). She
References was a daughter, sister, wife, mother, friend,
educator, administrator, student of humani-
ties, scholar, facilitator, and confidante. She
was amazingly intelligent, opinionated, quick
to respond, loving, caring, trustworthy, and
global in her vision of nursing.
Levine was born in Chicago and was raised
with a sister and a brother with whom she
shared a close, loving relationship (Levine,
1988b). She was also very fond of her father,
who was a hardware man. He was often ill and
Myra Levine
frequently hospitalized with gastrointestinal
problems. She thinks that this might have
been why she had such a great interest in nurs-
ing. Levines mother was a strong woman who
kept the home filled with love and warmth.
She was very supportive of Levines choice to
be a nurse. [My mother] probably knew as
much about nursing as I did (Levine, 1988b)
because she was devoted to caring for her
father when he was ill.
Levine began attending the University of
Chicago but chose to attend Cook County
School of Nursing when she could no longer
afford the university. Being in nursing school
was a new experience for her; she called it
a great adventure (Levine, 1988b). She
received her diploma from Cook County in
1944. She later received her Bachelor of Sci-
ence degree from the University of Chicago in
1949 and her Master of Science in nursing
from Wayne State University in 1962.
Aside from her husband and children, edu-
cation was Levines primary interest, although

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84 S E C T I O N III Conceptual Models/Grand Theories in the Interactive/Integrative Paradigm

she had clinical experience in the operating about the first edition of this book has been the
room and in oncology nursing. She was a civil- exchange of interests that has resulted from the
ian nurse at the Gardiner General Hospital; willingness with which its readers and users have
Director of Nursing at Drexel Home in Chicago; communicated with its author. (Levine, 1973, p. vii)
Clinical Instructor at Bryan Memorial Hospi-
Levines original book (1969b) provided a
tal in Lincoln, Nebraska; and Administrative
model for teaching medical surgical nursing
Supervisor at University of Chicago Clinics
and created a dialogue among colleagues
and Henry Ford Hospital in Michigan. She
about the plan itself. The text has continued
was Chairperson of Clinical Nursing at Cook
to create dialogue about the art and science
County School of Nursing and a faculty mem-
of nursing with ongoing research serving as
ber at Loyola University, Rush University, and
a testament to its value (Delmore, 2003;
University of Illinois. She was a visiting profes-
Mefford, 1999, 2004).
sor at Tel Aviv University in Israel and Recanti
School of Nursing at Ben Gurion University
of the Negev in Beer Sheeva, Israel. She Foundations of Clinical Nursing
was Professor Emeritus in Medical Surgical Levines original reason for writing the book
Nursing, University of Chicago; a Charter was to find a way to teach the foundations of
Fellow of the American Academy of Nursing, nursing that would focus on nursing itself and
and a member of Sigma Theta Tau Interna- was organized in such a way that students
tional, from which she received the Elizabeth would learn the skill as well as the rationale
Russell Belford Award as distinguished educa- for it. She felt that too often the focus was on
tor. She received an honorary doctorate from skill alone. Her intent was to bring practice
Loyola University in 1992. and research together to establish nursing as
an applied science. The book was used as a
beginning nursing text by Levine and many of
Overview of the Model her colleagues.
The F. A. Davis Company published the first The first chapter of her text was entitled,
edition of Myra Levines textbook, Introduc- Introduction to Patient-Centered Nursing
tion to Clinical Nursing, in 1969 and the sec- Care, a model of care delivery that is now
ond and last editions in 1973. In discussing acclaimed as the answer to cost-effective
the first edition of her book, Levine (1969a, delivery of health care services today. She
p. 39) said: I decided against using holistic believed that patient-centered care was indi-
in favor of organismic, largely because the vidualized nursing care (Levine, 1973, p. 23).
term holistic had been appropriated by pseu- She discussed the theory of causation, a uni-
doscientists endowing it with the mythology fied theory of health and disease, the meaning
of transcendentalism. I used holism in the of the conservation principles, the hospital as
second edition in 1973 because I realized it environment, and patient-centered interven-
was too important to be abandoned to the tion. The nursing care chapters in her text
mystics. I believed that it was the proper focus on care of the patient with:
description of the way the internal environ-
1. Failure of the nervous system
ment and the external environment were
2. Failure of integration resulting from
joined in the real world. In the introduction
hormonal imbalance
to the second edition, she wrote:
3. Disturbance of homeostasis: fluid and
There is something very final about a printed page, electrolyte imbalance
and yet books do have a life all their own. They 4. Disturbance of homeostasis: nutritional needs
gather life from the use to which they are put, and 5. Disturbance of homeostasis: systemic
when they succeed in communicating among oxygen needs
many individuals in many places, then their intent 6. Disturbance of homeostasis: cellular
is most truly served. The most remarkable fact oxygen needs
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C H A P T E R 7 Myra Levines Conservation Model 85

7. Disease arising from aberrant cellular growth sense of well-being, energy exchange at the
8. Inflammatory problems organismic level and at the cellular level, per-
9. Holistic response ception of self, the effect of space on self-per-
ception, and the circadian rhythm.
Her way of organizing the material was a As Levine wrote her book, major changes
shift from teaching nursing based on the dis- occurred in the curriculum at Cook County
ease model. Her final chapter on the holistic Hospital (Levine, 1988b). She and her col-
response represented a major change from leagues began to focus on the importance of
disease to systems thinking. Informed by oth- nursing research and taught perception, sleep,
er disciplines, she discussed the integrated distance (space), and periodicity as factors in
system, the interaction of systems creating the health and disease (see Box 7-1).

Box 71 Inuences on the Conservation Model


Levine used the inductive method to develop her model. She borrowed information from other
disciplines while retaining the basic structure of nursing in the model (Levine, 1988a). As she con-
tinued to write about her model, she integrated information from other sciences and increasingly
cited personal experiences as evidence of her works validity. The following is a list of the influences
in the development of her philosophy of nursing and the Conservation Model.
1. Levine indicated that Florence Nightingale, through her focus on observation (Nightingale,
1859), provided great attention to energy conservation and recognized the need for structural
integrity. Levine relates Nightingales discussion of social integrity to Nightingales concern for
sanitation, which she says implies an interaction between the person and the environment.
2. Irene Beland influenced Levines thinking about nursing as a compassionate art and rigid
intellectual pursuit (Levine, 1988b). Levine also credited Beland (1971) for the theory of
specific causation and multiple factors.
3. Feynman (1965) provided support for Levines position that conservation was a natural law,
arguing that the development of theory cannot deny the importance of natural law (Levine,
1973).
4. Bernard (1957) is recognized for his contribution in the identification of the interdependence
of bodily functions (Levine, 1973).
5. Levine (1973) emphasized the dynamic nature of the internal milieu, using Waddingtons
(1968) term homeophoresis.
6. Use of Batess (1967) formulation of the external environment as having three levels of factors
(perceptual, operational, and conceptual) challenging the integrity of the individual helped to
emphasize the complexity of the environment.
7. The description of illness is based on Wolf s (1961) description of disease as adaptation to
noxious environmental forces.
8. Selyes (1956) definition of stress is included in Levines (1989c) description of her organis-
mic stress response as being recorded over time and . . . influenced by the accumulated experi-
ence of the individual (p. 30).
9. The perceptual organismic response incorporates Gibsons (1966) work on perception as a
mediator of behavior. His identification of the five perceptual systems, including hearing,
sight, touch, taste, and smell, contributed to the development of the perceptual response.
10. The notion that individuals seek to defend their personhood is grounded in Goldsteins
(1963) explanation of soldiers who, despite brain injury, sought to cling to some semblance of
self-awareness.
11. Dubos (1965) discussion of the adaptability of the organism helped support Levines
explanation that adaptation occurs within a range of responses.
12. Levines personal experiences influenced her thinking. When hospitalized, she said, the
experience of wholeness is universally acknowledged (Levine, 1996, p. 39).
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86 S E C T I O N III Conceptual Models/Grand Theories in the Interactive/Integrative Paradigm

Assumptions and Values of Values


the Conservation Model All nursing actions are moral actions.
Assumptions The sanctity of life and the relief of suffering
The person is viewed as a holistic being: are moral imperatives.
The experience of wholeness is the Ethical behavior is the day-to-day expres-
foundation of all human enterprises sion of ones commitment to other per-
(Levine, 1991, p. 3). sons and the ways in which human beings
Human beings respond in a singular yet relate to one another in their daily inter-
integrated fashion. actions (Levine, 1977, p. 846).
Each individual responds wholly and com- A fully informed individual should make
pletely to every alteration in his or her life decisions regarding life and death in
pattern. advance of crises. These decisions are not
Individuals cannot be understood out of the the role of the health care provider or the
context of their environment. family (Levine, 1989b).
Ultimately, decisions for nursing care are Judgments by nurses or doctors about quality
based on the unique behavior of the indi- of life are inappropriate and should not be
vidual patient. . . . A theory of nursing used as a basis for the allocation of care
must recognize the importance of unique (Levine, 1989b).
detail of care for a single patient within Persons who require the intensive interven-
an empiric framework which successfully tions of critical care units enter with a con-
describes the requirements of all patients tract of trust. To respect trust is a moral
(Levine, 1973, p. 6). responsibility (Levine, 1988b, p. 88).
Patient-centered care means individualized
nursing care. It is predicated on the reality The Composition of the Conservation
of common experience: every man (sic) is Model
a unique individual, and as such requires a As an organizing framework for nursing prac-
unique constellation of skills, techniques, tice, the goal of the Conservation Model is to
and ideas designed specially for him (sic) promote adaptation and maintain wholeness
(Levine, 1973, p. 23). using the principles of conservation.
Every self-sustaining system monitors its The model guides the nurse to focus on
own behavior by conserving the use of the influences and responses at the organismic
resources required to define its unique level. The nurse accomplishes the goals of the
identity (Levine, 1991, p. 4). model through the conservation of energy,
The nurse is responsible for recognizing the structure, and personal and social integrity
state of altered health and the patients (Levine, 1967). Interventions are provided to
organismic response to altered health. improve the patients condition (therapeutic)
Nursing is a unique contributor to patient or to promote comfort (supportive) when
care (Levine, 1988a). change in the patients condition is not possi-
The patient is in an altered state of health ble. The outcomes of the interventions are
(Levine, 1973). A patient is someone who assessed through the organismic response.
seeks health care because of a desire to Although Levine identified two concepts
remain healthy or someone who identifies critical to the use of her modeladaptation
a known risk behavior or a desire to and wholenessconservation is fundamental
reduce a possible one. to the outcomes expected when the model is
A guardian-angel activity assumes that the used. Conservation is addressed as the third
nurse accepts responsibility and shows con- major concept of the model. Using the model
cern based on knowledge that makes it pos- in practice requires that the nurse understand
sible to decide on the patients behalf and the commonplaces (Barnum, 1994) of health,
in his [or her] best interest (Levine, 1973). person, environment, and nursing.
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C H A P T E R 7 Myra Levines Conservation Model 87

Before delving into the inner workings of organismic responses vary (renal perfusion,
Levines model, it is necessary to understand blood vessel integrity) based on genetic
its components. alterations, age, gender, and therapeutic
management techniques.
Adaptation Redundancy represents the fail-safe options
available to the individual to ensure continued
Adaptation is the process of change, and
adaptation. Levine (1991) believed that health
conservation is the outcome of adaptation.
is dependent on the ability to select from
Adaptation is the process whereby the
redundant options. She hypothesized that
patient maintains integrity within the reali-
aging may be the result of the failure of redun-
ties of the environment (Levine, 1966,
dant systems. If this is the case, then survival is
1989a). Adaptation is achieved through the
dependent on redundant options, which are
frugal, economic, contained, and controlled
often challenged and limited by illness, disease,
use of environmental resources by the indi-
and the normal aging process. When the com-
vidual in his or her best interest (Levine,
pensatory response to cardiac disease is no
1991, p. 5). In her view:
longer able to maintain an adequate blood flow
The environmental fit that underscores success- to vital organs during activity, survival becomes
ful adaptation suggests that every species has fixed increasingly difficult. Adaptation represents
patterns of response uniquely designed to ensure the accommodation between the internal and
success in essential life activities, demonstrating external environments.
that adaptation is both historical and specific. How-
ever, tremendous opportunities for individual Conservation
accommodations are locked into the gene struc- Conservation is the product of adaptation and is a
ture of each species; every individual is one of a common principle underlying many of the basic
kind. (p. 5) sciences. It is critical to understanding an essential
element of human life: Implicit in the knowledge of
Every individual has a unique range of
conservation is the fact of wholeness, integrity, unity
adaptive responses. These responses will vary
all of the structures that are being conserved
based on heredity, age, gender, or challenges
conservation of the integrity of the person is essen-
of an illness experience. For example, the
tial to ensuring health and providing the strength to
response to weakness of the cardiac muscle is
confront disability . . . the importance of conserva-
increased heart rate, dilation of the ventricle,
tion in the treatment of illness is precisely focused
and thickening of the myocardial muscle.
on the reclamation of wholeness, of health.
Although the responses are the same, the tim-
Every nursing act is dedicated to the conservation,
ing and the manifestation of the organismic
or keeping together, of the wholeness of the indi-
response (e.g., pulse rate) will be unique for
vidual. (Levine, 1991, p. 3)
each individual.
Redundancy, history, and specificity Individuals are continuously defending
characterize adaptation. These characteris- their wholeness to keep together the life sys-
tics are rooted in history and awaiting tem. Individuals defend themselves in con-
the specific circumstances to which they stant interaction with their environment,
respond (Levine, 1991, p. 6). The genetic choosing the most economic, frugal, and
structure develops over time and provides energy-sparing options that safeguard their
the foundation for these responses. Speci- integrity. Conservation seeks to achieve a bal-
ficity refers to the fact that while sharing ance of energy supply and demand that is
traits with a species, individual potential within the unique biological capabilities of
creates a variety of adaptation outcomes. the individual (Schaefer, 1991a).
For example, diabetes has a genetic compo- Maintaining the proper balance requires
nent, which explains the fundamental that the nursing intervention be coupled
decrease in sugar metabolism. However, the with the patients participation to ensure that
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88 S E C T I O N III Conceptual Models/Grand Theories in the Interactive/Integrative Paradigm

activities are within the safe limits of the encroachment of the disability can be set
patients ability to participate. Although ener- aside entirely, and the individual is free to
gy cannot be directly observed, the conse- pursue once more his or her own interests
quences of energy exchanges are predictable, without constraint (p. 4). In all of lifes chal-
recognizable, and manageable (Levine, 1973, lenges, individuals will constantly attempt to
1991). attain, retain, maintain, or protect their
integrity (health, wholeness, and unity).
Wholeness To Levine, the holistic individual is a
Wholeness is based on Eriksons (1964) thinking being who is aware of the past and
description of wholeness as an open system: oriented to the future. The wholeness (integri-
Wholeness emphasizes a sound, organic, ty) of the person demands that the individual
progressive mutuality between diversified life has meaning only in the context of social
functions and parts within an entirety, the life (Levine, 1973, p. 17). The person
boundaries of which are open and fluid responds to change in an integrated, sequen-
(p. 63). Levine (1973) stated that the unceas- tial, yet singular fashion while in constant
ing interaction of the individual organism interaction with the environment. Levine
with its environment does represent an open (1996) defined the person as a spiritual
and fluid system, and a condition of health, being, quoting Genesis 1:27: And God creat-
wholeness, exists when the interaction or con- ed man in his own image, in the image of God
stant adaptations to the environment, permit created He him. Male and female created He
easethe assurance of integrity ... in all the them. Sanctity of life is manifested in
dimensions of life (p. 11). This continuously everyone. The holiness of life itself [testifies]
dynamic, open interaction between the inter- to its spiritual reality (p. 40). Person can be
nal and external environment provides the an individual, a family, or a community.
basis for holistic thought: the view of the Levine (1968a, 1968b, 1973) recognizes
individual as whole. that the person is defined to a certain degree
based on the boundaries defined by Hall
Health, Person, Environment, and Nursing (1966) as personal space. Levine rejected the
Health and disease are patterns of adaptive notion that energy can be manipulated and
change. From a social perspective, health is transferred from one human to another as in
the ability to function in social roles. Health is therapeutic touch. Yet someone is affected by
culturally determined: [I]t is not an entity, the presence of another relative to his or her
but rather a definition imparted by the ethos personal space boundaries. Admittedly, some
and beliefs of the groups to which the indi- of this is based on cultural ethos, yet what is it
vidual belongs (M. Levine, personal commu- about the bubble that results in a specific
nication, February 21, 1995). organismic response? It may be that the energy
Health is an individual response that may involved in the interaction is not clearly
change over time in response to new situa- defined, fueling the skeptics criticism and
tions; new life challenges; aging; or social, challenging scientists to examine the ques-
political, economic, or spiritual factors. tion. Levine encouraged creativity to explore
Health implies unity and integrity. The goal this question, but rejected activities that were
of nursing is to promote health. not scientifically supported.
Levine (1991) clarified what she meant by The environment completes the wholeness
health as ...the avenue of return to the daily of the individual. The individual has both an
activities compromised by illness. It is not internal and external environment. The inter-
only the insult or the injury that is repaired nal environment combines the physiological
but the person himself or herself. It is not and pathophysiological aspects of the individ-
merely the healing of an afflicted part. It is ual and is constantly challenged by the exter-
rather a return to selfhood, where the nal environment.
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C H A P T E R 7 Myra Levines Conservation Model 89

The external environment includes factors for recognition, respect, self-awareness, human-
that impinge on and challenge the individual. ness, selfhood, and self-determination. The
The environment as described by Levine conservation of social integrity recognizes the
(1973) was adapted from the following three individual as a social being who functions in a
levels of environment identified by Bates society that helps to establish boundaries of
(1967). the self. The value of the individual is recog-
The perceptual environment includes nized, together with an appreciation that the
aspects of the world that individuals are able individual resides within a family, a communi-
to seize or interpret through the senses. The ty, a religious group, an ethnic group, a politi-
individual seeks, selects, and tests informa- cal system, a nation and a global world
tion from the environment in the context of (Levine, 1973).
his [her] definition of himself [herself ], and The outcome of nursing involves the
so defends his [her] safety, his [her] identity, assessment of organismic responses. The nurse
and in a larger sense, his [her] purpose is responsible for responding to a request for
(Levine, 1971, p. 262). health care and for recognizing altered health
The operational environment includes fac- and the patients organismic response to
tors that may physically affect individuals but altered health. An organismic response is a
are not directly perceived by them, such as change in behavior or change in the level
radiation, microorganisms, and pollution. of functioning during an attempt to adapt
The conceptual environment includes the to the environment. Organismic responses are
cultural patterns characterized by spiritual intended to maintain the patients integrity.
existence and mediated by language, thought, According to Levine (1973), the levels of
and history. Factors that affect behavior, such organismic response include:
as norms, values, and beliefs, are also part of
1. Response to fear (flight/fight response). The
the conceptual environment.
most primitive response is the physiologi-
Nursing is human interaction (Levine,
cal and behavioral readiness to respond to
1973, p. 1). The nurse enters into a
a sudden and unexpected environmental
partnership of human experience where shar-
change. It is an instantaneous response to
ing moments in timesome trivial, some
a real or imagined threat.
dramaticleaves its mark forever on each
2. Inflammatory response. The second level of
patient (Levine, 1977, p. 845). The goal of
response is intended to provide for struc-
nursing is to promote adaptation and main-
tural integrity (as a defense against noxious
tain wholeness (health). The goal is accom-
stimuli) and the promotion of healing.
plished through the use of the conservation
3. Response to stress. The third level of
principles: energy and structural, personal,
response is developed over time and influ-
and social integrity.
enced by each stressful experience encoun-
The Model tered by the patient. If the experience is
prolonged, the stress can lead to damage to
Energy conservation is dependent on the
the systems.
free exchange of energy with the internal and
4. Perceptual response. The fourth level of
external environment to maintain the bal-
response involves gathering information
ance of energy supply and demand. Conser-
from the environment and converting it to
vation of structural integrity is dependent on
a meaningful experience.
an intact defense system (immune system)
that supports healing and repair to preserve The organismic responses are redundant in
the structure and function of the whole the sense that they coexist. The four respons-
being. es help individuals protect and maintain their
The conservation of personal integrity integrity. They are integrated by cognitive
acknowledges the individual as one who strives abilities, the wealth of previous experiences,
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90 S E C T I O N III Conceptual Models/Grand Theories in the Interactive/Integrative Paradigm

the ability to define relationships, and the Applications to Practice


strength of adaptive abilities.
The nurse uses the scientific process and The models universality is supported by its
creative abilities to provide nursing care to the use in a variety of situations and patient con-
patient (Schaefer, 1991a). The nursing ditions across the life span. A growing body
process incorporates these abilities, thereby of research provides evidence to support its
improving the patients care (see Table 7-1). application to nursing practice. The focus of

Table 7 1 Use of the Nursing Process According to Levine


Process Application of the Process
Assessment Collection (through observation and interview) of challenges to the internal
and external environments. The nurse observes the patient for organismic
responses to illness, reads medical reports, evaluates results of diagnostic
studies, and talks with patients and their families (support persons) about
their needs for assistance. The nurse assesses for physiological and patho-
physiological challenges to the internal environment and the factors in the
perceptual, operational, and conceptual levels of the external environment
that challenge the individual.
Trophicognosis* Nursing diagnosis that gives the provocative facts meaning.
The nurse arranges the provocative facts in a way that provides meaning
to the patients predicament. A judgment is the trophicognosis.**
Hypotheses Direct the nursing interventions with the goal of maintaining wholeness
and promoting adaptation.
Nurses seek validation of the patients problems with the patients or
support persons. The nurses then propose hypotheses about the problems
and the solutions, such as Eight glasses of water a day will improve
bowel evacuation. These become the plan of care.
Interventions Test the hypotheses.
Nurses use hypotheses to direct care. The nurse tests proposed hypotheses
and designs interventions based on the conservation principles: conserva-
tion of energy, structural integrity, person integrity, and social integrity.
Interventions are not imposed but are determined to be mutually accept-
able. The expectation is that this approach will maintain wholeness and
promote adaptation.
Evaluation Observation of organismic response to interventions.
The outcome of hypothesis-testing is evaluated by assessing for organis-
mic response that means the hypotheses are supported or not supported.
Consequences of care are either therapeutic or supportive: therapeutic
measures improve the sense of well-being; supportive measures provide
comfort when the downward course of illness cannot be inuenced. If the
hypotheses are not supported, the plan is revised and new hypotheses
are proposed.
*The novice nurse may use the conservation principles at this point to assist with the organization of the provocative facts.
The expert nurse integrates this into the environmental assessments.
**Trophicognosis is a nursing care judgment arrived at through the use of the scientic process (Levine, 1965). The
scientic process is used to make observations and select relevant data to form hypothetical statements about the patients
predicaments (Schaefer, 1991a).
Source: Levines Nursing Process Using Critical Thinking. In: M. R. Alligood & A. Marriner-Tomey (Eds.). (1997). Nursing
theory: Utilization and application. St. Louis, MO: C. V. Mosby. Revised and used with permission of C. V. Mosby.
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C H A P T E R 7 Myra Levines Conservation Model 91

this section is on how practitioners have used determine the childs tolerance of activities
the model to provide care with evidence and to respond to his cues. The nurse encour-
appropriately integrated with use. aged the mother to communicate through
Roberts, Fleming, and Yeates-Giese (1991) touch and language. The mother successfully
designed interventions to maintain perineal recognized the childs cues and discontinued
integrity for women in labor based on the activities when he became tired.
Conservation Model. The findings support Mefford (1999, 2004) tested a theory
that the normal adaptations of the birthing of health promotion for preterm infants
process provide the most physically, emo- derived from Levines Conservation Model.
tionally and socially beneficial means for this She found a significant inverse relationship
physiological function (p. 69). Episiotomy between the consistency of caregiver and the
should be reserved for specific situations age at which the infant achieved health. An
where it is warranted, rather than being used inverse relationship also existed between the
prophylactically, because it does not appear to use of resources by preterm infants during the
be protective. initial hospital stay and the consistency of
Langer (1990) used the Conservation caregivers. This suggests that with increasing
Model to develop a protocol for minimal han- age (and perhaps experience) of the care
dling of premature infants. Based on the goal provider, the infants may receive a higher
of maintaining the integrity of the infant and quality of care. These findings can be helpful
family, the integrities were used to identify in making assignments to patient care units.
activities that would help reduce the handling Mefford has indicated that she plans to con-
of each infant while maintaining the whole- tinue her work with the model to develop the
ness of the infantfamily unit. For example, theory of health promotion across the life
swaddling was used to maintain the personal span (L. C. Mefford, personal communica-
integrity of the infant to limit agitation from tion, 2008).
suctioning, and to make sure parents were Using a case study approach, Dever
part of the health care team in order to main- (1991) demonstrated how the use of the
tain their social integrity. Conservation Model can assist nurses in the
Savage and Culbert (1989) adopted the care of children. She based care on the
Conservation Model as a framework to estab- assumption that children have an amazing
lish a care plan for a family with a develop- capacity to adapt and recover if the right
mentally disabled child. The integrities were mix of interventions is provided. The conser-
used to conduct an assessment, identify short- vation principles served as a guide to ensure
term goals, plan nursing actions, and evaluate comprehensive care.
outcomes. A case study identified nutritional Cooper (1990) developed a framework for
intake as a threat to energy conservation. One wound care focusing on structural integrity
nursing action was to help the mother posi- while noting that conservation must be
tion her child for optimal alignment and understood as part of the integrated role of
demonstrate manual jaw closure and place- the nurse. She noted that energy conservation
ment of food in the mouth using a spoon. The was essential to protecting the patient and
outcome was achieved when the mother that nursing processes should be dedicated to
demonstrated proper positioning and noted the promotion of healing. Dibble, Bostrom-
that feeding was easier using the new tech- Ezerati, and Ruzzuto (1991) used the model
niques. The childs limited cognition was a to identify nursing actions that would pro-
challenge to the familys personal integrity. mote structural integrity and limit the devel-
A standardized assessment revealed that opment of phlebitis and infiltration at an
the child had the cognitive function of a intravenous site.
2-month-old with some skills up to those of a OLaughlin (1986) approached nursing
6-month-old. The short-term goal was to care of a patient after a radical hysterectomy
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using the Conservation Model. She outlined (1994) used the Conservation Model to study
the role of the nurse according to the integri- the effect of the boomerang pillow technique
ties and indicated that the nurse (1) conserves on respiratory capacity. The findings support-
energy when energy is needed for healing by ed that boomerang pillows provide comfort
maintaining good catheter care to reduce the without compromising respiratory capacity.
chance of infection, (2) ensures that the blad- Dow and Mest (1997) used the Conservation
der is emptied regularly to prevent overdisten- Model to design interventions to meet the
sion and structural damage, (3) assesses the psychosocial needs of the client with chronic
patient for how changes in micturition will obstructive pulmonary disease (COPD) living
affect her lifestyle and encourages the patient in the community. They focused on the
to participate in decisions about how to man- personal and social integrities. The clients
age her bladder and adapt to lifestyle changes, personal integrity can be challenged by forced
and (4) integrates aspects of the patients early retirement, feelings of guilt from not
social life into her plan of care. being able to provide for the family, and man-
Neswick (1997) used a case study of a aging personal issues such as being over-
patient with an ostomy to demonstrate how weight. Consideration was given to the need
the model helps provide holistic care. Energy for the spouse to take on new roles, which can
focused on the nutrition needed to heal; add stress to the family structure. Recom-
structural focused on maintaining skin mended interventions included counseling,
integrity; personal addressed issues associated exercise, and relaxation as well as teaching
with going public with an ostomy; and social about medications.
integrity stressed the importance of rehabili- Several practitioners have used the Con-
tation. After the completion of a prevalence servation Model to assist patients with fatigue
and incidence study of skin care, Burd et al. and develop interventions to reduce this
(1994) used the model to evaluate strategies disabling symptom (Schaefer & Shober-
in the prevention of skin breakdown. Rotylycki, 1993; Schaefer, Swavely, Rothen-
Leach (2006) published a white paper on berger, Hess, & Willistin, 1996). Schaefer
the use of the Conservation Model to guide (1991b) used the model to conceptualize the
wound care practices, specifically venous leg experience of fatigue in patients with conges-
ulcers (VLUs). In the context of VLUs, nurs- tive heart failure. In talking with clients, she
es focus on the maintenance of energy conser- learned that the feeling of fatigue affects ones
vation and structural integrity by providing way of being by overcoming the entire body.
external dressings and compression devices to Interventions for fatigue must take into con-
improve venous flow. In contrast to Mefford sideration all of the integrities in order to have
(2004), Leach uses Levine for short-term goal a positive organismic response. Mock et al.
achievement only. He does not support the (2007) used the model to design and test
use of the Levine Conservation Model as a interventions for the fatigue experienced by
basis for health promotion or maintenance. patients with cancer. The four conservation
This conflicts with Levines (1973) view of principles guided the development of an exer-
individuals as past-aware and future-oriented. cise intervention that is currently being
Webb (1993) used the Conservation tested. For example, energy conservation
Model to provide care for patients undergoing addresses fatigue and sleep; structural integri-
Hartmans procedure. Using a case study ty focuses on physical function; personal
approach, the author demonstrated how the integrity includes emotional desires and qual-
use of trophicognoses (see Table 9-1) can be ity of life; and social integrity focuses on social
successful in developing a plan of care for a function.
surgical patient. In the critical care environment, the Con-
Roberts, Brittin, and deClifford (1995) servation Model has been used by several
and Roberts, Brittin, Cook, and deClifford practitioners to provide care for a variety of
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C H A P T E R 7 Myra Levines Conservation Model 93

clients. Brunner (1985) used the model to the Conservation Principles to explain the
develop a conceptual plan of care for patients perioperative experience and the role of the
in critical care. She used the integrities to nurse in maintaining wholeness. She briefly
develop an assessment and showed how the explained the model to provide a context for
data could be used to determine the nursing care and stressed the importance of the
diagnosis, short-term goals, nursing actions, unique approach to each patient. Conserva-
and outcomes. Ballard, Robley, Barrett, Fraser, tion of energy focused on maintaining physi-
and Mendoza (2006) approached the complex ological function during the operative experi-
experience of therapeutic paralysis from a sys- ence; maintenance of structural integrity
tems perspective, and asked how the system focused on the prevention of injury and the
adapts and functions to maintain the internal promotion of healing; personal integrity
and external environment. Guided by the addressed the possibility that patients admit-
Conservation Model, she learned that patients ted to the operating room might be unfamil-
reconstructed their lives; living through a life- iar with the environment and were, at times,
threatening ordeal resulted in a modification away from their support system such that the
of the stress response. nurse had to focus on helping the patient
The nurses role is to maintain integrity manage feelings of loneliness and loss; and
while helping patients live with themselves in finally the nurse determined the patients
new ways. Use of the Conservation Model needs relative to family and friends to main-
facilitates this process. Using the principle of tain social integrity. Lynn-McHale and Smith
conservation of energy, Littrell and Schumann (1991) developed a family assessment tool
(1989) explained the importance of promot- based on the Conservation Model with the
ing sleep for the patient with a myocardial goal of providing comprehensive care. Exam-
infarction. They linked their discussion to the ples of assessment criteria included: energy
requirement to balance energy resources and perception of the event; structuralfamily
needs in order to promote healing related to function; personallife events; and social
the infarction. The nurses goals are to ensure work patterns.
undisturbed restful sleep by clustering activi- Taylor (1974) used the model to explain
ties, creating a familiar sleep environment, how to develop outcomes of nursing care. She
using monitors, minimizing noise and pain, argued that by using a framework, nurses
avoiding care activities during REM sleep, would be able to identify critical points along
and limiting visitors. McCall (1991) used the the continuum of care to assure the achieve-
model to develop an assessment tool and pro- ment of outcomes. Using the neurological
vide care for patients with epilepsy in a neu- patient as the paradigm case, Taylor clustered
rological intensive care unit. Schaefer (1991b) potential problems encountered by the patient
used the model to design care for patients and listed examples of outcomes. For exam-
with congestive heart failure, and Bayley ple, in the early phase of illness, energy is
(1991) showed how the model can be used to compromised by respiratory paralysis and
develop a plan of care for clients with burns. immobility. Early outcomes include the suc-
Using the model, Pond and Taney (1991) cessful maintenance of respiratory function
provided care for emergency room clients and adequate control of pain and discomfort.
while developing a collaborative practice, a As the patient approaches recovery, possible
project sustained by the emergency room issues associated with energy conservation
practitioners (physicians and nurses) interest include poor appetite and becoming easily
in collaborating. The model worked because fatigued. Outcomes might include normal
it was precise and useful; physicians were able weight and activity consistent with pathology.
to communicate the clients needs with clari- Pond (1991) used the model in her nurse
ty and common understanding between all practitioner practice to care for the homeless
practitioners. Crawford-Gamble (1986) used population. She recognized that individuals
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94 S E C T I O N III Conceptual Models/Grand Theories in the Interactive/Integrative Paradigm

who were homeless had severe health and Model to assess and develop interventions
social service needs. Her goal was to promote for staff during the process of change. The
health for this aggregate. Levines (1973) following are examples of how the integrities
concept of the environment was particularly were operationalized in the assessment: energy
relevant to the person living on the street. The conservation included sleep patterns and nutri-
integrities were used to assess and meet the tion; structural integrity addressed skin and
needs of the homeless. For example, energy body movement; personal integrity included
conservation focused on food and nutrition self-esteem, independence, and control; and
programs; structural integrity addressed injury social integrity addressed stable support and
prevention and safety in shelters; personal family.
integrity focused on privacy for interpersonal Levines Conservation Model was used
interactions and community education about successfully as a basis for the undergraduate
the homeless; and social integrity included and graduate programs at Allentown College
self-awareness, parenting and interaction (now DeSales University). The model was
group interventions. operationalized through the nursing process
Schaefer (2006a, 2006b) has used the for students in the undergraduate program
model to organize the care of individuals (Grindley & Paradowski, 1991). Levines
with chronic illness. The model provides an approach to care and philosophical discus-
inclusive framework for assessing the needs sions about nursing provided a context for
of the individuals, identifying trophicog- the graduate program (Schaefer, 1991c). The
noses, developing a plan of care based on faculty believed that graduate students should
hypothetical statements, and evaluating for learn about more than one nursing model or
organismic patient responses. Use of this theory. They agreed that the match between
process also forms potential research ques- individual practice and the nature of the model
tions, because of the use of hypothetical must be a good fit, making it imperative that
statements that are tested based on the the student select or work with a model
organismic outcomes. appropriate for the setting and the type of
Hirschfeld (1976) has used the principles client in their practice.
of conservation in the care of older adults.
Cox (1991) used the model to provide long- The Model Modified for Use in
term care to older clients. She describes how Community-Based Care
she instructed staff to provide care according The principles of community health nursing
to the conservation principles and identify that are fundamental to community-based
goals for each principle. She extended care care can be practiced in any setting. The
beyond the walls of the agency by encourag- discussion that follows focuses on community-
ing staff to help residents maintain ties to based care using Levines Conservation Model
the local community, preserving their social to provide a foundation for the future of nurs-
integrity. Happ, Williams, Strumpf, and Burger ing practice, demonstrating the models utility
(1996) applied the Conservation Model to for community nursing practice.
the case of the frail elderly. She used the con- The focus of health in the community is
cept of wholeness to encourage staff to build based on the assumption that community-
and maintain relationships with elderly based care is often informed by the one-
clients. Foreman (1989, 1991) claims that the on-one care provided to individuals. Using
model works well in caring for clients with Levines Conservation Model, community
dementia when all the conservation principles was initially defined as a group of people
are used to assess, organize, and evaluate care. living together within a larger society, shar-
The Conservation Model has also been ing common characteristics, interests, and
used to develop programs in administration and location (National League for Nursing Self
education. Jost (2000) used the Conservation Study Report, 1978). Clark (1992) provided
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C H A P T E R 7 Myra Levines Conservation Model 95

examples of the use of the conservation houses of worship and health care settings
principles with the individual, family, and might be included. In this area, the effect
community as a testament to the models of communities external to the one being
flexibility/universality. assessed would be addressed to determine
The approach begins with the collection factors that may influence the function of the
of facts and a thorough community assess- target community.
ment (provocative facts). The internal envi- The novice nurse will benefit from using
ronment assessment directs the nurse to the conservation principles to guide continued
examine the patterns of health and disease assessment to assure a thorough understanding
among the people and their use of programs of the community. When considering energy
available to promote a healthy community. conservation, areas to assess might include:
The assessment of the external environment
1. Hours of employment
directs the nurse to examine the perceptual,
2. Water supply
operational, and conceptual levels of the envi-
3. Community budget
ronment in which the people live.
4. Food sources
The perceptual environment incorporates
the factors that are processed by the senses. An assessment of structural integrity might
On a community basis, these factors might include:
include an assessment of how the media
1. City planning
affects the health of the people; the influence
2. Availability of resources
of air quality on health patterns and housing
3. Transportation
development; the availability of nutritious and
4. Traffic patterns
affordable foods throughout the community;
5. Public services
noise pollution; and relationships among the
communitys subcultures. An assessment of personal integrity might
Understanding the operational environ- include:
ment requires a more detailed assessment of
1. Community identity
the factors in the environment that affect the
2. Mission of the government
individuals health but are not perceived by the
3. Political environment
people. These might include surveillance of
communicable diseases; assessment for the use An assessment of the social integrity might
of toxins in industry; disposal of waste prod- include:
ucts; consideration for exposure to electromag-
1. Recreation
netic fields from power lines; and examination
2. Social services
of buildings for asbestos, lead, and radon.
3. Opportunities for employment
The conceptual environment focuses the
assessment on the ethnic and cultural patterns See Table 7-2, Levines Conservation
in the community. An assessment of types of ModelNursing Process in the Community.

Table 7 2 Levines Conservation Model Nursing Process in the Community


Process Application of the Process
Assessment Collection of provocative facts through observation and interview.
The nurse uses observation, review of census data, statistics, data from
community member interviews, and so on to collect provocative facts
about the community. Use of windshield assessments or other formally
developed community assessments are helpful in the collection of data.
Continued
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96 S E C T I O N III Conceptual Models/Grand Theories in the Interactive/Integrative Paradigm

Table 7 2 Levines Conservation Model Nursing Process in


the Communitycontd
Process Application of the Process
Trophicognosis Community diagnosis.
The nurse organizes the data in such a way as to provide meaning. A
judgment or trophicognosis is made.
Hypotheses Direct the nurse to provide interventions that will promote adaptation and
maintain wholeness of the community.
In discussion with the community members, the nurse validates her judg-
ments about the communitys predicament. The nurse then proposes
hypotheses about the problems and solutions, such as Providing shelter
to abused women will reduce the morbidity associated with continuous
uninterrupted abuse.
Interventions Test the hypotheses.
The nurse uses the hypotheses to direct the plan of care for the community.
The nurse tests the proposed hypotheses to try to remedy the predicament.
The nurse selects the most appropriate solutions with the help of the com-
munity members. Interventions are based on the conservation principles of
energy, structural integrity, personal integrity, and social integrity. The shel-
ter for abused women provides for structural integrity of the community
while preserving the energy, personal, and social integrity of the women
who choose shelter.
Evaluation Observation of organismic response to interventions.
The outcome of hypothesis-testing is evaluated by assessing for organis-
mic response. For example, an expected outcome of shelters for abused
women might be a reduction in emergency room visits for injury resulting
from suspected abuse or an increase in the number of women who are
able to remove themselves from an abusive relationship.

Practice Exemplar
Missy is a 32-year-old woman who is cur- way affected by the illness. Her physician
rently in her third trimester of pregnancy. assured her that she would be fine and that
She and her husband have been married for there was no evidence that FM affects or is
5 years; she works as a consultant for a retail passed on to the fetus.
business. Although her job is demanding, It took several years before Missy and her
she can choose to work at home 2 days a husband were able to become pregnant. Need-
week. She considers herself healthy, except less to say they were very pleased with the
that she was diagnosed with fibromyalgia news. Because there was limited information
(FM) at age 26. She has been able to on how medication used to treat FM might
manage her FM with amitriptyline (Elavil) affect the fetus, Missy stopped the Elavil
25 mg nightly and exercise. Deciding to while trying to become pregnant. She used
become pregnant was difficult because little relaxation, warm baths, and stretching to help
is known about how FM might affect preg- her sleep and to control the muscular discom-
nancy and whether the child would be in any fort associated with FM with limited success.
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C H A P T E R 7 Myra Levines Conservation Model 97

The first trimester of pregnancy was nor- Baby Vertex position


mal. She was tired and experienced some Heart rate assessed at
morning sickness in the evening. She did 140 beats/min
not feel the need for medicinal intervention, Movement is vigorous
primarily because she wanted to be sure she
Using the Levine Conservation Model,
did not put her child at risk. She noted that
the nurses goal is to promote wholeness in
she felt a bit down and out when she
the context of Missys pregnancy.
thought she would be on cloud nine because
she was pregnant. She was comfortable dur- Assessment
ing her second trimester, although she still Challenges to Missys Internal
felt tired. Compared to her friends who were
Environment
also pregnant, she rated her tiredness as being
worse. Working 2 days a week from home Missy is experiencing a normal pregnancy
did give her the chance to rest more when with the exception of weight gain of
needed, while still meeting the deadlines and 16 pounds in one month. Her vital signs are
needs of her employer. normal; her diastolic pressure is 86 mm Hg.
When Missy arrived at the office for her She rates her pain level as 7 on a scale of 0 to
32-week check-up, the nurse noted that she 10. The nurse questions Missy and learns that
did not seem to be herself, was more reserved because of her fatigue, she is not eating as
than normal, and seemed to be moving very well as she had before. She is more likely to
slowly. In casual conversation, Missy said that eat fast food to cut down on preparation time.
she had been feeling down in the dumps Her husband is gone 2 days a week and she
and was having trouble sleeping. does not feel like cooking for herself.
On careful assessment the nurse found Challenges to Missys External
that Missy was sleeping about 6 interrupted Environment
hours a night and was anxious about her
delivery because her FM symptoms had come Missys perceptual environment is affected by
back with a vengeance. She did not know her high level of pain and fatigue (feeling
how she would ever be able to go through more tired than normal). Her operational
environmental assessment reveals that she is
labor, and she could not sleep because she was
bothered by the summer heat. She thinks
having so much lower back pain and indiges-
heat might be the source of her fatigue and
tion. Because she was tired, she was not walk-
feeling down in the dumps. Her conceptual
ing every day as she was accustomed to doing.
environment is challenged by her concerns
Her husband was supportive and tried to
about being able to manage labor, given her
do as much as he could for her. He worked
generalized discomfort and more severe pain
full-time and commuted to New York by
in her lower back. She is disappointed about
train 2 days a week. The following objective
the return of her FM symptoms because she
data were obtained:
fears that this will interfere with her ability to
Blood pressure 136/86 mm Hg go through natural childbirth. She is also
Temperature 98.2F (36.8C) concerned about her ability to be a good
Respirations 18 breaths/min mother because of the aches and pain associ-
Pulse 88 beats/min ated with the FM.
Weight 166 lbs (75.5 kg; normal
weight 120 lbs [54.5 kg]; Energy Conservation
last visit 150 lbs [68 kg]) Missys fatigue serves as a clue to an alter-
Urine No ketones, blood, or ation in function. Missy may not be getting
glucose an adequate supply of nutrients to support
Continued
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Practice Exemplar cont.


bodily functions. In addition she reports dys- Hypotheses
pepsia. She is taking her daily prenatal vita- Alteration in sleep position will improve the
mins, yet her nutrition may be inadequate quality of Missys sleep.
because of eating fast foods. She is more Exploring comfort options for her lower
fatigued than usual, and the fatigue is affect- back pain will result in improved comfort
ing her ability to engage in activities of daily and more restful sleep.
living. Identifying challenges related to delivery will
help to reduce her anxiety.
Structural Integrity
Reviewing the expected changes post deliv-
Missys pregnancy is progressing normally. ery will help Missy anticipate when she
Indicators suggest that the baby is growing might need assistance because of her FM.
and behaving normally. Fetal movement is as Discussing ways to parent in the context of
expected. Missy reports lower back pain FM will improve her self-esteem as a new
which is making it difficult for her to sleep. mother.
Referring Missy for a nutritional consult will
Personal Integrity help her meet her nutritional needs and
Missy is frustrated by the return of her FM control her indigestion during her last
symptoms and is afraid they may make labor trimester.
and delivery difficult. These symptoms are
challenging her ability to go through a natu- Nursing Interventions
ral delivery, something both she and her Energy Conservation
husband have planned for. The nutritional consultation will help Missy
identify simple ways to meet her nutritional
Social Integrity needs. The nutritionist will conduct a brief
The possibility of not being able to go assessment of food normally eaten during a
through natural childbirth with her hus- 24-hour period. Potentially helpful interven-
band as coach challenges their social integri- tions that can be reinforced by nurses include:
ty, changing how they had expected to expe- selecting healthier fast foods; eating smaller
rience the birth of their child. Because she meals several times a day (fruit, vegetables, pro-
has felt down in the dumps, she is begin- tein); preparing foods in larger quantities to
ning to question her ability to be a good reduce the anxiety and fatigue associated with
mother. She wants to breastfeed her child always cooking; and avoiding gas-forming food
and is concerned about the demands that such as carbonated beverages, beans and some
this may place on her ability to function. green vegetables, like cucumber and broccoli.
Restful sleep is important for both physi-
Trophigcognoses ological and emotional renewal. The goal is
Inadequate nutrition based on frequent fast to help Missy sleep comfortably so that she
food meals actually feels rested. For Missy, pregnancy
Lower back pain related to normal pregnancy and the fibromyalgia are partners in the chal-
changes and fibromyalgia lenges associated with sleeping and the
Lack of restful sleep related to lower back subsequent back pain. Discuss the use of pil-
pain and indigestion lows to support the body in a comfortable
Inadequate self-esteem related to fear of not position. She currently uses several pillows at
being able to fulfill her role as a mother night to make it easier for her to breathe.
Anxiety related to anticipated discomfort Suggestions to support this modified sleep-
during delivery ing position include using soft pillows to
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C H A P T E R 7 Myra Levines Conservation Model 99

support her lower back and arms. This will It is important to reassure Missy that she
help reduce pressure on tender points, reliev- can be a good mother even with the FM.
ing some discomfort. Advise her to take a She may need some assistance in adjusting
brief nap in the morning and the afternoon activities to reduce discomfort when caring
to help her reenergize her emotions and pre- for her child across the spectrum of growth
vent physiological disruptions. and development. Because she wants to
Encourage her to discuss the possibility of breast feed, it is important that she be
using very low dose amitriptyline for sleep referred to a lactation consultant who will
and pain management. Discussing this with work with her to assure adequate latching
the physician or nurse practitioner will help and positions of comfort for the feedings.
alleviate any fears about the effect of the Women with FM have more difficulty with
medication on the baby, and the medication endurance than with ability to physically
may help relieve the patients discomfort. function. This means that Missy may need
Additional interventions for sleep and pain to reposition during breastfeeding to avoid
include a warm bath before bed, the use of stiffness and aching associated with FM. It
aromatherapy such as lavender, mild exercise is also important to begin a discussion about
(walking several times a day for 10 minutes how she will care for her child. It is appro-
each time), use of music or environmental priate to recommend that she have some
sounds to induce relaxation, keeping the help for the first 2 to 4 weeks after the baby
room temperature comfortable and constant, comes home, so that she can get the rest she
and establishing a routine bedtime and time needs and still bond with her child. It is also
to arise in the morning. helpful to talk about things that she hopes
to do with her child, so that she can begin
Structural Conservation to develop a healthy positive approach to
Improving Missys nutrition will support the motherhood. For example, throwing a ball
healing process needed after delivery of her for a long time challenges the endurance.
child. The nurse will want to stress the However, she will be able to throw the ball
importance of blood work to assess physio- for short periods of time without the fatigue
logical nutrition and follow-up in response to associated with low endurance. She will
changes in her eating habits. Acknowledge learn through trial and error how long she
Missys commitment to taking her prenatal can tolerate an activity. Usually at the first
vitamins and how important this is for the sign of muscle fatigue or aching, the activity
health and well-being of her baby. should be stopped. Reading is wonderful for
children and can be a source of great inter-
Personal Integrity action and mothering, yet it requires limited
Missy is anxious about delivery. Additional use of muscles and energy.
information is needed to determine what it
is about delivery that concerns her. Once Social Integrity
the challenges are identified, the nurse can It is recommended that Missys husband
reassure Missy that every effort will be join her for the last several health visits
made to support a normal delivery with the before birth so that he is included in the dis-
least amount of discomfort. Interventions cussions and planning for the baby. This will
will need to be adjusted to accommodate give him a chance to have questions
her FM. For example, the intensity of sus- answered and can be a great way to foster the
tained contractions may require greater dis- parenting relationship. Missy acknowledges
traction (preferred music) and careful his support and willingness to help. If they
coaching. have difficulty communicating concerns and

Continued
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Practice Exemplar cont.


desires related to the pregnancy and recov- No protein in her urine
ery, they might benefit from a referral to a Average weight gain of 1 pound per week
counselor familiar with FM. To maintain until delivery
her social integrity, she will want to main- Meeting with her husband and a lactation
tain a balance in her life so that her sense of consultant
being is not stressed. Reports that she has made arrangements
for her mother (or other support person)
Organismic Responses to spend 2 weeks with her after the baby
is born. Her sister will then spend a
In response to the above interventions, the
week so that she will have help for
nurse will observe for the following organis-
3 weeks.
mic responses.
Discomfort controlled during delivery
Reduced lower back pain and restful sleep Successful delivery of a healthy child
Controlled dyspepsia Expresses excitement about becoming a new
Normal hemoglobin and hematocrit mother

Summary
Levines notion of the environment as com- assessment of the internal environments
plex provides an excellent basis for continuing response to the challenge of the external envi-
to develop an improved understanding of ronment (e.g., destruction from hurricanes)
the environment. Studying the interactions will immediately identify the altered health
between the external and the internal environ- status of the community and the community
ment will provide for a better understanding of needs. An assessment of the external environ-
adaptation. This focus will provide for addi- ment will provide an understanding of the
tional information about the challenges in the changes occurring due to the assault on
external environment and how they change the internal environment and a more detailed
over time. It is important that we understand assessment of the perceptual, organismic,
the changes that occur and how the person and conceptual levels of the environmental
who adapted before now changes the adaptive challenges. There is no question that this
response in order to maintain balance or approach to describing, defining, and plan-
integrity. This adaptive response will inform ning for environmental challenges will
the organismic response. With an improved identify (1) the perceptual challenges; (2) the
repertoire of organismic responses, we can test organismic challenges that may not be imme-
how to predict these responses, and thus assure diately known to the residents (e.g., pollution
that adaptive responses occur. This acknowl- of air and water); and (3) the conceptual issues
edges that the nurse may recognize that the that increase nurses awareness of the social,
most appropriate goal is to maintain comfort political, economic, and global impact on the
only (e.g., supportive interventions). predicament. This provides nurses with the
Moving to a more global perspective, the opportunity to develop a political agenda and
environment as defined according to Levine perhaps design public policy that might
(1973) provides nurses with the opportunity improve interventions in the context of a dis-
to enhance their understanding of it and aster. The Conservation Model has the com-
to provide interventions for communities ponents needed to provide nurses with a global
that suffer from environmental disasters. An perspective of the environment.
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C H A P T E R 7 Myra Levines Conservation Model 101

The methods of nurses and advanced prac- work for examining the effect of ventilator
tice nurses are changing rapidly to keep up with weaning on the patients energy and structur-
the current speed of health care system changes. al integrity. Researchers must replicate these
Levines Conservation Model provides an studies and publish their findings to ensure
approach that educates good nurses and pro- the continued development of the art and sci-
vides a foundation for their practice, whatever ence of nursing. Levine will applaud their
the role or the setting. Nurse practitioners, case efforts.
managers, program planners, nurse midwives,
Theory is the poetry of science. The poets words are
nurse anesthetists, and nurse entrepreneurs are
familiar, each standing alone, but brought together
encouraged to test the model as a basis for
they sing, they astonish, they teach. The theorist
improving and guiding their practice.
offers a fresh vision, familiar concepts brought
There is a renewed interest in the use of
together in bold, new designs. . . . The theorist and
the model as a basis of nursing research.
poet seek excitement in the sudden insights that
Zalon (2004) noted that the use of the
make ordinary experience extraordinary, but theory
integrities as guiding principles for research
caught in the intellectual exercises of the academy
and identification of variables continues to
becomes alive only when it is made a true instru-
result in wholeness. Delmore (2006) found
ment of persuasion. (Levine, 1995, p. 14)
that the model was an appropriate frame

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Roberts, K. L., Brittin, M., & deClifford, J. (1995). Taylor, J. W. (1989). Levines conservation principles:
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Chapter
8
Dorothy Johnsons Behavioral
System Model and Its
Applications
B ONNIE H OLADAY

Introducing the Theorist Introducing the Theorist


Overview of Johnsons Behavioral Dorothy Johnsons earliest publications per-
System Model
tained to the knowledge base nurses needed for
Applications of the Model
nursing care ( Johnson, 1959, 1961). Through-
Practice Exemplar
out her career, Johnson stressed that nursing
Summary
had a unique, independent contribution to
References
health care that was distinct from delegated
medical care. Johnson was one of the first
grand theorists to present her views as a con-
ceptual model. Her model was the first to pro-
vide both a guide to understanding and a guide
to action. These two ideasunderstanding
seen first as a holistic, behavioral system
process mediated by a complex framework and
second as an active process of encounter and
responseare central to the work of other the-
Dorothy Johnson
orists who followed her lead and developed
conceptual models for nursing practice.
Dorothy Johnson was born on August 21,
1919, in Savannah, Georgia. She received her
associate of arts degree from Armstrong
Junior College in Savannah, Georgia, in 1938
and her bachelor of science in nursing degree
from Vanderbilt University in 1942. She prac-
ticed briefly as a staff nurse at the Chatham-
Savannah Health Council before attending
Harvard University, where she received her
master of public health (MPH) in 1948. She
began her academic career at Vanderbilt Uni-
versity School of Nursing. A call from Lulu
Hassenplug, Dean of the School of Nursing,
enticed her to go to the University of Califor-
nia at Los Angeles (UCLA) in 1949. She
served there as an assistant, associate, and
professor of pediatric nursing until her retire-
ment in 1978. She passed away in 1999.

104
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C H A P T E R 8 Dorothy Johnsons Behavioral System Model and Its Applications 105

During her academic career, Dorothy systems introduces into the rhetoric about
Johnson addressed issues related to nursing nursing theory development some of the
practice, nursing education, and nursing sci- specifics that make it possible to test hypothe-
ence. While she was a pediatric nursing advi- ses and conduct critical experiments.
sor at the Christian Medical College School
of Nursing in Vellare, South India, she wrote Five Core Principles
a series of clinical articles for the Nursing Johnsons model incorporates five core prin-
Journal of India ( Johnson, 1956, 1957). She ciples of system thinking: wholeness and
worked with the California Nurses Associa- order, stabilization, reorganization, hierar-
tion, the National League for Nursing, and chic interaction, and dialectical contradic-
the American Nurses Association to examine tion. Each of these general systems principles
the role of the clinical nurse specialist, the has analogs in developmental theories that
scope of nursing practice, and the need Johnson used to verify the validity of her
for nursing research. She also completed a model ( Johnson, 1980, 1990). Wholeness and
Public Health Servicefunded research proj- order provide the basis for continuity and
ect (Crying as a Physiologic State in the identity, stabilization for development, reor-
Newborn Infant) in 1963 ( Johnson & ganization for growth and/or change, hierar-
Smith, 1963). The foundations of her model chic interaction for discontinuity, and dialec-
and her beliefs about nursing are clearly tical contradiction for motivation. Johnson
evident in these early publications. conceptualized a person as an open system
with organized, interrelated, and interde-
Overview of Johnsons pendent subsystems. By virtue of subsystem
interaction and independence, the whole of
Behavioral System Model the human organism (system) is greater than
Johnson has noted that her theory, the the sum of its parts (subsystems). Wholes and
Johnson Behavioral System Model ( JBSM), their parts create a system with dual con-
evolved from philosophical ideas, theory, and straints: Neither has continuity and identity
research; her clinical background; and many without the other.
years of thought, discussions, and writing The overall representation of the model can
( Johnson, 1968). She cited a number of also be viewed as a behavioral system within
sources for her theory. From Florence an environment. The behavioral system and
Nightingale came the belief that nursings the environment are linked by interactions and
concern is a focus on the person rather than transactions. We define the person (behavioral
the disease. Systems theorists (Buckley, 1968; system) as comprising subsystems and the
Chin, 1961; Parsons & Shils, 1951; Rapoport, environment as comprising physical, interper-
1968; Von Bertalanffy, 1968) were all sources sonal (e.g., father, friend, mother, sibling), and
for her model. Johnsons background as a sociocultural (e.g., rules and mores of home,
pediatric nurse is also evident in the develop- school, country, and other cultural contexts)
ment of her model. In her papers, Johnson components that supply the sustenal impera-
cited developmental literature to support the tives (Grubbs, 1980; Holaday, 1997; Johnson,
validity of a behavioral system model 1990; Meleis, 1991).
(Ainsworth, 1964; Crandal, 1963; Gerwitz,
1972; Kagan, 1964; Sears, Maccoby, & Levin, Wholeness and Order
1954). Johnson also noted that a number of The developmental analogy of wholeness and
her subsystems had biological underpinnings. order is continuity and identity. Given the
Johnsons theory and her related writings behavioral systems potential for plasticity, a
reflect her knowledge about both development basic feature of the system is that both conti-
and general systems theories. The combina- nuity and change can exist across the life
tion of nursing, development, and general span. The presence of or potentiality for at
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106 S E C T I O N III Conceptual Models/Grand Theories in the Interactive/Integrative Paradigm

least some plasticity means that the key way is removed but soon shows age-appropriate
of casting the issue of continuity is not a mat- motor skills. An adult newly diagnosed with
ter of deciding what exists for a given process asthma who does not receive proper educa-
or function of a subsystem. Instead, the issue tion until a year after diagnosis can success-
should be cast in terms of determining pat- fully incorporate the material into her daily
terns of interactions among levels of the activities. These are examples of homeorhetic
behavioral system that may promote continu- processes or self-righting tendencies that can
ity for a particular subsystem at a given point occur over time.
in time. Johnsons work infers that continuity What we as nurses observe as develop-
is in the relationship of the parts rather than ment or adaptation of the behavioral system
in their individuality. Johnson (1990) noted is a product of stabilization. When a person is
that at the psychological level, attachment ill or threatened with illness, he or she is
(affiliative) and dependency are examples of subject to biopsychosocial perturbations. The
important specific behaviors that change over nurse, according to Johnson (1980, 1990),
time while the representation (meaning) may acts as the external regulator and monitors
remain the same. Johnson stated: [D]evelop- patient response, looking for successful adap-
mentally, dependence behavior in the socially tation to occur. If behavioral system balance
optimum case evolves from almost total returns, there is no need for intervention. If
dependence on others to a greater degree not, the nurse intervenes to help the patient
of dependence on self, with a certain amount restore behavioral system balance. It is hoped
of interdependence essential to the survival of that the patient matures and with additional
social groups (1990, p. 28). In terms of behav- hospitalizations the previous patterns of
ioral system balance, this pattern of depend- response have been assimilated and there are
ence to independence may be repeated as the few disturbances.
behavioral system engages in new situations
during the course of a lifetime. Reorganization
Adaptive reorganization occurs when the
Stabilization behavioral system encounters new experiences
Stabilization or behavioral system balance is in the environment that cannot be balanced by
another core principle of the JBSM. Dynamic existing system mechanisms. Adaptation is
systems respond to contextual changes by defined as change that permits the behavioral
either a homeostatic or homeorhetic process. system to maintain its set points best in new
Systems have a set point (like a thermostat) situations. To the extent that the behavioral
that they try to maintain by altering internal system cannot assimilate the new conditions
conditions to compensate for changes in with existing regulatory mechanisms, accom-
external conditions. Human thermoregula- modation must occur either as a new relation-
tion is an example of a homeostatic process ship between subsystems or by the establish-
that is primarily biological but is also behav- ment of a higher order or different cognitive
ioral (turning on the heater). Narcissism or schema (set, choice). The nurse acts to provide
the use of attribution of ability or effort are conditions or resources essential to help the
behavioral homeostatic processes we use to accommodation process, may impose regula-
interpret activities so they are consistent with tory or control mechanisms to stimulate or
our mental organization. reinforce certain behaviors, or may attempt to
From a behavioral system perspective, repair structural components ( Johnson, 1980).
homeorrhesis is a more important stabilizing The difference between stabilization and
process than is homeostasis. In homeorrhesis, reorganization is that the latter involves
the system stabilizes around a trajectory change or evolution. A behavioral system is
rather than a set point. A toddler placed in a embedded in an environment, but it is capable
body cast may show motor lags when the cast of operating independently of environmental
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C H A P T E R 8 Dorothy Johnsons Behavioral System Model and Its Applications 107

constraints through the process of adaptation. roles, and cognitive status when faced with
The diagnosis of a chronic illness, the birth illness or the threat of illness. Nurses inter-
of a child, or the development of a healthy ventions during these periods can make a
lifestyle regimen to prevent problems in later significant difference in the lives of the per-
years are all examples wherein accommodation sons involved. Behavioral system balance is
not only promotes behavioral system balance, restored and a new level of development is
but also involves a developmental process that attained.
results in the establishment of a higher order Johnsons model is unique, in part, because
or more complex behavioral system. it takes from both general systems and devel-
opmental theories. One may analyze the
Hierarchic Interaction patients response in terms of behavioral sys-
Each behavioral system exists in a context tem balance, and, from a developmental
of hierarchical relationships and environmental perspective ask, Where did this come from
relationships. From the perspective of general and where is it going? The developmental
systems theory, a behavioral system that has component necessitates that we identify and
the properties of wholeness and order, stabi- understand the processes of stabilization and
lization, and reorganization will also demon- sources of disturbances that lead to reorgani-
strate a hierarchic structure (Buckley, 1968). zation. These need to be evaluated by age,
Hierarchies, or a pattern of relying on particu- gender, and culture. The combination of
lar subsystems, lead to a degree of stability. systems theory and development identifies
A disruption or failure will not destroy the nursings unique social mission and our spe-
whole system but instead lead to decomposi- cial realm of original responsibility in patient
tion to the next level of stability. care ( Johnson, 1990, p. 32).
The judgment that a discontinuity has
occurred is typically based on a lack of corre- Major Concepts of the Model
lation between assessments at two points Next, we review the model as a behavioral
of time. For example, ones lifestyle before system within an environment.
surgery is not a good fit postoperatively. These
discontinuities can provide opportunities for Person
reorganization and development. Johnson conceptualized a nursing client as
a behavioral system. The behavioral system
Dialectical Contradiction is orderly, repetitive, and organized with
The last core principle is the motivational interrelated and interdependent biological
force for behavioral change. Johnson (1980) and behavioral subsystems. The client is seen
described these as drives and noted that these as a collection of behavioral subsystems that
responses are developed and modified over interrelate to form the behavioral system.
time through maturation, experience, and The system may be defined as those complex,
learning. A persons activities in the environ- overt actions or responses to a variety of stim-
ment lead to knowledge and development. uli present in the surrounding environment
However, by acting on the world, each person that are purposeful and functional (Auger,
is constantly changing it and his or her goals, 1976, p. 22). These ways of behaving form an
and therefore changing what he or she needs organized and integrated functional unit that
to know. The number of environmental determines and limits the interaction between
domains that the person is responding to the person and environment and establishes
include the biological, psychological, cultural, the relationship of the person to the objects,
familial, social, and physical setting. The events, and situations in the environment.
person needs to resolve (maintain behavioral Johnson (1980, p. 209) considered such
system balance of ) a cascade of contradictions behavior to be orderly, purposeful and pre-
between goals related to physical status, social dictable; that is, it is functionally efficient and
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108 S E C T I O N III Conceptual Models/Grand Theories in the Interactive/Integrative Paradigm

effective most of the time, and is sufficiently described in Table 8-1. Johnson noted that
stable and recurrent to be amenable to these subsystems are found cross-culturally
description and exploration. and across a broad range of the phylogenetic
scale. She also noted the significance of social
Subsystems and cultural factors involved in the develop-
The parts of the behavioral system are called ment of the subsystems. She did not consider
subsystems. They carry out specialized tasks the seven subsystems as complete, because
or functions needed to maintain the integrity the ultimate group of response systems to be
of the whole behavioral system and manage identified in the behavioral system will
its relationship to the environment. Each of undoubtedly change as research reveals new
these subsystems has a set of behavioral subsystems or indicated changes in the struc-
responses that is developed and modified ture, functions, or behavioral groupings in the
through motivation, experience, and learning. original set ( Johnson, 1980, p. 214).
Johnson identified seven subsystems. Each subsystem has functions that serve to
However, in this authors operationalization meet the conceptual goal. Functional behav-
of the model, as in Grubbs (1980), I have iors are the activities carried out to meet these
included eight subsystems. These eight sub- goals. These behaviors may vary with each
systems and their goals and functions are individual, depending on the persons age, sex,

Table 8 1 The Subsystems of Behavior


Achievement Subsystem
Goal Mastery or control of self or the environment
Function To set appropriate goals
To direct behaviors toward achieving a desired goal
To perceive recognition from others
To differentiate between immediate goals and long-term goals
To interpret feedback (input received) to evaluate the achievement of goals
Afliative Subsystem
Goal To relate or belong to someone or something other than oneself; to achieve
intimacy and inclusion
Function To form cooperative and interdependent role relationships within human social
systems
To develop and use interpersonal skills to achieve intimacy and inclusion
To share
To be related to another in a denite way
To use narcissistic feelings in an appropriate way
Aggressive/Protective Subsystem
Goal To protect self or others from real or imagined threatening objects, persons, or
ideas; to achieve self-protection and self-assertion
Function To recognize biological, environmental, or health systems that are potential
threats to self or others
To mobilize resources to respond to challenges identied as threats
To use resources or feedback mechanisms to alter biological, environmental, or
health input or human responses in order to diminish threats to self or others
To protect ones achievement goals
To protect ones beliefs
To protect ones identity or self-concept
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C H A P T E R 8 Dorothy Johnsons Behavioral System Model and Its Applications 109

Table 8 1 The Subsystems of Behaviorcontd


Dependency Subsystem
Goal To obtain focused attention, approval, nurturance, and physical assistance; to maintain
the environmental resources needed for assistance; to gain trust and reliance
Function To obtain approval, reassurance about self
To make others aware of self
To induce others to care for physical needs
To evolve from a state of total dependence on others to a state of increased
dependence on the self
To recognize and accept situations requiring reversal of
self-dependence (dependence upon others)
To focus on another or oneself in relation to social, psychological, and cultural
needs and desires
Eliminative Subsystem
Goal To expel biological wastes; to externalize the internal biological environment
Function To recognize and interpret input from the biological system that signals readiness
for waste excretion
To maintain physiological homeostasis through excretion
To adjust to alterations in biological capabilities related to waste excretion while
maintaining a sense of control over waste excretion
To relieve feelings of tension in the self
To express ones feelings, emotions, and ideas verbally or nonverbally
Ingestive Subsystem
Goal To take in needed resources from the environment to maintain the integrity of the
organism or to achieve a state of pleasure; to internalize the external environment
Function To sustain life through nutritive intake
To alter ineffective patterns of nutritive intake
To relieve pain or other psychophysiological subsystems
To obtain knowledge or information useful to the self
To obtain physical and/or emotional pleasure from intake of nutritive or
nonnutritive substances
Restorative Subsystem
Goal To relieve fatigue and/or achieve a state of equilibrium by reestablishing or
replenishing the energy distribution among the other subsystems; to redistribute
energy
Function To maintain and/or return to physiological homeostasis
To produce relaxation of the self system
Sexual Subsystem
Goal To procreate, to gratify or attract; to fulll expectations associated with ones
gender; to care for others and to be cared about by them
Function To develop a self-concept or self-identity based on gender
To project an image of oneself as a sexual being
To recognize and interpret biological system input related to sexual gratication
and/or procreation
To establish meaningful relationships in which sexual gratication and/or
procreation may be obtained
Sources: Based on J. Grubbs (1980). An interpretation of the Johnson behavioral system model. In: J. P. Riehl & C. Roy
(Eds.), Conceptual models for nursing practice (2nd ed., pp. 217254). New York: Appleton-Century-Crofts; D. E. Johnson
(1980). The behavioral system model for nursing. In: J. P. Riehl & C. Roy (Eds.), Conceptual models for nursing practice
(2nd ed., pp. 207216). New York: Appleton-Century-Crofts; D. Wilkie (1987). Operationalization of the JBSM. Unpub-
lished paper. University of California, San Francisco; and B. Holaday (1972). Operationalization of the JBSM. Unpub-
lished paper. University of California, Los Angeles.
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110 S E C T I O N III Conceptual Models/Grand Theories in the Interactive/Integrative Paradigm

motives, cultural values, social norms, and larger the behavioral repertoire of alternative
self-concepts. For the subsystem goals to be behaviors in a situation, the more adaptable is
accomplished, behavioral system structural the individual. The fourth structural compo-
components must meet functional require- nent of each subsystem is the observable
ments of the behavioral system. action of the individual. The concern is with
Each subsystem is composed of at least four the efficiency and effectiveness of the behavior
structural components that interact in a specific in goal attainment. Actions are any observable
pattern: goal, set, choice, and action. The goal of responses to stimuli.
a subsystem is defined as the desired result or For the eight subsystems to develop and
consequence of the behavior. The basis for the maintain stability, each must have a constant
goal is a universal drive whose existence can be supply of functional requirements (sustenal
supported by scientific research. In general, the imperatives). The concept of functional
drive of each subsystem is the same for all peo- requirements tends to be confined to condi-
ple, but there are variations among individuals tions of the systems survival, and it includes
(and within individuals over time) in the specif- biological as well as psychosocial needs. The
ic objects or events that are drive-fulfilling, in problems are related to establishing the types
the value placed on goal attainment, and in of functional requirements (universal versus
drive strength. With drives as the impetus for highly specific) and finding procedures for
the behavior, goals can be identified and are validating the assumptions of these require-
considered universal. ments. It also suggests a classification of the
The behavioral set is a predisposition to act various states or processes on the basis of
in a certain way in a given situation. The some principle and perhaps the establishment
behavioral set represents a relatively stable and of a hierarchy among them. The Johnson
habitual behavioral pattern of responses to par- model proposes that, for the behavior to be
ticular drives or stimuli. It is learned behavior maintained, it must be protected, nurtured,
and is influenced by knowledge, attitudes, and and stimulated: It requires protection from
beliefs. The set contains two components: per- noxious stimuli that threaten the survival of
severation and preparation. The perseveratory the behavioral system; nurturance, which pro-
set refers to a consistent tendency to react to vides adequate input to sustain behavior; and
certain stimuli with the same pattern of behav- stimulation, which contributes to continued
ior. The preparatory set is contingent upon the growth of the behavior and counteracts stag-
function of the perseveratory set. The prepara- nation. A deficiency in any or all of these
tory set functions to establish priorities for functional requirements threatens the behav-
attending or not attending to various stimuli. ioral system as a whole, or the effective func-
The conceptual set is an additional compo- tioning of the particular subsystem with
nent to the model (Holaday, 1982). It is a which it is directly involved.
process of ordering that serves as the mediat-
ing link between stimuli from the preparatory Environment
and perseveratory sets. Here attitudes, beliefs, Johnson referred to the internal and external
information, and knowledge are examined environment of the system. She also referred to
before a choice is made. There are three levels the interaction between the person and the
of processingan inadequate conceptual set, environment and to the objects, events, and sit-
a developing conceptual set, and a sophisticated uations in the environment. She also noted
conceptual set. that there are forces in the environment that
The third and fourth components of each impinge on the person and to which the person
subsystem are choice and action. Choice refers adjusts. Thus, the environment consists of all
to the individuals repertoire of alternative elements that are not a part of the individuals
behaviors in a situation that will best meet the behavioral system but influence the system and
goal and attain the desired outcome. The can serve as a source of sustenal imperatives.
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C H A P T E R 8 Dorothy Johnsons Behavioral System Model and Its Applications 111

Some of these elements can be manipulated by system balance and stability are demonstrated
the nurse to achieve health (behavioral system by observed behavior that is purposeful,
balance or stability) for the patient. Johnson orderly, and predictable. Such behavior is
provided no other specific definition of the maintained when it is efficient and effective in
environment, nor did she identify what she managing the persons relationship to the
considered internal versus external environ- environment.
ment. But much can be inferred from her writ- Behavior changes when efficiency and
ings, and system theory also provides addition- effectiveness are no longer evident or when a
al insights into the environment component of more optimal level of functioning is per-
the model. ceived. Individuals are said to achieve efficient
The external environment may include and effective behavioral functioning when
people, objects, and phenomena that can their behavior is commensurate with social
potentially permeate the boundary of the demands, when they are able to modify their
behavioral system. This external stimulus behavior in ways that support biologic imper-
forms an organized or meaningful pattern atives, when they are able to benefit to the
that elicits a response from the individual. fullest extent during illness from the physi-
The behavioral system attempts to maintain cians knowledge and skill, and when their
equilibrium in response to environmental fac- behavior does not reveal unnecessary trauma
tors by assimilating and accommodating to as a consequence of illness ( Johnson, 1980,
the forces that impinge upon it. Areas of p. 207).
external environment of interest to nurses Behavior system imbalance and instability
include the physical settings, people, objects, are not described explicitly but can be inferred
phenomena, and psychosocialcultural attrib- from the following statement to be a malfunc-
utes of an environment. tion of the behavioral system:
Johnson provided detailed information
The subsystems and the system as a whole tend to
about the internal structure and how it func-
be self-maintaining and self-perpetuating so long
tions. She also noted that [i]llness or other
as conditions in the internal and external environ-
sudden internal or external environmental
ment of the system remain orderly and predictable,
change is most frequently responsible for
the conditions and resources necessary to their
system malfunction ( Johnson, 1980, p.
functional requirements are met, and the interrela-
212). Such factors as physiology; tempera-
tionships among the subsystems are harmonious.
ment; ego; age; and related developmental
If these conditions are not met, malfunction
capacities, attitudes, and self-concept are
becomes apparent in behavior that is in part disor-
general regulators that may be viewed as a
ganized, erratic, and dysfunctional. Illness or other
class of internalized intervening variables
sudden internal or external environmental change
that influence set, choice, and action. They
is most frequently responsible for such malfunc-
are key areas for nursing assessment. For
tions. (Johnson, 1980, p. 212)
example, a nurse attempting to respond
to the needs of an acutely ill hospitalized Thus, Johnson equates behavioral system
6-year-old would need to know something imbalance and instability with illness. How-
about the developmental capacities of a ever, as Meleis (1991) has pointed out, we
6-year-old, and about self-concept and ego must consider that illness may be separate
development, to understand the childs from behavioral system functioning. Johnson
behavior. also referred to physical and social health, but
did not specifically define wellness. Just as the
Health inference about illness may be made, it may be
Johnson viewed health as efficient and effec- inferred that wellness is behavioral system
tive functioning of the system and as behav- balance and stability, as well as efficient and
ioral system balance and stability. Behavioral effective behavioral functioning.
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112 S E C T I O N III Conceptual Models/Grand Theories in the Interactive/Integrative Paradigm

Nursing and Nursing Therapeutics As a result of the inability to meet functional


Nursing is viewed as a service that is comple- requirements, structural impairments may take
mentary to that of medicine and other health place. In addition, functional stress may be
professions, but which makes its own distinc- found as a result of structural damage or from
tive contribution to the health and well-being the dysfunctional consequences of the behavior.
of people. ( Johnson, 1980, p. 207) She dis- Other problems develop when the systems
tinguished nursing from medicine by noting control and regulatory mechanisms fail to
that nursing views the patient as a behavioral develop or become defective.
system, and medicine views the patient as a Four diagnostic classifications to delineate
biological system. In her view, the specific these disturbances are differentiated in the
goal of nursing action is to restore, maintain, model. A disorder originating within any one
or attain behavioral system balance and stabil- subsystem is classified as either an insufficiency,
ity at the highest possible level for the indi- which exists when a subsystem is not func-
vidual ( Johnson, 1980, p. 214). This goal tioning or developed to its fullest capacity due
may be expanded to include helping the per- to inadequacy of functional requirements, or
son achieve an optimal level of balance and as a discrepancy, which exists when a behavior
functioning when this is possible and desired. does not meet the intended conceptual goal.
The goal of the systems action is behavioral Disorders found between more than one
system balance. For the nurse, the area of con- subsystem are classified either as an incom-
cern is a behavioral system threatened by the patibility, which exists when the behaviors of
loss of order and predictability through illness two or more subsystems in the same situation
or the threat of illness. The goal of a nurses conflict with each other to the detriment of
action is to maintain or restore the individuals the individual, or as dominance, which exists
behavioral system balance and stability or to when the behavior of one subsystem is used
help the individual achieve a more optimal more than any other, regardless of the situa-
level of balance and functioning. tion or to the detriment of the other subsys-
Johnson did not specify the steps of the tems. This is also an area where Johnson
nursing process but clearly identified the role believed additional diagnostic classifications
of the nurse as an external regulatory force. would be developed. Nursing therapeutics
She also identified questions to be asked when deal with these three areas.
analyzing system functioning, and she provided The next critical element is the nature of
diagnostic classifications to delineate distur- the interventions the nurse would use to
bances and guidelines for interventions. respond to the behavioral system imbalance.
Johnson (1980) expected the nurse to base The first step is a thorough assessment to find
judgments about behavioral system balance the source of the difficulty or the origin of the
and stability on knowledge and an explicit problem. There are at least three types of
value system. One important point she made interventions that the nurse can use to bring
about the value system is that given that the about change. The nurse may attempt to
person has been provided with an adequate repair damaged structural units by altering the
understanding of the potential for and means individuals set and choice. The second would
to obtain a more optimal level of behavioral be for the nurse to impose regulatory and
functioning than is evident at the present control measures. The nurse acts outside the
time, the final judgment of the desired level of patient environment to provide the condi-
functioning is the right of the individual tions, resources, and controls necessary to
( Johnson, 1980, p. 215). restore behavioral system balance. The nurse
The source of difficulty arises from structur- also acts within and upon the external envi-
al and functional stresses. Structural and func- ronment and the internal interactions of the
tional problems develop when the system is subsystem to create change and restore stabil-
unable to meet its own functional requirements. ity. The third, and most common, treatment
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C H A P T E R 8 Dorothy Johnsons Behavioral System Model and Its Applications 113

modality is to supply or to help the client find researchers have demonstrated the usefulness
his or her own supplies of essential functional of Johnsons model in a clinical practice in a
requirements. The nurse may provide nurtu- variety of ways. The majority of the research
rance (resources and conditions necessary for focuses on clients functioning in terms of
survival and growth; the nurse may train the maintaining or restoring behavioral system
client to cope with new stimuli and encourage balance, understanding the system and/or
effective behaviors), stimulation (provision of subsystems by focusing on the basic sciences,
stimuli that brings forth new behaviors or or focusing on the nurse as an agent of action
increases behaviors, that provides motivation who uses the JBSM to gather diagnostic data
for a particular behavior, and that provides or to provide care that influences behavioral
opportunities for appropriate behaviors), and system balance.
protection (safeguarding from noxious stim- Derdiarian (1990, 1991) examined the
uli, defending from unnecessary threats, and nurse as an action agent within the practice
coping with a threat on the individuals domain. She focused on the nurses assessment
behalf ). The nurse and the client negotiate of the patient using the DBSM and the effect
the treatment plan. of using this instrument on the quality of
care (Derdiarian, 1990, 1991). This approach
expanded the view of nursing knowledge from
Applications of the Model exclusively client-based to knowledge about
Fundamental to any professional discipline the context and practice of nursing that is
is the development of a scientific body of model-based. The results of these studies
knowledge that can be used to guide its found a significant increase in patient and
practice. JBSM has served as a means for nurse satisfaction when the DBSM was used.
identifying, labeling, and classifying phe- Derdiarian (1983, 1983b, 1988) also found
nomena important to the nursing discipline. that a model-based, valid, and reliable instru-
Nurses have used the JBSM model since the ment could improve the comprehensiveness
early 1970s, and the model has demonstrat- and the quality of assessment data; the method
ed its ability to provide a medium for theo- of assessment; and the quality of nursing diag-
retical growth; organization for nurses nosis, interventions, and outcome. Derdiari-
thinking, observations, and interpretations ans body of work reflects the complexity of
of what was observed; a systematic structure nursings knowledge as well as the strategic
and rationale for activities; direction to the problem-solving capabilities of the JBSM.
search for relevant research questions; solu- Her article (Derdiarian, 1991) demonstrated
tions for patient care problems; and, finally, the clear relationship between Johnsons theo-
criteria to determine if a problem has been ry and nursing practice.
solved. Others have demonstrated the utility of
Johnsons model for clinical practice. Coward
Practice-Focused Research and Wilke (2000) used the JBSM to examine
Stevenson and Woods (1986) state: Nursing cancer pain control behaviors. DHuyvetter
science is the domain of knowledge con- (2000) found that defining trauma as a dis-
cerned with the adaptation of individuals and ease, and approaching it within the context of
groups to actual or potential health problems, the JBSM, helps the practitioner develop
the environments that influence health in effective interventions. Box 8-1 highlights the
humans and the therapeutic interventions research on this theory.
that promote health and affect the conse- Lewis and Randell (1990) used the JBSM
quences of illness (1986, p. 6). This position to identify the most common nursing diag-
focuses efforts in nursing science on the noses of hospitalized geopsychiatric patients.
expansion of knowledge about clients health They found that 30 percent of the diagnoses
problems and nursing therapeutics. Nurse were related to the achievement subsystem.
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114 S E C T I O N III Conceptual Models/Grand Theories in the Interactive/Integrative Paradigm

Box 81 Bonnie Holadays Research Highlighted

My program of research has examined normal and atypical patterns of behavior of children with a
chronic illness and the behavior of their parents and the interrelationship between the children and
the environment. My goal was to determine the causes of instability within and between
subsystems (e.g., breakdown in internal regulatory or control mechanisms) and to identify the
source of problems in behavioral system balance.
My first study (Holaday, 1974) compared the achievement behavior of chronically ill and
healthy children. The study showed that chronically ill children differed in attributional tenden-
cies when compared with healthy children and showed that the response patterns differed within
the chronically ill group when compared on certain dimensions (e.g., gender, age at diagnosis).
Males and children diagnosed at birth attributed both success and failure to the presence or
absence of ability and little to effort. This is a pattern found in children with low achievement
needs. The results indicated behavioral system imbalance and focused my attention on interventions
directed toward set, choice, and action.
The next series of studies used the concept of behavioral set and examined how mothers and
their chronically ill infants interacted (Holaday, 1981, 1982, 1987). Patterns of maternal response
provided information related to the setting of the set goal or behavioral set; that is, the degree of
proximity and speed of maternal response. Mothers with chronically ill infants rarely did not
respond to a cry indicating a narrow behavioral set. Further analysis of the data led to the identifi-
cation of a new structural component of the model-conceptual set. A persons conceptual set was
defined as an organized cluster of cognitive units that were used to interpret the content informa-
tion from the preparatory and perseveratory sets. A conceptual set may differ both in the number
of cognitive units involved and in the degree of organization exhibited. The various cognitive units
that make up a conceptual set may vary in complexity depending on the situation. Three levels of
conceptual set have been identified, ranging from a very simple to a complex set with a high degree
of connectedness between multiple perspectives (Holaday, 1982). Thus, the conceptual set functions
as an information collection and processing unit. Examining a persons set, choice, and conceptual
set offered a way to examine issues of individual cognitive patterns and its impact on behavioral
system balance.
The most recent study (Holaday, Turner-Henson, & Swan, 1997) drew from the knowledge
gained from previous studies. This study viewed the JBSM as holistic, in that it assumed that all
part processesbiological, physical, psychological, and socioculturalare interrelated; develop-
mental, in that it assumed that development proceeds from a relative lack of differentiation toward
a goal of differentiation and hierarchic integration of organismic functioning; and system-oriented,
in that a unit of analysis was the person in the environment where the persons physical and/or
biological (e.g., health), psychological, interpersonal, and sociocultural levels of organization are
operative and interrelated with the physical, interpersonal, and sociocultural levels of organization
in the environment. Our results indicate that it was possible to determine the impact of a lack of
functional requirements on a childs actions and to identify behavioral system imbalance and the
need for specific types of nursing intervention.
The goal of my research program has been to describe the relations both among and within the
subsystems that make up the integrated whole and to identify the type of nursing interventions that
restore behavioral system balance.

They also found that the JBSM was more Education


specific than NANDA (North American
Johnsons model was used as the basis for
Nursing Diagnosis Association) diagnoses,
undergraduate education at the UCLA
which demonstrated considerable overlap.
School of Nursing. The curriculum was devel-
Poster, Dee, and Randell (1997) found the
oped by the faculty; however, no published
JBSM was an effective framework to use to
material is available that describes this
evaluate patient outcomes.
process. Texts by Wu (1973) and Auger
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C H A P T E R 8 Dorothy Johnsons Behavioral System Model and Its Applications 115

(1976) extended Johnsons model and provid- quality of nursing care (Dee & Auger, 1983).
ed some idea of the content of that curricu- The early works of Dee and Auger led to
lum. Later, in the 1980s, Harris (1986) further refinement in the patient classification
described the use of Johnsons theory as system. Behavioral indices for each subsystem
a framework for UCLAs curriculum. The have been further operationalized in terms of
Universities of Hawaii, Alaska, and Colorado critical adaptive and maladaptive behaviors.
also used the JBSM as a basis for their under- Behavioral data is gathered to determine the
graduate curricula. effectiveness of each subsystem (Dee & Ran-
Loveland-Cherry and Wilkerson (1983) dell, 1989; Dee, 1990).
analyzed Johnsons model and concluded that The scores serve as an acuity rating
the model could be used to develop a curricu- system and provide a basis for allocating
lum. The primary focus of the program would resources. These resources are allocated based
be the study of the person as a behavioral sys- on the assigned levels of nursing intervention,
tem. The student would need a background in and resource needs are calculated based on the
systems theory and in the biological, psycho- total number of patients assigned according to
logical, and sociological sciences. levels of nursing interventions and the hours
of nursing care associated with each of the
Nursing Practice and Administration levels (Dee & Randell, 1989) (Table 8-2).
Johnson has influenced nursing practice The development of this system has provided
because she enabled nurses to make state- nursing administration with the ability to
ments about the links between nursing input identify the levels of staff needed to provide
and health outcomes for clients. The model care (licensed vocational nurse versus regis-
has been useful in practice because it identi- tered nurse), bill patients for actual nursing
fies an end product (behavioral system bal- care services, and identify nursing services
ance), which is nursings goal. Nursings that are absolutely necessary in times of budg-
specific objective is to maintain or restore etary restraint. Recent research has demon-
the persons behavioral system balance and strated the importance of a model-based
stability, or to help the person achieve nursing database in medical records (Poster,
a more optimum level of functioning. The Dee, & Randell, 1997) and the effectiveness
model provides a means for identifying the of using a model to identify the characteristics
source of the problem in the system. Nursing of a large hospitals managed behavioral
is seen as the external regulatory force that acts health population in relation to observed
to restore balance ( Johnson, 1980). nursing care needs, level of patient function-
One of the best examples of the models ing on admission and discharge, and length of
use in practice has been at the University of stay (Dee, Van Servellen, & Brecht, 1998).
California, Los Angeles, Neuropsychiatric The work of Vivien Dee and her col-
Institute (UCLANPI). Auger and Dee leagues has demonstrated the validity and
(1983) designed a patient classification sys- usefulness of the JBSM as a basis for clinical
tem using the JBSM. Each subsystem of practice within a health care setting. From the
behavior was operationalized in terms of crit- findings of their work, it is clear that the
ical adaptive and maladaptive behaviors. The JBSM established a systematic framework for
behavioral statements were designed to be patient assessment and nursing interventions,
measurable, relevant to the clinical setting, provided a common frame of reference for all
observable, and specific to the subsystem. The practitioners in the clinical setting, provided a
use of the model has had a major impact on framework for the integration of staff knowl-
all phases of the nursing process, including a edge about the clients, and promoted conti-
more systematic assessment process, identifi- nuity in the delivery of care. These findings
cation of patient strengths and problem areas, should be generalizable to a variety of clinical
and an objective means for evaluating the settings.
116
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Table 8 2 Nursing Stafng Budget Unit: 2-South


Actual No. Levels of Nursing Interventions Patient Total Cost Cost per Patient
Page 116

Shift Patients I II III IV I Hours Budget Actual Var Budget Actual Var
Night 12.3 1.5 7.1 3.5 0.1 2.49 1.65 181734 154156 27578 40.2 35.2 5.0
Day 12.0 1.2 7.3 3.4 0.2 4.24 2.91 358208 338014 20194 79.1 79.6 0.4
Evening 12.2 1.2 7.3 3.6 0.1 3.82 2.55 183008 270855 87847 40.4 61.9 21.5
Totals 10.55 7.11 722950 763025 40075 159.7 176.7 16.9
Source: Dee, V., & Randell, B. (1989). NPH Patient Classication System: A theory-based nursing practice model for stafng. Paper presented at the UCLA Neuropsychiatric Institute and
Hospital.
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C H A P T E R 8 Dorothy Johnsons Behavioral System Model and Its Applications 117

Practice Exemplar
K ELLY W HITE lowing his chemotherapy treatments. These
During the change of shift report that morn- episodes have caused raw, tender patches of
ing, I was told that a new patient had just skin around his rectal area that become
been wheeled onto the floor at 7:00 A.M. As increasingly more painful and irritated with
a result, it was my responsibility to complete each bowel movement.
the admission paperwork and organize the Jim is exceptionally tearful this morning as
patients day. He was a 49-year-old man who he expresses concerns about his own future and
was admitted through the emergency depart- the future of his family. He informs me that
ment to our oncology floor for fever and neu- Ellens mother is flying in from out-of-state to
tropenia secondary to recent chemotherapy care for the children while he is hospitalized.
for lung cancer.
Immediately after my initial rounds, to Assessment
ensure all my patients were stable and com-
Johnsons Behavioral Systems Model guided
fortable, I rolled the computer on wheels into
the assessment process. The significant behav-
his room to begin the nursing admission
ioral data are as follows:
process. Jim explained to me that he was
diagnosed with small cell lung carcinoma Achievement subsystem:
(SCLC) 2 months ago after he was admitted Jim is losing control of his life and of the
to another hospital for coughing, chest pain, relationships that matter most to him as
and shortness of breath. He went on to person, his family.
explain that a recent MRI showed metastasis He is a high school graduate.
to the liver and brain. Affiliative protective subsystem:
His past health history revealed that he Jim is married but describes that his wife is
irregularly visited his primary health care distancing herself from him. He feels he
provider. He is 6 feet 3 inches tall and weighs is losing his best friend at a time when
168 pounds (76.4 kg). He states that he has he really needs this support.
lost 67 pounds in the past 6 months. His Aggressive protective subsystem:
appetite has significantly diminished since Jim is protective of his health now (he quit
everything tastes like metal. He has a histo- smoking when he began chemotherapy),
ry of smoking 3 packs per day of cigarettes for but has a long history of neglecting his
30 years. He states he quit when he began his health (smoking for 30 years, unexplained
chemotherapy. weight loss for 4 months, irregular visits
Jim, a high school graduate, is married to to his primary health care provider).
his high school sweetheart, Ellen. He lives Dependency subsystem:
with his wife and three children in their Jim is realizing his ability to care for self and
home. He and his wife are currently unem- family is and will continue to diminish as
ployed secondary to recent layoffs at the fac- his health deteriorates. He questions who
tory where they both worked. He explained he can depend on since his wife is not
that Ellen has been emotionally pushing him emotionally available to him.
away, and from time to time disappears from Eliminative subsystem:
the home for hours at a time without explain- Jim is experiencing frequent, burning,
ing her whereabouts. He informs me that uncontrolled diarrhea for days at a time
before his diagnosis, they were the best of following his chemotherapy treatments.
friends and were inseparable. These episodes have caused raw, tender
He has tolerated his treatments well until patches of skin around his rectal area that
now, except for having frequent, burning, become increasingly more painful and
uncontrolled diarrhea for days at a time fol- irritated with each bowel movement.
Continued
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118 S E C T I O N III Conceptual Models/Grand Theories in the Interactive/Integrative Paradigm

Ingestive subsystem: he acquiesced and allowed me to order a social


Jim has lost 67 pounds in 6 months and has work consult; recognizing that he would no
a decreased appetite secondary to the longer be able to adequately meet his familys
chemotherapy side effects. needs independently at this time.
Restorative subsystem: We also addressed the skin impairment
Jim currently experiences shortness of issues in his rectal area. I was able to offer him
breath, pain, and fatigue. ideas on how to keep the area from experienc-
Sexual subsystem: ing further breakdown. Lastly, the wound
Jim has shortness of breath and possible care nurse was consulted.
pain on exertion, which may be leading to
concerns about his sexual abilities. Evaluation
Jims wife, Ellen, is distant these days, which During his 10-day hospitalization, Jim and
would be having an impact on the couples his wife agreed to speak to a counselor regard-
intimacy. ing their thoughts on Jims diagnosis and
prognosis upon his discharge. Jims rectal area
The environmental assessment is as follows:
healed as he did not receive any chemothera-
Internal/external: py/radiation during his stay. He received tips
After the admission process was completed, on how to prevent breakdown in that area
I had several concerns for my new patient. from the wound care nurse who took care of
I recognized that Jim was a middle-aged him on a daily basis. Jim gained 3 pounds dur-
man whose developmental stage was com- ing his stay and maintained that he would
promised regarding his productivity with continue drinking nutrition supplements dai-
family and career due to his illness. Mental ly, regardless of his appetite changes during
and physical abilities could be impaired as his cancer treatment. Jims stamina and thirst
this disease process advances. In addition, for life grew stronger as his body grew physi-
this may create further strain on his rela- cally stronger. As he was being discharged, he
tionship with his wife, as she attempts to whispered to me that he was thankful for the
deal with her own feelings about his diag- care he had received while on our floor, as he
nosis. Family support would be essential as believed that the nurses had brought him and
Jims journey continued. Lastly, Jim needed his wife closer than they had been in months.
to be educated on the expectations of his He stated that they were talking about the
diagnosis, participate in a plan for treat- future and that Ellen had acknowledged her
ment during his hospital stay and assist in fears to him the previous evening. Jim was
the development of goals for his future. wheeled out of the hospital, as he continued to
have shortness of breath on extended exertion.
Diagnostic Analysis As his wife drove away from the hospital, Jim
Jim is likely uncertain about his future as a hus- waved to me with a genuine smile and a
band, father, employee, and friend. Realizing sparkle in his eye.
this, I encouraged Jim to verbalize his concerns
regarding these four areas of his life while I Epilogue
completed my physical assessment and assisted Jim passed away peacefully three months later
him in settling into his new environment. At at home, with his wife and children at his side.
first he was hesitant to speak about his family His wife contacted me soon afterwards to let
concerns, but soon opened up to me after I sat me know that the nursing care Jim received
down in a chair at his bedside and simply made during his first stay on our unit opened the
him my complete focus for 5 minutes. As a doors to allow them both to recognize that they
result of this brief interaction, together, we were needed to modify their approach to the course
able to develop short-term goals related to his of his disease. In the end, they flourished as a
hospitalization and home life throughout the couple and a family, creating a supportive tran-
rest of my shift with him that day. In addition, sition for Jim and the entire family.
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C H A P T E R 8 Dorothy Johnsons Behavioral System Model and Its Applications 119

Summary
The Johnson Behavioral System Model cap- problems breathing), ones psychological self
tures the richness and complexity of nursing. (e.g., achievement goals, need for assistance,
While the perspective presented here is embed- self-concept), self in relation to the physical
ded in the past, there remains the potentiality environment (e.g., allergens, being away from
for the theorys further development and the home), and transactions related to the sociocul-
uncovering and shaping of significant research tural context (e.g., attitudes and values about
problems that have both theoretical and practi- the sick). The study of transitions (e.g., the
cal value. There are a variety of problem areas onset of puberty, menopause, death of a spouse,
worthy of investigation that are suggested onset of acute illness) also represents a treasury
by the JBSM assumptions and from previous of open problems for research with the JBSM.
studies described on this books website http:// Findings obtained from these studies will
davisplus.fadavis.com. Some examples include not only provide an opportunity to revise and
examining the levels of integration (biological, advance the theoretical conceptualization of
psychological, and sociocultural) within and the JBSM, but will also provide information
between the subsystems. For example, a study about nursing interventions. The JBSM
could examine the way a person deals with the approach leads us to seek common organiza-
transition from health to illness with the onset tional parameters in every scientific explanation
of asthma. There is concern with the relations and does so using a shared language about
between ones biological system (e.g., unstable, nursing and nursing care.

References

Ainsworth, M. (1964). Patterns of attachment behavior Nursing: Part 2. Journal of Nursing Administration,
shown by the infant in interactions with mother. 13(5), 1823.
Merrill-Palmer Quarterly, 10, 5158. Dee, V., & Randell, B. P. (1989). NPH patient classifica-
Auger, J. (1976). Behavioral systems and nursing. tion system: A theory based nursing practice model for
Englewood Cliffs, NJ: Prentice-Hall. staffing. Paper presented at the UCLA Neuropsychi-
Auger, J., & Dee, V. (1983). A patient classification atric Institute, Los Angeles, CA.
system based on the Behavioral Systems Model of Dee, V., Van Servellen, G., & Brecht, M. (1998).
Nursing: Part 1. Journal of Nursing Administration, Managed behavioral health care patients and their
13(4), 3843. nursing care problems, level of functioning and
Buckley, W. (Ed.). (1968). Modern systems research for the impairment on discharge. Journal of the American
behavioral scientist. Chicago: Aldine. Psychiatric Nurses Association, 4(2), 5766.
Chin, R. (1961). The utility of system models and Derdiarian, A. K. (1983). An instrument for theory and
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Benne, W. Bennis, & R. Chin (Eds.), The planning model for nursing: The cancer patient. Nursing
of change. New York: Holt. Research, 32, 196201.
Coward, D. D., & Wilke, D. J. (2000). Metastatic bone Derdiarian, A. K. (1988). Sensitivity of the Derdiarian
pain: Meanings associated with self-report and Behavioral Systems Model Instrument to age, site
management decision making. Cancer Nursing, and type of cancer: A preliminary validation study.
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Crandal, V. (1963). Achievement. In: H. W. Stevenson Derdiarian, A. K. (1990). The relationships among the
(Ed.), Child psychology. Chicago: The University of subsystems of Johnsons Behavioral System Model.
Chicago Press. Image, 22, 219225.
Cronbach, L. J., & Meehl, P. (1955). Construct validity Derdiarian, A. (1991). Effects of using a nursing model-
in psychological tests. Psychological Bulletin, 52, based instrument on the quality of nursing care.
281301. Nursing Administration Quarterly, 15(3), 116.
Dee, V. (1990). Implementation of the Johnson Model: Derdiarian, A. K., & Forsythe, A. B. (1983). An instru-
One hospitals experience. In: M. Parker (Ed.), ment for theory and research development using the
Nursing theories in practice (pp. 3363). New York: behavioral systems model for nursing: The cancer
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systems model for nursing practice instrument. models for nursing practice (2nd ed., pp. 207216).
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DHuyvetter, C. (2000). The trauma disease. Journal of Johnson, D. E. (1990). The Behavioral System Model
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Grubbs, J. (1980). An interpretation of the Johnson Johnson, D. E., & Smith, M. M. (1963). Crying as a
behavioral system model. In: J. P. Riehl & C. Roy physiologic state in the newborn infant. Unpublished
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Harris, R. B. (1986). Introduction of a conceptual model Kagan, J. (1964). Acquisition and significance of sex role
into a fundamental baccalaureate course. Journal of identity. In: R. Hoffman & G. Hoffman (Eds.),
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Angeles. care: An instance of ineffective coping in the geri-
Holaday, B. (1974). Achievement behavior in chronical- atric patient. In: R. M. Carroll-Johnson (Ed.), Clas-
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Nursing Research, 30, 343348. Johnsons behavioral system model. In: J. Fitzpatrick
Holaday, B. (1982). Maternal conceptual set develop- & A. Whall (Eds.), Conceptual models of nursing:
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chronically ill infant crying. Maternal Child Nursing Meleis, A. I. (1991). Theoretical nursing: Development
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Holaday, B. (1987). Patterns of interaction between Parsons, T., & Shils, E. A. (Eds.). (1951). Toward a
mothers and their chronically ill infants. Maternal general theory of action: Theoretical foundations for the
Child Nursing Journal, 16, 2945. social sciences. New York: Harper & Row.
Holaday, B. (1997). Johnsons behavioral system model in Poster, E. C., Dee, V., & Randell, B. P. (1997). The
nursing practice. In: M. Alligood & A. Marriner- Johnson Behavioral Systems Model as a framework
Tomey (Eds.), Nursing theory: Utilization and applica- for patient outcome evaluation. Journal of the American
tion (pp. 4970). St. Louis, MO: Mosby-Year Book. Psychiatric Nurses Association, 3(3), 7380.
Holaday, B., Turner-Henson, A., & Swan, J. (1997). Rapoport, A. (1968). Forward to modern systems
The Johnson Behavioral System Model: Explaining research for the behavior scientist. In: W. Buckley
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Walker & B. Newman (Eds.), Blueprint for use of scientist. Chicago: Aldine.
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administration (pp. 3363). New York: National child rearing. White Plains, NY: Row & Peterson.
League for Nursing. Stevenson, J. S., & Woods, N. F. (1986). Nursing science
Johnson, D. E. (1956). A story of three children. The and contemporary science: Emerging paradigms.
Nursing Journal of India, XLVII(9), 313322. In Setting the agenda for year 2000: Knowledge devel-
Johnson, D. E. (1957). Nursing care of the ill child. The opment in nursing (pp. 620). Kansas City, MO:
Nursing Journal of India, XLVIII(1), 1214. American Academy of Nursing.
Johnson, D. E. (1959). The nature and science of nurs- von Bertalanffy, L. (1968). General systems theory: Foun-
ing. Nursing Outlook, 7, 291294. dations, development, application. New York: George
Johnson, D. E. (1961). The significance of nursing care. Braziller.
American Journal of Nursing, 61, 6366. Wilkie, D. (1987). Unpublished operationalization
Johnson, D. E. (1968). One conceptual model of nursing. of the Johnson model. University of California,
Unpublished lecture. Vanderbilt University. San Francisco.
Johnson, D. E. (1980). The behavioral system model for Wu, R. (1973). Behavior and illness. Englewood Cliffs,
nursing. In: J. P. Riehl & C. Roy (Eds.), Conceptual NJ: Prentice-Hall.
Box 8-1 Authors Research Highlighted
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Chapter
9
Dorothea Orems Self-Care
Deficit Theory
D ONNA L. H ART WEG
AND L AUREEN M. F LECK

Introducing the Theorist Introducing the Theorist


Historical Evolution of Orems Dorothea E. Orem (19142007) was a gentle,
Self-Care Deficit Theory
caring scholar whose life was dedicated to cre-
Practice Applications
ation and development of a theoretical struc-
Practice Exemplar
ture to improve nursing practice. As a vora-
Summary
cious reader and extraordinary thinker, she
References
framed her ideas in both the theoretical and
the practical. She viewed nursing knowledge as
theoretical with conceptual structure and ele-
ments as exemplified in her Self-Care Deficit
Nursing Theory (SCDNT) and as practically
practical with knowledge, rules, and defined
roles for practice situations (Orem, 2001).
Orems personal life experiences, formal
education, and employment, as well as the
influence of philosophical and logicians such
Dorothea E. Orem
as Aristotle, Thomas Aquinas, Harre (1970),
and Wallace (1983) directed her thinking
(Orem, 2006; Parker, 2006). She sought to
understand the phenomena she observed, cre-
ating conceptualizations of nursing education,
disciplinary knowledge, and finally, a general
theory of nursing or SCDNT. Working inde-
pendently at first, then later collaboratively,
Orem continued these intellectual efforts
until her death at age 93. Her insights and
passion are evident throughout the world as
others continue her legacy. This introduction
focuses on her independent work during the
early developmental period.
Orems ability to observe and think was
influenced in part by her initial nursing edu-
cation at Providence Hospital School of
Nursing in Washington, DC, a diploma
school run by the Daughters of Charity
known for their service commitment to the
poor (Libster, 2008). She graduated in 1934
and quickly moved into staff/supervisory

121
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122 S E C T I O N III Conceptual Models/Grand Theories in the Interactive/Integrative Paradigm

positions, including an operating room and an that a nurse(s) should be brought into the sit-
emergency room. After her BSN Ed (1939) uation (i.e., that a person should be under
from Catholic University of America, she nursing care)? (Orem, 2001, p. 20). The
held faculty positions at that institution and answer to the question is the proper object:
later at Provident Hospital School of Nursing,
The condition is the inability of persons to provide
Detroit. With completion of the MSN Ed at
continuously for themselves the amount and qual-
Catholic University (1946), Orem became
ity of required self-care because of situations of
Director of Nursing Service and Education at
personal health. With children it is the inability of
Provident in Detroit (Taylor, 2007). She cred-
parents or guardians to provide the amount and
its her inability to answer questions in meet-
quality of care required by their child because of
ings as well as a metaphysics course she took
their childs health situation. (Orem, 2001, p. 20)
at the University of Detroit with influencing
her ability to sort, structure, and understand From this clarity of focus, Orems solitary
parts and the whole (Taylor, 2007). These thinking and writing moved to more collabo-
experiences did not influence specific concep- rative work, a model of intellectual teamwork
tualizations of nursing, but stimulated ques- necessary for a practical science to inform and
tions and frustrations about a lack of structure change nursing administration, education,
for nursing knowledge. research, and practice. Elaboration of her
Orems early formulations on the nature of leadership within these groups and the explo-
nursing occurred while working for the Indi- sion of theoretical application throughout the
ana State Board of Health, 1949 to 1957 United States and other countries throughout
(Hartweg, 1991). She became aware of nurs- the world are described within the chapters
es ability to do nursing, but their inability to historical section.
describe nursing to colleagues as well as To recognize her contributions, Orem
administrators and physicians. Without this received honors from organizations such as
understanding, she knew that nurses could Sigma Theta Tau International, the American
not improve practice. Using knowledge of sci- Academy of Nursing, National League for
ence learned from biology courses in her Nursing, The Catholic University of America,
bachelors and masters programs, she made and honorary doctorates from Georgetown
an initial effort to define nursing in a 1959 University (1976), Incarnate Word College,
report to the Indiana Board, The art of nursing San Antonio, TX (1980), Illinois Wesleyan
in hospital service: An analysis (Orem, 2003). University, Bloomington, IL (1988), and the
Although Orem claims this publication did University of MissouriColumbia (1998)
not influence her subsequent thinking, the (Allison & Balmat, 2003).) To promote col-
language of the patient doing for himself or laboration, the International Orem Society
the nurse helping him learn to do for himself for Nursing Science and Scholarship was
appears as antecedent language for the con- formed in 1991 with this mission: To dis-
cept of self-care. While working for the seminate information related to development
Office of Education, Vocational Section of of nursing science and its articulation with the
the Technical Division in Washington, DC, science of self-care (www.scdnt.com). This
she formulated this question: Why do people has been realized through publications of
need nursing? Orem states that after she was the organizations newsletter (19932001),
able to answer that question the pieces started archived at the website. The newsletter was
coming together (Taylor, 2007). In Guides for replaced in 2002 by a peer-reviewed journal,
Developing Curriculum for the Education of Self-Care, Dependent Care & Nursing (see
Practical Nurses, she expressed what is now her www.scdnt.com/ja/jarchive.html). The schol-
signature: the proper object of nursing. She arly articles, multiple conferences and insti-
formulated this question: What condition tutes, and ten world congresses are tributes to
exists in a person when judgments are made her work and critical for continued theory
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C H A P T E R 9 Dorothea Orems Self-Care Deficit Theory 123

development in an increasingly complex, Orem as leader, represented nurses in practice,


global discipline. education, and administration. Five members
Many of Orems original papers are were from the original Nursing Model Com-
published in Self-Care Theory in Nursing: mittee. All members came with a commit-
Selected papers of Dorothea Orem (Renpenning ment to develop a structure for nursing
& Taylor, 2003) or available in the Mason knowledge for nursing as a practice discipline.
Chesney Archives of the Johns Hopkins The members rich thinking, including those
Medical Institutions for the Orem Collec- of Joan Backscheider, Sarah Allison, and Cora
tion (http://www.medicalarchives.jhmi.edu/ Balmat, provided additional structure to
papercollections.html#O). Audios and videos Orems earlier work. The process and out-
of the theorist are available through the comes of this collaboration were published in
Helene Fuld Health Trust (1988) and the two books edited by Orem: Concept Formal-
National League for Nursing (1987). ization: Process and Product (NDCG, 1973,
1979). Contemporary scholars continue to
reference these publications to understand the
Historical Evolution of Orems foundation and application of concepts to
Self-Care Deficit Theory nursing practice. Group members such as
This historical section builds on Orems inde- Allison (1973), Backscheider (1974), and
pendent work and continued development Kinlein (1977a, 1977b) also published their
through committees, theory development unique applications and views. As theory
groups, formal conferences/institutes, interna- application spread, Orem consulted in practice
tional exchanges or partnerships, and finally, and in education, such as a nurse-managed
the work of the International Orem Society clinic at The Johns Hopkins University and
for Nursing Science and Scholarship. A result the nursing program at the University of
was the emergence of proteges and scientists Southern Mississippi (Taylor, 2007). The
who continue SCDNT development and Center for Experimentation and Develop-
application to practice. ment in Nursing at The Johns Hopkins
Students, colleagues, and scholars assisted Hospital provided an opportunity for innova-
Orem to refine her ideas on the structure of tion and theory-driven practice. Changes in
nursing knowledge for a practice discipline. administration as well as personal tragedy
Although Orem continued to work inde- resulted in a new practice direction. Two
pendently throughout the initial collaborative NDCG members who were involved in early
period, two groups reviewed her ideas and development and practice applications were
contributed to early development (Taylor, killed in a car accident and another seriously
2007). The first was the Nursing Model injured, ending the significant contribution of
Committee of the nursing faculty at Catholic this unique group
University of America, a group Orem chaired. Concurrent with group work, Orem pub-
When neither graduate students nor faculty lished the first of six editions of Nursing: Con-
were able to generate research questions in the cepts of Practice (1971). The title of Orems
nursing discipline, questions from a research major work reflects her clarity of purpose.
committee provided impetus to form the Orems conceptualizations are about nursing
Nursing Model Committee to develop ideas practice, both theoretical and scientific. The
about nursing as a mode of thought, as well as a 1980 edition reflects input from the NDCG,
mode of doing (Helene Fuld Health Trust, with formalized concepts and propositions
1988). In 1968, the Nursing Development (Hartweg, 1991). The last edition in 2001
Conference Group (NDCG) was formed and includes theoretical expansion to multiperson
continued the work of the Nursing Model groups, such as family and community
committee. Initially called the Improvement (Taylor & Renpenning, 2001). Other major
in Nursing Group, the 11 members, with theoretical developments are evident in books
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124 S E C T I O N III Conceptual Models/Grand Theories in the Interactive/Integrative Paradigm

and articles such as Theory of Dependent Bangkok, Thailand, and Illinois Wesleyan
Care (Taylor, Renpenning, Geden, Neuman, University, Bloomington, IL. With the accred-
& Hart, 2001). Nursing: Concepts of Practice iting expectation and concurrent faculty devel-
has formally been translated into Japanese, opment, exceptional theory-based curricula
Spanish, German, Italian, and Dutch ( John were developed in all types of prelicensure pro-
Scott, personal communication, April 22, grams, including those leading to a diploma,
2009). Informal translations are numerous, as ADN, and BSN. Examples include Morris
graduate students throughout the world (e.g., Harvey College in Charleston, West Virginia,
Thailand) study and apply SCDNT con- Georgetown University, University of Missouri
structs or test the theory. Columbia, and Illinois Wesleyan University
An explosion of theory in the early 1970s (Taylor, 2007). Many educational programs
can be traced in part to changes in nursing used Orems conceptualizations to frame the
education as more nurses gained graduate curriculum or to guide nursing practice
degrees, including many in other disciplines. (Hartweg, 2001; Ransom, 2008). Unpublished
However, one change that propelled develop- 1990s research by Taylor and Hartweg revealed
ment and application of nursing theory in the Orems conceptualization was the most fre-
United States was a requirement for theory- quently used of all known nursing theorists in
based curriculum imposed in 1974 by the U.S. programs.
National League for Nursing accrediting arm. As increasing numbers of nursing doctoral
Educational programs across the country programs emerged in the 1980s, study groups
sought consultants, faculty with knowledge of and grants resulted in significant scholarship
emerging theories, and conferences to support through dissertations and collaborative theory
faculty development. Susan Taylor, Professor of development. For example, an Orem research
Nursing at the Sinclair School of Nursing, group was created in 1984 at Wayne State
University of MissouriColumbia, provided University (WSU), Detroit, MI. Faculty and
significant leadership resulting in development doctoral students met weekly to explore
of practitioners, educators, and researchers. theory development and testing. Publications
Beginning in earnest in the early 1980s, she resulted from the groups work such as those
facilitated theory dissemination through for- by Denyes, OConnor, Oakley, and Ferguson
mation of a network, initiation and coordina- (1989) or by Gast et al. (1989). Marjorie
tion of a newsletter, and the creation of sum- Isenberg, also at WSU, provided European
mer institutes and research conferences that leadership at the University of Limburg,
reached nurses throughout the world. Each Maastricht, the Netherlands. This effort led
semi-annual conference used work sessions, to theory testing, instrument development
focusing on development of selected concepts. and testing, and a surge of development in
For example, the Sixth Annual Self-Care most European countries. As international
Deficit Theory Conference in 1987 explored students received doctorates from WSU and
concepts of nursing agency and nursing sys- other institutions, they returned home and
tems. Other countries began their own nursing continued theory development and dissemi-
development groups, most notably, Canada. By nation in their graduate programs. An exam-
1989, the global impact was evident when the ple is Thailand, with burgeoning research and
First International Self-Care Deficit Nursing development throughout the countrys gradu-
Theory (SCDNT) Conference was held in ate programs and in governmental initiatives
Kansas City with participants from the United (Hanucharurnkul, Leucha, Wittya-Sooporn,
States, Sweden, the Netherlands, Canada, & Maneesriwongul, 2001).
Thailand, Australia, and Japan (Hartweg, This international collaboration required
1991). These conferences led to collaboration formal organization beyond the resources
among institutions and exchange of faculty of a single institution. In 1991, the Interna-
such as those from Mahidol University, tional Orem Society for Nursing Science and
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Scholarship was founded by scholars from what and why, but also the who and how
the United States, Canada, Belgium, and (Orem, 2006). This is an action theory with
the Netherlands. With Orem, 3 of the clear specifications for nurse and patient roles.
11 founders were members of the Nursing The grand theory comprises three minor
Development Conference Group, continuing interrelated theories: the theory of self-care,
the legacy and expertise. Since that time, theory of self-care deficit, and theory of nurs-
10 biennial congresses have been held in ing systems. The building blocks of these
Belgium, Canada, Germany, South Africa, theories are six major concepts and one
Thailand, and the United States. During peripheral concept. The following is a brief
these congresses, scholars present theory devel- overview of each of these elements. Readers
opment, research, and practice papers. As are encouraged to refer to relevant sections in
reported in the IOS journal, workgroups Orem, Concepts of Practice (2001) or other
(e.g., Metcalfe, 2008) share ideas and develop citations to enhance understanding.
international collaborative efforts. Foundational to learning any theory is
Although the workgroups and congresses exploration of underlying assumptions, the
provided important application and develop- key to conceptual understanding. Many of
ment, in 1995 Orem convened a group of these principles emerged from Orems inde-
scholars from the United States, Germany, pendent work, as well as from discussions
Belgium, and Canada. who met semiannually within the Nursing Development Conference
at her home in Savannah and independently Group. Five general assumptions or principles
in small groups. Scholars such as Susan Tay- about humans provided guidance to Orems
lor and Kathryn Renpenning continue the conceptualizations (Orem, 2001, p. 140).
theoretical work with extensive publications. Readings by Aristotle, Thomas Aquinas,
Changes in U.S. educational accrediting Talcott Parsons, Pitirim Sorokin, and others
standards in the past two decades resulted in influenced her thinking related to human
fewer graduates educated in theory-based action, human agency for deliberate action,
curricula. However, scholarly curricular devel- units of action, and social interaction (Orem,
opment continues throughout the United 2003). When thinking about humans within
States (Biggs, 2008; Secrest, 2008). Biggs the context of the theory, Orem viewed two
(2008) reported a tremendous increase in types: those who need nursing care and those
global application of Orems SCDNT. In who produce it (Orem, 2006). In the simplest
reviewing the literature, she compared 143 terms, this is the patient and the nurse,
articles published between 1974 and 1999 respectively. These assumptions also reveal the
(Taylor, Geden, Isaramalai, & Wangvatunyu, powers and properties of humans necessary
2000) with 400 items between 1999 and for self-care. Consistent with most Orem
2007. Research has increased in sophistication writings, the term patient will be used to refer
and methodology, with use of qualitative to the recipient of care.
methods, but remains focused on concepts
such as self-care agency with its well-tested Three Theories Within Self-Care
measurement tools. Many other concepts, Deficit Nursing Theory
such as foundational capabilities and nursing Orem states the three theories in their artic-
system, need development and testing. ulations with one another express the whole
that is self-care deficit nursing theory
The Theoretical Structure (Orem, 2001, p. 141). The theory of nursing
Orems general theory of nursing is correctly system encompasses the theory of self-care
referred to as Self-Care Deficit Nursing deficit, which subsumes the theory of self-
Theory (SCDNT). Orem believed a general care. The three interlocking theories each
model or theory created for a practical science express a central idea, presuppositions, and
such as nursing encompasses not only the propositions. The central idea presents the
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126 S E C T I O N III Conceptual Models/Grand Theories in the Interactive/Integrative Paradigm

general focus of the theory; the presupposi- presents two sets of presuppositions that
tions are assumptions specific to this theory; articulate this theory with the theory of self-
the propositions are statements about the care (dependent care) and what she calls the
concepts and their interrelationships. The idea of social dependency. To engage in self-
propositions have changed over time with care, persons must have values and capabilities
refinement of SCDNT. These occurred in to learn (to know), to decide, and to manage
part through theory testing that validated or self (to produce and regulate care). The sec-
invalidated hypotheses generated from the ond set presents the context of nursing as a
relationships. health service when people are in a state of
Orem uses terminology at various levels of social dependency.
abstraction within the three sets of theories. The theory of self-care deficit includes
The reader is advised to thoroughly study nine propositions called principles or guides
SCDNT concepts, including the synonyms. for future development and theory testing
For example, capabilities is also called abili- through research. These statements are essen-
ties, power, and agency. tial ideas of the larger, SCDNT. Orem
describes the situations that affect legitimate
1. Theory of Self-Care (Dependent-Care) nursing. Nursing is legitimate or needed when
The central idea describes self-care and the individuals self-care capabilities and care
dependent care in contrast to other forms of demands are equal to, less than, or more than at
care. Self-care for ones self or for dependent a point in time. With the existence of this
care (that is, care performed by another such inequity, a self-care deficit exists and nursing
as a family member) must be learned and is needed. Legitimate nursing also occurs
must be deliberately performed for life, when a future deficit relationship is predicted
human functioning, and well-being. Six pre- such as an upcoming surgery.
suppositions articulate Orems notions about
necessary resources, capabilities for learning, Theory of Nursing Systems
and motivation for self-care. However, there The third theory encompasses the others.
are situational variations that affect self-care The central focus is the product of nursing,
such as culture. establishing both structure and content for
Orem (2001) expanded two sets of propo- nursing practice as well as the nursing role
sitions from previous writings. She introduced (see Orem, 2001, pp. 111, 147149). The
requirements necessary for life, health, and four presuppositions direct the nurse to major
well-being and explained the complexity of a complexities of nursing practice. For exam-
self-care system. A person performing self- ple, Orem states Nursing has results-achieving
care or dependent care must first estimate or operations that must be articulated with the
investigate what can and should be done. This is interpersonal and societal features of nursing
a complex action of knowing and seeking (Orem, 2001, p. 147). Although much of
information on specific care measures. The the theory relates to diagnosis, actions, and
self-care sequence continues by deciding what outcomes based on a deficit relationship
can be done, and finally producing the care (see between self-care capabilities (or dependent-
Orem, 2001, pp. 143145). care) and self-care demand, Orem also
presents theoretical work related to the inter-
2. Theory of Self-Care Deficit personal relationship between nurse and per-
(Dependent-Care Deficit) son(s) receiving nursing and a social contract
The central idea describes why people need between the nurse and patient(s) (Orem,
nursing (see Orem, 2001, pp. 146147). 2001, pp. 314317). These components are
Requirements for nursing are health-related often overlooked when studying the SCDNT
limitations for knowing, deciding, and pro- and are important antecedents and concurrent
ducing care to self or a dependent. Orem actions in the detailed process of nursing.
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The theory of nursing systems includes Concepts


seven propositions related to most SCDNT SCDNT is constructed from six basic con-
concepts but adds nursing agency (capabilities cepts and a peripheral concept. Four concepts
of the nurse) and nursing systems (complex are patient related: self-care/dependent care,
actions). Nursing agency and nursing systems self-care agency/dependent care agency, thera-
are linked to the concepts of the person peutic self-care demand, and self-care deficit/
receiving care or dependent care, such as self- dependent care deficit. Two concepts relate to
care capabilities (agency), self-care demands the nurse: nursing agency and nursing system.
(therapeutic self-care demand), and limita- Basic conditioning factors, the peripheral con-
tions (deficits) for self-care. Through this, the cept, is related to both the self-care agent
general theory or SCDNT becomes concrete (person receiving care)/dependent care agent
to the practicing nurse. Although the lan- (family member/friend providing care) and
guage is implicit, Orem proposes that nursing also to the nurse (nurse agent). Orem defines
systems are determined by the persons (or agent as the person who engages in a course of
dependent care agents) self-care limitations action or has the power to do so (Orem, 2001,
(capabilities in relationship to health-related p. 514). Hence there is self-care agent,
self-care demand). Nursing systems therefore dependent care agent, and nurse agent. The
vary by the amount of care the nurse must unit of service is a person, whether the indi-
provide, such as a total care system (the vidual (self-care agent) or others on whom the
unconscious critical care patient) or partial person is socially dependent (dependent-care
care system (patient in rehabilitation). agent). Orem also addresses multiperson situ-
Theoretical work by Orem scholars con- ations and multiperson units such as entire
tinues in development as nursing practice families, groups, or communities.
evolves. For example, dependent care con- Each concept is defined and presented
cepts within the general theory developed with levels of abstraction. Varied constructs
over time as its importance emerged and was within each concept allow theoretical testing
recognized. This expansion was necessary for at the level of middle-range theory or at the
situations when the nurse provides care or practice application level whether with the
guidance, not only to a patient, but also to a individual or multiperson situations. All build
caregiver. A dependent care agent (caregiver) on Orems independent work, and collabora-
is a mature or maturing person having or tion with the early NDCG, and the recent
assuming responsibility for a dependent person nursing development groups who studied
(Orem, 2001, p. 285). This may be a family with Orem. Research, including many disser-
member or friend providing home care or tations, as well as changes in practice also
hospital care in a developing country. Factors contribute to understanding of concepts. A
that promote expansion of such concepts/ kite-like model provides a visual guide for
theories vary, including an increased aging the six concepts and their interrelationships
and chronically ill population, early dis- (Fig. 9-1). For a model of concepts and rela-
charge from hospitals, the global application tionships on Dependent Care Theory, the
of SCDNT, and health care cost constraints. reader is referred to Taylor et al. (2001). For a
In collaboration with Orem, significant the- model on multiperson structure, the reader
oretical development on dependent care should read Taylor and Renpenning (2001),
resulted in a Theory of Dependent Care The Practice of Nursing in Multiperson Situa-
(Taylor, 2001). Although Orem (2001) refers tions, Family, and Community.
to concepts such as self-care, with parenthet-
ical concepts of dependent care and others, Basic Conditioning Factors
the reader should refer to Taylor and others The peripheral concept, basic conditioning fac-
for a separate theory not included in Nurs- tors (BCFs), is related to three major concepts.
ing: Concepts of Practice. For simplicity, only the patient component
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128 S E C T I O N III Conceptual Models/Grand Theories in the Interactive/Integrative Paradigm

Self-care
R R

Self-care R Self-care
Conditioning Conditioning
agency demands
factors factors

Deficit R
R

Conditioning Nursing
factors agency

Figure 9 1 Structure of SCDNT.

is presented rather than the parallel dependent values and practices. Sociocultural includes
care components. In general, basic condition- economic conditions as well as others. The
ing factors relate to the patient concepts (self- BCFs related to nursing agency include those
care agency and therapeutic self-care demand) such as age but expand to include nursing
and one nurse concept (nursing agency). These experience and education. A clinical specialist
conditioning factors are values that affect the in diabetes has more capabilities in caring for
constructs: age, gender, developmental state, the self-care agent with type 2 diabetes than
health state, sociocultural orientation, health one without such credentials. All these affect
care system factors, family system factors, pat- the parameters of the nurses capability to
tern of living, environmental factors, resource provide care.
availability, and adequacy (Orem, 2001, p. 245). This list has changed over time and con-
For example, the family system factor such as tinues in refinement. Moore and Pichler
living alone or with others may affect the per- (2000) summarized research and recommend
sons ability (self-care agency) to care for self directions for theory development related to
after hospital discharge. The self-care demand the BCFs. Others such as Allison and
(care requirements) of a person taking insulin McLaughlin (1999) recommend expanding
for type 2 diabetes will vary based on availabil- BCFs related to dependent care and commu-
ity of resources and health system services (e.g., nity. The latter include factors such as public
access to medications and care services). These policy and transportation.
same BCFs apply to nursing agency, such as
health state. A nurse with recent back surgery Self-Care (Dependent Care)
may have limitations in nursing capabilities Orem (2001) defined self-care as the practice of
(nurse agency) in relationship to specific care activities that individuals initiate and perform
demands of the patient. on their own behalf in maintaining life, health,
These BCF categories have many subfac- and well-being (p. 43). Self-care is purposeful
tors that have not been explicitly defined. For action performed in sequence and with a pat-
example, sociocultural orientation refers to tern. Although engagement in purposeful self-
culture with its various components such as care may not improve health or well-being,
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C H A P T E R 9 Dorothea Orems Self-Care Deficit Theory 129

a positive outcome is assumed. Dependent well-being. Decision-making follows, such


care is performed by mature, responsible as deciding to avoid alcohol or choosing
persons on behalf of socially dependent indi- to engage in chemotherapy. Finally, the indi-
viduals or self-care agents. The purpose of viduals must take action such as not drinking
dependent care is to meet socially dependent when offered alcohol and accepting of
persons health-related demands (dependent chemotherapy treatment. Without each phase,
care demand) or needs and/or develop their self-care does not occur. The pregnant woman
self-care capabilities (self-care agency) (Taylor may know the dangers to her fetus, decide not
et al., 2001). to drink, but deliberately engage in drinking
Although the practice of maintaining life when pressured. The woman with cancer may
is self-explanatory, Orem (2001) viewed out- know the health outcome without treatment,
comes of health and well-being as related decide to have treatment, then not follow
but different. Health is a state of physical through because of a transportation problem
psychological, structuralfunctional soundness that disrupts her husbands employment.
and wholeness. In contrast, well-being is pre- Because each phase of the action sequence has
conceived as experiences of contentment, pleasure, many components, nurses often provide par-
and kinds of happiness; by spiritual experiences; by tial support to patients and self-care action
movement toward fulfillment of ones self-ideal; does not occur. If skills related to the operation
and by continuing personalization (Orem, 2001, to avoid alcohol when pressured or the opera-
p. 186). Self-care performed deliberately for tions necessary for transportation to a cancer
well-being versus structural/functional health center are not anticipated by the nurse for
was conceptualized and developed as health these patients, the self-care action sequences
promotion self-care by Hartweg (1990, 1993) may not be completed. Then outcomes related
and Hartweg and Berbiglia (1996). Research to life, health, and well-being are affected.
increasingly explores self-care to promote well-
being (Matchim, Armer, & Stewart, 2008). Self-Care Agency (Dependent
When persons without sufficient develop- Care Agency)
ment or structural/functional wholeness are Orem (2001) defined self-care agency (SCA)
unable to perform self-care, dependent-care as complex acquired capability to meet ones
may become necessary for life, health, and continuing requirements for care of self that
well-being. This is performed by the depend- regulates life processes, maintains or promotes
ent-care agent on behalf of the self-care integrity of human structure and functioning
agent, such as an infant, child, or cognitively [health] and human development, and pro-
impaired person. motes well-being (p. 254). Capability, ability,
Key to understanding self-care and and power are all terms used to express agency.
dependent care is the concept of deliberate Self-care agency is therefore the mature or
action, a voluntary behavior to achieve a goal. maturing individuals capability for deliberate
When one engages in deliberate action, it is action to care for self. Dependent care agency
preceded by investigating and deciding what is the capability or power to know and meet a
choice to make (Orem, 2001). In practice, the socially dependent persons self-care demands
nurses attention and understanding of each of or limitations of self-care agency (Taylor,
these phases of investigating, deciding, and 2001). Viewed as the summation of all human
producing self-care is essential for positive capabilities needed for performing self-care, these
health outcomes. Take two situations: A preg- range from very basic ability such as memory
nant woman must avoid alcohol for the childs to capability for a specific action in a sequence
health; a woman with breast cancer requires to meet a specific self-care demand or require-
chemotherapy for life and health. Each ment. At this concrete level, the capabilities of
woman must first know and understand the knowing, deciding, and acting or producing
relationship of self-care to life, health, and self-care are necessary. If these capabilities do
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130 S E C T I O N III Conceptual Models/Grand Theories in the Interactive/Integrative Paradigm

not exist, then abilities of others are necessary, and skills to produce self-care. If a mature
such as the family member or nurse. A three- person becomes comatose, the abilities to
part, hierarchical model of self-care agency maintain attention, to reason, to make deci-
provides a visualization of this structure sions, to physically carry out the actions are
(Fig. 9-2). Understanding these elements is not functioning. The self-care actions neces-
necessary to determine the self-care agent role, sary for life, health, and well-being must then
dependent-care agent role, and the nurse role. be performed by the dependent care agent or
the nurse agent.
Foundational Capabilities and
Dispositions Capabilities for Estimative,
Foundational capabilities and dispositions
Transitional, and Productive
are at the most basic level (Orem, 2001, Operations
pp. 262263). These are capabilities for all The most concrete level of self-care agency
types of deliberate action, not just self-care. is one specific to the individuals detailed
Included are abilities related to perception, components of self-care demand or require-
memory, and orientation. One example is the ments. Capabilities related to estimative
deliberate act of repairing a car. One must operations are those necessary to determine
have perception of the concept of the car and what self-care actions are needed in a specif-
its parts, memory of methods of repair, and ic nursing situation at one point in time, that
orientation of self to the equipment and vehi- is, capabilities of investigating and estimat-
cle. If these foundational abilities are not ing what needs to be done. This includes
present, then those related to performing self- capabilities of learning in situations related
care cannot occur. If there is no memory, then to health and well-being. For example, does
one cannot learn to care for self. the newly diagnosed person with asthma
have the capability to learn about regular
Power Components exercise activities and rescue medication?
At the midlevel of the hierarchy are the power Does the person know how to obtain the
components, or 10 powers or types of abilities necessary resources? Transitional operations
necessary for self care. Examples are the valu- relate to abilities necessary for decision-
ing of health, ability to acquire knowledge making, such as reflecting on the course of
about self-care resources, and physical energy action and making the decision. The patient
for self-care. At a very general level, these may have capabilities to learn and obtain
capabilities relate to knowledge, motivation, resources, but not the ability to make the
decision. The asthma patient has the capa-
bility to learn about the exercise and medica-
tion, but not the capability to make the
decision to follow through on directions.
Capabilities for productive operations are
Capabilities those necessary for preparing the self for the
for self-care action, carrying out the action, monitoring
operations the effects, and evaluating the actions effec-
tiveness. If the person decides to use the
Power components
inhaler, does the person have the ability to
(enabling capabilities
for self-care) take time to engage in the necessary self-
care, to monitor the changes, and determine
Foundational capabilities
the effectiveness of the action? Just as the
and disposition action sequence is important in the self-care
concept, these types of capabilities reveal the
Figure 9 2 Structure of Self-Care Agency. complexity of human capability.
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C H A P T E R 9 Dorothea Orems Self-Care Deficit Theory 131

At the concrete practice level, self-care and interpersonal skills. Both scientific nurs-
agency also varies by development and oper- ing knowledge and knowledge of the person
ability. For example, the nurse must deter- and environment are merged to formulate
mine if capabilities for learning are fully what needs to be done in a particular nursing
developed at the level necessary to under- situation (NDCG, 1979). The process of cal-
stand and retain information about the culating the TSCD includes adjusting values
required actions. For example, a mature adult by the basic conditioning factors. For exam-
with late stage Alzheimers disease is not able ple, a mental health patient will have different
to retain new information. The self-care needs based on the type of mental health con-
agency is therefore developed but declining, dition (health state), family system factors,
creating the possible need for dependent care and health care resources.
agency or nursing agency. A second determi-
nation is the operability of agency. Is agency Self-Care Requisites
not operative, partially operative, or fully To provide the framework for determining
operative? A comatose patient may have fully the TSCD, three types of self-care requisites
developed capabilities before a motor vehicle (or requirements) for action were developed:
accident, but the trauma results in inoperable universal, developmental, and health devia-
cognitive functioning. SCA is therefore tion. These are the purposes or goals for which
developed, but not operative at that moment in actions are performed for life, health, and
time. In this situation, the nurse agent or well-being. The individual sleeps once each
dependent care agent (or both) will provide day and engages in daily activities to meet the
all care. requisite or goal of maintaining a balance of
These important classifications were devel- activity and rest. Without rest, a human can-
oped by the NDCG (1979). not survive. Therefore, these are general state-
ments within a three-part framework that
Therapeutic Self-Care Demand provide a level of abstraction similar to the
Therapeutic self-care demand (TSCD) is a power components of self-care agency.
complex theoretical concept that summa- Denyes, Orem, and Bekel (2001) presented
rizes all actions that should be performed an explication of the self-care requisite to
over time for life, health, and well-being. maintain an adequate intake of water. This
When first developed, the concept was example demonstrates the complexity of
referred to as action demand or self-care actions necessary to meet a very basic human
demand (Orem, 2001). Readers will therefore need. Yet, without consideration of this com-
see these terms used in Orems writings and plexity, analysis and diagnosis of patient
in the literature. The word therapeutic is requirements is not complete.
essential to ones understanding. Considera- Universal self-care requisites: The eight
tion is always on a therapeutic outcome of universal self-care requisites (USCR) are nec-
life, health, and well-being. A Pakistani essary for all human beings of all ages and in
mother in a remote village may expect to all conditions, such as air, food, activity and
apply horse or cow dung to the severed rest, solitude, and social interaction. The BCFs
umbilical cord to facilitate drying, a cultural- influence the quality and quantity of the action
ly adjusted self-care measure for a newborn. necessary to achieve the purpose. Actions to
With horse/cow dung as the major carrier of be performed over time that meet the requi-
Clostridium tetanus, this dependent care site, prevention of hazards to human life, human
action may lead to disease and infant death, functioning, and human well-being (the pur-
not a therapeutic outcome. pose), will vary for an infant (e.g., keeping
Constructing or calculating a TSCD crib rails up) versus an adult (e.g., ambulation
requires extensive nursing knowledge of safety). Some requisites are very general yet
evidenced-based practice, communication, provide important concepts necessary for all
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132 S E C T I O N III Conceptual Models/Grand Theories in the Interactive/Integrative Paradigm

humans. One example is the concept of nor- associated with human pathology (Orem, 2001,
malcy, the eighth USCR. The goal is promo- p. 235). For a person with history of breast
tion of human functioning and development cancer, seeking regular diagnostic tests is a
within social groups in accord with human poten- goal to preserve life, health, and well-being.
tial, human limitations, and the human desire to A teenager in treatment for severe acne takes
be normal (Orem, 2001, p. 225). Practice action to meet HDSCR 5: to modify the
examples in the literature have emerged, such self-concept (and self-image) in accepting oneself
as the importance of normalcy to individuals as being in a particular state of health and in
with learning disabilities (Horan, 2004). need of a specific form of health care (Orem,
These two requisites, prevention of hazards 2001, p. 235).
and promotion of normalcy, also relate to the Each TSCD, through the three types
other six USCRs. For example, when main- of self-care requisites, is individualized and
taining a sufficient intake of food, one must adjusted by the basic conditioning factors
consider hazards to ingestion of food. Avoid- (BCFs) such as age, health state, and sociocul-
ing pesticides is one example. tural orientation. Once adjusted to the specific
Developmental self-care requisites: Orem patient in a unique situation, the purposes are
(2001) identified three types of developmen- specific for the patient or type of patient.
tal self-care requisites (DSCRs). The first These are called particularized self-care
refers to actions necessary for general human requisites. Dennis and Jesek-Hale (2003)
developmental processes throughout the lifes- proposed a list of particularized self-care req-
pan. These requisites are often met by uisites for a nursing population of newborns.
dependent care agents when caring for devel- Although created for nursery newborns, that
oping infants and children or when disaster is, a group particularized by age, the individual
and serious physical or mental illness affects patient adjustments are then made. For exam-
adults. Engagement in self-development, the ple, a newborns sucking needs may vary,
second DSCR, refers to demands for action necessitating variation in feeding methods.
by individuals in positive roles and in positive
mental health. Examples include self-reflection, Self-Care Deficit (Dependent-Care
goal-setting, and responsibility in ones roles. Deficit)
The third DSCR, interferences with develop- As a theoretical concept, self-care deficit
ment, express goals achieved by actions that expresses the value of the relationship
are necessary in situational crises such as between two other concepts: self-care agency
loss of friends and relatives, loss of job, or ter- and therapeutic self-care demand (Orem,
minal illness. Originally subsumed under 2001). When the persons self-care agency is
USCRs, Orem created the developmental self- not adequate to meet all self-care requisites
care requisite types to indicate the importance (TSCD), a self-care deficit exists. This quali-
of human development to life, health, and tative and quantitative relationship at the
well-being. conceptual level of abstraction is expressed
Health deviation self-care requisites: Health as equal to, more than, or less than
deviation self-care requisites (HDSCR) are (see Fig. 9-1). A deficit relationship is also
situation-specific requisites or goals when described as complete or partial; a complete
people have disease, injuries, or are under pro- deficit suggests no capability to engage in
fessional medical care. These six often under- self-care or dependent care. An example of a
used requisites guide actions when pathology complete deficit may exist in a premature
exists or when medical interventions are pre- infant in a neonatal intensive care unit. A
scribed. The first HDSCR refers in part to a partial self-care deficit may exist in a patient
patient purpose: to seek and secure appropriate recovering from a routine bowel resection one
medical assistance for genetic, physiological, or day after surgery. This person is able to pro-
psychological conditions known to produce or be vide some self-care.
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Understanding self-care deficit is necessary the therapeutic dependent self-care demand is


to appreciate Orems concept of legitimate termed a dependent-care system (Taylor et al.,
nursing. If a nurse determines a patient has 2001). These actions relate to three types of
self-care agency (estimative, transitional, subsystems: interpersonal, social/contractual,
and productive capabilities) to carry out a and professional-technological.
sequence of actions to meet the self-care req- The interpersonal subsystem includes all
uisites, then nursing is not necessary. A self- necessary actions or operations such as enter-
care deficit or anticipated self-care deficit ing into and maintaining effective relation-
must exist before a nursing system is designed ships with the patient and/or family or others
and implemented. The nurse reflects with the involved in care. The social/contractual sub-
patient: Is self-care agency (and/or depend- system relates to all nursing actions/operations
ent care agency) adequate to meet the thera- to reach agreements with the patient and oth-
peutic self-care demand, comprising of all the ers related to information necessary to deter-
three requisite types? If adequate, there is no mine the therapeutic self-care demand and
need for nursing. self-care agency of an individual and care-
A dependent-care deficit may occur when givers. Within this subsystem, the nurse, in
two or more persons provide care to the collaboration with the patient or dependent-
socially dependent person, the self-care agent. caregiver, determine roles for all care partici-
This occurs when an actual or potential deficit pants (Orem, 2001). These are based on social
relationship exists between the dependent norms and other variables such as basic con-
care demand and the capabilities (agency) of ditioning factors. Although other nursing the-
the dependent care agent and the self-care ories emphasize interpersonal interactions,
agent (Taylor et al., 2001). When this deficit Orems general theory clearly specifies details
occurs, then a need for nursing exists. When a of interpersonal and contractual operations as
parent has the capabilities to meet all health- necessary antecedents and concurrent compo-
related self-care requisites of an ill child, then nents of care. This element of Orems model
no nursing is needed. is often overlooked and clarifies the decision-
As the presence of an existing or potential making process and collaborative relationship
self-care deficit is identified and legitimate within the nursepatientfamily/multiperson
nursing is needed, an analysis by the nurse/ roles.
patient/dependent care agents results in iden- The professionaltechnological subsystem
tification of types of limitations in relation- comprises actions/operations that are diagnos-
ship to the particularized self-care requisites. tic, prescriptive, regulatory, evaluative, and case
These are generally described as limitations management. The latter involves placing all
of knowing, limitations or restrictions of operations within a system that uses resources
decision-making, and limitations in ability to effectively and efficiently with a positive
engage in result-achieving courses of action. patient outcome. Orem views the professional
Orem classified these into sets of limitations technological subsystem as the process of
(see Orem, 2001, pp. 279282). nursing, a nonlinear one that integrates all
operations of this subsystem with those of
Nursing System the interpersonal and the socialcontractual.
Orem describes a nursing system as an action This involves collecting data to determine
system, or actions and sequence of actions existing and projected universal, developmen-
performed for a purpose. This is a composite tal, and health-deviation self-care requisites,
of all the nurses concrete actions completed or and methods to meet these requisites as
to be completed for or with a self-care agent to adjusted by the basic conditioning factors.
promote life, health, and well-being. The Using the interpersonal and socialcontractual
composite of actions and their sequence pro- subsystems, the nurse incorporates modifica-
duced by the dependent-care agent to meet tions of her or his diagnosis and prescriptions
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134 S E C T I O N III Conceptual Models/Grand Theories in the Interactive/Integrative Paradigm

in collaboration with the patient and family on of nursing actions and if adjustments should
what is possible. The nurse also identifies the be made. These emphasize validity of opera-
patients usual self-care practices and assesses tions or actions in relationship to standards.
the persons estimative, transitional, and pro- Selecting valid operations in the plan and
ductive capabilities for knowledge, skills, and in evaluation incorporate evidence-based
motivation in relationship to the known self- practices. These processes, including diagno-
care requisites. That is, are the capabilities sis, prescription, designing, planning, regulat-
(self-care agency/dependent care agency) ing, and controlling, can be viewed as ele-
needed to meet the self-care requisites devel- ments of Orems steps in the process of
oped, operable, and adequate? Are there limi- nursing (Fig. 9-3).
tations in knowing, deciding, or producing Orems language of the nursing process
self-care? If so, there is no need for nursing varies from the standard language of assess-
and no nursing system is developed. If there is ment, diagnosis, planning, implementation,
a self-care deficit or dependent-care deficit,
then the nurse and patient or caregivers reach
agreement about the patients role, the familys
Accomplishes patients
role, and the nurses role. Orem (2001) chart- therapeutic self-care
ed the progression of these steps by subsys-
tems (pp. 311, 314317). Nurse
Compensates for patients
With determination of a real or potential inability to engage in
action
self-care
self-care deficit or dependent-care deficit, the
nurse develops one of three types of nursing Supports and protects
systems: wholly compensatory, partly com- patient
pensatory, or supportive-educative (develop-
Wholly compensatory system
mental). The nurse then continues the query:
Who can or should perform actions that require Performs some self-care
movement in space and controlled manipulation? measures for patient
(Orem, 2001, p. 350). If the answer is only
the nurse, then a wholly compensatory sys- Compensates for self-care
limitations of patient
tem is designed. If the patient has some capa-
bilities to perform operations or actions, then Nurse Assists patient as required
the nurse and patient share responsibilities. action
If the patient can perform all actions that
control movement in space and controlled Performs some self-care
measures
manipulation, but nurse actions are required
for support (physical or psychological), then Regulated self-care Patient
the system is supportiveeducative. Note, in agency action
all systems, the self-care deficit is the neces-
Accepts care and
sary element that leads to the design of a
assistance from nurse
nursing system. Using the interpersonal and
socialcontractual operations, the nurse first Partly compensatory system
enters into an interpersonal relationship and
Accomplishes self-care
an agreement to determine a real or potential
Patient
self-care deficit, prescribe roles, and imple- action
Regulates the exercise
ment productive operations of self-care and/ Nurse
and development of
or dependent-care. Regulation or treatment action
self-care agency
operations are designed or planned and then
produced or performed. Control operations are Supportive-educative system
used to appraise and evaluate the effectiveness Figure 9 3 Basic Nursing System.
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C H A P T E R 9 Dorothea Orems Self-Care Deficit Theory 135

and evaluation. The interaction of the three role functions, nurses perform a specific
aforementioned subsystems creates a model sequence of actions in relationship to the
for true collaboration with the recipient of identified patient and/or dependent care
care or the caregiver. agents self-care limitations in combination
The three steps of Orems process of nurs- with other health professionals to meet the
ing are as follows: (1) diagnosis and prescrip- self-care requirements.
tion; (2) design and plan; and (3) produce Although comparisons are made between
and control. For example, Orem considers the these steps and those of the general nursing
term assessment too limiting. Within Orems process, Orems complexity is unique in address-
process, assessments are made throughout ing an integration of interpersonal, social
the iterative socialcontractual and professional- contractual, and professionaltechnological
technological operations. During the first step subsystems. The intricacy of her steps is also
of diagnosis, data are collected on the basic evident in the complexity of the diagnostic
conditioning factors and a determination is and prescriptive components. The exemplar
made about their relationship to the self-care in this chapter provides one simplified exam-
requisites and to self-care agency. How does ple of this process.
health state (e.g., type 2 diabetes) affect the
individuals universal, developmental, and Nursing Agency
health-deviation self-care requirements? How Nursing agency is the power or ability to
does the basic conditioning factor, health state, nurse. The agency or capabilities are necessary
affect the individuals self-care agency (capa- to know and meet patients therapeutic self-care
bilities)? What, if any, are limitations for demands and to protect and to regulate the exer-
deliberate action related to the estimative cise of development of patients self-care agency
(investigativeknowing), transitional (decision- (Orem, 2001, p. 290). Nursing agency is anal-
making), and productive (performing) phases ogous to self-care agency, but with capabilities
of self-care? (Orem, 2001, p. 312). The nurse performed on behalf of legitimate patients.
collects information and analyzes and makes Similar to self-care agency, nursing agency is
judgments about the information within the affected by basic conditioning factors. The
limits of nursing agency (capabilities to nurse, nurses family system, as well as nursing edu-
such as expertise). cation and experience, may affect his or her
Orem describes nursing as a specialized ability to nurse.
helping service and identifies five helping Orem categorizes nursing capabilities
methods to overcome self-care limitations or (agency) as interpersonal, socialcontractual,
regulate functioning and development of and professional-technological. That is, the
patients or their dependents. Nurses employ nurse must have capabilities within each of the
one or more of these methods throughout the subsystems described in the nursing system.
process of nursing, including acting for or Capabilities that result in desirable interper-
doing for another, guiding another; support- sonal nurse characteristics include effective
ing another; providing for a developmental communication skills and ability to form rela-
environment, and teaching another (Orem, tionships with patients and significant others.
2001, pp. 5660). Acting for or doing for Socialcontractual characteristics require the
another includes physical assistance such as ability to apply knowledge of variations in
positioning the patient. Assuming self-care patients to nursing situations and to form con-
agency that is developed and operable, the tracts with patients and others for clear role
nurse replaces this method with others that boundaries. Desirable professionaltechnologic
focus on cognitive development, such as characteristics require abilities to perform
guiding and teaching. These methods are not techniques related to the process of nursing:
unique to nursing, but are used by most diagnosis of therapeutic self-care demand of
health professionals. Through their unique an assigned patient with consideration of all
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136 S E C T I O N III Conceptual Models/Grand Theories in the Interactive/Integrative Paradigm

self-care requisites (universal, developmental, common needs. For example, the focus of a
and health deviation) and a concomitant diag- student health nurse at a university may be a
nosis of a patients self-care agency. Others group of first-year students and the self-care
include the ability to prescribe roles: Assum- requisite, prevention of the hazards of alcohol
ing a self-care deficit (and therefore legitimate poisoning. The self-care limitations of the
patient), what are the roles and related respon- group may be knowledge of binge drinking
sibilities of the nurse, the patient, the aide, and outcomes and the skills to resist peer pressure
the family? Nurses must also have the ability at parties. This environment and situation, the
to know and apply care measures such as gen- college milieu and new independence, creates
eral helping techniques (teaching, guiding) the common set of self-care requisites. The
and specialized interventions and technologies action system designed by the college health
such as those identified with evidence-based nurse is to develop the knowledge, decision-
practice. These nursing capabilities also have making, and result-producing skills of new
implications for design of undergraduate cur- students collectively so life, health, and well-
ricula as nursing agency is developed in preli- being are enhanced for the group, as well as
censure students. the college community.
Family or others in a communal living
Multiperson Situations and Units arrangement are another type of multiperson
The concepts just presented relate to care for unit of service. Because of the interrelation-
an individual. The focus is on the persons ship of the individuals in the living unit, the
therapeutic self-care demand or self-care purpose of nursing varies from that for a com-
agency. When a dependent care agent pro- munity group. In this situation, the focus is
vides care, the primary focus is still the person often an individual, as well as the family as a
with the deficit, not the dependent care agent. unit. The health-related requirements of one
Nursing care to groups and to communities individual trigger the need for nursing, but
requires an expanded model. also affect the unit as a whole. In one situa-
Taylor and Renpenning (2001) extended tion, an elderly parent moves into the family
application to families, groups, and communi- home. Not only is the therapeutic self-care
ties, where the recipient of nursing care is demand of the parent involved, but also the
more than a single individual with a self-care needs of all family members as it affects the
deficit. They distinguish among types of mul- self-care requisites of all members. These
tiperson units, such as community groups and models continue in development as nursing
family or residential group units. These authors expands to populations.
present categories of multiperson care sys-
tems, create family and community as basic
conditioning factors, and present a model of Practice Applications
community as aggregate. This model appro- Much has been written about application of
priately incorporates additional basic condi- Orems Self-Care Deficit Nursing Theory
tioning factors such as public policy, health (SCDNT) to nursing practice. Nursing schol-
care system changes, and community devel- ars investigated the practice application during
opment. Other frameworks such as a commu- the theorys development and others expanded
nity participation model have been developed its use throughout the United States and
(Isaramalai, 2002). international nursing arena. Biggs (2008) con-
Community groups have a selected num- ducted the most recent review of the nursing
ber of common self-care requisites and or lim- literature from 1999 to 2007. The results
itations of knowledge, decision-making, and revealed more than 400 articles, including
producing care. This can be directed to entire those in International Orem Society Newsletters
communities, to groups within the communi- and Self-Care, Dependent-Care, and Nursing,
ties, or to other situations when groups have the official journal of the International Orem
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C H A P T E R 9 Dorothea Orems Self-Care Deficit Theory 137

Society. Although Biggs noted a tremendous in a newborn nursery. This relates to a thera-
increase in publications during the last 10 years, peutic self-care demand as conditioned by
the author observed that SCDNT research age. The article provides the practitioner with
has not always contributed to theory progres- a foundation for application with healthy
sion and development. She identified deficient infants in the nursery setting before further
areas such as those related to concepts such as particularizing to the individual infant. Oliver
therapeutic self-care demand, self-care deficit, (2003) describes the use of SCDNT as the
nursing systems, and the methods of helping nurse collaborates with the dependent-care
or assisting. These limitations of development agents to develop self-care agency in autistic
have restricted SCDNTs applicability to spe- preschoolers. This example demonstrates the
cific nursing situations or use in varied nursing nurses role in collaborating with all key care
roles. providers to strengthen the childs capabili-
For this chapter a literature review was ties. Others, such as Schmidt (2008), exem-
conducted to provide diverse examples of plify development of a nursing system as ther-
SCDNTs utility for nursing practice in a apeutic self-care demand and self-care agency
variety of settings and situations. Evidence- are diagnosed and prescribed and nursing
based research studies were also reviewed for agency is determined.
examples valuable to practitioners. Between Schmidt (2008) presented a case study
2000 and 2009 more than 700 citations of using SCDNT for a specific patient within a
SCDNT in nursing practice were identified dependent-care nursing situation. The author
through CINAHL, OVID, and Medline created a unique nursing system using guided
search engines. Key terms were self-care imagery to manage pain of a 10-year-old
deficit theory in nursing practice, self-care, child with vaso-occlusive sickle cell anemia.
Orem, and evidence-based nursing practice. This school-aged child presented with years
This search was further restricted to Orem of hospitalizations and chronic care treat-
nursing practice and evidence-based nursing ment. The presence of pain conditioned his
practice. The resulting 127 citations, includ- self-care requisites, thereby increasing his
ing five books and chapters, were subsequently therapeutic self-care demand and decreasing
reviewed. Although a Proquest dissertation his ability care for self, that is, limiting his
search revealed 300 citations using the theory, self-care agency. A self-care deficit was deter-
they were not included in this review. mined. Consistent with the theory and devel-
Selected practice and evidence-based opment of a nursing system, the capabilities
research publications are presented in two of the nurse in relationship to the specific
tables, one on application to nursing practice deficit were also considered to promote a pos-
using case studies or nursing process exam- itive outcome, in this case reduction of pain
ples, the second on evidence-based research. and ability to care for self. In this situation,
Table 9-1 appears in this chapter and Table 9-2 nursing agency of the assigned practitioner
within the ancillary materials on http:// includes expertise from 5 years of experience
davisplus.fadavis.com. Domestic and interna- and certification in guided imagery beyond
tional examples are included as well as a range the general pediatric staff nurse knowledge
of clinical settings and types of nursing situa- and skills. With the mother as a dependent
tions. This narrative provides an extension of care agent providing most of the physical care,
the tables to encourage the reader to explore the nurse determines the legitimate nursing
the bibliography for additional resources in this specific situation the addition of
applicable to relevant practice situations. guided imagery. Because the child provides
Examples in Table 9-1 demonstrate the some self-care and participates in dependent
practical utility across age groups, health care, a partially compensatory nursing system
states, and settings. For example, Dennis and is needed. The nurses method of assisting is
Jesek-Hale (2003) focus on the normal infant to teach him self-management of pain using
Table 9 1 Examples of Practice Applications
Author/Year Country Health or Illness Focus Settings SCDNT Concept(s) Patient or Practice Focus (Selected Examples)
138

Conway, McMillan, Cardiac rehabilita- Cardiac step-down unit Nurse agency Knowledge of nurses responses to patients
& Solman tion: Adult needs; nursing actions from acute care to
(2006) discharge
2168_Ch09_121-145.qxd

Australia
Dennis & Jesek-Hale Normal newborn Newborn nursery Therapeutic self- Therapeutic self-care demand:
(2003) basic needs care demand Feeding/elimination/activity and rest/
4/9/10

United States prevention of hazards for normal newborns


Grando Mental health situa- Outpatient psychiatric Self-care agency Nurse practitioners exploration: Inabilities to
(2005) tions: Personal crisis, clinic manage self-care requirements
United States relationship abuse
6:32 PM

and psychosis
Herber, Schnepp, Leg ulcers Outpatient wound clinic Therapeutic self- Nurse-led program for patients and dependents:
& Rieger management: Adult care demand Determination of therapeutic self-care demands:
(2008) and self-care Health deviation self-care;
Germany agency Self-care agency: Decision-making operations
Page 138

Kumar Type 2 diabetes Outpatient vascular Self-care agency Knowledge: Impaired learning and functioning:
(2007) management: Adult ofce; Imbalanced nutrition inuencing weight loss
United States clinical nurse specialist success and control of peripheral vascular pain
Diabetes management: Adequate nutrition (for
weight loss), pain control, and health beliefs of
powerlessness and coping
Martinez Rectal cancer: Adult Home care Self-care agency Knowledge; determination and promotion of
(2005) self-care agency to meet therapeutic self-care
United States demand related to severe anxiety, stress, and
body image disturbance.
Interventions identied
Oliver Autism in preschool Preschool Self-care agency Self care agency enhancement through
(2003) child setting collaboration between dependent care agents
United States (multidisciplinary management)
Case management
S E C T I O N III Conceptual Models/Grand Theories in the Interactive/Integrative Paradigm

Sampaio, Aquino, Chagas disease: Home care Self-care agency Knowledge of stoma care, control of complica-
de Araujo, & Galvo Adult tions and access to health services
(2007)
Brazil
Schmidt Sickle cell anemia: Acute care setting: Self-care agency; Self-care agency enhancement through guided
(2009) School-age child Inpatient Nursing agency imagery and teaching for pain management
United States Nursing certication related to abilities;
Guides creation of nursing systems
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C H A P T E R 9 Dorothea Orems Self-Care Deficit Theory 139

guided imagery. After each session, the child pragmatic adequacy in multiple situations,
reports feeling a little bit better with pain cases, and nursing preparation.
ratings decreasing from 8 to 6 to 3 over sever- A concept more recently described by
al sessions. Concomitantly, he uses less pain Orem (2001) is the notion of self-management.
medication, increases ambulation, and is soon She defines this as the ability to manage
discharged, meeting all outcomes objectives. self in stable or changing environments and
In contrast to the partly compensatory ability to manage ones personal affairs (p. 111).
system, Herber (2008) developed a supportive- This definition relates to the extent and con-
educative nursing system within a depend- tinuity of contacts and interactions one
ent care situation. The health state of leg would expect over time with nursing. For
ulcers conditions the therapeutic self-care example, chronic conditions are collabora-
demand and self-care agency. With the tively managed with the self-care agent,
illness or disability emphasis, Herber focus- dependent-care agent by nurse practitioners,
es on the health-deviation self-care requi- home health nurses, or telenurses. However,
sites. As the reader considers the various neither the theory nor extensive research
examples, the complexity of Orems con- guides the practitioner on an extended model
cepts become apparent, revealing SCDNTs of care.

Practice Exemplar
Marion W. presents to a primary care office external environmental factors such as the
seeking care for recent fatigue. She is assigned physical or biological.
to the nurse practitioner. The nurse explains Marion is 42, female, in a developmental
the need for information to determine what stage of adulthood where she carries out tasks
needs to be done and by whom to promote of family and work responsibilities as a pro-
Marions life, health, and well-being. Infor- ductive member of society. The history related
mation regarding Marion is gathered in part to patterns of living and family system reveals
using Orems conceptualizations as a guide. employment as a school crossing guard, a role
First, the nurse introduces herself and then that allows time after school with her chil-
describes the information she will seek to dren, ages 5, 7, and 9. Her husband works for
help her with the health situation. Marion the city, but recently had hours cut to 4 days
agrees to provide information to the best of per week. Therefore money is very tight.
her knowledge. As the nurse and Marion They pay bills on time, but no money remains
have entered into a professional relationship at the end of the month. She has learned to
and agreed to the roles of nurse and patient, stretch their money by shopping at the local
the nurse initiates the three steps of Orems discount store for clothes and food and cook-
process of nursing: ing one-pot meals so they have leftovers to
stretch throughout the week. As an African
Step 1: Diagnosis and Prescription
American, she worships in a community-
I. Basic Conditioning Factors based Black church, a source of spiritual
As basic conditioning factors affect the value strength and social support. Marion has a
of therapeutic self-care demand and self-care high-school education.
agency, the nurse seeks information regarding Questions about her health state and health
the following: age, gender, developmental system reveal Marion has type 2 diabetes and
state, patterns of living, family system factors, was diagnosed more than 5 years ago. Except
sociocultural factors, health state, health care for periodic fatigue, she believes she has man-
system factors, availability of resources, and aged this chronic condition by following the
Continued
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140 S E C T I O N III Conceptual Models/Grand Theories in the Interactive/Integrative Paradigm

Practice Exemplar cont.


treatment plan, faithfully taking oral medica- additional self-care actions beyond the pre-
tion, and checking blood sugar once per day. scribed medication, short walks, and daily
The morning reading is 230 mg/dL. Although blood glucose testing, the risks of uncontrolled
the family has no health insurance, Marion has diabetes may lead to diabetic retinopathy,
access to the community health care clinic and nephropathy, and coronary artery disease
free oral medications. There is a small co-pay (American Diabetes Association [ADA], 2009).
for her blood glucose testing strips, which is One particularized self-care requisite
now a concern. The children receive health (PSCRs) is presented as an example, with the
care through the State Childrens Health related actions Marion should perform to
Insurance Program. The neighborhood Marion improve her health and well-being. Once the
lives in has a safe, outdoor environment. actions to be performed and concomitant meth-
The latter has been a comfort because she ods are identified, then the nurse determines
works as a crossing guard and walks her chil- Marions self-care agency: the capabilities of
dren to school. Although she enjoys this exer- knowing (estimative operations), deciding
cise, her increasing fatigue discourages addi- (transitional operations), and performing these
tional exercise. actions (productive operations).
When asked about her perception of her PSCR: Reduce and maintain blood glu-
current condition, Marion expressed concern cose level within normal parameters through
for her weight and considers this a partial increased blood glucose monitoring, appro-
explanation for the fatigue. She desires to lose priate healthy food choices, and increased
weight but admits she has no will power, activity. If this PSCR is achieved, Marions
snacks late at night, and finds healthy foods weight will be decreased, a related purpose
too expensive. At 205 lbs (93 kg) and 5 feet that provides motivation to engage in self-
3 inches (1.6 m), Marion is classified as obese care. The methods to achieve the PSCR
with a body mass index of 38 kg/m2. include detailed actions:
A. Increase blood glucose monitoring to
II. Calculating the Therapeutic Self-Care twice per day; 100110 mg/dL fasting and
Demand <140 mg/dL at 2 hours after a main meal.
With Marion, the nurse identifies many 1. Obtain discounted glucose monitoring
actions that should be performed to meet the strips from ABC drug company.
universal, developmental, and health deviation 2. Obtain assistance from community clinic
self-care requisites. Her health state and health for monthly replacement request to ABC
system factors (including prior treatment drug company.
modalities) are major conditioners of two uni- 3. Monitor glucose level through testing two
versal self-care requisites: maintain a sufficient times per day, with one test before break-
intake of food and maintain a balance between fast and one test 2 hours after a main
activity and rest. Throughout the interview, the meal. Add more testing when needed for
nurse determines that Marion is clear about symptoms of high or low blood sugar
her chronic condition and has accepted herself (ADA, 2009).
in need of continued monitoring and care. 4. Seek assistance from health professional
Two health deviation self-care requisites when levels are below 60 mg/dL and not
also emerge as the primary focus for seeking responsive to sugar intake or higher than
helping services: being aware and attending to 300 mg/dL with feelings of fatigue, thirst,
effects and results of pathological conditions; or visual disturbances.
and effectively carrying out medically prescribed 5. Adjust activity and meal planning/portion
diagnostic and therapeutic measures. Without sizes when levels are not within parameters.
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C H A P T E R 9 Dorothea Orems Self-Care Deficit Theory 141

B. Make healthy food choices. communication skills to seek resources from


the community center? Does she have the
6. Seek knowledge of healthy food choices
knowledge regarding blood glucose parame-
for family meal planning from dietician
ters and methods to adjust exercise and diet
at clinic.
to maintain the levels? The nurse and Marion
7. Review family expenses with health pro-
together determine capabilities for each of
fessional to adjust grocery budget to pur-
these components of each action necessary to
chase affordable but healthy foods.
meet her particularized self-care requisite.
8. Eat three balanced meals per day includ-
After collecting and analyzing data about
ing midmorning, afternoon, and evening
her abilities in relationship to the required
snack as desired. These meals and snacks
actions, the nurse determines the absence or
will have portion sizes established
existence of a self-care deficit, that is, is self-
between Marion and the nurse.
agency adequate to meet the therapeutic self-
9. All meals will have a selection of protein,
care demand? The nurse quickly determines
fats, and carbohydrates and the snacks
throughout the data collection period that
will be limited to 15 grams of carbohy-
Marions foundational and disposition capa-
drate or less.
bilities (necessary for any deliberate action)
C. Increase physical activity to 150 minutes/ and the power components (necessary for
week. self-care) are developed and operable. The
question is the adequacy of self-care agency
10. Gain knowledge regarding step walking
in relationship to this PSCR.
program to increase activity. Discuss com-
munity options for safe walking areas. 1. Blood glucose monitoring: The nurse learns
11. Explore budget to include properly fit- that Marion possesses necessary capabilities
ting foot wear. Tennis shoes with socks of knowing, deciding, and performing to
are to be worn for each walk. Obtain free obtain additional testing strips from ABC
pedometer from clinic to measure per- drug company and to increase her blood
formance of steps and walking. glucose testing to two times per day. After
12. Review pedometer measures three times a questioning, the nurse determines Marion
week. Increase steps by 10% each week if is aware of norms and in general the effect
natural increase in steps has not occurred. of food and exercise. In addition to verbal-
For example, if walking 2000 steps/walk izing available time for testing, Marion also
increase next walk by 200 steps as a goal. recalls that the school nurse where she
Maintain goals until 10,000 step/day is works agreed to be a resource if blood glu-
achieved (ADA, 2009). cose readings are not within the required
range. She agreed to seek out this resource
III. Determining Self-Care Agency if adjustment in exercise or food intake is
The nurse and Marion then seek information needed. The nurse practitioner concludes
about self-care agency or the capabilities Marions self-care capabilities of knowing,
related to knowledge, decision-making, and deciding, and performing the necessary
performance necessary to meet this PSCR. actions is intact to meet the particularized
This includes the ability to seek and obtain self-care requisite, maintain blood glucose
required resources important to each action. level at 100110 mg/dL fasting and <140
What capabilities are necessary to increase mg/dL at 2 hours after a main meal.
blood glucose testing? Does Marion have the 2. Dietary practices: The nurse seeks infor-
knowledge about access to drug company mation from Marion on her knowledge of
resources (testing strips) available to persons effective dietary practices and healthy
with their income level? Does she have the foods, including flexibility in the family

Continued
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142 S E C T I O N III Conceptual Models/Grand Theories in the Interactive/Integrative Paradigm

Practice Exemplar cont.


budget, shopping practices, and family Marions ability to learn, availability of time,
cultural practices that may influence her and her motivation to lose weight, and hence
food purchases. The nurse learns Marion have less fatigue. If Marion decides to make
has misinformation about her selected healthier food choices that are affordable and
foods and is aware of resources, such as the also increase her general activity, she will need
local health department that offers free monitoring, counseling, and support from a
classes by a registered dietician. However, health professional related to the blood glu-
transportation to dietary classes is not pos- cose levels, access to resources for classes,
sible as her husband uses the only car to budgeting, and purchase of equipment.
drive to work. Although Marion under- With analysis of self-care agency in rela-
stands the relationship of her high blood tionship to the particularized self-care requi-
glucose levels to the resulting fatigue, she site, the nurse and patient establish the
seems to focus on losing weight, a possible presence of a self-care deficit. Now that legit-
motivational asset. Marion maintains the imate nursing has been established, a nursing
ability to shop, cook, use the stove safely, system is designed.
and ingest all food types.
3. The nurse assesses that Marion enjoys Step 2: Design and Plan
walking and generally feels safe in the sur- of Nursing System
rounding environment. She also possesses Now that the self-care limitations of knowing
time while the children are at school to are identified, the nurse will use helping
take walks. The nurse discovers that Mari- methods of guiding and supporting by
on is not aware of proper foot care or the designing a supportive-educative nursing sys-
step program for increasing exercise. Mari- tem. The design involves planning Marions
on does not believe the family budget can activities to meet the particularized self-care
manage both changes in food purchases as requisite with nurse guidance and monitor-
well as the purchase of good walking shoes. ing and also to establishing the nurses
role. Together they agree on communica-
IV. Self-Care Limitations tion methods to work together, to monitor
Marion has self-care limitations in the area of progress as Marion attends classes to learn
knowledge and decision-making about healthy dietary practices and increase activity.
required dietary actions. The limitations of Marion agrees to share information related to
knowing are related to healthy dietary prac- blood glucose testing with the school nurse
tices. This includes the use of carbohydrate and the pharmacist at the community clinic
counting. She lacks knowledge about purchas- when refilling medication and supplies.
ing options for healthier foods and methods The nurse agrees to seek out resources for
to incorporate these into her meal effort. transportation to the health department for
Although interested, she is unable to enroll in dietary classes, purchase of footwear, assistance
dietary classes at the health department due to to fill out forms, and also to meet with Marion
transportation issues. Marion has knowledge every 2 weeks to review food consumption
and decision-making authority for managing and activity records. Although the goal is to
the family budget, but has no experience maintain blood glucose levels at 100110 mg/
incorporating healthier foods into the plan- dL fasting and <140 mg/dL at 2 hours after
ning. Marion also has self-care limitations in a main meal, the priority actions relate
relationship to knowledge of the step pro- to dietary changes, followed by slow, incremen-
gram, proper footware, and related foot care. tal changes in activity. The nurse expects it
No resources exist to purchase the necessary will take 1 month to obtain the necessary
walking shoes. Major capabilities include footwear. Objectives will be reviewed at
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C H A P T E R 9 Dorothea Orems Self-Care Deficit Theory 143

1 month. Marion knows that weight loss is her resource for weekly reports on blood glucose
objective, but she must start changes in dietary levels. She also seeks out additional testing
practices. The goal for weight loss will be set at strips and calls the clinic to obtain the routine
the first months meeting after attendance at forms for monthly renewal requests. They
the dietary sessions and initial experience with proceed through each of these actions as
changing the familys food purchases and meal agreed upon as socialcontractual operations.
planning. Marion and the nurse practitioner Throughout this step, the interpersonal oper-
begin implementing their roles as prescribed. ations are essential as the nurse evaluates
Marions progress and new roles are deter-
Step 3: Treatment, Regulation, Case mined and agreed upon. This continues over
Management, Control/Evaluation time, with continued review of the design, the
Marion and the nurse begin implementing role prescriptions, until Marions therapeutic
their agreed upon actions as they collaborate self-care demand is decreased or self-care
within the nursing system. The nurse practi- agency is developed so no self-care deficit
tioner maintains contact via phone with exists, and nursing is no longer required.
Marion as she completes actions, such as Throughout the process, nursing agency
seeking resources for the dietary classes and was evident. The capabilities related to inter-
footwear. Marion contacts the school nurse personal, social-contractual, and professional-
where she works to see if she will be a technological operations were evident.

Summary
This chapter provided an overview of Orems minor interrelated theories: the theory of self-
Self-Care Deficit Nursing Theory. Orem care, theory of self-care deficit, and theory of
created this general theory of nursing to address nursing systems. The building blocks of these
the proper objective of nursing through the theories are six major concepts and one periph-
question, What condition exists in a person eral concept. Orems SCDNT has been applied
when judgments are made that a nurse(s) extensively in nursing practice throughout the
should be brought into the situation (i.e., that a United States and internationally. It is applica-
person should be under nursing care)? (Orem, ble to nursing in diverse settings and with
2001, p. 20). The grand theory comprises three diverse populations.

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Gary, R. (2006). Self-care practices in women with of the self-as-career inventory questionnaire for the Thai
diastolic heart failure. Heart and Lung, 35(1), 918. population. Unpublished doctoral dissertation,
Gast, H., Denyes, M. J., Campbell, J. C., Hartweg, University of Missouri.
D. L., Schott-Baer, D., & Isenberg, M. (1989). Self- Kinlein, M. L. (1977a). Independent nursing practice with
care agency: Conceptualizations and operationaliza- clients. Philadelphia: J. B. Lippincott.
tions. Advances in Nursing Science, 12(1), 2638. Kinlein, M. L. (1977b). The self-care concept. American
Geden, E. A., Isaramalai, S., & Taylor, S. G. (2001). Journal of Nursing, 77, 598601.
Self-care Deficit Nursing Theory and the nurse Kumar, C. (2007). Application of Orems self-care
practitioners practice in primary care settings. deficit theory and standardized nursing languages in
Nursing Science Quarterly, 14(1), 2933. a case study of a woman with diabetes. International
Glasson, J., Chang, E., Chenoweth, L., & Hancock, K. Journal of Nursing Terminologies and Classifications,
(2006). Evaluation of a model of nursing care for 18(3), 103110.
older patients using participatory action research in Libster, M. (2008). Perspectives on the history of self-
an acute medical ward. Journal of Clinical Nursing, care. Self-Care, Dependent-Care, & Nursing, 16(2),
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Grando, V. T. (2005). A Self-Care Deficit Nursing Martinez, L. (2005). Self-care for stoma surgery:
Theory practice model for advanced practice psychi- mastering independent stoma self-care skills in an
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Hanucharurnkul, S., Leucha, Y., Wittya-Sooporn, J. & Matchim, Y. M., Armer, J. M., & Stewart, B. R. (2008).
Maneesriwongul, W. (2001). An integrative review A qualitative study of participants perceptions of
and meta-analysis of self-care research in Thailand: effect of mindfulness meditation practice on self-
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Metcalfe, S. A. (2008). Report from SCDNT in nursing of the Orems theory. Acta Paul Enferm, 21(1),
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Oliver, C. J. (2003). Triage of the autistic spectrum child Orem-based curriculum. Self-Care, Dependent-Care,
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(1973). Concept formalization: Process and product. Quarterly, 21(3), 238246.
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Nursing Development Conference Group [NDCG] and families. Nursing Science Quarterly, 14(1), 79.
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(2nd Ed.). Boston: Little Brown. Deficit Nursing Theory: A historical analysis.
Orem, D. E. (1987). Orems general theory of nursing. Self-Care, Dependent Care, & Nursing, 15(1),
In: R. Parse (Ed.), Nursing science: Major paradigms, 2225.
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W. B. Saunders. (2000). Orems self-care deficit nursing theory: Its
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St. Louis: Mosby. science. Nursing Science Quarterly, 13, 104111.
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Deficit Theory of nursing: Events and circum- tice of nursing in multiperson situations, family and
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Nursing Theory. In: M. E. Parker(Ed.) Nursing Neuman, B. M., & Hart, M. A. (2001). A theory
theories and nursing practice (2nd ed., pp. 141149). of dependent-care: A corollary theory to Orems
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Parker, M. E. (2006). Nursing theories & nursing practice. 14(1), 3947.
(2nd Ed). Philadelphia: F. A.Davis. Wallace, W. A. (1983). From a realist point of view:
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Renpenning, K. Mc., & Taylor, S. G. (Eds.). (2003). Legwand, C. (2008). Using the teach-back and
Self-care theory in nursing: Selected papers of Dorothea Orems self-care deficit nursing theory to increase
Orem. New York: Springer. childhood immunization communication among
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(2008). Nursing care to an ostomy patient: application Pediatric Nursing, 31, 722.
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Chapter
10
Imogene Kings Theory
of Goal Attainment
I MOGENE K ING , C HRISTINA L.
S IELOFF, M ARY B. K ILLEEN ,
AND M AUREEN A. F RE Y

Introducing the Theorist: The Nightingale Introducing the Theorist:


Tribute to Imogene King The Nightingale Tribute to
Kings Conceptual System
and Theory of Goal Attainment: In Her Imogene King1
Own Words Imogene M. King was born on January 30,
Concept and Middle Range Theory 1923 in West Point, Iowa, and died on
Development within December 24, 2007 in St. Petersburg, Florida
Kings Conceptual System or Theory and is buried in Fort Madison, Iowa. She
of Goal Attainment received a diploma in Nursing from St. Johns
Practice Applications Hospital School of Nursing, St. Louis, Missouri
Practice Exemplar in 1945. While working in a variety of staff
Summary nurse roles, King completed a Bachelor of
References Science in Nursing Education, which she
received from St. Louis University in 1948; she
completed a Master of Science in Nursing
from St. Louis University in 1957. From 1947
to 1958, King worked as an instructor in
medicalsurgical nursing and served as assis-
tant director at St. Johns Hospital School of
Nursing. She went on to study with Mildred
Montag as her dissertation chair at Teachers
College, Columbia University, New York,
receiving a Doctor of Education (EdD)
Imogene M. King
in 1961.
From 1968 to 1972, King was the director
of the School of Nursing at Ohio State
University in Columbus. During this time,
her book, Toward a Theory for Nursing: Gener-
al Concepts of Human Behavior (1971), was
published. In this early work, King concluded,

1This tribute has been modified slightly from the origi-


nal version that was reproduced, with permission, from
C. L. Sieloff & P. R. Messmer. (2009). Conceptual
systems framework and middle range theory of goal
attainment. In: A. Marriner-Tomey & M. R. Alligood
(Eds.), Nursing theorists and their work (7th ed.).
St. Louis, MO: Mosby-Elsevier.

146
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C H A P T E R 1 0 Imogene Kings Theory of Goal Attainment 147

a systematic representation of nursing is professor emeritus at the University of South


required ultimately for developing a science to Florida, and continued to guest lecture there.
accompany a century or more of art in the King continued to provide community
everyday world of nursing (1971, p. 129). service and helped plan care through her con-
The book was awarded the American Journal ceptual system and theory at various health
of Nursing Book of the Year Award in 1973 care organizations, including Tampa General
(King, 1995). Hospital (Messmer, 1995). King never really
From 1961 to 1966, King was an assis- retired, as she continued to collaborate with
tant and associate professor of nursing students, faculty, and colleagues who were
at Loyola University in Chicago, where using her theory, and even went round the
she developed a masters degree program clock to implement her theory at Tampa
in nursing based on a nursing conceptual General Hospital.
framework. Her first theory article appeared In 1948, King joined the American Nurses
in 1964 in the Nursing Science journal edited Association (ANA) as a member of the
by Martha Rogers. Missouri Nurses Association and was active
Between 1966 and 1968, King served as in Illinois and Ohio as well. On her move to
Assistant Chief of Research, Grants Branch, Tampa, Florida, she became very active
Division of Nursing, in the United States member in the Florida Nurses Association
Department of Health, Education, and Wel- (FNA) and FNA District 4, Tampa. King
fare under Jessie Scott. While she was in held offices in various organizations includ-
Washington, DC, her article A Conceptual ing president of the Florida Nurses Founda-
Frame of Reference for Nursing was pub- tion, served on the FNA and the FNA
lished in Nursing Research (King, 1968). District IV boards, and frequently was a del-
From 1968 to 1972, King served as Direc- egate from the FNA to the ANA House of
tor of the Nursing Department at Ohio State Delegates. In 1997, King received a gold
University. She returned to Chicago in 1972 medallion from Governor Chiles for advanc-
as a professor in the Loyola University gradu- ing the nursing profession in the state of
ate program, and served as the Coordinator of Florida. King was inducted into the FNA
Research in Clinical Nursing at the Loyola Hall of Fame and the ANA Hall of Fame in
Medical Center, Department of Nursing, 2004. In 1994, King was also inducted into
from 1978 to 1980. In May, 1998, King the American Academy of Nursing (AAN),
received an honorary doctorate from Loyola served on the AAN Theory-Guided Practice
University, where her collection is housed. Panel, and was honored as a Living Legend
From 1972 to 1975, King was a member of in 2005. In 1996, King received the Jessie M.
the Defense Advisory Committee on Women Scott Award at the ANA convention. King
in the Services for the United States Depart- was thrilled when Jessie Scott attended the
ment of Defense. She was also elected alder- presentation.
man for a 4-year term (19751979) in Ward 2, King was inducted into the Teachers Col-
Wood Dale, Illinois, in 1975. lege, Columbia University Hall of Fame in
In 1980, King was appointed professor at 1999. The King International Nursing Group
the University of South Florida, College of (K. I. N. G.) was created to facilitate the dis-
Nursing in Tampa, Florida (Houser & Player, semination and utilization of Kings concep-
2007). In 1981, the manuscript for her second tual system, Theory of Goal Attainment, and
book, A Theory for Nursing: Systems, Concepts, related theories. Even after the organization
Process, was published. In addition to her first became inactive, King consulted with mem-
two books, she authored multiple book chap- bers of the organization on an individual basis
ters and articles in professional journals, and a regarding her theory. The K. I. N. G. has been
third book, Curriculum and Instruction in reactivated to honor Dr. King.
Nursing: Concepts and Process, was published in King was one of the original Sigma Theta
1986. King retired in 1990, and was named Tau International (STTI) Virginia Henderson
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148 S E C T I O N III Conceptual Models/Grand Theories in the Interactive/Integrative Paradigm

Fellows, and received the STTI Elizabeth in those works influenced my ideas relative to
Russell Belford Founders Award for Excel- organizing a conceptual frame of reference for
lence in Education in 1989 (Messmer, 2007). nursing. Because concepts offer one approach
King was keynote speaker at two STTI theory to structure knowledge for nursing, a compre-
conferences in 1992, and presented at multiple hensive review of nursing literature provided
regional, national, and international STTI me with ideas to identify five comprehensive
conferences on application of her theory. concepts as a basis for a conceptual system
Kings theory books were translated into for nursing. The overall concept is a human
Japanese, Spanish, and German. In addition, being, commonly referred to as an individ-
she authored numerous articles on her theory ual or a person. Initially, I selected abstract
and served on the editorial board of Nursing concepts of perception, communication, inter-
Science Quarterly. King authored several chap- personal relations, health, and social institu-
ters in various books, for example, Frey and tions (King, 1968). These ideas forced me to
Sieloff s Advancing Kings Systems Framework review my knowledge of philosophy relative
and Theory of Nursing (1995), and Sieloff and to the nature of human beings (ontology) and
Freys Middle Range Theory Development Using to the nature of knowledge (epistemology).
Kings Conceptual Systems (2007). She served as
an advisor for Sieloff s (2003) development of Philosophical Foundation
an instrument to measure the power of a nurs- In the late 1960s, while auditing a series of
ing group within an organization, Killeens courses in systems research, I was introduced
(2007) instrument to measure patient satisfac- to a philosophy of science called General
tion with professional nursing care, and Freys System Theory (Von Bertalanffy, 1968).
(1995) seminal work on adolescent patients This philosophy of science gained momen-
diagnosed with type 1 diabetes.1 tum in the 1950s, although its roots date to
an earlier period. This philosophy refuted
logical positivism and reductionism and
Kings Conceptual proposed the idea of isomorphism and per-
System and Theory spectivism in knowledge development. Von
Bertalanffy, credited with originating the
of Goal Attainment: idea of General System Theory, defined this
In Her Own Words philosophy of science movement as a gener-
My first theory publication pronounced the al science of wholeness: systems of elements
problems and prospect of knowledge devel- in mutual interaction (von Bertalanffy,
opment in nursing (King, 1964). Over 30 years 1968, p. 37).
ago, the problems were identified as: (1) lack My philosophical position is rooted in
of a professional nursing language; (2) a General System Theory, which guides the
theoretical nursing phenomena; and (3) lim- study of organized complexity as whole
ited concept development. Today, theories systems. This philosophy gave me the impe-
and conceptual frameworks have identified tus to focus on knowledge development as
theoretical approaches to knowledge devel- an information-processing, goal-seeking, and
opment and utilization of knowledge in prac- decision-making system. General System The-
tice. Concept development is a continuous ory provides a holistic approach to study nurs-
process in the nursing science movement ing phenomena as an open system and frees
(King, 1988). ones thinking from the parts-versus-whole
My rationale for developing a schematic dilemma. In any discussion of the nature of
representation of nursing phenomena was nursing, the central ideas revolve around the
influenced by the Howland Systems Model nature of human beings and their interaction
(Howland, 1976) and the Howland and with internal and external environments. Dur-
McDowell conceptual framework (Howland ing this journey, I began to conceptualize a the-
& McDowell, 1964). The levels of interaction ory for nursing. However, because a manuscript
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C H A P T E R 1 0 Imogene Kings Theory of Goal Attainment 149

was due in the publishers office, I organized about interactions. From this research litera-
my ideas into a conceptual system (formerly ture, I identified the characteristics of percep-
called a conceptual framework), and the tion and defined the concept for my framework.
result was the publication of a book entitled I continued searching literature for knowledge
Toward a Theory of Nursing (King, 1971). of each of the concepts in my framework. An
update on my conceptual system was published
Design of a Conceptual System in 1995 (King, 1995).
A conceptual system provides structure for
organizing multiple ideas into meaningful Process for Development Concept
wholes. From my initial set of ideas in 1968 Searching for scientific knowledge in nursing
and 1971, my conceptual framework was is an ongoing dynamic process of continuous
refined to show some unity and relationships identification, development, and validation of
among the concepts. The conceptual system relevant concepts (King, 1975, p. 25). What is
consists of individual systems, interpersonal a concept? A concept is an organization of ref-
systems, and social systems and concepts erence points. Words are the verbal symbols
that are important for understanding the used to explain events and things in our envi-
interactions within and between the systems ronment and relationships to past experiences.
(Fig. 10-1). Northrop (1969) noted: [C]oncepts fall into
The next step in this process was to review different types according to the different
the research literature in the discipline in sources of their meaning. A concept is a
which the concepts had been studied. For term to which meaning has been assigned.
example, the concept of perception has been Concepts are the categories in a theory.
studied in psychology for many years. The lit- The concept development and validation
erature indicated that most of the early stud- process is as follows:
ies dealt with sensory perception. Around the
1. Review, analyze, and synthesize research
1950s, psychologists began to study interper-
literature related to the concept.
sonal perception, which related to my ideas
2. From the above review, identify the char-
acteristics (attributes) of the concept.
3. From the characteristics, write a concep-
tual definition.
4. Review literature to select an instrument
SOCIAL SYSTEMS or develop an instrument.
(Society)
5. Design a study to measure the character-
istics of the concept.
INTERPERSONAL SYSTEMS 6. Decisions are made on selection of the
(Group) population to be sampled.
7. Collect data.
PERSONAL
SYSTEMS 8. Analyze and interpret data.
(Individuals) 9. Write results of findings and conclusions.
10. State implications for adding to nursing
knowledge.
Concepts that represent phenomena in
nursing are structured within a framework and
theory to show relationships.
Multiple concepts were identified from my
analysis of nursing literature (King, 1981). The
concepts that provided substantive knowledge
about human beings (self, body image, percep-
Figure 10 1 Kings conceptual system. tion, growth and development, learning, time,
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150 S E C T I O N III Conceptual Models/Grand Theories in the Interactive/Integrative Paradigm

and personal space) were placed within the The concepts of self, perception, commu-
personal system, those related to small groups nication, interaction, transaction, role, growth
(interaction, communication, role, transac- and development, stress, time, and personal
tions, and stress) were placed within the inter- space were selected for the Theory of Goal
personal system, and those related to large Attainment.
groups that make up a society (decision mak-
ing, organization, power, status, and authority) Transaction Process Model
were placed within the social system (King, A transaction model, shown in Figure 10-2,
1995). However, knowledge from all of the was developed that represented the process
concepts is used in nurses interactions with whereby individuals interact to set goals that
individuals and groups within social organiza- result in goal attainment (King, 1981, 1995).
tions, such as the family, the educational sys- The model is a human process that can be
tem, and the political system. Knowledge of observed in many situations when two or
these concepts came from my synthesis of more people interact, such as in the family
research in many disciplines. Concepts, when and in social events (King, 1996). As nurses,
defined from research literature, give nurses we bring knowledge and skills that influence
knowledge that can be applied in the concrete our perceptions, communications, and inter-
world of nursing. The concepts represent basic actions in performing the functions of the
knowledge that nurses use in their role and role. In your role as a nurse, after interacting
functions either in practice, education, or with a patient, sit down and write a descrip-
administration. In addition, the concepts pro- tion of your behavior and that of the patient.
vide ideas for research in nursing. It is my belief that you can identify your per-
One of my goals was to identify what I call ceptions, mental judgments, mental action,
the essence of nursing. That brought me back and reaction (negative or positive). Did you
to the question, What is the nature of human make a transaction? That is, did you exchange
beings? A vicious circle? Not really! Because information and set a goal with the patient?
nurses are first and foremost human beings Did you explore the means for the patient to
who give nursing care to other human beings, use to achieve the goal? Was the goal
my philosophy of the nature of human beings achieved? If not, why? It is my opinion that
has been presented along with assumptions most nurses use this process but are not aware
I have made about individuals (King, 1989a). that it is based in a nursing theory. With
Recognizing that a conceptual system repre- knowledge of the concepts and of the process,
sents structure for a discipline, the next step nurses have a scientific base for practice that
in the process of knowledge development was can be clearly articulated and documented to
to derive one or more theories from this show quality care. How can a nurse document
structure. Lo and behold, a theory of goal this transaction model in practice?
attainment was developed (King, 1981,
1992). More recently, others have derived Documentation System
theories from my conceptual system (Frey & A documentation system was designed to
Sieloff, 1995). implement the transaction process that leads to
goal attainment (King, 1984). Most nurses use
Theory of Goal Attainment the nursing process of assess, diagnose, plan,
Generally speaking, nursing cares goal is to implement, and evaluate, which I call a
help individuals maintain health or regain method. My transaction process provides
health (King, 1990). Concepts are essential the theoretical knowledge base to implement
elements in theories. When a theory is derived this method. For example, as one assesses
from a conceptual system, concepts are select- the patient and the environment and makes a
ed from that system. Remember my question: nursing diagnosis, the concepts of perception,
What is the essence of nursing? communication, and interaction represent
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C H A P T E R 1 0 Imogene Kings Theory of Goal Attainment 151

Feedback

PERCEPTION

JUDGMENT

ACTION
NURSE
REACTION INTERACTION TRANSACTION

ACTION

JUDGMENT
PATIENT

PERCEPTION

Feedback
Figure 10 2 Transaction process model. (From King, I. M. [1981]. A theory for nursing: Systems, concepts, process
[p. 145]. New York: John Wiley & Sons.)

knowledge the nurse uses to gather informa- about their care and about dying. This trans-
tion and make a judgment. A transaction is action process provides a scientifically based
made when the nurse and patient decide process to help nurses implement federal laws
mutually on the goals to be attained, agree on such as the Patient Self-Determination Act
the means to attain goals that represent the (Federal Register, 1995).
plan of care, and then implement the plan.
Evaluation determines whether or not goals Goal Attainment Scale
were attained. If not, you ask why, and the Analysis of nursing research literature in the
process begins again. The documentation is 1970s revealed that very few instruments were
recorded directly in the patients chart. The designed for nursing research. In the late 1980s,
patients record indicates the process used to the faculty at the University of Maryland,
achieve goals. On discharge, the summary experts in measurement and evaluation,
indicates goals set and goals achieved. One applied for and received a grant to conduct
does not need multiple forms when this docu- conferences to teach nurses to design reliable
mentation system is in place, and the quality of and valid instruments. I had the privilege of
nursing care is recorded. Why do nurses insist participating in this two-year continuing edu-
on designing critical paths, various care plans, cation conference, where I developed a Goal
and other types of forms when, with knowl- Attainment Scale (King, 1989b). This instru-
edge of this system, the nurse documents ment may be used to measure goal attain-
nursing care directly on the patients chart? ment. It may also be used as an assessment
Why do we use multiple forms to complicate tool to provide patient data to plan and imple-
a process that is knowledge-based and also ment nursing care.
provides essential data to demonstrate out-
comes and to evaluate quality nursing care? Vision for the Future
Federal laws have been passed that indicate My vision for the future of nursing is that nurs-
that patients must be involved in decisions ing will provide access to health care for all
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152 S E C T I O N III Conceptual Models/Grand Theories in the Interactive/Integrative Paradigm

citizens. The United States health care system who generated both a framework and a mid-
will be structured using my conceptual system. range theory further expanded her work.
Entry into the system will be via nurses assess- Today, new publications related to Dr. Kings
ment so individuals are directed to the right work are a frequent occurrence. Additional
place in the system for nursing care, medical middle-range theories have been generated
care, social services information, health teach- and tested, and applications to practice have
ing, or rehabilitation. My transaction process expanded. Following her retirement, Dr. King
will be used by every practicing nurse so that continued to publish and examine new appli-
goals can be achieved to demonstrate quality cations of her work. The purpose of this part
care that is cost-effective. My conceptual sys- of the chapter is to provide an updated review
tem, Theory of Goal Attainment, and Transac- of the state of the art in terms of the applica-
tion Process Model will continue to serve a use- tion of Kings Conceptual System (KCS) and
ful purpose in delivering professional nursing mid-range theory in a variety of areas: prac-
care. The relevance of evidence theorybased tice, administration, education, and research.
practice, using my theory, joins the art of nurs- Publications, identified from a review of the
ing of the twentieth century to the science of literature, are summarized and briefly dis-
nursing in the twenty-first century. cussed. Finally, recommendations are made
for future knowledge development in relation
to Kings conceptual system and mid-range
Concept and Middle Range theory, particularly in relation to the impor-
Theory Development within tance of their application within an evidence-
based practice environment.
Kings Conceptual System or In conducting the literature review, the
Theory of Goal Attainment authors began with the broadest category
Concept development within a conceptual of applicationapplication within Kings
framework is particularly valuable, as it often Conceptual System to nursing care situations.
explicates concepts more clearly than a theorist Because a conceptual framework is, by nature,
may have done in his or her original work. very broad and abstract, it can only serve to
Concept development may also demonstrate guide, rather than prescriptively direct, nurs-
how other concepts of interest to nursing can ing practice.
be examined through a nursing lens. Such Kings Conceptual System has been used to
explication further assists the development of guide nursing practice in multiple settings and
nursing knowledge by enabling the nurse to with multiple populations. For example, Frey
better understand the application of the con- and colleagues (2007) used intervention
cept within specific practice situations. Exam- research in a population of adolescents with
ples of concepts developed from within Kings poorly controlled type 1 diabetes. Whelton
work include the following: collaborative (2007) described the nursing act as a human
alliance relationship (Hernandez, 2007); deci- act in an application of KCS using philosophi-
sion making (Ehrenberger, Alligood, Thomas, cal analysis. For additional information, please
Wallace, & Licavoli, 2007), empathy (May, visit DavisPlus at http://davisplus.fadavis.com.
2007), and patient satisfaction with nursing care Development of middle-range theories is a
(Killeen, 2007) (see http://davisplus.fadavis. com). natural extension of a conceptual framework.
Middle-range theories, clearly developed from
within a conceptual framework, accomplish two
Practice Applications goals: (1) Such theories can be directly applied
Since the first publication of Dr. Imogene to nursing situations, whereas a conceptual
Kings work (1971), nursings interest in the framework is usually too abstract for such direct
application of her work to practice has grown. application; and (2) validation of middle-range
The fact that she was one of the few theorists theories, clearly developed within a particular
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C H A P T E R 1 0 Imogene Kings Theory of Goal Attainment 153

conceptual framework, lends validation to the theory focuses on concepts relevant to all
conceptual framework itself. nursing situationsthe attainment of client
In addition to the mid-range Theory of goals. The application of the mid-range The-
Goal Attainment (King, 1981), several other ory of Goal Attainment (King, 1981) is doc-
mid-range theories have been developed from umented in several categories: (1) general
within Kings Interacting Systems framework. application of the theory, (2) exploring a par-
In terms of the personal system, Brooks and ticular concept within the context of the The-
Thomas (1997) used Kings framework to ory of Goal Attainment, (3) exploring a par-
derive a theory of perceptual awareness. ticular concept related to the Theory of Goal
The focus was to develop the concepts of Attainment, and (4) application of the theory
judgment and action as core concepts in in nonclinical nursing situations. For example,
the personal system. Other concepts in the King (1997) described the use of the Theory
theory included communication, perception, of Goal Attainment in nursing practice. Alli-
and decision-making. good (1995) applied the theory to orthopedic
In relation to the interpersonal system, sev- nursing with adults. Short-term group psy-
eral middle-range theories have been devel- chotherapy was the focus of theory applica-
oped regarding families. Doornbos (2007), tion for Laben, Sneed, and Seidel (1995). In
using her Family Health Theory, addressed contrast, Benedict and Frey (1995) examined
family health in terms of families with adults the use of the theory within the delivery of
with persistent mental illness. Wicks, Rice, and emergency care.
Talley (2007) further explored their middle- The mid-range Theory of Goal Attain-
range theory regarding the broader concept of ment (King, 1981) is also used when nurses
family health in the context of chronic wish to explore a particular concept within a
obstructive pulmonary disease. In relation to theoretical context. Palmer (2006) examined
social systems, Sieloff (2007) developed the anxiety with short-term memory loss while
Theory of Group Power within Organizations patients awareness of their illness was
to assist in explaining the power of groups explored by Wang and Yang (2006).
within organizations. For additional informa- Nurses also use the Theory of Goal
tion please visit DavisPlus at http://davisplus. Attainment (King, 1981) to examine concepts
fadavis.com. related to the theory. This application was
Instrument development in nursing con- demonstrated by Smith (2003), and Jones and
tinues to be needed in order to measure rele- Bugge (2006).
vant nursing concepts. However, instruments Finally, the theory has been applied in non-
developed for a research study rarely undergo clinical nursing situations. Secrest, Iorio, and
the rigor of research undertaken for the pur- Martz (2005) used the theory in examining the
pose of instrument development. empowerment of nursing assistants. Kameoka,
However, review of the literature identi- Funashima, and Sugimori (2007) explored the
fied instruments specifically designed with- relationship of nurse goal attainment and work
in Kings framework. King (1988) developed satisfaction using the theory. For additional
the Health Goal Attainment instrument, information, please visit DavisPlus at http://
designed to detail the level of attainment davisplus.fadavis.com.
of health goals by individual clients. The
Nurse Performance Goal Attainment (NPGA)
Nursing Process and Nursing
was developed by Kameoka, Funashima, and Terminologies, Including
Sugimori (2007). Standardized Nursing Languages
Within the nursing profession, the nursing
Practice process has consistently been used as the
Kings mid-range theory has found great basis for nursing practice. Kings framework
application to nursing practice, since the and mid-range Theory of Goal Attainment
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154 S E C T I O N III Conceptual Models/Grand Theories in the Interactive/Integrative Paradigm

(1981) have been clearly linked to the assist in knowledge development in nursing
process of nursing. Although many pub- in the future.
lished applications have broad reference to With the advent of SNLs, outcome iden-
the nursing process, several deserve special tification is identified as a step in the nursing
recognition. First, Dr. King herself (1981) process following assessment and diagnosis
clearly linked the Theory of Goal Attain- (McFarland & McFarland, 1997, p. 3). Kings
ment to nursing process as theory, and to (1981) concept of mutual goal-setting is
nursing process as method. Application of analogous to the outcomes identification step,
Kings work to nursing curricula further because Kings concept of goal attainment
strengthened this link. is congruent with the evaluation of client
In addition, the steps of the nursing outcomes.
process have long been integrated within the In addition, Kings concept of perception
KCS and the mid-range Theory of Goal (1981) lends itself well to the definition of
Attainment (Daubenmire & King, 1973; client outcomes. Johnson and Maas (1997)
Husband, 1988; Woods, 1994). In these defined a nursing-sensitive client outcome
process applications, assessment, diagnosis, as a measurable client or family caregiver
and goal-setting occur, followed by actions state, behavior, or perception that is concep-
based on the nurseclient goals. The evalua- tualized as a variable and is largely influ-
tion component of the nursing process consis- enced and sensitive to nursing interven-
tently refers back to the original goal state- tions (p. 22). This is fortuitous since the
ment(s). In related research, Frey and Norris development of nursing knowledge requires
(1997) also drew parallels between the the use of client outcome measurement.
processes of critical thinking, nursing, and The use of standardized client outcomes
transaction. as study variables increases the ease with
Over time, nursing has also developed which research findings could be compared
nursing terminologies that are used to assist across settings and contributes to knowledge
the profession to improve communication development. Therefore, Kings concept of
both within, and external to, the profession. mutually set goals could be studied as
These terminologies include the nursing expected outcomes. Also, by using SNLs,
diagnoses, nursing interventions, and nurs- Kings (1981) mid-range Theory of Goal
ing outcomes. With the use of these stan- Attainment could be conceptualized as the
dardized nursing languages (SNLs), the nurs- attainment of expected outcomes as the
ing process is further refined. Standardized evaluation step in the application of the
terms for diagnoses, interventions, and out- nursing process.
comes also potentially improve communica- In summary, although these terminologies,
tion among nurses. including SNLs, were developed after many of
Using SNLs also enables the develop- the original nursing theorists had completed
ment of middle-range theory by building their works, nursing frameworks such as the
on concepts unique to nursing, such as KCS (1981) can still find application and
those concepts of King that can be directly use within the terminologies. In addition, it is
applied to the nursing process: action, reac- this type of application that further demon-
tion, interaction, transaction, goal-setting, strates the frameworks utility across time. For
and goal attainment. Biegen and Tripp- example, Chaves and Araujo (2006), Ferreira
Reimer (1997) suggested middle-range the- De Sourza, Figueiredo De Martino and Daena
ories be constructed from the concepts in De Morais Lopes (2006), Goyat, Rossi, and
the taxonomies of the nursing languages Dalri (2006), and Palmer (2006) implemented
focusing on outcomes. Alternatively, Kings nursing diagnoses within the context of Kings
framework and theory may be used as a the- framework. (See http://davisplus.fadavis.com
oretical basis for these phenomena, and may for Table 10-4.)
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C H A P T E R 1 0 Imogene Kings Theory of Goal Attainment 155

Applications with Clients Across Applications in Client Systems


the Life Span In addition to discussing client populations
Additional evidence of the scope and useful- across the life span, client populations can be
ness of Kings framework and theory is its identified by focus of care (client system)
use with clients across the life span. Several and/or focus of health problem (phenomenon
applications have targeted high-risk infants of concern). The focus of care, or interest, can
(Frey & Norris, 1997; Norris & Hoyer, 1993; be an individual (personal system) or group
Syzmanski, 1991). Frey (1993, 1995, 1996) (interpersonal or social system). Thus, appli-
developed and tested relationships among cation of Kings work, across client systems,
multiple systems with children, youth, and would be divided into the three systems iden-
young adults. Interestingly, these studies con- tified within the KCS (1981): personal (the
sidered personal systems (infants), interper- individual), interpersonal (small groups), and
sonal systems (parents, families), and social social (large groups/society).
systems (the nursing staff and hospital envi- Use with personal systems has included
ronment). Clearly, a strength of Kings frame- both patients and nurses. Patients as personal
work and theory is their utility in encompass- systems were the focus of applications to
ing complex settings and situations. nursing students (May, 2007). Brooks and
The Conceptual System (KCS) and mid- Thomas (1997) considered critical care nurs-
range Theory of Goal Attainment have also es as the personal system of interest.
been used to guide practice with adults (young When the focus of interest moves from an
adults, adults, mature adults) with a broad range individual to include interaction between two
of concerns. Goyat et al. (2006) used Kings people, the interpersonal system is involved.
work in their study of adults experiencing Interpersonal systems often include clients
burns. Additional examples of applications and nurses. An example of an application to
focusing on adults include women with breast a nurse-client dyad and larger groups is
cancer (Funghetto, Terra, & Wolff, 2003) and Campbell-Beggs (2000) approach to animal-
women with weight problems ( Jewell, 2007). assisted therapy to promote abstinence from
Gender-specific work included Sharts-Hopkos the use of chemicals by groups (p. 31).
(2007) use of a middle-range Theory of Health In relation to interpersonal systems, or
Perception to study the health status of women small groups, many publications focus on the
during menopause transition and Martins family. Gonot (1986) proposed the Concep-
(1990) application of the framework toward tual System (KCS) as a model for family ther-
cancer awareness among males. apy. Frey and Norris (1997) used both the
Several of the applications with adults have Conceptual System (KCS) and Theory of
targeted the mature adult, thus demonstrating Goal Attainment in planning care with fami-
contributions to the nursing specialty of lies of premature infants.
gerontology. Reed (2007) used a middle- Kings Conceptual System (KCS) and
range theory to examine the relationship of mid-range Theory of Goal Attainment have
social support and health in older adults. a long history of application with large
Zurakowski (2007) also used a middle-range groups or social systems (organizations, com-
theory to examine the relationship between munities). The earliest applications involved
social and interpersonal influences in older the use of the framework and theory to guide
adults living in nursing homes. Clearly, these continuing education (Brown & Lee, 1980)
applications, and others, show how the com- and nursing curricula (Daubenmire, 1989;
plexity of Kings framework and mid-range Gulitz & King, 1988). More contemporary
theory increases its usefulness for nursing. For applications address a variety of organiza-
additional information, please visit DavisPlus tional settings. For example, the framework
at http://davisplus.fadavis.com. served as the basis for the development of a
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156 S E C T I O N III Conceptual Models/Grand Theories in the Interactive/Integrative Paradigm

middle range theory relating to practice in a ence of parenting was studied by Norris and
nursing home (Zurakowski, 2007). In addi- Hoyer (1993), and health behaviors were
tion, applications proposed the Theory of Hannas (1995) focus of study.
Goal Attainment as the practice model for King (1981) stated that individuals act to
case management (Hampton, 1994; Tritsch, maintain their own health. Although not
1996). These latter applications are especial- explicitly stated, the converse is probably true
ly important, as they may be the first use of as well: Individuals often do things that are
the framework by other disciplines. not good for their health. Accordingly, it is
Applicable to administration and manage- not surprising that the Conceptual System
ment in a variety of settings, a mid-range the- (KCS) and related mid-range theory are often
ory of group power within organizations has directed toward patient and group behaviors
been developed (Sieloff, 1995, 2003, 2007). that influence health. Frey (1997), Frey and
Educational settings, also considered as social Denyes (1989), and Frey and Fox (1990)
systems, have been the focus of application of looked at both health behaviors and illness
Kings work (Bello, 2000). (See http://davisplus. management behaviors in several groups of
fadavis.com for Table 10-8.) children with chronic conditions. In addition,
Frey (1996) expanded her research to include
Focus on Phenomena of Concern to risky behaviors.
Clients As stated previously, diseases or diagnoses
Within Kings work, it is critically important are often identified as the focus for the appli-
for the nurse to focus on, and address, the cation of nursing knowledge. Hernandez
phenomenon of concern to the client. With- (2007) conducted research with patients with
out this emphasis on the clients perspective, type 1 diabetes, while women with breast
mutual goal-setting cannot occur. Hence, a cancer were the focus of the work of
clients phenomena of concern was selected Funghetto et al. (2003). In addition, clients
as neutral terminology that clearly demon- with chronic obstructive pulmonary disease
strated the broad application of Kings work were involved in research by Wicks and col-
to a wide variety of practice situations. For leagues (2007).
additional information, please visit DavisPlus Clients experiencing a variety of psychi-
at http://davisplus.fadavis.com. atric concerns have also been the focus of
Health is one area that certainly binds work, using Kings conceptualizations (Murray
clients and nurses. Improved health is clearly & Baier, 1996; Schreiber, 1991). Clients con-
the desired end point, or outcome, of nursing cerns ranged from psychotic symptoms
care and something to which clients aspire. (Kemppainen, 1990) to families experiencing
Review of the outcome of nursing care, as chronic mental illness (Doornbos, 2007), to
addressed in published applications, tends to clients in short-term group psychotherapy
support the goal of improved health directly (Laben, Sneed, & Seidel, 1995). For addi-
and/or indirectly, as the result of the applica- tional information, please visit DavisPlus at
tion of Kings work. Health status is explicitly http://davisplus.fadavis.com.
the outcome of concern in practice applica-
tions by Smith (1988). Several applications Application within Nursing
used health-related terms. For example, Specialties
Kohler (1988) focused on increased morale A topic that frequently divides nurses is their
and satisfaction, and DeHowitt (1992) stud- area of specialty. However, by using a consis-
ied well-being. tent framework across specialties, nurses
Health promotion has also been an would be able to focus more clearly on their
emphasis for the application of Kings ideas. commonalities, rather than highlighting their
Sexual counseling was the focus of work by differences. A review of the literature clearly
Villeneuve and Ozolins (1991). The experi- demonstrates that Dr. Kings framework and
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C H A P T E R 1 0 Imogene Kings Theory of Goal Attainment 157

related theories have application within a ing. Spratlen (1976) drew heavily from Kings
variety of nursing specialties. (See http:// framework and theory to integrate ethnic cul-
davisplus.fadavis.com for Table 10-10.) This tural factors into nursing curricula and to
application is evident whether one is review- develop a culturally oriented model for mental
ing a traditional specialty, such as surgical health care. Key elements derived from Kings
nursing (Khowaja, 2006; Palmer, 2006; work were the focus on perceptions and com-
Susleck, Secrest, Holweger, & Myhan, 2007), munication patterns that motivate action, reac-
or in the nontraditional specialties of forensic tion, interaction, and transaction. Rooda
nursing (Laben, Dodd, & Sneed, 1991) and/ (1992) derived propositions from the mid-
or nursing administration (Secrest, Iorio, & range Theory of Goal Attainment as the
Martz, 2005). framework for a conceptual model for multi-
cultural nursing.
Application in Varied Work Settings Cultural relevance has also been demon-
An additional potential source of division strated in reviews by Frey, Rooke, Sieloff,
within the nursing profession is the work sites Messmer, and Kameoka (1995) and Husting
where nursing is practiced and care is deliv- (1997). Although Husting identified that
ered. As the delivery of health care moves cultural issues were implicit variables
from the more traditional site of the acute throughout Kings framework, particular
care hospital to community-based agencies attention was given to the concept of health,
and clients homes, it is important to high- which, according to King (1990), acquires
light commonalities across these settings, and meaning from cultural values and social
it is important to identify that Kings frame- norms.
work and mid-range Theory of Goal Attain- Undoubtedly, the strongest evidence for
ment continue to be applicable. Although the cultural utility of Kings conceptual
many applications tend to be with nurses and framework and mid-range Theory of Goal
clients in traditional settings, successful appli- Attainment (1981) is the extent of work that
cations have been shown across other, includ- has been done in other cultures. Applications
ing newer and nontraditional, settings. From of the framework and related theories have
hospitals (Hessig, Arcand, & Frost, 2004; been documented in the following countries
Kameoka, Funashima, & Sugimori, 2007) to beyond the United States: Canada (Coker
nursing homes (Zurakowski, 2007), Kings et al., 1995), Japan (Kameoka et al., 2007),
framework and related theories provide a Portugal (Chauves & Araujo, 2006; Goyat
foundation on which nurses can build their et al., 2006; Pelloso & Tavares, 2006), and
practice interventions. In addition, the use of Sweden (Rooke, 1995a, 1995b). In Japan, a
the KCS and related theories are also evident culture very different from the United States
within quality improvement projects (Ander- with regard to communication style, Kameoka
son & Mangino, 2006; Durston, 2006; (1995) used the classification system of
Khowaja, 2006). For additional information, nurse-patient interactions identified within
please visit DavisPlus at http://davisplus. the Theory of Goal Attainment (King, 1981)
fadavis.com. to analyze nurse-patient interactions. In
addition to research and publications regard-
Multicultural Applications ing the application of Kings work to nursing
Multicultural applications of Kings Conceptual practice internationally, publications by and
System (KCS) and related theories are many. about Dr. King have been translated into
Such applications are particularly critical as other languages, including Japanese (King,
many theoretical formulations are limited by 1976, 1985; Kobayashi, 1970). Therefore,
their culture-bound nature. Several authors perception and the influence of culture on
specifically addressed the utility of Kings perception were identified as strengths of
framework and theory for transcultural nurs- Kings theory.
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158 S E C T I O N III Conceptual Models/Grand Theories in the Interactive/Integrative Paradigm

Multidisciplinary Applications to research, Fawcett (2008) maintains that


When originally developing the Conceptual nursing theory is evidence. Research and the-
Systems Framework, King (1981) borrowed ory must be examined using rigorous research
from knowledge external to nursing and and theoretical evaluation.
used a systems framework perspective to From an evidence-based practice and
assist in explaining nursing phenomena. King perspective, the profession must
This use of knowledge across disciplines implement three strategies to apply theory-
occurs frequently and can be very appropri- based research findings effectively. First,
ate if both disciplines perspectives are simi- nursing as a discipline must agree on rules of
lar and reformulation occurs. Because of evidence in evaluation of quality research
Kings emphasis on the attainment of goals that reflect the unique contribution of nurs-
and the relevancy of goal attainment to ing to health care. Second, the nursing rules
many disciplines, both within and external of evidence must include heavier weight for
to health care, it is reasonable to expect research that is derived from, or adds to,
that Kings work could find application nursing theory. Third, the nursing rules of
beyond nursing-specific situations. Two evidence must reflect higher scores when
specific examples of this include the appli- nursings central beliefs are affirmed in the
cation of Kings work to case management choice of variables. This third strategy, for
(Hampton, 1994; Sowell & Lowenstein, the use of concepts central to nursing, has
1994) and to managed care (Hampton, clear relevance for evidence-based practice
1994). Both case management and managed when using Kings (1981) concepts as refor-
care incorporate multiple disciplines as they mulated within interventions or outcomes.
work to improve the overall quality and Outcomes, as in Kings concept of goal
cost efficiency of the health care provided. attainment, provide data for evidence-based
These applications also address the continu- practice.
um of care, a priority in todays health-care Currently, safety and quality initiatives in
environment. Specific researchers (Khowaja, organizations, with evidence-based practice as
2006; Fewster-Thuente & Velsor-Friedrich, the innovation, use many concepts initially
2008) detailed their research related to mul- defined by King and found in middle-range
tidisciplinary activities and interdisciplinary theories (Sieloff & Frey, 2007). Kings (1981)
collaborations, respectively. (See http:// work on the concepts of client and nurse per-
davisplus.fadavis.com for Table 10-14.) ceptions, and the achievement of mutual goals
has been assimilated and accepted as core
Relationship to Evidence-Based beliefs of the discipline of nursing. Research
Practice conducted with a King theoretical base is well
A nursing definition of evidence-based prac- positioned for application by nurse caregivers
tice (EBP) is A problem-solving approach to (Durston, 2006), nurse administrators (Sieloff,
clinical practice that integrates a systematic 2007), and client-consumers (Killeen, 2007)
search for and critical appraisal of the most as part of evolving evidence-based nursing
relevant evidence to answer a burning clinical practice. (See http://davisplus.fadavis.com for
question, ones own clinical expertise and Table 10-12.)
patients preferences and values (Melnyk &
Fineout-Overholt, 2005, p. 6). Nursing, as a Recommendations for Future
discipline, has continued to evolve in the use Applications Related to Kings
of scientific evidence. Framework and Theory
Finding and applying relevant evidence Obviously, new nursing knowledge has resulted
requires good clinical judgment (Melnyk & from applications of Kings framework and
Fineout-Overholt, 2005). The validity of the theory. However, nursing, as are all sciences, is
best evidence is important in EBP. In addition evolving. Additional work continues to be
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C H A P T E R 1 0 Imogene Kings Theory of Goal Attainment 159

needed. Based on a review of the applications (4) analyzing the future impact of managed
previously discussed, recommendations for care, continuous quality improvement, and
future applications focus on: (1) the need technology on Kings concepts; (5) identifica-
for evidence-based nursing practice that is tion, or development and implementation, of
theoretically derived; (2) the integration of additional relevant instruments; and (6) clari-
Kings work in evidence-based nursing prac- fication of effective nursing interventions,
tice; (3) the integration of Kings concepts including identification of relevant NICs,
within standardized nursing language (SNLs); based on Kings work.

Practice Exemplar
Application of the Theory of Goal Kings theory, goals. The nursing members are
Attainment to Interdisciplinary familiar with Kings theory and all members
teams, Quality Improvement and value using theory to guide practice. Claires
Evidence-Based Practice proposal is accepted. Claire experienced
Claire Smith RN, BSN is a recent nursing working on EBP group projects as a student
graduate in her first position on a medical so she feels comfortable volunteering to
ICU in a suburban community hospital. develop a draft of the theoretical foundation
Claires manager suggests Claire join the for the project. Two other committee mem-
units interdisciplinary quality improvement bers agree to work on the plan and present it
committee for development of her leadership at the next meeting.
on the unit. The goal of the committee is to These are the questions Claire and her
improve patient care by using the best avail- colleagues discussed and their conclusions.
able evidence to develop and implement
1. How does Kings Theory of Goal Attainment
practice protocols.
help the units QI committee?
At the first meeting, Claire was asked if
she had any burning clinical questions as a Goal attainment theory is derived from
new graduate. She stated that she was taught Kings conceptual system which includes
to avoid use of normal saline for tracheal suc- personal, interpersonal, and social systems.
tioning. However, she noticed many respira- The QI committee is a type of interpersonal
tory therapists and some nurses routinely system. An interpersonal system encompasses
using normal saline with suctioning. When individuals in groups interacting to achieve
asked about this practice, she was told that goals. The QI committee is engaged in the
normal saline was useful to break up secre- committees goal attainment for the benefit of
tions and aid in their removal. The commit- patients. Role expectations and role per-
tee affirmed Claires observation of contra- formance of nurses and clients influence
dictory practices between what is taught and transactions (King, 1981, p. 147). When
what is done in practice. After discussion, the used in interdisciplinary teams, the transac-
group formulated the following clinical ques- tion process in Kings theory facilitates mutual
tion: Does instilling normal saline decrease goal-setting with nurses, and ultimately
favorable patient outcomes among patients with patients, based on each member of the teams
endotracheal tubes or tracheostomies? specific knowledge and functions.
Claire suggests to the committee that Multidisciplinary care conferences, an
Kings Theory of Goal Attainment might be example of a situation where goal-setting
useful as a theoretical guide for this project among professionals occurs, is a label for an
because the normal saline clinical question is indirect nursing intervention within the
focused on patient outcomes, or according to Nursing Interventions Classification (NIC)
Continued
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160 S E C T I O N III Conceptual Models/Grand Theories in the Interactive/Integrative Paradigm

Practice Exemplar cont.


(Dochterman & Bulechek, 2000). Some of can be measured by whether or not the
the activities listed under this NIC reflect patient goals, i.e., outcomes, have been
Kings (1981) concepts: establish mutually attained. The QI Committee engages in goal
agreeable goals; solicit input for client care attainment through communication by set-
planning; revise client care plan, as necessary; ting goals, exploring means and agreeing on
discuss progress toward goals; and provide means to achieve goals. In this example,
data to facilitate evaluation of client care members will gather information, examine
plan (p. 460). data and evidence, interpret the information
and participate in developing a protocol for
2. How does King define goals and goal attain-
patients to achieve quality patient outcomes,
ment and how are these related to quality
that is, goals.
patient outcomes?
3. How does Kings Theory of Goal Attain-
According to Kings Theory of Goal
ment provide a theoretical foundation for
Attainment (1981), goals are mutually agreed
the clinical problem of normal saline with
upon, and through a transaction process, are
suctioning?
attained. Goals are similar to outcomes that
are achieved after agreement on the defini- First, use of Kings theory will help guide
tions and measurement of the outcomes. the literature search to include studies that
Quality improvement has shown agreement address interventions or processes that lead
that evaluation of care must include process to favorable patient outcomes or goals
and outcomes. Outcomes are the results of among patients similar to the population
interventions or processes. The term out- on the unit. Claires subgroup enlisted the
come assumes a process is central to effective help of the hospital librarian in searching
care. Outcome is defined as a change in a the literature using the elements of the clin-
patients health status. Effectiveness of care ical question and the theoretical concepts

Clinical problem Kings


Application to the project
elements concepts

Population: patients Members of the


with endotracheal Clients and nurses Interdisciplinary
tubes or tracheostomies Committee

Transaction Clinical problem


Intervention: normal
process: formulated and relevance
saline with suctioning
Disturbance to unit discussed.

Evidence sought and


examined to select
Outcomes Goals explored
measurable goals/
outcomes.

Explore means to Implementation plan


Outcomes
achieve goals devised.

Agree on means Implementation plan


Outcomes
to achieve goals accepted by members.

Figure 10 3 Theoretical foundation for a quality improvement project using


Imogene Kings Theory of Goal Attainment derived from Kings Conceptual
System (1981).
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C H A P T E R 1 0 Imogene Kings Theory of Goal Attainment 161

as key words. Second, the theoretical formu- Institute, and TRIP databases. All types of
lation of the study helps organize the imple- evidence (nonexperimental, experimental,
mentation and evaluation plans so they are qualitative studies, systematic reviews) were
attainable. included. The evidence was evaluated by the
QI committee and determined that the evi-
4. What key words would you use for the search
dence included physiological and psychologi-
considering the clinical question and Kings
cal effects of instillation of normal saline. The
theory?
collective evidence, relevant to their units
Key words used are: endotracheal tubes, tra- practice problem, supported against the rou-
cheostomies, normal saline, suctioning, outcomes, tine use of normal saline with suctioning
Kings theory of goal attainment, and goal (similar to Halm & Kriski-Hagel, 2008).
attainment. From the evidence, the committee selected
the specific outcomes to track for the project:
5. How does a theoretical foundation, such as
sputum recovery, oxygenation, and subjective
Kings Theory of Goal Attainment, apply to a
symptoms of pain, anxiety, and dyspnea.
quality improvement or EBP project?
Owing to anticipated small samples, hemo-
Claire used these criteria from her nursing dynamic alterations and infections were not
program to develop a theoretical foundation selected as outcomes. The committee devised
for the project. a theory-based implementation plan to dis-
The theoretical foundation for the project continue normal saline for suctioning using
was presented to the committee and accepted the 5 Ws (who, what, where, when, why) and
(Fig. 10-3). how as the outline for the plan. Change
processes were employed in the plan. Evalua-
6. What were the results of the committees
tion of the attainment of outcomes will
work?
address the effectiveness of the plan using the
The search strategy included MEDLINE, measurable outcomes and the degree to
CINAHL, Cochrane Library, Joanna Briggs which they were attained.

Summary
An essential component in the analysis scope because interaction is a part of every
of conceptual frameworks and theories is nursing encounter.
the consideration of their adequacy (Ellis, Although evaluation of the scope of Kings
1968). Adequacy depends on the three framework and mid-range theory has result-
interrelated characteristics of scope, useful- ed in mixed reviews (Austin & Champion,
ness, and complexity. Conceptual frameworks 1983; Carter & Dufour, 1994; Frey, 1996;
are broad in scope and are sufficiently Jonas, 1987; Meleis, 1985), the nursing pro-
complex to be useful for many situations. fession has clearly recognized their scope and
Theories, on the other hand, are narrower in usefulness. In addition, the variety of practice
scope, usually addressing less abstract con- applications evident in the literature clearly
cepts, and are more specific in terms of the attests to the complexity of Kings work. As
nature and direction of relationships and researchers continue to integrate Kings theory
focus. and framework with the dynamic health-care
King fully intended her conceptual system environment, future applications involving
for nursing to be useful in all nursing situa- evidence-based practice will continue to
tions. Likewise, the mid-range Theory of demonstrate the adequacy of Kings work in
Goal Attainment (King, 1981) has broad nursing practice.
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162 S E C T I O N III Conceptual Models/Grand Theories in the Interactive/Integrative Paradigm

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Revista Brasileira de Enfermagem, 56(5), 528532. Jewell, D. A. (2007). Perceptions of dyspnea, physical
Gonot, P. J. (1986). Family therapy as derived from activity, and functional status in obese women.
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Norwalk, CT: Appleton-Century-Crofts. classification (NOC). St. Louis, MO: Mosby-Year
Gorski, M. S., & Hackbarth, D. (2005). Quality of care Book.
in nursing homes. Online Journal of Clinical Innova- Jonas, C. M. (1987). Kings goal attainment theory:
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Goyat, S., Rossi, L., & Dalri, M. (2006, JanFeb). Journal of the Gerontological Nursing Association,
Nursing diagnoses for family members of adult 11(4), 912.
burned patients near hospital discharge [Portuguese]. Jones, A., & Bugge, C. (2006, September). Improving
Revista Latino-Americana de Enfermagem, 14(1), understanding and rigour through triangulation: an
102109. Retrieved August 22, 2008, from exemplar based on patient participation in interac-
CINAHL with Full Text database. tion. Journal of Advanced Nursing, 55(5), 612-621.
Gulitz, E. A., & King, I. M. (1988). Kings general Retrieved August 22, 2008, from CINAHL with
systems model: Application to curriculum develop- Full Text database.
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Halm, M. A., & Kriski-Hagel, K. (2008). Instilling Changing behaviors: Nurse educators and clinical
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program. Journal of Nursing Staff Development, 11(6), King, I. M. (1989b). Kings systems framework for nurs-
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Kameoka, T. (1995). Analyzing nurse-patient interac- of nursing administration: Theory, research, education
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Advancing Kings systems framework and theory of goal King, I. M. (1990). Health as a goal for nursing. Nursing
attainment (pp. 251260). Thousand Oaks, CA: Science Quarterly, 3, 123128.
Sage. King, I. M. (1992). Kings theory of goal attainment.
Kameoka, T., Funashima, N., & Sugimori, M. (2007). Nursing Science Quarterly, 5, 19.
If goals are attained, satisfaction will occur in nurse- King, I. M. (1995). The theory of goal attainment. In:
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Sieloff & M. A. Frey (Eds.), Middle Range Theory systems framework and theory of goal attainment
Development Using Kings Conceptual System (p. 23). Thousand Oaks, CA: Sage.
(pp. 261-272). New York: Springer. King, I. M. (1996). The theory of goal attainment in
Kemppainen, J. K. (1990). Imogene Kings theory: research and practice. Nursing Science Quarterly,
A nursing case study of a psychotic client with 9, 61.
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Khowaja, D. (2006). Utilization of Kings interacting Kobayashi, F. T. (1970). A conceptual frame of reference
systems framework and theory of goal attainment for nursing. Japanese Journal of Nursing Research,
with new multidisciplinary model: Clinical path- 3(3), 199204.
way. Australian Journal of Advanced Nursing, 24(2), Kohler, P. (1988). Model of shared control. Journal of
4450. Gerontological Nursing, 14(7), 2125.
Killeen, M. B. (2007). Development and initial testing Laben, J. K., Dodd, D., & Sneed, L. (1991). Kings
of a theory of patient satisfaction with nursing care. theory of goal attainment applied in group therapy
In: C. L. Sieloff & M. A. Frey (Eds.), Middle range for inpatient juvenile offenders, maximum security
theory development using Kings conceptual system state offenders, and community parolees, using
(pp. 138163). New York: Springer. visual aids. Issues in Mental Health Nursing, 12(1),
King, I. M. (1964). Nursing theory: Problems and 5164.
prospect. Nursing Science Quarterly, 2, 294. Laben, J. K., Sneed, L. D., & Seidel, S. L. (1995). Goal
King, I. M. (1968). A conceptual frame of reference for attainment in short-term group psychotherapy set-
nursing. Nursing Research, 17, 2731. tings: Clinical implications for practice. In: M. A.
King, I. M. (1971). Toward a theory for nursing: General Frey & C. L. Sieloff (Eds.), Advancing Kings systems
concepts of human behavior. New York: John Wiley & framework and theory of nursing (pp. 261277).
Sons. Thousand Oaks, CA: Sage.
King, I. M. (1975). A process for developing concepts Martin, J. P. (1990). Male cancer awareness: Impact of
for nursing through research. In P. J. Verhonick an employee education program. Oncology Nursing
(Ed.), Nursing research (p. 25). Boston: Little, Brown. Forum, 17, 5964.
King, I. M. (1976). Toward a theory of nursing: General May, B. A. (2007). Relationships among basic empathy,
concepts of human behavior (Sugimori, M., trans.). self-awareness, and learning styles of baccalaureate
Tokyo: Igaku-Shoin. prenursing students within Kings personal system.
King, I. M. (1981). A theory of goal attainment: Systems, In: C. L. Sieloff & M. A. Frey (eds). Middle range
concepts, process. New York: John Wiley & Sons. theory development using Kings conceptual system
King, I. M. (1984). Effectiveness of nursing care: Use (pp. 164177). New York: Springer.
of a goal oriented nursing record in end stage renal McFarland, G. K., & McFarland, E. A. (1997). Nursing
disease. American Association of Nephrology Nurses diagnosis and intervention: Planning for patient care.
and Technicians Journal, 11(2), 1117, 60. St. Louis, MO: Mosby-Year Book.
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concepts, process (Sugimori, M., trans.). Tokyo: progress (2nd ed.). Philadelphia: J. B. Lippincott.
Igaku-Shoin. Melnyk, B. M., & Fineout-Overholt, E. (2005). Evi-
King, I. M. (1986). Curriculum and instruction in nurs- dence-based practice in nursing and healthcare: A guide
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Century-Crofts. Wilkins.
King, I. M. (1988). Concepts: Essential elements of Messmer, P. R. (1992). Implementing theory based
theories. Nursing Science Quarterly, 1(1), 2224. nursing practice. Florida Nurse, 40(3), 8.
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Messmer, P. R. (2007). Tribute to the theorists: Imogene Frey (Eds.), Middle range theory development using
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20(3), 198. Springer.
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(pp. 178195). New York: Springer. establish psychotic patients awareness of illness
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context of chronic obstructive pulmonary disease. In: Zurakowski, T. L. (2007). Theory of social and interper-
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Chapter
11
Sister Callista Roys
Adaptation Model
C ALLISTA R OY AND LIN Z HAN

Introducing the Theorist Introducing the Theorist


Overview of the Roy Adaptation Model Sister Callista Roy is a highly respected nurse
Model Concepts theorist, writer, lecturer, researcher, teacher,
Practice Applications and member of a religious community. She
Theoretical Basis for Practice Exemplar currently holds the position of professor and
Practice Exemplar nurse theorist at Boston College Connell
Summary School of Nursing. Roys name is one of the
References most recognized in the field of nursing today
worldwide. She is considered among nursings
great living thinkers. However, she notes that
her best work is yet to come and will likely be
done by one of her students. As a theorist,
Roy often emphasizes her primary commit-
ment to define and develop nursing knowl-
edge. She regards her work with the Roy
Adaptation Model as a rich source of knowl-
edge for improving nursing practice for indi-
viduals and groups. In the first decade of the
Sister Callista Roy
21st century, Roy has provided an expanded,
values-based concept of adaptation based on
insights related to the place of the person in
the universe and in society. She hopes these
developments: the redefinition of adaptation;
enhanced philosophical, scientific and cultural
assumptions; theoretical understanding of life
processes of the adaptive modes; and process-
es described for individuals and for groups,
will become the basis for developing knowl-
edge that will make nursing a major social
force in this century.
In her personal and professional growth,
Roy credits the major influences of her family,
her religious commitment, and her teachers
and mentors. Roy was born in Los Angeles,
California, on October 14, 1939. Her middle
name, Callista, came from St. Callistus, the
saint of the day from the Roman Catholic cal-
endar. She is the oldest daughter of a family of
seven boys and seven girls. A deep spirit of

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faith, hope, love, commitment to God, and interest of advancing nursing practice by
service to others was central in the family. Her developing basic and clinical nursing knowl-
mother was a licensed vocational nurse and edge based on the Roy Adaptation Model.
instilled the values of always seeking to know This group later became the Roy Adaptation
more about people, as well as their care, and Association. The executive committee contin-
of selfless giving as a nurse. Roy noted that ues the work of synthesizing research based
she also had excellent teachers in parochial on the model and other projects in research,
schools, high school, and college. At age 14 education, and practice. The research publica-
she began working at a large general hospital, tions in English now identified number more
first as a pantry girl, then as a maid, and finally than 350.
as a nurses aide. After a soul-searching One of Roys major activities has been
process of discernment, she entered the Sis- planning New England Knowledge Confer-
ters of Saint Joseph of Carondelet, of which ences from 1996 to 2001 and a collaborative
she has been a member for 50 years. Her col- nursing knowledge conference with the Inter-
lege education began with a bachelor of arts national Philosophy of Nursing Society in
degree with a major in nursing at Mount 2008. Roy has been a major speaker through-
St. Marys College, Los Angeles, followed out North America and 31 other countries
by masters degrees in pediatric nursing and over the past 40 years on topics related to
sociology at the University of California, Los nursing theory, research, curriculum, clinical
Angeles, and a Ph.D. in sociology at the same practice, and professional trends for the future.
school. Later, Roy had the opportunity to She was a Senior Fulbright Scholar in
be a clinical nurse scholar in a 2-year postdoc- Australia and her visiting faculty appoint-
toral program in neuroscience nursing at the ments include La Sabana University, Colombia;
University of California at San Francisco. Autonomous University in Nuevo Leon,
Important mentors in her life have included Mexico; St. Marys College, Fukuoka, Japan;
Dorothy E. Johnson, Ruth Wu, Connie University of Lund, Sweden; and University
Robinson, and Barbara Smith Moran. of Conception, Chile as well as invited scholar
Roy is best known for developing and of the Ministry of University Affairs, Bangkok,
continually updating the Roy Adaptation Thailand for educators from 19 schools. Roy
Model as a framework for theory, practice, served on the Board of the International
and research in nursing. Books on the model Network for Doctoral Education from 2003
have been translated into many languages, to 2006 and is Faculty Senior Nurse Scientist
including French, Italian, Spanish, Finnish, at the Yvonne L. Munn Center for Nursing
Chinese, Korean, and Japanese. Two recent Research at Massachusetts General Hospital.
publications that Roy considers significant are She was a Charter Member of the Nursing
The Roy Adaptation Model (2009) and Nursing Research Study Section, Division of Research
Knowledge Development and Clinical Practice Grants, National Institutes of Health and
(with D. Jones, 2007). Another important has received 42 research and training grants
work is The Roy Adaptation Model-based covering a wide range of topics including
Research: Twenty-five Years of Contributions neuroscience.
to Nursing Science, published as a research Roy was honored as a Living Legend by
monograph by Sigma Theta Tau. The latter is both the American Academy of Nursing and
a critical analysis of the 25 years of model- the Massachusetts Association of Registered
based literature, which includes 163 studies Nurses. She has received many other awards,
published in 46 English-speaking journals, including the National League for Nursing
and dissertations and theses. This project was Martha Rogers Award for advancing nursing
completed by the Boston-Based Adaptation science; the Sigma Theta Tau International
Research in Nursing Society (BBARNS), a Founders Award for contributions to profes-
group of scholars founded by Roy in the sional practice; and honorary doctorates from
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C H A P T E R 1 1 Sister Callista Roys Adaptation Model 169

Eastern Michigan University, Alverno College mode is described in greater detail as back-
in Milwaukee, St. Josephs College in Standish, ground for a specific exemplar that describes
Maine, and St. Anselms College in Manchester, nursing care for a Chinese family dealing with
New Hampshire. Roy holds several teaching a parent diagnosed with dementia.
awards, two institution-wide from Mount
St. Marys College in Los Angeles and Boston Historical Development
College. She has received Massachusetts State Under the mentorship of Dorothy E. Johnson,
House recognition for her volunteer work Roy first developed a description of the adap-
with women in prison. Roy has also received tation model while a masters nursing student
the outstanding Alumna Award and Caron- at the University of California at Los Angeles.
delet Medal from Mount St. Marys, where The first publication on the Model appeared
she holds a concurrent position as research in 1970 (Roy, 1970) while Roy was on the
professor in nursing at her alma mater. faculty of the baccalaureate nursing program
The Roy Adaptation Model has been in of a small liberal arts college. There, she had
use for 40 years, providing direction for nurs- the opportunity to lead the implementation of
ing practice, education, and research. Exten- this model of nursing as the basis of the nurs-
sive implementation efforts around the world, ing curriculum. During the next decade, more
and continuing philosophical and scientific than 1500 faculty and students at Mount
developments by the theorist, have con- St. Marys College helped to clarify, refine,
tributed to model-based knowledge for nurs- and develop this approach to nursing. The
ing practice. The purpose of this chapter is to constant influence of practice was important
describe the model as the foundation for a during this development. One example of
knowledge-based practice. The developments data from practice used in model develop-
of the model, including assumptions and ment was to derive four adaptive modes from
major concepts are described. The reader is 500 samples of patient behavior described by
introduced to the knowledge that the model nursing students. At a conference held at
provides as the basis for planning nursing Mount St. Marys College in 1981, an evalu-
care. We provide an overview of applications ation noted that the model met the criteria of
in practice and a practice exemplar that views significance, usefulness, and completeness.
a family through the lens of one adaptive The mid-1970s to the mid-1980s saw the
mode, the group identify mode. expansion of the use of the model in nursing
education. Roy and the faculty at her home
institution consulted on curriculum in more
Overview of the Roy than 30 schools. By 1987 it was estimated
Adaptation Model that more than 100,000 students had gradu-
The Roy Adaptation Model (Roy, 1970, ated from curricula based on the Roy model.
1984, 1988a, 1988b, 2009; Roy & Andrews, Theory development was also a focus during
1991, 1999; Roy & Roberts, 1981) provides a this time, and 91 propositions based on the
framework for nursing practice with individu- model were identified. These described rela-
als and groups as well as for designing nursing tionships between and among the regulator
care systems in health care organizations. and cognator and the four adaptive modes
The model can be understood by looking at (Roy & Roberts, 1981). In the 1980s, Roy
the historical development, assumptions, and also was influenced by postdoctoral work in
major concepts. These elements provide the neuroscience nursing and an increasing num-
basis for showing how the model provides ber of commitments in other countries. Dur-
both theoretical knowledge and guidance for ing the 1990s, as a faculty member and
the process of nursing care. Organizational nurse-theorist at Boston College, Roy found
applications of the model in practice are that working with PhD students challenged
described. Finally, the self-identity adaptive and deepened her thinking. She focused on
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170 S E C T I O N III Conceptual Models/Grand Theories in the Interactive/Integrative Paradigm

contemporary movements in nursing knowl- being one. Veritivity is the principle of human
edge and the continued integration of spiri- nature that affirms a common purposefulness
tuality with an understanding of nursings of human existence, within the Roy Adapta-
role in promoting adaptation. The first tion Model. Veritivity affirms people in society
decade of the 21st century included a greater viewed in the context of the purposefulness
focus on philosophy, knowledge for practice, of human existence, unity of purpose of
and global concerns. humankind, activity and creativity for the
common good, and the value and meaning
Philosophical, Scientific, and Cultural of life.
Assumptions Currently, Roy views the 21st century as a
Assumptions provide the beliefs, values, and time of transition, transformation, and need
accepted knowledge that form the basis for for spiritual vision. The further development
the work. For the Roy Adaptation Model, the of the philosophic assumptions focuses on
concept of adaptation rests on scientific and peoples mutuality with others, the world, and
philosophic assumptions that Roy has devel- a God-figure. The development and expan-
oped over time. The scientific assumptions sion of the major concepts of the model show
initially reflected von Bertalanffys (1968) the influence of the theorists scientific and
general systems theory and Helsons (1964) philosophic background and global experi-
adaptation-level theory. Later beliefs about ences. For nursing in the 21st century, Roy
the unity and meaningfulness of the created (1997) provided a redefinition of adaptation
universe were included (Young, 1986). Early and a restatement of the assumptions that are
identification of the philosophic assumptions the foundations of the model, which led
for the model named humanism and veritivity. expanded philosophical and scientific assump-
In 1988, Roy introduced the concept of veri- tions in contemporary society and to adding
tivity as an option to total relativity. Veritivity cultural assumptions. These assumptions are
was a term coined by Roy, based on the Latin listed in Table 11-1 and further described in
word veritas. For Roy, the word offered the the basic work on the model (Roy, 2009). Roy
notion of the rootedness of all knowledge also uses the idea of cosmic unity that stresses

Table 11 1 Assumptions of the Roy Adaptation Model for the 21st Century
Philosophic Assumptions
Persons have mutual relationships with the world and the God-gure.
Human meaning is rooted in an omega point convergence of the universe.
God is intimately revealed in the diversity of creation and is the common destiny of creation.
Persons use human creative abilities of awareness, enlightenment, and faith.
Persons are accountable for entering the process of deriving, sustaining, and transforming the
universe.
Scientic Assumptions
Systems of matter and energy progress to higher levels of complex self organization.
Consciousness and meaning are consistent of person and environment integration.
Awareness of self and environment is rooted in thinking and feeling.
Human decisions are accountable for the integration of creative processes.
Thinking and feeling mediate human action.
System relationships include acceptance, protection, and fostering interdependence.
Persons and the Earth have common patterns and integral relations.
Person and environment transformations created human consciousness.
Integration of human and environment meanings result in adaptation.
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Table 11 1 Assumptions of the Roy Adaptation Model for the 21st Centurycontd
Cultural Assumptions
Experiences within a specic culture will inuence how each element of the RAM model is
expressed.
Within a culture, there may be a concept that is central to the culture and will inuence some
or all of the elements of the RAM to a greater or lesser extent.
Cultural expressions of the elements of the RAM may lead to changes in practice activities such
as nursing assessment.
As RAM elements evolve within a cultural perspective, implications for education and research
may differ from experience in the original culture.

her vision for the future and emphasizes the him or her to escape harm. The cognator sub-
principle that people and Earth have common system involves the cognitive and emotional
patterns and integral relationships. Rather processes that interact with the environment.
than the system acting to maintain itself, the In the example of the individual who escapes
emphasis shifts to the purposefulness of human from an oncoming car, the cognator acts to
existence in a creative universe. process the emotion of fear. The person also
processes perceptions of the situation and
comes to a new decision about where and how
Model Concepts to cross the street safely.
The underlying assumptions of the Roy The coping processes for the group relate
Adaptation Model are the basis for and are to stability and change. The stabilizer subsys-
evident in the specific description of the tem has structures, values, and daily activities
major concepts of the model. The major con- to accomplish the primary purpose of the
cepts include people as adaptive systems (both group. Thus a family group is structured to
individuals and groups), the environment, earn a living and to provide for the nurturance
health, and the goal of nursing. and education of children. Family values also
influence how the members respond to the
People as Adaptive Systems environment to fulfill their responsibilities to
Roy describes people, both individually, and maintain the family. Groups also have process-
in groups, as holistic adaptive systems, com- es to respond to the environment with innova-
plete with coping processes acting to maintain tion and change by way of the innovator
adaptation and to promote person and envi- subsystem. For example, organizations use
ronment transformations. As with any type of strategic planning activities and team building
system, people have internal processes that act sessions. When the innovator is functioning
to maintain the integrity of the individual or well, the group creates new goals and growth,
group. These processes have been broadly cat- achieving new mastery. Nurses can use innova-
egorized as a regulator subsystem and a cog- tor subsystems to create organizational change
nator subsystem for the person and stabilizer in practice.
and innovator for the group. The regulator Both the cognator-regulator and stabilizer-
uses physiologic processes such as chemical, innovator coping processes are manifested in
neurologic, and endocrine responses to cope four particular ways in each individual and
with the changing environment. For example, in groups of people. These four ways of cate-
when an individual sees a sudden threat, such gorizing the effects of coping activity are
as an oncoming car approaching when step- called adaptive modes. These four modes,
ping off the curb, an increase of adrenal hor- initially developed for human systems as indi-
mones provides immediate energy enabling viduals, were expanded to encompass groups.
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These are termed the physiologicphysical, position. The basic need underlying the role
self-conceptgroup identity, role function, function mode for the individual has been
and interdependence modes. These four major identified as social integrity, the need to know
categories describe responses to and interac- who one is in relation to others in order to act.
tion with the environment and are how adap- The underlying processes include developing
tation can be observed. roles and role taking.
For individuals, the physiologic mode in Behavior related to interdependent rela-
the Roy Adaptation Model is associated with tionships of individuals and groups is the
the way people as individuals interact as phys- interdependence mode, the final adaptive
ical beings with the environment. Behavior in mode Roy describes. For the individual, the
this mode is the manifestation of the physio- mode focuses on interactions related to the
logic activities of all the cells, tissues, organs, giving and receiving of love, respect, and
and systems comprising the human body. The value. The basic need of this mode is termed
physiologic mode has nine components: the relational integrity, the feeling of security
five basic needs of oxygenation, nutrition, in nurturing relationships. Two specific
elimination, activity and rest, and protection relationships are the focus within the inter-
and four complex processes that are involved dependence mode for the individual: signif-
in physiologic adaptation, including the senses; icant others, persons who are the most
fluid, electrolyte, and acidbase balance; neu- important to the individual, and support
rologic function; and endocrine function. The systems, others contributing to meeting inter-
underlying need for the physiologic mode is dependence needs. Interdependence process-
physiologic integrity. es include affectional adequacy and develop-
The category of behavior related to the mental adequacy.
personal aspects of individuals is termed the For people in groups it is more appropri-
self-concept.The basic need underlying the self- ate to use the term physical in referring to
concept mode has been identified as psychic the first adaptive mode. At the group level,
and spiritual integrity; one needs to know this mode relates to the manner in which the
who one is in order to be or exist with a sense human adaptive system of the group mani-
of unity. Self-concept is defined as the com- fests adaptation relative to basic operating
posite of beliefs and feelings that a person resources, that is, participants, physical facil-
holds about him- or herself at a given time. ities, and fiscal resources. The basic need
Formed from internal perceptions and per- associated with the physical mode for the
ceptions of others, self-concept directs ones group is resource adequacy, or wholeness
behavior. Components of the self-concept achieved by adapting to change in physical
mode are the physical self, including body resource needs. Processes in this mode for
sensation and body image; and the personal groups include resource management and
self, including self-consistency, self-ideal, and strategic planning.
moralethicalspiritual self. Processes in the Group identity is the relevant term used
mode are the developing self, perceiving self, for the second mode related to groups. Iden-
and focusing self. tity integrity is the need underlying this group
Behavior relating to positions in society is adaptive mode. The mode comprises interper-
termed the role function mode for both the sonal relationships, group self-image, social
individual and the group. From the perspec- milieu, and culture.
tive of the individual, the role function mode A nurse can have a self-concept of seeing
focuses on the roles that the individual occu- self as physically capable of the work involved.
pies in society. A role, as the functioning unit In addition, the nurse feels comfortable
of society, is defined as a set of expectations meeting self expectations of being a caring
about how a person occupying one position professional. In a social system, such as a
behaves toward a person occupying another nursing care unit, an associated culture can be
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described. There is a social environment modes further demonstrate the holistic nature
experienced by the nurses, administrators, of humans as adaptive systems. The adaptive
and other staff that is reflected by those who modes and coping processes for individuals
are part of the nursing care group. The group and groups of individuals are described by
feels shared values and counts on each other. the Roy model (Roy, 2009). One example is
As such, the self-conceptgroup identity described in this chapter as the basis for prac-
mode can reflect adaptive or ineffective tice, the group identity mode.
behaviors associated with an individual nurse
or the nursing care unit as an adaptive sys- Environment
tem. As we note below, two processes identi- The Roy model defines environment as all
fied in this mode are group shared identity the conditions, circumstances, and influences
and family coherence. surrounding and affecting the development
Roles within a group are the vehicle and behavior of individuals and groups.
through which the goals of the social system Given the models view of the place of the
are actually accomplished. They are the action person in the evolving universe, environment
components associated with group infrastruc- is a biophysical community of beings with
ture. Roles are designed to contribute to the complex patterns of interaction, feedback,
accomplishment of the groups mission, or the growth and decline, constituting periodic
tasks or functions associated with the group. and long-term rhythms. Individual and envi-
The role mode includes the functions of ronmental interactions are input for the
administrators and staff, the management of individual or group as adaptive systems. This
information, and systems for decision making input involves both internal and external fac-
and maintaining order. The basic need associ- tors. Roy used the work of Helson (1964), a
ated with the group role function mode is physiologic psychologist, to categorize these
termed role clarity, the need to understand factors as focal, contextual, and residual
and commit to fulfill expected tasks, in order stimuli. A specific internal input stimulus is
to achieve common goals. Processes involve an adaptation level that represents the indi-
socializing for role expectations, reciprocating viduals or groups coping capacities. This
roles, and integrating roles. changing level of ability has an internal
For groups, the interdependence mode per- effect on adaptive behaviors. Roy defined
tains to the social context in which the group three levels of adaptation: integrated, com-
operates. It involves private and public contacts pensatory, and compromised. Integrated adap-
both within the group and with those outside tation occurs when the structures and func-
the group. The components of group interde- tions of the adaptive modes are working as a
pendence include context, infrastructure, and whole to meet human needs. The compensa-
resources. The processes for group interde- tory adaptation level occurs when the cogna-
pendence include relational integrity, develop- tor and regulator or stabilizer and innovator
mental adequacy, and resource adequacy. are activated by a challenge. Compromised
The four adaptive modes are interdepend- adaptation occurs when integrated and com-
ent, which can be illustrated by drawing the pensatory processes are inadequate, creating
modes as overlapping circles. The physiologic an adaptation problem.
physical mode is intersected by each of the
other three modes. Behavior in the physiologic Health
physical mode can have an effect on or act as Roys concept of health is related to the con-
a stimulus for one or all of the other modes. In cept of adaptation and the idea that adaptive
addition, a given stimulus can affect more responses promote integrity. Individuals and
than one mode, or a particular behavior can groups are viewed as adaptive systems that
be indicative of adaptation in more than one interact with the environment and grow,
mode. Such complex relationships among change, develop, and flourish. Health is the
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reflection of personal and environmental compensation for inadequate oxygenation.


interactions that are adaptive. According Similarly, the self-concept mode has three
to the Roy Adaptation model, health is processes identified to meet the persons need
defined as (1) a process, (2) a state of being, for psychic and spiritual integrity: the devel-
and (3) becoming whole and integrated in a oping self, the perceiving self, and the focus-
way that reflects individual and environment ing self. On the group level, two examples of
mutuality. processes identified to meet the need for a
shared self image are group shared identity
Goal of Nursing and family coherence.
When Roy began her theoretical work, the To develop knowledge for practice from
goal of nursing was the first major concept of the grand theory, Roy described a five-step
her nursing model to be described. She began process for developing middle or practice level
by attempting to identify the unique function theory and nursing knowledge:
of nursing in promoting health. As a number
1. Select a life process.
of health care workers have the goal of pro-
2. Study the life process in the literature and
moting health, it seemed important to identify
in people.
a unique goal for nursing. While she was
3. Develop an intervention strategy to
working as a staff nurse in pediatric settings,
enhance the life process.
Roy noted the great resiliency of children in
4. Derive a proposition for practice.
responding to major physiologic and psycho-
5. Test the proposition in research.
logical changes. Yet nursing intervention was
needed to support and promote this positive Processes can also be identified by using
coping. It seemed then that the concept of qualitative research to identify and describe
adaptation, or positive coping, might be used human experiences.
to describe the goal or function of nursing. The nursing process based on the model
From this initial notion, Roy developed a stems from the assumptions and concepts of
description of the goal of nursing: the promo- the model. First-level assessment of behavior
tion of adaptation for individuals and groups involves gathering data about the behavior of
in each of the four adaptive modes, thus con- the person or group as an adaptive system in
tributing to health, quality of life, and dying each of the adaptive modes. Second-level
with dignity. assessment is the assessment of stimuli, that
is, the identification of internal and external
stimuli that influence the persons adaptive
Practice Applications behaviors. Stimuli are classified as focal, con-
The assumptions and concepts of the model textual, and residual. Focal refers to those fac-
provide the basis for theory building for nurs- tors most immediately confronting the per-
ing practice, as well as a specific approach to son, contextual are all other stimuli affecting
the nursing process. As early as the 1970s, the situation, and residual stimuli are those
human life processes and patterns were iden- whose effect on the situation are unclear. The
tified as the common focus of nursing knowl- nurse uses the first- and second-level assess-
edge (Donaldson & Crowley, 1978). Adapta- ment to make a nursing judgment called a
tion is a significant life process that leads nursing diagnosis. In collaboration with the
to health. To lead to middle range theories person or group, the data are interpreted in
within the model, Roy identified the major statements about the adaptation status of the
life processes within each adaptive mode. person, including behavior and most relevant
For example, in the physiological mode there stimuli. The adaptation level is then classified
are processes and patterns for the need as integrated, compensatory, or compromised.
for oxygenation that include ventilation, pat- Also, in collaboration with the person or
terns of gas exchange, transport of gases, and group, the nurse sets goals, establishing clear
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statements of the behavioral outcomes for Theoretical Basis for Practice


nursing care. Interventions then involve the
determination of how best to assist the person
Exemplar
in attaining the established goals. These may Within a general understanding of the Roy
involve changing stimuli or strengthening Adaptation Model for practice, a specific
coping ability. The aim is to promote an inte- practice exemplar is presented. As theoretical
grated adaptation level. Evaluation involves background for discussion of this exemplar,
judging the effectiveness of the nursing inter- the group identity mode is discussed in
vention in relation to the resulting behavior in greater detail. It reflects how people in groups
comparison with the goal established. The perceive themselves based on environmental
steps of the nursing process have been given feedback about the group. Persons in a group
in sequential order; however, the process is have perceptions about their shared relations,
ongoing and the steps can be simultaneous. goals, and values. The social milieu and
For example, the nurse may be intervening in the culture provide feedback for the group.
one adaptive mode and assessing in another at Milieu is another word for environment,
the same time. while social relates to human societies,
Senesac (2003) reviewed published proj- therefore social milieu refers to the human-
ects that have implemented the Roy Adapta- made environment of the group in which
tion Model in institutional practice settings the group is embedded. The economic, polit-
and identified seven distinct projects ranging ical, religious, family, and other structures are
from an ideology basis for a single unit to included. Each structure has established
hospital-wide projects. In some cases the pub- beliefs. Social culture is a specific part of
lished project developed from a unit imple- the milieu or environment of the group. Eth-
mentation to a full agency implementation, as nicity and socioeconomic status in particular
in one of the early projects reported by make up the social culture. The belief systems
Mastal, Hammond, and Roberts (1982). of the milieu and social culture are particular-
Gray (1991) discussed involvement in five ly significant for a group. They act as stimuli
projects. She reported that not all implemen- for the group, which affects other groups with
tation projects were completed due to changes which the group interacts. The group self-
in hospital management, philosophy, or direc- image and shared responsibility for goal
tion. Grays initial work was at a 132- achievement is central to group identity. Iden-
bed acute care, not-for-profit childrens hospi- tity integrity is the basic need underlying
tal. Other projects varied from a 100-bed the group identity mode. Identity integrity
proprietary hospital to a 248-bed nonprofit, implies the honesty, soundness, and com-
community-owned hospital. The main focus pleteness of the group members identification
of the implementation projects was to improve with the group at large. As noted, according
patient care through quality nursing care to the Roy Adaptation Model, groups have
plans and in some cases to develop perform- basic life processes in each adaptive mode.
ance standards. Two implementation projects Nursing care uses the understanding of these
in Colombia were reported on by Moreno processes to evaluate the adaptation level and
(2007). One project was in an ambulatory to provide care to promote integrated process-
rehabilitation service (Moreno, 2001) and the es at the highest level of adaptation possible.
other a pediatric intensive care unit of a cardi- There may be many basic processes for the
ology institute (Monroy et al., 2003). As shared identity mode. As examples, two
hospitals in the United States work toward processes have been identified and developed
certification of Magnet Status, more nursing to date: the groups shared identity process
groups are requesting information about and family coherence. A significant consider-
application of the Roy Adaptation Model in ation is the family, which most often is the
institutional health care settings. first group with which a person identifies.
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Practice Exemplar
Family coherence is an indicator of positive denotes the respect and obedience that a
adaptation and refers to a state of unity or a child, primarily a son, should show to his par-
consistent sequence of thought that connects ents, especially to his father. David, along
family members who share group identity, with his family, visits his parents regularly
goals, and values (Roy, 2009). This section and, if needed, helps with their house chores.
presents an exemplar case about family coher- Davids parents were happy that they were
ence involving a Chinese American family able to keep the family together, see their son
(Zhan, 2003). graduate from college, marry, and work a
decent job. At Chinese New Year, all the
Introduction to the Practice Wang family membersFrank Wang, Lisa
Exemplar: The Wang Family Wang, Davids parents, and his wife and
The Wang family includes David Wang, his daughterget together to celebrate. The
wife Teresa, and their 7-year-old daughter, Wang family visit and help each other regu-
Vivian. When David moved to a metropoli- larly throughout the year. Family coherence
tan area of the United States with his par- exists as evidenced by shared group identity,
ents at the age of 10, his father was 38 and values, relations, and goals of building a good
his mother 35. On their arrival, the parents life in the United States.
worked in a local Chinese restaurant. Ten At the age of 78, Davids father suffered a
years later, they opened a small Chinese stroke and later died. Davids mother, age 75,
restaurant in the citys Chinatown. Davids began to show decline in memory by often
father retired at the age of 75, and David repeating herself, being unable to find her
continued managing the restaurant. After way in familiar places, misplacing objects in
retirement, Davids parents regularly partici- the house, and becoming easily irritated. Sev-
pated in activities organized by Chinatowns eral times, she burned cooking pots and
Council on Aging. They are currently 78 began to confuse the time of day. David
(father) and 75 (mother) years old. thought his mothers loss of memory was
Davids extended family includes his a sign of aging. As her condition grew worse,
uncle, Frank Wang, and his cousin, Lisa David finally took his mother for a physical
Wang, a 32-year-old social worker in a com- examination. She was diagnosed with demen-
munity hospital, Lisas husband, and their tia and referred to a specialist for further
5-year old son. As David grew up in the fam- evaluation that confirmed her diagnosis. David
ily with his parents, they had a shared self- recognized that his mother was unable to live
image as Chinese immigrants, and a shared independently and sold his parents condo-
group identity as the Wang family. The Wang minium. He arranged for his mother to come
family shares a strong cultural commitment to live with his family in their three-bedroom
to filial piety as a virtue to be cultivated. To house where David and his wife could care
the family members, this means to be good for her. Lisa Wang, Davids cousin, visited
to ones parents; to take care of ones parents; them regularly on weekends and helped with
to engage in good conduct not just toward the house chores. David was glad that he was able
parents, but also outside the home in order to to keep the family together despite the pass-
bring a good name to ones parents and ing of his father and cognitive impairment
ancestors; to perform the duties of ones job of his mother. David and his wife took on
well in order to obtain the material means to the family caregiver role while trying to keep
support the parents; offer sacrifices to the their respective jobs.
ancestors; and to show love, respect, and sup- As Davids mothers cognitive function
port. The term filial, meaning of a child, deteriorated, David was virtually overwhelmed
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by caring for his mother while keeping his living arrangement and space allocation for
responsibility of managing the restaurant. As family members; and division of family
he was the one who provided primary finan- caregiving responsibilities. The nurse assesses
cial support for his family, his wife had to quit how decisions are made in the family,
a full-time job as an administrative assistant from small daily decisions to larger, health
to attend to her mother-in-laws care when carerelated decisions. The nurse observes
David was not available. When David and his that David and his wife show love, respect,
wife tried to find someone in the Chinese and loyalty to Davids mother and to each
community who could provide respite care to other. Although the mothers needs for care
their mother, they heard some strong negative are met, individual needs of both David and
reactions. Some considered his mothers his wife Teresa are unmet. As they alternate
dementia as insanity or a mental disorder; care for their ill mother, they find it quite
some talked about dementia as contagious; challenging to maintain their own jobs
some noted his mothers dementia being and attend to their daughter, Vivians, ele-
caused by a bad Feng Shui.1 The perception of mentary schoolwork and her growth needs.
dementia triggered a strong negative response An increase in demand for care of Davids
from the Chinese community, and as a result, mother lessens the time the parents have for
his mothers friends stopped visiting her. One their daughter. They struggle to find alterna-
day David received a phone call from his tives for family caregiving responsibilities and
daughters elementary school. The teacher both feel stressed from time to time. The
told David that his daughter Vivian did not nurse discovers that the Wang family holds a
come to the school twice last week and her strong Chinese tradition of filial piety, and
grades were declining. Both David and his they feel a moral obligation to take care of
wife Teresa were feeling overwhelmed and their elderly mother. However, a strong stigma
depressed. attached to dementia in the Chinese commu-
nity takes an emotional toll on them.
Analysis of the Practice Exemplar
In the case of the Wang family, the focus of Assessment of Stimuli
nursing practice is on the relational system of The nurse conducts a second level of assess-
the family. The family is addressed as an adap- ment by meeting with the Wang family,
tive system to begin planning nursing care. including Frank Wang and his daughter
Lisa, to identify influencing factors or stim-
Assessment of Behaviors uli, related to group identity and family
The nurse first meets with David and Teresa coherence. Roy (2009) explained that fami-
to assess family structure, function, relation- lies are constantly interpreting changes in the
ships, and consistency. The nurse collects data reactions of others toward them. According-
on members of the Wang family; the division ly, the nurse notes that the major stimuli
of chores such as housekeeping, shopping, for the Wang family are the demands they
and/or repairs; their employment status; the face and the problems posed for them
to solve. Davids mother with dementia
1Feng Shui refers to an ancient Chinese belief in which requires attendant medical and personal care.
Feng, the force of wind, and Shui, the flow of water, are Although David Wang and Teresa need to
viewed as living energies that flow around ones home work to support the family, ensure their own
and workplace, and that affect ones life and well- health insurance coverage, and pay for the
being. If Feng Shui flows gently and peacefully, it cost of personal care, they find it quite diffi-
brings happiness and health to ones family. Feng Shui
can stagnate according to the location, shape, and
cult to care for Davids mother while main-
forms of ones environment. As it occurs, one can be taining full-time jobs. They are trying to find
ill, poor, and unfortunate (Beattie, 2000). Chinese-speaking home health aides from

Continued
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178 S E C T I O N III Conceptual Models/Grand Theories in the Interactive/Integrative Paradigm

Practice Exemplar cont.


their community, as Davids mother has responsibility because he is the only son and,
limited English language skills. However, according to traditional Chinese culture, has a
with the strong social stigma toward demen- moral responsibility to care for his mother.
tia, it becomes very challenging to find The nurse asks each member of the Wang
someone from the Chinese community. The family group to find common orientations by
Wang family agrees that stigma and reaction sharing their thinking and feelings. The
from the external social environment are Wang family reflects on questions that Chinn
stressors to their family caregiving. The (2008) posed: Do I know what I do, and do
strong negative responses to dementia from I do what I know? (Praxis) Am I expressing
groups outside the family have brought of my own will in the context of love and
shame to the Wang family and isolated respect for others? (Empowerment) Am I
Davids mother from her ethnic community. fully aware of others and myself, and do I
bring such awareness to discussion? (Aware-
Nursing Diagnosis ness) Do I honor and encourage everyones
After the initial assessment, the nurse arrives opinions, skills, and contributions? (Coopera-
at three tentative diagnoses. First, the Wang tion) and Do I welcome practices that
family has shared values and goals based on a encourage growth and change for others, the
strong ethnic heritage related to the group group, and myself? (Evolvement) (Chinn,
responsibility to maintain values and goals. 2008, p. 13). David and Teresa openly share
Second, family conflict exists as the demand their feelings and frustrations. Lisa and her
of family caregiving for Davids mother father, Frank Wang, express their willingness
increases. Third, strong stigma attached to to share responsibility and help out.
dementia from an out-group in the social The nurse helps the Wang family set up
milieu (in this case, the Chinese community) short-term goals based on shared cognitive
creates prejudice against the Wang family and and emotional orientations and common
causes some members of the Wang family to values. They all want to maintain quality of
feel distressed and ambivalent. life for their loved one and to share family
The nurse calls a meeting with the Wang caregiving responsibilities together with
family and again includes Davids extended Frank and Lisa Wang. Lisa arranges for two
family: Uncle Frank Wang and Lisa Wang. home health aides to alternately provide
After several attempts to coordinate every- personal care to Davids mother during
ones schedule, finally the family meeting weekdays and one day on weekends. This
time is set. At the family meeting, the nurse arrangement allows David to attend to his
continues to assess behaviors of shared iden- management work and his wife to spend
tity and cohesion in the Wang family. What more time with their daughter. Lisa also uses
are common perceptions, feelings, and expe- her social worker skill to triage family care-
riences of caring for the loved one with giving activity which helps David greatly.
dementia? What are shared understandings Frank Wang helps with some shopping.
of dementia? What are emotional, cognitive, Davids wife spends more time attending
and motivational responses to family caregiv- to her daughters schoolwork and personal
ing for the loved one with dementia? The needs. The Wang family coherence is evi-
nurse observes the family dynamics, listens to dent and strengthened.
reports from David and his wife, and Lisa and
her father. The nurses focus is on patterns of Goal Setting
family behavior. After hearing everyone, the nurse knows the
At this meeting, the nurse learns that Wang family better as individuals and as a
David considers family caregiving solely his group. At the following meeting, the nurse
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C H A P T E R 1 1 Sister Callista Roys Adaptation Model 179

works with the Wang family to set attainable resources in support of family caregiving;
goals. Goals and values determine the actions and by reinforcing their shared goals, values,
of the Wang family. Attaining goals requires relations, and group identity.
shared responsibilities and some division of
labor. The Wang family values their commit- Evaluation
ment and caring for their loved one and set a The nurse follows up and evaluates the effec-
goal to find ways to sustain family coherence tiveness of the nursing intervention in rela-
while providing quality care arrangement for tion to the groups adaptive behaviors in
their loved one. agreement with the stated goals as described
Setting goals includes (1) working together by the model. The nurse attends the Wang
with home health aides to provide the best familys biweekly meetings and learns that
care for their loved one; (2) supporting each Lisa Wang used her social worker network
other through not only shared feelings and and found appropriate home health aides for
thoughts, but also shared responsibilities of Davids mother, allowing Teresa more time to
family caregiving based on each family mem- attend to Vivians schoolwork. Vivian has not
bers desire, skill, and availability; (3) commu- had an absence from school since the meet-
nicating with the Chinese community about ing. Frank Wang, an activist in the Chinese
their perception of dementia and finding community, began to talk with other Chinese
ways to demystify dementia. The Wang fam- about dementia, although there is still a
ily decides to have Lisa Wang, a social work- strong stigma attached to the disease. David
er, lead in searching for home health aides; Wang hired another manager to sustain the
David Wang convenes family meetings as restaurant business which brings a stable
needed; and Frank Wang plans to talk with income to support the family and his moth-
Chinese community key players. At the end ers personal care and leaves him time to take
of this meeting, despite stressors they have his mother for clinical appointments. Davids
encountered, the Wang family members, mothers old friend stopped and visited her
again, feel a sense of unity through compen- briefly.
satory adaptation process. A particular factor influencing an adapta-
tion problem in the Wang family is related to
Intervention strong stigma attached to dementia in the
Nursing intervention in the case of the Chinese community. Stigma can be socially
Wang family involves focusing on the stim- pervasive and distort the perceptions of indi-
uli affecting the behavior and managing the viduals. It can impact how the disease is per-
stimuli by altering, increasing, or decreasing, ceived and conceptualized, how caregiving
removing, or maintaining stimuli as pro- for persons with dementia is supported, and
posed by the Roy Adaptation Model. The how dementia diagnosis and services are
nurse (1) assesses the Wang family with sought. To reduce stigma in promotion of
respect to shared values, shared goals, shared effective adaptation of individual family
relations, group identity, and social environ- caregivers and health care providers, families
ment and stimuli; (2) works with the Wang and the community need to work together
family to write down shared goals, values, toward a better understanding of dementia,
and expectations; (3) encourages the family its diagnosis, treatment, and care options.
to explore additional resources. The nurse Educational and service outreach is the first
also helps the Wang family use effective step to reduce stigmatizing in the Chinese
coping strategies to strengthen compensatory community. Educational materials and serv-
processes by acknowledging how good the ices need to be linguistically appropriate and
family is at transcending the crisis; by work- adaptable to Chinese patients and their fam-
ing with the family to identify additional ilies. Publishing information on dementia
Continued
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180 S E C T I O N III Conceptual Models/Grand Theories in the Interactive/Integrative Paradigm

Practice Exemplar cont.


and related educational articles in widely beliefs. These norms determine patterns of
circulated Chinese newspapers helps reach interaction with the health and social serv-
out to Chinese families, particularly elderly ices system, health care decision-making,
Chinese immigrants who often read Chinese the extent to which social support is avail-
newspapers as a way to connect them to their able to caregivers. In addition, these cultur-
culture and people. Bilingual professional al beliefs and values have implications for
staff and linguistically appropriate oral and the psychosocial experience of family care-
written instructions on dementia are helpful givers and the clients. Roys Group Identity
(Valle, 1998). Model provides a useful conceptual frame-
When interacting with the Chinese fam- work that guides health care providers for
ily, or families of other cultures, health care working with families of diverse ethnic
providers need to assess cultural norms and backgrounds.

Summary
This chapter focused on the Roy Adaptation introduced by outlining how to develop
Model as a foundation for knowledge- middle- and practice-level theory that is
based practice. The backgound of the theo- tested in research. In particular, the effects
rist and the historical development of the of the Roy Adaptation Model on practice
model were presented briefly. The most were articulated from a general summary of
recent theoretical developments by Roy major practice projects and by the use of the
were the main focus of the description of the self-identity adaptive mode as an example of
model assumptions and major concepts. using theory-based knowledge to provide
The process for theory becoming the basis care for a Chinese family dealing with a
for developing knowledge for practice was parent diagnosed with dementia.

References

Beattie, A (2000). Using Feng Shui. Raincoast Book Monroy, P. (2003). Aproximacin a la experiencia de
Dist.Ltd. aplicacin del Modelo de Callista Roy en la Unidad
Boston-Based Adaptation Research in Nursing Society. de cuidado intensivo peditrico. Enfermera Hoy,
(1999). Roy adaptation model-based research: 25 years 1(1), 1720.
of contributions to nursing science. Indianapolis, IN: Moreno-Ferguson, M. E. (2001). Rehabilitation
Centre Nursing Press. ambulatory service in Clnica Puente del Comn-
Chinn, P. L. (2008). Peace and power: Creative leadership Teletn, Cha, Colombia. From Moreno-Ferguson,
for building community (7th ed.). Sudbury, MA: Jones M. E. (2007). Application of the Roy Adaptation
and Bartlett. Model in Latin America: Literature review. Roy
Donaldson, S. K., & Crowley, D. (1978). The discipline Adaptation Association Conference 2007,
of nursing. Nursing Outlook, 26, 113120. Los Angeles, CA.
Gray, J. (1991). The Roy Adaptation Model in nursing Moreno-Ferguson, M. E. (2007). Application of the Roy
practice. In C. Roy & H. A. Andrews (Eds.), The Adaptation Model in Latin America: Literature review.
Roy Adaptation Model: The definitive statement Roy Adaptation Association Conference 2007,
(pp. 429443). Norwalk, CT: Appleton & Lange. Los Angeles, CA.
Helson, H. (1964). Adaptation level theory. New York: Roy, C. (1970). Adaptation: A conceptual framework for
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Mastal, M. F., Hammond, H., & Roberts, M. P. (1982). Roy, C. (1984). Introduction to nursing: An adaptation
Theory into Hospital Practice: A Pilot Implemen- model (2nd ed.). Englewood Cliffs, NJ:
tation. The Journal of Nursing Administration, Prentice-Hall.
12, 915.
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Roy, C. (1988a). Altered cognition: An information pro- Roy, C., & Jones, D. (Eds.) (2007). Nursing knowledge
cessing approach. In: P. H. Mitchell, L. C. Hodges, development and clinical practice. New York: Springer.
M. Muwaswes, & C. A. Walleck (Eds.), AANNs Roy, C., & Roberts, S. (1981). Theory construction in
neuroscience nursing, phenomenon and practice: Human nursing: An adaptation model. Englewood Cliffs,
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Norwalk, CT: Appleton & Lange. Senesac, P. (2003). Implementing the Roy Adaptation
Roy, C. (1988b). Human information processing. In: Model: From theory to practice. Roy Adaptation
J. J. Fitzpatrick. R. L. Taunton, & J. Q. Benoliel Association Review, 4(2), 5.
(Eds.), Annual review of nursing research Valle, R. (1998). Caregiving across cultures: Working with
(pp. 237261). New York: Springer. dementing illness and ethnically diverse populations.
Roy, C. (1997). Knowledge as universal cosmic imperative. Boca Raton, FL: Taylor & Francis.
Proceedings of nursing knowledge impact conference von Bertalanffy, L. (1968). General system theory: Foun-
1996 (pp. 95118). Chestnut Hill, MA: Boston dations, development, applications. New York: George
College Press. Braziller
Roy, C. (2009). The Roy adaptation model (3rd ed.). Young, L. B. (1986). The unfinished universe. New York:
Upper Saddle River, NJ: Prentice-Hall Health. Simon & Schuster.
Roy, C., & Andrews, H. A. (1991). The Roy Adaptation Zhan, L. (2003). Asian Americans: Vulnerable population,
Model: The definitive statement. East Norwalk, CT: model intervention, and clarifying agendas. Sudbury,
Appleton & Lange. MA: Jones and Bartlett.
Roy, C., & Andrews, H. A. (1999). The Roy adaptation
model (2nd ed.). Stamford, CT: Appleton & Lange.
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Chapter
12
Betty Neumans Systems
Model
PATRICIA D EAL AYLWARD

Introducing the Theorist Introducing the Theorist


Overview of the Neuman Systems Model Betty Neuman developed the Neuman Sys-
Applications tems Model (NSM) in 1970 to provide
Practice Exemplar unity, or a focal point, for student learning
Summary (Neuman, 2002b, p. 327) at the School
References of Nursing, University of California at
Los Angeles (UCLA). Neuman recognized
the need for educators and practitioners to
have a framework to view nursing compre-
hensively within various contexts. Although
she developed the model strictly as a teaching
aid, it is now used globally as a nursing con-
ceptual model and as a guide for clinical prac-
tice in the full array of health care disciplines.
Betty Neumans autobiography is presented
in her latest book edition (Neuman, 2002b).
Betty Neuman
Neuman was born in southeastern Ohio on a
100-acre family farm on September 11, 1924.
Her father died at age 37 when she was 11,
and she, her mother, and two brothers worked
hard to keep the farm.
Neuman idealized nursing because her
father had praised nurses during his 6 years of
intermittent hospitalizations. In gratitude, she
developed a strong commitment to become an
excellent bedside nurse. She also attributed
her decisions about her lifes work to the very
important influence of her mothers charity
experiences as a self-taught rural midwife.
Betty Neuman graduated from high school
soon after the onset of World War II.
Although she had dreamed of attending near-
by Marietta College, she lacked the financial
means, and instead became an aircraft instru-
ment repair technician. After the Cadet
Nurse Corps Program became available, she
entered the 3-year diploma nurse program at
People Hospital, Akron, Ohio (currently
General Hospital Medical Center).

182
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C H A P T E R 1 2 Betty Neumans Systems Model 183

During her career, Neuman worked in a health disciplines, at all levels, and across all
variety of nursing positions including com- cultural boundaries (Neuman, personal com-
municable disease nurse, school nurse, indus- munication, August 1, 2008; Neuman, 2002b,
trial nurse, and private duty nurse, developing p. 331).
a broad base of knowledge and skills in criti-
cal care. Later she worked as an office nurse in
her husbands obstetrical practice. Overview of the Neuman
She completed her baccalaureate degree Systems Model
in nursing and masters degree, with a major
in public health nursing from UCLA. Dur-
The philosophic base of the Neuman Systems
ing her masters program at UCLA, she
Model encompasses wholism, a wellness orien-
worked on special education projects, as a
tation, client perception and motivation, and a
relief psychiatric head nurse, and as a volun-
dynamic systems perspective of energy and vari-
teer crisis counselor. Because of this experience
able interaction with the environment to miti-
Neuman became one of the first California
gate possible harm from internal and external
Nurse Licensed Clinical Fellows of the
stressors, while caregivers and clients form a
American Association of Marriage and Family
partnership relationship to negotiated desired
Therapy.
outcome goals for optimal health retention,
Neuman became a UCLA faculty member
restoration, and maintenance. This philosophic
in January 1967, assuming chairmanship of
base pervades all aspects of the model.
the program from which she had graduated.
She expanded the masters program for stu- B ET TY N EUMAN (2002c, p. 12)
dents in the psychiatric specialty, focusing it
on interdisciplinary practice in community As its name suggests, the Neuman Sys-
mental health. tems Model is classified as a systems model
In 1970, she developed the Neuman Sys- or a systems category of knowledge. Neuman
tems Model. The model was first published (1995) defined system as a pervasive order
in the MayJune 1972 issue of Nursing that holds together its parts. With this defi-
Research. Since 1980, several important nition in mind, she writes that nursing can
changes have enhanced the model. A nurs- be readily conceptualized as a complete
ing process format was designed, and in whole, with identifiable smaller wholes or
1989 Neuman introduced the concepts of parts. The complete whole structure is main-
the created environment and the spiritual tained by interrelationships among identifi-
variable. In collaboration with Dr. Audrey able smaller wholes or parts through regula-
Koertvelyessy, Neuman developed a Theory tions that evolve out of the dynamics of the
of Client System Stability. She continues to open system. In the system there is dynamic
clarify concepts and components of the model. energy exchange, moving either toward or
Neuman completed a doctoral degree in away from stability. Energy moves toward
clinical psychology in 1985 from Pacific negentropy or evolution as a system absorbs
Western University in Los Angeles and has energy to increase its organization, complex-
received honorary doctorates from Neumann ity, and development when it moves toward a
College in Aston, Pennsylvania in 1992 and steady or wellness state. An open system of
Grand Valley State University in Allendale, energy exchange is never at rest. The open
Michigan, in 1998. She is an honorary fellow system tends to move cyclically toward dif-
in the American Academy of Nursing. ferentiation and elaboration for further
Neuman has expressed her hope that growth and survival of the organism. With
through continued nurturance, the Neuman the dynamic energy exchange, the system
Systems Model will live well into the twenty- can also move away from stability. Energy
first century to benefit nursing, and other can move toward extinction (entropy) by
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184 S E C T I O N III Conceptual Models/Grand Theories in the Interactive/Integrative Paradigm

gradual disorganization, increasing random- 4. Each individual clientclient system has


ness, and energy dissipation. evolved a normal range of response to
The Neuman Systems Model illustrates a the environment that is referred to as a
clientclient system and presents nursing as a normal line of defense, or usual wellness/
discipline concerned primarily with defining stability state. It represents change over
appropriate nursing actions in stressor-related time through coping with diverse stress
situations or in possible reactions of the encounters. The normal line of defense
clientclient system. The client and environ- can be used as a standard from which to
ment may be positively or negatively affected measure health deviation.
by each other. There is a tendency within any 5. When the cushioning, accordion-like
system to maintain a steady state or balance effect of the flexible line of defense is no
among the various disruptive forces operating longer capable of protecting the client
within or upon it. Neuman has identified client system against an environmental
these forces as stressors, and suggests that stressor, the stressor breaks through the
possible reactions and actual reactions with normal line of defense. The interrelation-
identifiable signs or symptoms may be miti- ships of variablesphysiological, psycho-
gated through appropriate early interventions logical, sociocultural, developmental,
(Neuman, 1995). and spiritualdetermine the nature and
degree of system reaction or possible
Unique Perspectives of the Neuman reaction to the stressor.
Systems Model 6. The client, whether in a state of wellness
or illness, is a dynamic composite of
Neuman (2002c, p. 14) has identified 10 unique
the interrelationships of variables
perspectives inherent within her model. They
physiological, psychological, sociocultural,
describe, define, and connect concepts essen-
developmental, and spiritual. Wellness
tial to understanding the conceptual model
is on a continuum of available energy to
that is presented in the next section of this
support the system in an optimal state of
chapter.
system stability.
1. Each individual client or group as a client 7. Implicit within each client system are
system is unique; each system is a compos- internal resistance factors known as
ite of common known factors or innate lines of resistance, which function to
characteristics within a normal, given stabilize and return the client to the
range of response contained within a basic usual wellness state (normal line of
structure. defense) or possibly to a higher level
2. The client as a system is in a dynamic, of stability following an environmental
constant energy exchange with the stressor reaction.
environment. 8. Primary prevention relates to general
3. Many known, unknown, and universal knowledge that is applied in client assess-
environmental stressors exist. Each differs ment and intervention in identification
in its potential for disturbing a clients and reduction or mitigation of possible
usual stability level, or normal line of or actual risk factors associated with envi-
defense. The particular interrelationships ronmental stressors to prevent possible
of client variablesphysiological, psycho- reaction. The goal of health promotion
logical, sociocultural, developmental, and is included in primary prevention.
spiritualat any point in time can affect 9. Secondary prevention relates to sympto-
the degree to which a client is protected matology following a reaction to stres-
by the flexible line of defense against sors, appropriate ranking of intervention
possible reaction to a single stressor or a priorities, and treatment to reduce their
combination of stressors. noxious effects.
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C H A P T E R 1 2 Betty Neumans Systems Model 185

10. Tertiary prevention relates to the adaptive flexible line moves closer to the normal line of
processes taking place as reconstitution defense. The effectiveness of the buffer sys-
begins and maintenance factors move the tem can be reduced by single or multiple
client back in a circular manner toward stressors. The flexible line of defense can be
primary prevention. rapidly altered over a relatively short time
period by states of emergency, or short-term
The Conceptual Model conditions, such as loss of sleep, poor nutri-
Neumans original diagram of her model is tion, or dehydration (Neuman, 1995, 2002c).
illustrated in Figure 12-1. The conceptual Consider the latter examples. What are the
model was developed to explain the effects of short-term loss of sleep, poor nutri-
clientclient system as an individual person tion, or dehydration on a clients normal state
for the discipline of nursing. Neuman chose of wellness? Will these situations increase
the term client to show respect for collabo- the possibility for stressor penetration? The
rative relationships that exist between the answer is that the possibility for stressor
client and the caregiver in Neumans model, as penetration may be increased. The actual
well as the wellness perspective of the model. response depends on the accordionlike func-
The model can be applied to an individual, a tion previously described, along with the
group, a community, or a social issue and other components of the client system.
is appropriate for nursing and other health
disciplines (Neuman, 1995, 2002c). Normal Line of Defense
The Neuman Systems Model provides a The normal line of defense represents what
way of looking at the domain of nursing: the client has become over time, or the usual
humans, environment, health, and nursing. state of wellness. The nurse should determine
the clients usual level of wellness in order
ClientClient System to recognize a change. The normal line of
The clientclient system (see Fig. 12-1) con- defense is considered dynamic, because it can
sists of the flexible line of defense, the normal expand or contract over time. The usual well-
line of defense, lines of resistance, and the ness level or system stability can decrease,
basic structure energy resources (shown at the remain the same, or improve following treat-
core of the concentric circles in Fig. 12-2). ment of a stressor reaction. The normal line of
Five client variablesphysiological, psycho- defense is dynamic because of its ability to
logical, sociocultural, developmental, and become and remain stabilized, with life stres-
spiritualoccur and are considered simulta- sors over time protecting the basic structure
neously in each concentric circle that makes and system integrity are protected (Neuman,
up the clientclient system (Neuman, 1995, 1995, 2002c).
2002c).
Lines of Resistance
Flexible Line of Defense Neuman identified the series of concentric
Stressors must penetrate the flexible line of broken circles that surround the basic struc-
defense before they are capable of penetrat- ture as lines of resistance for the client. When
ing the rest of the client system. Neuman the normal line of defense is penetrated by
described this line of defense as accordionlike environmental stressors, a degree of reaction,
in function. The flexible line of defense acts or signs and/or symptoms, will occur. Each
like a protective buffer system to help prevent line of resistance contains known and
stressor invasion of the client system and pro- unknown internal and external resource fac-
tects the normal line of defense. The client tors. These factors support the clients basic
has more protection from stressors when the structure and the normal line of defense,
flexible line expands away from the normal resulting in protection of system integrity.
line of defense. The opposite is true when the Examples of the factors that support the
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186 S E C T I O N III Conceptual Models/Grand Theories in the Interactive/Integrative Paradigm

Stressors
Identified
Classified as knowns
or possibilities, i.e.,
Loss Basic structure
Pain Basic factors common to
Sensory deprivation all organisms, i.e.:
Cultural change Normal temperature
range
Genetic structure
Inter Stressor Stressor Response pattern
Intra Personal
factors Organ strength or
Extra weakness
Ego structure
Knowns or commonalities

ible Line of Defe


Flex nse

mal Line of Defe


N or n
s of Resista se
Primary prevention Line nc
Reduce possibility of e
encounter with stressors
Strengthen flexible line
of defense
Degree of BASIC
Reaction STRUCTURE
ENERGY
Secondary prevention RESOURCES
Early case-finding and
Treatment of symptoms
Rec

Reaction
onst
itutio

Tertiary prevention
Readaptation Stressors
Reeducation to prevent
n

More than one stressor


future occurrences could occur
Maintenance of stability simultaneously*
Same stressors could vary
Reaction as to impact or reaction
Individual intervening Normal defense line varies
variables, i.e.: with age and development
Basic structure NOTE:
idiosyncrasies *Physiological, psychological,
Natural and learned sociocultural, developmental, and
resistance spiritual variables are considered
Time of encounter simultaneously in each client
with stressor concentric circle.
Inter
Intra Personal
Extra factors Reconstitution
Could begin at any degree
or level of reaction
Interventions Range of possibility may
Can occur before or after resistance extend beyond normal line
lines are penetrated in both reaction of defense
and reconstitution phases
Interventions are based on: Inter
Degree of reaction Intra Personal
Resources Extra factors
Goals
Anticipated outcome

Figure 12 1 The Neuman Systems Model. (Original diagram copyright 1970 by Betty Neuman. A holistic
view of a dynamic open clientclient system interacting with environmental stressors, along with client
and caregiver collaborative participation in promoting an optimum state of wellness.) (From Neuman, 1995,
p. 17, with permission.)
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C H A P T E R 1 2 Betty Neumans Systems Model 187

Basic Structure
Basic structure
Basic factors common to The basic structure or central core consists
all organisms, i.e.: of factors that are common to the species.
Normal temperature
range Neuman offered the following examples of
Genetic structure basic survival factors: temperature range, genet-
Response pattern
Organ strength or
ic structure, response pattern, organ strength or
weakness weakness, ego structure, and knowns or com-
Ego structure monalities (Neuman, 1995, 2002c).
Knowns or commonalities
Five Client Variables
ible Line of Defen
Neuman (1995, p. 28; 2002c, p. 17) identified
Flex se five variables that are contained in all client
l Line of Defe systems: physiological, psychological, socio-
r ma ns
No e cultural, developmental, and spiritual. These
es of Resistan
Lin ce variables are considered simultaneously in
each client concentric circle. They are present
in varying degrees of development and in a
BASIC wide range of interactive styles and potential.
STRUCTURE
ENERGY Neuman offers the following definitions for
RESOURCES each variable:
Physiological: Refers to bodily structure and
function
Psychological: Refers to mental processes
and relationships
Sociocultural: Refers to combined social and
cultural functions
NOTE:
Physiological, psychological, sociocultural, Developmental: Refers to life-developmental
developmental, and spiritual variables occur processes
and are considered simultaneously in each
client concentric circle.
Spiritual: Refers to spiritual beliefs and
Figure 12 2 Clientclient system. The structure influence
of the client-client system, including the five vari-
Neuman elaborated that the spiritual vari-
ables that are occurring simultaneously in each
client concentric circle. (From Neuman, 1995, p. 26, able is an innate component of the basic
with permission.) structure. While it may or may not be
acknowledged or developed by the client or
client system, Neuman views the spiritual
basic structure and normal line of defense variable as being on a continuum of develop-
include the bodys mobilization of white ment that penetrates all other client system
blood cells and activation of the immune sys- variables and supports the clients optimal
tem mechanisms. There is a decrease in the wellness. The clientclient system can have a
signs or symptoms, or a reversal of the reac- complete lack of awareness of the spiritual
tion to stressors, when the lines of resistance variables presence and potential, deny its
are effective. The system reconstitutes itself presence, or have a conscious and highly
and system stability is returned. The level of developed spiritual understanding that sup-
wellness may be higher or lower than it was ports the clients optimal wellness.
before the stressor penetration. When the Neuman explained that the spirit controls
lines of resistance are ineffective, energy the mind, and the mind consciously or uncon-
depletion and death may occur (Neuman, sciously controls the body. She used an analo-
1995, 2002c). gy of a seed to clarify this idea.
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188 S E C T I O N III Conceptual Models/Grand Theories in the Interactive/Integrative Paradigm

It is assumed that each person is born with a spir- that spiritual variable considerations are nec-
itual energy force, or seed, within the spiritual essary for a truly wholistic perspective and for
variable, as identified in the basic structure of the a truly caring concern for the clientclient
client system. The seed or human spirit with its system.
enormous energy potential lies on a continuum Fulton (1995) has studied the spiritual
of dormant, unacceptable, or undeveloped to variable in depth. She elaborated on research
recognition, development, and positive system studies that extend our understanding of the
influence. Traditionally, a seed must have environ- following aspects of spirituality: spiritual
mental catalysts, such as timing, warmth, mois- well-being, spiritual needs, spiritual distress,
ture, and nutrients, to burst forth with the energy and spiritual care. She suggested that spiritu-
that transforms into a living form that then, in al needs include (1) the need for meaning and
turn, as it becomes further nourished and devel- purpose in life; (2) the need to receive love
ops, offers itself as sustenance, generating power and give love; (3) the need for hope and cre-
as long as its own source of nurture exists. ativity; and (4) the need for forgiving, trusting
(Neuman, 2002c, p. 16) relationships with self, others, and God or a
deity, or a guiding philosophy.
The spiritual variable affects or is affected
by a condition and interacts with other vari-
ables in a positive or negative way. Neuman Environment
gave the example of grief or loss (psychologi- A second concept identified by Neuman is the
cal state), which may inactivate, decrease, ini- environment, as illustrated in Figure 12-3.
tiate, or increase spirituality. There can be She defined environment broadly as all inter-
movement in either direction of a continuum nal and external factors or influences sur-
(Neuman, 1995, 2002c). Neuman believes rounding the identified client or client

Basic structure
Basic factors common to
Stressors Stressor Stressor all organisms, i.e.:
Identified Normal temperature
le Line of Defe
Classified as knowns
or possibilities, i.e.:
Flexib nse range
Genetic structure
Loss Response pattern
mal Line of Defen
N or
Pain Organ strength or
s
Sensory deprivation s of Resistan e weakness
Cultural change Line ce Ego structure
Knowns or commonalities
Inter Personal
Intra factors
Extra
BASIC
STRUCTURE
ENERGY
RESOURCES

Stressors
More than one stressor
could occur simultaneously
Same stressors could vary
as to impact or reaction
Normal defense line varies
with age and development

Figure 12 3 Environment. Internal and external factors surrounding the clientclient system. (From
Neuman, 1995, p. 27, with permission.)
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C H A P T E R 1 2 Betty Neumans Systems Model 189

system (Neuman, 1995, p. 30; 2002c, p. 18), of the binding of available energy. This envi-
including: ronment represents an open system that
exchanges energy with the internal and exter-
Internal environment: Intrapersonal factors
nal environments. The created environment
External environment: Inter- and extraper-
supersedes or goes beyond the internal and
sonal factors
external environments while encompassing
Created environment: Intra-, inter-, and
both; it provides an insulating effect to change
extrapersonal factors (Neuman, 1995, p. 31;
the response or possible response of the client to
2002c, pp. 1819)
environmental stressors. Neuman (1995, 2002c)
The internal environment consists of all gave the following examples of responses: use
forces or interactive influences contained of denial or envy (psychological), physical
within the boundaries of the clientclient rigidity or muscle constraint (physiological),
system. Examples of intrapersonal forces are life-cycle continuation of survival patterns
presented for each variable. (developmental), required social space range
(sociocultural), and sustaining hope (spiritual).
Physiological variable: Autoimmune
Neuman believes the caregiver, through
response, degree of mobility, range of body
assessment, will need to determine (1) what
function.
has been created (nature of the created envi-
Psychological and sociocultural variables:
ronment), (2) the outcome of the created
Attitudes, values, expectations, behavior
environment (extent of its use and client val-
patterns, coping patterns, conditioned
ue), and (3) the ideal that has yet to be creat-
responses
ed (the protection that is needed or possible,
Developmental variable: Age, degree of
to a lesser or greater degree). This assessment
normalcy, factors related to the present
is necessary to best understand and support
situation
the clients created environment (Neuman,
Spiritual variable: Hope, sustaining forces
1995, 2002c). Neuman suggested that further
(Neuman, 1995, 2002c)
research is needed to understand the clients
The external environment consists of all awareness of the created environment and its
forces or interactive influences existing out- relationship to health. Neuman believes that
side the clientclient system. Interpersonal as the caregiver recognizes the value of the
factors in the environment are forces between client-created environment and purposefully
people or client systems. These factors include intervenes, the interpersonal relationship can
the relationships and resources of family, become one of important mutual exchange
friends, or caregivers. Extrapersonal factors (Neuman, 1995, 2002c).
include education, finances, employment, and
other resources (Neuman, 1995, 2002c). Health
Neuman (1995, 2002c) identified a third Health is a third concept in Neumans model.
environment as the created environment. She believes that health, or wellness, and ill-
The client unconsciously mobilizes all system ness are on opposite ends of the continuum.
variables, including the basic structure of Health is equated with optimal system stabil-
energy factors toward system integration, sta- ity (the best possible wellness state at any giv-
bility, and integrity to create a safe environ- en time). Client movement toward wellness
ment. This safe, created environment, offers a exists when more energy is built and stored
protective perceptive coping shield that helps than expended. Client movement toward ill-
the client to function. A major objective of ness and death exists when more energy is
this environment is to stimulate the clients needed than is available to support life. The
health. Neuman pointed out that what was degree of wellness depends on the amount
originally created to safeguard the health of of energy required to return to and maintain
the system may have a negative effect because system stability. The system is stable when
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190 S E C T I O N III Conceptual Models/Grand Theories in the Interactive/Integrative Paradigm

more energy is available than is being used. these actions are initiated to best retain,
Health is seen as varying levels within a nor- attain, and maintain optimal client health or
mal range, rising and falling throughout the wellness. Neuman (1995, 2002c) believes the
lifespan. These changes are in response to nurse creates a linkage among the client, the
basic structure factors and reflect satisfactory environment, health, and nursing in the
or unsatisfactory adjustment by the client sys- process of keeping the system stable.
tem to environmental stressors (Neuman,
1995, 2002c). Prevention as Intervention
The nurse collaborates with the client to
Nursing establish relevant goals. These goals are
Nursing is a fourth concept in Neumans derived only after validating with the client
model and is depicted in Figure 12-4. Nurs- and synthesizing comprehensive client data
ings major concern is to keep the client and relevant theory to determine an appro-
system stable by (1) accurately assessing priate nursing diagnostic statement. With
the effects and possible effects of environ- the nursing diagnostic statement and goals
mental stressors and (2) assisting client in mind, appropriate interventions can be
adjustments required for optimal wellness. planned and implemented (Neuman, 1995,
Nursing actions, which are called prevention 2002c).
as intervention, are initiated to keep the sys- Primary prevention as intervention involves
tem stable. Neuman created a typology for her the nurses actions that promote client well-
prevention as intervention nursing actions ness by stress prevention and reduction of risk
that includes primary prevention as interven- factors. These interventions can begin at any
tion, secondary prevention as intervention, point a stressor is suspected or identified,
and tertiary prevention as intervention. All of before a reaction has occurred. They protect

Primary prevention
Reduce possibility of
encounter with stressors
Strengthen flexible line
of defense

Secondary prevention
Early case-finding and
Treatment of symptoms

Inter Personal
Intra factors
Tertiary prevention Extra
Readaptation
Reeducation to prevent Interventions
future occurrences Can occur before or after resistance
Maintenance of stability lines are penetrated in both reaction
and reconstitution phases
Interventions are based on:
Degree of reaction
Resources
Goals
Anticipated outcome

Figure 12 4 Nursing. Accurately assessing the effects and possible effects of


environmental stressors (inter-, intra-, and extrapersonal factors) and using
appropriate prevention by interventions to assist with client adjustments for
an optimal level of wellness. (From Neuman, 1995, p. 29, with permission.)
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C H A P T E R 1 2 Betty Neumans Systems Model 191

the normal line of defense by reducing the Nursing Tools for Model
possibility of an encounter with a stressor and Implementation
strengthen the flexible lines of defense.
Neuman designed the Neuman Systems Model
Health promotion is a significant interven-
Nursing Process format and the Neuman
tion. The goal of primary prevention as inter-
Systems Model Assessment and Intervention
vention is to retain optimal stability or
Tool: Client Assessment and Nursing Diag-
wellness. Ideally, the nurse should consider
nosis to facilitate implementation of the
primary prevention along with secondary and
Neuman model. These tools are presented in
tertiary preventions as interventions when
the fourth edition of The Neuman Systems
actual client problems exist.
Model (Neuman, 2002a, pp. 347359).
Once a reaction from a stressor occurs,
The Neuman Systems Model Nursing
the nurse can use secondary prevention as
Process format reflects a process that guides
intervention to treat the symptoms within
information processing and goal-directed
the nurses scope of practice, reduce the
activities. Neuman uses the nursing process
degree of reaction to the stressors, and pro-
within three categories: nursing diagnosis,
tect the basic structure by strengthening the
nursing goals, and nursing outcomes. In 1982,
lines of resistance. The goal of secondary
the Neuman nursing process format was vali-
prevention as intervention is to attain opti-
dated by doctoral students. The formats
mal client system stability or wellness and
validity and social utility have been supported
energy conservation. The nurse uses as much
in a wide variety of nursing education and
of the clients existing internal and external
practice areas.
resources (lines of resistance) as possible to
stabilize the system.
Reconstitution represents the return and The Neuman Systems Model Assessment
maintenance of system stability following and Intervention Tool
nursing intervention for stressor reaction. The Client Assessment and Nursing Diagnosis is
state of wellness may be higher, the same, or used to guide the nursing process. The nurse
lower than the state of wellness before the sys- collects wholistic comprehensive data to deter-
tem was stabilized. Death occurs when second- mine the impact or possible impact of envi-
ary prevention as intervention fails to protect ronmental stressors on the client system, then
the basic structure and thus fails to reconstitute validates the data with the client before for-
the client (Neuman, 1995, 2002c). mulating a nursing diagnosis. Selected nursing
Tertiary prevention as intervention can diagnoses are prioritized and related to rele-
begin at any point in the clients reconstitu- vant knowledge. Nursing goals are determined
tion. This includes interventions that promote mutually with the caregiverclientclient
(1) readaptation, (2) reeducation to prevent system, along with mutually agreed on pre-
further occurrences, and (3) maintenance of vention as intervention strategies. Mutually
stability. These actions are designed to main- agreed on goals and interventions are consis-
tain an optimal wellness level by supporting tent with current mandates within the health
existing strengths and conserving client sys- care system for client rights related to health
tem energy. Tertiary prevention tends to lead care issues.
back toward primary prevention in a circular The Client Assessment and Nursing
fashion. Neuman pointed out that one or all Diagnosis tool with primary, secondary, and
three of these prevention modalities give tertiary prevention as intervention was devel-
direction to or may be used simultaneously for oped to convey appropriate nursing actions
nursing actions with possible synergistic ben- with each typology of prevention. There
efits (Neuman, 1995, 2002). These interven- are clear instructions for writing appropriate
tions may be planned and carried out at the nursing actions (Neuman, 2002a, p. 354),
same time. which students are encouraged to review
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192 S E C T I O N III Conceptual Models/Grand Theories in the Interactive/Integrative Paradigm

before writing these nursing actions. Keep in inception. She conducted an integrative
mind that the nature of stressors and their review of literature addressing application of
threat to the clientclient system are first the model to clinical practice, including
determined for each type of prevention practice applications of Neuman variables
before any other nursing actions are initiated. and intra-, inter-, and extrapersonal stres-
The same stressors could produce variable sors, and identified 115 publications with
impacts or reactions. Nursing outcomes are practice-related titles through May 2000.
determined by the accomplishment of the An additional 12 articles have been pub-
interventions and evaluation of goals after lished to date. These numbers do not
intervention. include doctoral dissertations and masters
theses.
The Neuman Systems Model is being
Applications used in diverse practice settings. The model
Because the model is flexible and adaptable is used in critical care nursing, psychiatric
to a wide range of groups and situations, mental health nursing, gerontological nurs-
people have used it globally for more than ing, perinatal nursing, community nursing,
three decades. Neumans first book, The occupational health nursing, rehabilitation,
Neuman Systems Model: Application to Nurs- and advanced nursing practice (Amaya,
ing Education and Practice, was published in 2002; Bueno & Sengin, 1995; Chiverton &
1982 as a response to requests for data and Flannery, 1995; McGee, 1995; Peirce &
support in applying the model. The fourth Fulmer, 1995; Russell, Hileman, & Grant,
edition was published in 2002 to clearly 1995; Stuart & Wright, 1995; Trepanier,
reflect the broad, cross-cultural applications Dunn, & Sprague, 1995; Ware & Shannahan,
of the Neuman Systems Model and is used 1995).
as a primary resource for global applications In the United States, the model is used
highlighted in this chapter (Neuman & to guide practice with clients with acute
Fawcett, 2002). and chronic health care problems (e.g., hyper-
tension, chronic obstructive pulmonary dis-
Application of the Neuman Systems ease, renal disease, cardiac surgery, cognitive
Model to Nursing Practice impairment, mental illness, multiple sclerosis,
The function of a conceptual model in pain, grief, pediatric cancers, perinatal stres-
nursing practice is to provide a distinctive sors); meet family needs of clients in critical
frame of reference that guides approaches to care; provide stable support groups for parents
patient care (Amaya, 2002, p. 43). There is with infants in neonatal intensive care units;
a critical need for meaningful definitions and meet the needs of home caregivers, with
and conceptual frames of reference for nurs- emphasis on clients with cancer, HIV/AIDS,
ing practice if the profession is to be estab- and head traumas.
lished as a science (Neuman, 2002c). Nurs- Internationally, the model is being used
es who conduct their practice from a nursing in Canada, the United Kingdom, Sweden,
theory base, while assisting individuals and the Netherlands, New Zealand, Australia,
families to meet their health needs are more Jordan, Israel, Slovenia, Japan, Korea,
likely to provide comprehensive, individual- and Taiwan (Betty Neuman, personal com-
ized care that exemplifies best practices munication, January 10, 1999; Crawford
(Ume-Nwangbo, DeWan, & Lowry, 2006, & Tarko 2002; Beddome, 1995; Beynon,
p. 31). 1995; Craig, 1995a; Damant, 1995; Davies
Amaya (2002) asserted that the value of & Proctor, 1995; Engberg, Bjalming, &
the Neuman Systems Model is supported by Bertilson, 1995; Felix, Hinds, Wolfe, &
the substantial body of literature related to Martin, 1995; Vaughan & Gough, 1995;
its applications that has emerged since its Verberk, 1995).
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C H A P T E R 1 2 Betty Neumans Systems Model 193

Practice Exemplar
A nurse guided by the Neuman Systems each of these factors. Gloria identified caring
Model met Gloria Washington while provid- for her mother with Alzheimers disease as
ing care for her mother in Glorias home. her major stressor.
Glorias 74-year-old mother has Alzheimers
disease and Gloria has been her caregiver for Assessment
4 years. The nurse was aware that, according
The nurses assessment of Glorias environ-
to Neuman, the family client system includes
mental factors is identified below. Examples
Gloria and her mother. This nurse uses
of assessment data for each variable are
practice-based research to guide her work
included.
(best practice). She recently read Jones-
Cannon and Daviss (2005) research study Intrapersonal factors
that examined the coping strategies of African Physiological: Gloria experiences occasional
American daughters who have functioned as signs and symptoms of increased anxiety
caregivers. In their study, African American such as rapid heart rate and increased
caregivers of a family member with dementia blood pressure.
or a stroke believed that attending support Psychological: Gloria occasionally worries
groups and knowing that their parent needed about the future, but she tries to focus on
them influenced their caregiving experience the present and prides herself on her
positively. Most caregivers identified that sense of humor.
religion gave them a strong tolerance for the Sociocultural: Gloria values her belief that
caregiving situation and served to mediate African American families take care of
strain. Caregivers who voiced a lack of sup- their elderly.
port from family, especially siblings, had Developmental: Gloria is in Ericksons
much anger and resentment. (1959) developmental stage of middle
The nurse used this new knowledge to adulthood with its crisis of generativity
enhance the nursing process with Gloria. versus stagnation. She strives to look out-
Through using the Neuman Systems Model side of herself to care for others.
Assessment and Intervention Tool she learned Spiritual: Gloria reports that religion, faith,
that Gloria is a 52-year-old divorced African and prayer help her cope with caregiving
American woman who is employed full-time demands.
by a company for which she enjoys working. Interpersonal factors
She also has a teenage daughter who lives Physiological: Gloria occasionally has inter-
with her, and a grown son who lives away rupted sleep when her mother awakens
from home. Gloria attends the Baptist church and wanders during the night.
in her neighborhood 2 or 3 times a week, and Psychological: Gloria reminds herself when
attributes this experience to her ability to care physically caring for her mother that this
for her mother. is an expected part of her mothers aging.
The nurse assessed for stressors as they Sociocultural: Gloria is the full-time caregiv-
were perceived by Gloria and by herself. The er of her mother who has Alzheimers
nurse assessed for discrepancies between disease. She works full-time with sup-
their perceptions and found none. She iden- portive people, but does not attend an
tified the intrapersonal, interpersonal, and Alzheimers support group because she
extrapersonal factors that made up Glorias didnt know anything about them.
environment. To ensure the assessment was Developmental: Gloria has significant
wholistic and comprehensive she identified relationships with her co-workers.
the physiological, psychological, sociocultural, Spiritual: Gloria is supported by her pastor
developmental, and spiritual variables for and friends at church.

Continued
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194 S E C T I O N III Conceptual Models/Grand Theories in the Interactive/Integrative Paradigm

Practice Exemplar cont.


Extrapersonal factors time. Together they planned nursing actions
Physiological: Gloria received the gift of a for primary prevention as intervention.
comfortable bed mattress from a co- The nurse also used the tool and nursing
worker that promotes her sleep. process to provide wholistic comprehensive
Psychological: Gloria shared that reading her care for Glorias mother, and the family client
Bible helps her think positive thoughts. system was strengthened. By strengthening
Sociocultural: Gloria earns $35,000/year. Glorias lines of defense, the nurse helped
Developmental: Gloria can feel in charge of strengthen Glorias mothers lines of defense.
the situation with a comfortable house The model is dynamic as the individual and
for her mom. family client systems are assessed continuously,
Spiritual: Gloria attends church services in leading to new diagnoses, goals, and inter-
her neighborhood 2 to 3 times per week ventions that promote optimal wholistic
The nurse applied the Neuman Systems comprehensive nursing care. The desired out-
Model nursing process format focusing on: come goal for Gloria in the case example was
(1) nursing diagnosis (based on valid database), optimal health retention.
(2) nursing goals negotiated with the client If this had been an actual problem of care-
including appropriate levels of prevention as giver role strain, they would have identified
interventions, and (3) nursing outcomes. secondary prevention as interventions and ter-
The nurse prepared a comprehensive list tiary prevention as interventions that would
of nursing diagnoses based on her wholistic activate resource factors (lines of resistance) to
and comprehensive assessment and then pri- protect Glorias basic structure (organ strength
oritized the list. She validated her findings or ability to cope). An example of each follows.
with Gloria to ensure that their perceptions Secondary prevention as intervention: Assist
were in agreement. Gloria to schedule respite care for a deter-
The nurse and Gloria identified Glorias mined period of time
full-time role as a caregiver for her mother Tertiary prevention as intervention: Provide
with Alzheimers disease as a significant stres- ongoing education at each visit about
sor. The nurse considered the research study by practical resources that will provide
Jones-Cannon and Davis (2005) that reported caregiver support.
that caregivers of a family member with
dementia believed attendance at a support The nurse would have continued to use the
group influenced their caregiving in a positive nursing process by implementing and evaluat-
way. One of the nursing diagnoses they deter- ing their plan; reassessing, as part of evaluation,
mined was risk for caregiver role strain. for a reduction or elimination of caregiver role
While this was identified as a risk, they both strain; and maintenance of system stability.
agreed there was not a supporting sign or Neuman refers to this as reconstitution.
symptom to validate the existence of caregiver Reconstitution represents the return and
role strain at this time. However, it was very maintenance of system stability, following
important to prevent this strain in the future. treatment of a stressor reaction, which may
The nurse recognized that their observa- result in a higher or lower level of wellness than
tions provided a glimpse of Glorias normal line previously. It represents successful mobilization
of defense, then they identified an immediate of energy resources (Neuman, 2002c, p. 324).
goal to strengthen her flexible line of defense. The desired outcome goals are for optimal
The goal is that Gloria will report that she health retention, restoration, and maintenance.
has participated in a monthly Alzheimer sup- In Neumans model high importance is placed
port group session by (date). They could have on validating nurse and client perceptions,
identified intermediate and future goals at that validating data, in Neumans model.
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C H A P T E R 1 2 Betty Neumans Systems Model 195

Application of the Neuman Systems Linda, CA; Los Angeles County Medical
Model to Nursing Education Center, Los Angeles, CA; Louisiana College,
Pineville, LA; Mansfield College, Mansfield,
Lowry (2002) discussed the history of the PA; Milligan College, Milligan, TN; Minnesota
Neuman Systems Model implementation in Intercollegiate Consortium, St. Olaf, MN;
educational programs using the model. The Neumann College, Aston, PA; Santa Fe Com-
acceptance and use of the Neuman Systems munity College, Gainesville, FL; Seattle
Model accelerated in the mid-1970s in the Pacific College, WA; Southern Adventist
United States when the National League for University, Collegedale, TN; St. Anselms
Nursing (NLN) mandated the use of a concep- College, Manchester, NH; Texas Womans
tual model for the nursing curriculum. Other University, Houston, TX; University of
schools of nursing adapted the model, includ- Nevada, Las Vegas, NV; and the University of
ing schools in Canada and San Juan, Puerto Tennessee, Martin, TN.
Rico. Over the next 10 years other schools fol- Additional nursing programs have been
lowed in Scandinavian countries, England, identified in the literature as users of the
Australia, Holland, Kuwait, Taiwan, and Thai- model. Practical nursing programs using
land. The NLN eliminated their requirement the model include Gulf Coast Community
for a specific conceptual framework for cur- College, Panama City, FL; and Santa
riculum development in the early 1990s. Some Fe Community College, Gainesville, FL.
faculties have adapted eclectic frameworks that Other associate degree nursing programs
retain some of the models concepts. that have used the model include Los
In the United States, practical nursing, Angeles Valley College, Van Nuys, California;
associate degree, diploma, baccalaureate, and and Yakima Valley Community College,
graduate and multilevel nursing programs Yakima, Washington (Glazebrook, 1995;
have chosen to use the Neuman Systems Hilton & Grafton, 1995; Klotz, 1995; Lowry,
Model as a curriculum framework or for 2002; Lowry & Newsome, 1995; Stittich,
selected courses. Schools chose the Neuman Flores, & Nuttall, 1995; Strickland-Seng,
model for the models consistency with the 1995).
schools philosophy related to the metapara- Educational programs in the United States
digm concepts of humans, environment, reported benefits with using the model. The
health, and nursing. model (1) facilitated cultural considerations in
Lowry (2002) conducted a study to deter- the curriculum related to the populations the
mine the current use of the model. Thirty- schools and graduates served (Stittich, Flores,
four programs in the United States and two & Nuttall, 1995); (2) provided a nursing
programs in other countries responded. The focus as opposed to medical focus (Lowry
following schools returned a survey and con- & Newsome, 1995); (3) included the concept
tinue to use the model: Athens Area Technical of clients as holistic beings (Lowry &
College, Athens, GA, California State Uni- Newsome, 1995); (4) allowed flexibility in
versity, Fresno, CA; Cecil Community Col- arrangement of content and conceptualization
lege, North East, MD; Central Florida Com- of program needs (Lowry & Newsome,
munity College, Ocala, FL; Douglas College, 1995); (5) was comprehensive and facilitated
Vancouver, British Columbia, Canada; Dutch seeing the person as composites of the five
Reformed College for Higher Education in variables; (6) provided a framework to study
the Netherlands; Gulf Coast Community individual illness and reaction to stressors;
College, Panama City, FL; Fitchburg State (7) was broad enough to allow educational
College, Fitchburg, MA; Holy Name College, programs to consider family as the context
Oakland, CA; Indiana UniversityPurdue within which individuals live or as the unit of
University, Ft. Wayne, IN; Lander University, care; (8) was a guide for comprehensive nurs-
Greenwood, SC; Loma Linda University, Loma ing practice with individuals, families, and
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196 S E C T I O N III Conceptual Models/Grand Theories in the Interactive/Integrative Paradigm

groups (Cammuso & Wallen, 2002); and July 25, 2008; de Kuiper, 2002; Engberg,
(9) considered the created environment. 1995; McCulloch, 1995; Vaughan & Gough,
Education programs have developed eval- 1995).
uation instruments to determine the effects De Kuiper (2002) described the use of the
of using the model as a framework for nursing Neuman Systems Model at the Dutch
knowledge. The curriculum evaluation instru- Reformed University in Holland. A new cur-
ment cited in the literature is the LowryJopp riculum was needed that would combine
Neuman Model Evaluation Instrument, a clear philosophy of nursing and a clear state-
which was developed to examine the efficacy ment about the Christian identity of the
of using the model at Cecil Community Col- school. After serious study, the Neuman
lege (Lowry & Newsome, 1995). The results Systems Model was selected. In Holland the
of a 5-year longitudinal study showed that the 19 schools of nursing are rated numerically
graduates used the model most of the time based on quality of education. Before the
when fulfilling roles of care provider and introduction of the model, the university fell
teacher. All classes in the study claimed col- in 12th place. After implementation, the uni-
leagues rarely knew, accepted, or encouraged versity topped the list for 3 consecutive years.
model use. Therefore, colleagues in work set- McCulloch (1995) reported that a survey of
tings tended to have a negative effect on the all Australian university programs showed
use of models. that 4 undergraduate programs used the mod-
International educational programs have el as the major organizational curriculum
used the model. Craig (1995b) reported on framework, and another 16 programs intro-
the experiences of 10 educational institu- duced undergraduate and postgraduate stu-
tions in Canada in six Canadian provinces: dents to the Neuman Model as one of several
the University of Saskatchewan, University models.
of Prince Edward Island, University of Cal- Vaughan and Gough (1995) found that
gary, Brandon University of New Brunswick, many nursing and midwifery students chose
Universit de Moncton, University of West- to use the model in their own practice in
ern Ontario, University of Windsor, Okana- the United Kingdom. They also reported
gan College, University of Toronto, and Uni- that Avon and Gloucestershire College of
versity of Ottawa. Reported model strengths Health used the model as the guiding prin-
included the holistic approach, which ciple behind curriculum development for
addressed levels of prevention that guided child care.
the student to focus on the client in his Engberg (1995) reported on colleges in
or her own environment. The model also Sweden. Most colleges throughout Sweden
assisted students to perform in-depth assess- use the Neuman Systems Model as the theo-
ments, to categorize comprehensive data, retical framework in the module of primary
and to plan specific interventions with the health in nursing education.
client. Students reported some difficulty in
understanding the complexity of the model Nursing Administration and the
and the developmental and spiritual vari- Neuman Systems Model
ables. In addition, they noted that it was not The Neuman Systems Model has been used to
always easy to differentiate between the lines guide nursing administration in the United
of defense and resistance or to assess the States. These settings include an interdiscipli-
degree of stressor penetration. The Neuman nary collaborative team across nine agencies,
Model is also being used in educational adult and childrens hospitals; a community
institutions in Holland, South Australia, the nursing center, a psychiatric hospital, a contin-
United Kingdom, Sweden, and Turkey uing care retirement community, and Okla-
(Eileen Gigliotti, personal communication, homa State Public Health Nursing (Frioux,
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C H A P T E R 1 2 Betty Neumans Systems Model 197

Roberts, & Butler, 1995; Lowry, Burns, must assume and be able to make shifts in
Smith, & Jacobson, 2000; Rodriguez, 1995; focus: patient/client as consumer, organiza-
Sanders & Kelley, 2002; Scicchitani, Cox, tion as consumer, and employee/staff as
Heyduk, Maglicco, & Sargent, 1995; Torakis, consumer. She included a blending of the
2002; Walker, 1995). concepts and principles for total quality
Sanders and Kelley (2002) acknowledge management and continuous quality improve-
the changes in administrative practice and ment to strengthen the collaboration between
the work environment to an integrated the health care provider and the client
health care system in a managed care mar- system toward achieving mutual goals. Her
ket, along with changes in expectations for work shows that a nursing framework is
health professionals. They maintain that effective in guiding an interdisciplinary
the primary role of the nurse administrator approach to preparing nursing and health
is to maintain system integrity by realigning care administrators.
the nursing or organizational system to Poole and Flowers (1995) reported on care
its internal and external environments. management. They demonstrated how the
Sanders and Kelley believe that problems Neuman Systems Model is used in case man-
and issues identified in this complex system agement of pregnant substance abusers. Kelley
require multidimensional, comprehensive, and Sanders (1995) used an assessment tool
and collaborative interventions to maintain, that intertwined the management process, the
restore, or revive the health of complex sys- Neuman Systems Model, and environmental
tems. An integrated framework with a more dimensions.
comprehensive approach to assessing and The Neuman Systems Model has been
resolving problems in nursing administra- used in diverse nursing administration set-
tion and to evaluate the total systems tings in other countries. Sanders and Kelley
response to stressors should be used by nurse (2002) reported that these settings included
administrators. public health in Canada and Wales, primary
Sanders and Kelley (2002) conducted an health care in Sweden, and psychiatric nurs-
integrative review of the literature regarding ing in the Netherlands. De Munck and
the Neuman Systems Model and administra- Merks (2002) reported that the Neuman
tion of nursing. As part of the review they Systems Model is being used to guide the
looked at published reports of administrative administration of nursing services at Emer-
research. They found studies on examination gis, Institute for Mental Health Care in
of the effects of environmental stressors on Holland and described the way in which it is
autonomy, stress, and burnout of staff nurses; being used.
and the effect of an educational program on
nurses attitudes. Value for the Future
Lowry, Burns, Smith, and Jacobson Neuman and Reed (2007) dialogued about
(2000) reported on a demonstration project projected applications of the Neuman
in one south Florida county designed to Systems Model in the year 2050. The value
develop interdisciplinary collaborative teams of the model is its wholistic perspective,
for delivery of health care across a continu- which is timeless and expansive in being
um of nine agencies, settings, and a hospital adaptable to all client care situations
that serves a predominately rural population (p. 112). Neuman speculated that the ideal
that included farm workers and used the nurse role will be one of coordinating client
Neuman Systems Model as the clinical prac- health care toward optimal wellness within
tice model. an identified interactive client system.
Hinton-Walker (1995) identified three Greater emphasis on in-depth assessment
categories of roles the nurse administrator of client needs for appropriate interventions
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198 S E C T I O N III Conceptual Models/Grand Theories in the Interactive/Integrative Paradigm

will be required. An organizing framework Networking to Enhance Applications


is imperative to categorize and highlight of the Model
gaps in knowledge, and to maintain conti-
There are opportunities to network with others
nuity of care over multiple venues and disci-
using the model in a variety of applications and
plines due to the increase in the amount
settings. One way is to attend a Neuman Sys-
of available data. With the increased techni-
tems Model International Symposium, which is
cal aspects of care, special consideration
held every 2 years. International scholars gather
needs to be given to client intra- and inter-
to share ideas, insights, innovations, practice,
personal needs to offset possible depersonal-
and research from the model. The Neuman Sys-
ization. Evidence-based practice and mid-
tems Model Web site provides the latest infor-
dle-range theory development will increase.
mation: http://neumansystemsmodel.org/.
With the identification of best practices
The Neuman Archives were established
there will be a need for a comprehensive
to preserve and protect the work of Betty
description of practice that allows for
Neuman and others working with the
critique and interpretation of evidence.
model. The archives are located at Neumann
According to Neuman and Reed, a great
College, Aston, Pennsylvania, and can be
need exists for unification, integration, and
accessed through contacts by telephone
validation of client healthcare processes on
(610-361-5206; 610-558-5545) or e-mail
a continuing basis into the future for
(CARRM@neumann.edu).
wholistic care (p. 113).

Summary
The Neuman Systems Model has been used the lay literature all catapulted the Neuman
for more than three decades, first as a teaching systems model into acceptance by the nursing
tool and later as a conceptual model to observe profession. These same values are very much
and interpret the phenomena of nursing and alive in todays world. If anything, there is more
health care globally. The model is well accepted emphasis on wholistic health and wholistic
by the nursing profession. The concept of nursing today than there was 37 years
client wholeness, the goal of optimal health ago (Neuman & Reed, 2007, p. 111). Addi-
and utilization of primary prevention strategies tional citations compiled by Fawcett (2002,
to maintain wellness, and popular thinking in pp. 364400) may be helpful to the reader.

References

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Verberk, F. (1995). In Holland: Application of the (3rd ed., pp. 415430). Norwalk, CT: Appleton &
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Chapter
13
Helen Erickson, Evelyn Tomlin,
and Mary Ann Swains
Theory of Modeling
and Role Modeling
H ELEN L. E RICKSON

Introducing the Theorist Introducing the Theorist


Overview of Modeling and My life journey, filled with challenges, oppor-
Role-Modeling Theory tunities, and choices, has helped me discover
Theoretical Constructs the essence of my Self, to understand my
Practice Applications Reason for Being, and uncover my Life Pur-
Practice Exemplar pose (Erickson, H., 2006a). The essence of my
References Self is reflected in my values and beliefs; my
Reason for Being is to learn that uncondition-
al acceptance is a key component of human
relationships; and my Life Purpose is to facil-
itate growth in others. These understandings
emerged as I wandered the pathways of my
life, sometimes joined with others and some-
times connected only to God. The following
paragraphs offer snippets of my journey and
an occasional glimpse into my Self and the
underlying philosophy of Modeling and Role-
Helen L. Erickson Mary Ann Swain
Modeling.
Born and raised in a north-central Michigan
town with one older brother and two younger
sisters, I grew up knowing that family relations
are essential. My father worked for the highway
department, often spending 12- to 24-hour
days building roads during the summer and
keeping them open in the winter. During my
early years, our mother took care of the family,
sewed clothes, and canned food needed to last
throughout the cold Michigan winter. Later,
she worked part-time as a retail clerk. My
sisters and I learned that women can do what-
ever they choose. Family recreation consisted of
evening croquet games, a Sunday afternoon
drive, picnics at one of the lakes, berry picking,
an occasional movie, family board games, and
reading. I learned that family connections, car-
ing about others, positive attitudes, respect for
202
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C H A P T E R 1 3 Helen Erickson, Evelyn Tomlin, and Mary Ann Swains MRM Theory 203

the environment, and hard work are basic units in the hospital, working in every unit
essentials of life. except the labor room. My appetite for learn-
I was 5 when World War II was declared. ing seemed insatiable. I learned about blind
Although too young to understand the full prejudice, discrimination, and the importance
implications of the war, I learned that it was of staying true to ones values and beliefs while
important to stand up for our beliefs and life negotiating a health care system. I also learned
principles. I remember sending letters to family that people have their own stories about their
members fighting overseas; our family gather- lives, stories that provide insight into their
ing around the radio for the news; rationing; needs and how we can help them.
and the sirens that notified us when we needed When we left Texas in 1959 with our first-
to go into a blackout. I also remember the born daughter, we returned to Michigan and
evening the siren declared the end of the war. extended family. I worked in a small commu-
Our family immediately went to town to join nity hospital and then in a home for the
the street celebrations. Everyone was excited handicapped for 2 years. I learned that people
and hopeful about the future. That evening I often considered unworthy or inadequate due
knew that nearly anything is possible if we are to liabilities acquired through birth or acci-
persistent, our goals have integrity, and we are dent were honest, loving people with integri-
honest with others and ourselves. ty often exceeding that of the more fortunate
From the time I was a preteen until I gradu- members of society. In 1960, we added one
ated from high school, I worked to earn my more child to our family, deepening my
own money. Some of my jobs included babysit- understanding of human nature and the
ting, keeping house for a family in need, wait- uniqueness of people.
ressing, and clerking. Each job was an opportu- In 1961, we moved to San German, Puerto
nity to learn about myself and each was a step Rico, where I worked as a dorm nurse for
toward nursing school. Although I was one of 3 months. Then, frustrated with the ineffi-
only four who took advanced math courses, no ciency of the system, I designed a health
one suggested that I should go to a college care system for Inter-American University
or university. Instead, I enrolled in a nursing (IAU). The president responded positively
diploma program at Saginaw General Hospital. and named me the director of the IAU Health
I loved nursing and knew I had been wise Care System for students, faculty, and fami-
in my choice of life work. I decided to become lies. In 1963 we enhanced our family with our
a missionary after I graduated, perhaps to go third child, first son.
to Africa or some place where I might help We moved to Ann Arbor, Michigan in
people! In my junior year I met my future 1964 so my husband could earn a PhD.
husband and his family. His father, Milton I worked as a staff nurse part time for a few
Erickson, well known for his work with hyp- months at St. Josephs Hospital, and then
nosis and mindbody healing, taught me that resigned so we could add yet one more member
people know more about themselves than to our family. In 1967, I resumed part-time
health care providers did, that their inner- staff nursing at the University of Michigan
knowing is essential to healing, and that we Hospital, primarily on medicalsurgical units,
can help them by facilitating them to reveal but sometimes floating to other units, often
their own view of the world. My projected life working extra shifts.
course changed; instead of moving to Africa, During my years of clinical experience
I committed to married life, moved to Texas I had developed a practice model that guided
and accepted the position of head nurse in the my professional activities. Determined to
emergency room of the Midland Memorial label and articulate what I had learned, to
Hospital, Midland, Texas. Little did I know be true about human nature and nursing,
that I was on a mission of my own! I entered the University of Michigans
For the next 2 years, I worked 6 days a week RN-BSN program in 1972. Although I had
and often did double shifts, floating to other nearly 16 years of experience, no credit was
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204 S E C T I O N III Conceptual Models/Grand Theories in the Interactive/Integrative Paradigm

awarded for past learning. However, we were where I assumed the role of professor of nurs-
allowed to earn credit by examination, and ing and chair of adult health nursing. During
clinical practice was acknowledged for experi- my tenure at The University of Texas, I served
enced nurses. Two years later I had earned a as vice-chair of the Faculty Senate, assistant
BSN, but realized that this credential did not dean for graduate affairs in the School of
validate me as an expert. Although I had been Nursing, chair of Adult Holistic Nursing,
recruited to work as a faculty member in conducted research on MRM, taught numer-
the RN-BSN program and to consult at the ous courses, and chaired several doctoral
University Hospital, I knew that I had to con- dissertations. When I retired in 1997, the
tinue my education to be able to articulate my Helen L. Erickson Endowed Lectureship
ideas further and to validate myself as an on Holistic Nursing was established at the
expert. University of Texas in Austin.
I entered the masters program in nursing Since 1997, I have served on the Board of
at the University of Michigan, enrolling in Directors, the American Holistic Nurses
both the medicalsurgical and psychiatric Certification Corporation (AHNCC), first
programs in 1974, and graduated in 1976. as a member and co-chair and then as
During this time, affirmed and supported by chair of the board. During this period of
Evelyn Tomlin, I talked freely about the nurs- time we launched AHNCC, developed two
ing model I had derived from practice. I also national certification processesincluding
labeled and articulated it, theorized and tested an examination for certification at the Basic
the Adaptive Potential Assessment Model, Level and another for certification at the
and worked with Mary Ann Swain testing Advanced Leveland an Endorsement
some of my hypotheses (Erickson & Swain, Program for schools of nursing that offer
1982). I continued my faculty position, curricula in holistic nursing. I have authored
advancing to chairman of the undergraduate or co-authored various chapters on MRM
program and assistant dean. After earning my and/or holistic nursing (Clayton & Erickson,
masters degree, I maintained these roles, 2006; Erickson, 1996, 2002, 2006be, 2007,
while expanding my research activities, con- 2008; Erickson, Erickson, & Jensen, 2006;
sulting, speaking, supervising graduate stu- Walker & Erickson, 2006), some of which
dents, and continuously working to merge are included in the second book on Modeling
theory, practice, and research. and Role-Modeling. I anticipate continued
Over the next 10 years, my model of nurs- involvement in the movement of holistic
ing acquired a life of its own. By the early nursing, recently recognized by ANA as a
1980s, I had received several speaking invita- nursing specialty.
tions, yet little had been written (Erickson,
1976; Erickson & Swain, 1982). Together Overview of Modeling
Evelyn, Mary Ann, and I further elaborated
and articulated some of the concepts. The title and Role-Modeling Theory
Modeling and Role-Modeling (MRM), first Modeling and Role-Modeling (MRM) is
coined by Milton Erickson, was selected as based in several nursing principles that guide
the best way to describe this work. The origi- the assessment, intervention, and evaluation
nal edition was printed in November, 1982 aspects of professional nursing. These princi-
(Erickson, Tomlin, & Swain, 2009), has had ples are reflected in the data collection cate-
eight reprints, and is now considered a classic gories (Erickson, Tomlin, & Swain, 2009,
by the Society for the Advancement of Mod- pp. 148168), and linked to intervention aims
eling and Role-Modeling (SAMRM). and goals (Erickson et al., 2009, pp. 168201).
I left Michigan in 1986, spent 2 years at Although both intervention aims and inter-
the University of South Carolina School of vention goals involve nursing actions, the
Nursing as associate dean of academic affairs difference between them is based in their
and then moved to the University of Texas purpose. Nursing interventions should have
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C H A P T E R 1 3 Helen Erickson, Evelyn Tomlin, and Mary Ann Swains MRM Theory 205

intent; nurses should aim to make something perspective of their circumstances. We aim to
happen when they interact with clients. At the learn how that individual describes the situa-
same time, there should be general markers tion, what he expects will happen, and his
that help us evaluate the efficacy of our inter- perceived resources and life goals. As we listen
ventions; these are called intervention goals. and observe, we interpret the information
Table 13-1 shows the relations among MRM based on the constructs embedded in the
principles of nursing, types of data needed to theory. Simplistically stated, modeling is the
practice this model, the aims of nursing process we use to build a mirror image of an indi-
actions, and specific goals. viduals worldview. This worldview helps us
understand what that person perceives to be
Modeling important, what has caused his problems, what
The modeling process involves an assessment will help him, and how he wants to relate to others.
of a clients situation. It starts when we initi- Table 13-2 shows the categories of data
ate an interaction with an individual and con- and the type of information needed in the
cludes with an understanding of that persons modeling process.

Table 13 1 Relations Among MRM Principles, Categories of Data, Intervention


Goals, and Aims
Principles Categories of Data Goals Aims
The nursing process requires Description of Develop a trusting and Build trust.
that a trusting and functional the situation functional relationship
relationship exist between between self and your
nurse and client. client.
Afliated-individuation is Expectation Facilitate a self- Promote clients
contingent on the individ- projection that is positive
uals perceiving that he or futuristic and positive. orientation.
she is an acceptable,
respectable, and worthwhile
human being.
Human development is (External) Promote afliated- Promote clients
dependent on the individuals Resource individuation with the control.
perceiving that he or she has potential minimum degree of
some control over life while ambivalence possible.
concurrently sensing a state
of afliation.
There is an innate drive (Internal) Promote a dynamic, Afrm and
toward holistic health that is Resource adaptive, and holistic promote clients
facilitated by consistent and potential state of health. strengths.
systematic nurturance.
Human growth is dependent (Internal) Promote (and nurture) Set mutual
on satisfaction of basic Resource coping mechanisms that goals that are
needs and is facilitated by potential satisfy basic needs and health directed.
growth-need satisfaction. permit growth-need satis-
faction.
Goal and life Facilitate congruent
tasks actual and chronologi-
cal development stages.
Adapted with permission from Erickson, H., Tomlin, E., & Swain, M. A. (Eds.). (2009). Modeling and role-modeling:
A theory and paradigm for nursing (p. 171). Cedar Park, TX: EST.
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206 S E C T I O N III Conceptual Models/Grand Theories in the Interactive/Integrative Paradigm

Table 13 2 Categories of Data and Purpose for Obtaining Data


Categories of Data Collection Purpose of Data Is to Obtain
Description of the Situation 1. An overview of clients perception of the problem
2. The etiology of the problem including stressors and
destressors
3. Clients perceived therapeutic needs
Expectations 1. Immediate expectations
2. Long-term expectations
Resource Potential 1. External: Social network, support system, and health
care system.
2. Internal: Self-strengths, adaptive potential, feeling states,
physiological states
Goal and Life Tasks 1. Current goals
2. Plans for future
Adapted with permission from Erickson, H., Tomlin, E., & Swain, M. A. (Eds.). (2009). Modeling and role-modeling: A
theory and paradigm for nursing (p. 119). Cedar Park, TX: EST.

Table 13-3 shows the priority given to the MRM model (Table 13-4; Erickson et al.,
information we collect. Primary data include 2009, pp. 148167). We interpret the mean-
information acquired directly from the client; ing of what has been provided and search for
secondary data include the nurses observa- linkages among the data that will help us
tions and information collected from the understand the clients worldview. As we ana-
family. Tertiary data include all information lyze the data, implications for nursing actions
collected from medical records and other emerge (Erickson et al., 2009, pp. 168220).
sources. Primary and secondary data are Nursing actions are then artistically designed
essential for professional practice while terti- with intent (i.e., the aims of interventions)
ary data are added as needed. and specific outcomes (i.e., intervention goals).
Our overall objectives are to help people find
Role-Modeling meaning in their experiences and to enhance
The role-modeling process requires both objec- their sense of well-being.
tive and artistic actions. First we analyze the The following sections elaborate each of
data using theoretical propositions in the these objectives. The first section addresses
the philosophical assumptions that underlie
this model; theoretical underpinnings follow
with implications for practice. Finally, the
global applications of MRM are presented.
Table 13 3 Sources of Information Philosophical Assumptions
Primary Source Clients self-care Nursing has a metaparadigm that includes
knowledge four extant constructs: person, environment,
Secondary Source Information from health, and nursing; sometimes social justice
family and nurses is added as a fifth construct (Schim, Benkert,
observations
Bell, Walker, & Danford, 2007). The opera-
Tertiary Source Medical records and tional definitions of these constructs provide
other information
related to clients case the context necessary to clarify how an indi-
viduals actions are unique to nursing as
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C H A P T E R 1 3 Helen Erickson, Evelyn Tomlin, and Mary Ann Swains MRM Theory 207

Table 13 4 Selected Theoretical Propositions in MRM Theory


1. Developmental task resolution is related to basic need status.
2. Growth depends on basic need status and is facilitated by growth need satisfaction.
3. Basic need satisfaction leads to object attachment.
4. Object loss leads to basic need decits.
5. Afliated-individuation is dependent on ones perception of acceptance and worth.
6. Feelings of worth result in a sense of futurity.
7. Development of self-care resources is related to basic need satisfaction.
8. Ability to mobilize coping resources is related to need satisfaction.
9. Responses to stressors are mediated by internal and external resources.
10. Ability to mobilize appropriate and adequate resources determines resultant health status.

opposed to the actions of another profession. though they are wholistic, we can break them
Although all nursing theories are developed down into systems, organs, and other parts.
and articulated within this context, our per- When we view them as holistic, we under-
sonal philosophy impacts how we define and stand that all the dimensions of the human
operationalize the constructs of nursing, and being are interconnected; what affects one part
therefore how we articulate our models has the potential to affect other parts. Our
(Erickson, 2010). For this reason, it is impor- holistic nature is manifested through our innate
tant to be clear about our own philosophical instincts and drives: instincts and drives neces-
beliefs and how they impact our conceptual sary for humans to maneuver through the
definitions and our theoretical models. Nurses pathways of their life journey. Table 13-5 pro-
can use clear philosophical statements to vides examples of each of these.
determine if the underpinnings of a theoreti- While some might argue that all animals
cal model are consistent with their own belief have an innate instinct to cope, and some have
systems (Erickson, 2010). When they are not, an innate ability to receive and interpret stim-
discrepancies among nursings philosophical uli, most would agree that not all animals
beliefs, the nurses personal belief system, and have an innate drive to receive stimuli in a
the theoretical propositions often create dis- cognitive form, acquire skills necessary to per-
sonance that impedes the nurses ability to use ceive and understand stimuli, to give and
the model (Erickson et al., 2009). receive feedback, or the freedom to speak,
The philosophical assumptions underlying or the freedom to choose. These latter charac-
the MRM theory and paradigm are described teristics are unique to the human species, are
in the text that follows. The first section pres- innate, and often motivate our behavior (Maslow,
ents MRMs orientation toward two of nurs- 1968, 1982). I have added one instinct
ings metaparadigm constructs: person and an inherent instinct for holistic well-being
environment. Health, nursing, and social jus- and two human drives: the drive for healthy
tice are described in the following sections. affiliated-individuation and the drive for self-
actualization. These instincts and drives affect
Person and Environment how we function as holistic beings. The holis-
Humans are inherently holistic. This means tic person is one in whom the whole is greater
that the parts are interconnected and dynami- than the sum of the parts, while a wholistic
cally interactive; what affects one part affects person is one in whom the whole is equal
another. This is different from the wholistic to the sum of the parts (Erickson, Tomlin, &
person wherein the parts are associated but Swain, 2009, pp. 45-46).
not necessarily interconnected or interactive As holistic beings, our mind, body, and spirit
(Fig. 13-1). When we approach people as are inextricably interrelated with continuous
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208 S E C T I O N III Conceptual Models/Grand Theories in the Interactive/Integrative Paradigm

Biophysical

and Spiritual D.G.P.I.


Biophysical Social
Genetic base
Cognitive Psychological

Psychological Cognitive

Social

The Holistic model The Wholistic model


Figure 13 1 Holism versus wholism.

feedback loops. Cells in each dimension can and vice versa. To agree that we are holistic is
produce stimuli affecting responses in cells of to believe that we are human beings, living in a
other dimensions. Cellular responses have the context that includes all that is within us
potential to become new stimuli, moving the and within our external environmentholistic
chain reaction around and among the dimen- beings, constantly in process both internally
sions of the human being. These interactions and externally. These dynamically interactive
are dynamic and ongoing. Because we have an dimensions cannot be separated without a loss
internal environment (i.e., within the confines of information about the person, a loss that
of our physical being) and an external environ- diminishes our ability to fully understand the
ment (i.e., outside the confines of the biopsy- persons situation. There are three strategies
chosocial being), external stimuli have the that facilitate a trusting-functional relation-
potential to create multiple internal responses, ship. Consider, for example, the student who

Table 13 5 Selected List of Human Instincts and Drives


Instincts Inherent in Human Nature To receive and interpret stimuli
To cope and adapt to stressors
To experience mindbodyspirit intraconnectedness, or
holistic well-being
Drives that Motivate Our Behavior To cognitively interpret stimuli
To acquire skills necessary to perceive and interpret stimuli
To give and receive feedback
To communicate freely
To choose and act freely
To experience balanced afliated-individuation
To be self-actualized
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C H A P T E R 1 3 Helen Erickson, Evelyn Tomlin, and Mary Ann Swains MRM Theory 209

states that she has the flu because she is too spiritual beings with an inherent drive to be
stressed; she had three exams, work, and no connected spiritually with our soul (Erickson
time to sleep. Although we all know influenza et al., 2009; Erickson, Erickson, & Jensen,
is caused by a virus, we also know that our abil- 2006). More specifically, our drive for individ-
ity to resist a virus depends on the status of our uation is to fulfill our psychosocial needs while
immune system at any given time. Couple that doing soul-work unique to our life journey.
with an understanding of how the mind and
body interact (i.e., psychoneuroimmunology) Health
and we can appreciate how influenza and stress Health is a matter of perception. It is a state
are related (Walker & Erickson, 2006). of well-being in the whole person, not just a
Humans are also inherently intuitive. We part of the person. It is not the presence,
know (at some level) what we need. We know absence or control of disease; ones ability to
what has made us sick, and what will help us get adapt; or ones ability to perform social roles.
well, grow, develop, and heal. We have instinc- Instead, it is a eudemonistic health that incor-
tual information about our own personhood porates all of these and more. It is a sense of
and our mindbodyspirit linkages. This infor- well-being in the holistic, social being. It
mation is called self-care knowledge. Our percep- includes ones perceptions of her life quality,
tions of what we have available to help us are her ability to find meaning in her existence,
called self-care resources. Self-care resources are and a capacity to enjoy a positive orientation
both internal and external. We have resources toward the future. As a result, personal per-
within ourselves as well as resources within our ceptions of health may differ from those of
external environment. Our actions, thoughts, others. It is possible for persons with no obvi-
biophysical responses, and behavior, that help ous physical problem to perceive a low level of
us get our needs met are our self-care actions. health, while at the same time others, taking
We are inherently social beings with an their last mortal breath, may perceive them-
innate drive to grow and develop, to become selves as very healthy. The perception of
the most that we can be, find meaning in our health status is always related to perceived
lives, fulfill our potential, and self-actualize. balance of affiliated-individuation.
However, we are very vulnerable. Our ability
to grow and develop is dependent upon Nursing
repeated satisfaction of our needs. We want and Nursing is the unconditional acceptance of the
need to be connected or affiliated to others in inherent worth of another human being.
some way. Simultaneously, we also need to When we have unconditional acceptance for
perceive ourselves as unique and individuated another person, we recognize that all humans
from these same people. We call this affiliated- have an innate need to be loved, to belong, to
individuation (Acton, 1992; Erickson et al., be respected, and to feel worthy. Uncondition-
2009, p. 47; 2006, pp. 182207). al acceptance of a person as a worthwhile
Our drive to be both affiliated and individ- being is not the same as accepting all behaviors
uated at the same time mandates a balance without conditions. It does mean, however,
between being connected while perceiving a that we recognize that behaviors are motivated
sense of ones self as a unique human being, by unmet needs. Our work, then, is to help
separate from others. We achieve our drive for people find ways to get their needs met with-
a balanced affiliated-individuation through out hurting or harming themselves or others.
our interactions with others. How well we We do this through nurturance and facili-
achieve this balance at any point in our life tation of the holistic person. Our goal is to
will determine how we relate to others in the help people grow, develop, and when neces-
following years. sary, to heal. We use all of our skills acquired
While we are social beings with a drive for through formal education as well as our own
affiliated-individuation with others, we are also innate ability to connect with others to help
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210 S E C T I O N III Conceptual Models/Grand Theories in the Interactive/Integrative Paradigm

them recover from illnesses and to live mean- Adaptive Potential. The Adaptive Potential
ingful lives. We do this from the beginning of Assessment Model (APAM; Fig. 13-2), first
physical life to the end, even as people are labeled in 1976 (Erickson, 1976; Erickson &
taking their last breath. Within this context, Swain, 1982; Erickson et al., 2009), was
our intent, or what we aim to facilitate when derived by synthesizing Selyes (1974, 1976,
we interact with another human being, is 1980, 1985) work with that of George Engel
important. (1964). Our Adaptive Potential has three
states: equilibrium, arousal, and impoverish-
Social Justice ment. Equilibrium, a state of nonstress or
As professional nurses, we are committed to eustress, represents maximum ability to mobi-
live by the ethics of our profession, to serve as lize resources. The individual in equilibrium is
advocates for our clients, and to serve the in a healthy balance between need demands
public as defined by our professional stan- and need resources.
dards. For nurses who use the MRM theory, Arousal and impoverishment are both
this means that we are committed to recog- stress states; needs are unmet, creating stres-
nize the individuals worldview as valid infor- sors and the related stress responses. However,
mation, to act on that information with the people in arousal are temporarily able to
intent of nurturing and facilitating growth mobilize their resources while those in
and well-being in our clients, and to practice impoverishment are not. Persons in the first
within the context of the Standards of Holis- group (arousal) need help solving their prob-
tic Nursing as defined by the American lem, finding alternatives. They tend to be
Holistic Nurses Association (AHNA, 2007) tense and anxious, but do not demonstrate
and recognized by the American Nurses depleted resources through the expression of
Association (ANA, 2008). fatigue and sadness. On the other hand,
impoverished people show the wear and tear
of prolonged stress. They have diminished
Theoretical Constructs physical resources and are fatigued and sad.
People have an innate instinct to cope and People in arousal are at risk for becoming
adapt to stressors and related stress responses impoverished and impoverished people are at
that confront us constantly. We adapt as much risk for depleting their resources, getting sick,
as we are able to, given our life situation. developing complications, and even dying
We need oxygen, glucose, protein, to (Barnfather, 1987; Barnfather & Ronis, 2000;
maintain our physical systems; we also need to Benson, 2006, pp. 242254; Erickson, 1976;
feel safe and to be loved. When these needs Erickson et al., 2009, pp. 7583; Erickson &
are perceived to be unmet, they create stres- Swain, 1982). As indicated, a persons ability
sors; stressors produce the stress response.
Stress responses can become new stressors
mandating still more responses, and so on
Equilibrium
(Benson, 2006, pp. 240266; Erickson, 1976;
Erickson et al., 2009). Many of our stress
responses are instinctual, a part of our human
Co
r
so

makeup; however, some have to be learned


pin
Str
es

g
es

and developed. As our needs are met, the


Str

pin

so
Co

stressors decrease and we are able to work


r

through the stress response.


Stressor
Adaptive Potential Arousal
Stress
Impoverishment
Our ability to mobilize resources at any Figure 13 2 The adaptive potential assessment
moment in time can be identified as our model.
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C H A P T E R 1 3 Helen Erickson, Evelyn Tomlin, and Mary Ann Swains MRM Theory 211

to cope is related to how well his or her needs repeatedly, need assets are built. Conversely,
are met at any given point in time. when the need is not met, the tension rises,
and need deficits emerge. When the tension
Human Needs continues, need deprivation exists. Need sta-
Human needs, classified as basic, social, and tus can be classified on a 05 scale ranging
growth needs, drive our behavior. They pro- from deprivation to asset status (Fig. 13-3).
vide motivation for our self-care actions and Growth needs are different. Because people
emerge in a quasi-hierarchical order. Physio- have an innate drive for self-actualization,
logical needs must be met to some degree growth needs emerge when basic needs are
before social needs emerge. Growth or higher- met (to some degree). Unmet growth needs
level needs emerge after the basic and social do not create tension unless they are related to
needs have been met to some degree. Table a basic need. Instead, satisfaction of growth
13-6 provides examples of each. For a more needs creates tension. The need increases in
detailed taxonomy of human needs, see intensity. Until one feels satiated, the need to
Erickson, H., 2006a, pp. 484485. continue to behave in ways that will meet growth
Basic needs are related to survival of the needs continues.
species. When they are unmet, tension rises,
motivating behavioral response(s) necessary Need Satisfaction and the Object
to decrease the tension. When self-care Attachment Process
actions decrease the tension, the need dissi- Objects that repeatedly meet humans needs
pates. When the need is completely satisfied, become attachment objects. These objects take
the tension disappears. When needs are met on significance unique to the individual, are

Table 13 6 Basic and Growth Needs Inherent to the Human Being


Classication
Hierarchical Level of Need Type of Need Purpose Examples
Basic Needs Physiolog- 1. Survival Required for Food, water, oxygen,
ical needs biological temperature control, etc.
homeostasis.
2. Stimulation Required for Activity, manipulation,
physical and exploration.
emotional
growth
Social 1. Safety and Required for Fair and predictable
needs security healthy growth world, safety from harm,
nurturing care.
2. Love and Required for Affection, kindness, mutual
belonging healthy growth/ trust, identity
development
3. Esteem and Required for Condence, respect,
self-esteem healthy growth/ dignity, attention,
development adequacy.
Growth Needs Required for Meaningfulness in life
continuous Playfulness
development Simplicity
Goodness and truth
Beauty
Adapted with permission from Erickson, H. (Ed.). (1975). An operational taxonomy of human needs. In: Erickson H. (Ed.).
(2006) Modeling and role-modeling: A view from the clients world. Cedar Park, TX: Unicorns Unlimited.
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212 S E C T I O N III Conceptual Models/Grand Theories in the Interactive/Integrative Paradigm

Deprivation Deficit Unmet Met Satisfied Assets (Fig. 13-4). Grief resolution occurs as the
0 1 2 3 4 5 individual finds new ways to view the lost
Figure 13 3 The needs status scale, 05. object or finds alternative objects that meet their
needs. Commonly accepted processes of grief
include sequential phases of shock/disbelief,
both human and nonhuman, have a physical anger, bargaining, sadness, and acceptance
form (so they stimulate one of the five senses) (Kbler-Ross). Other models (Engel, Bowlby)
or are abstract (such as an idea) and are nec- indicate slightly different phases (Erickson, M.,
essary throughout life. When a person per- 2006, p. 229). Table 13-7 compares three of
ceives that the object is or will be lost, a griev- these models. I believe that their differences
ing response occurs. Loss is a subjective are based in the nature of the lost object, its
experience known by the individual; it can be meaning to the individual, and the resources
real, threatened, or perceived. Any loss pro- accrued before the experienced loss. Resources
duces a grieving process. Ones difficulty in are based upon ones ability to work through
resolving the loss depends on the significance the normal developmental tasks encountered
of the lost object. during the human journey. This issue is dis-
The grieving response is normal, occurs in cussed further in the text that follows.
a predetermined sequence, and is self-limited. Attachment to new objects is necessary for
Normal grieving processes take about 1 year continued growth and grief resolution. The

Health-
High level
promoting
wellness
behaviors

Secure Resolution
attachment Positive of loss with
Satisfied
to object developmental reattachment
needs
meeting residual and satisfied
needs needs

Situational of
Basic Holistic
developmental
needs well-being
loss and grief

Insecure
attachment Nonresolution
Negative
Unmet with continued of loss with
developmental
needs unmet needs continued
residual
and morbid unmet needs
grief

Health Physical and


impeding psychological
behaviors problems

Figure 13 4 The needsattachmentdevelopmentlossreattachment model.


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C H A P T E R 1 3 Helen Erickson, Evelyn Tomlin, and Mary Ann Swains MRM Theory 213

Table 13 7 Stages of Grief According to Contributing Authors


Engel Kbler-Ross Bowlby
Shock/disbelief Denial/shock
Awareness Anger/hostility Protest
Resolution Bargaining
Loss resolution Depression Despair
Idealization Acceptance Detachment
Italicized stages indicate unresolved loss with movement toward morbid grief.
Reprinted with permission from Erickson, H. (Ed.). (2006). Modeling and role-modeling: A view from the clients world
(p. 229). Cedar Park, TX: Unicorns Unlimited.

new object can be the same object, perceived less able to articulate the focus of their feel-
in a new way, or a completely new object. ings or recognize the loss that produced the
Sometimes transitional objects are used to grieving response in the beginning. They
facilitate this process. Transitional objects are often use language that describes giving-up
those that symbolize the lost object, and are rather than letting go, and sometimes express
never human, but are almost always concrete. nostalgia for the lost object. In contrast, those
For example, mothers attached to their chil- who have let go of the lost object, worked
dren as preschoolers often experience a loss through the normal grief response, and reat-
when their children start school and become tached to a new object can usually describe
increasingly independent. It is common to see the importance of moving on.
these mothers attach to their childs baby
shoes, pictures, or some other symbol of who Need Satisfaction and Life
they were in their previous life stage. Orientation
Morbid grief emerges when the individual The degree to which a persons needs are met
is unable to find alternative objects that will repeatedly determines how he or she relates to
repeatedly meet their needs. Because we are others; it effects their life orientation. When
holistic beings, morbid grief has the potential needs are met repeatedly, people are able to
to result in physical symptoms, illness, and grow and develop, to integrate mindbody
over the long period, disease. What happens spirit, perceive themselves as worthy human
in one part of the holistic person has the beings, and to experience a healthy balance of
potential of creating disease in another part, affiliated-individuation. When this happens,
disease that becomes distressful, mandates they are interested in others as individuals
mobilization of resources often not available, who are unique and worthwhile. They enjoy
and therefore producing alternative biophysi- both a sense of connectedness and a sense of
cal responses, depleting psychoneuroimmuno- individuation. Their life orientation is called a
logical resources (Erickson & Walker, 2006). being orientation because they are interested in
Behaviors that indicate emergence of mor- becoming all they can be and in participating
bid grief include an inability to move on and in the same way with others.
let go of the lost object, combined with vacil- However, when needs are repeatedly unmet,
lation between anger and sadness (Erickson, growth is limited and people have difficulty
M., 2006, pp. 209239; Lindeman, 1944, with their developmental processes. Their rela-
pp. 141148). Initially individuals are able to tionships with others exist within a context of
focus their anger and sadness, but with time, what can be obtained from the other. They are not
anger grows into hostility and sadness into interested in the well-being of the other, might
depression. When this happens, people are be threatened by growth in significant others,
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214 S E C T I O N III Conceptual Models/Grand Theories in the Interactive/Integrative Paradigm

and are intolerant of the uniqueness of others. mandate attention as they emerge. Our abili-
More interested in what they can get from ty to work on these developmental tasks
someone than what they can give, these people depends on our ability to mobilize resources.
often view others as a source of getting their basic Resources are derived by getting our needs
needs met. As a result, often unable to meet the met at any given time as well as our past expe-
needs of significant others, they are perceived as riences. Since our experiences are always con-
needy people. Their life orientation is called a textual, how we resolve our developmental
deficit orientation. Being and deficit orienta- tasks will determine the resources we have to
tions exist on a scale; most people have some of work on current tasks. As we work through a
both. The balance between the two is what stage-related task, a developmental residual is
determines ones overriding traits or personal produced. This residual includes positive and
attributes, ones values and virtues, and ones negative attributes, strengths, and virtues. In
ways of interacting with others. our original work, we followed Erik Eriksons
work to define eight stages, their tasks, and
Developmental Processes the associated residual. Our more recent work
People have an inherent drive for self- has modified work, expanding the stages to
actualization. This requires that they pass include one pre-birth and another at the time
through predetermined chronological devel- of death (Erickson, M., 2006, pp. 121181;
opmental stagesstages with tasks that Table 13-8).

Table 13 8 Developmental Stages, Residual, Virtues, and Strengths


Stages/Age Residual Virtue Strength(s)
Integration of Spirit Unity vs. duality Groundedness Awareness
(Prepost birth)
Building Trust Trust vs. mistrust Hope Drive toward future
(Birth15 months)
Acquiring Autonomy Autonomy vs. Will power Self-control
(1236 months) introspection
Taking Initiative Initiative vs. Purpose Drive
(27 years) responsibility
Developing Industry Competency vs. Competence Methodological
(513 years) inferiority problem-solving
Developing Identity Self-identity vs. Fidelity Devotion
(1130 years) role confusion
Building Intimacy Intimacy vs. Love Afliation with
(2050 years) isolation individuation
Developing Generativity vs. Caring Production
Generativity stagnation
(midlife to 60s)
Ego Integrity Ego integrity vs. Wisdom Renunciation
(60s to transformation) despair
Transformation Reconnecting vs. Oneness Peace, cosmic
(end of physical life) disconnecting understanding,
compassion
Adapted with permission from Erickson, H. (Ed.). (2006). Modeling and role-modeling: A view from the clients world
(Table 5.1, pp. 128129). Cedar Park TX: Unicorns Unlimited.
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Sequential Development become more fully connected with the multi-


Development occurs as a series of predeter- ple dimensions of their mind, body, and spirit,
mined stages with specific tasks in each stage. and as a result, they become more fully actu-
It is also chronological: unique, sequential alized. A caring-healing environment, created
stages, and their related tasks emerge during a by the nurses intent, fosters growth and well-
specific time frame in our lives. During that being in their clients.
time, the task becomes predominate in our Because people have inherent instincts and
life journey, drawing resources, focusing drives to grow, develop, and heal, when neces-
attention, and motivating behaviors. sary, all nursing actions focus on facilitation
and nurturance of these innate abilities. We
Epigenisis use ourselves to connect with our clients in such
a way that we can create trusting functional
Development is also epigenetic. Although
relationships with them, relationships that have
we have specific tasks that focus our atten-
a purpose or are aimed at some outcome. In the
tion at specific times in life, we also rework
MRM model, these relationships aim to
earlier life tasks and set the framework for
affirm their worth; help them mobilize and
later tasks at the same time. This later work
build resources needed to cope with their
is done within the context of the appointed life
stressors/stress; foster a hope for the future;
task. Simply stated, we repeatedly work on
and promote a sense of affiliated-individua-
all of the developmental tasks at every stage
tion. When people have these experiences, a
of life, although we have a key task that
sense of well-being follows. While we use
dominates at any given time. Our ability to
every professional skill we have acquired,
manage these multiple tasks is dependent on
these are secondary to using ourselves as heal-
the residual we have produced throughout
ing agents. As nurses, we nurture and facili-
the process and our current ability to have
tate people to become the most that they can
our needs met.
be. We help them actualize their life roles and
find meaning in their existence. When this
Linkages happens, it affects not only our clients, but it
Several major theoretical linkages exist in the also affects those who are significant in their
MRM model. Relations exist between/among: lives.
1. Adaptive potential and need status As nurses, every interaction with our
2. Need status, object attachment, loss, and clients and their loved ones provides us with
new attachment status. opportunities to affect the future; I call this
3. Developmental task resolution and need the long-arm affect (Erickson, H., 2006b,
satisfaction. p. 390). How we perceive our roles as nurses
will determine our intent. This in turn affects
Several theoretical propositions are derived what we do, how we interact, the focus of our
from these major linkages (see Table 13-4). work, and the outcomes of our relationships.
Many others exist, too numerous to list While we cannot always change what will
individually. happen in our lives or those of others, we can
set the intent to help people grow, heal, and
move on. J. M.s letter suggests that not only
Practice Applications did I help his family deal with a life tragedy,
We cannot cure people, but we can help them but I also helped them discover ways to find
heal and grow, even as they are taking their meaning in the experience. I helped them
first or last breath. When people heal they grow, heal, and to move on.
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216 S E C T I O N III Conceptual Models/Grand Theories in the Interactive/Integrative Paradigm

Practice Exemplar
A man who was the strong, dominant mem- death) notifying me that his mother had
ber of his family was lying in bed, inconti- died. He knew I would want to know that
nent, riddled with cancer and feeling hope- because of what they had learned from me,
less. When I learned that he no longer she was able to pass at home with her fami-
allowed his family to visit, I gently took his ly at her side, singing her favorite songs and
hand and told him I was happy to be his strumming on the guitar. He went on to
nurse that evening. He ...looked at me with state:
very sad eyes...[and said] that he didnt want
his family to see him in this condition. ...he In the year my Dad was with you people in
had always taken care of his family, and Ann Arbor, you were of incalculable aid and
now...he couldnt take care of himself comfort to both my parentsyou gave them
(Erickson, H., 2006a, p. 325). I rephrased his confidence in you and your staff, and the dig-
words, and then told him that although he nity and respect which makes life worth liv-
had been the bread-winner in the past and ing; no one else could, or did, more genuinely
that his family members had enjoyed that, all have their gratitude and respect. When I
they wanted now was to be with him, to share would come down and all seemed to be lost,
his life, that he was important because he the one bright spot was that Mrs. Erickson
loved them and they loved him. He agreed would be coming on, and we could breathe a
and for the next few days his family members little more easily as Dads anxiety visibly
took turns just being with him. On the third receded. Your kindness and humanity made
day when he quietly passed, he and his fami- the world a better place at that time and
ly were able to grieve with dignity and peace. without you the experience would have been
Eight years later I received a letter from more difficult than you probably believe.
his son (only 16 at the time of his fathers Thank you, J. M.

Initiating the Relationship Establishing a Mind-Set


I have found three sequential strategies, Establishing a mind-set involves three strate-
important for those using the MRM model: gies: centering, focusing, and opening. Center-
Establishing a Mind-Set, Creating a Nurturing ing helps to organize our resources so that we
Space, and Facilitating the Story (Erickson, can connect energetically with our client. It
H., 2006b, pp. 309317; Table 13-9). Each requires that we temporarily put aside other
can be done in seconds once the essence of the thoughts, worries, or concerns, and believe
strategy is understood. However, before you that at some level we can discover what we
can start, it is necessary to explore your own need to know to help our clients, and to focus
beliefs about human nature and nursing, and on the other with the intent of nurturing their
to consider how these affect your practice. growth and facilitating their healing. When
This helps you clarify how to get your needs we focus on our clients needs, we initiate an
meta prerequisite to meeting the needs of energetic connection, necessary for a caring
others. Unless we know how to initiate our healing environment.
own self-care, we have difficulty mobilizing
the energy necessary to focus on the needs of Creating a Nurturing Space
our clients. Finally, we have to open ourselves Creating a nurturing space follows naturally
to the worth of each individual, to uncondi- when we have established a mind-set. Our
tionally accept that each human has an inherent goal is to create a caringhealing environ-
need to be valued, to be treated with respect, and ment. Although one cannot force growth
to live with dignity. in others, we can create environments that
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Table 13 9 Three Strategies that Facilitate a TrustingFunctional Relationship


Establish a Mind-Set Self-care preliminaries Enhance sense-of-self.
Moving forward Center self.
Focus intent.
Open self to the essence of other.
Create a Nurturing Space Reduce distracting stimuli. Attend to sounds, lights, smells, and
other stimuli that are distracting and.
discomforting
Respect clients space. Recognize and respect clients physical/
energetic space.
Connect spirit to spirit. Use eye contact, soft tones, and gen-
tle touch to connect with client.
Facilitate the Clients Story Tap self-care knowledge. Address stimuli, encourage focus on
nurseclient linkage.
Relate to beliefs about clients self-care
knowledge as primary.
Encourage clients perceptions of the
situation.
Adapted with permission from Erickson, H. (Ed.). (2006). Modeling and role-modeling: A view from the clients world
(pp. 307317). Cedar Park, TX: Unicorns Unlimited.

nurture growth. We do this by decreasing comforting another human being. You will
adverse stimuli while increasing positive ones. also understand that how you touch, look, or
It is important to remember that you are speak to someone conveys a message about
entering the clients space and to respect it. your intent to comfort or not to comfort.
Even though you may think it is important
to close the door, turn on the radio, fluff Facilitating the Story
pillows, you will want to assess whether your Facilitating the story is the third strategy that
actions serve to comfort the client or not. MRM nurses use. Disclosure of our clients
Each of these processes helps you connect self-care knowledge provides basic informa-
with your client in such a way that you will tion needed before we can decide what nurs-
initiate a trusting relationship and create a ing actions are requiredinformation that
caringhealing environment. provides insight into their worldview. We
Any stimuli that affects the five senses has learn about their perceptions and beliefs, what
the possibility of being comforting, uncom- they believe about their current situation,
fortable, or discomforting. We can influence what they expect will happen, what resources
these by our actions in the milieu and by our they believe they have, and what they would
interactions with our client. For example, a like to do to alter the situation. It also allows
noisy hallway or bright lights shining in our them to ... contextualize life experiences and
eyes are stimuli that seem to drain energy present them in a way that softens associated
from us, and no doubt our clients experience feelings (Erickson, H., 2006b, p. 315).
the same thing. Or consider a beautiful pic- Our clients self-care knowledge is best
ture, the glimpse of a fully leafed tree swaying obtained by allowing them to tell their story
in a gentle breeze, soft music of our choice, in their own way. We use active listening
clean sheets against our skin, or the gentle to facilitate them. This can be done very
touch of a loving person. In thinking about quickly by initiating the discussion with
how you respond to these stimuli you will statements such as, Tell me about your situ-
understand that these have the possibility of ation followed by Why do you think this
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218 S E C T I O N III Conceptual Models/Grand Theories in the Interactive/Integrative Paradigm

has happened? or What do you think has them as draining rather than invigorating.
caused it? and How do you feel about We cannot always make these distinctions
that? and so forth (Erickson et al., 2009, without asking the client how they perceive
pp. 153167). The data are then organized their relationship with their significant other
into four distinct but interrelated categories: (Erickson et al., 2009, pp. 160163).
description of the situation, expectations, A persons story usually includes informa-
resource potential, and goals (see Table tion about interactions among the dimensions
13-2). Information provided by our clients of the holistic person, but nurses often have
has to be interpreted, aggregated, and analyzed trouble understanding the significance of
before we can use it to plan interventions what they have heard. For example, when
(Erickson et al., 2009, pp. 153168). people say they are sick because they are too
stressed, our first response might be to think
Understanding the Data about the cause and effect of diseasefor exam-
In data interpretation, we use the philosophi- ple, bacteria (not stress) causes infections.
cal and theoretical underpinnings discussed However, the MRM model supports a holistic
earlier as we attend to words, affects, and perspective; we know that mind and body are
nonverbal language, searching for evidence of inextricably interactive. Therefore, we recog-
coping potential (i.e., adaptive potential), nize that psychosocial stress stimulates the
needs status, and developmental residual. hypothalamicpituitaryadrenal axis interac-
Sometimes it is necessary to clarify what we tions, compromising the immune system.
observe to avoid superimposing our own When this happens, we have more difficulty
interpretations on these data. For example, fighting bacterial invasions. As a result, we
clients might have a spouse or significant oth- know that psychosocial stress has the poten-
er, but not perceive this individual as support- tial of causing signs and symptoms of physical
ive. When this happens, they often describe illness and/or disease.

Practice Exemplar
Most data are easy to understand although Mr. S. looked surprised and said that he
there are some that are symbolic of earlier didnt know what had made him think of that
losses. A middle-aged man I worked with a event and that he hadnt thought about it for
number of years ago had just been admitted years. When I asked him what he expected
to the hospital for a work-up. Mr. S. had would happen, he said that he guessed this
complained of chronic fatigue for the past meant that he was going to die. He went on to
6 months. An hour or so before I saw him, he say that he thought he had developed leukemia
had learned that he had acute leukemia. because he hadnt been responsible, and when he
When I asked him to tell me about his situa- wasnt responsible, people died. As we explored
tion he told me about his leukemia and then his resources he explained that he had been
launched into a story about his childhood. He promoted about 9 months ago and that his
described a time when he was about 16 years new job required skills he didnt think he had.
old, had been told to watch his younger sister, His conclusions were that he was sick because
and had let her ride a horse without supervi- he had worried himself to death. He also
sion. She fell off and was killed. He remem- stated that he didnt want his wife to come see
bered that his father told him that he had not him, that he needed to decide what he wanted
been responsible and that he needed to grow- to do first, and how he could take care of her
up and be a man. now that he was sick. When I asked if she or
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C H A P T E R 1 3 Helen Erickson, Evelyn Tomlin, and Mary Ann Swains MRM Theory 219

someone else could help him consider sound decisions, to be independent, to


options, he said no, that it was his responsibil- determine who he was as a unique human
ity to take care of himself. To understand being in society. He had learned that when
these data I needed to recognize that: he wasnt responsible, people died.
While he identified his wife as his
People who link new stressful experiences significant other, he was over-individuated.
to past experiences are usually dealing with He needed to decide how to tell his wife
a loss related to the past experience. In his case, about his problemhis problem of not
it was not only the loss of his sister, but also being responsible, not being a man. He
the meaning of the loss. As a 16-year-old boy, did not perceive that it was appropriate to
he was learning about his ability to make seek comfort from her or others.

The second phase, data aggregation, some- Although Mr. S. is chronologically in the
times occurs as we are interpreting data derived stage of Intimacy versus Isolation, his
from the primary source (i.e., the client), but not stressors are related to residuals from the
always. To aggregate the data accurately, we stage of Competency versus Limitations.
need to consider data derived from the second- Mr. Ss healthy affiliatedindividuation has
ary and tertiary sources as well as the data been threatened due to over-individuation.
derived from the client. Although data can be Mr. S. wished to be responsible to take
aggregated with only the clients story and the care of his wife.
nurses clinical knowledge, it is helpful to hear
the familys perspective also. Sometimes it is Proactive Nursing Care
also important to include the information col-
Often the process of assessing our clients world-
lected from tertiary sources.
view serves as a therapeutic intervention.
When aggregating data, we consider all
People in arousal commonly state that they
the information and look for consistencies as
feel much better after talking. Some will ask
well as inconsistencies across the sources of
for minimal help, but some require more
information. Additional information may be
sophisticated help. In any case, based on
necessary to clarify perspectives. Usually, this
our diagnoses, nursing care is planned
phase helps in determining what needs to be
within the context of the MRM principles
done when moving into the intervention
of care, aimed at facilitating well-being in
phase of the nursing process.
our clients, and designed specifically to meet
Data analysis is the next step. Again, you
intervention goals. We do this as we manage
may be doing all threeinterpreting, aggregat-
technical care such as wound management,
ing, and analyzingsimultaneously. During
intravenous insertion, and so forth. We use
the analysis phase you look for theoretical link-
nonjudgmental language, caring tones, and
ages among the data, make diagnoses. An
direct statements that relay information
example that follows the case described earlier
needed to feel safe and cared about. We also
would be:
use Ericksonian hypnotherapeutic techniques
Mr. S. is in arousal with unmet safety and to promote growth and facilitate healing
belonging needs, unresolved loss with mor- (Erickson et al., 2009, pp. 8485, 145147;
bid grief, and both positive and negative Erickson, H., 2006b, pp. 315317; 372374;
residual from adolescence on. Strong posi- Zeig, 1982).
tive residual from early childhood provides We can also do this without ever touching
some resources that could be mobilized the person because we use ourselves as conduits
with assistance. of healing energy. Sometimes knowing that
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220 S E C T I O N III Conceptual Models/Grand Theories in the Interactive/Integrative Paradigm

someone cares about us and our life helps us Global Applications of the Model
grow and heal. We project these messages
through our actions when we unconditionally The MRM theory and paradigm have been
accept the worth of another human being. recognized by AHNA as one of the extant
Watzlawick (1967) states that we cannot holistic nursing theories. It is used in a variety
not communicate. Our attitudes, nonverbal of settings including educational institutions
behaviors, and touch are often more impor- as a framework for entire programs or specific
tant than what we say when we convey our courses, hospitals to guide practice, and for
intent to help others heal and grow; words independent practice (Table 13-10). The Society
are not always necessary. Our demeanor, for the Advancement of Modeling and Role-
the way we look at the person, what we focus Modeling (mrmnursingtheory.org) was estab-
on first, and how we touch our clients relays lished in 1985 under the supervision of Car-
our intent. When we enter a relationship olyn Kinney and 32 others. Members meet
with the intent to comfort and nurture the biennially with retreats in the alternate year to
other person, our energy field connects achieve four major goals shown in Table 13-11.
with his; we convey presence and initiate a Several articles, chapters, and books have
caringhealing environment (Erickson, H., been published reporting the use of MMR
2006b, pp. 300324). across populations from pediatrics to the

Table 13 10 Agencies Using/Teaching MRM


Academic East Carolina University, Theoretical foundation for transition
Programs Greenville, North Carolina from RN to graduate student
Harding University, School of Nursing, Theoretical foundation for
Searcy, Arkansas pediatric clinical course
Humboldt State University, School of Theoretical foundation, BSN and
Nursing, Eureka, California RNBSN programs
Metro State University, School of Nursing, Theoretical foundation, and
St. Paul, Minnesota student advising
The College of St. Catherines, School of Theoretical foundation, ADN
Nursing, St. Paul, Minnesota Program
The University of Texas at Austin, School Theoretical foundation, the
of Nursing Alternate Entry Program
Washtenaw Community College, School Theoretical foundation, ADN
of Nursing, Ypsilanti, Michigan Program
Health Care Contemporary Health Care, Austin, Theoretical foundation for nursing
Agencies Texas practice
Oregon Health & Science University, Theoretical foundation for nursing
Portland, Oregon practice
Salina Regional Health Center, Salina, Theoretical foundation for nursing
Kansas practice
The University of Texas Health System, Theoretical foundation for nursing
San Antonio, Texas practice
The University of Tennessee Medical Theoretical foundation for nursing
Center, Knoxville, Tennessee practice
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C H A P T E R 1 3 Helen Erickson, Evelyn Tomlin, and Mary Ann Swains MRM Theory 221

Table 13 11 Goals Set by SAMRM, 1985


1. Promote the continuous study and integration of the theoretical propositions and philosophi-
cal foundations through research, practice, and continuous education.
2. Develop a network for the support, stimulation, and growth of the membership through
newsletters, conferences, and membership meetings
3. Disseminate knowledge and information through conferences and publication of conference
proceedings
4. Address societal needs by contributing to improvement of health care through proactive pro-
motion of holistic health.

Table 13 12 Practice/Intervention Studies Related to MRM Theory and Paradigm


Author Tested Source
Erickson, H., MRM and well-being Research in Nursing & Health,
& Swain, M. 5, 93101
(1982)
Walsh, K., van MRM applied to two clinical Journal of Advanced Nursing,
den Bosch, T., & cases 14(9), 755761
Boehm, S. (1989)
Finch, D. (1987) Clinical assessment of develop- Unpublished masters thesis, the
mental residual University of Michigan
Erickson, H., & MRM and hypertension Issues in Mental Health
Swain, M. (1990) reduction Nursing, 11(3), 217235
Finch, D. (1990) MRM nursing assessment model Modeling and Role-Modeling:
Theory, Practice and Research,
1(1), 203213
Kinney, C. (1990) Long-term effect of MRM on Issues in Mental Health
growth and development Nursing, 11, 375395
Erickson, H. (1990) MRM with mindbody problems In Brief Therapy, J. Zeig & S.
Gilligan
Barnfather, J. (1991) MRM and school nurse role Public Health Nursing, 8(4),
234238
Holl, R. (1992) MRM vs. contracting and Dissertation Abstracts Interna-
well-being tional, 53, 4030B
Holl, R. (1993) MRM vs. restricted visiting Critical Care Nursing Quarterly,
16(2), 7082
Webster, D., Vaughn, MRM and brief solution-focused Issues in Mental Health
K., Webb, M., & therapy Nursing, 16(6), 505518
Player, A. (1995)
Erickson, M. (1996) EMBAT and maternal well-being Issues in Mental Health
Nursing, 17, 185200
Sappington, J., & A case study Journal of Holistic Nursing,
Kelly, J. (1996) 14(2), 130141
Jensen, B. (1999) Caregiver responses to MRM Dissertation Abstracts Interna-
tional, B 56/06, 3127
Scheela, R. (1999) Remodeling sex offenders Journal of Psychosocial Nursing
and Mental Health Services,
37(9), 2531
Mayhew, P., Acton, Communication, dementia, and Gerontological Nursing, 22,
G., Yauk, S., & well-being 106110
Hopkins, B. (2001)
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222 S E C T I O N III Conceptual Models/Grand Theories in the Interactive/Integrative Paradigm

elderly (Table 13-12). Some describe MRM MRM in particular types of nursing, such as
in various settings ranging from critical care with clients with psychiatric concerns,
units, home health care, and independent employed mothers with preschool children,
practice. In addition, some (such as Noreen and undereducated adult learners. The MRM
Frisch, Jane Kelly, Gloria Weber, and Janet Web site provides a selected listing of these
Barnfather) have written about the use of publications (mrmnursingtheory.org).

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(2nd ed.). New York: D. Van Nostrand. Walker, M., & Erickson, H. (2006). Mind, body and
Maslow, A. (1982). The farthest reaches of human nature. spirit relations. In: H. Erickson (Ed.), Modeling
New York: D. Van Nostrand. and role-modeling: A view from the clients world
Schim, S., Benkert, R., Bell, S., Walker, D., & Danford, (pp. 6791). Cedar Park, TX: Unicorns Unlimited.
C. (2007). Social justice: Added metaparadigm Wazlawick, P. (1967). Pragmatics of human communica-
concept for urban health nursing. Public Health tion: A study of interactional patterns, pathologies, and
Nursing, 24(1), 7380. paradoxes. New York: W. W. Norton.
Selye, H. (1974). Stress without distress. Philadelphia: Zeig, J. (Ed.) (1982). Ericksonian approaches to hypnosis
J. B. Lippincott. and psychotherapy. New York: Brunner/Mazel.
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Chapter
14
Barbara Dosseys Theory
of Integral Nursing
B ARBARA M ONTGOMERY D OSSE Y

Introducing the Theorist Introducing the Theorist


Overview of the Theory Barbara Montgomery Dossey, PhD, RN,
How the Theory of Integral Nursing AHN-BC, FAAN, is internationally recog-
Guides Nursing Practice nized as a pioneer in the holistic nursing move-
Practice Exemplar ment. She is International Co-Director and
Summary board member of the Nightingale Initiative
References for Global Health (NIGH), Washington, DC
and Ottawa, Ontario, Canada, and Director,
Holistic Nursing Consultants in Santa Fe,
New Mexico. She is a Florence Nightingale
scholar and an author or co-author of 23
books. Her most recent books include Holistic
Nursing: A Handbook for Practice (5th ed.,
2008), Being with Dying: Compassionate End-
of-Life Care Training Guide (2007), Florence
Nightingale Today: Healing, Leadership, Global
Action (2005), and Florence Nightingale:
Barbara Montgomery
Dossey Mystic, Visionary, Healer (Commemorative
Edition, 2010).
Dosseys Theory of Integral Nursing (2008)
is considered a grand theory that presents the
science and art of nursing. Her collaborative
global nursing project, the Nightingale Decla-
ration Campaign (NDC), has developed a UN
Resolution proposal for adoptionrecognizing
the contributions of nurses globally as they
engage in the promotion of world health,
including the United Nations Millennium
Development Goals (MDGs). Barbara Dossey
is a Fellow of the American Academy of Nurs-
ing. She is certified in holistic nursing. She
is an nine-time recipient of the prestigious
American Journal of Nursing Book of the Year
Award. She was named the 1985 Holistic
Nurse of the Year by the American Holistic
Nurses Association and the 1998 Healer of
the Year by the Nurse Healers Professional
Associates International, Inc.; she received

224
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C H A P T E R 1 4 Barbara Dosseys Theory of Integral Nursing 225

the 1999 Pioneering Spirit Award from the and workplace? What am I doing locally that
American Association of Critical Care Nurses can impact the health and well being of
and the 1999 Scientific and Medical Network humanity and our Earth? How am I connected
Book of the Year award from the Scientific to my nursing colleagues and concerned citi-
and Medical Network, United Kingdom. In zens in my community, in other cities and
2001, she was recognized as TWU 100 Great nations? What is my calling?
Nursing Alumni, Texas Womans University, The Theory of Integral Nursing is a grand
Denton, Texas. In 2003, she received the theory that guides the science and art of inte-
Distinguished Alumna Award from Baylor gral nursing practice, education, research, and
University, Waco, Texas. With her husband, health care policy. It invites nurses to think
Larry, she received the 2003 Archon Award widely and deeply about an individuals per-
from Sigma Theta Tau International, the sonal health, as well as that of the local com-
international honor society of nursing, honor- munity and the global village. This theory
ing the contributions that they have made to recognizes the philosophical foundation and
promote global health. In 2004, Barbara and legacy of Florence Nightingale (18201910),
Larry also received the Pioneer of Integrative (Dossey, 2010; Dossey et al., 2005) healing
Medicine Award from the Aspen Center for and healing research, the metaparadigm of
Integrative Medicine, Aspen, Colorado. nursing (nurse, person(s), health, and envi-
Barbara Dossey is a Nightingale scholar ronment [society]), six patterns of knowing
and advocate. For the 72nd General Episco- (personal, empirics, aesthetics, ethics, not
pal Church Convention in Philadelphia knowing, sociopolitical), and several non-
July 1997, Barbara wrote three of five docu- nursing theories. It builds on existing theoret-
ments to accompany the Resolution Propos- ical work in nursing and on our solid holistic
al to request the reconsideration of Nightin- and multidimensional theoretical nursing
gales commemoration and for her name to foundation of other nurse theorists (see
be placed on the church calendar list of Acknowledgments); it is not a freestanding
Lesser Feasts and Fasts in the Book of Common theory. It incorporates concepts from various
Prayer. The official vote to accept Nightin- philosophies and fields that include holistic,
gale into the church calendar occurred in multidimensionality, integral, chaos, spiral
July 2000. The inaugural Florence Nightin- dynamics, complexity, systems, and many other
gale Commemorative Service was held on paradigms. See Acknowledgments. [Note:
August 12, 2001, at the Washington National Concepts specific to the Theory of Integral Nurs-
Cathedral, Washington, DC. To commemo- ing are in italics throughout this chapter. Please
rate the 100th year since Nightingales death consider these words as a frame of reference and a
in 1910, a Florence Nightingale Centennial way to explain what you have observed or expe-
Service will be held at the Cathedral April rienced with yourself and others.]
25, 2010, 4-5 PM. Integral nursing is a comprehensive integral
worldview and process that includes holistic
theories and other paradigms; holistic nursing
Overview of the Theory is included (embraced) and transcended (goes
As you begin to explore the Theory of Inte- beyond); this integral process and integral
gral Nursing, I invite you to reflect on the fol- worldview enlarges our holistic nursing knowl-
lowing questions: Why am I here? What is edge and understanding of bodymindspirit
my lifes purpose? How can I strengthen my connections and our knowing, doing, and
passion in nursing and in my life? Are my per- being to more comprehensive and deeper lev-
sonal and professional actions sourced from els. To delete the word integral or to substitute
my souls purpose and wisdom? What am I the word holistic diminishes the impact of the
currently doing to become more aware of my expansiveness of the integral process and inte-
personal health and the health of my home gral worldview and its implications.
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226 S E C T I O N III Conceptual Models/Grand Theories in the Interactive/Integrative Paradigm

The Theory of Integral Nursing includes (using green products, turning off lights when
an integral process, integral worldview, and not in the room, using water efficiently) and
integral dialogues that is praxistheory in simultaneously address our personal health and
action (Dossey, 2008a,b). An integral process the health of the communities where we live. In
is defined as a comprehensive way to organ- 2000, the United Nations Millennium Goals
ize multiple phenomena of human experi- were recommended to articulate clearly how to
ence and reality from four perspectives: (1) achieve health and decrease health disparities
the individual interior (personal/intentional); (United Nations, 2000). As we expand our
(2) individual exterior (physiology/behavioral); awareness of individual and collective states of
(3) collective interior (shared/cultural); and healing consciousness and integral dialogues,
(4) collective exterior (systems/structures). An we are able to explore integral ways of knowing,
integral worldview examines values, beliefs, doing, and being. We can unite 15 million nurs-
assumptions, meaning, purpose, and judg- es, midwives, and concerned citizens through
ments related to how individuals perceive the Internet to create a healthy world through
reality and relationships from the four per- many endeavors such as the Nightingale Decla-
spectives. Integral dialogues are transformative ration (Dossey et al., 2007; NIGH, 2007). You
and visionary exploration of ideas and possi- are invited to sign the Nightingale Declaration
bilities across disciplines where these four per- at http://www.nightingaledeclaration.net. Our
spectives are considered as equally important Nightingale nursing legacy, as discussed in the
to all exchanges, endeavors, and outcomes. next section, is foundational to the Theory of
With an increased integral awareness and an Integral Nursing and to understanding our
integral worldview, we are more likely to raise important roles as 21st-century nurses.
our collective nursing voice and power to
engage in social action in our role and work of Philosophical Foundation: Florence
service for societylocal to global. Nightingales Legacy
As you read this chapter, 15 million nurses Florence Nightingale (18201910), the philo-
and midwives are engaged in nursing and sophical founder of modern secular nursing
health care around the world (NIGH, 2007). and the first recognized nurse theorist, was an
Together, we are collectively addressing integralist. Her worldview focused on the
human healthof individuals, of communi- individual and the collective, the inner and
ties, of environments (interior and exterior) outer, and human and nonhuman concerns.
and the world as our first priority. We are She identified environmental determinants
educated and preparedphysically, emo- (clean air, water, food, houses, etc.) and social
tionally, socially, mentally, and spirituallyto determinants (poverty, education, family rela-
accomplish the required activities effectively tionships, employment), from local to global.
on the groundto create a healthy world. She also experienced and recorded her per-
Nurses are key in mobilizing new approaches sonal understanding of the connection with
in health education and health care the Divine, the awareness that something
delivery in all areas of the profession and greater than she, the Divine, was present in all
society as a whole. Theories, solutions, aspects of her life.
and evidence-based practice protocols can Nightingales work was social action that
be shared and implemented around the clearly articulated the science and art of an
world through dialogues, the Internet, and integral worldview for nursing, health care,
publications. and humankind. Her social action was also
We are challenged to act locally and think sacred activism (Harvey, 2007), the fusion of
globally and to address ways to create healthy the deepest spiritual knowledge with radical
environments (Dossey et al., 2005). For exam- action in the world. Nightingale was ahead of
ple, we can address global warming in our per- her time; her dedicated and focused 50 years
sonal habits at home as well as in our workplace of work and service still inform and impact
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C H A P T E R 1 4 Barbara Dosseys Theory of Integral Nursing 227

the nursing profession and our global mission patients and families, some of our greatest
of health and healing. In the 1880s, Nightin- teachers, we reflected on how to blend the art
gale began to write in letters that it would of caringhealing modalities with the science
take 100 to 150 years before sufficiently edu- of technology and traditional modalities.
cated and experienced nurses would arrive to I discussed these ideas with a critical care
change the health care system. We are that and cardiovascular nursing soulmate, Cathie
generation of 21st-century Nightingales who Guzzetta, PhD, RN, AHN-BC, FAAN. We
can transform health care and carry forth her began writing teaching protocols and present-
vision to create a healthy world. ing in critical care courses as well as writing
textbooks and articles with other contributors.
Personal Journey Developing My husband and I both had health
the Theory of Integral Nursing challengesmine was postcorneal transplant
As a young nurse attending my first nursing rejection, and my husbands challenge was
theory conference in the late 1960s, I was blinding migraine headaches. We both began
captivated by nursing theory and the eloquent to take courses related to bodymindspirit
visionary words of these theorists as they therapies (biofeedback, relaxation, imagery,
spoke about the science and art of nursing. music, meditation, and other reflective prac-
This opened my heart and mind to the explo- tices) and begin to incorporate them into our
ration and necessity to understand and use daily lives. As we strengthened our capacities
nursing theory. Thus, I began my profes- with self-care and self-regulation modalities,
sional commitment to address theory in all our personal and professional philosophies
endeavors as well as to increase my knowledge and clinical practices changed. We took
of other disciplines that could inform a deeper teaching seriously and integrated these modal-
understanding about the human experience. ities into the traditional health care setting
I realized that nursing was not an either that today is called integrative and integral
science or art, but both. From the begin- health care.
ning of my critical care and cardiovascular As a founding member in 1980 of the
nursing focus, I learned how to combine American Holistic Nurses Association
science and technology with the art of nurs- (AHNA), and with my AHNA colleagues,
ing. For example, for patients with severe pain our collective holistic nursing endeavors were
after an acute myocardial infarction, I gave recognized as the specialty of holistic nursing
pain medication while simultaneously guiding by the American Nurses Association (ANA)
them in a relaxation or imagery practice to in November 2006. The AHNA and ANA
enhance relaxation and release anxiety. I also Holistic Nursing: Scope and Standards of Prac-
experienced a difference in myself when I tice were published in June 2007 (AHNA &
used this approach to combine the science ANA, 2007). I believe that this important
and art of nursing. holistic specialty can now be expanded by
In the late 1960s, I began to study and using an integral lens.
attend workshops on holistic and mindbody- Beginning in 1992 in London, my Florence
related ideas as well as read in other disciplines Nightingale primary, historical research of
such as systems theory, quantum physics, inte- studying and synthesizing her original letters,
gral theory, and Eastern and Western philoso- army and public health documents, manu-
phy and mysticism. I was reading theorists scripts, and books, deepened my understanding
from nursing and other disciplines that of her relevance for nursing as Nightingale was
informed my knowing, doing, and being in indeed an integralist that is discussed later.
caring, healing, and holism. My husband, an This led to my Nightingale authorship (Dossey,
internist, who was caring for critically ill 2010; Dossey et al., 2005, 2008) and my col-
patients and their families, was with me on laborative Nightingale Initiative for Global
this journey of discovery. As we cared for Health and the Nightingale Declaration
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228 S E C T I O N III Conceptual Models/Grand Theories in the Interactive/Integrative Paradigm

(NIGH, 2007), the first global nursing internet American new-paradigm philosophers, to
signature campaign. My professional mission strengthen the central concept of healing. His
now is to articulate and use the integral process elegant, four-quadrant model was developed
and integral worldview in my nursing and over 35 years. In the eight-volume The Col-
health care endeavors and to explore rituals of lected Works of Ken Wilber (Wilber, 1999,
healing with many. My sustained nursing 2000), Wilber synthesizes the best known and
career focus with nursing colleagues on whole- most influential thinkers to show that no
ness, unity and healing and my Florence individual or discipline can determine reality
Nightingale scholarship have resulted in or lay claim to all the answers. Many concepts
numerous protocols and standards for practice, within this integral nursing theory have been
education, research, and health care policy. My researched or are in very formative stages of
integral focus since 2000, and my many con- development within integral medicine, inte-
versations with Ken Wilber and the integral gral health care administration, integral busi-
team and other interdisciplinary integral col- ness, integral health care education, and inte-
leagues, has led to my development of the The- gral psychotherapy (Wilber, 2000a,b, 2005a).
ory of Integral Nursing at this time. Within the nursing profession, other nurses
are exploring integral and related theories
Theory of Integral Nursing and ideas. When nurses use an integral lens,
Developmental Process and they are more likely to expand nurses roles
Intentions in transdisciplinary dialogues and to explore
The Theory of Integral Nursing advances the commonalities and differences across disci-
evolutionary growth processes, stages, and plines (Baye, 2007a,b; Clark, 2006; Fiandt
levels of human development and conscious- et al., 2003; Frisch, 2008; Jarrin, 2007; Quinn
ness toward a comprehensive integral philos- et al., 2003; Watson, 2005; Zahourek, 2008).
ophy and understanding. It can assist nurses
to map human capacities that begin with Content, Context, and Process
healing and evolve to the transpersonal self in
To present the Theory of Integral Nursing,
connection with the Divine, however defined
Barbara Barnums (Barnum, 2004) framework
or identified, in their endeavors to create a
to critique a nursing theorycontent, con-
healthy world.
text, and processprovides an organizing
The intention (purpose) in a nursing theory
framework that is most useful. The philo-
is the aim of the theory. The Theory of Inte-
sophical assumptions of the Dossey Theory of
gral Nursing has three intentions: (1) to
Integral Nursing are as follows:
embrace the unitary whole person and the
complexity of the nursing profession and 1. An integral understanding recognizes the
health care; (2) to explore the direct applica- individual as an energy field connected
tion of an integral process and integral to the energy fields of others and the
worldview that includes four perspectives of wholeness of humanity; the world is open,
realitiesthe individual interior and exterior dynamic, interdependent, fluid, and con-
and the collective interior and exterior; and tinuously interacting with changing vari-
(3) to expand nurses capacities as 21st-century ables that can lead to greater complexity
Nightingales, health diplomats, and integral and order.
nurse coaches for integral health, from local to 2. An integral worldview is a comprehensive
global. way to organize multiple phenomena of
human experience from four perspectives
Integral Foundation of reality: (a) individual interior (subjec-
and the Integral Model tive, personal); (b) individual exterior
The Theory of Integral Nursing adapts the (objective, behavioral); (c) collective interior
work of Ken Wilber, one of the most significant (interobjective, cultural); and (d) collective
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C H A P T E R 1 4 Barbara Dosseys Theory of Integral Nursing 229

exterior (interobjective, systems/


structures).
Healing
3. Healing is a process inherent in all living
things; it may occur with curing of symp-
toms, but it is not synonymous with curing.
Figure 14 1 A, Healing.
4. Integral health is experienced by a person
as wholeness with development toward
personal growth and expanding states of and being, and is a lifelong journey and
consciousness to deeper levels of personal process of bringing together aspects of oneself
and collective understanding of ones phys- at deeper levels of harmony and inner know-
ical, mental, emotional, social, and spiritual ing leading toward integration. This healing
dimensions. process places us in a space to face our fears,
5. Integral nursing is founded on an integral to seek and express self in its fullness where
worldview using integral language and we can learn to trust life, creativity, passion,
knowledge that integrates integral life and love. Each aspect of healing has equal
practices and skills each day. importance and value that leads to more com-
6. Integral nursing is broadly defined to plex levels of understanding and meaning.
include knowledge development and all Healing capacities are inherent in all living
ways of knowing. things. No one can take healing away from
7. An integral nurse is an instrument in life; however, we often get stuck in our heal-
the healing process and facilitates healing ing or forget that we possess it due to lifes
through her or his knowing, doing, and continuing challenges and perceived barriers
being. to wholeness. Healing can take place at all
8. Integral nursing is applicable in practice, levels of human experience, but it may not
education, research, and health care policy. occur simultaneously in every realm. In truth,
healing will most likely not occur simultane-
Content Components ously or even in all realms, and yet, the person
Content of a nursing theory includes the sub- may still have a perception of healing having
ject matter and building blocks that give a occurred (Gaydos, 2005).
theory its form. It comprises the stable ele- Healing embraces the individual as an
ments that are acted on or that do the acting. energy field that is connected with the energy
In the Theory of Integral Nursing the subject fields of all humanity and the world. Healing
matter and building blocks are (1) healing; is transformed when we consider four per-
(2) the metaparadigm of nursing; (3) patterns spectives of reality in any moment: (1) the
of knowing; (4) the four quadrants that are individual interior (personal/intentional), (2)
adapted from Wilbers (2000b) integral theory individual exterior (physiology/behavioral),
(individual interior [subjective, personal/ (3) collective interior (shared/cultural), and
intentional], individual exterior [objective, (4) collective exterior (systems/structures).
behavioral], collective interior [intersubjective, Using our reflective integral lens of these four
cultural], and collective exterior [interobjec- perspectives of reality assists us to more likely
tive, systems/structures]); and (5) Wilbers experience a unitary grasp on the complexity
(2000b) all quadrants, all levels, all lines that emerges in healing.
(Wilber, 2006). Healing is not predictable; it may occur
Content Component 1: Healing. The first with curing of symptoms, but it is not syn-
content component in a Theory of Integral onymous with curing. Curing may not
Nursing is healing, illustrated as a diamond always occur, but the potential for healing is
shape in Figure 14-1A. The Theory of Integral always present even until ones last breath.
Nursing enfolds from the central core concept Intention and intentionality are key factors
of healing. Healing includes knowing, doing, in healing (Engebretson, 1998; Zahourek,
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230 S E C T I O N III Conceptual Models/Grand Theories in the Interactive/Integrative Paradigm

2004). Intention is the conscious determina- strive to be integrally informed, they are more
tion to do a specific thing or to act in a spe- likely to move to a deeper experience of a con-
cific manner; it is the mental state of being nection with the Divine or Infinite, however
committed to, planning to, or trying to per- defined or identified. Integral nursing provides
form an action. Intentionality is the quality a comprehensive way to organize multiple
of an intentionally performed action. phenomena of human experience in the four
Content Component 2: Metaparadigm of perspectives of reality as previously described.
Nursing. The second content component in the The nurse is an instrument in the healing
Theory of Integral Nursing is the recognition process, bringing her or his whole self into
of the metaparadigm in a nurse theory: nurse, relationship to the whole self of another or a
person/s, health, and environment (society) group of significant others and thus reinforc-
(Fig. 14-1B). Starting with healing at the ing the meaning and experience of oneness
center, a Venn diagram surrounds healing and and unity.
implies the interrelation, interdependence, A person(s) is defined as an individual
and impact of these domains as each informs (patient/client, family members, significant
and influences the others; a change in one will others) who engages with a nurse in a manner
create a degree(s) of change in the other(s), that is respectful of a persons subjective expe-
thus impacting healing at many levels. These riences about health, health beliefs, values,
concepts are important to the Theory of Inte- sexual orientation, and personal preferences.
gral Nursing because they are encompassed It also includes an individual nurse who inter-
within the quadrants of human experience as acts with a nursing colleague, other health
seen in Content Component 4. care team members, or a group of community
An integral nurse is defined as a 21st-century members or other groups.
Nightingale. Using terms coined by Patricia Integral health is the process through which
Hinton Walker, PhD, RN, FAAN (Walker, we reshape basic assumptions and worldviews
2007) nurses endeavors of social action and about well-being and see death as a natural
sacred activism engage nurses as health process of the cycle of life. Integral health may
diplomats and integral nurse coaches that be symbolically seen as a jewel with many
are coaching for integral health. As nurses facets that is reflected as a bright gem or a
rough stone depending on ones situation
and personal growth that influence states of
health, health beliefs, and values. The jewel
may also be seen as a spiral or as a symbol of
transformation to higher states of conscious-
Nurse Health ness to more fully understand the essential
nature of our beingness as energy fields and
expressions of wholeness. This includes evolv-
ing ones state of consciousness to higher lev-
els of personal and collective understanding of
Healing
ones physical, mental, emotional, social, and
spiritual dimensions. It acknowledges the
individuals interior and exterior experiences
and the shared collective interior and exterior
Person/s Environment experiences with others where authentic power
(society) is recognized within each person. Disease and
illness at the physical level may manifest for
many reasons and variables. It is important
Figure 14 1 B, Healing and Meta-Paradigm of not to equate physical health, mental health,
Nursing. and spiritual health, as they are not the same
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C H A P T E R 1 4 Barbara Dosseys Theory of Integral Nursing 231

thing. They are facets of the whole jewel of patterns of knowing in nursing (Fig. 14-1C).
integral health. These six patterns of knowing are personal,
An integral environment(s) has both interior empirics, aesthetics, ethics, not-knowing, and
and exterior aspects. The interior environment sociopolitical. As a way to organize nursing
includes the individuals mental, emotional, knowledge Carper (1978) in her now classic
and spiritual dimensions including feelings and 1978 article, identified the four fundamental
meanings as well as the brain and its compo- patterns of knowing (personal, empirics,
nents that constitute the internal aspect of the ethics, aesthetics) followed by the introduc-
exterior self. It includes patterns that may not tion of the pattern of not-knowing by
be understood or may manifest related to vari- Munhall (1993), and the pattern of sociopo-
ous situations or relationships. These patterns litical knowing by White (1995). All of these
may be related to living and nonliving people patterns continue to be refined and reframed
and things, for example, a deceased relative, with new applications and interpretations
pet, lost precious object(s) that surface through (Averill & Clements, 2007; Barnum, 2003;
flashes of memories stimulated by a current sit- Burhardt, 2008; Chinn & Kramer, 2004;
uation (e.g., a touch may bring forth past Cowling, 2004; Fawcett et al., 2001; Halifax
memories of abuse, suffering). Insights gained et al., 2007; Koerner, 2007; McKivergin,
through dreams and other reflective practices 2008; Meleis, 2005; Newman, 2003). These
that reveal symbols, images, and other connec- patterns of knowing assist nurses in bringing
tions also influence ones internal environment. themselves into a full presence in the
The exterior environment includes objects that moment, to integrate aesthetics with science,
can be seen and measured that are related to and to develop the flow of ethical experience
the physical and social in some form in any of with thinking and acting.
the gross, subtle, and causal levels that are Personal knowing is the nurses dynamic
expanded later in Content Component 4. process of being whole that focuses on the
Content Component 3: Patterns of Knowing. synthesis of perceptions and being with self.
The third content component in a Theory It may be developed through art, meditation,
of Integral Nursing is the recognition of the dance, music, stories, and other expressions of

Personal Empirics

Not knowing Healing Socio-political

Aesthetics Ethics
Figure 14 1 C, Healing and
patterns of knowing in
nursing.
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232 S E C T I O N III Conceptual Models/Grand Theories in the Interactive/Integrative Paradigm

the authentic and genuine self in daily life and other key factors in theoretical, evidence-
nursing practice. based practice and research. This pattern
Empirical knowing is the science of nursing includes informed critique and social justice
that focuses on formal expression, replication, for the voices of the underserved in all areas of
and validation of scientific competence in society along with protocols to reduce health
nursing education and practice. It is expressed disparities. [Note: As all patterns of knowing in
in models and theories and can be integrated the Theory of Integral Nursing are superimposed
into evidence-based practice. Empirical indi- on Wilbers four quadrants these patterns will be
cators are accessed through the known senses primarily positioned as seen; however, they may
that are subject to direct observation, meas- also appear in one, several, or all quadrants and
urement, and verification. inform all other quadrants.]
Aesthetic knowing is the art of nursing that Content Component 4: Quadrants. The fourth
focuses on how to explore experiences and content component in the Theory of Integral
meaning in life with self or another that Nursing examines four perspectives for all
includes authentic presence, the nurse as a known aspects of reality, or expressed another
facilitator of healing, and the artfulness of a way, it is how we look at and/or describe any-
healing environment (Gaydos, 2004). It calls thing (Fig. 14-1D). Healing, the core concept
forth resources and inner strengths from the in the Theory of Integral Nursing, is trans-
nurse to be a facilitator in the healing process. formed by adapting Ken Wilbers integral
It is the integration and expression of all the model (Wilber, 2000b). Starting with healing
other patterns of knowing in nursing praxis. at the center to represent our integral nursing
By combining knowledge, experience, instinct, philosophy, human capacities, and global mis-
and intuition, the nurse connects with a sion, dotted horizontal and vertical lines illus-
patient/client to explore the meaning of a sit- trate that each quadrant can be understood as
uation about the human experiences of life, permeable and porous, with each quadrant
health, illness, and death. experience(s) integrally informing and empow-
Ethical knowing is the moral knowledge ering all other quadrant experiences. Within
in nursing that focuses on behaviors, expres- each quadrant we see I, We, It, and Its
sions, and dimensions of both morality and to represent four perspectives of realities that
ethics. It includes valuing and clarifying are already part of our everyday language and
situations to create formal moral and ethical awareness.
behaviors intersecting with legally prescribed
duties. It emphasizes respect for the person,
the family, and the community that encour-
ages connectedness and relationships that
enhance attentiveness, responsiveness, com- I It
e

Me
tiv

munication, and moral action. subjective objective


as
pr e

Not knowing is the capacity to use healing


ure

personal biological
Inter

able

presence, to be open spontaneously to the intentional behavioral


moment with no preconceived answers or
Healing
goals to be obtained. It engages authenticity,
We Its
Quali

mindfulness, openness, receptivity, surprise,


ve

mystery, and discovery with self and others in intersubjective interobjective


tati
t
ativ

the subjective space and the intersubjective cultural systems


nti

shared values structures


e

space that allows for new solutions, possibili-


ua
Q

ties, and insights to emerge.


Sociopolitical knowing addresses the impor-
tant contextual variables of social, economic, Figure 14 1 D, Healing and the four quadrants
geographic, cultural, political, historical, and (I, We, It, Its).
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C H A P T E R 1 4 Barbara Dosseys Theory of Integral Nursing 233

Virtually all human languages use first- we. So we can simplify first-, second- and
person, second-person, and third-person third-person as: I, we, it and its.
pronouns to indicate three basic dimensions These four quadrants show the four primary
of reality (Wilber, 2000b). First-person is the dimensions or perspectives of how we experi-
person who is speaking, which includes pro- ence the world; these are represented graphi-
nouns like I, me, mine in the singular, and we, cally as the upper-left (UL), upper-right (UR),
us, ours in the plural (Wilber, 2000b, 2005a). lower-left (LL), and lower-right (LR) quad-
Second-person means the person who is spo- rants. It is simply the inside and the outside of
ken to, which includes pronouns like you and an individual and the inside and outside of the
yours. Third-person is the person or thing collective. It includes expanded states of con-
being spoken about, such as she, her, he, him, sciousness where one feels a connection with
or they, it, and its. For example, if I am speak- the Divine and the vastness of the universe, the
ing about my new car, I am first-person, and infinite that is beyond words. Integral nursing
you are second-person, and the new car is considers all of these areas in our personal devel-
third-person. If you and I are communicating, opment and any area of practice, education,
the word we is used to indicate that we research, and health care policylocal to global.
understand each other. We is technically Each quadrant, which is intricately linked and
first person plural, but if you and I are com- bound to each other, carries its own truths and
municating, then you are second person and language (Wilber, 2000b). The specifics of the
my first person is part of this extraordinary quadrants are provided in Figure 14-1E.

Integral Model

Upper left Upper right


Individual interior Individual exterior
(intentional/personal) (behavioral/biological)

I space includes self and consciousness It space that includes brain and organisms
(self-care, fears, feelings, beliefs, values, (physiology, pathophysiology [cells, molecules,
esteem, cognitive capacity, emotional maturity, limbic system, neurotransmitters, physical
moral development, spiritual maturity, personal sensations], biochemistry, chemistry, physics,
communication skills, etc.) behaviors [skill development in health, nutrition,
exercise, etc.])

Subjective I It Objective
Interpretive Observable
Qualitative We Its Quantitative

Collective interior Collective exterior


(cultural/shared) (systems/structures)

We space includes the relationship to each Its space includes the relation to social
other and the culture and worldview (shared systems and environment, organizational
understanding, shared vision, shared meaning, structures and systems [in healthcare
shared leadership and other values, integral financial and billing systems], educational
dialogues and communication/morale, etc.) systems, information technology, mechanical
structures and transportation, regulatory
structures [environmental and governmental
policies, etc.]

Lower left Lower right

Figure 14 1 E, Integral Model and quadrants.


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234 S E C T I O N III Conceptual Models/Grand Theories in the Interactive/Integrative Paradigm

Upper-left (UL). In this I space (subjec- policies, etc.), any aspect of the technologi-
tive) can be found the world of the individ- cal environment, and the natural world.
uals interior experiences. These are the Integral nursing identifies the Its in the
thoughts, emotions, memories, perceptions, structure that can be enhanced to create
immediate sensations, and states of mind more integral awareness and integral part-
(imagination, fears, feelings, beliefs, values, nerships to achieve health and healing
esteem, cognitive capacity, emotional matu- local to global.
rity, moral development, and spiritual
We see that the left-hand quadrants
maturity). Integral nursing starts with I.
(UL, LL) describe aspects of reality as inter-
(Note: When working with various cultures,
pretive and qualitative (see Fig. 14-1D). In
it is important to remember that within many
contrast, the right-hand quadrants (UR, LR)
cultures, the I comes last or is never verbal-
describe aspects of reality as measurable and
ized or recognized as the focus is on the We
quantitative. When we fail to consider these
and relationships. However, this development
subjective, intersubjective, objective, and
of the I and an awareness of ones personal
interobjective aspects of reality our endeavors
values is critical.)
and initiatives become fragmented and nar-
Upper-right (UR). In this It (objective)
row, inhibiting our ability to reach meaning-
space can be found the world of the individ-
ful outcomes and goals. The four quadrants
uals exterior. This includes the material
are a result of the differences and similarities
body (physiology [cells, molecules, neuro-
in Wilbers investigation of the many aspects
transmitters, limbic system], biochemistry,
of identified reality. The model describes the
chemistry, physics), integral patient care
territory of our own awareness that is already
plans, skill development (health, fitness,
present within us and an awareness of things
exercise, nutrition etc.), behaviors, leadership
outside of us. These quadrants help us con-
skills, and integral life practices (see Process
nect the dots of the actual process to more
and Integral Nursing Principles), and any-
deeply understand who we are, and how we
thing that we can touch or observe scientifi-
are related to others and all things.
cally in time and space. Integral nursing
Content Component 5: AQAL (All Quad-
with our nursing colleagues and health care
rants, All Levels). The fifth content compo-
team members includes the It of new
nent in the Theory of Integral Nursing is the
behaviors, integral assessment and care
exploration of Wilbers all quadrants, all
plans, leadership and skills development.
levels, all lines, all states, all types or A-Q-
Lower-left (LL). In this We (intersubjec-
A-L (pronounced ah-qwul), as seen in Figure
tive) space can be found the interior collec-
14-1F. These levels, lines, states, and types are
tive of how we can come together to share
important elements of any comprehensive
our cultural background, stories, values,
map of reality. The integral model simply
meanings, vision, language, relationships,
assists us in further articulating and connect-
and to form partnerships to achieve a heal-
ing all areas, awareness, and depth in these
ing mission. This can decrease our fragmen-
four quadrants. Briefly stated, these levels,
tation and enhance collaborative practice
lines, states, and types are as follows.
and deep dialogue around things that really
matter. Integral nursing is built upon We. Levels: Levels of development that become
Lower-right (LR). In this Its space permanent with growth and maturity (e.g.,
(interobjective) can be found the world of cognitive, relational, psychosocial, physical,
the collective, exterior things. This includes mental, emotional, spiritual) that represent
social systems/structures, networks, organi- a level of increased organization or level of
zational structures, and systems (including complexity. These levels are also referred to
financial and billing systems in health care), as waves and stages of development. Each
information technology, regulatory struc- individual possesses both the masculine and
tures (environmental and governmental the feminine voice or energy. One is not
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C H A P T E R 1 4 Barbara Dosseys Theory of Integral Nursing 235

Spirit Casual

Mind Subtle

Body Gross

Personal Empirics

I It
subjective objective
personal Nurse Health biological

M ea
tive

intentional behavioral
Interpre

sureab
le
Not knowing Socio-political
Healing

ve
Qualitat

titati
Quan
We Its
ive

intersubjective Person/s Environment interobjective


cultural (society) systems
shared values structures

Aesthetics Ethics

Me Group

Us Nation

All of us Global
Figure 14 1 F, Healing and AQAL (all quadrants, all levels).

superior to the other; they are two equiva- beauty, and full meaning]; self-identity line
lent types at each level of consciousness [who am I?]; spiritual line [where spirit is
and development. viewed as its own line of unfolding, and not
Lines: Developmental areas that are known just as ground and highest state], and values
as multiple intelligences (e.g., cognitive line line [what a person considers most impor-
[awareness of what is]; interpersonal line tant; studied by Clare Graves and brought
[how I relate socially to others]; emotional/ forward by Don Beck (Beck, 2007) in his
affective line [the full spectrum of emotions]; Spiral Dynamics Integral that is beyond the
moral line [awareness of what should be]; scope of this article].
needs line [Maslows hierarchy of needs]; States: Temporary changing forms of
aesthetics line [self-expression of art, awareness (e.g., waking, dreaming, deep
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236 S E C T I O N III Conceptual Models/Grand Theories in the Interactive/Integrative Paradigm

sleep, altered meditative states [due to body of dense matter, but of a shifting to a
meditation, yoga, contemplative prayer, etc.]; light, energy, emotional feelings, and fluid and
altered states [due to mood swings, physiolo- flowing images. Examples might be in our
gy and pathophysiology shifts with disease/ shift during a dream, during different types of
illness, seizures, cardiac arrest, low or high bodywork, walks in nature, or other experi-
oxygen saturation, drug-induced]; peak ences that move us to a profound state of
experiences [triggered by intense listening bliss. The causal body is the body of the infi-
to music, walks in nature, love-making, nite that is beyond space and time. Causal
mystical experiences such as hearing voice also includes nonlocality where minds of indi-
of God or voice of a deceased person, etc.]. viduals are not separate in space and time
Types: Differences in personality and (Dossey, 1989). When this is applied to con-
masculine and feminine expressions and sciousness, separate minds behave as if they
development (e.g., cultural creative types, are linked regardless of how far apart in space
personality types, enneagram). and time they may be. Nonlocal consciousness
may underlie phenomena such as remote
This part of the Theory of Integral Nurs- healing, intercessory prayer, telepathy, premo-
ing (see Fig. 14-1F) starts with healing at the nitions, as well as so-called miracles. Nonlo-
center surrounded by three increasing concen- cality also implies that the soul does not die
tric circles with dotted lines of the four quad- with the death of the physical bodyhence,
rants. This part of the integral theory moves immortality forms some dimension of con-
to higher orders of complexity through per- sciousness. Nonlocality can also be both upper
sonal growth, development, expanded stages and lower quadrant phenomena.
of consciousness (permanent and actual mile- The LL, the We space, is the interior col-
stones of growth and development), and evo- lective dimension of individuals that come
lution. These levels or stages of development together. The concentric circles from the cen-
can also be expressed as being self-absorbed ter outward represent increasing levels of
(such as a child or infant) to ethnocentric complexity of our relational aspect of shared
(centers on group, community, tribe, nation) cultural values, as this is where teamwork and
to worldcentric (care and concern for all peo- the interdisciplinary and transpersonal disci-
ples regardless of race or national origin, col- plinary development occur. The inner circle
or, sex, gender, sexual orientation, creed, and represents the individual labeled as me; the
to the global level). second circle represents a larger group labeled
In the UL, the I space, the emphasis is on us; the third circle is labeled as all of us to rep-
the unfolding awareness from body to mind resent the largest group consciousness that
to spirit. Each increasing circle includes the expands to all people. These last two circles
lower as it moves to the higher level. may include people, but also animals, nature,
In the UR, the It space, is the external and nonliving things that are important to
of the individual. Every state of consciousness individuals.
has a felt energetic component that is The LR, the Its space, the exterior social
expressed from the wisdom traditions as three system and structures of the collective, is rep-
recognized bodies: gross, subtle, and causal resented with concentric circles. An example
(Wilber, 2000b, 2005). We can think of these within the inner circle might be a group of
three bodies as the increasing capacities of a health care professionals in a hospital clinic or
person toward higher levels of consciousness. department or the complex hospital system
Each level is a specific vehicle that provides and structure. The middle circle expands in
the actual support for any state of awareness. increased complexity to include a nation; the
The gross body is the individual physical, third concentric circle represents even greater
material, sensorimotor body that we experi- increased complexity to the global level where
ence in our daily activities. The subtle body the health of all humanity and the world are
occurs when we are not aware of the gross considered. It is also helpful to emphasize that
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C H A P T E R 1 4 Barbara Dosseys Theory of Integral Nursing 237

these groupings are the physical dynamics Spirit Casual


such as the working structure of a group of Mind Subtle
health care professionals versus the relational Body Gross
aspect that is a LL aspect, and the physical and
technical structural of a hospital or a clinic.
Integral nurses strive to integrate concepts
and practices related to body, mind, and spir-
it (the all-levels) in self, culture, and nature
(all quadrants part). The individual interior
and exteriorI and Itas well as the Healing
collective interior and exteriorWe and
Itsmust be developed, valued, and inte-
grated into all aspects of culture and society.
The AQAL integral approach suggests that
we consciously touch all of these areas and do
so in relation to self, to others, and the natu-
ral world. Yet to be integrally informed does Me Group
not mean that we have to master all of these
Us Nation
areas; we just need to be aware of them and
All of us Global
choose to integrate integral awareness and
Figure 14 1 G, Theory of Integral Nursing
integral practices. Because these areas are
(healing, metaparadigm, patterns of knowing in
already part of our being-in-the-world and nursing, four quadrants, and AQAL).
cannot be imposed from the outside (they are
part of our makeup from the inside), our chal-
lenge is to identify specific areas for develop-
ment and find new ways to deepen our daily
integral life practices. participation. This is a radical leap into holistic,
systemic, and integral modes of consciousness.
Structure Wilber also expands to a third-tier of stages of
The structure of the Theory of Integral Nurs- consciousness that addresses an even deeper
ing is shown in Figure 14-1G. All content level of transpersonal understanding that is
components are represented together as an beyond the scope of this chapter (Wilber,
overlay that creates a mandala to symbolize 2006).
wholeness. Healing is placed at the center,
then the metaparadigm of nursing, the pat- Context
terns of knowing, the four quadrants, and all Context in a nursing theory is the environ-
quadrants and all levels of growth, develop- ment in which nursing acts occur and the
ment, and evolution. [Note: Although the pat- nature of the world of nursing. In an integral
terns of knowing are superimposed as they are in nursing environment the nurse strives to be an
the various quadrants, they can also fit into other integralist, which means that she or he strives
quadrants.] to be integrally informed and is challenged to
Using the language of Ken Wilber (2000b) further develop an integral worldview, inte-
and Don Beck (Beck, 2007) and his Spiral gral life practices, and integral capacities,
Dynamics Integral, individuals move through behaviors, and skills. The term nurse healer is
primitive, infantile consciousness to an inte- used to describe that a nurse is an instrument
grated language that is considered first-tier in the healing process and a major part of the
thinking. As they move up the spiral of growth, external healing environment of a patient or
development, and evolution and expand their family. An integral nurse values, articulates,
integral worldview and integral consciousness, and models the integral process and integral
they move into what is second-tier thinking and worldview and integral life practices and
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238 S E C T I O N III Conceptual Models/Grand Theories in the Interactive/Integrative Paradigm

self-care. Nurses assist and facilitate the indi- fragmented. Collaborative practice has not
vidual person/s (client/patient, family, and been realized because only portions of reality
co-workers) to access their own healing process are seen as being valid within health care and
and potentials; they do not do the actual heal- society.
ing. An integral nurse recognizes her/himself The nursing profession asks nurses to wrap
as a healing environment interacting with a around all of life on so many levels with self
person, family, or colleague in a being with and others that we can often feel over-
rather than an always doing to or doing for whelmed. So how do we get a handle on all
another person, and enters into a shared expe- of life? The question always arises, How can
rience (or field of consciousness) that pro- overworked nurses and student nurses use an
motes healing potentials and an experience of integral approach or apply the Theory of
well-being. Integral Nursing? How do we connect the
Relationship-centered care is valued and complexity of so much information that aris-
integrated as a model of caregiving that is es in clinical practice? The answer is to start
based in a vision of community where three right now. Remember that healing, the core
types of relationships are identified: (1) patient concept in this theory, is the innate natural
practitioner relationship, (2) community phenomenon that comes from within a per-
practitioner relationship, and (3) practitioner son and reflects the indivisible wholeness, the
practitioner relationship (Tresoli, 1994). interconnectedness of all people, all things.
Relationship-based care is also valued as it This practice situation that follows addresses
provides the map and highlights the most these questions.
direct routes to achieve the highest levels Imagine that you are caring for a very
of care and serve to patients and families ill patient who needs to be transported to
(Koloroutis, 2004). the radiology department for a procedure.
The current transportation protocol between
Process the unit and the radiology department lacks
Process in a nursing theory is the method by continuity. In this moment, shift your feelings
which the theory works. An integral healing and your interior awareness (and believe it!)
process contains both nurse processes and to: I am doing the best that I can in this
patient/family and health care workers moment, and I have all the time needed to
processes (individual interior and individual take a deep breath and relax my tight chest
exterior), and collective healing processes of and shoulder muscles. This helps you con-
individuals and of systems/structures (interior nect these four perspectives as follows: (1) the
and exterior). This is the understanding of the interior self (caring for yourself in this
unitary whole person interacting in mutual moment); (2) the exterior self (using a
process with the environment. research-based relaxation and imagery inte-
gral practice to change your physiology);
(3) the self in relationship to others (shifting
How the Theory of Integral your awareness creates another way of being
with your patient and the radiology team
Nursing Guides Nursing member); and (4) the relationship to the exte-
Practice rior collective of systems/structures (consider-
The Theory of Integral Nursing can guide ing how to work with the radiology team and
nursing practice and strengthen our 21st- department to improve a transportation pro-
century nursing endeavors. It considers equally cedure in the hospital).
important data, meanings, and experiences Professional burnout is high, with many
from the personal interior, the collective nurses disheartened. Self-care is a low priority;
interior, the individual exterior, and the time is not given or valued within practice
collective exterior. Nursing and health care are settings to address basic self-care such as
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C H A P T E R 1 4 Barbara Dosseys Theory of Integral Nursing 239

short breaks for personal needs and meals. and feeling of connection in life. In the next
This is worsened by short staffing and over- section, four integral nursing principles are
time. Also, we do not consistently listen to the discussed that provide further insight into
pain and suffering that nurses experience how the Theory of Integral Nursing guides
within the profession, nor do we consistently nursing practice and meaning in practice. See
listen to the pain and suffering of the patient Figure 14-1F for specifics for each principle.
and family members or our colleagues. Often
there is a lack of respect for each other, with Integral Nursing Principle 1: Nursing
verbal abuse occurring on many levels in the Starts with I
workplace. Integral Nursing Principle 1 recognizes the
Nurse retention and a global nursing short- interior individual I (subjective) space. Each
age are at a crisis level throughout the world. of us must value the importance of exploring
As nurses deepen their understanding related ones health and well-being starting with our
to an integral process and integral worldview own personal work on many levels. In this I
and use daily integral life practices, we will space integral self-care is valued, which means
more consistently be healthy and model health that integral reflective practices become part
and understand the complexities within heal- of and can be transformative in our develop-
ing and society. This enhances nurses capaci- mental process. This includes how each of us
ties for empowerment, leadership, and acting continually addresses our own stress, burnout,
as change agents for a healthy world. suffering, and soul pain. It can assist us to
An integral worldview and approach can understand the necessity of personal healing
help each nurse and student nurse increase and self-care related to nursing as art where
her or his self-awareness, as well as the aware- we develop qualities of nursing presence and
ness of how self affects others, that is the inner reflection.
patient, family, colleagues, and the workplace Nurse presence is also used and is a way of
and community. As the nurse discovers her approaching a person in a way that respects and
or his own innate healing from within, he/ honors the persons essence; it is relating in a
she is able to model self-care and how to way that reflects a quality of being with and
release stress, anxiety, and fear that manifest in collaboration with. Our own inner work
each day in this human journey. All nursing also helps us to hold deeply a conscious aware-
curricula can be mapped in the integral quad- ness of our own roles in creating a healthy
rants so that students learn to think integrally world. We recognize the importance of
about how these four perspectives create the addressing ones own shadow as described
whole. by Jung (1981). This is a composite
of personal characteristics and potentials that
Meaning of the Theory have been denied expression in life and of
of Integral Nursing which a person is unaware; the ego denies the
for Practice characteristics because they are in conflict and
A key concept in the Theory of Integral incompatible with a persons chosen conscious
Nursing is meaning, which addresses that attitude.
which is indicated, referred to, or signified Mindfulness is the practice of giving atten-
(Dossey, 2003). Philosophical meaning is relat- tion to what is happening in the present
ed to ones view of reality and the symbolic moment such as our thoughts, feelings, emo-
connections that can be grasped by reason. tions, and sensations. To cultivate the capacity
Psychological meaning is related to ones con- of mindfulness practice one may include
sciousness, intuition, and insight. Spiritual mindfulness meditation practice, centering
meaning is related to how one deepens prayer, and other reflective practices such as
personal experience of a connection with the journaling, dream interpretation, art, music,
Divine, to feel a sense of oneness, belonging or poetry that leads to an experience of
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240 S E C T I O N III Conceptual Models/Grand Theories in the Interactive/Integrative Paradigm

non-separateness and love; it involves devel- is where bearing witness and loving kindness
oping the qualities of stillness and to be pres- manifest in the face of suffering and is part of
ent for ones own suffering that will also allow our integral practice. The realization of the
for full presence when with another. self and another as not being separate are
In our personal process, we recognize con- experienced; it is the ability to open ones
scious dying where time and thought is given heart and be present for all levels of suffering
to contemplate ones own death. Through a so that suffering may be transformed for
reflective practice one rehearses and imagines others, as well as for the self. A useful phrase
ones final breath to practice preparing for to consider is Im doing the best that I can.
ones own death. The experience prepares us Compassionate care assists us in living as well
to not be so attached to material things and as when being with the dying person, the
spending so much time thinking about the family, and others. We can touch the roots of
future but living in the moment as often as we pain and become aware of new meaning in
can and to live fully until death comes. We are the midst of pain, chaos, loss, grief, and also in
more likely to participate with deeper com- the dying process.
passion in the death process and to become An integral nurse considers transpersonal
more fully engaged in the death process. dimensions. This means that interactions
Death is seen as the mirror in which the entire with others move from conversations to a
meaning and mystery of life is reflectedthe deeper dialogue that goes beyond the individ-
moment of liberation. Within an integral per- ual ego; it includes the acknowledgment and
spective the state of transparency, the under- appreciation for something greater that may
standing that there is no separation between be referred to as spirit, nonlocality, unity, or
our practice and our everyday life is recog- oneness. Transpersonal dialogues contain an
nized. This is a mature practice that is wise integral worldview and recognize the role of
and empty of a separate self. spirituality that is the search for the sacred or
holy that involves feelings, thoughts, experi-
Integral Nursing Principle 2: Nursing ences, rituals, meaning, value, direction, and
is Built Upon We purpose as valid aspects of the universe. It is a
Integral Nursing Principle 2 recognizes the unifying force of a person with all that is
importance of the We (intersubjective) the essence of beingness and relatedness that
space. In this We space nurses come permeates all of life and is manifested in ones
together and are conscious of sharing their knowing, doing, and being; it is usually,
worldviews, beliefs, priorities and values related though not universally, considered the inter-
to working together in ways to enhance inte- connectedness with self, others, nature, and
gral self-care and integral health care. Deep God/Life Force/Absolute/Transcendent.
listening, the being present and focused with Within nursing, health care, and society,
intention to understand what another person there is much suffering (may be physical,
is expressing or not expressing is used. Bearing mental, emotional, social, spiritual), moral
witness to others, the state achieved through suffering, moral distress, and soul pain. We
reflective and mindfulness practices is also are often called upon to be with these
valued (Dossey, 2008a,b; Halifax et al., 2007). difficult human experiences and to use our
Through mindfulness one is able to achieve nursing presence. Our sense of We sup-
states of equanimity, that is, the stability of ports us to recognize the phases of suffer-
mind that allows us to be present with a good ingmute suffering, expressive suffering,
and impartial heart no matter how beneficial and new identity in suffering (Halifax et
or difficult the conditions; it is being present al., 2007). When we feel alone, as nurses, we
for the sufferer and suffering just as it is while experience mute suffering; this is an inabili-
maintaining a spacious mindfulness in the ty to articulate and communicate with others
midst of lifes changing conditions. Compassion ones own suffering. Our challenge in nursing
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C H A P T E R 1 4 Barbara Dosseys Theory of Integral Nursing 241

is to more skillfully enter into the phase of is also recognized, which is the perceived
expressive suffering where sufferers seek knowing of events, insights, and things without
language to express their frustrations and a conscious use of logical, analytical processes;
experiences such as in sharing stories in a it may be informed by the senses to receive
group process. Outcomes of this experience information. Integral nurses recognize love as
often move toward new identity in suffering the unconditional unity of self with others.
through new meaning-making wherein one This love then generates loving kindness and
makes new sense of the past, interprets new the open, gentle, and caring state of mindful-
meaning in suffering, and can envision a new ness that assist ones with nursing presence.
future. A shift in ones consciousness allows Integral communication is a free flow of verbal
for a shift in ones capacity to be able to and nonverbal interchange between and among
transform her or his suffering from causing people and pets and significant beings such as
distress to finding some new truth and God/Life Force/Absolute/Transcendent. This
meaning of it. As we create times for sharing type of sharing leads to explorations of meaning
and giving voice to our concerns, new levels and ideas of mutual understanding and growth
of healing may happen. and loving kindness. Intuition is a sudden
From an integral perspective, spiritual care insight into a feeling, a solution, or problem
is an interfaith perspective that takes into wherein time and actions and perceptions fit
account dying as a developmental and natu- together in a unified experience such as under-
ral human process that emphasizes meaning- standing about pain and suffering, or a moment
fulness and human and spiritual values. in time with another. This is an aspect that may
Religion is recognized as the codified and rit- lead to recognizing and being with the pattern
ualized beliefs, behaviors, and rituals that of not knowing.
take place in a community of like-minded
individuals involved in spirituality. Our chal- Integral Nursing Principle 3:
lenge is to enter into deep dialogue to more It Is About Behavior and Skill
fully understand religions different than our Development
own so that we may be tolerant where there Integral Nursing Principle 3 recognizes the
are differences. importance of the individual exterior It
Integral action is the actual practice and (objective) space. In this It space of the
process that creates the condition of trust individual exterior each person develops and
wherein a plan of care is co-created with the integrates her or his integral self-care plan.
patient and care can be given and received. Full This includes skills, behaviors, and action
attention and intention to the whole person, steps to achieve a fit body and to consider
not merely the current presenting symptoms, body strength training and stretching, and
illness, crisis, or tasks to be accomplished, rein- conscious eating of healthy foods. It also
forces the persons meaning and experience of includes modeling integral life skills. For the
community and unity. Engagement between integral nurse and patient it is also the space
an integral nurse and a patient and the family where the doing to and doing for occurs.
or with colleagues is done in a respectful man- However, the integral nurse also combines
ner; each patients subjective experience about her or his nursing presence with nursing acts
health, health beliefs, and values are explored. to assist the patient to access personal
We deeply care for others and recognize our strengths, to release fear and anxiety, and to
own mortality and that of others. provide comfort and safety. There is aware-
The integral nurse uses intention, the con- ness of conscious dying to assist the patient
scious awareness of being in the present who wishes to have minimal medication and
moment with self or another person to help treatment to stay as alert as possible while
facilitate the healing process; it is a volitional receiving comfort care until she or he makes
act of love. An awareness of the role of intuition their death transition.
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Integral nurses, with nursing colleagues inform and shape nursing practice, education,
and health care team members, compile the data research, and policylocal to globalto
around physiological and pathophysiological achieve a healthy world. The Theory of Inte-
assessment, nursing diagnosis, outcomes, plans gral Nursing engages us to think deeply and
of care (including medications, technical pro- purposefully about our role as nurses as we
cedures, monitoring, treatments, traditional face a changing picture of health due to glob-
and integrative practice protocols), imple- alization that knows no natural or political
mentation, and evaluation. This is also the boundaries.
space that includes patient education and
evaluation. Integral nurses co-create plans Practice
of care with patients, when possible combin- The Theory of Integral Nursing was pub-
ing caring-healing interventions/modalities and lished in this authors co-authored text in
integral life practices that can interface and 2008 and is currently being used in many
enhance the success of traditional medical clinical settings. The textbook clearly devel-
and surgical technology and treatment. Some ops the integral and holistic process and clin-
common interventions are relaxation, music, ical application in traditional settings. It
imagery, massage, touch therapies, stories, includes guidance about the use of comple-
poetry, healing environment, fresh air, sun- mentary and integrative interventions.
light, flowers, soothing and calming pictures,
pet therapy, and more. Education
The Theory of Integral Nursing can assist
Integral Nursing Principle 4: educators to be aware of all quadrants while
Its Is Systems and Structures organizing and designing curriculum, contin-
Integral Nursing Principle 4 recognizes the uing education courses, health education pre-
importance of the exterior collective Its sentations, teaching guides, and protocols. In
(interobjective) space. In this Its space most nursing curricula there is minimal focus
integral nurses and the health care team on the individual subjective I and the collec-
come together to examine their work, their tive intersubjective We; the emphasis is on
priorities, use of technologies and any aspect teaching concepts such as physiology and
of the technological environment, and create pathophysiology and passing an examination
exterior healing environments that incorpo- or learning a new skill or procedure. Thus the
rate nature and the natural world when pos- learner retains only small portions of what is
sible such as with outdoor healing gardens, taught. Before teaching any technical skills,
green materials inside with soothing colors, the instructor might guide a student or
and sounds of music and nature. Integral patient in an integral practice such as relax-
nurses identify how they might work ation and imagery rehearsal of the event to
together as an interdisciplinary team to encourage the student to be in the present
deliver more effective patient care and to moment.
coordinate care while creating external heal- At Quinnipiac University, Hamden,
ing environments. Connecticut, Cynthia Barrere, PhD, RN,
HNC and Mary Helming, PhD, RN,
AHN-BC introduced the Theory of Integral
Application of the Theory of Integral Nursing to their nurse educator colleagues
Nursing in Practice, Education, who use the theory in their holistic under-
Research, Health Care Policy, Global graduate and graduate curricula as they pre-
Nursing pare holistic nurses for the future. Darlene
The world is currently anchored in one of the Hess, PhD, NP, AHN-BC (Barrere, 2008)
most dramatic social shifts in health care his- has used the Theory of Integral Nursing in
tory, and the Theory of Integral Nursing can her Brown Mountain Visions consulting
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C H A P T E R 1 4 Barbara Dosseys Theory of Integral Nursing 243

practice to design an RN to BSN curriculum Health Care Policy


(Hess, 2008). Hess also uses the integral A Theory of Integral Nursing can guide us to
process in her private practice. Diane consider many areas related to health care
Pisanos, RNC, MS, NNP (Pisanos, 2008) policy. Compelling evidence in all of the
integrates integral theory and process to health care professions shows that the origins
organize her life and health coaching prac- of health and illness cannot be understood by
tice. Linda Bark, PhD, RN, MCC (Bark, focusing only on the physical body. Only by
2007) uses the integral theory and process in expanding the equations of health, exempli-
her As One Integral Coaching and holistic fied by an integral approach or an AQAL
nursing practice. approach to include our entire physical, men-
The Theory of Integral Nursing princi- tal, emotional, social, and spiritual dimensions
ples and the integral model were used in and interrelationships can we account for a
2006 to organize major concepts in an host of health events. Some of these include,
eight-day intensive integral end-of-life care for example, the correlations, between poverty,
professional training program at Upaya Zen poor health and shortened lifespan; job dis-
Center, Santa Fe, New Mexico (Halifax satisfaction and acute myocardial infarction;
et al., 2007). This training program balances social shame and severe illness; immune sup-
didactic presentations and experiential group pression and increased death rates during
process work. For every 90 minutes of bereavement; improved health and longevity
didactic, there is a related 90 minutes of as spirituality and spiritual awareness is
experiential integral process practices that increased.
reinforce the didactic.
Integral Theory is emerging as a distinct
academic discipline. More than 500 scholars Global Health Nursing
representing 50 different disciplines gathered The Theory of Integral Nursing can assist
at the First Biennial Integral Theory Confer- us as we engage in global health partner-
ence, Integral Theory in Action: Serving Self, ships and projects. Global health is the
Others & Kosmos held August 710, 2008, at exploration of the emerging value base and
JFK University in Pleasant Hills, California. new relationships and agendas that emerge
At the conference, the Theory of Integral when health becomes an essential compo-
Nursing was featured in a plenary session and nent and expression of global citizenship
panel. (Gostin, 2007; Karpf, 2009; WHO, 2007).
It is an increased awareness that health is a
Research basic human right and a global good that
A Theory of Integral Nursing can assist needs to be promoted and protected by the
nurses to consider the importance of quali- global community. Severe health needs
tative and quantitative research (Dossey, exist in almost every community and
2008a,b; Esbjorn-Hargens, 2006). Our nation throughout the world as previously
challenges in integral nursing are to described in the UN Millennium Goals
consider the findings from both qualitative (MDGs). Thus, all nurses must raise their
and quantitative data and always consider voices and speak about global nursing as
triangulation of data when appropriate. We their health and healing endeavors assist
must always value introspective, cultural, individuals to become healthier. As
and interpretive experiences, and expand Nightingale said... We must create a pub-
our personal and collective capacities of lic opinion, which must drive the govern-
consciousness as evolutionary progression ment instead of the government having to
towards achieving our goals. In other words, drive us.... an enlightened public opinion,
knowledge does emerge from all four wise in principle, wise in detail (Nightin-
quadrants. gale, 1892).
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Practice Exemplar
A nurse can use the Theory of Integral Nurs- executives and have problems with alcohol
ing in any clinical situation; it assists us to abuse. His two daughters are happily married
integrate the art and science of nursing simul- and each has two preschool children.
taneously with all actions/interactions. As One Sunday, J. D. placed second in a city
discussed previously, healing, the core con- marathon and was very disappointed he did-
cept, can occur on many levels (physical, nt win. On finishing a morning shower on
mental, emotional, social, spiritual). Having Monday morning after a restful nights sleep
an integral awareness and creating a space for before a scheduled international trip, J. D.
the possibility that healing can occur allows had severe back pain. He tried stretching
for a unique field of experience. As nurses exercises and the pain went away, so he relat-
engage in their own healing, reflective inte- ed it to a back strain from the marathon. He
gral practices, personal development and self- then drove to his office and collapsed onto
care, they literally embody a very special way the steering wheel after he parked his car. A
of being with others. That is, they walk their friend saw this and immediately called 911.
talk of caring-healing. There is a mutual He was taken to a nearby emergency room,
respect for self and others in each encounter where he was immediately assessed and sent
as the nurse is always part of the patients for cardiac catheterization where he received
external environment. (See Process section a stent to open the complete occlusion of his
and Integral Nursing Principles.) Even while right coronary artery. Later that night in the
giving medications and performing various CCU, his cardiologist confirmed from his
acute care technical skills, a nurses healing electrocardiogram that he had a severe inferi-
presence in each encounter can reflect a or myocardial infarction with cardiac irri-
being with and in collaboration with. tability; a few days later he developed peri-
Nurses must engage in their own develop- carditis secondary to the infarction.
ment and also personally experience the vari- His cardiac situation was even more com-
ous reflective practices (relaxation, imagery, plicated. His cardiologist informed him that
reframing) before engaging the patient in he also had an 80% blockage at the bifurca-
these practices. tion in his left anterior descending coronary
artery and circumflex that was in a difficult
Background place for a stent. Because he had excellent
J. D. is a lean, extroverted, competitive, 64 collateral circulation, he was placed on cardiac
64-year-old global energy corporate executive medications and told that he would be mon-
who travels internationally. J. D., an avid jog- itored over the next few months to determine
ger, had a recent executive physical with nor- if he needed further invasive procedures or
mal stress test and blood work and was possibly open heart surgery. He was started
declared a picture of good health. His father on gradual CCU cardiac rehabilitation.
and paternal grandfather both died of heart J. D. was very quiet when the nurse
attacks in their 60s. He eats a Mediterranean entered the room after the cardiologist left.
diet when possible and drinks several glasses The nurse had a hunch that J. D. might want
of wine with meals. He uses a treadmill or to talk about what he was experiencing. After
runs daily. J. D. has been a widower for a brief exchange, the nurse followed with fur-
2 years after a tragic head-on automobile ther exploration of the meaning and negative
accident in which his wife was hit by a DWI images that he conveyed. She asked him if he
driver. He has four grown children who live wanted to pursue some new ideas that might
in the same city who quarrel over loopholes in help him relax as well as his inner healing
their inheritance left by their mother and resources and strengths. He said that he
maternal grandmother. The two sons are both would. This encounter took 10 minutes.
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C H A P T E R 1 4 Barbara Dosseys Theory of Integral Nursing 245

Nurse: In your recovery now with your heart Nurse: This has nothing to do with drawing,
healing, how do you experience your but something usually happens when you
healing? place a few marks to create an image of
J. D.: There is this sac around my heart; every your words.
time I take a deep breath, my breath is cut J. D.: Do you mean the image of a broken vase?
off by the pain [pericarditis]. My heart is
He began to place an image on the paper.
like a broken vase. I dont think it is healing.
When halfway through with the drawing he
Nurse: I can understand some of your frus-
said, I know this sounds crazy, but my father
tration and concern. However, some impor-
had a heart attack when he was 63. I was vis-
tant things that are present right now
iting my parents. Dad hadnt been feeling
show me that you are better than when
well, even complained of his stomach hurting
you first came to the CCU. Your persistent
that morning. He was in the living room, and
chest pain is gone and your heartbeats are
as he fell, he knocked over a large Chinese
now regular, which shows that the stent is
porcelain vase that broke in two pieces. I can
very effective. If you focus on what is
remember so clearly running to his side. I can
going right, you can help your heart and
see that vase now, cracked in a jagged edge
lift your spirits. Let me share some ideas
down the front. He made it to the hospital,
so that you might be able to shift to some
but died 2 days later. You know, I think that
positive thoughts.
might be where that image of a broken heart
J. D.: I dont know if I can.
came from.
Nurse: I would like to show you how to breathe
more comfortably. Place your right hand on Nurse: Your story contains a lot of meaning.
your upper chest, and your left hand on your Remembering this image and event can be
belly, and begin to breathe with your belly. very helpful to you in your healing. What
With your next breath in, through your are some of the things that you are most
nose, let the breath fill your belly with air. worried about just now?
And as you exhale through your mouth, let J. D.: Dying young.
your stomach fall back to your spine. As you
Tears filled his eyes. I have this funny
focus on this way of breathing, notice how
feeling in my stomach just now. I dont want
still your upper chest feels.
to die. Im too young. I have so much to con-
J. D.: (After three complete breaths). This is
tribute to life. Ive been driving myself to
the easiest breathing Ive done today.
excess at work. I need to learn to relax and
Nurse: As you focused on breathing with
manage my stress and change my life.
your belly, you let go of fearing the dis-
comfort with your breathing. Can you tell Nurse: J. Each day you are getting stronger.
me more about the image you have of your This time over the next few weeks can be
heart as a broken vase? a time to reflect on what are the most
J. D.: I saw this crack down the front of my important things in your life. Whenever
heart right after the doctor told me about you feel discouraged, let images come to
my big arteries that have the 80% block- you of a beautiful vase that has a healed
age. This is very scary. crack in it. This is exactly what your heart
Nurse: (Taking a small plastic bag full of is doing right now. Even as we are talking,
crayons out of her pocket and picking up a the area that has been damaged is healing.
piece of paper). Is it possible for you to As it heals, there will be a solid scar that
choose a few crayons and draw your bro- will be very strong, just in the same way
ken heart using those images you just that a vase can be mended and become
talked about? strong again. New blood supplies also
J. D.: I cant draw. come into the surrounding area of your

Continued
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Practice Exemplar cont.


heart to help it heal. Positive images can what I need to think or feel about living. I
help you heal, because you send a different cant believe that Im using these words.
message from your mind to your body Well, its bigger than I thought. Its very
when you are relaxed and thinking about rough, like heavy jute rope tied in a knot
becoming strong and well. You help your across my chest. It has a sound like a rope
body, mind, and spirit function at their that keeps a sailboat tied to a boat dock.
highest level. Is it possible for you to once Im now rocking back and forth. I dont
again draw an image of your heart as a know why this is happening.
healed vase, and notice any difference in Nurse: Stay with the feeling, and let it fill you
your feelings? as much as it can. If you need to change
J. D.: Thanks for this talk. With a smile, he the experience, all you have to do is take
picked up several crayons and began to several deep breaths.
draw a healing image to encourage hope J. D.: Its filling me up. Where are these
and healing. sounds, feelings, and sensations coming
from?
When J. D. entered the outpatient cardiac
Nurse: They are coming from your wise, inner
rehabilitation program he was motivated to
self, your inner healing resources. Just let
learn stress management skills and express his
yourself stay with the experience. Continue
emotions. Two weeks into the program, J. D.
to use as many of your senses as you can to
did not appear to be his usual extroverted self.
describe and feel these experiences.
The cardiac rehabilitation nurse engaged him
J. D.: Nothing is happening. Ive gone blank.
in conversation, and before long, he had tears
Nurse: Focus again on your breath in and
in his eyes. He stated that he was very
feel the breath as you let it go. Can you
discouraged about having heart disease. He
allow an image of your heart to come to
said, It just has a grip on me. The nurse
you under that tight grip?
took him into her office and they continued
J. D.: It is so small I can hardly see it. Its all
the dialogue. After listening to his story, she
wrapped up.
asked J. D. if he would like to explore his feel-
Nurse: In your imagination, can you intro-
ings further. He nodded yes. This next session
duce yourself to your heart as if you were
took 15 minutes.
introducing yourself to a person for the
To facilitate the healing process, she
first time? Ask your heart if it has a name?
thought it might be helpful to have J.D. get
J. D.: It said hello, but it was with a gesture
in touch with his images and their locations
of hello, no words.
in his body. She began by saying, If it seems
Nurse: That is fine. Just say, Nice to meet
right to you, close your eyes and begin to
you, and see what the response might be.
focus on your breathing just now. She guided
J. D.: My heart seems like an old soul, very
him in a general exercise of head-to-toe
wise. This feels very comfortable.
relaxation, accompanied by an audiocassette
Nurse: Ask your heart a question for which
music selection of sounds in nature. As his
you would like an answer. Stay with this
breathing patterns became more relaxed and
and listen for what comes.
deeper, indicating relaxation, she began to
guide him in exploring the grip in his After long pause:
imagination.
Nurse: Focus on where you experience the J. D.: The answer is practice patience that I
grip. Give it a size, a shape, a sound, am on the right track, that my heart dis-
a texture, a width, and a depth. ease has a message, dont know what it is.
J. D.: Its in my chest, but not like chest pain. Nurse: Just stay with your calmness and inner
Its dull, deep, and blocks my knowing quiet. Notice how the grip has changed for
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C H A P T E R 1 4 Barbara Dosseys Theory of Integral Nursing 247

you. There are many more answers to know anything about them. I have
come for you. This is your wise self that grandkids that I rarely see. I get frustrat-
has much to offer you. Whenever you ed with my corporation as I feel we are
want, you can get back to this special kind contributing to environmental pollution.
of knowing. All you have to do is take the We (the corporation) can do more about
time. When you set aside time to be quiet changing this. You helped me identify
with your rich images, you will get more my needs and how I can contribute dif-
information. You might also find special ferently. I feel a new kind of ownership
music to assist you in this process. Your about my life.
skills with this way of knowing will
increase each time you use this process Evaluation and Outcomes
now that whatever is right for you in this Together the patient and the nurse evaluate
moment is unfolding, just as it should. In an encounter and determine whether the
a few moments, I will invite you back into relaxation and imagery experience were use-
a wakeful state. On five, be ready to come ful and discuss future outcomes. Such ses-
back into the room and feel wide-awake sions frequently open up profound informa-
and relaxed. One two three four tion and possibilities. To evaluate the session
eyelids lighter, taking a deep breath further, the nurse may again explore the sub-
and five, back into the room, awake and jective effects of the experience with the
alert, ready to go about your day. patient. Relaxation and imagery are integral
J. D.: Where did all that come from? Ive life practices for connecting with our unlim-
never done that before. ited capabilities and capacities. The patient
Nurse: All of these experiences are your can experience more self-awareness, self-
inner healing resources that are always acceptance, self-love, and self-worth. These
with you to help you recognize quality integral life practices can be transferred to
and purpose in living each day. All you daily life as resources for self-care. The best
have to do is take the time to remember to way to develop confidence and skill in using
use them and direct your self-talk and relaxation and imagery in a clinical setting is
images towards a desired outcome. If you for the nurse to embody these practices in
want, I can teach and share more of these her or his own life as a part of personal self-
skills. care and enrichment.
J. D.: Ever since my wife died I have had a Learning how to be authentic and fresh
sense of what is the meaning of my life, in interactions and in each moment can be
what is my purpose. Some days I feel like enhanced as we learn to bear witness by
I have lost my soul. I go through my days deep listening and simply noticing what is
doing and doing, and yes I do accomplish going on. It is so easy to get locked into our
a lot. But deep down I am not happy. I analytical logic that we block ourselves from
have been asking myself the question, reaching into our hearts and moving into
What am I doing...or NOT doing...that our intuitions or emotions. With time and
is feeding the problems I dont want and practice, we give space to what might
believing that I can find happiness out appear. Both good and negative thoughts
there. Today with you in this experience always contain some wisdom. After such a
a light switch got turned on in me. My patient encounter, it is a time to really
happiness is buried inside me. I have to reflect on what happened: how did you stay
gain access to it again somehow. I try to focused for the patient and stay in the
fix my kids by giving them more money. moment? In this kind of encounter, we can
I actually dont really sit down with never predict what will happen. As we
them. Sometimes I feel like I dont really engage in our work, our challenge is to be
Continued
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Practice Exemplar cont.


aware of learning to bear witness and not experience or access a deeper place on inner
try to fix anything and just to explore the wisdom. Reflection is often how the con-
moment with self and other(s). It seems trast of the light and shadow, the dark
that when we least expect it, we might nights of the soul are resolved.

Summary
The Theory of Integral Nursing addresses may find that there is also more balance and
how we can increase our integral awareness, harmony each day.
our wholeness and healing, and strengthen Our time demands a new paradigm and a
our personal and professional capacities to new language where we take the best of what
more fully open to the mysteries of lifes we know in the science and art of nursing that
journey and the wondrous stages of self- includes holistic and human caring theories
discovery with self and others. There are and modalities. With an integral approach
many opportunities to increase our integral and worldview we are in a better position to
awareness, application, and understanding share with others the depth of nurses knowl-
each day. Reflect on all that you do each day edge, expertise, and critical-thinking capaci-
in your work and lifeanalyzing, communi- ties and skills for assisting others in creating
cating, listening, exchanging, surveying, health and healing. Only an attention to the
involving, synthesizing, investigating, inter- heart of nursing, for sacred and heart
viewing, mentoring, developing, creating, reflect a common meaning, can we generate
researching, teaching, and creating new the vision, courage, and hope required to unite
schemes for what is possible. Before long, nursing in healing. This assists us as we
you will realize how all these four quadrants engage in health care reform to address the
and realities fit together. You might find you challenges in these troubled timeslocal
are completely missing a quadrant, thus an to global. It is not an abstract matter of phi-
important part of reality. As we address and losophy, but of survival.
value the individual interior and exterior, the
I and It, as well as the collective interior See Barbara Dosseys Web site at http://www.
and exterior, the We and Its a new level dosseydossey.com to download the Theory of Integral
of integral understanding emerges and we Nursing PowerPoint and one-page handout

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Commission at the Center for the Health Profes- CO: Sounds True.
sions, University of California. Wilber, K. (2005b). Integral life practice. Denver,
United Nations (2000). United Nations millennium devel- CO: Integral Institute.
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Watson, J. (2005). Caring science as sacred science. B. Dossey & L. Keegan (Eds.), Holistic nursing: A
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and update. Advances in Nursing Science 17(4), 7386. Zahourek, R. (2004). Intentionality forms the matrix of
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Section
IV
Conceptual Models/Grand
Theories in the Unitary
Transformative Paradigm
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Section

IV Conceptual Models/Grand Theories in


the UnitaryTransformative Paradigm
There are three grand theories clustered in the UnitaryTransformative Paradigm. In this para-
digm the human being and environment are conceptualized as irreducible fields, open with the
environment. The person and environment are continuously changing and evolving through
mutual patterning toward greater complexity. In Chapter 15, Rogers Science of Unitary Human
Beings (SUHB) is explicated by Howard Butcher and Violet Malinski. The SUHB is based on the
premise that humans and environments are patterned, pandimensional energy fields in contin-
uous mutual process with each other. Persons participate in their well-being, which is relative
and personally defined. Several theories, research traditions, and practice traditions have
evolved from this conceptual system. Parses Humanbecoming School of Thought is featured in
Chapter 16, written by the theorist herself. Humanbecoming is defined as a basic human
science that has co-created human experiences as its central focus. The School of Thought por-
tends a view that unitary human beings are expert in their own health and lives. For Parse,
human beings choose meanings that reflect value priorities co-created in transcending with the
possibles. The School of Thought has well-developed research and practice methods that guide
the inquiry and practice of nurses embracing humanbecoming. Newmans Theory of Health as
Expanding Consciousness (HEC) is explicated in Chapter 17 by Margaret Dexheimer Pharris.
According to HEC, health is an evolving unitary pattern of the whole, including patterns of dis-
ease. Consciousness, or the informational capacity of the whole, is revealed in the evolving pat-
tern. Pattern identifies the humanenvironmental process and is characterized by meaning.
Concepts important to nursing practice include expanding consciousness, time, presence, res-
onating with the whole, pattern, meaning, insights as choice points, and the mutuality of the
nursepatient relationship. These concepts are reflected in the praxis method developed to
guide practice-research.

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Chapter
15
Martha E. Rogers Science
of Unitary Human Beings
H OWARD K ARL B U TCHER AND
V IOLET M. M ALINSKI

Introducing the Theorist Introducing the Theorist


Overview of Rogers Science of Unitary Martha E. Rogers, one of nursings foremost
Human Beings
scientists, was a staunch advocate for nursing as
Applications of the Conceptual System
a basic science from which the art of practice
Practice Exemplar
would emerge. A common refrain throughout
Summary
her career was the need to differentiate skills,
References
techniques, and ways of using knowledge from
the body of knowledge that would guide prac-
tice to promote well-being for humankind.
The practice of nursing is not nursing. Rather,
it is the use of nursing knowledge for human
betterment (Rogers, 1994a, p. 34). Rogers
identified the humanenvironmental mutual
process as nursings central focus, not health
and illness. She repeatedly emphasized the
need for nursing science to encompass human
Martha E. Rogers
beings in space as well as on Earth. Who was
this visionary who introduced a new worldview
to nursing?
Martha Elizabeth Rogers was born in
Dallas, Texas, on May 12, 1914, a birthday
she shared with Florence Nightingale. Her
parents soon returned home to Knoxville,
Tennessee, where Martha and her three
siblings grew up. Rogers spent 2 years at the
University of Tennessee in Knoxville before
entering the nursing program at Knoxville
General Hospital. Next, she attended George
Peabody College in Nashville, Tennessee,
where she earned her Bachelor of Science
degree in public health nursing, choosing that
field as her professional focus. Rogers spent
the next 13 years in rural public health nurs-
ing in Michigan, Connecticut, and Arizona,
where she established the first visiting nurse
service in Phoenix, serving as its executive

253
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254 S E C T I O N IV Conceptual Models/Grand Theories in the UnitaryTransformative Paradigm

director (Hektor, 1989/1994). Recognizing to amend the Education Law in New York
the need for advanced education, in 1945 she State, proposing licensure as an independent
earned a masters degree in nursing from nurse (IN) for those who had a minimum of
Teachers College, Columbia University, in the a baccalaureate degree. The group also intro-
program developed by another nurse theorist, duced a new exam and licensure as a regis-
Hildegard Peplau. In 1951 she left public tered nurse (RN) for those with either a
health nursing in Phoenix to return to acade- diploma or an associate degree in nursing who
mia, this time earning a masters of public passed the traditional boards (Governing
health and a doctor of science degree from Council of the Society for Advancement in
Johns Hopkins University in Baltimore, Nursing, 1977/1994).
Maryland. Rogers is best remembered for the para-
In 1954, Rogers was appointed head of the digm she introduced to nursing that displays
Division of Nursing at New York University her visionary, future-oriented perspective.
(NYU), beginning the second phase of her Early stages of theoretical ideas appeared in
career overseeing baccalaureate, masters, and her 1961 and 1964 books and were more fully
doctoral programs in nursing and developing developed in the 1970 book, then revised and
the nursing science she knew was integral to refined in a number of articles and book chap-
the knowledge base nurses needed. She articu- ters written between 1980 and 1994. She
lated the need for a valid baccalaureate educa- helped create the Society of Rogerian Schol-
tion that would serve as the basis for graduate ars, Inc., chartered in New York in 1988, as
and doctoral studies in nursing. Such a pro- one avenue for furthering the development of
gram, she believed, required 5 years of study in her nursing science. Rogers (1970, 1980,
theoretical content in nursing, as well as liberal 1988, 1992) Science of Unitary Human
arts and the biological, physical, and social sci- Beings is a major conceptual system unique
ences. Under her leadership, NYU established to nursing that offers nurses a radically new
such a program. At the doctoral level, Rogers way of viewing persons and their universe. It
opposed the federally funded nurse-scientist is congruent with the most contemporary
doctoral programs that prepared nurses in dis- emerging scientific theories describing a
ciplines other than the science of nursing. Dur- worldview of wholeness (Bohm, 1980; Briggs
ing the 1960s, she successfully shifted the focus & Peat, 1984, 1989; Capra, 1996; Lovelock,
of doctoral research from nurses and their 1991; Mitchell, 1996; Sheldrake, 1988; Tal-
functions to humans in mutual process with bot, 1991; Woodhouse, 1996). Although the
the environment. She wrote three books that Science of Unitary Human Beings was first
explicated her ideas: Educational Revolution in postulated nearly 40 years ago, scientific
Nursing (1961), Reveille in Nursing (1964), and support for her postulates of energy fields,
the landmark An Introduction to the Theoretical pandimensionality, openness, and pattern is
Basis of Nursing (1970). From 1963 to 1965 she increasing every year (Capra, 2002; Gleick,
edited Nursing Science, a journal that was far 2000; Green, 1999; Kaku, 2005; Laszlo, 1996;
ahead of its time; it offered content on theory Lorenz, 1994; McTaggert, 2008; Radin, 2006;
development, the emerging science of nursing, Randall, 2005; Rosenblum & Kuttner, 2006).
as well as research and issues in education and Boxes 15-1 and 15-2 provide additional
practice. information on hospitals that currently use
In 1974, Rogers and a number of nursing her work, see Applications of the Conceptual
colleagues established the Society for Advance- System section on page 261.
ment in Nursing. Among other issues, this Rogers died in 1994, leaving a rich legacy
group supported differentiation in education in her writings on nursing science, the space
and practice for professional and technical age, research, education, and professional and
careers in nursing. They drafted legislation political issues in nursing.
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C H A P T E R 1 5 Martha E. Rogers Science of Unitary Human Beings 255

Overview of Rogers Science Rogers was aware that the world looks very
different from the vantage point of the newer
of Unitary Human Beings view as contrasted with the older, traditional
The historical evolution of the Science of worldview. She pointed out that we are
Unitary Human Beings has been described already living in a new reality, one that is a
by Malinski and Barrett (1994). This chap- synthesis of rapidly evolving, accelerating
ter presents the science in its current form ways of using knowledge (Rogers, 1994a,
and identifies work in progress to expand it p. 33), even if people are not always fully
further. aware that these shifts have occurred or are in
process. She urged that nurses be visionary,
Rogers Worldview looking forward and not backward, and not
Rogers (1992) identified the need for and artic- allowing themselves to become stuck in the
ulated a new worldview in nursing, one that was present, in the details of how things are now,
commensurate with new knowledge emerging but envision how they might be in a universe
across disciplines, which rooted nursing science where continuous change is the only given.
in a pandimensional view of people and their Rogers (1994b) cautioned that, although
world (p. 28). Rogers (1994a) identified the traditional modalities of practice and methods
unique focus of nursing as the irreducible of research serve a purpose, they are inade-
human being and its environment, both defined quate for the newer worldview, which urges
as energy fields (p. 33). Human encompasses nurses to use the knowledge base of Rogerian
both Homo sapiens and Homo spatialis, the evo- nursing science creatively to develop innova-
lutionary transcendence of humankind as we tive new modalities and research approaches
voyage into space, and environment encom- that would promote the betterment of
passes outer space, the cosmos itself. humankind.
Beginning in 1968, Rogers described the
new worldview underpinning her conceptual Postulates of Rogerian
system to students and colleagues. It has been Nursing Science
available in print with some revisions in Rogers (1992) identified four fundamental
language since 1986 (Madrid & Winstead- postulates that form the basis of the new
Fry, 1986; Malinski, 1986a; Rogers, 1990a, reality:
1990b, 1992, 1994a, 1994b). Rogers (1992)
Energy fields
described the evolution from older to newer
Openness
worldviews in such shifting perspectives as cell
Pattern
theory to field theory, entropic to negentrop-
Pandimensionality (formerly called both
ic universe, three-dimensional to pandimen-
four-dimensionality and multidimensionality)
sional, personenvironment as dichotomous
to personenvironment as integral, causation Rogers (1990a) defined the energy field as
and adaptation to mutual process, dynamic the fundamental unit of the living and the
equilibrium to innovative growing diversity, non-living, noting that it is dynamic, infinite,
homeostasis to homeodynamics, waking as and continuously moving (p. 7). Although
a basic state to waking as an evolutionary Rogers did not define energy per se, Todaro-
emergent, and closed to open systems. She Franceschis (1999) wide-ranging philosophi-
pointed out that in a universe of open sys- cal study of the enigma of energy sheds light
tems, energy fields are continuously open, on a Rogerian conceptualization of energy.
infinite, and integral with one another. A She highlighted the communal, transforma-
view of change as predictable, or even proba- tive nature of energy, noting that energy is
bilistic, yields to change as diverse, creative, everywhere and is always changing and actu-
innovative, and unpredictable. alizing potentials. Energy transformation is
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256 S E C T I O N IV Conceptual Models/Grand Theories in the UnitaryTransformative Paradigm

the basis of all that is, both in living and environment are not separated by boundaries.
dying. The energy of each flows continuously through
Rogers identified two energy fields of con- the other in an unbroken wave. Rogers repeat-
cern to nurses, which are distinct but not sep- edly emphasized that person and environment
arate: the human field and the environmental are themselves energy fields; they do not have
field. The human field can be conceptualized energy fields, such as auras, surrounding
as person, group, family, or community. Parts them. In an open universe, there are multiple
have no meaning in unitary science. The potentials and possibilities. Nothing is prede-
human and environmental fields are irre- termined or foreordained. Causality breaks
ducible; they cannot be broken down into down, paving the way for a creative, unpre-
component parts or subsystems. For example, dictable future. People experience their world
the unitary human is not described as a in multiple ways, evidenced by the diverse
biopsychosociocultural or bodymindspirit manifestations of field patterning that contin-
entity. Rogers (1994b) interpreted such desig- uously emerge.
nations as representative of current uses of Rogers (1992, 1994a) described pattern as
holistic, meaning a summation of parts to changing continuously while giving identity
arrive at the whole, wherein a nurse would to each unique humanenvironmental field
assess the domains, subsystems, or compo- process. Although pattern is an abstraction, not
nents identified, then synthesize the accumu- something that can be observed directly, it
lated data to arrive at a picture of the total reveals itself through its manifestations
person. Instead, she maintained that each (Rogers, 1992, p. 29). Individual characteris-
field, human and environmental, is identified tics of a particular person are not characteris-
by pattern, defined as the distinguishing tics of field patterning. Pattern manifestations
characteristic of an energy field perceived as a reflect the humanenvironmental field mutual
single wave (Rogers, 1990a, p. 7). Pattern process as a unitary, irreducible whole.
manifestations and characteristics are specific Person and environment cannot be examined
to the whole. or understood as separate entities. Pattern
Because human and environmental fields manifestations reveal innovative diversity
are integral with each other, they cannot be flowing in lower and higher frequency
separated. They are always in mutual process. rhythms within the humanenvironmental
A concept such as adaptation, a change in one mutual field process. Rogers identified some
preceding a change in another, loses meaning of these manifestations as lesser and greater
in this nursing science. Change occurs simul- diversity; longer, shorter, and seemingly con-
taneously for human and environment. tinuous rhythms; slower, faster, and seemingly
The fields are pandimensional, defined as a continuous motion; time experienced as slow-
non-linear domain without spatial or temporal er, faster, and timeless; pragmatic, imagina-
attributes (Rogers, 1992, p. 29). Pandimen- tive, and visionary; and longer sleeping, longer
sional reality transcends traditional notions of waking, and beyond waking. Beyond waking
space and time, which can be understood as refers to emergent experiences and percep-
perceived boundaries only. Examples of pandi- tions such as hyperawareness, unitive experi-
mensionality include phenomena commonly ences attained in meditation, precognition,
labeled paranormal that are, in Rogerian dj vu, intuition, tacit knowing, mystical
nursing science, manifestations of the chang- experiences, clairvoyance, and telepathy. She
ing diversity of field patterning and examples explained seems continuous as a wave fre-
of pandimensional awareness. quency so rapid that the observer perceives it
The postulate of openness resonates as a single, unbroken event (Rogers, 1990a,
throughout the preceding discussion. In an p. 10). This view of the ongoing process of
open universe, there are no boundaries other change is captured in Rogers principles of
than perceptual ones. Therefore, human and homeodynamics.
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C H A P T E R 1 5 Martha E. Rogers Science of Unitary Human Beings 257

Principles of Homeodynamics by transmission of this theoretical knowledge,


Like adaptation, homeostasismaintaining and nursing practice is the creative use of this
balance or equilibriumis an outdated con- knowledge. Research is done in relation to the
cept in the worldview represented in Rogerian theories (Rogers, 1994a, p. 34) to illuminate
nursing science. Rogers chose homeodynam- the nature of the humanenvironmental field
ics to convey the dynamic, ever-changing change process and its many unpredictable
nature of life and the world. Her three princi- potentials.
ples of homeodynamicsresonancy, helicy, Theory of Accelerating Evolution
and integralitydescribe the nature and
process of change in the humanenvironmental The Theory of Accelerating Evolution was
field process. Resonancy specifies the nonlin- derived by Rogers, who purported that the
ear, continuous flow of lower and higher only norm is accelerating change. Higher
frequency wave patterning in the human frequency field patterns that manifest grow-
environmental field process, the way change ing diversity open the door to wider ranges of
occurs. experiences and behaviors, calling into ques-
Both lower and higher frequency aware- tion the very idea of norms as guidelines.
ness and experiencing are essential to the Human and environmental field rhythms
wholeness of rhythmical patterning. As Phillips are accelerating. We experience faster envi-
(1994, p. 15) described it, [W]e may find ronmental motion now than ever before, in
that growing diversity of pattern is related to cars and high-speed trains and planes, for
a dialectic of low frequencyhigh frequency, example. It is common for people to experi-
similar to that of orderdisorder in chaos the- ence time as rapidly speeding by. People
ory. When the rhythmicities of lower-higher are living longer. Rather than viewing aging
frequencies work together, they yield innova- as a process of decline or as running down,
tive, diverse patterns. as in an entropic worldview, this theory
Helicy describes the creative and diverse views aging as a creative process whereby
nature of ongoing change in field patterning. field patterns show increasing diversity in
Integrality specifies the context of change such manifestations as sleeping, waking, and
as the integral humanenvironmental field dreaming.
process where person and environment are Rogers hypothesized that hyperactive chil-
inseparable. dren provide a good example of speeded-
Together the principles suggest that the up rhythms relative to other children. They
mutual patterning process of human and would be expected to show indications of
environmental fields changes continuously, faster rhythms, increased motion, and other
innovatively, and unpredictably, flowing in behaviors indicative of this shift. She expect-
lower and higher frequencies. Rogers (1990a, ed that relative diversity would manifest in
p. 9) believed that they serve as guides both to different patterns for individuals within any
the practice of nursing and to research in the age cohort, concluding that chronological age
science of nursing. is not a valid indicator of change in this sys-
tem: [I]n fact, as evolutionary diversity con-
tinues to accelerate, the range and variety of
Theories Derived from the Science differences between individuals also increase;
of Unitary Human Beings the more diverse field patterns evolve more
Rogers clearly stated her belief that multiple rapidly than the less diverse ones (Rogers,
theories can be derived from the Science of 1992, p. 30).
Unitary Human Beings. They are specific to The Theory of Accelerating Evolution
nursing and reflect not what nurses do, but an provides the basis for reconceptualizing the
understanding of people and our world aging process. Rogers (1970, 1980) used
(Rogers, 1992). Nursing education is identified the principle of helicy and the Theory of
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Accelerating Evolution to put forward the The idea of a pandimensional or nonlinear


notion that aging is a continuously creative domain provides a framework for under-
process of growing diversity of field pattern- standing paranormal phenomena. A nonlin-
ing. Therefore, aging is not a process of ear domain unconstrained by space and time
decline or running down. Rather, field pat- provides an explanation of seemingly inexpli-
terns become increasingly diverse as we age, cable events and processes. Rogers (1992)
as older adults need less sleep; are more sat- even asserted that within the Science of
isfied with personal relationships; are better Unitary Human Beings, psychic phenomena
able to handle their emotions; are better able become normal rather than paranormal.
to cope with stress; and have increasing crys- Dean Radin, director of the Conscious Research
tallized intelligence, wisdom, and improved Laboratory at the University of Nevada in
problem-solving abilities (Whitbourne, 2008). Las Vegas, suggests that an understanding of
Butcher (2003) expanded on Rogers negen- nonlocal connections along with the relation-
tropic view of aging in outlining key ele- ship between awareness and quantum effects
ments for a unitary model of aging as provides a framework for understanding para-
emerging brilliance that includes replacing normal phenomena (Radin, 1997). Deep
ageist stereotypes with new positive images interconnectedness demonstrated by Bells
of aging; and developing policies, lifestyles, Theorem embraces the interconnectedness
and technologies that enhance successful of everything unbounded by space and time.
aging and longevity. Within a unitary view In addition, the work of Dossey (1993,
of aging, later life becomes a potential 1999), Nadeau and Kafatos (1999), Sheldrake
for growth, a life imbued with splendor, (1988), and Talbot (1991) explicates the role
meaning, accomplishment, active involve- of nonlocality in evolution, physics, cosmology,
ment, growth, adventure, wisdom, experi- consciousness, paranormal phenomena, heal-
ence, compassion, glory, and brilliance ing, and prayer.
(Butcher, 2003, p. 64). Within a nonlinearnonlocal context, para-
normal events are our experience of the deep
Theory of Emergence of Paranormal nonlocal interconnections that bind the uni-
Phenomena verse together. Existence and knowing are
Another theory derived by Rogers is the locally and nonlocally linked through deep
Emergence of Paranormal Phenomena, in connections of awareness, intentionality, and
which she suggests that experiences common- interpretation. Pandimensionality embraces the
ly labeled paranormal are actually manifes- infinite nature of the universe in all its dimen-
tations of changing diversity and innovation sions and includes processes of being more
of field patterning. They are pandimensional aware of naturally occurring changing energy
forms of awareness, examples of pandimen- patterns. Pandimensionality also includes inten-
sional reality that manifest visionary, beyond tionally participating in mutual process with a
waking potentials. Meditation, for example, nonlinearnonlocal potential of creating new
transcends traditionally perceived limitations energy patterns. Distance healing, the healing
of time and space, opening the door to new power of prayer, therapeutic touch, out-
and creative potentials. Therapeutic touch of-body experiences, phantom pain, precogni-
provides another example of such pandimen- tion, dej vu, intuition, tacit knowing, mystical
sional awareness. Both participants often experiences, clairvoyance, and telepathic expe-
share similar experiences during therapeutic riences are a few of the energy field manifesta-
touch, such as a visualization of common tions patients and nurses experience that can
features that evolves spontaneously for both, a be better understood as natural events in
shared experience arising within the mutual a pandimensional universe characterized by
process both are experiencing, with neither nonlinearnonlocal humanenvironmental field
able to lay claim to it as a personal, private integrality propagated by increased awareness
experience. and intentionality.
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C H A P T E R 1 5 Martha E. Rogers Science of Unitary Human Beings 259

Todaro-Franceschi (2006) identified the with dominance, force, and hierarchy. Power,
existence of synchronicity experiences in within a Rogerian perspective, is being aware
many who were grieving the loss of a spouse, of what one is choosing to do, feeling free
a pioneering effort in delineating a unitary to do it, doing it intentionally, and being
view of death and dying. From the results of actively involved in the change process. A
her qualitative study she described how such persons ability to participate knowingly in
experiences help the bereaved to relate to change varies in given situations. Thus, the
their deceased loved ones in a new, meaning- intensity, frequency, and form in which power
ful way rather than in the traditional view of manifests vary. Power is neither inherently
learning to let go and move on. good nor evil; however, the form in which
power manifests may be viewed as either con-
Manifestations of Field Patterning structive or destructive, depending on ones
Rogers third theory, Rhythmical Correlates value perspective (Barrett, 1989). Barrett
of Change, was changed to manifestations of (1989) stated that her theory does not value
field patterning in unitary human beings, different forms of power, but instead recog-
discussed earlier. Here Rogers suggested that nizes differences in power manifestations.
evolution is an irreducible, nonlinear process The Power as Knowing Participation in
characterized by increasing diversity of field Change Tool (PKPCT) is a measure of ones
patterning. She offered some manifestations relative frequency of power. Barrett (1989)
of this relative diversity, including the rhythms suggests that the Power Theory and the
of motion, time experience, and sleeping PKPCT may be useful in a wide variety of
waking, encouraging others to suggest further nursing situations. Barretts Power Theory is
examples. The next part of this chapter covers useful with clients who are experiencing
Rogerian sciencebased practice and research hopelessness, suicidal ideation, hypertension,
in more detail. obesity, drug and alcohol dependence, grief
In addition to the theories that Rogers and loss, self-esteem issues, adolescent tur-
derived, a number of others have been moil, career conflicts, marital discord, cultur-
developed by Rogerian scholars that are use- al relocation trauma, or the desire to make a
ful in informing Rogerian patternbased lifestyle change. In fact, all health/illness
practice including the Theory of Enlighten- experiences involve issues concerning know-
ment (Hills & Hanchett, 2001) and the ing participation in change. The nurse
Theory of Enfolding Health-as-Wholeness- invites the client to complete the PKPCT as
and-Harmony (Carboni, 1995a). Two addi- a means to identify the clients power pat-
tional theories are presented in the text that tern. To prevent biased responses, the nurse
follows. should refrain from using the word power.
The power score is determined on each of
Theory of Power as Knowing the four subscales: awareness, choices, free-
Participation in Change dom to act intentionally, and involvement in
Barretts (1989) Theory of Power as knowing creating changes. The scores are documented
participation in change was derived directly as part of the clients pattern profile and
from Rogers postulates and principles, and shared with the client during voluntary
it interweaves awareness, choices, freedom to mutual patterning. Scores are considered as a
act intentionally, and involvement in creating tentative and relative measure of the ever-
changes. Power is a natural continuous theme changing nature of ones field pattern in rela-
in the flow of life experiences and dynami- tion to power.
cally describes how humans participate with Instead of focusing on issues of control,
the environment to actualize their potential. the nurse helps the client identify the changes
Barrett (1983) pointed out that most theories and the direction of change the client desires
of power are causal and define power as the to make. Using open-ended questions, the
ability to influence; prevent; or cause change nurse and the client mutually explore choices
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260 S E C T I O N IV Conceptual Models/Grand Theories in the UnitaryTransformative Paradigm

and options and identify barriers preventing The term kaleidoscoping was used because
change, strategies, and resources to overcome it evolves directly from Rogers writings and
barriers; the nurse facilitates the clients conveys the unpredictable and continuously
active involvement in creating the changes. shifting flow of patterns, sometimes turbu-
For example, asking the questions, What do lent, that one experiences when looking
you want? What choices are open to you through a kaleidoscope. Rogers (1970)
now? How free do you feel to do what you explained that the organization of the
want to do? and How will you involve your- living system is maintained amidst kaleido-
self in creating the changes you want? can scopic alterations in the patterning of
enhance the clients awareness, choice-making, system (p. 62).
freedom to act intentionally, and his or her The Theory of Kaleidoscoping with
involvement in creating change (Barrett, Turbulent Life Events is used in conjunction
1998). with the pattern manifestation knowing and
A wide range of voluntary mutual patterning appreciation and voluntary mutual pattern-
strategies may be used to enhance knowing ing processes. In addition to engaging in the
participation in change, including meaningful processes already described in pattern mani-
dialogue, dance/movement/motion, sound, light, festation knowing and appreciation, the
color, music, rest/activity, imagery, humor, ther- nurse identifies manifestations of patterning
apeutic touch, bibliotherapy, journaling, draw- and mutually explores the meaning of the
ing, and nutrition (Barrett, 1998). The PKPCT turbulent situation with the client. A pattern
can be used at intervals to evaluate the clients profile describing the essence of the clients
relative changes in power. experiences, perceptions, and expressions
related to the turbulent life event is con-
Theory of Kaleidoscoping structed and shared with the client.
in Lifes Turbulence In the Theory of Kaleidoscoping, volun-
Butchers (1993) Theory of Kaleidoscoping tary mutual patterning also incorporates the
in Lifes Turbulence was derived from Rogers processes of transforming turbulent events
Science of Unitary Human Beings, chaos by cultivating purpose, forging resolve, and
theory (Briggs & Peat, 1989; Peat, 1991), and recovering harmony (Butcher, 1993). Culti-
Csikszentmihalyis (1990) Theory of Flow. vating purpose involves assisting clients in
It focuses on facilitating well-being and har- identifying goals and developing an action
mony amid turbulent life events. Turbulence system. The action system comprises pattern-
is a dissonant commotion in the human ing strategies designed to promote harmony
environmental field characterized by chaotic amid adversity and facilitate the actualization
and unpredictable change. Any crisis may be of the potential for well-being.
viewed as a turbulent event in the life process. In moments of turbulence, clients may
Nurses often work closely with clients who want to increase their awareness of the com-
are in a crisis. The turbulent life event plexity of the situation. Creative suspension
may be an illness, the uncertainty of a med- is a technique that may be used to facilitate
ical diagnosis, marital discord, or loss of a comprehension of the situations complexity
loved one. Turbulent life events are often (Peat, 1991). Guided imagery is a useful
chaotic in nature, unpredictable, and always strategy for facilitating creative suspension
transformative. because it potentially enhances the clients
Kaleidoscoping is a way of engaging in ability to enter a timeless suspension directed
a mutual process with clients who are in the toward visualizing the whole situation and
midst of experiencing a turbulent life event facilitating the creation of new strategies and
by mutually flowing with turbulent manifes- solutions. Forging resolve is assisting the
tations of patterning (Butcher, 1993). Flow clients in becoming involved and immersed in
is an intense harmonious involvement in the their action system. Because chaotic and tur-
humanenvironmental mutual field process. bulent systems are infinitely sensitive, actions
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are gentle or subtle in nature and are distrib-


Box 151 Nursing Practice Evolves
uted over the entire system involved in the
change process. Entering chaotic systems The relevance of Rogerian nursing science to
with a big splash or trying to force a change both human well-being and nursing is precisely
in a particular direction will likely lead to the transformative vision of people and the
world that it offers. Recognizing this, the
increased turbulence (Butcher, 1993). nursing department at Bronx Lebanon Hospi-
Forging resolve involves incorporating tal Center, Bronx, New York, has made the
flow experiences into the change process. decision to use Rogerian nursing science as the
Flow experiences promote harmonious framework for practice throughout the hospi-
humanenvironmental field patterns. A wide tal. People are complex, society is changing,
and nursings image is changing and so is our
range of flow experiences can be incorporat- practice, which is driven by the science of
ed into daily activities: art, music, exercise, nursing, according to Jeanine M. Frumenti,
reading, gardening, meditation, dancing, Vice President, Patient Care Services/Chief
sports, sailing, swimming, carpentry, sewing, Nursing Officer (personal communication,
yoga, or any activity that is a source of July 21, 2008). Rogerian nursing science was
chosen because it is inclusive and reflective of
enjoyment, concentration, and deep involve- peoples ever changing relationship to their
ment. The incorporating of flow experiences environment, whereas many other nursing
into daily patterns potentiates the recovery theories are reflective of the art of nursing.
of harmony. Recovering harmony is achiev- According to Frumenti, nurses need to be
ing a sense of courage, balance, calm, and open to unfolding pattern and pandimen-
sional experiences; everything is integrated
resilience amid turbulent and threatening and changing. It is her hope that Rogerian
life events. The art of kaleidoscoping with nursing science will assist Bronx Lebanon
turbulence is a mutual creative expression of nurses in actualizing transformative practice
beauty and grace and is a way of enhancing for themselves and their clients.
perseverance through difficult times.

Applications of the Providing Leadership in Nursing


Box 152
Conceptual System Education
New worldviews require new ways of think- The Washburn University School of Nursing
ing, sciencing, languaging, and practicing. in Topeka, Kansas, was a pioneer in the use
Rogers nursing science postulates a pandi- of Rogerian nursing science as a framework
for its curriculum. The schools Web site
mensional universe of humanenvironmental (www.washburn.edu) provides a summary of
energy fields manifesting as continuously Rogerian nursing science and contains the
innovative, increasingly diverse, creative, and statement that The School of Nursing has
unpredictable unitary field patterns. The become a national model in the use of the
principles of homeodynamics provide a Rogerian theoretical framework.
way to understand the process of human-
environmental change, paving the way for
Rogerian theorybased practice. Rogers This focus gives nurses a central role in
often reminded us that unitary means whole. health care rather than medical care. She also
Therefore, people are always whole, regard- noted that health services should be commu-
less of what they are experiencing in the nity based, not hospital based. Hospitals are
moment, and therefore do not need nurses to properly used to provide satellite services in
facilitate their wholeness. Rogers identified specific instances of illness and trauma; they
noninvasive modalities as the basis for nurs- do not provide health services. Rogers urged
ing practice now and in the future. She stat- nurses to develop autonomous, community-
ed that nurses must use nursing knowledge based nursing centers.
in non-invasive ways in a direct effort to pro- Larkin, one unitary nurse who has answered
mote well-being (Rogers, 1994a, p. 34). the call for noninvasive nursing modalities, has
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262 S E C T I O N IV Conceptual Models/Grand Theories in the UnitaryTransformative Paradigm

pioneered the use of Ericksonian hypnothera- intentionality from both intent and intention
peutic support groups. In a study comparing and identifies it as the matrix for healing, a
individuals diagnosed with chronic physical transformative process.
illnesses in Ericksonian versus traditional sup- Rogers also questioned the concept of spir-
port groups, persons in the former experienced ituality, which she saw as too often confused
pandimensional health and power, contrary to with religiosity. Smith (1994) and Malinski
the view within the prevailing biomedical para- (1991, 1994) have both explored a Rogerian
digm that such individuals experience dimin- view of spirituality. For example, Malinski
ishing health and powerlessness (Larkin, 2007). (2004) described it as the experience of
Unfortunately, a number of ideas relevant wholeness and unity with all living beings
to nursing practice that Rogers discussed and the natural environment, whereby people
verbally never made it into print, for example, find meaning and purpose in both living
healing, intentionality, and expanded views and dying. As such, spirituality is a unitary
on therapeutic touch. In three audiotaped experience with relevance for healing and
and transcribed dialogues among Rogers, well-being. Butcher (2008) reviewed the last
Malinski, and Meehan on January 26, 1988, 15 years of advances in Rogerian science list-
for example, she described healing as a ing additional concepts that have been con-
process, everything that happens as persons ceptualized within the Science of Unitary
actualize potentials they identify as enhancing Human Beings including hope, compassion,
health and wellness for themselves. Todaro- caring, despair, time, awareness, risk-taking,
Franceschi (1999) described healing in a and empowerment.
similar way, with nurses knowingly participat-
ing in the healing process by helping people Rogerian Practice Methods
actualize their unique potentialswhatever A hallmark of a maturing scientific practice
those potentials may be (p. 104). Cowling discipline is the development of specific prac-
(2001) described healing as appreciating tice and research methods evolving from the
wholeness, offering unitary pattern apprecia- disciplines extant conceptual systems. Rogers
tion as the praxis for exploring wholeness (1992) asserted that practice and research
within the unitary humanenvironmental methods must be consistent with the Science
mutual process. of Unitary Human Beings in order to study
Rogers also reminded us that change is a irreducible human beings in mutual process
neutral process, neither good nor bad, one with a pandimensional universe. Therefore,
that we cannot direct but in which we par- Rogerian practice and research methods must
ticipate. In this vein, in the transcribed dia- be congruent with Rogers postulates and
logue among Rogers, Malinski, and Meehan principles if they are to be consistent with
on therapeutic touch, Rogers described Rogerian science.
therapeutic touch as a neutral process, one The goal of nursing practice is the pro-
that facilitates the patterning most com- motion of well-being and human better-
mensurate with well-being for the person, ment. Nursing is a service to people wher-
whatever that is. There is no exchange of ever they may reside. Nursing practicethe
energy, no identification of desired out- art of nursingis the creative application
comes. Rather than intentionality, Rogers of substantive scientific knowledge devel-
suggested knowing participation as most oped through logical analysis, synthesis, and
congruent with her thinking, seeing inten- research. Since the 1960s, the nursing
tionality as too closely tied to will and process has been the dominant nursing
intent. However, she did suggest that a practice method. The nursing process is an
unitary view of intentionality was worthy appropriate practice methodology for many
of study. Zahoureks (2004, 2005) grounded nursing theories. However, there has been
theory study of intentionality differentiates some confusion in the nursing literature
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concerning the use of the traditional nursing During the last decade, a number of practice
process within Rogers nursing science. methods have been derived from Rogers pos-
In early writings, Rogers (1970) did make tulates and principles.
reference to nursing process and nursing diag-
nosis. But in later years she asserted that nurs- Barretts Rogerian Practice Method
ing diagnoses were not consistent with her Barretts Rogerian practice methodology for
scientific system. Rogers (quoted in Smith, health patterning is the accepted alternative
1988, p. 83) stated: to the nursing process for Rogerian practice
and is currently the most widely used Rogerian
Nursing diagnosis is a static term that is quite
practice model. Barretts (1988) practice
inappropriate for a dynamic system it
model was derived from the Science of
(nursing diagnosis) is an outdated part of an
Unitary Human Beings and consisted of two
old worldview, and I think by the turn of the
phases: pattern manifestation appraisal and
century, there are going to be new ways of
deliberative mutual patterning. Barrett (1998)
organizing knowledge.
expanded and updated the methodology by
Furthermore, nursing diagnoses are partic- refining each of the phases, now more appro-
ularistic and reductionist labels describing priately referred to as processes. Each of the
cause and effect (i.e., related to) relation- processes has also been renamed for greater
ships inconsistent with a nonlinear domain clarity and precision. Pattern manifestation
without spatial or temporal attributes (Rogers, knowing is the continuous process of appre-
1992, p. 29). The nursing process is a stepwise hending the human and environmental field
sequential process inconsistent with a nonlin- (Barrett, 1998). Appraisal means to estimate
ear or pandimensional view of reality. In addi- an amount or to judge the value of something,
tion, the term intervention is not consistent negating the egalitarian position of the nurse,
with Rogerian science. Intervention means to whereas knowing means to recognize the
come, appear, or lie between two things nature, achieve an understanding, or become
(American Heritage Dictionary, 2000, p. 916). familiar or acquainted with something. Vol-
The principle of integrality describes the untary mutual patterning is the continuous
human and environmental field as integral process whereby the nurse assists clients in
and in mutual process. Energy fields are open, freely choosingwith awarenessways to
infinite, dynamic, and constantly changing. participate in their well-being (Barrett, 1998).
The human and environmental fields are The change to the term voluntary empha-
inseparable, so one cannot come between. sizes freedom, spontaneity, and choice of
The nurse and the client are already insepara- action. The nurse does not invest in changing
ble and interconnected. Outcomes are also the client in a particular direction, but rather
inconsistent with Rogers principle of helicy: facilitates and mutually explores with the
expected outcomes infer predictability. The client options and choices and provides infor-
principle of helicy describes the nature of mation and resources so the client can make
change as being unpredictable. Within an informed decisions regarding his or her health
energy-field perspective, nurses in mutual and well-being. Thus, clients feel free to
process assist clients in actualizing their field choose with awareness how they want to
potentials by enhancing their ability to partic- participate in their own change process.
ipate knowingly in change (Butcher, 1997). The two processes are continuous and non-
Given the inconsistency of the traditional linear; therefore they are not necessarily
nursing process with Rogers postulates and sequential. Patterning is continuous and
principles, the Science of Unitary Human occurs simultaneously with knowing. Control
Beings requires the development of new and and predictability are not consistent with
innovative practice methods derived from Rogers postulate of pandimensionality and
and consistent with the conceptual system. principles of integrality and helicy. Rather,
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264 S E C T I O N IV Conceptual Models/Grand Theories in the UnitaryTransformative Paradigm

acausality allows for freedom of choice and other words, intuition, tacit knowing, and
means outcomes are unpredictable. The goal other forms of awareness beyond the five
of voluntary mutual patterning is the actual- senses are ways of apprehending manifesta-
ization of potentialities for well-being through tions of pattern. Fifth, all pattern information
knowing participation in change. has meaning only when conceptualized and
interpreted within a unitary context. Synopsis
Cowlings Rogerian Practice and synthesis are requisites to unitary know-
Constituents ing. Synopsis is a process of deliberately view-
Cowling (1990) proposed a template com- ing together all aspects of a human experience
prising 10 constituents for the development (Cowling, 1997). Interpreting pattern infor-
of Rogerian practice models. Cowling (1993b, mation within a unitary perspective means
1997) refined the template and proposed that that all phenomena and events are related
pattern appreciation was a method for uni- nonlinearly. Also, phenomena and events are
tary knowing in both Rogerian nursing not discrete or separate but rather coevolve
research and practice. Cowling preferred the together in mutual process. Furthermore, all
term appreciation rather than assessment pattern information is a reflection of the
or appraisal because appraisal is associated human/environmental mutual field process.
with evaluation. Appreciation has broader The human and environmental fields are
meaning, which includes being fully aware or inseparable. Thus, any information from the
sensitive to or realizing; being thankful or client is also a reflection of his or her environ-
grateful for; and enjoying or understanding ment. Physiological and other reductionistic
critically or emotionally (Cowling, 1997, measures have new meaning when interpreted
p. 130). Pattern appreciation has a potential within a unitary context. For example, a blood
for deeper understanding. pressure measurement interpreted within a
The first constituent for unitary pattern unitary context means the blood pressure is a
appreciation identifies the human energy field manifestation of a pattern emerging from the
emerging from the humanenvironmental entire human/environmental field mutual
mutual process as the basic referent. Pattern process rather than being simply a physiolog-
manifestations emerging from the human ical measure. Thus, any expression from the
environmental mutual process are the focus client is unitary and not particular by reflect-
of nursing care. Next, the persons experi- ing the unitary field from which it emanates
ences, perceptions, and expressions are uni- (Cowling, 1993b).
tary manifestations of pattern and provide a The sixth constituent in Cowlings practice
focus for pattern appreciation. Third, pat- method describes the format for documenting
tern appreciation requires an inclusive per- and presenting pattern information. Rather
spective of what counts as pattern informa- than stating nursing diagnoses and reporting
tion (energetic manifestations) (Cowling, assessment data in a format that is particu-
1993b, p. 202). Thus, any information gath- laristic and reductionistic by dividing the data
ered from and about the client, family, into categories or parts, the nurse constructs a
or communityincluding sensory informa- pattern profile. Usually the pattern profile is
tion, feelings, thoughts, values, introspective in the form of a narrative summarizing the
insights, intuitive apprehensions, laboratory clients experiences, perceptions, and expres-
values, and physiological measuresare sion inferred from the pattern appreciation
viewed as energetic manifestations emerg- process. The pattern profile tells the story
ing from the human/environmental mutual of the clients situation and should be
field process. expressed in as many of the clients own words
The fourth constituent is that the nurse as possible. Relevant particularistic data such
uses pandimensional modes of awareness as physiological data interpreted within a uni-
when appreciating pattern information. In tary context may be included in the pattern
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C H A P T E R 1 5 Martha E. Rogers Science of Unitary Human Beings 265

profile. Cowling (1990, 1993b) also identified processes: pattern manifestation appreciation
additional forms of pattern profiles, including and knowing, and voluntary mutual pattern-
single words or phrases and listing pattern ing. The focus of nursing care guided by
information, diagrams, pictures, photographs, Rogers nursing science is on pattern transfor-
or metaphors that are meaningful in convey- mation by facilitating pattern recognition
ing the themes and essence of the pattern during pattern manifestation knowing and
information. appreciation and by facilitating the clients
Seventh, the primary source for verifying ability to participate knowingly in change,
pattern appreciation and profile is the client. harmonizing personenvironment integrality,
Verifying can occur by sharing the pattern and promoting healing potentialities and well-
profile with the client for revision and confir- being through voluntary mutual patterning.
mation. During verification, the nurse also
discusses options, identifies goals with the Pattern Manifestation Knowing
client, and plans mutual patterning strategies. and Appreciation
Sharing the pattern profile with the client Pattern manifestation knowing and apprecia-
enhances participation in the planning of care tion is the process of identifying manifestations
and facilitates the clients knowing participa- of patterning emerging from the human
tion in the change process (Cowling, 1997). environmental field mutual process and involves
The eighth constituent identifies knowing focusing on the clients experiences, percep-
participation in change as the foundation for tions, and expressions. Knowing refers to
health patterning. Knowing participation in apprehending pattern manifestations (Barrett,
change is being aware of what one is choosing 1988), whereas appreciation seeks a percep-
to do, feeling free to do it, doing it intention- tion of the full force of pattern (Cowling,
ally, and being actively involved in the change 1997). Pattern is the distinguishing feature of
process. The purpose of health patterning is the humanenvironmental field. Everything
to assist clients in knowing participation in experienced, perceived, and expressed is a man-
change (Barrett, 1988). Ninth, pattern appre- ifestation of patterning. During the process of
ciation incorporates the concepts and princi- pattern manifestation knowing and apprecia-
ples of unitary science; approaches for health tion, the nurse and client are coequal partici-
patterning are determined by the client. Last, pants. In Rogerian practice, nursing situations
knowledge derived from pattern appreciation are approached and guided by a set of
reflects the unique patterning of the client Rogerian-ethical values, a scientific base for
(Cowling, 1997). practice, and a commitment to enhance the
clients desired potentialities for well-being.
Unitary Pattern-Based Unitary patternbased practice begins by
Praxis Method creating an atmosphere of openness and free-
Butcher (1997, 1999a, 2001) synthesized dom so clients can freely participate in the
Cowlings Rogerian practice constituents with process of knowing participation in change.
Barretts practice method to develop a more Approaching the nursing situation with an
inclusive and comprehensive practice model. appreciation of the uniqueness of each person
In a 2006 publication, Butcher expanded the and with unconditional love, compassion, and
praxis model by illustrating how the Roger- empathy can help create an atmosphere of
ian cosmology, ontology, epistemology, aes- openness and healing patterning. Rogers
thetics, ethics, postulates, principles, and the- (1966/1994) defined nursing as a humanistic
ories all form an interconnected nexus science dedicated to compassionate concern
informing both Rogerian-based practice and for humans. Compassion includes energetic
research models (Butcher, 2006a, p. 9). The acts of unconditional love and means (1) rec-
unitary patternbased practice (Fig. 15-1) ognizing the interconnectedness of the nurse
consists of two nonlinear and simultaneous and client by being able to fully understand
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266 S E C T I O N IV Conceptual Models/Grand Theories in the UnitaryTransformative Paradigm

Unitary pattern-based praxis

Rogerian Cosmology Rogerian Philosophy

Rogerian Science

Pattern-based practice Rogerian Theories Pattern-based research

Pattern manifestation
Knowing and appreciation
Unitary field pattern
portrait research
method
Voluntary mutual
patterning

Knowing participation in change

Pattern transformation

Potentialities for human betterment and well-being

Figure 15 1 The Unitary Pattern-Based Praxis Model. (Model from Butcher, H. K.


[2006a]. Unitary pattern-based praxis: A nexus of Rogerian cosmology, philosophy, and science.
Visions: The Journal of Rogerian Nursing Science, 14[2], 833.)

and know the suffering of another; (2) creating living through sensing and being aware as a
actions designed to transform injustices; and source of knowledge and includes any item or
(3) not only grieving in anothers sorrow and ingredient the client senses (Cowling, 1997).
pain, but also rejoicing in anothers joy The clients own observations and description
(Butcher, 2002). of his or her health situation includes his or
Pattern manifestation knowing and appre- her experiences. Perceiving is the apprehend-
ciation involves focusing on the experiences, ing of experience or the ability to reflect while
perceptions, and expressions of a health situa- experiencing (Cowling, 1993a, p. 202). Per-
tion, revealed through a rhythmic flow of ception is making sense of the experience
communion and dialogue. In most situations, through awareness, apprehension, observa-
the nurse can initially ask the client to tion, and interpreting. Asking clients about
describe his or her health situation and their concerns, fears, and observations is a way
concern. The dialogue is guided toward focus- of apprehending their perceptions. Expres-
ing on uncovering the clients experiences, sions are manifestations of experiences and
perceptions, and expressions related to the perceptions that reflect human field pattern-
health situation as a means to reaching a ing. In addition, expressions are any form
deeper understanding of unitary field pattern. of information that comes forward in the
Humans are constantly all-at-once experienc- encounter with the client. All expressions are
ing, perceiving, and expressing (Cowling, energetic manifestations of field patterns.
1993a). Experience involves the rawness of Body language, communication patterns, gait,
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behaviors, laboratory values, and vital signs rhythms, comfortdiscomfort, wakingbeyond


are examples of energetic manifestations of waking experiences, and degree of knowing
humanenvironmental field patterning. participation in change provide important
Because all information about the client information regarding each clients thoughts
environmenthealth situation is relevant, and feelings concerning a health situation.
various health assessment tools, such as the The nurse can also use a number of pattern
comprehensive holistic assessment tool devel- appraisal scales derived from Rogers postulates
oped by Dossey, Keegan, and Guzzetta and principles to enhance the collecting and
(2004), may also be useful in pattern knowing understanding of relevant information specific
and appreciation. However, all information to Rogerian science. For example, nurses can
must be interpreted within a unitary context. use Barretts (1989) power as knowing partici-
A unitary context refers to conceptualizing all pation in change tool as a way of knowing
information as energetic/dynamic manifesta- clients energy field patterns in relation to their
tions of pattern emerging from a pandimen- capacity to knowingly participate in the con-
sional humanenvironmental mutual process. tinuous patterning of human and environmen-
All information is interconnected, is insepara- tal fields as manifest in frequencies of aware-
ble from environmental context, unfolds ness, choice making ability, sense of freedom to
rhythmically and acausally, and reflects the act intentionally, and degree of involvement in
whole. Data are not divided or understood creating change. Watsons (1993) assessment of
by dividing information into physical, psycho- dream experience scale can be used to know
logical, social, spiritual, or cultural categories. and appreciate the clients dream experiences,
Rather, a focus on experiences, perceptions, and Ferences (1979) human field motion tool
and expressions is a synthesis more than and is an indicator of the wave frequency pattern of
different from the sum of parts. From a uni- the energy field.
tary perspective, what may be labeled as Hastings-Tolsmas (1992) diversity of
abnormal processes, nursing diagnoses, or ill- human field pattern scale may be used as a
ness or disease are conceptualized as episodes means for knowing and appreciating a clients
of discordant rhythms or nonharmonic reso- perception of the diversity of their energy
nancy (Bultemeier, 2002). field pattern, Johnstons (1994) human image
A unitary perspective in nursing practice metaphor scale can be used as a way of know-
leads to an appreciation of new kinds of infor- ing and appreciating the clients perception
mation that may not be considered within of the wholeness of their energy field, and the
other conceptual approaches to nursing prac- well-being picture scale of Gueldner et al.
tice. The nurse is open to using multiple (2005) affords a way to measure a persons
forms of knowing, including pandimensional sense of unitary well-being. Paletta (1990)
modes of awareness (intuition, meditative developed a tool consistent with Rogerian
insights, tacit knowing) throughout the pat- Science that measures the subjective aware-
tern manifestation knowing and appreciation ness of temporal experience.
process. Intuition and tacit knowing are artful The pattern manifestation knowing and
ways to enable seeing the whole, revealing appreciation is enhanced through the nurses
subtle patterns, and deepening understanding. ability to grasp meaning, create a meaningful
Pattern information concerning time percep- connection, and participate knowingly in the
tion, sense of rhythm or movement, sense clients change process (Butcher, 1999a).
of connectedness with the environment, ideas Grasping meaning entails using sensitivity,
of ones own personal myth, and sense of active listening, conveying unconditional
integrity are relevant indicators of human acceptance, while remaining fully open to the
environmenthealth potentialities (Madrid & rhythm, movement, intensity, and configura-
Winstead-Fry, 1986). A persons hopes and tion of pattern manifestations (Butcher,
dreams, communication patterns, sleeprest 1999a, p. 51). Through integrality, nurse and
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268 S E C T I O N IV Conceptual Models/Grand Theories in the UnitaryTransformative Paradigm

client are always connected in mutual process. patterning. The goal of voluntary mutual
However, a meaningful connection with the patterning is to facilitate each clients ability
client is facilitated by creating a rhythm and to participate knowingly in change, harmo-
flow through the intentional expression of nize personenvironment integrality, and pro-
unconditional love, compassion, and empathy. mote healing potentialities, lifestyle changes,
Together, in mutual process, the nurse and and well-being in the clients desired direction
client explore the meanings, images, symbols, of change without attachment to predeter-
metaphors, thoughts, insights, intuitions, mined outcomes. The process is mutual in
memories, hopes, apprehensions, feelings, and that both the nurse and the client are changed
dreams associated with the health situation. with each encounter, each patterning one
Rogerian ethics are integral to all unitary another and coevolving together. Voluntary
patternbased practice situations. Rogerian signifies freedom of choice or action without
ethics are pattern manifestations emerging external compulsion (Barrett, 1998). The
from the humanenvironmental field mutual nurse has no investment in changing the
process that reflect those ideals concordant client in a particular way.
with Rogers most cherished values and are Whereas patterning is continuous, volun-
indicators of the quality of knowing partici- tary mutual patterning may begin by sharing
pation in change (Butcher, 1999b). Thus, the pattern profile with the client. Sharing the
unitary patternbased practice includes mak- pattern profile with the client is a means of
ing the Rogerian values of reverence, human validating the interpretation of pattern infor-
betterment, generosity, commitment, diversity, mation and may spark further dialogue,
responsibility, compassion, wisdom, justice- revealing new and more in-depth informa-
creating, openness, courage, optimism, humor, tion. Sharing the pattern profile with the
unity, transformation, and celebration inten- client facilitates pattern recognition and also
tional in the humanenvironmental field may enhance the clients knowing participa-
mutual process (Butcher, 1999b, 2000). tion in his or her own change process. An
When initial pattern manifestation knowing increased awareness of ones own pattern may
and appreciation is complete, the nurse synthe- offer new insight and increase ones desire to
sizes all the pattern information into a mean- participate in the change process. In addition,
ingful pattern profile. The pattern profile is an the nurse and client can continue to explore
expression of the personenvironmenthealth goals, options, choices, and voluntary mutual
situations essence. The nurse weaves together patterning strategies as a means to facilitate
the expressions, perceptions, and experiences in the clients actualization of his or her human
a way that tells the clients story. The pattern environmental field potentials.
profile reveals the hidden meaning embedded A wide variety of mutual patterning strate-
in the clients humanenvironmental mutual gies may be used in Rogerian practice, includ-
field process. Usually the pattern profile is in a ing many interventions identified in the
narrative form that describes the essence of Nursing Intervention Classification (Bulechek,
the properties, features, and qualities of the Butcher, & Dochterman, 2008). However,
humanenvironmenthealth situation. In addi- interventions, within a unitary context, are
tion to a narrative form, the pattern profile may not linked to nursing diagnoses and are
also include diagrams, poems, listings, phrases, reconceptualized as voluntary mutual pattern-
and/or metaphors. Interpretations of any meas- ing strategies, and the activities are reconcep-
urement tools may also be incorporated into the tualizied as patterning activities. Rather than
pattern profile. linking voluntary mutual patterning strategies
to nursing diagnoses, the strategies emerge in
Voluntary Mutual Patterning dialogue whenever possible out of the pat-
Voluntary mutual patterning is a process terns and themes described in the pattern
of transforming humanenvironmental field profile. Furthermore, Rogers (1988, 1992,
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C H A P T E R 1 5 Martha E. Rogers Science of Unitary Human Beings 269

1994) placed great emphasis on modalities their potentials related to their desire for well-
that are traditionally viewed as holistic and being and betterment.
noninvasive. In particular, the use of sound, The unitary patternbased practice method
dialogue, affirmations, humor, massage, jour- identifies the aspect that is unique to nursing
naling, exercise, nutrition, reminiscence, aroma, and expands nursing practice beyond the tra-
light, color, artwork, meditation, storytelling, ditional biomedical model dominating much
literature, poetry, movement, and dance are of nursing. Rogerian nursing practice does not
just a few of the voluntary mutually pattern- necessarily need to replace hospital-based and
ing strategies consistent with a unitary per- medically driven nursing interventions and
spective. In addition, patterning modalities actions for which nurses hold responsibility.
have been developed that are conceptualized Rather, unitary patternbased practice com-
within the Science of Unitary Human Beings plements medical practices and places treat-
such as Butchers metaphoric unitary land- ments and procedures within an acausal,
scape narratives (2006b) and written emo- pandimensional, rhythmical, irreducible, and
tional expression (2004a), therapeutic touch unitary context. Unitary patternbased prac-
(Malinski, 1993), guided imagery (Butcher & tice provides a new way of thinking and being
Parker, 1988; Levin, 2006), magnet therapy in nursing that distinguishes nurses from other
(Kim, 2001), and music (Horvath, 1994; health care professionals and offers new and
Johnston, 2001). Sharing of knowledge through innovative ways for clients to reach their
health education and providing health educa- desired health potentials.
tion literature and teaching also have the The Science of Unitary Human Beings
potential to enhance knowing participation in reflects Rogers optimism and hope for the
change. These and other noninvasive modali- future. She envisioned humankind poised on
ties are well described and documented in both the threshold of a fantastic and unimagined
the Rogerian (Barrett, 1990; Madrid, 1997; future (Rogers, 1992, p. 33), looking toward
Madrid & Barrett, 1994) and the holistic space while simultaneously engaging in a
nursing practice literature (Dossey, 1997; transformative Rogerian revolution in health
Dossey, Keegan, & Guzzetta, 2004). care on Earth. One manifestation will surely
The nurse continuously apprehends changes be the establishment of autonomous Rogerian
in patterning emerging from the human nursing centers here on Earth and ultimately
environmental field mutual process through- in space. Research Applications of the Science
out the simultaneous pattern manifestation of Unitary Human Beings Research is the
knowing and appreciation and voluntary bedrock of nursing practice. The Science of
mutual patterning processes. While the con- Unitary Human Beings has a long history of
cept of outcomes is incompatible with theory-testing research. As new practice the-
Rogers notions of unpredictability, outcomes ories and health patterning modalities evolve
in the Nursing Outcomes Classification from the Science of Unitary Human Beings,
(Moorhead, Johnson, Maas, & Swanson, there remains a need to test the viability
2008) can be reconceptualized as potentiali- and usefulness of Rogerian theories and
ties of change or client potentials (Butcher, voluntary health patterning strategies. The
1997, p. 29), and the indicators can be used as mass of Rogerian research has been reviewed
a means to evaluate the clients desired direc- in a number of publications (Caroselli &
tion of pattern change. At various points in Barrett, 1998; Dykeman & Loukissa, 1993;
the clients care, the nurse can also use the Fawcett, 2005; Fawcett & Alligood, 2003;
scales derived from Rogers science (previously Kim, 2008; Malinski, 1986a; Phillips, 1989;
discussed) to co-examine changes in pattern. Watson, Barrett, Hastings-Tolsma, Johnston,
Regardless of which combination of voluntary & Gueldner, 1997). For additional informa-
patterning strategies and evaluation methods tion, please visit DavisPlus at http://davisplus.
is used, the intention is for clients to actualize fadavis.com.
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270 S E C T I O N IV Conceptual Models/Grand Theories in the UnitaryTransformative Paradigm

Practice Exemplar
E LIZABETH A NN M ANHART B ARRET T me he felt more relaxed, so I invited him to
Barrett continues to refine her theory and complete the PKPCT (Power as Knowing
practice method, as evidenced at A Cele- Participation in Change Tool) and I scored it
bration of Barretts Theory of Power held immediately. Then I briefly explained the
June 6, 2008, when she and other researchers, power theory and pointed out that his scores
practitioners, and administrators presented on the four power dimensions on this semantic
papers. Her brochure describes how to live differential type tool with 12 opposite adjec-
powerfully through Health Patterning, with tive pairs rated on a 1- to 7-point scale pro-
the therapist and client engaging in a vided a 48-item snapshot of how he viewed
dialogue of meaning and various health his capacity to participate in change in a
patterning modalities individualized through knowing manner. His scores indicated that
a Power Prescription aimed toward power for all four power dimensionsawareness,
enhancement, with no attachment to out- choices, freedom to act intentionally, and
comes...Power Prescriptions enrich power- involvement in creating changehis power
as-freedom and diminish power-as-control, was chaotic rather than orderly, avoiding
thereby facilitating well-being and healing.... rather than seeking, and unpleasant rather
The following is a vignette from her practice. than pleasant. Thats exactly how I feel about
John, a tall, thin, 37-year-old man, dressed what is going on in my job right now. Of
in a business suit, white shirt, and tie, walked course, its unpleasant; everything about
into my office for our first session pulling a straightening out this mess seems like con-
large backpack on wheels. Before sitting stant chaos, and I am the first to admit I have
down, he opened the backpack, removed been avoiding it like the plague.
many papers, and began to place several We worked together to come up with a
stacks on the floor. Im desperate. I need your Power Prescription Plan that would allow
help with this mess, he said. Is there any- him to identify from his paperwork what he
thing in your life that feels like a mess you had billed and what he had neglected to bill
need to sort out? I asked. At that point, John and to throw away duplicates and other
welled up and a few tears trickled down his extraneous material. Being relaxed after the
cheeks. Im afraid Im going to be fired from TT experience allowed him to offer the nec-
my job as a salesman. I havent kept clear essary information so that I could help him
records and now my boss is claiming I havent design the plan. As we talked, I emphasized
billed customers for many orders that have that carrying out the plan required giving
been delivered. These papers are all mixed himself the freedom to act on his intention to
up and I cant make heads or tails out of straighten out his life by beginning with
them. I counted them last night and there are straightening out his papers. He could see
569 sheets of paper, some duplicates, some that avoidance just prolonged the chaos of
with dates before the time frame my boss is confusion and if, he involved himself in
questioning. I want you to read them and creating this change, it would certainly be a
help me straighten out this mess. Ive been pleasant relief.
trying for weeks and I just cant think straight After some suggestions as to how he could
anymore. organize his paperwork, he left feeling he had
Johns pattern manifestations of flushed a direction and was relieved to know that the
face; rapid, pressured speech; and clammy outcome of his job situation was unpre-
hands during an initial handshake revealed dictable and that rather than attaching to an
that his discomfort was intense. I suggested a outcome, he would focus on what he was
therapeutic touch session, briefly explained doing to correct the situation. He planned to
the process, and he agreed. Afterward, he told laminate the Power Prescription that I gave
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C H A P T E R 1 5 Martha E. Rogers Science of Unitary Human Beings 271

him and carry it with him as a reminder. It sourced from oneself, and not to be intimi-
goes like this: I am free to choose with dated by power-as-control, where others may
awareness how I participate in changes I attempt to dominate. Then, a therapeutic
intend to create. touch session brought a close to our time
John returned the following week carrying together.
only a small briefcase. He opened it and As a nurse with a practice based on
handed me two folders. I can hardly believe Rogers Science of Unitary Human Beings, I
that I have sorted those papers I brought see the world and clients, whom I prefer to
here last week into two small groups. One call healing partners, in a nonlinear, acausal
folder contains invoices that have been paid way. The simple approach used with John,
and the other folder contains information based on the Rogerian practice methodolo-
regarding delivered materials that I have gy, could serve as a prototype for him to
neglected to complete the paperwork that realize he had power and could use it in
would allow for payment. I am showing you any situation in his life. Pattern manifesta-
copies of what I showed my boss. He said he tion knowing and appreciation and voluntary
appreciated my clarification of what had mutual patterning flowed in a moment-to-
happened and that the necessary procedures moment changing rhythm. Therapeutic touch
would be carried out so that the outstanding and imagery were not used as solutions to a
funds could be collected. By seeking a solu- problem defined by a diagnosis; rather, these
tion in an orderly way, I not only did what I are Health Patterning modalities. The ther-
had not been able to do in the midst of apeutic touch sessions based on his pattern
chaos, but the nightmare turned into a pleas- manifestations and the specific selection of
ant experience. an imagery exercise for this particular person
John, where do you see yourself in your life are what I define as Power Prescriptions.
right now? He said the mess he came in Health patterning modalities are general;
with the previous week had been cleaned up Power Prescriptions are specific to the per-
and he felt like his old self. He came for a son or group. Rogers four postulates and
specific purpose and the issue was resolved three principles describe the way change
and he felt no need to continue. He asked if works in this particular worldview of people
I could give him a way to help himself to relax and their environments.
on his own. Short imagery exercises are inte- Power is the capacity to participate know-
gral to my Health Patterning practice. So, I ingly in change, and my work is intended
briefly instructed him in the use of imagery to teach people how to participate know-
and gave him an imagery exercise that incor- ingly in creating changes in their lives.
porated color, sound, light, and motion. Health Patterning is helping people make
Rogers believed those four modalities would the changes they want to make. I see power
be used increasingly in the future of nursing as a phenomenon that just exists in the
practice. I suggested he tape record the exer- world and there are two types, power-as-
cise and that hearing his own voice could control, based on the causal, material world-
reinforce his confidence to believe that he was view, and power-as-freedom reflecting the
taking charge of his life. I gave him a copy of acausal, spiritual worldview. Practice, in
my brochure that describes Health Patterning accord with Rogers science, helps people
and the Power as Knowing Participation actualize their power-as-freedom in accord
in Change(sm) Theory. I explained that our with the legacy she laid out as a framework
work had been about helping him further for nurses to use in all the many ways of
develop and use his power-as-freedom, being a nurse.
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272 S E C T I O N IV Conceptual Models/Grand Theories in the UnitaryTransformative Paradigm

Summary
Nursing is the study of caring for persons understanding of the experiences, perceptions,
experiencing humanenvironmenthealth tran- and expressions of health events and leads to
sitions (Butcher, 2004b, p. 76). If nursings innovative ways of practicing nursing. There is
content and contribution to the betterment of an ever-growing body of literature demon-
the health and well-being of a society is not strating the application of Rogerian science to
distinguishable from other disciplines and has practice and research. Rogers nursing science
nothing unique or valuable to offer, then is applicable in all nursing situations. Rather
nursings continued existence may be ques- than focusing on disease and cellular biologi-
tioned. Thus, nursings survival rests on its cal processes, the Science of Unitary Human
ability to make a difference in promoting the Beings focuses on humans as irreducible
health and well-being of people. Making a wholes inseparable from their environment.
difference refers to nursings contribution to For 30 years, Rogers advocated that nurses
the clients desired health goals, and offering should become the experts and providers of
care is distinguishable from the services of noninvasive modalities that promote health.
other disciplines. Now, the growth of alternative medicine and
Every disciplines uniqueness evolves from noninvasive practices is outpacing the growth
its philosophical and theoretical perspective. of traditional medicine. If nursing continues
The Science of Unitary Human Beings offers to be dominated by biomedical frameworks
nursing a distinguishable and new way of con- that are indistinguishable from medical care,
ceptualizing health events concerning human nursing will lose an opportunity to become
well-being that is congruent with the most expert in holistic health care modalities. The
contemporary scientific theories. As with Science of Unitary Human Beings offers
all major theories embedded in a new world- nursing a distinguishable and new way of
view, new terminology is needed to create clar- conceptualizing health events concerning
ity and precision of understanding and mean- human well-being that is congruent with the
ing. Rogers nursing science leads to a new most contemporary scientific theories.

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(pp. 914). Norwalk, CT: Appleton-Century-Crofts. (pp. 324339). Thousand Oaks, CA: Sage.
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Chapter
16
Rosemarie Rizzo Parses
Humanbecoming School of
Thought
R OSEMARIE R IZZO PARSE

Introducing the Theorist Introducing the Theorist


Overview of Parses Humanbecoming Rosemarie Rizzo Parse is a Distinguished Pro-
School of Thought
fessor Emeritus at Loyola University Chicago
Summary
as well as a Fellow in the American Academy
References
of Nursing, where she initiated and is immedi-
ate past chair of the Nursing TheoryGuided
Practice Expert Panel. She is founder and edi-
tor of Nursing Science Quarterly; president of
Discovery International, which sponsors inter-
national nursing theory conferences; and
founder of the Institute of Humanbecoming,
where each summer in Pittsburgh she teaches
new material on the ontological, epistemologi-
cal, and methodological aspects of the human-
Rosemarie Rizzo Parse becoming school of thought. There are also
sessions on the Humanbecoming Community
Change Model (Parse, 2003a), the Human-
becoming TeachingLearning Model (Parse,
2004), the Humanbecoming Mentoring Model
(Parse, 2008c), the Humanbecoming Leading
Following Model (Parse, 2008b), and the
Humanbecoming Family Model (Parse, 2008a).
The goal of all sessions is the understanding of
the meaning of humanuniverse from a human-
becoming perspective.
Dr. Parse has published more than 100
articles and 9 books. Her books include
Nursing Fundamentals (Parse, 1974); Man-
Living-Health: A Theory of Nursing (Parse,
1981); Nursing Research: Qualitative Methods
(Parse, Coyne, & Smith, 1985); Nursing Sci-
ence: Major Paradigms, Theories, and Critiques
(Parse, 1987); Illuminations: The Human Becom-
ing Theory in Practice and Research (Parse,
1995); The Human Becoming School of Thought
(Parse, 1998a); Hope: An International Human
Becoming Perspective (Parse, 1999a); Qualitative

277
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Inquiry: The Path of Sciencing (Parse, 2001), and education advance knowledge to new
and Community: A Human Becoming Perspec- realms of understanding. The goal of the pro-
tive (Parse, 2003a). Her books and other pub- fession is to provide service to humankind
lications have been translated into many through living the art of the science. Mem-
languages, as her theory is a guide for practice bers of the nursing profession are responsible
in health care settings and her research for regulating the standards of practice and
methodologies are used by nurse scholars education based on disciplinary knowledge
in Australia, Canada, Denmark, Finland, that reflects safe health service to society in all
Greece, Italy, Japan, South Korea, Sweden, settings (Parse, 1999b).
Switzerland, Taiwan, the United Kingdom, the
United States, and many other countries. The Profession of Nursing
Dr. Parse has received two lifetime achieve- The profession of nursing consists of people
ment awards, one from the Midwest Nursing educated according to nationally regulated,
Research Society and one from the Asian defined, and monitored standards that are
Nurses Association. The Rosemarie Rizzo Parse intended to preserve the integrity of health
Scholarship was endowed in her name at the care for members of society. They are specified
Henderson State University School of Nursing. predominantly in medical terms, according to
She is a sought-after speaker and consultant for a tradition largely related to nursings early
local, national, and international venues. subservience to medicine. Recently, nurse
Dr. Parse is a graduate of Duquesne leaders in health care systems and in regulat-
University in Pittsburgh and received her ing organizations have been developing
masters and doctorate from the University of standards (Mitchell, 1998) and regulations
Pittsburgh. She was a member of the faculty (Damgaard & Bunkers, 1998) consistent with
of the University of Pittsburgh, dean of the discipline-specific knowledge as articulated
School of Nursing at Duquesne University, in the theories and frameworks of nursing.
professor and coordinator of the Center for This is a very significant development that will
Nursing Research at Hunter College of the fortify the identity of nursing as a discipline
City University of New York (19831993), with its own body of knowledgeone that
and professor and Niehoff Chair in Nursing specifies the service that society can expect
Research at Loyola University Chicago (1993 from members of the profession. With the
2006). Since January 2007, she has been rapidly changing health policies and the gen-
a consultant and visiting scholar at the eral dissatisfaction of consumers with health
New York University College of Nursing. care delivery, clearly stated expectations for
services from each of nursings paradigms are a
Authors Reflections on the Discipline welcome change (Parse, 1999b).
and Profession of Nursing
At present, nurse leaders in research, adminis- The Discipline of Nursing
tration, education, and practice are focusing The discipline of nursing encompasses at least
attention on expanding the knowledge base of two paradigmatic perspectives about human-
nursing through enhancement of the disci- universe. The totality paradigm posits the
plines frameworks and theories. Nursing is human as bodymindspirit whose health
both a discipline and a profession (Parse, is considered a state of biological, psychologi-
1999b). The goal of the discipline is to expand cal, social, and spiritual well-being. The
knowledge about human experiences through bodymindspirit perspective is particulate
creative conceptualization and research. The focusing on the biopsychosocialspiritual
knowledge base of the discipline is the scien- parts of the whole human as the human inter-
tific guide to living the art of nursing. The acts with and adapts to the environment. The
discipline-specific knowledge is born and ontology leads to research and practice on
fostered in academic settings where research phenomena related to preventing disease and
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C H A P T E R 1 6 Rosemarie Rizzo Parses Humanbecoming School of Thought 279

maintaining and promoting health according the dictionary definition of man, the name of
to societal norms. The totality paradigm the theory was changed to human becoming
frameworks and theories are more closely (Parse, 1992). No aspect of the principles
aligned with the medical model tradition. changed at that time. With the publication
Nurses practicing according to this paradigm of The Human Becoming School of Thought
are concerned with participation of persons (1998a), Parse expanded the original work to
in health care decisions, but have specific reg- include descriptions of three research method-
imens and goals to bring about change for the ologies and additional specifics related to the
people they serve (Parse, 1999b). practice methodology (Parse, 1987), thus clas-
In contrast, the simultaneity paradigm sifying the science of humanbecoming as a
views the human as indivisible, unpredictable, school of thought (Parse, 1997b). The funda-
everchanging (Parse, 1987, 1998a, 2007b), mental idea of humanbecoming that humans
wherein health is considered personal becom- are indivisible, unpredictable, everchanging, as
ing recognized with changing value priorities. specified in the ontology, precludes any use of
Health is not static but, rather, is everchanging terms such as physiological, biological, psy-
as humans choose ways of living. The ontol- chological, or spiritual to describe the human.
ogy leads research and practice scholars to These terms are particulate, thus inconsistent
focus on, for example, energy field patterns with the ontology. Other terms inconsistent
(Rogers, 1992), lived experiences, and quality with humanbecoming include words often
of life (Parse, 1981, 1992, 1997a, 1998a). used to describe people, such as noncompliant,
Nurses living the simultaneity paradigm dysfunctional, and manipulative.
beliefs hold that their primary concern is peo- In 2007, Parse set forth a clarification of
ples perspectives of their health situations the ontology of the school of thought. She
and their desires. Nurses focus on knowing specified humanbecoming as one word and
participation (Rogers, 1992) and bearing wit- humanuniverse as one word (Parse, 2007b).
ness, as persons in the nurses presence choose Joining the words creates one concept
ways of changing health patterns (Parse, and further confirms the idea of indivisibil-
1981, 1987, 1992, 1995, 1997a). Because the ity. She also described postulates to clarify
ontologies of these paradigmatic perspectives the ontology further (Parse, 2007b). The
are different, they lead to different research ontologythat is, the assumptions, postu-
and practice modalities, different ethical con- lates, and principlessets forth beliefs that
siderations, and different professional services are clearly different from other nursing
to humankind. As in other disciplines, various frameworks and theories. Discipline-specific
theories constitute each paradigm. Humanbe- knowledge is articulated in unique language
coming emanates from the simultaneity para- specifying a position on the phenomenon
digm and is a basic human science that has of concern for each discipline. The human-
co-created human experiences as a central becoming language is unique to nursing.
focus. It is called a school of thought because For example, the three humanbecoming
it encompasses an ontology, epistemology, principles contain nine concepts written in
and methodologies (Parse, 1997b). verbal form with -ing endings to make clear
the importance of the ongoing process of
change as basic to humanuniverse emer-
Overview of Parses gence. In addition, each concept is explicated
with paradoxes as apparent opposites,
Humanbecoming School further specifying the uniqueness of the
of Thought humanbecoming language.
Parses (1981) original work was titled Man- The humanbecoming school of thought
Living-Health: A Theory of Nursing. When the encompases the ontology, the epistemology,
term mankind was replaced with male gender in and the research and practice methodologies.
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The Ontology arise from the three major themes of the


The assumptions, postulates, and principles assumptions: meaning, rhythmicity, and tran-
of the humanbecoming school of thought scendence. Each principle describes a theme
comprise the ontology (Parse, 2007b). with three concepts. Each of the concepts
explicates fundamental paradoxes of human-
becoming (Parse, 1998a, 2007b). The para-
Philosophical Assumptions
doxes are rhythms lived all-at-once as pattern
The assumptions of the humanbecoming preferences (Parse, 2007b). Paradoxes are not
school of thought are written at the philo- opposites or problems to be solved but rather
sophical level of discourse (Parse, 1998a). are ways humans live their chosen meanings.
There are nine fundamental assumptions, This way of viewing paradox is unique to the
four about the human and five about becom- humanbecoming school of thought (Mitchell,
ing (Parse, 1998a, 2008b). Three additional 1993a; Parse, 1981, 1994b, 2007b).
assumptions about humanbecoming were syn- The new statements of principles are pre-
thesized from these nine assumptions (Parse, sented in detail in Parse (2007b). With
1998a, 2008b). The assumptions arose from a the first principle (see Parse, 1981, 1998a,
synthesis of ideas from the Science of Unitary 2007b), Parse explicates the idea that humans
Human Beings (Rogers, 1992) and from exis- construct personal realities with unique choos-
tential phenomenological thought (Parse, ings arising with illimitable humanuniverse
1981, 1992, 1994a, 1995, 1997a, 1998a). In options. Reality, the meaning given to a situa-
the assumptions, Parse posits humans as indi- tion, is the individual humans everchanging
visible, unpredictable, and everchanging, co- seamless symphony of becoming (Parse,
creating a unique becoming. She also posits 1996). The seamless symphony is the unique
humans as experts on their own health and story of the human as mystery emerging with
quality of life. Humans live an all-at-onceness the explicit-tacit knowings of imaging. The
in freely choosing meanings that arise with human lives the confirmingnot confirming of
illimitable experiences. The chosen meanings valuing as cherished beliefs, while languaging
are the value priorities co-created in tran- with speakingbeing silent and movingbeing
scending with the possibles (Parse 1998a). still [see Parse (2007b) for details].
The second principle (Parse, 1981, 1998a,
Postulates and Principles 2007b) describes the rhythmical humanuni-
In 2007, Parse (2007b) elaborated certain verse patterns of relating. The paradoxical
truths embedded in the conceptualizations of rhythm revealingconcealing is disclosingnot
the ontology. In so doing she expanded the disclosing all-at-once (Parse, 1998a, p. 43).
idea of co-creating reality as a seamless sym- Not all is explicitly known or can be told in
phony of becoming (Parse, 1996), a central the unfolding mystery of humanbecoming.
thought foundational to the ontology, as fore- Enablinglimiting is living the opportunities
grounded with four postulates of illimitability, restrictions present in all choosings all-
paradox, freedom, and mystery [see Parse at-once (Parse, 1998a, p. 44). There are
(2007b) for detailed descriptions of the postu- opportunities and restrictions irrespective of
lates]. The meanings of the postulates perme- the choice; all choosings are potentiating
ate all three of the principles; the words of the restricting (see Parse, 2007b for details).
postulates are not used in the statements of the Connectingseparating is being with and apart
principles. Thus, the wording has been clari- from others, ideas, objects and situations
fied to provide semantic consistency without all-at-once (Parse, 1998a, p. 45). It is coming
changing the original meaning of the princi- together and moving apart; there is close-
ples. The principles of humanbecoming, often ness in the separation and distance in the
referred to as the theory, describe the central closenessa rhythmical attendingdistancing
phenomenon of nursing (humanuniverse), and [see Parse (2007b) for details].
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With the third principle, Parse (1981, The Humanbecoming Hermeneutic Method
1998a, 2007b) explicated the idea that humans was created in congruence with the assump-
are everchanging, that is, moving on with the tions and principles of Parses theory, drawing
possibilities of their intended hopes and from works by Bernstein (1983), Gadamer
dreams. A changing diversity unfolds as humans (1976, 1960/1998), Heidegger (1962), Langer
affirm and do not affirm in the pushing (1976), and Ricoeur (1976, 1981).
resisting of powering, as creating new ways of The purpose of these two basic research
living the conformitynonconformity and methods is to advance the science of human-
certaintyuncertainty of originating sheds becoming by studying lived experiences from
new light on the familiarunfamiliar of trans- participants descriptions (Parse Method) and
forming. Powering is the pushingresisting of from written texts and art forms (Humanbe-
affirmingnot affirming being in light of non- coming Hermeneutic Method). The phe-
being (Parse, 1998a). The beingnonbeing nomena for study with the Parse Method are
rhythm is all-at-once living the everchanging universal lived experiences such as joy, sorrow,
now moment as it melts with the not-yet. hope, grieving, and courage, among others.
Humans, in originating, seek to conformnot Written texts from any literary source or art
conform, that is, to be like others and unique form may be the subject of research with the
all-at-once, while living the ambiguity of Humanbecoming Hermeneutic Method.
the certaintyuncertainty embedded in all The processes of both methods call for a
change. The changing diversity arises with unique dialogue, researcher with participant,
transforming the familiarunfamiliar, as illim- or researcher with text or art form. The
itable possibles are viewed in a different light. researcher in the Parse Method is in true
The three principles, together with the presence as the participant moves with an
postulates and assumptions, comprise the unstructured dialogue about the lived experi-
ontology of the humanbecoming school of ence under study. The researcher in the
thought. The principles are referred to as the Humanbecoming Hermeneutic Method is in
humanbecoming theory. The concepts, with true presence with the emerging possibilities
the paradoxes, describe humanuniverse. This in the horizon of meaning arising in dialogue
ontological base gives rise to the epistemology with texts or art forms. True presence is an
and methodologies of humanbecoming. Epis- intense attentiveness to unfolding essences
temology refers to the focus of inquiry. Con- and emergent meanings. The researchers
sistent with the humanbecoming school of intent with these research methods is to dis-
thought, the focus of inquiry is on humanly cover structures (Parse Method) and emergent
lived experiences. meanings (Humanbecoming Hermeneutic
Method). The contributions of the findings
Humanbecoming Research from studies using these two methods include
Methodologies new knowledge and understanding of humanly
Sciencing humanbecoming is coming to lived experiences (Parse, 1998a, p. 62).
know; it is an ongoing inquiry to discover and Many nurse scholars worldwide have con-
understand the meaning of lived experiences. ducted studies using the Parse Method, some
The humanbecoming research tradition has of which have been published (see Doucet &
two basic research methods and one applied Bournes, 2007). Parse (1999a) was also a
research method (Parse, 1998a, 2005). The principal investigator for a research study on
three methods flow from the ontology of the lived experience of hope using the Parse
the school of thought. The basic research Method, with participants from Australia,
methods are the Parse Method (Parse, 1987, Canada, Finland, Italy, Japan, Sweden,
1990, 1992, 1995, 1997a, 1998a, 2001) and Taiwan, the United Kingdom, and the United
the Humanbecoming Hermeneutic Method States. The findings from these studies and
(Cody, 1995; Parse, 1995, 1998a, 2001, 2005). the stories of the participants are published in
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Hope: An International Human Becoming Per- sometimes misinterpreted as simply asking


spective (Parse, 1999a). Collaborative research persons what they want and respecting their
projects using the Parse Research Method desires. Often nurses say it is what they always
also have been published on feeling very tired do (Mitchell, 1993b); this is not true pres-
(Baumann, 2003; Huch & Bournes, 2003; ence. True presence is an intentional reflec-
Parse, 2003b). Four studies have been pub- tive love, an interpersonal art grounded in a
lished in which authors used the Humanbe- strong knowledge base (Parse, 1998a, p. 71).
coming Hermeneutic Method (Cody, 1995, The knowledge base underpinning true pres-
2001; Ortiz, 2003; Parse, 2007a; see Doucet ence is specified in the assumptions, postu-
& Bournes, 2007). lates, and principles of humanbecoming (Parse,
The applied research method is the 1981, 1992, 1995, 1997a, 1998a, 2007b). True
qualitative descriptive preprojectprocess presence is a free-flowing attentiveness that
postproject method. It is used when a arises from the belief that the humanuniverse
researcher wishes to evaluate the changes, sat- is indivisible, unpredictable, everchanging.
isfactions, and effectiveness of health care Humans freely choose with situations, struc-
when humanbecoming guides practice (Parse, ture personal meaning, live paradoxical
1998a, 2001, 2006). The major purpose of rhythms, and move beyond with changing
the method is to understand what happens diversity (Parse, 1998a, 2007b). Parse (1987,
when humanbecoming is lived nurse with 1998b) states that to know, understand, and
person, family, and community. A number of live the beliefs of human becoming requires
researchers have conducted studies using this concentrated study of the ontology, episte-
method (Bournes & Ferguson-Par, 2007, mology, and methodologies and a commit-
2008; Bournes et al., 2007; Jonas, 1995a; ment to a different way of being with people.
Legault & Ferguson-Par, 1999; Maillard- The different way that arises from the
Strby, 2007; Mitchell, 1995; Northrup & humanbecoming beliefs is true presence.
Cody, 1998; Santopinto & Smith, 1995), True presence is a powerful human uni-
and a synthesis of the findings of these and verse connection. It is lived in face-to-face
other such studies was written and published discussions, silent immersions, and lingering
(Bournes, 2002; Doucet & Bournes, 2007). presence (Parse, 1987, 1998a). Nurses may
be with persons, families, and communities
Humanbecoming: The Art in discussions, imaginings, or remembrances
From the humanbecoming perspective, the through stories, films, drawings, photographs,
disciplines goal is quality of life. The goal of movies, metaphors, poetry, rhythmical move-
the nurse living the humanbecoming beliefs is ments, and other expressions (Parse, 1998a).
true presence in bearing witness and being Many publications explicate the art of
with others in their changing health patterns. true presence and humanbecoming-guided
True presence is lived nurse with person, fam- practice (see, e.g., Arndt, 1995; Banonis, 1995;
ily, and community in illuminating mean- Bournes, 2000, 2003, 2006; Bournes & Flint,
ing, synchronizing rhythms, and mobilizing 2003; Bournes, Bunkers, & Welch, 2004;
transcendence (Parse, 1987, 1992, 1994a, 1995, Bournes & Naef, 2006; Butler, 1988; Butler &
1997a, 1998a). The nurse with individuals or Snodgrass, 1991; Chapman, Mitchell, &
groups is in true presence with the unfolding Forchuk, 1994; Cody, Mitchell, Jonas-Simpson,
meanings as persons explicate, dwell with, and & Maillard-Strby, 2004; Hansen-Ketchum,
move on with changing patterns of diversity. 2004; Hutchings, 2002; Jonas, 1994, 1995b;
Living true presence is unique to the art of Jonas-Simpson & McMahon, 2005; Karnick,
humanbecoming. True presence is not to be 2005, 2007; Lee & Pilkington, 1999; Mattice
confused with terms now prevalent in the & Mitchell, 1990; Mitchell, 1988, 1990;
literature such as authentic presence, trans- Mitchell & Bournes, 2000; Mitchell, Bournes,
forming presence, presencing, and others. It is & Hollett, 2006; Mitchell & Bunkers,
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C H A P T E R 1 6 Rosemarie Rizzo Parses Humanbecoming School of Thought 283

2003; Mitchell & Cody, 1999; Mitchell & insights and even surprises, as situations are
Copplestone, 1990; Mitchell & Pilkington, seen in the new light that arises with the true
1990; Naef, 2006; Norris, 2002; Paille & presence of nurses who bear witness and
Pilkington, 2002; Quiquero, Knights, & Meo, do not label. Labeling or diagnosing is objec-
1991; Rasmusson, 1995; Rasmusson, Jonas, & tifying, ignoring the importance of persons
Mitchell, 1991; Smith, 2002; Stanley & dignity and freedom. Humanbecoming nurs-
Meghani, 2001; and others). es believe that persons know their way and
live their health situations according to their
The Art of Humanbecoming Lived with unique value priorities. When with recipients
Persons and Others of health care, the humanbecoming nurse asks
It is important here to clarify some terminol- what is most important for the moment, and
ogy. Nursing practice is a generic term that explores meanings, wishes, intents, and
refers to the genre of activities of the profes- desires related to the situation from the per-
sion in general. The term practice is not appro- spective of the recipients. Nurses are with per-
priate to use when referring to humanbecom- sons in ways that honor these wishes and
ing, because according to various dictionary desires. Persons are seamless symphonies of
definitions it means a habit, or to drill, exer- becoming and nurses are only one note in the
cise, try repeatedly, or do over and over again. symphony.
The word practice is antithetical to the ontol-
ogy, as a major focus of humanbecoming is The Art of Humanbecoming Lived with
human freedom and dignity. Humanbecom- Community
ing nurses live the art of the science of The humanbecoming school of thought is a
humanbecoming. The art of humanbecoming guide for research, practice, education, and
refers to living true presence, which arises administration in settings throughout the
directly from a sound understanding of the world. Scholars from five continents have
ontology of the school of thought. True pres- embraced the belief system and live human-
ence flows only from nurses and health pro- becoming in a variety of venues, including
fessionals who have studied; understand; health care centers and university nursing
believe in; and live the humanbecoming programs. The Humanbecoming Community
assumptions, postulates, and principles. The Change Concepts (Parse, 2003a), the Human-
term living is the proper term to describe becoming TeachingLearning Model (Parse,
what nurses experience when with recipients 2004), The Humanbecoming Mentoring
of health care. Nurses and others who live Model (Parse, 2008c), and the Humanbe-
humanbecoming believe that persons, fami- coming LeadingFollowing Model (Parse,
lies, and communities are the experts on their 2008b) are disseminated and utilized in prac-
own health care situations. tice settings worldwide. Many health centers
In nurse with person health care situations, throughout the world have humanbecoming
nurses in true presence come to persons with as a guide to health care (Bournes, Bunker, &
an availability to be with and bear witness, as Welch, 2004; Cody, Mitchell, & Jonas, 2004).
persons illuminate the meaning of the situa- In several university-affiliated practice set-
tion, synchronize rhythms, and mobilize tran- tings in Canada, humanbecoming practice
scendence (Parse, 1981, 1987, 1998a, 2007b). has been evaluated, and the theory has pro-
The illuminating of meaning, synchronizing vided underpinnings for standards of care
of rhythms, and the mobilizing of transcen- (Bournes, 2002; Legault & Ferguson-Par,
dence occurs in the true presence of the 1999; Mitchell, 1998; Mitchell, Closson,
humanbecoming nurse, as persons explicate Coulis, Flint, & Gray, 2000; Northrup &
their situations, dwell with the moment, and Cody, 1998) and nursing best practice guide-
move on all-at-once. In explicating, dwelling lines (Nelligan et al., 2002). For example, in
with, and moving on, they experience new Toronto, Sunnybrook Health Science Centre
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284 S E C T I O N IV Conceptual Models/Grand Theories in the UnitaryTransformative Paradigm

and University Health Network have both (Bournes et al., 2007). The Regina project
created multidisciplinary standards of care was implemented in collaboration with
that arise from the beliefs and values of the Regina QuAppelle Health Region and the
humanbecoming school of thought. Saskatchewan Union of Nurses.
In the settings worldwide where humanbe- Findings from the research (Bournes &
coming has guided nursing practice on a large Ferguson-Par, 2007, 2008; Bournes et al.,
scale, researchers examined the effects on 2007) to evaluate implementation of the
the nurses and persons who were involved humanbecoming 80/20 model have been
(Bournes & Ferguson Par, 2007, 2008; extremely positive. For example, interviews
Bournes et al., 2007; Jonas, 1995a; Legault & with nurses, patients, families, and other
Ferguson-Par, 1999; Maillard-Strby, 2007; health professionals in the Bournes and
Mitchell, 1995; Northrup & Cody, 1998; Ferguson-Par (2007) study supported the
Santopinto & Smith, 1995). The findings of humanbecoming theory as an effective basis
the studies describe what happened when for learning and implementing patient-
humanbecoming was used as a guide for nurs- centered care that benefits both nurses and
ing practice on an orthopedic surgery and patients (p. 251). Patients and families in that
rheumatology unit (Bournes & Ferguson-Par, study reported that they appreciated the rev-
2007), on a cardiac surgery unit (Bournes erent consideration given to them by nurses
et al., 2007), on a medical oncology unit and who had learned about humanbecoming-
a general surgery unit (Bournes & Ferguson- guided patient-centered care (p. 251). They
Par, 2008), in a family practice unit affiliated also described being confident engaging in
with a large teaching hospital ( Jonas, 1995a), discussions with nurses who were understand-
on a 41-bed vascular and general surgery unit ing and attentive experts interested in who
(Legault & Ferguson-Par, 1999), on an acute they were and what was important to them
care medical unit (Mitchell, 1995), on three (p. 251). Similarly, the nurse participants
acute care psychiatry units (Northrup & in Bournes and Ferguson-Pars (2007) and
Cody, 1998), on three units in a 400-bed Bournes and colleagues (2008) studies report-
community teaching hospital (Santopinto & ed that after learning about humanbecoming-
Smith, 1995), and on a medical oncology guided nursing practice they were more con-
unit (Maillard-Strby, 2007). The findings cerned with listening to patients and families,
from five of the studies are summarized being with them, getting to know what
in Bournes (2002) and are consistent with is important to them, and respecting them
those of more recent evaluations (Bournes & as the experts about their quality of life.
Ferguson-Par, 2007, 2008; Bournes et al., They also reported being more satisfied with
2007; Maillard-Strby, 2007). their worka theme noted by nurse leaders
Bournes and Ferguson-Par (2007, 2008) and allied health participants who shared
and Bournes, Plummer, Hollett, and Ferguson- that nurses...listened more and focused on
Par (2008) examined the impact of an patients perspectives (Bournes & Ferguson-
innovative academic employment model (the Par, 2007, p. 251). Participants in both studies
humanbecoming 80/20 modelin which described the benefits of the program, not
nurses spend 80% of their paid work time in only in relation to how it changed their rela-
direct patient care guided by humanbecoming tionships with patients, but also in relation to
and 20% of their paid work time learning how it changed their view of how to be with
about humanbecoming and engaging in relat- their colleagues in more meaningful ways (see
ed professional development activities). The Bournes & Ferguson-Par, 2007; Bournes
humanbecoming 80/20 model has been et al., 2007). In addition, study findings show
implemented on four unitsthree in Toronto, that the cost of providing education about
Ontario (Bournes & Ferguson-Par, 2007, humanbecoming-guided practice and staffing
2008) and one in Regina, Saskatchewan the 80/20 aspect of the model is offset by
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C H A P T E R 1 6 Rosemarie Rizzo Parses Humanbecoming School of Thought 285

higher nurse and patient satisfaction scores Riverside, California. Faculty and students
and a reduction in sick time and overtime learn and live the art of humanbecoming in
(Bournes & Ferguson-Par, 2007; Bournes the various venues where they practice. The
et al., 2007). At a large academic teaching Nursing Center for Health Promotion with
hospital, the humanbecoming 80/20 model is the Charlotte Rainbow PRISM Model was
currently being tested as the basis for a men- established in Charlotte, North Carolina,
toring program among experienced critical as a venue for nurses to offer health care deliv-
care nurses and new nurses who want to work ery to homeless women and children with
in critical care (Bournes et al., 2008). The diverse backgrounds. The PRISM Model,
mentoring program is based on the Human- based on humanbecoming, is the guide
becoming Mentoring Model (Parse, 2008c). to practice (Cody, 2003). At the Espace
In South Dakota, a parish nursing model Mediane community nursing center in Geneva,
was built on the Eight Beatitudes and Switzerland (for persons who have concerns
the principles of humanbecoming to guide about cancer and palliative care), practice and
nursing practice in the health model at the teachinglearning are guided by humanbe-
First Presbyterian Church in Sioux Falls coming, meaning that nurses in the center live
(Bunkers, 1998a, 1998b; Bunkers, Michaels, true presence with visitors. They also link
& Ethridge, 1997; Bunkers & Putnam, 1995). with academic partners to provide an academ-
Bunkers and Putnam (1995) state, The ic service for postgraduate nursing students
nurse, in practicing from the human becom- specializing in oncology and palliative care
ing perspective and emphasizing the teach- (Cody et al., 2004). A study to evaluate what
ings of the Beatitudes, believes in the endless happens when the art of humanbecoming is
possibilities present for persons when there is initiated in a palliative care inpatient setting is
openness, caring, and honoring of justice and currently in process in Fribourg, Switzerland
human freedom (p. 210). Also, the Board of (F. Maillard-Strby, personal communication,
Nursing of South Dakota has adopted a deci- August, 7, 2008).
sioning model based on the humanbecoming Shifting practice from the traditional med-
school of thought (Damgaard & Bunkers, ical model mode to living the art of humanbe-
1998). Augustana College (in Sioux Falls) coming is a challenge for healthcare institu-
has humanbecoming as one theoretical focus tions and requires high-level administrative
of the curricula for the baccalaureate and commitment for resources, including educa-
masters programs. The humanbecoming tional opportunities for nurses. The commit-
theory is the basis of Augustanas Health ment to humanbecoming practice requires a
Action Model for Partnership in Community change in value priorities system-wide
(Bunkers, Nelson, Leuning, Crane, & Josephson, (Bournes, 2002; Bournes & DasGupta, 1997;
1999). The purpose of the model is to Linscott et al., 1999; Mitchell et al., 2000).
respond in a new way to nursings social Approximately 300 participants world-
mandate to care for the health of society by wide who are interested in living the art
gaining an understanding of what is wanted of humanbecoming subscribe to Parse-L,
from those living these health experiences an e-mail listserv where Parse scholars
(Bunkers et al., 1999, p. 94). The creation of share ideas. There is a Parse home page on
the model was for persons homeless and low the Internet that is updated regularly (see
income who are challenged with the lack of www.humanbecoming.org). Every other year,
economic, social and interpersonal resources most of the 100 or more members of the
(Bunkers et al., 1999, p. 92). International Consortium of Parse Scholars
The humanbecoming school of thought is meet in Canada for a weekend immersion
the theoretical foundation of the baccalaure- in humanbecoming research and practice.
ate and masters curricula at the California The DVD The Human Becoming School of
Baptist University College of Nursing in Thought: Living the Art of Human Becoming
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286 S E C T I O N IV Conceptual Models/Grand Theories in the UnitaryTransformative Paradigm

(International Consortium of Parse Scholars, 1997), available from Fitne (www.fitne.net).


2007) (available from the International Con- Another video showing nurse with persons is
sortium of Parse Scholars at www.humanbe- The Grief of Miscarriage (Gerretsen & Pilk-
coming.org) shows Parse nurses in true pres- ington, 1990). There is also a video called Im
ence with persons in different settings and Still Here, which is a humanbecoming
features Rosemarie Rizzo Parse talking research-based drama on living with demen-
about humanbecoming in practice. Parse tia (Ivonoffski, Mitchell, Krakauer, & Jonas-
is also featured on the video in the Simpson, 2006). It is available from the
Portraits of Excellence Series called Rose- Murray Alzheimer Research and Education
marie Rizzo Parse: Human Becoming (Fitne, Program at the University of Waterloo.

Summary
Through the efforts of Parse scholars, the findings from applied research projects related
humanbecoming school of thought will con- to fostering understanding of humanbecoming
tinue to emerge as a major force in the 21st- in practice also will continue to be synthesized.
century evolution of nursing knowledge. These syntheses will guide decisions for con-
Knowledge gained from basic research studies tinually creating the vision for sciencing and
will continue to be synthesized to explicate fur- living the art of the humanbecoming school of
ther the meaning of lived experiences. The thought for the betterment of humankind.

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Parse, R. R., Coyne, B. A., & Smith, M. J. (1985). Nurs- Stanley, G. D., & Meghani, S. H. (2001). Reflections
ing research: Qualitative methods. Bowie, MD: Brady. on using Parses theory of human becoming in a
Quiquero, A., Knights, D., & Meo, C. O. (1991). palliative care setting in Pakistan. Canadian Nurse,
Theory as a guide to practice: Staff nurses choose 97, 2325.
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Chapter
17
Margaret Newmans Theory
of Health as Expanding
Consciousness
M ARGARET D EXHEIMER P HARRIS

Introducing the Theorist I dont like controlling, manipulating other


Overview of the Theory people.
Applications of the Theory I dont like deceiving, withholding, or treating
Practice Exemplar people as subjects or objects.
Summary I dont like acting as an objective non-person.
References I do like interacting authentically, listening,
understanding, communicating freely.
I do like knowing and expressing myself in
mutual relationships.
M ARGARET N EWMAN (1985)

Introducing the Theorist


Nurses who base their practice on Margaret
Newmans theory of health as expanding con-
sciousness (HEC) focus on being fully pres-
Margaret A. Newman ent to meaning and patterns in the lives of
their patients. Newman (2005) stated, [O]ne
does not practice nursing using the theory, but
rather the theory becomes a way of being with
the clienta way of offering clients an oppor-
tunity to know and be known and to find their
way (p. xiv). Through their relationship with
a nurse who understands the theory of HEC
and attends to the evolving pattern of what is
meaningful in their lives, patients are able to
realize a previously undiscovered path for
action. Just as patients health predicaments
are situated within the evolving pattern of
complex relationships and events in their
lives, so too, Newmans theory has evolved
within the context of the meaningful relation-
ships and events of her life.
The foundation for Newmans theory was
laid long before she entered nursing school
(Newman, 1997c). When she was a child,
Newmans father, who was an avid reader of

290
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C H A P T E R 1 7 Margaret Newmans Theory of Health as Expanding Consciousness 291

philosophical works, would often say to her, disease, her life was not defined by it. In other
Mind over matter! Newman learned early words, she could experience health and
on that the way you look at a situation helps wholeness in the midst of having a chronic
you move through it; this was an outlook that and progressive disease. The second impor-
carried her through many difficult times and tant realization was that time, movement, and
taught her that there are various ways in space are in some way interrelated with
which to view situations. health, which can be manifested by increased
As a child growing up in Memphis, connectedness and quality of relationships.
Tennessee, Newman had many friends, The restrictions of movement that
attended dance school, loved math and the Newmans mother experienced due to the ALS
arts, and enjoyed interacting with guests altered her experience of time, space, and con-
at her parents tourist home. When it was sciousness. While caring for her physically
time to choose a college, Margarets mothers immobilized mother, Newman experienced
position as the secretary at the Baptist church similar alterations in her own movement, space,
strongly influenced Newmans decision to time, and consciousness (Newman, 1997c).
attend college at Baylor University in Texas. Previously both Margaret Newman and her
Although Newman did not major in nurs- mother had been very active. They were leaders
ing as an undergraduate, two experiences at of organizations and both were involved in
Baylor sparked her interest in the nursing several social groups; they were always busy. In
profession. First, she contemplated entering the midst of this terminal disease process, with
missionary service but felt she could not its resultant constrictions on time, space, and
attend to peoples spiritual well-being without movement, both mother and daughter experi-
also attending to their physical needs; this enced a greater sense of connectedness and
realization created a tug toward nursing. The increased insight into the meaning of their
other strong tug occurred during her junior experience and the meaning of health. Newman
year when Newmans roommate, a nursing came to know her mother in a very deep and
student, was called to assist in the aftermath significant way (Newman, 2008b). These early
of a tornado. But these influences were not seeds of the HEC theory found fertile ground
strong enough to persuade her to change col- in 1959 when Newman entered nursing school
lege majors at that time. at the University of Tennessee (UT) in Mem-
After graduating from Baylor University phis. Her mother died 2 weeks before the
Newman returned to Memphis to work and to beginning of the fall semester for the nursing
care for her mother who had been diagnosed a program at UT. In her first semester of nursing
few years earlier with amyotrophic lateral scle- school at UT, Newman realized that nursing
rosis (ALS), a degenerative neurological disease would require everything she hadall of her
that progressively diminishes the movement of intelligence and all of her humanness (2008b).
all muscles except those of the eyes. The process One of her professors, Marie Buckley, stressed
of caring for her mother over a 5-year period the importance of graduate school for nurses
was transformative. Not knowing the trajectory and encouraged the nursing students to consider
of the disease, Newman learned to live day by how to construct an independent nursing prac-
day, fully immersed in the present (Newman, tice; this was an idea that intrigued Newman
2008b). Newman (2008a) stated she learned and that she continued to promote in various
that each day is precious and that the time of ways throughout her career.
ones life is contained in the present (p. 225). Another professor, Dorothy Hocker, who
Caring for her mother provided Newman held high expectations for students during
with two additional significant realizations. their clinical rotations, also had a strong
The first was that simply having a disease impact on Newmans view of the nature of
does not make a person unhealthy. Although nursing practice. As a student, Newman was
Newmans mothers life was confined by the frustrated with nursing texts and lectures with
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292 S E C T I O N IV Conceptual Models/Grand Theories in the UnitaryTransformative Paradigm

lengthy discussions on diseases and their nursing shortage and looked at nursing inter-
medical treatments but had only a few sen- actions during short spans of time (Newman,
tences about the nursing care for people diag- 1966).
nosed with the disease. At that time, most of When she graduated from UCSF in 1964,
the knowledge in nursing texts was medical, Newman was recruited back to Memphis to
with only a sprinkling of nursing knowledge become the director of the Clinical Research
added at the very end. Newman wanted to Center. In this position, Newman went
acquire more knowledge specific to the pro- against the conventional grain of the day; she
fession of nursing. On one clinical rotation educated the medical director on the nature of
day, she had a very challenging teenage nursing functions so that the nursing staff
patient with type 1 diabetes. The teen had would not be asked to do things physicians
been hospitalized many times for diabetic could do for themselves or which staff from
comas. Newman watched in horror as a resi- other departments could do. Newman encour-
dent physician berated the patient, telling her aged the scholarly development of the nursing
she was going to die if she didnt shape up. staff and created time for nurses to go to the
Newman had studied everything there was to library to enrich their knowledge base. Further
know about type 1 diabetes, yet felt at a loss as studies and reflection helped Newman articu-
to how to reach the patient. She did not know late that nurses who can be fully present with
what she as a nurse should do. She consulted patients while doing tasks are able to compre-
Dorothy Hocker, who went into the room hend in a holistic sense what patients need to
and asked one or two questions and immedi- achieve a greater sense of health. Seeing and
ately connected with the patient in a signifi- honoring the whole of patients lives as the
cant and caring manner, which allowed the important context in which the task at hand is
teenager to open up and talk about her situa- being performed requires a paradigm shift, a
tion. In this interaction, Newman witnessed shift in point of view. Newman felt that nurse
the power of nursing presence. theorist Martha Rogers at New York Univer-
A 1961 article by Dorothy Johnson on sity (NYU) was articulating a new paradigm of
the significance of nursing care provided the health that expanded the nature of nursing
theoretical basis for what Newman had wit- practice. Rogers Science of Unitary Human
nessed in the interaction between Dorothy Beings theory resonated with Newmans
Hocker and the young patient with diabetes. evolving conceptualizations of nursing and
Johnsons writings influenced Newmans health; it enhanced Newmans ability to see
desire to explore more thoroughly the nature the whole by entering into the part (Newman,
of nursing practice. Johnson differentiated 1997b).
nursing knowledge from medical knowledge After directing the Clinical Research
and proposed that nurses provide a dynamic Center for 212 years, Newman decided to
equilibrium for patients as they experience pursue doctoral studies in nursing at NYU
crises. where she would be able to study with Martha
After graduating from UTs baccalaureate Rogers. She was also excited about living in
nursing program, Newman stayed on at UT New York City. Newman received 4 years of
as a clinical instructor. The next year she funding for her doctoral studies. In her doc-
went to the University of California, San toral work at NYU, Newman began studying
Francisco to obtain her masters degree in movement, time, and space as parameters of
medicalsurgical nursing. While there, she health; however, she did so out of a logical
conducted two studies of nursing practice. positivist scientific paradigm. She designed an
One study explored the usefulness of nurse- experimental study that manipulated partici-
directed abdominal exercises for preventing pants movements, then measured their per-
constipation in medicalsurgical patients on ception of time (Newman, 1982). Her results
bed rest. The other was influenced by the showed a changing perception of time across
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C H A P T E R 1 7 Margaret Newmans Theory of Health as Expanding Consciousness 293

the life span, with subjective time (as com- part of her theory development work, she
pared to objective time) increasing with age conducted a pilot study of pattern identifca-
(Newman, 1987). Although her results seemed tion. She invited Richard Cowling from Case
to support what she later would term health Western and Jim Vail from the Army Nurse
as expanding consciousness, at the time Corps to collaborate with her. Newman was
Newman felt they did little to inform or shape at that time also a consultant to the Army
nursing practice, which was what most inter- Nurse Corps. The study participants were
ested her (Newman, 1997a). nurses at Walter Reed Hospital. Newman
After receiving her PhD in 1971, Newman interviewed a nurse while Vail and Cowling
joined the NYU faculty. While there, Newman watched from another room. She asked the
published a seminal article in Nursing Outlook woman to describe meaningful events in her
on nursings theoretical evolution (Newman, life and diagrammed the unfolding trajectory
1972), and with colleague Florence Downs of her life. When she returned to the woman
coauthored two editions of a book on research the next day to reflect the sequential patterns
in nursing (Downs & Newman, 1977). She also Newman had identified, the woman was able
conducted postdoctoral workshops at NYU on to see that experiences she had previously
nursing theory development and spent the viewed as being extremely negative (e.g., a
summer of 1976 consulting with nurses in divorce), actually were stepping stones to
Brazil. Newmans early career in academia was expanded possibilities; she was suddenly able
centered on articulating the knowledge of the to view her life in a new way. The nurse
discipline and how it is developed. researchers and participants were excited
In 1977, Newman joined the faculty at Penn about the insights they gained. Newman went
State as the professor-in-charge of graduate on to develop a pattern recognition nursing
studies. At that time, she was invited to speak praxis (theory, practice, and research as one)
at a theory conference to be held in New York process.
in 1978. It was in that address that she first Newmans pattern recognition process
clearly articulated her theory of health. The served as the basis for the work of several grad-
transcript of her talk was published as a chapter uate students at the University of Minnesota,
in a book she wrote about theory development most notably Susan Moch (1990), Merian
in nursing (Newman, 1979), which was one Litchfield (1993, 1999), Helga Jonsdottir
of the first books published on the subject. (1998), Frank Lamendola (1998), Emiko
Newman also organized a Nursing Theory Endo (1998), Patricia Tommet (2003), and
Think Tank, which was limited to 15 PhD Norma Kiser-Larson (2002). This group met
prepared nurse scholars who were involved regularly with Newman to dialogue about the
in nursing theory development. Newman evolution of the theory of HEC as they expe-
remained actively involved with this group rienced it in their work. The graduate students
until its tenth year. She was also a member of studies and the group dialogue, which focused
a group of nurse theorists facilitated by Sister on the meaning of the studies, elaborated and
Callista Roy to discern how to organize nurs- expanded the theory.
ing diagnoses so that they would be rooted in While at the University of Minnesota,
the knowledge of the discipline of nursing. Newman published two editions of her book,
This group presented papers in 1978 and Health as Expanding Consciousness (Newman,
1980 to the North American Nursing 1986, 1994a), which attracted international
Diagnosis Association (NANDA). In 1982, attention. She conducted a series of lectures
they presented an organizing framework they and dialogues in New Zealand in 1985 and in
had developed for nursing diagnoses called Finland in 1987 on health as expanding con-
Patterns of Unitary Man (Humans). sciousness and nursing knowledge development.
In 1984, Newman took a position as nurse Together with colleagues in Tucson, Ari-
theorist at the University of Minnesota. As zona, Newman conducted a study of nurses
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working with a nurse case management proj- studies at New York University also greatly
ect; she found that as nurses reflected on their influenced her quest for exploring and artic-
pattern over time, they gained insights for ulating the knowledge of the discipline of
improved practice and increased general well- nursing. Reading and reflecting on the
being (Newman, Lamb, & Michaels, 1991). philosophical work of scholars from various
This work substantiated the theory of health disciplinesmainly Bentov (1978), Bohm
as expanding consciousness. (1980), Johnson (1961), Prigogene (1976),
Shortly after retiring from her position Rogers (1970), and Young (1976)stretched
at the University of Minnesota, Margaret Newmans view of the possibilities of nurs-
Newman returned to Memphis, Tennessee, ing, and thus enriched the theory of HEC.
where she continues to work on nursing Work and dialogue with colleagues and stu-
knowledge development through her writing dents further explicated the theory.
and by dialoguing with students and scholars
from around the world. Most recently she Academic and Philosophical
published a book titled Transforming Presence: Influences on the Theory
The Difference that Nursing Makes (Newman, During her time at the University of California,
2008b). Another book edited by Carol Picard San Francisco, Newman explored how nurses
and Dorothy Jones (2005), Giving Voice to could respond to patients in a meaningful
What we Know: Margaret Newmans Theory of way during short time spans. Newmans
Health as Expanding Consciousness in Nursing interest in attending to what is meaningful
Practice, Research, and Education, provides to the patient was influenced by Ida
examples of how the theory of HEC has been Jean Orlandos deliberative nursing approach.
applied to shape nursing practice, administra- Inspired by Orlandos theoretical work,
tion, and education. Newman began making deliberative observa-
The honors awarded to Dr. Newman tions about patients and reflecting what she
include being named a Fellow of the Ameri- observed back to the patient. The specific
can Academy of Nursing and a New York attention stimulated patients to respond by
University Distinguished Scholar in Nurs- talking about what was meaningful in their
ing. She has received Sigma Theta Tau unique circumstances.
Internationals Founders Award for Excel- In a publication of the results of her explo-
lence in Nursing Research and the E. Louise ration of this approach to nursing during
Grant Award for Nursing Excellence from short time spans, Newman (1966) recounted
the University of Minnesota. She has been walking into the room of a patient who had
honored as an outstanding alumnus by both been in the hospital for some time. The
the University of Tennessee and New York patient was reading the newspaper and New-
University. In 2008 Dr. Newman was named man noticed that the woman was reading the
a Living Legend by the American Academy want ads. Newman simply stated, Reading
of Nursing. the want ads, huh? and waited for a response.
The woman, who had been diagnosed with a
chronic lung problem, worked in a factory
Overview of the Theory that exuded toxic fumes and she would no
As previously described, the seeds for the longer be able to work there. She was deeply
theory of health as expanding consciousness concerned about her future. What ensued
(HEC) were planted in Margaret Newmans through their dialogue was a breakthrough for
childhood and experience of caring for the patient, whose health care predicament
her mother as a young adult. Newmans was couched in the larger context of her
undergraduate studies at the University of potential loss of income. Newman asked the
Tennessee, masters studies at the University woman if she had discussed this with her
of California, San Francisco, and doctoral physician, and the woman responded that she
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C H A P T E R 1 7 Margaret Newmans Theory of Health as Expanding Consciousness 295

had not discussed it with anyone. When Basic Assumptions of the Theory of
Newman asked why not, the woman replied Health as Expanding Consciousness
that no one had asked her about it. Once the
Reflecting on these theoretical works helped
meaning of her illness was understood within
Newman prepare for her Toward a Theory of
the context of her entire life, not just her
Health presentation at the 1978 nursing the-
physical state, a path toward health became
ory conference in New York City. It was at
apparent for the patient. This process of
that conference that the theory of health as
focusing on meaning in patients lives to
expanding consciousness was first formally
understand where the current health predica-
explicated. In her address (Newman, 1978)
ment fits in the whole of peoples lives has
and in a written overview of the address
endured as central to HEC.
(Newman, 1979), Newman outlined the
Newmans theoretical insights evolved as she
basic assumptions that were integral to her
delved into the works of Martha Rogers and
theory at that time. Drawing on the work
Itzhak Bentov, while at the same time reflecting
of Martha Rogers and Itzhak Bentov and
back on her own experience (Newman, 1997b).
on her own experience and insight, she pro-
Several of Martha Rogers assumptions became
posed that:
central in enriching Margaret Newmans theo-
retical perspective (Newman, 1997b). First and Health encompasses conditions known as
foremost, Rogers saw health and illness not as disease or pathology, as well as states where
two separate realities, but rather as a unitary disease is not present.
process. This was congruent with Margaret Disease/pathology can be considered a
Newmans earlier experience with her mother manifestation of the underlying pattern of
and with her patients. On a very deep level, the person.
Newman knew that people can experience The pattern of the person manifesting itself
health even when they are physically or men- as disease was present before the structural
tally ill. Health is not the opposite of illness, and functional changes of disease.
but rather health and illness are both manifes- Removal of the disease/pathology will not
tations of a greater whole. One can be very change the pattern of the individual.
healthy in the midst of a terminal illness. If becoming ill is the only way a persons
Second, Rogers argued that all of reality is a pattern can be manifested, then that is
unitary whole and that each human being health for the person.
exhibits a unique pattern. Rogers (1970) saw Health is the expansion of consciousness
energy fields to be the fundamental unit of all (Newman, 1979).
that is living and nonliving, and she posited that
there is interpenetration between the fields of Newmans presentation drew thunderous
person, family, and environment. Person, family, applause as she ended with, [t]he responsibil-
and environment are not separate entities, but ity of the nurse is not to make people well, or
rather are an interconnected, unitary whole to prevent their getting sick, but to assist peo-
(Rogers, 1990). Finally, Rogers saw the life ple to recognize the power that is within them
process as showing increasing complexity. to move to higher levels of consciousness
These assumptions from Rogers theory, along (Newman, 1978).
with the work of Itzhak Bentov (1978), helped Although Margaret Newman never set out
to enrich Margaret Newmans (1997b) concep- to become a nursing theorist, in that 1978
tualization of health and eventually the articu- presentation in New York City she articulated
lation of her theory. Bentov viewed life as a a theory that resonated with what was mean-
process of expanding consciousness, which ingful in the practice of nurses in many coun-
he defined as the informational capacity of the tries throughout the world. Nurses wanted to
system and the quality of interactions with the go beyond combating diseases; they wanted to
environment. accompany their patients in the process of
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discovering meaning and wholeness in their phenomenon. The nurse and client form a
lives. Margaret Newmans proposed theory mutual partnership to attend to the pattern
served as a guide for them to do so; it offered of meaningful relationships and experiences
a new way of looking at the essence of nurs- in the clients life. In this way, a patient who
ing practice. has had a heart attack can understand the
experience of the heart attack in the context
Developing the Theory of HEC of all that is meaningful in his or her life,
After identifying the basic assumptions of the and through the insight gained with pattern
theory of HEC, the next step was to focus on recognition, experience expanding conscious-
how to test the theory with nursing research ness. Newmans (1994a, 1997a, 1997b)
and how the theory could inform nursing methodology does not divide peoples lives
practice. Newman began to concentrate on: into fragmented variables, but rather attends
to the nature and meaning of the whole,
The mutuality of the nurseclient interac-
which becomes apparent in the nursepatient
tion in the process of pattern recognition
dialogue.
The uniqueness and wholeness of the pat-
A nurse practicing within the HEC the-
tern in each client situation
oretical perspective possesses multifaceted
The sequential configurations of pattern
levels of awareness and is able to sense how
evolving over time
physical signs, emotional conveyances, spir-
Insights occurring as choice points of
itual insights, physical appearances, and
action potential
mental insights are all meaningful manifes-
The movement of the life process toward
tations of a persons underlying pattern.
expanded consciousness (Newman, 1997a).
These manifestations also provide insight
To test the theory of HEC, which embraces into the nature of the persons interactions
reality as an undivided whole, Newman found with his or her environment. It takes disci-
that Western scientific research methodolo- plined study and reflection on practical
gies, which isolate particulate variables and experience applying the theory for nurses to
analyze the relationships between them, were be able to see pattern as insight into the
insufficient. whole. Newman (2008b) states that practic-
Newman saw a need to articulate that her ing within a unitary paradigm requires a
work fell within a new paradigm of nursing. completely new way of seeing realityit is
Like Martha Rogers (1970, 1990), Newman like moving to Copernicuss view of the
sees human beings as unitary and inseparable solar system after always seeing the world as
from the larger unitary field that combines flatreality is seen from a whole new per-
person, family, and community all at once. spective and there is no going back to the
Seeing change as unpredictable and transfor- old way of viewing the world.
mative, she named the paradigm within which Newman (1997a) asserted that knowledge
her work and the work of Martha Rogers are emanating from the unitarytransformative
situated the unitary-transformative paradigm paradigm is the knowledge of the discipline
(Newman, Sime, and Corcoran-Perry, 1991). and that the focus, philosophy, and theory of
A nurse practicing within the unitary the discipline must be consistent with each
transformative paradigm does not think of other and therefore cannot flow out of differ-
mind, body, spirit, and emotion as separate ent paradigms. Newman (1997a) stated:
entities, but rather sees them as manifestations
of an undivided whole. The paradigm of the discipline is becoming clear.
Newmans theory (1979, 1990, 1994a, We are moving from attention on the other as
1997a, 1997b, 2008b) proposes that we can- object to attention to the we in relationship, from
not isolate, manipulate, and control vari- fixing things to attending to the meaning of
ables in order to understand the whole of a the whole, from hierarchical one-way intervention
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C H A P T E R 1 7 Margaret Newmans Theory of Health as Expanding Consciousness 297

to mutual process partnering. It is time to break and of treatmentinviting a new sense of


with a paradigm of health that focuses on power, harmonic integration within the immune
manipulation, and control and move to one of reflec- system. Lamendola and Newman quoted
tive, compassionate consciousness. The paradigm of Thompson (1989), who stated that we need to
nursing embraces wholeness and pattern. It reveals learn to tolerate aliens by seeing the self as a
a world that is moving, evolving, transforming cloud in a clouded sky and not as a lord in a
a process. (p. 37) walled-in fortress. This change in perspective
helps nurses and patients move away from
Newman points the way for nurses to military metaphors in relationship to patients
practice and conduct research within a bodies (i.e., combating disease, waging battles
unitarytransformative paradigm. The unitary against invading cells, etc.) to focus instead on
transformative paradigm sees the process of harmony and balance. Nursing care within a
the nursepatient partnership as integral to the unitary perspective unveils meaning and opens
evolving definition of health for the patient the possibility for a new way of living for
(Litchfield, 1993, 1999; Newman, 1997a), and people with chronic conditions.
is synchronous with participatory philosophi-
cal thought (Skolimowski, 1994) and research
methodology (Heron & Reason, 1997). Applications of the Theory
When nurses view the world from a uni- Essential Aspects of Nursing Practice within
tary perspective, they begin to see the nature the HEC Perspective
of relationships and their meaning in an Newman (2008b) synthesizes the basic
entirely new light. The work of Frank assumptions of HEC in the following way:
Lamendola and Margaret Newman (1994) Health is an evolving unitary pattern of the
with people with HIV/AIDS illustrates this. whole, including patterns of disease.
In a study they conducted, they found that the Consciousness is the informational capacity
experience of HIV/AIDS opened participants of the whole and is revealed in the evolving
to suffering and physical deterioration and at pattern.
the same time introduced greater sensitivity Pattern identifies the humanenvironmental
and openness to themselves and others. process and is characterized by meaning. (p. 6)
Drawing on the work of cultural historian
William Irwin Thompson, systems theorist Concepts important to nursing practice
Will McWhinney, and musician David grounded in the theory of HEC include
Dunn, Lamendola and Newman, stated: expanding consciousness, time, presence, res-
onating with the whole, pattern, meaning,
They [Thompson, McWhinney, and Dunn] see the insights as choice points, and the mutuality of
loss of membranal integrity as a signal of the loss of the nursepatient relationship.
autopoetic unity analogous to the breaking down of
boundaries at a global level between countries, ide- Expanding Consciousness
ologies, and disparate groups. Thompson views Ultimate consciousness has been equated with
HIV/AIDS not simply as a chance infection but part of love, which embraces all experience equally
a larger cultural phenomenon and sees the pathogen and unconditionally: pain as well as pleasure,
not as an object but as heralding the need for living failure as well as success, ugliness as well as
together characterized by a symbiotic relationship. beauty, disease as well as nondisease.
(Lamendola & Newman, 1994, p. 14)
M. A. N EWMAN (2003, P. 241)
These authors pointed out that the AIDS
epidemic has necessitated greater intercon- Consciousness within the theory of HEC
nectedness on the interpersonal, community, is not limited to cognitive thought. Margaret
and global level. It has also called for a Newman (1994a) defined consciousness as
re-conceptualization of the nature of the self the information of the system: The capacity of
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298 S E C T I O N IV Conceptual Models/Grand Theories in the UnitaryTransformative Paradigm

the system to interact with the environment. people transcend their own egos, dedicate
In the human system the informational their energy to something greater than the
capacity includes not only all the things we individual self, and learn to build order against
normally associate with consciousness, such as the trend of disorder. The process of expand-
thinking and feeling, but also all the informa- ing consciousness may look differently with
tion embedded in the nervous system, the changes in cognitive function; nurses must
immune system, the genetic code, and so on. carefully discern patterns of meaning when
The information of these and other systems this is the case. For example, when being pres-
reveals the complexity of the human system ent to people with dementia or to very young
and how the information of the system inter- children, nurses realize that there is no past or
acts with the information of the environmen- futurethere is only the present and they
tal system (p. 33). must be fully present in the present on a
To illustrate consciousness as the interac- deeper level than cognitive and verbal processes
tional capacity of the personenvironment, can take them (Newman, 2008b). People are
Newman (1994a) drew on the work of Bentov best able to experience expanding conscious-
(1978), who presents consciousness on a con- ness when they are not chained to linear time.
tinuum ranging from rocks on one end of the
spectrum (which have little known interaction Time and Presence
with their environment), to plants (which The time experienced
draw nutrients and provide carbon dioxide), In a moment
to animals (which can move about and inter- Expands or diminishes
act freely), to humans (who can reflect and With consciousness.
make in-depth plans regarding how they want If I am fully present
to interact with their environment), and ulti- There is
mately to spiritual beings on the spectrums No time.
other end. Newman sees death as a transfor- Only consciousness.
mation point, with a persons consciousness M ARGARET N EWMAN (2008 A , P. 225)
continuing to develop beyond the physical
life, becoming a part of a universal conscious- Newmans earliest published work points
ness (Newman, 1994a). to the ability of nurses to quickly and effec-
The process of expanding consciousness is tively, in a short time span, attend to what is
characterized by the evolving pattern of the most important to patients and by engaging
personenvironment interaction (Newman, patients in a dialogue about what is of utmost
1994a). The process of expanding conscious- importance to them, to discern the patients
ness is defined by Newman (2008b) as a unique path toward health (Newman, 1966).
process of becoming more of oneself, of find- Newmans latest work asserts that it is only
ing greater meaning in life, and of reaching when nurses move away from a sense of linear
new heights of connectedness with other peo- time to a more universal frequency of syn-
ple and the world (p. 6). Nurses and their chronization that they can be truly present to
clients know that there has been an expansion patients in a meaningful and whole manner
of consciousness when there is a richer, more (Newman, 2008a). Newman stated:
meaningful quality to their relationships.
Relationships that are more open, loving, There is a need to get back to the natural cycles of
caring, connected, and peaceful are a manifes- the universe. The time of civilization (clock time and
tation of expanding consciousness. These the Gregorian calendar) is not the same as the time
deeper, more meaningful relationships, may be of the rest of the biosphere, our living planet earth.
interpersonal, or they may be relationships Natural time is radial in nature, projecting from the
with the wider community or biosphere. center, and continuously moving in the direction of
Expanding consciousness is evident when greater consciousness (2008a, p. 227).
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C H A P T E R 1 7 Margaret Newmans Theory of Health as Expanding Consciousness 299

Newman asserted that the artificial time the unitary, transformative level includes and
frame of clinic schedules and hospital shift transcends energy transfer at the sensorial
work places nurses at odds with the natural level. It is nonenergetic, nonlocal, and present
rhythm of nursepatient relationships, serves everywhere (p. 35). She differentiated this
the needs of health systems administrations information transfer from the transfer of sen-
more than those of patients, and disrupts a sory information (like heat and touch, which
meaningful nursing practice. She pointed out involve physical energy transfer) and suggests
that the discipline of nursing has followed a nurses continually rely on this information
trajectory from adherence to artificial linear transfer when intuitive insights arise during
time to the synchronization of time in inter- the care of patients. Newman cautioned that
personal relationships, and now must move to intellectualization breaks the field of reso-
the instantaneous flow of information in nance. If we analyze or evaluate an experience
each center of consciousness and that it is before we have resonated with it, the field is
time to opt for practice that reflects this brokenthe resonance is damped (p. 37).
dimension (Newman, 2008a, p. 227). When For instance, sometimes when we see famil-
nurses must move out of a Western sense of iar symptoms of a disease, we jump into a
time, they can be more fully present to diagnostic conclusion and preclude receptivi-
patients. tity to other data that would present a more
Newman (2008b) asserted that it is only in complete picture. It assumes we are all the
relationship that people can fully come to same (p. 45). Resonance enables nurses to
know themselves. She drew on the work of sense the unique situation and concerns of
Smith (2001), who suggested that when the patients.
nurse considers the patient a mystery to be To resonate with patients and form open
engaged in rather than a problem to be solved, relationships, nurses must let go of personal
the relationship is characterized by presence judgments about patients and transcend cul-
(Newman, 2008b, p. 53). Newman further tural beliefs and values. In other words, the
stated that presence is enhanced by the nurse needs to free him- or herself of all
nurses openness and sensitivity to the other should and ought to attitudes and all per-
and involves the nurse letting go of judgments sonal preoccupations that might prevent total
of good or bad in relationship to patients presence. Newman states there is no prescrip-
health behaviors. tive way to sense the whole through reso-
When nurses are truly present to patients nance. She recommended that nurses pay
they concentrate more on intuitive knowing attention to the client at the simplest level,
than on the gathering of facts and health- begin with whatever presents itself, and
related data. They enter into a relaxed alert- assume that it is purposeful (Newman,
ness and realize that transforming presence 2008b). Learning to resonate with patients
involves a keen awareness of their oneness involves relational engagement and reflection.
with the patient (Newman, 2008b; Newman, Most conventional education programs
Smith, Pharris, & Jones, 2008). Understand- teach analytic processes attending to what is
ing the concept of resonance enables a trans- logical. This leads students away from
forming presence. understanding the whole. Methods that
involve empirical investigation assume that
Resonating with the Whole the whole comes after the parts; these meth-
Newman (2008b) described resonance as the ods tend to blind investigators to their rela-
mechanism for acquiring essential informa- tionship with the whole. Newman (2008b)
tion to guide nursing actions and to under- drew on the work of Bohm (1980) to stress
stand meaning in patients lives. She stated, that wholeness is what is real, with fragmen-
This is an important distinction in the expli- tation as our response to fragmentary
cation of nursing knowledge. Knowledge at thought. The whole is irreducible and
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300 S E C T I O N IV Conceptual Models/Grand Theories in the UnitaryTransformative Paradigm

omnipresent (p. 40). Newman (2008b) dif- Pharris (1999) offered the example of a
ferentiated between the general and the uni- 16-year-old young man placed in an adult cor-
versal. Seeing comprehensively is concrete rectional facility after a murder conviction.
and holistic, whereas generalization is abstract This young man was constantly getting into
and analytical; these ways of seeing go in fights and generally feeling lost. As he and the
opposite directions (p. 47). Resonance is a nurse researcher met over several weeks to gain
way to sense into the whole through attention insight into patterns of meaningful people and
to one aspect or part of it, always with an eye events in his life, the process seemed to be
on comprehending the whole. Resonance blocked, with no pattern emerging and little
enables nurses to tap into the pattern of the insight gained. He spoke of how he felt he had
whole. lost himself several years back when he went
from being a straight-A student from a stable
Attention to Pattern and Meaning family to stealing cars, drinking, getting into
Essential to Margaret Newmans theory is fights, and eventually murdering someone.
the belief that each person exhibits a distinct One week he walked into the room where the
pattern, which is constantly unfolding and nurse was waiting and his movements seemed
evolving as the person interacts with the envi- more controlled and labored; he sat with his
ronment. Pattern is information that depicts arms tightly cradling his bloated abdomen,
the whole of a persons relationship with the and his chest was expanded as though he were
environment and gives an understanding of about to explode. His palms were glistening
the meaning of the relationships all at once with sweat. His face was erupting with acne.
(Endo, 1998; Newman, 1994a). Pattern is He talked as usual in a very detached manner,
characterized by meaning (Newman, 2008b) but his words came out in bursts. The nurse
and is a manifestation of consciousness. chose to give him feedback about what she
To describe the nature of pattern, Newman was seeing and sensing from his body. She
draws on the work of David Bohm (1980), reflected that he seemed to be exerting a great
who said that anything explicate (that which deal of energy holding back something that
we can hear, see, taste, smell, touch) is a man- was erupting within him. With this insight, he
ifestation of the implicate (the unseen under- was quiet for a few minutes and tears began
lying pattern) (Newman, 1997b). In other rolling down his cheeks. Suddenly he began
words, there is information about the under- talking about a very painful family history of
lying pattern of each person in all that we sexual abuse that had been kept secret for
sense about them, such as their movements, many years. It became obvious that the expe-
tone of voice, interactions with others, activi- rience of covering up the abuse had been so
ty level, genetic pattern, vital signs. People can all-encompassing that it was suppressing his
be identified from a distance by someone who pattern.
knows them, just from the way in which they This young man had reached a point at
move. There is also information about their which he realized his old ways of interacting
underlying pattern in all that they tell us with others were no longer serving him, and
about their experiences and perceptions, he chose to interact with his environment in a
including stories about their life, recounted different way. By the next meeting, his move-
dreams, and portrayed meanings. ments had become smooth and sure, his com-
The HEC perspective sees disease, disor- plexion had cleared up, he was now able to
der, disconnection, and violence as an explica- reflect on his insights, and he no longer was
tion of the underlying implicate pattern of the involved in the chaos and fighting in his cell-
person, family, and community. Reflecting on block. He was able to let go of his need to con-
the meaning of these conditions can be part of trol everything and was able to connect with
the process of expanding consciousness the emotions of his childhood experiences; he
(Newman, 1994a, 1997a, 1997b). was also able to cry for the first time in years.
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C H A P T E R 1 7 Margaret Newmans Theory of Health as Expanding Consciousness 301

In their subsequent work together, this system fluctuates in an orderly manner until
young man and the nurse were able to distin- some disruption occurs, and the system moves
guish between his implicate pattern, which in a seemingly random, chaotic, disorderly
had now become clear through their dialogue, way until at some point it chooses to move
and the impact that keeping the abusive expe- into a higher level of organization (Newman,
rience a secret had had on him and on other 1997b). Nurses see this all the timethe
members of his family. He was able to free patient who is lost to his work and has no
himself of the shame he was carrying, which time for his family or himself, and then sud-
did not belong to him. Since that time, the denly has a heart attack, which leaves him
young man has been able to transcend previ- open to reflecting on how he has been using
ous limitations and has become involved in his energy. Insights gained through this
several efforts to help others, both in and out reflection give rise to transformation and
of the prison environment. He has entered decisions about where energy will be spent;
into several warm and loving relationships and his life becomes more creative, relational,
with family members and friends and has and meaningful. Nurses also see this in people
achieved academic success. This was evidence diagnosed with a terminal illness that causes
of expanding consciousness for the young them to reevaluate what is really important,
man. He reflected that he wished he had had attend to it, and then to state that for the first
a nurse to talk with prior to catching his time they feel as though they are really living.
case (being arrested for murder). He had The expansion of consciousness is an innate
been seen by a nurse in the juvenile detention tendency of humans; however, some experi-
center, who performed a physical examination ences and processes precipitate more rapid
and gave him aspirin for a headache. A few transformations. Nurse researchers working
days before the murder, he saw a nurse practi- within the theory of HEC have clearly demon-
tioner in a clinic who wrote a prescription strated how nurses can create a mutual partner-
for antibiotics and talked with him about safe ship with their patients to reflect on their
sex. These interactions are explications of evolving pattern and the points of transforma-
the pattern of the U.S. health care system and tion. Through this process, expanding con-
the increasingly task-oriented role that nurs- sciousness is realized (Barron, 2005; Endo,
ing is being pressured to take ( Jonsdottir, 1998; Endo, Minegishi, & Kubo, 2005; Endo
Litchfield, & Pharris, 2003, 2004). et al., 2000; Flanagan, 2005; Jonsdottir, 1998;
The focus of nursing is on pattern and Jonsdottir et al., 2003, 2004; Kiser-Larson,
meaning. That which is underlying makes 2002; Lamendola, 1998; Lamendola &
itself known in the physical realm. Nurses Newman, 1994; Litchfield, 1993, 1999, 2005;
grounded in the theory of HEC are able to be Moch, 1990; Neill, 2002a, 2002b; Newman,
in relationships with patients, families, and 1995; Newman & Moch, 1991; Noveletsky-
communities in such a way that insights aris- Rosenthal, 1996; Pharris, 2002, 2005; Pharris
ing in their pattern recognition dialogue shed & Endo, 2007; Picard, 2000, 2005; Ruka,
light on an expanded horizon of potential 2005; Tommet, 2003).
actions (Newman, 1997a; Litchfield, 1999). Newman (1999) pointed out that nurse
client relationships often begin during periods
Insights Occurring as Choice Points of disruption, uncertainty, and unpredictability
of Action Potential in patients lives. When patients are in a state
The disruption of disease and other traumatic of chaos because of disease, trauma, loss, etc.,
life events may be critical points in the they often cannot see their past or future
expansion of consciousness. To explain this clearly. In the context of the nursepatient
phenomenon, Newman (1994a, 1997b) drew partnership, which centers on the meaning
on the work of Ilya Prigogine (1976), whose the patient gives to the health predicament,
theory of dissipative structures asserts that a insight for action arises and it becomes clear
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302 S E C T I O N IV Conceptual Models/Grand Theories in the UnitaryTransformative Paradigm

to the patient how to get on with life The brokenness of the situation . . . is only a point
( Jonsdottir et al., 2003, 2004; Litchfield, 1999; in the process leading to a higher order. We need
Newman, 1999). Litchfield (1993, 1999) sees to join in partnership with clients and dance their
this as experiencing an expanding present that dance, even though it appears arrhythmic, until
connects to the past and creates an extended order begins to emerge out of chaos. We know,
horizon of action potential for the future. and we can help clients know, that there is a basic,
Endo (1998), in her work in Japan with underlying pattern evolving even though it might
women with cancer; Noveletsky-Rosenthal not be apparent at the time. The pattern will be
(1996), in her work in the United States with revealed at a higher level of organization. (p. 228)
people with chronic obstructive pulmonary
disease; and Pharris (2002), in her work with The disruption brought about by the pres-
U.S. adolescents convicted of murder, found ence of disease, illness, and traumatic or stress-
that it is when patients lives are in the great- ful events creates an opportunity for transfor-
est states of chaos, disorganization, and uncer- mation to an expanded level of consciousness
tainty that the HEC nursing partnership and (Newman, 1997b, 1999) and represents a time
pattern recognition process is perceived as when patients most need nurses who are
most beneficial to patients (Fig. 17-1). attentive to that which is most meaningful.
Many nurses who encounter patients in Newman (1999, p. 228) stated, Nurses have a
times of chaos strive for stability; they feel responsibility to stay in partnership with
they have to fix the situation, not realizing clients as their patterns are disturbed by illness
that this disorganized time in the patients life or other disruptive events. This disrupted
presents an opportunity for growth. Newman state presents a choice point for the person
(1999) states: to either continue going on as before, even

Emergence of new
order at higher level of
organization

Period of disorganization,
unpredictability,
uncertainty (response to
Normal
disease, trauma, loss, etc.)
predictable
fluctuation

Giant
fluctuation

Time when partnership with


an HEC nurse can be of
greatest benefit
Figure 17 1 Prigogines theory of dissipative structures applied to health as expanding consciousness
(HEC) nursing.
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C H A P T E R 1 7 Margaret Newmans Theory of Health as Expanding Consciousness 303

though the old rules are not working, or to Potential Freedom Real Freedom
shift into a new way of being. To explain the
concept of a choice point more clearly, Newman
drew on Arthur Youngs (1976) theory of the
Binding Unbinding
evolution of consciousness.
Young suggested that there are seven
stages of binding and unbinding, which begin
with total freedom and unrestricted choice, Centering De-centering
followed by a series of losses of freedom. After
these losses comes a choice point and a rever-
sal of the losses of freedom, ending with total
freedom and unrestricted choice. These stages Choice
can be conceptualized as seven equidistant Figure 17 2 Youngs spectrum of the evolution of
points on a V shape (Fig. 17-2). Beginning at consciousness.
the uppermost point on the left is the first
stage, potential freedom. The next stage is choice point and the stages of decentering
binding. In this stage, the individual is sacri- and unbinding that a person moves on to
ficed for the sake of the collective, with no higher levels of consciousness (Newman,
need for initiative because everything is being 1999). Newman proposed a corollary between
regulated for the individual. The third stage, her theory of health as expanding conscious-
centering, involves the development of an ness and Youngs theory of the evolution of
individual identity, self-consciousness, and consciousness in that we come into being
self-determination. Individualism emerges in from a state of potential consciousness, are
the self s break with authority (Newman, bound in time, find our identity in space, and
1994b). The fourth stage, choice, is situated at through movement we learn the law of the
the base of the V. In this stage, the individual way things work and make choices that ulti-
learns that the old ways of being are no longer mately take us beyond space and time to a
working. It is a stage of self-awareness, inner state of absolute consciousness (Newman,
growth, and transformation. A new way of 1994b, p. 46).
being becomes necessary. Newman (1994b)
described the fifth stage, decentering, as being The Mutuality of the NurseClient
characterized by a shift from the development Interaction in the Process of Pattern
of self (individuation) to dedication to some- Recognition
thing greater than the individual self. The
We come to the meaning of the whole not by
person experiences outstanding competence;
viewing the pattern from the outside, but by
his or her works have a life of their own
entering into the evolving pattern as it unfolds.
beyond the creator. The task is transcendence
of the ego. Form is transcended, and the ener- M. A. N EWMAN
gy becomes the dominant featurein terms
of animation, vitality, a quality that is some- Nursing within the HEC perspective
how infinite. In this stage, the person experi- involves being fully present to the patient
ences the power of unlimited growth and has without judgments, goals, or intervention
learned how to build order against the trend strategies. It involves being with rather than
of disorder (pp. 4546). doing for. It is caring in its deepest, most
Newman (1994b) stated that few experi- respectful sense with a focus on what is
ence the sixth stage, unbinding, or the seventh important to the patient. The nursepatient
stage, real freedom, unless they have had these interaction becomes like a pure reflection pool
experiences of transcendence characterized by through which both the nurse and the patient
the fifth stage. It is in the moving through the achieve a clear picture of their pattern and
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304 S E C T I O N IV Conceptual Models/Grand Theories in the UnitaryTransformative Paradigm

come away transformed by the insights may be uncomfortable. It is in the state of


gained. disequilibrium that the potential for growth
To illustrate the mutually transforming exists. She states, The rhythmic relating of
effect of the nursepatient interaction, nurse with client at this critical boundary is a
Newman (1994a) offers the image of a smooth window of opportunity for transformation
lake into which two stones are thrown. As the in the health experience (Newman, 1999,
stones hit the water, concentric waves circle p. 229).
out until the two patterns reach one another
and interpenetrate. The new pattern of their Relevance of HEC Across Cultures
interaction ripples back and transforms the Margaret Newmans theory of health as
two original circling patterns. Nurses are expanding consciousness is being used
changed by their interactions with their throughout the world, but it has been more
patients, just as patients are changed by their quickly embraced and understood by nurses
interactions with nurses. This mutual trans- from indigenous and Eastern cultures, who
formation extends to the surrounding envi- are less bound by linear, three-dimensional
ronment and relationships of the nurse and thought and physical concepts of health
patient. and who are more immersed in the metaphys-
In the process of doing this work, it is ical, mystical aspect of human existence.
important that the nurse sense his or her own Increasingly, however, HEC is being enthusi-
pattern. Newman states: We have come to astically embraced by nurses in industrialized
see nursing as a process of relationship that nations who are finding it difficult to nurse
co-evolves as a function of the interpenetra- in the modern technologically driven and
tion of the evolving fields of the nurse, client, intervention-oriented health care system,
and the environment in a self-organizing, which is dependent on diagnosing and treat-
unpredictable way. We recognize the need for ing diseases ( Jonsdottir et al., 2003, 2004).
process wisdom, the ability to come from the Practicing from an HEC perspective involves
center of our truth and act in the immediate a holistic approach, which places what is
moment (Newman, 1994b, p. 155). Sensing meaningful to patients back into the center of
ones own pattern is an essential starting point the nurses focus and what is meaningful
for the nurse. In her book Health as Expanding to students back into the center of the focus
Consciousness, Newman (1994a, pp. 107109) of nurse educators. This person-centered
outlines a process of focusing to assist nurses approach has wide appeal across cultures.
as they begin working in the HEC perspec-
tive. It is important that the nurse be able to Focusing on the Process of Health
practice from the center of his or her own Patterning and the NursePatient
truth and be fully present to the patient. The Partnership
nurses consciousness, or pattern, becomes like Merian Litchfield (1993), from New Zealand,
the vibrations of a tuning fork that resonate at was the first researcher to apply the theory of
a centering frequency, and the client has the health as expanding consciousness to a nurs-
opportunity to resonate and tune to that clear ing partnership with families. Litchfield
frequency during their interactions (Newman, (1993, 1999, 2005) has led the way in focus-
1994a; Quinn, 1992). The nursepatient rela- ing on the process of the nursing partnership
tionship ideally continues until the patient with patients and families. In her first study,
finds his or her own rhythmic vibrations with- Litchfield (1993) described health patterning
out the need of the stabilizing force of the as a process of nursing practice whereby,
nursepatient dialogue. Newman (1999) through dialogue, families with researcher as
points out that the partnership demands that practitioner, recognize pattern in the life
nurses develop tolerance for uncertainty, dis- process providing opportunity for insight as
organization, and dissonance, even though it the potential for action; a process by which
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C H A P T E R 1 7 Margaret Newmans Theory of Health as Expanding Consciousness 305

there may be increased self-determination as a vision and action potential, and transforma-
feature of health (p. 10). Litchfield (1993) tion. Participants differed in the pace of evolv-
describes her research as a shared process of ing movement toward a turning point and in
inquiry through which participants are the characteristics of personal growth at the
empowered to act to change their circum- turning point. The characteristics of growth
stances (p. 20). Through her research over ranged from assertion of self, to emancipa-
several years with families with complex tion of self, to transcendence of self. Reflect-
health predicaments requiring repeated hos- ing on her experience, Endo (1998) put
pitalizations, Litchfield (1993, 1999, 2005) forth that pattern recognition is not intended
found that she could not stand outside of the to fix clients problems from a medical diag-
process of recognizing pattern to observe a nostic standpoint, but to provide individuals
fixed health pattern of the family. She sees the with an opportunity to know themselves, to
pattern as continuously evolving dialectically find meaning in their current situation and
in the dialogue within the nursing partner- life, and to gain insight for the future (p. 60).
ship. The findings are literally created in the Endo et al. (2000) conducted a similar
participatory process of the partnership study with Japanese families in which the
(Litchfield, 1999). For this reason, Litchfield wife-mother was hospitalized because of a
did not use diagrams to reflect pattern, as she cancer diagnosis. Families found meaning
thought they would imply that the pattern is in their patterns and reported increased
static rather than continually evolving. As the understanding of their present situation. In the
family reflects on the pattern of their interac- pattern recognition process, most families
tions with each other and the environment, reconfigured from being a collection of sepa-
insight into action may involve a transforma- rated individuals to trustful, caring relationships
tive process, with the same events being seen as a family unit, showing more openness and
in a new light. Family health is seen as a func- connectedness. The researchers concluded that
tion of the nursefamily relationship. Many of pattern recognition as a nursing intervention
the families in partnership with Litchfield was a meaning-making transforming process
gained insight into their own predicaments in in the familynurse partnership (p. 604).
such a way that they required less interaction Early research emanating from Margaret
and service from traditional health care serv- Newmans HEC theoretical perspective added
ices and thus a cost saving in health care serv- to understanding the interrelatedness of time,
ices was realized (1999, 2005). movement, space, and consciousness as mani-
festations of health. These studies pointed to
Exploring Pattern Recognition the need to look at health as expanding con-
as a Nursing Intervention sciousness using a research methodology that
Emiko Endo (1998) explored HEC pattern acknowledges, understands, and honors the
recognition as a nursing intervention in undivided wholeness of the human health
Japan with women living with ovarian can- experience. They pointed to a need to step
cer. She asked, When a person with cancer inside to view the whole from withinwhich
has an opportunity to share meaning in the is simply a metaphorical process since the
life process within the nurseclient relation- researcher has been integrally within the
ship, what changes may occur in the evolv- whole all along. These studies cleared away
ing pattern? Attending to the flow of the murky waters surrounding what previously
meaningful thoughts for each participant appeared to be separate islands, but are now
and building on the previous work of clearly visible as mountaintops on one undi-
Litchfield (1993), Endo found four com- vided piece of land, newly emerged but always
mon phases of the process of expanding there as a whole. As a result, a new generation
consciousness for all participants: client of qualitative HEC research emerged, and a
nurse mutual concern, pattern recognition, deeper understanding of health from a holistic
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306 S E C T I O N IV Conceptual Models/Grand Theories in the UnitaryTransformative Paradigm

perspective has surfaced. This new under- and orchestrated services as needs emerged in
standing inspires practice. the process of pattern recognition. The
research group found that families became
HEC-Inspired Practice more open and spontaneous through the
Patricia Tommet (2003) used the HEC process of pattern recognition, and their inter-
hermeneutic dialectic methodology to explore actions evidenced more focus, purposefulness,
the pattern of nurseparent interaction in and cooperation. In analyzing costs of medical
families faced with choosing an elementary care for one participating family, it was esti-
school for their medically fragile children. She mated that a 3 to 13 percent savings could be
found a pattern of living in uncertainty in the seen by employing the model of family nurs-
families during the intense period of disrup- ing, with greater savings being possible when
tion and disorganization after the birth of family nurses are available immediately after a
their medically fragile child through the first family disruption takes place (Litchfield &
few years. After 2 to 3 years, the families Laws, 1999). Based on Litchfields work with
exhibited a pattern of order in chaos where they families with complex health predicaments,
learned how to live in the present, letting go of the government funded a large demonstration
the way they lived in the past. Tommet found project to support family nurses who would be
that families changed from being passive able to nurse from unitary-transformative per-
recipients to active participants in the care of spective and partner with families without
their children (p. 90) and that the experience having predetermined goals and outcomes
of their childrens birth and life transformed that the families and nurses must achieve.
these families and through them, transformed These nurses are free to focus on family health
systems of care (p. 86). Tommet demonstrated as defined and experienced by the families
insights gained in family pattern recognition themselves.
and concluded that a nurseparent partnership
could have a more profound impact on these Endo and colleagues (Endo, Minegishi, & Kubo,
families, and hence the services they use, dur- 2005; Endo, Miyahara, Suzuki, & Ohmasa, 2005) in
ing the first 3 years of their childrens lives. Japan have expanded their work to incorporate the
Working with colleagues in New Zealand, pattern recognition process at the hospital nursing
Litchfield undertook a pilot project that unit level. After engaging the professional nursing
included 19 families in a predicament of strife staff in reading and dialogue about the theory of
(Litchfield & Laws, 1999). The goal of the HEC, nurses are encouraged to incorporate the
pilot project, which built on Litchfields pre- exploration of meaningful events and people into
vious work (1993, 1999), was to explore a their practice with their patients. Nurses keep jour-
model of nurse case management incorporat- nals and come together to reflect on the experience
ing the use of a family nurse who understands of expanding consciousness in their patients and in
the theory of health as expanding conscious- themselves. Endo, Miyahara, Suzuki, and Ohmasa
ness. In the context of a familyfamily nurse (2005) conclude: Retrospectively it was found
partnership, the unfolding pattern of family through dialogue in the research/project meetings
living was attended to. Family nurses shared that in the usual nurse-client relationships, nurses
their stories of the families with the research were bound by their responsibilities within the med-
group, who reflected together on the families ical model to help clients get well, but in letting go
changing predicaments and the whole picture of the old rules, they encountered an amazing expe-
of family living in terms of how each family rience with clients transformations. The nurses
moved in time and place. Subsequent visits transformation occurred concomitantly, and they
with the families focused on recognition of were free to follow the clients paths and incorpo-
pattern and potential for action. The family rate all realms of nursing interventions in everyday
nurse mobilized relief services if necessary practice into the unitary perspective. (p. 145)
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Jane Flanagan (2005) transformed the prac- violent perpetration. System change ensued.
tice of presurgical nursing by developing the Pharris (2005) and colleagues extended
pre-admission nursing practice model, which is the community pattern recognition process
based on HEC. The nursing practice model through partnerships within a multiethnic
shifted from a disease focus to a process focus, community interested in understanding and
with attention being given to the nurses know- transforming patterns of racism and health dis-
ing their patients and that which is meaningful parities. They engaged women and girls from
to them so that the surgery experience could be all walks of life in the community in dialogue
put in proper context and appropriate care pro- about their experiences of health, well-being,
vided. Nursing presurgical visits were empha- and racism. Findings were woven into a spoken
sized. Flanagan reported that the nursing staff word narrative that was presented in various
was exuberant to be free to be a nurse once forms (performances at meetings and gather-
again, and patients frequently stopped by to ings, through community television and radio,
comment on their preoperative experience and and showing of DVD recordings) to members
evolving life changes. of the community so that meaningful dialogue
Similarly, Susan Ruka (2005) made HEC could ensue. The process of reflecting on the
pattern recognition the foundation of care at a community pattern generated insight into the
long-term-care nursing facility, transforming nature of the community and what actions
the nursing practice and the sense of connect- could be taken to dismantle racism and
edness among staff, families, and residents: each enhance health and well-being.
became more peaceful, relaxed, and loving. In a related study comparing the evolving
patterns of Hmong women living in the
Application of HEC United States with diabetes, Yang, Xiong,
at the Community Level Vang, and Pharris (2009) found that the
Pharris (2002, 2005) attempted to understand womens blood sugars rose and fell with their
a community pattern of rising youth homicide experiences of trauma, loss, separation, and
rates by conducting a study with incarcerated isolation. Dialogue on these findings, which
teens convicted of murder. The youth in the were presented as a play at a community din-
study reported the pattern recognition process ner for Hmong women living with diabetes,
to be transformative, and expanding con- shed light on needed individual, family, and
sciousness was visible in changed behaviors, community actions so that Hmong women
increased connectedness, and more loving living with diabetes could lead happy and
attention to meaningful relationships. The healthy lives.
experience of the young men demonstrated Sharon Falkenstern (2003, 2009) found
that alterations in movement, time, and space the community pattern to emerge as signifi-
inherent in the prison system can intensify the cant when she studied the process of HEC
process of expanding consciousness. When nursing with families with a child with special
the experiences of meaningful events and health care needs. She reports that the nurs-
relationships were compared across partici- ing partnership is very important to families
pants, the pattern of disconnection with the as they struggle to make sense of their experi-
community became evident. People from var- ences and try to discern how to get on with
ious aspects of the community (youth work- their lives. The evolving pattern of the fami-
ers, juvenile detention staff, emergency hospi- lies in Falkensterns study illuminated the
tal staff, pediatric nurses and physicians, social social and political forces on families from the
workers, educators, etc.) were engaged in dia- educational, disabilities support, and health
logues reflecting on the youths stories and the care systems, as well as community patterns of
community pattern. Insights transformed caring, prejudice, and racism. Falkenstern
community responses to youths at risk for summarized her experience of using HEC
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308 S E C T I O N IV Conceptual Models/Grand Theories in the UnitaryTransformative Paradigm

with families with children with special health can play an important role in engaging
care needs in the following way: communities in dialogue as these stories are
shared and reflected upon. More work needs
My experience with this study has rekindled my
to be done on methods of engaging commu-
passion for nursing. I felt affirmed that in the world
nities in dialogue about patterns of health
of managed health care and educational cutbacks,
and their meanings. For example, if an HEC
a movement is growing to recapture the essence
nurse were to take on the task of engaging
and value of nursing. While there is still much to be
nurses at the national level in a dialogue
done for nursing within the political realm of health
about what is meaningful in their practice,
care, each nurse can control where and how they
expanding consciousness would be manifest
choose to practice. Especially, I realized that a nurse
as the profession reorganizes at a higher
can experience joy and renewed energy by choos-
level of functioning, promoting health care
ing to practice nursing within health as expanding
systems change. In the process, the popula-
consciousness. (2003, p. 232)
tion would no doubt experience a fuller,
The pattern of the community is visible in more equitable, and deeper sense of health
the stories of individuals and families. Nurses and meaning.

Practice Exemplar
Sandra is an adult nurse practitioner working her life situation. She knew that the focus of
in a community clinic in an urban area of the her care for Gloria would arise out of their
United States; she is about to enter the room dialogue; she could not prescribe or predeter-
of Gloria, a new patient with diabetes and mine the best care for Gloria.
hypertension. Gloria was referred by Anna, a Before entering the room where Gloria is
physician colleague who felt that Gloria was waiting, Sandra consciously attends to freeing
noncompliant, as evidenced by her uncon- herself of any personal preoccupations or
trolled hypertension and hemoglobin A1c expectations of what might happen. She
levels that consistently hovered around 10. wants to fully attend to Gloria and sense what
Anna felt that Gloria needed more care than is of greatest importance to her right now,
she could provide for her. knowing that this will guide Sandras nursing
Sandras graduate program in nursing was actions so that they can be of most benefit to
based on the theory of health as expanding Gloria. Sandra is confident that she will get a
consciousness; the faculty paid attention to sense of this not only by asking questions and
knowing her and what was meaningful to her listening deeply, but also through intuitive
in her educational and vocational journey. hunches that will arise through her resonant
She experienced a relationship-based educa- presence with Gloria.
tion process where the teacher is seen as a On entering the room, Sandra warmly
catalyst to help students become who they greets Gloria and concentrates on what she is
will become rather than be trained and the sensing from Glorias presence. She sits down
learning process is a dance between content next to Gloria in a relaxing and open manner.
and resonance (Newman, 2008b, p. 75). What most strongly called Sandras attention
Sandra felt known and loved by the faculty. is that Gloria is wringing her hands, which
She had ample experience performing prob- are sweaty; and her muscles seem very tense.
lem-solving approaches through the medical After pausing for a moment, Sandra chooses
paradigm that leads to diagnoses yet, she real- to reflect back to Gloria what she sees. Your
ized that her nursing actions were best guid- muscles seem tense, like you might be anxious
ed by a dialogue focused on understanding about something. How has life been going for
Glorias physical health within the context of you? Gloria looks at Sandra, curious that
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C H A P T E R 1 7 Margaret Newmans Theory of Health as Expanding Consciousness 309

Sandra is interested in her life. She responds, womens walking group, which might be a
Well things have been hard. Sandra source of support. They also talk about a
responds, Hmm, tell me about that. Gloria womens group at the local library, but Gloria
explains that it has been difficult to take care of seems hesitant.
the two children she provides day care for. She During the course of their conversation,
says she doesnt have the energy, but needs the Sandra has tried to clear herself of her own
money to pay her rent, which leaves her very concerns, yet, as they talk, she keeps thinking
little money to buy food and she cannot afford about an experience of racism she witnessed
her medications. at that library. She decides that it is important
Sandra assures Gloria that the clinic has a information and shares the story with Gloria.
plan that will provide her with her medica- This provokes an outpouring of emotion
tions and that she will see that this is taken from Gloria as she recounts her experiences
care of todaythat she will go home with of racism. They discuss how distorting these
adequate medications. She tells Gloria that experiences are and how to move through
she would like to learn a little more about them. They talk about how blood sugar and
what has been meaningful in her life and asks pressure respond to these situations and ways
her to describe meaningful events. Sandra in which Gloria can best cope.
uses the exam table paper to draw a diagram Sandra does all of the things for Gloria
of what Gloria tells her. In very little time that her medical colleagues would do. She
Sandra has sketched a diagram of the flow of also discusses the services of the social work-
important events in Glorias life. She learns er, dietician, and psychologist at the clinic so
that when immigrating to the United States that Gloria can choose what might be most
from Africa. Gloria suffered intense abuse helpful to her at this time. Gloria hugs San-
and was separated from her family and dra as she leaves, saying that she feels so
friends. She has children in the United States much better, and adding, You are a very good
who constantly call her to babysit their chil- nurse! Gloria leaves with a greater under-
dren and to help them out. Gloria has also standing of herself, of what is meaningful to
experienced intimate partner violence and her her, and what actions she might take. Sandra
current economic stress and depression have is left with the same enhanced understanding
flowed from this experience. Gloria lives in a of herself and her practice.
small apartment in a neighborhood where she Sandra tucks the diagram they have drawn
would need to walk 2 miles to get to a store into a folder so that it can be elaborated upon
that sells fresh fruits and vegetables. She tells at subsequent visits. Sandra knows that
Sandra she is hesitant to leave her apartment. Glorias experience of health and well being
Sandra reflects back to Gloria that she sees will evolve and that she can serve as a catalyst,
all of Glorias energy going out to others and witnessing and engaging in dialogue about
none coming back to her. She has gone from the meaning of the pattern of Glorias evolv-
being very active to only moving around ing health. Sandra will continue to focus on
within her apartment. Tears run down what she senses as meaningful to Gloria and
Glorias cheeks as she listens to Sandras engage in a relationship centered on Glorias
reflection. That is so true! They talk about unfolding pattern of health. Hemoglobin A1c
sources of support, nurturance, and energy. levels and blood pressure readings are only
Gloria identifies a woman in her building one aspect of that pattern.
whose company she enjoys. They talk about As Sandra engages with more and more
the possibility of the two women walking to patients with similar predicaments, she gets a
the supermarket together and simply getting sense of the community pattern of health.
together to talk. They identify a neighborhood She brings her insight to the clinic staff
Continued
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310 S E C T I O N IV Conceptual Models/Grand Theories in the UnitaryTransformative Paradigm

Practice Exemplar cont.


meetings where a rich dialogue about com- microeconomic enterprises for women, work-
munity health ensues. Sandra joins the CEO ing with a community coop to provide an
for a dialogue with the clinics community affordable source of nutritious food in the
board of directors to offer their insights. immediate neighborhood, and lobbying for
Through the subsequent dialogue, the board health care financing reform.
of directors and CEO commit themselves to The circle of dialogue continues for Sandra.
ensuring that health care providers have suf- Her attention is on pattern and meaning in the
ficient time to attend to patients in a holistic evolving health of her patients and the com-
manner, sponsoring community forums on munity. She trusts that health is inherently
racism and how to deal with it, embedding a present in her patients and the community;
mental health practitioner in the medical and that reflection on what is meaningful is a
clinic, partnering with a community recre- catalyst for its evolving pattern. With this real-
ational facility so that patients have a safe ization, Sandra is able to return home where
place to exercise, encouraging community she can be fully present to her family.

Summary
Margaret Newmans theory of health as relationships and events. The focus is not on
expanding consciousness (HEC) calls nurses predetermined outcomes mandated by the
to focus on that which is meaningful in their health system or on fixing the patient, but
practice and in the lives of their patients. It rather on partnering with the patient in his or
attends to the evolving pattern of interactions her experience of health. Rather than simply
with the environment for individuals, fami- using technological tools and following pre-
lies, and communities. It is a theory that is scribed clinical pathways, nurses offer their
relevant across practice settings and cultures. own transforming presence, knowing that the
It informs and guides nursing practice, health direction of their interaction with patients
care administration, and education. The theo- will arise out of the relationshps focus on
ry of HEC presents a philosophy of being the patients evolving experience of health.
with rather than simply doing for. It involves a Insights gained inform population level dia-
different way of knowingof resonating with logue for health policy transformation.
patients, students, and health care colleagues. Newman (2008b) stated, This theory
The HEC nurse brings to the patient asserts that every person in every situation, no
encounter all that she or he has learned in matter how disordered and hopeless it may
school and in practice yet, begins with a sense seem, is part of a process of expanding con-
of nonknowing so that she or he can take in sciousnessa process of becoming more of
and begin with what is most meaningful to oneself, of finding greater meaning in life, and
the patient. The nurse attends to the patients of reaching new heights of connectedness
definition of health and sees it in the context with other people and the world (p. 6). HEC
of the patients expression of meaningful nurses attend to that process.

Acknowledgments
The author thanks St. Catherine University More information about Margaret Newmans
for sabbatical support and scholarly research theory of health as expanding consciousness can be
funding to review the Margaret A. Newman found on the Internet at www.healthasexpand-
archives housed at the University of Tennessee ingconsciousness.org
and to interview Dr. Newman. That work has
informed this chapter.
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C H A P T E R 1 7 Margaret Newmans Theory of Health as Expanding Consciousness 311

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Section
V
Caring Theories
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Section

V Caring Theories

Four of the grand theories in this book focus on the phenomenon of care or caring. Three of
these authors describe care or caring as the defining concept of the discipline of nursing. Rather
than place these in either the interactiveintegrative or unitarytransformative paradigm we
situated them in a category of their own. Leiningers Theory of Cultural Care Diversity and
Universality is covered in Chapter 18. Leininger describes the theory, while Marilyn McFarland
addresses the practice applications related to the theory. This chapter was not updated from the
2nd edition of the book. Leininger was the first to define care as the essence of nursing; she
asserts that care or nurturance can be understood only within cultural contexts. In Chapter 19,
Paterson and Zderads Humanistic Nursing Theory is presented by Susan Kleiman. While the
theory does not explicitly identify caring as its focus, it serves as a foundation and shares con-
cepts with other theories in this classification. For example, nursing is described as responding
to a call from a person, family, community, or humanity toward the purpose of nurturing well-
being and more-being. This idea of call and response toward facilitating becoming is founda-
tional to Boykin and Schoenhofers theory of Nursing as Caring and is related to Watsons
Theory of Human Caring, which are presented in Chapters 20 and 21. Watsons theory is com-
posed of the ten caritas processes, the transpersonal caring relationship, the caring occasion,
and caringhealing modalities. Watsons theory draws from a spiritual dimension affirming that
transpersonal caring is connecting and embracing the spirit or soul of another. She shares
examples of how her theory is being advanced and applied as a model for practice through the
Watson Caring Science Institute and the International Caritas Consortium. Boykin and Schoen-
hofer co-authored Chapter 21, on their theory of Nursing as Caring. The focus of nursing is the
person living and growing in caring. The theory focuses on coming to know the other as car-
ing, hearing, and answering calls for caring and nurturing the growth of the other as caring. This
theory has, and is currently, transforming care in a variety of settings.

316
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Chapter
18
Madeleine Leiningers Theory
of Culture Care Diversity and
Universality
M ADELEINE M. LEININGER AND
M ARILYN R. M C FARLAND

The Theory of Culture


Part One

Care Diversity and Universality Part One

Introducing the Theorist Introducing the Theorist


Overview of the Theory Madeleine M. Leininger, founder of the world-
The Sunrise Enabler: A Conceptual wide Transcultural Nursing Society, is the
Guide to Knowledge Discovery
founder and leader of the field of transcultural
Current Status of the Theory
nursing, focusing on comparative human care
theory and research. Dr. Leininger obtained
Part Two Implications for Nursing her initial nursing education at St. Anthony
School of Nursing in Denver, Colorado.
Practice She earned her undergraduate degree from
Mt. St. Scholastic College in Atchison,
Applications of the Theory Kansas and her masters degree from the
Summary Catholic University of America in Washington,
References DC. She completed her PhD in social
and cultural anthropology at the University
of Washington. Dr. Leininger served as dean
and professor of nursing at the Universities
of Washington and Utah, where she helped
initiate and direct the first doctoral programs
in nursing. She facilitated the development
of masters degree programs in nursing at
American and overseas institutions. A fellow
and Living Legend of the American Academy
of Nursing, she is a professor emeritus in the
Madeleine M. Leininger
College of Nursing at Wayne State University
and adjunct professor at the University of
Nebraska, College of Nursing.
Dr. Leininger has written or edited 30
books, published more than 250 articles, and
given more than 1,200 public lectures
throughout the United States and abroad.
Some of her well known books include Basic
Psychiatric Concepts in Nursing (Leininger &

317
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318 S E C T I O N V Caring Theories

Hofling, 1960); Caring: An Essential Human whatever she pursues is contagious, inspir-
Need (1981); Care: The Essence of Nursing and ing, and challenging.
Health (1984); Care: Discovery and Uses in Clin-
ical and Community Nursing (1988); Ethical and
Moral Dimensions of Care (1990d); and Culture Overview of the Theory
Care Diversity and Universality: A Theory of One of Dr. Leiningers most significant and
Nursing (1991a). Some of her books were the unique contributions was the development of
first in their areas of nursing to be published. her Culture Care Diversity and Universality
Nursing and Anthropology: Two Worlds to Blend Theory, which she introduced in the early
(1970) was the first book to bring together 1960s to provide culturally congruent and
nursing and anthropology. The first book on competent care (Leininger, 1991b, 1995). She
transcultural nursing was Transcultural Nurs- believed that transcultural nursing care could
ing: Concepts, Theories, and Practices (1978). provide meaningful, therapeutic health and
Qualitative Research Methods in Nursing (1985) healing outcomes. As she developed the the-
was the first qualitative research methods book ory, she identified transcultural nursing con-
in nursing. cepts, principles, theories, and research-based
Her published books and articles cover knowledge to guide, challenge, and explain
five decades of cumulative transcultural nurs- nursing practices. This was a significant inno-
ing and human care within many cultures vation in nursing and has helped open the
throughout the world. In 1989, Dr. Leininger door to new scientific and humanistic dimen-
founded the Journal of Transcultural Nursing, sions of caring for people of diverse and sim-
the first transcultural nursing journal in the ilar cultures.
world. Dr. Leininger conducted the first The Theory of Culture Care Diversity and
field study of the Gadsup of the Eastern Universality was developed to establish a sub-
Highlands of New Guinea in the early 1960s, stantive knowledge base to guide nurses in
and since then has studied approximately discovery and use of transcultural nursing
25 Western and non-Western cultures. She practices. At this time, during the postWorld
developed the first nursing research method War II period, Dr. Leininger realized nurses
called ethnonursing and led nurses to use would need transcultural knowledge and
her qualitative ethnonursing research meth- practices to function with people of diverse
ods. She also outlined new ways to provide cultures worldwide (Leininger, 1970, 1978).
culturally competent health care, coining the Many new immigrants and refugees were
phrase culturally congruent care in the coming to America, and the world was
1960s. In 1987, she initiated the idea of becoming more multicultural.
worldwide certification of nurses prepared in Leininger held that caring for people of
transcultural nursing to protect and respect many different cultures was a critical and essen-
the cultural needs and lifeways of people of tial need, yet nurses and other health profes-
diverse cultures. sionals were not prepared to meet this global
As a pioneering nurse educator, leader, challenge. Instead, nursing and medicine were
theorist, and administrator, Dr. Leininger focused on using new medical technologies
has been a risk taker and innovator. She has and treatment regimens. They concentrated on
never been afraid to bring forth new direc- biomedical study of diseases and symptoms.
tions and practical issues in education and Shifting to a transcultural perspective was a
service. Her persistent leadership has made major but critically needed change.
transcultural methods and human care This part of the chapter presents an
central to nursing and respected as formal overview of the Theory of Culture Care Diver-
areas of study and practice. Colleagues and sity and Universality, along with its purpose,
students have called her the Margaret goals, assumptions, theoretical tenets, predicted
Mead of the health field and the new hunches, and related general features. The next
Nightingale. Her genuine enthusiasm for part of the chapter discusses applications of the
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C H A P T E R 1 8 Madeleine Leiningers Theory of Culture Care Diversity and Universality 319

knowledge in clinical and community settings. of clients. Leininger was concerned about
For a more in-depth discussion of the theorists whether such learning would be possible,
perspectives, please consult the primary litera- given nursings traditional norms and orien-
ture on the theory (Leininger, 1970, 1981, tation toward medical knowledge.
1989a, 1989b, 1990a, 1990b, 1991a, 1995, At that time, she had questioned what made
1997a, 1998, 2002, 2006). nursing a distinct and legitimate profession.
She declared in the mid-1950s that care is (or
Factors Leading to the Theory should be) the essence and central domain of
A frequent question often posed to nursing. However, many nurses resisted this
Dr. Leininger is, What led you to develop idea, because they thought care was unimpor-
your theory? Her major motivation was the tant, too feminine, too soft, and too vague, and
desire to discover unknown or little known that it would never explain nursing and be
knowledge about cultures and their core accepted by medicine (Leininger, 1970, 1977,
values, beliefs, and needs. The idea for the 1981, 1984). Nonetheless, Leininger firmly
Culture Care Theory came to her while she held to the claim and began to teach, study, and
was a clinical child nurse specialist in a child write about care as the essence of nursing, its
guidance home in a large Midwestern city unique and dominant attribute (Leininger,
(Leininger, 1970, 1991a, 1995). From her 1970, 1981, 1988, 1991a). From both anthro-
focused observations and daily nursing pological and nursing perspectives, she held
experiences with the children in the home, that care and caring were basic and essential
she became aware that they were from many human needs for human growth, development,
different cultures, differing in their behav- and survival (Leininger, 1977, 1981). She
iors, needs, responses, and care expectations. argued that what humans need is human car-
In the home were youngsters who were ing to survive from birth to old age, when ill or
Anglo-Caucasian, African American, Jewish well. Nevertheless, care needed to be specific
American, Appalachian, and many other and appropriate to cultures.
cultures. Their parents responded to them Her next step in the theory was to con-
differently, and their expectations of care ceptualize selected cultural perspectives and
and treatment modes were different. The transcultural nursing concepts derived from
reality was a shock to Leininger, as she was anthropology. She developed assumptions of
not prepared to care for children of diverse culture care to establish a new knowledge base
cultures. Likewise, nurses, physicians, social for the new field of transcultural nursing.
workers, and health professionals in the Synthesizing or interfacing culture care into
guidance home were also not prepared to nursing was a real challenge. The new Theory
respond to such cultural differences. of Culture Care Diversity and Universality
It soon became evident that she needed had to be soundly and logically developed
cultural knowledge to be helpful to the chil- (Leininger, 1976, 1978, 1990a, 1990b, 1991a).
dren. Her psychiatric and general nursing Formulating such cultural care knowledge was
care knowledge and experiences were woe- needed to support the new discipline of tran-
fully inadequate. She decided to pursue doc- scultural nursing. Findings from the theory
toral study in anthropology. While in the could be the knowledge to care for people of
anthropology program, she discovered a different cultures. The idea of providing care
wealth of potentially valuable knowledge was largely taken for granted or assumed to be
that would be helpful from a nursing per- understood by nurses, clients, and the public
spective. To care for children of diverse cul- (Leininger, 1981, 1984). Yet the meaning of
tures and link such knowledge into nursing care from the perspective of different cultures
thought and actions was a major challenge. was unknown to nurses and not in the litera-
It was essential to incorporate into nursing ture before establishing the nursing theory in
new cultural knowledge that went beyond the early 1960s. Care knowledge had to be
the traditional physical and emotional needs discovered with cultures.
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320 S E C T I O N V Caring Theories

Before her work, there were no theories 6. There were signs that nurses, physicians,
explicitly focused on care and culture in nurs- and other professional health personnel
ing environments, let alone research studies to were becoming quite frustrated in caring
explicate care meanings and phenomena in for cultural strangers. Culture care factors
nursing (Leininger, 1981, 1988, 1990a, 1991a, of clients were largely misunderstood or
1995). Theoretical and practice meanings of neglected.
care in relation to specific cultures had not been 7. There were signs that consumers of dif-
studied, especially from a comparative cultural ferent cultures, whether in the home,
perspective. Leininger saw the urgent need to hospital, or clinic, were being treated in
develop a whole new body of culturally based ways that did not satisfy them and this
care knowledge to support transcultural nurs- influenced their recovery.
ing care. Shifting nurses thinking and attitudes 8. There were many signs of intercultural
from medical symptoms, diseases, and treat- conflicts and cultural pain among staff
ments to that of knowing cultures and caring that led to tensions.
values and patterns was a major task. But nurs- 9. There were very few health personnel
ing needed an appropriate theory to discover of different cultures caring for clients.
care, and Leininger held that her theory could 10. Nurses were beginning to work in for-
open many new knowledge doorways. eign countries in the military or as mis-
sionaries, and they were having great
Rationale for Transcultural Nursing: difficulty understanding and providing
Signs and Need appropriate caring for clients of diverse
The rationale and need for change in nursing in cultures. They complained that they
America and elsewhere (Leininger, 1970, 1978, did not understand the peoples needs,
1984, 1989a, 1990a, 1995) was as follows: values, and lifeways.

1. There were increased numbers of global For these reasons and many others, it was
migrations of people from virtually every clearly evident in the 1960s that people of dif-
place in the world due to modern elec- ferent cultures were not receiving care con-
tronics, transportation, and communica- gruent with their cultural beliefs and values
tion. These people needed sensitive and (Leininger, 1978, 1995). Nurses and other
appropriate care. health professionals urgently needed transcul-
2. There were signs of cultural stresses and tural knowledge and skills to work efficiently
cultural conflicts as nurses tried to care for with people of diverse cultures.
strangers from many Western and non- While anthropologists were clearly experts
Western cultures. about cultures, many did not know what to
3. There were cultural indications of con- do with patients, nor were they interested in
sumer fears and resistance to health nurses work, in nursing as a profession, or in
personnel as they used new technologies the study of human care phenomena in the
and treatment modes that did not fit their early 1950s. Most anthropologists in those
values and lifeways. early days were far more interested in med-
4. There were signs that some clients from ical diseases, archaeological findings, and in
different cultures were angry, frustrated, physical and psychological problems of cul-
and misunderstood by health personnel ture. Leininger therefore took a leadership
owing to ignorance of the clients cultural role in the new field she called transcultural
beliefs, values, and expectations. nursing. She needed to develop educational
5. There were signs of misdiagnosis and programs to provide culturally safe and con-
mistreatment of clients from unknown gruent care practices that could be beneficial
cultures because health personnel did not to cultures, to teach nurses about cultures, and
understand the culture of the client. to fit the knowledge in with care practices.
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C H A P T E R 1 8 Madeleine Leiningers Theory of Culture Care Diversity and Universality 321

She initiated a number of transcultural nurs- Commonalities


ing undergraduate and graduate courses and A major principal tenet was that cultural care
programs by the mid-1970s and early 1980s. diversities and similarities (or commonalities)
These offerings were gradually accepted by would be found within cultures. This tenet
nurses, helping them to care for diverse cul- challenges nurses to discover this knowledge
tures and enjoy the work with clients so that nurses could use cultural data to pro-
(Leininger, 1989a, 1995). vide therapeutic outcomes. It was predicted
Nurses were the largest and most direct there would be a gold mine of knowledge if
group of health care providers, so excellent nurses were patient and persistent to discover
opportunities existed for them to change care values and patterns within cultures, a
health care to incorporate culturally congruent dimension that had been missing from tradi-
care practices, the ultimate goal of transcultur- tional nursing. Leininger has stated that
al nursing. Nurses and those in other health human beings are born, they live, and they
care disciplines urgently needed to become die with their specific cultural values and
prepared to meet a growing multicultural beliefs, as well as with their historical and
world. Inadequate culturally based services environmental context, and that care has been
were leading to client dissatisfaction and new important for their survival and well-being.
sets of problems. In fact, some clients declined Leininger predicted that discovering which
to use health services because the staff were elements of care were culturally universal and
not culturally sensitive to their needs and care. which were different would drastically revolu-
As more courses and programs became tionize nursing and ultimately transform
available to educate nurses about transcultural health care systems and practices (Leininger,
nursing, the interest of nurses in the topic 1978, 1990a, 1990b, 1991a).
began to grow. As more nurses began to study
and use the Theory of Culture Care Diversity Worldview and Social Structure Factors
and Universality, the concept of transcultural Another major tenet of the theory was that
nursing became meaningful. Leininger had worldview and social structure factors
defined transcultural nursing as an area of such as religion (and spirituality), political
study and practice focused on cultural care and economic considerations, kinship (family
(caring) values, beliefs, and practices of partic- ties), education, technology, language expres-
ular cultures. The goal was to provide culture- sions, the environmental context, and cultural
specific and congruent care to people of diverse historywere important influences on health
cultures (Leininger, 1978, 1984, 1995). care outcomes (Leininger, 1995). This broad
The central purpose of transcultural nurs- and multifaceted view provided a holistic
ing was to use research-based knowledge to perspective for understanding people and
help nurses discover care values and practices grasping their world and environment within
and use this knowledge in safe, responsible, a historical context. Data from this holistic
and meaningful ways to care for people of dif- research-based knowledge was predicted to
ferent cultures. Today the Culture Care The- guide nurses for the health and well-being of
ory has led to a wealth of research-based the individual or to help disabled or dying
knowledge to guide nurses in the care of clients from different cultures. These social
clients, families, and communities of different structural factors influencing care of people
cultures or subcultures. from different cultures would provide new
insights to provide culturally congruent care.
Major Theoretical Tenets Systematic study by nurse researchers rather
In developing the Theory of Culture Care than superficial knowledge of culture would
Diversity and Universality, Leininger identi- be required to provide this level of care. These
fied several predictive tenets or premises as factors, together with the history of cultures
essential for nurses and others to use. and knowledge of their environmental factors,
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322 S E C T I O N V Caring Theories

had to be discovered to create the theory and to preservation or maintenance, (2) culture care
bring new insights and new knowledge. Also, accommodation or negotiation, and (3) culture
these data would disclose ways that clients care restructuring or repatterning (Leininger,
could stay well and prevent illnesses. Indeed, in 1991a, 1995). These three modes were very
order to meet the theorys goal of making deci- different from traditional nursing practices,
sions that would provide culturally congruent routines, or interventions. They were focused
care, holistic cultural knowledge would have to on ways to use theory data creatively to facili-
be discovered (Leininger, 1991a). tate congruent care to fit clients particular cul-
Discovering cultural care knowledge would tural needs. To arrive at culturally appropriate
require entering the cultural world to observe, care, the nurse had to draw on fresh culture
listen, and validate ideas. Transcultural nurs- care research and discovered knowledge from
ing is an immersion experience, not a dip in the people along with theory data findings.
and dip out experience. No longer could The care had to be tailored to client needs.
nurses rely only on fragments of medical Leininger believed that routine interventions
and psychological knowledge. Nurses needed would not always be appropriate and could
to become aware of the social structure, lead to cultural imposition, tensions, and con-
cultural history, language use, and the envi- flicts. Thus, nurses had to shift from relying on
ronment in which people lived in order to routine interventions and from focusing on
understand cultural and care expressions. symptoms to care practices derived from the
Thus, nurses had to be taught the philosophy clients culture and from the theory. They had
of transcultural nursing, the culture care theo- to use holistic care knowledge from the theory
ry, and how to discover culture knowledge. and not medical data. Most importantly, they
Transcultural nursing courses and programs had to use both generic and professional care
would provide the necessary instruction and data. This was a new challenge but a reward-
mentoring. ing one for the nurse and the client if thought-
fully done. Examples of the use of the three
Professional and Generic Care modalities containing theory findings can be
Another major and predicted tenet of the found in several published sources (Leininger,
theory was that differences and similarities 1995, 1999, 2002) and are presented in the
existed between the practices of two kinds of next part of this chapter.
care: professional and generic (traditional, Use of Leiningers theory has led to the
indigenous, or folk; Leininger, 1991a). These discovery of new kinds of transcultural nursing
differences were also predicted to influence the knowledge. Culturally based care has been
health and well-being of clients. Elucidating found to prevent illness and to maintain well-
these differences would identify gaps in care, ness. Methods for helping people throughout
inappropriate care, and also beneficial care. the life cycle from birth to death have been dis-
Such findings would influence the recovery covered. Cultural patterns of caring and health
(healing), health, and well-being of clients of maintenance also have been appreciated, along
different cultures. Marked differences between with environmental and historical factors.
generic and professional care ideas and actions Most importantly, use of Leiningers theory
could lead to serious clientnurse conflicts, has helped uncover significant cultural differ-
potential illnesses, and even death (Leininger, ences and similarities.
1978, 1995). Such differences needed to be
identified and resolved. Theoretical Assumptions: Purpose,
Goal, and Definitions of the Theory
Three Modalities This section discusses some of the major
Leininger also identified three new creative assumptions, definitions, and purposes of the
ways to attain and maintain culturally con- theory. The theorys overriding purpose was to
gruent care (Leininger, 1991a). The three discover, document, analyze, and identify the
modalities postulated were: (1) culture care cultural and care factors influencing humans
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C H A P T E R 1 8 Madeleine Leiningers Theory of Culture Care Diversity and Universality 323

in health, sickness, and dying and to thereby between cultures that demonstrate assis-
advance and improve nursing practices. tive, supportive, or enabling human care
The theorys goal was to use research- expressions (Leininger, 1991a, p. 47).
based knowledge to provide culturally con- 2. Culture care universality: Common, similar,
gruent, safe, beneficial, and satisfying care to or dominant uniform care meanings, pat-
people of diverse or similar cultures for their terns, values, lifeways, or symbols that are
health and well-being or for meaningful manifest with cultures and reflect assistive,
dying. Thus, the ultimate and primary goal of supportive, facilitative, or enabling ways to
the theory was to provide culturally congruent help people (Leininger, 1991a, p. 47).
care that was tailor-made for the lifeways and 3. Care: Abstract and concrete phenomena
values of people (Leininger, 1991a, 1995). related to assisting, supporting, or enabling
experiences toward or for others with evi-
Theory Assumptions dent or anticipated care needs to amelio-
Leininger postulated several assumptions or rate or improve a human condition or life-
basic beliefs (Leininger, 1970, 1977, 1981, way. Caring refers generally to care actions
1984, 1991a, 1997b): and activities (Leininger, 1991a, p. 46).
4. Culture: The learned, shared, and trans-
1. Care is essential for human growth, devel-
mitted values, beliefs, norms, and lifeways
opment, and survival and for facing death
of a particular group that guides their
or dying.
thinking, decisions, and actions in pat-
2. Care is essential to curing and healing;
terned ways (Leininger, 1991a, p. 47).
there can be no curing without caring.
5. Culture care: Subjectively and objectively
3. The forms, expressions, patterns, and
learned and transmitted values, beliefs,
processes of human care vary among all
and patterned lifeways that assist, support,
cultures of the world.
facilitate, or enable another individual or
4. Every culture has generic (lay, folk, or natu-
group to maintain well-being and health,
ralistic) care, and most also have professional
to improve their human condition and
care practices.
lifeway, or to deal with illness, handicaps,
5. Culture care values and beliefs are embed-
or death (Leininger, 1991a, p. 47).
ded in religious, kinship, social, political,
6. Professional care: Formally taught, learned,
cultural, economic, and historical dimen-
and transmitted professional care, health,
sions of the social structure and in language
illness, wellness, and related knowledge
and environmental contexts.
and skills that are found in professional
6. Therapeutic nursing care can occur only
institutions and held to be beneficial to
when culture care values, expressions, and/
clients (they are usually etic or outsiders
or practices are known and used explicitly
views) (Leininger, 1991a, 1995, p. 106).
to provide human care.
7. Generic (folk and lay) care: Culturally
7. Differences between caregiver and care
learned and transmitted indigenous
receiver expectations need to be understood
(or traditional, folk, lay, and home-based)
in order to provide beneficial, satisfying,
knowledge or skills used to provide assis-
and congruent care.
tive, supportive, enabling, or facilitative
8. Culturally congruent, specific, or universal
acts toward or for another individual or
care modes are essential to the health or
group (they are largely emic or insiders
well-being of people of all cultures.
views) (Leininger, 1995, p. 106).
9. Nursing is essentially a transcultural care
8. Health: A state of well-being that is cultur-
profession and discipline.
ally defined, valued, and practiced and
Orientational Theory Denitions reflects the ability of individuals (or groups)
1. Culture care diversity: Variability and/or to perform their daily role activities in cul-
differences in meanings, patterns, values, turally expressed, beneficial, and patterned
lifeways, or symbols of care within or ways (Leininger, 1991a, 1995, p. 106).
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324 S E C T I O N V Caring Theories

9. Culture care preservation or maintenance: based on cultural beliefs, values, and


Assistive, supporting, facilitative, or recurrent lifeways over time.
enabling professional actions and deci- 16. Religion and spiritual factors: Supernatural
sions that help people of a particular and natural beliefs and practices that
culture to retain and/or preserve relevant guide individual and group thoughts and
care values so that they can maintain actions toward the good or desired ways
their well-being, recover from illness, or to improve ones lifeways.
face handicaps and/or death (Leininger, 17. Political factors: Authority and power
1991a, p. 48). over others that regulates or influences
10. Culture care accommodation or negotiation: anothers actions, decisions, or behavior.
Assistive, supporting, facilitative, or 18. Technological factors: The use of electrical,
enabling creative professional actions and mechanical, or physical (nonhuman)
decisions that help people of a designated objects in the service of humans.
culture to adapt to or negotiate with others 19. Education factors: Formal and informal
for beneficial or satisfying health outcomes modes of learning.
(Leininger, 1991a, p. 48). 20. Economic factors: Production, distribution,
11. Culture care repatterning or restructuring: and use of negotiable material or con-
Assistive, supporting, facilitative, or sumable goods held valuable to or needed
enabling professional actions and decisions by humans.
that help clients reorder, change, or greatly 21. Environmental factors: The totality of
modify their own lifeways for new, differ- influences within ones geographic or eco-
ent, and beneficial health-care patterns logical living area.
while respecting the client(s) cultural val- 22. Culturally congruent care: Culturally based
ues and beliefs to provide beneficial and care knowledge and action modes used
healthy lifeways (Leininger, 1991a, p. 49). with individuals or groups in beneficial
(These patterns are mutually established and meaningful ways to improve ones
between care givers and receivers.) health and well-being or to face illness,
12. Ethnohistory: Past facts, events, disability, or death (Leininger, 2002).
instances, and experiences of individuals,
The above definitions are called orienta-
groups, cultures, and institutions that
tional rather than operational, in order to let
have been primarily experienced or
the researcher discern previously unknown
known in the past and that describe,
phenomena or ideas. Orientational terms
explain, and interpret human lifeways
allow discovery and are usually congruent
within a particular culture over time
with the client lifeways. They are important
(Leininger, 1991a, p. 48).
in using the qualitative ethnonursing dis-
13. Environmental context: The totality of an
covery method, which is focused on how
event, situation, or particular experience
people understand and experience their
that gives meaning to human expressions,
world using cultural knowledge and lifeways
interpretations, and social actions in par-
(Leininger, 1985, 1991a, 1997b, 1997c,
ticular physical, ecological, sociopolitical,
2002, 2006).
and/or cultural settings (Leininger,
1991a, p. 48).
14. Worldview: The way in which people The Sunrise Enabler:
look out on the world or their universe to A Conceptual Guide
form a picture or value stance about their
life or the world around them (Leininger, to Knowledge Discovery
1991a, p. 47). Leininger developed the sunrise enabler
15. Kinship and social factors: Family intergen- (Fig. 18-1) to provide a holistic and com-
erational linkages and social interactions prehensive conceptual picture of the major
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C H A P T E R 1 8 Madeleine Leiningers Theory of Culture Care Diversity and Universality 325

CULTURE CARE
Worldview

Cultural & Social Structure Dimensions

Cultural Values,
Kinship & Beliefs & Political &
Social Lifeways Legal
Factors Factors
Environmental Context,
Language & Ethnohistory

Religious & Economic


Philosophical Factors
Factors Influences

Care Expressions
Technological Patterns & Practices
Factors Educational
Factors
Holistic Health / Illness / Death
Focus: Individuals, Families, Groups, Communities or Institutions
in Diverse Health Contexts of

Generic (Folk) Professional


Care Nursing Care CareCure
Practices Practices

Transcultural Care Decisions & Actions

Cultural Care Preservation/Maintenance


Culture Care Accommodation/Negotiation
Code: (Influencers) Culture Care Repatterning/Restructuring
M. Leininger 2004
--kl
Culturally Congruent Care for Health, Well-being or Dying
Figure 18 1 Leiningers sunrise enabler to discover culture care. (M. Leininger 2004.)

factors influencing Culture Care Diversity The sunrise enabler can also be used as a
and Universality (Leininger, 1995, 1997b; valuable aid in cultural and health care assess-
Leininger & McFarland, 2002). The model ment of clients. As the researcher uses the
can be a valuable visual guide to elucidating model, the different factors alert him or her to
multiple factors that influence human care find culture care phenomena. Gender, sexual
and cultural lifeways of different cultures. orientation, race, class, and biomedical condi-
The enabler serves as a cognitive guide for tion are studied as part of the theory. These
the researcher to reflect on different predict- determinants tend to be embedded in the
ed influences on culturally based care. worldview and social structure and take time
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326 S E C T I O N V Caring Theories

to recognize. Care values and beliefs are usu- way as to feel comfortable and willing to share
ally lodged into environment, religion, kin- their ideas.
ship, and daily life patterns. The real challenge is to focus care mean-
The nurse can begin the discovery at any ings, beliefs, values, and practices related to
place in the enabler and follow the inform- informants cultures, so subtle and obvious
ants ideas and experiences about care. If one differences and similarities about care are
starts in the upper part of the enabler, one identified among key and general informants.
needs to reflect on all aspects depicted to The differences and similarities are important
obtain holistic or total care data. Some nurses to document with the theory. They may be
start with generic and professional care, then with historical, environmental, and social
look at how religion, economics, and other structure factors (differences about care with
influences affect these care modes. One religion, family, and economic, political, legal,
always moves with the informants interest or other factors). If informants ask about the
and story rather than the researchers interest. researchers views, the latter must be carefully
Flexibility in using the enabler will lead to a and sparsely shared. The researcher keeps in
total or holistic view of care. mind that some informants may want to
The three modes of action and decision (in please the researcher by talking about the pro-
the lower part) are very important to keep in fessional medicines and treatments. Profes-
mind. Nursing actions or decisions are studied sional ideas, however, often cloud or mask the
until one realizes the care needed. The nurse clients real interests and views. If this occurs,
discovers with the informant the appropriate the researcher must be alert to such tenden-
actions, decisions, or plans for care. Through- cies and keep the focus on the informants
out this discovery process, the nurse holds his ideas and on the domain of inquiry studied.
or her own etic biases in abeyance, so that the The informants knowledge is always kept
informants ideas will come forth, rather than central to the discovery process about culture
the researchers. Transcultural nurses are men- care, health, and well-being. If the researcher
tored in ways to withhold their biases or wishes finds some factors unfamiliar, such as kinship,
and to enter the clients worldview. economics, and political and other considera-
The nurse begins the study by making tions depicted in the model, the researcher
explicit a specific domain of inquiry. For should listen attentively to the informants
example, the researcher may focus on a ideas. Obtaining insight into the informants
domain of inquiry (DOI) such as culture care emic (insiders) views, beliefs, and practices is
of Mexican American mothers caring for central to studying the theory (Leininger,
their children in their home. Every word in 1985, 1991a, 1995, 1997b; Leininger &
the domain statement is important and is McFarland, 2002).
studied with the sunrise enabler and the the- Throughout the study and use of the
ory tenets. The nurse may have hunches about theory, the meanings, expressions, and pat-
the domain and care, but until all data have terns of culturally based care are important.
been studied with the theory tenets, she or he The nurse listens attentively to informants
cannot prove them. Informants viewpoints, accounts about care, and then documents
experiences, and actions are fully document- the ideas. What informants know and prac-
ed. Generally, informants select what they tice about care or caring in their culture is
like to talk about first, and the nurse accom- significant. Documenting ideas from the
modates their interest or stories about care. informants emic viewpoint is essential to
During in-depth study of the domain of arrive at accurate culturally based care.
inquiry, all areas of the sunrise enabler are Unknown care meanings, such as the con-
identified and confirmed with the informants. cepts of protection, respect, love, and many
The informants become active participants other care concepts, need to be teased out
throughout the discovery process in such a and explored in depth, as they are the key
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words and ideas in understanding care. Such is a qualitative method and is valuable in dis-
care meanings and expressions are not covering largely covert, complex care knowl-
always readily known; informants ponder edge in cultures or subcultures. The fact that
care meanings and are often surprised that it was the first specific research method
nurses are focused on care instead of med- designed so that the theory and method fit
ical symptoms. Sometimes informants may together has brought forth a wealth of new
be reluctant to share social structure and data. Quantitative data methods were not
factors such as religion and economical or helpful to find hidden care data.
political ideas, as they fear they may not be Fourth, the theory of culture care is the only
accepted or understood by health personnel. theory that searches for comprehensive care
Generic (folk or indigenous) knowledge data relying on social structure, worldview, and
often has rich care data and needs to be multiple factors in a culture to construct a
explored. Generic care ideas need to be holistic knowledge base about care. The theory
appropriately integrated into the three modes predicts the health and well-being of people
of action and decision for congruent care out- and focuses on the totality of lifeways of indi-
comes. Generic and professional care are viduals, families, groups, communities, and/
integrated so the clients benefit from both or institutions related to culture and care phe-
types of care. nomena. It gives a comprehensive picture of
The sunrise enabler was developed with care knowledge, often in a historical and envi-
the idea to let the sun enter the researchers ronmental context. Some nurse researchers
mind and discover largely unknown care fac- have studied care with limited variables or in
tors of cultures. Letting the sun rise and regard to medical symptoms and diseasesan
shine is important and offers fresh insights approach that is too limited and fails to iden-
about care practices. Generally, a wealth of tify care beliefs and values from the inform-
unexpected nursing care knowledge is discov- ants views. Discovering the totality of living
ered that has never been known and used in with a caring ethos in a culture has provided a
present-day nursing and medical services. wealth of new knowledge about clients life-
world and care.
Fifth, the theory has both abstract and
Current Status of the Theory practical dimensions. This characteristic helps
Currently, the theory of culture care diversity nurse researchers to discover what has the
and universality is being studied and used in potential to be known and used for human
many schools of nursing within the United caring and health practices. What exists and
States and other countries (Leininger & does not exist is important to discover, as is
McFarland, 2002). The theory has grown in the potential for future discoveries. Some the-
recognition and value for several reasons. ories deal only with abstract phenomena, but
First, it is the only nursing theory that focuses this theory has both abstract and practical
explicitly and in depth on discovering the realities.
meaning, uses, and patterns of culture care Sixth, the theory of culture care is a
within and between specific cultures. Second, synthesized concept; integrated with the
the theory provides a comparison of culture ethnonursing method, it has already provided
care between and within cultures. Thus, it has a wealth of many new insights (5 books and
greatly expanded nurses knowledge about 250 articles), showing different ways to care
care so essential for them to know and use in for people of diverse cultures. These transcul-
practices. Third, the theory has a built-in and tural nursing research findings are the new
tailor-made ethnonursing nursing research knowledge holdings that support the young
method that helps to realize the theory tenets. discipline of transcultural nursing. They are
It is different from ethnography and other the gold nuggets to transform health care to
research methods. The ethnonursing method realize therapeutic outcomes for different
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328 S E C T I O N V Caring Theories

cultures. Several transcultural nursing studies much they have learned about themselves,
reported in the Journal of Transcultural Nurs- new cultures, and, caring values and practices.
ing and other transcultural nursing books and Nurses discover their ethnocentric tendencies
journals since 1980 substantiate the theory as well as racial biases. Their findings are
(Leininger, 1991a, 1995, 1997b, 1997c). helpful to reduce cultural biases and preju-
Seventh, the theory and its research findings dices that influence quality of care to people
are stimulating nursing faculty and clinicians of different cultures. Ethnocentrism and
to use safe, appropriate, culture-specific care racial biases are being reduced with transcul-
in clinical and community settings. Nursing tural research. Many nurses also are interested
administrators in service and academia must be in discovering the differences and similarities
active change leaders to use transcultural nurs- among cultures, as it expands their world-
ing findings. Nursing faculty members should views and deepens their appreciation of
promote and teach ways to be effective with humans from diverse cultures. Learning to
different cultures (Leininger, 1998). Nurse con- become immersed in a culture has been a
sultants are using the theory findings for effec- major benefit. Most of all, nurses who
tive consultation services with members of thought such research would not yield bene-
various cultures. The theory is frequently used fits are overwhelmed to discover care meaning
to conduct culturally congruent health care and values from informants. Finally, the
assessments. Today, transcultural nursing con- strength of the theory is that it can be used in
cepts, policies, and standards of care are being any culture and at any time and within most
developed and used from findings (Leininger, disciplines. Other disciplines may have to
1991a). Interdisciplinary health personnel are modify the theory slightly to fit their goals.
becoming aware of transcultural nursing con- Several disciplines including dentistry, medi-
cepts which help them in their work. cine, social work, and pharmacy have reported
Eighth, informants are often very pleased using the culturally congruent care theory or
to have their culture understood and to have teaching it in their programs. Most encourag-
care made to fit their values and beliefs, a ing is the fact that the concept of culturally
most rewarding benefit of the theory. Con- congruent care (a term coined in the early
sumers also like the ethnonursing method as 1960s) has now become a major goal for the
they can tell their story and guide health U.S. federal government and several of its
researchers to discover truths about their state governments. The concept is growing in
culture. Informants speak of being more use and will become a global force.
comfortable with researchers. They dislike The theory of culture care is of global
narrowly focused studies on numbers, vari- interest and significance as we continue to
ables, and short instant responses. understand cultures and their care needs and
Ninth, users of the theory are thinking practices worldwide. Transcultural nursing con-
reflectively and valuing it. The theory encour- cepts, principles, theory, and findings must
ages the researcher or clinician to discover become fully incorporated into professional areas
culture from the people and to let them be in of teaching, practice, consultation, and research.
control of their ideas and their accounts. When this occurs, one can anticipate true tran-
Tenth, nurse researchers who have been scultural health practices and concomitant ben-
prepared in transcultural nursing and have used efits. Unquestionably, the theory will continue
the theory and method commonly say things to grow in relevance and use as our world
like, I love the theory. It is the only theory that becomes more intensely multicultural. Nurses
makes sense to help cultures. We grow in ideas and all health professionals will be expected in
and enjoy discovering new knowledge of the the near future to function competently with
lifeways of people and their meanings. diverse cultures. The theory, along with many
Eleventh, nurses who have used the theory transcultural nursing concepts, principles, and
and findings over time often speak of how research findings, will prove indispensable.
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Part Two focus on both types of care for the provision


of culturally congruent care for clients in
The purpose of this part of the chapter is to diverse nursing practice settings. Leininger
present the implications for nursing practice of (1991b) predicted that culturally congruent
the culture care theory and related ethnonurs- care would prevent cultural clashes, cultural
ing research findings. Many nursing theories illnesses, and other unfavorable human condi-
are rather abstract and do not focus on how tions under human control. These general
practicing nurses might use the research ideas are kept in mind as one uses findings
findings related to a theory. However, with the related to the theory in clinical practice.
Culture Care Theory, along with the eth-
The Three Care Modes
nonursing method, there is a built-in means
for discovering and confirming data with
and the Sunrise Enabler
informants in order to make nursing actions To provide a different focus from traditional
and decisions meaningful and culturally con- nursing, Leininger developed the unique three
gruent (Leininger, 2002). The Ethnonursing modes of care to incorporate theory findings
Research Method is provided at http:// (refer to sunrise enabler, Fig. 18-1): culture
davisplus.fadavis.com. care preservation or maintenance; culture care
accommodation or negotiation; and culture care
repatterning or restructuring. The theorist has
Applications of the Theory predicted that the researcher can use ethnore-
Over the past five decades, the culture care search findings to guide nursing judgments,
theory, along with the ethnonursing method, decisions, and actions related to providing
has been used by nurse researchers to discov- culturally congruent care (Leininger, 2002).
er knowledge that can be and has been used in Leininger prefers not to use the phrase
nursing practice. Nurses can use such knowl- nursing intervention, because this term often
edge to care for individual clients and to focus implies to clients from different cultures that
on care practices that are beneficial for fami- the nurse is imposing his or her (etic) views,
lies, groups, communities, cultures, and insti- which may not be helpful. Instead, the term
tutions. Our multicultural world has made it nursing actions and decisions is used, but
imperative that nurses understand different always with the clients helping to arrive at
cultures to work and care for people who have whatever actions or decisions are planned and
diverse and similar values, beliefs, and ideas implemented. The modes fit with the clients or
about nursing, health, caring, wellness, illness, peoples lifeways and yet are therapeutic and
death, and disabilities (Leininger, 1991b, satisfying for them. The nurse can draw upon
1995). As stated by Dr. Leininger in the first scientific nursing, medical, and other knowl-
part of this chapter, the goal of the Theory of edge with each mode.
Culture Care Diversity and Universality is to Data collected from the upper and lower
improve or maintain health and well-being by parts of the sunrise enabler provide culture
providing culturally congruent care to people care knowledge for nurse researchers to dis-
that is beneficial and fits with the lifeways of cover and establish useful ways to provide
the client, family, or cultural group. The sun- quality care practices. Active participatory
rise enabler serves as a cognitive map depict- involvement with clients is essential to arrive
ing the seven culture and social structure at culturally congruent care with one or all of
dimensions that influence care, which in turn the three action modes to meet clients care
influence the health and/or illness of clients. needs in their particular environmental con-
The culture care theory and the sunrise texts. The use of these modes in nursing care
enabler include what is similar (universal) and is one of the most creative and rewarding fea-
different (diverse) between generic or folk tures of transcultural and general nursing
care and professional care, and provides a practice with clients of diverse cultures.
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330 S E C T I O N V Caring Theories

It is most important (and a shift in nurs- and environmental); connectedness; protec-


ing) to carefully focus on the holistic dimen- tion (gender related); touching; and comfort
sions, as depicted in the sunrise enabler, to measures (McFarland, 2002). These care con-
arrive at therapeutic culture care practices. structs are the most critical and important
All the factors in the sunrise enabler must be universal or common findings to consider in
considered to arrive at culturally congruent nursing practice, but care diversities will also
care. These include worldview; technological, be found and must be considered. The ways in
religious, kinship, politicallegal, economic, which culture care is applied and used in spe-
and educational factors; cultural values and cific cultures will reflect both similarities and
lifeways; environmental context, language, differences among (and sometimes within)
and ethnohistory; and generic (folk) and pro- different cultures.
fessional care practices (Leininger, 2002). Next, three ethnonursing studies are
Care generated from the culture care theory reviewed with focus on the findings, which
will become safe, congruent, meaningful, and have implications for nursing practice.
beneficial to clients only when the nurse in
clinical practice becomes fully aware of and Culture Care of Lebanese Muslims
explicitly uses knowledge generated from the in the United States
theory and ethnonursing method, whether in In the late 1980s, Luna (1989) conducted an
a community, home, or institutional context. ethnonursing study of the culture care of Arab
The culture care theory, along with the eth- Muslim cultural groups in a large urban com-
nonursing method, are powerful means for munity in the Midwestern United States. In
new directions and practices in nursing. 1989, she published the findings relevant to the
Incorporating culture-specific care into client culture care of Lebanese Muslim Americans,
care is essential to the practice of profession- using Leiningers three modes of nursing
al care and to licensure as registered nurses. decisions and actions to provide culturally
Culture-specific care is the safe means to congruent and responsible care. The study
ensure culturally based holistic care that fits focused on the care for Lebanese Muslims in
the clients culturea major challenge for the hospital, clinic, and home-community
nurses who practice and provide services in contexts. She stated: [An] understanding
all health care settings. [of ] the cultural context in which Lebanese
Muslims attempt to adapt, survive, and prac-
The Use of Culture Care tice their faith in America necessitates a look
Research Findings into the community into which they migrate
Over the past five decades, Dr. Leininger and (Luna, 1994, p. 15). Lunas research findings
other research colleagues have used the cul- and the nursing practice implications related
ture care theory and the ethnonursing method to the home and community context in the
to focus on the care meanings and experiences late 1980s remain important as health care
of 100 cultures (Leininger, 2002). They dis- shifts from hospital care services to home or
covered 187 care constructs in Western and community settings. Luna discovered that
non-Western cultures (Leininger, 1998), as attending a clinic in a Midwestern United
reported in the Journal of Transcultural Nursing States urban context was often a new and dif-
(19891999). Leininger has listed the 11 most ferent approach to health care for Lebanese
dominant constructs of care in priority rank- Muslim women, especially during pregnancy
ing, with the most universal or frequently dis- and childbirth. Lunas study revealed that
covered first: respect for/about, concern many women relied on the traditional mid-
for/about; attention to (details)/in anticipa- wife in Lebanon for home deliveries. The
tion of; helpingassisting or facilitative acts; routine of monthly and weekly visits to the
active helping; presence (being physically prenatal clinic was incongruent with what
there); understanding (beliefs, values, lifeways, these clients had experienced in their home
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C H A P T E R 1 8 Madeleine Leiningers Theory of Culture Care Diversity and Universality 331

country. In the United States, prenatal care in By including Lebanese Muslim men in health
the clinic context involved long waiting peri- teaching and discharge planning, Luna discov-
ods with the husband missing work to take ered a way to use culture care preservation that
his wife to each appointment. Examination by recognized the family as a unit, rather than
a male physician was culturally incongruent focusing on the individual. Luna recognized
for the women, so culture care negotiation that the patriarchal organization of the family
and repatterning was essential for culturally should be preserved as a social structure fea-
congruent care. Luna described the clinic as ture, which acknowledges men for their roles
culturally decontextualized for clients and their in family care continuity rather than being
families because the prenatal care and the envi- narrowly interpreted as men always being in
ronmental clinic context in which the care was control. Negative stereotypes held by nurses
provided were not congruent with the clients about the Arab males reluctance to participate
cultural values, beliefs, and practices (Luna, in the birth process were also discovered, often
1989). Luna discovered some dominant and presenting a barrier to giving nursing care. To
universal care constructs for Lebanese Muslim counter this, Luna suggested the nurses use
men, which included surveillance, protection, culture care preservation to maintain and sup-
and maintenance of the family. For Lebanese port the generic culture care practices of men,
women, the dominant and universal care con- which included surveillance, protection, and
structs included emphasizing the positive maintenance of the family.
attributes of educating the children and main- Still another finding from Lunas study was
taining a family caring environment according the discovery of the importance of religious
to the precepts of Islam. A number of generic rituals to many Muslim clients as an essential
or folk care practices were discovered relating component of providing care within their cul-
to these care constructs that should be recog- tural context (Luna, 1989, 1994). Luna found
nized, preserved, and maintained by nurses to that some Muslims pray three to five times a
enhance the health and well-being of clients. day, and others do not pray at all. During the
For instance, the female network in the assessment of client culture (in the hospital
Lebanese Muslim culture is very important at context), Luna suggested the nurse should ask
the time of birth; Lebanese women come about the clients wishes regarding prayer.
together to care for one another and offer prac- Culture care accommodation could be prac-
tical and emotional assistance for new immi- ticed by negotiating for an agreeable time and
grants who are struggling to survive in a new a private place for clients to pray, which for
cultural context such as the United States. By many Muslims is an important cultural
recognizing the benefits of this network and by expression for their health and well-being.
allowing women flexibility in their visiting and She also suggested that nurses practice culture
presence in the hospital and clinic contexts, the care accommodation for clients by negotiat-
nurse would use culture care preservation to ing with a social service organization that
maintain these generic care practices for the served Arab clients in order to gather written
health and well-being of clients. and video materials in the Arabic language
Luna found that female modesty was an related to health for use in the hospital
important cultural care value for Lebanese and clinic settings. Luna (1989) identified
women; this was reflected in requests by approaches for culture care repatterning to
female clients to have only female nurses, improve attendance at the prenatal clinic for
physicians, and other caregivers. Culture care Lebanese Muslim women. Nurses should
accommodation of this generic care practice avoid direct confrontation and spend consider-
was accomplished by nurses negotiating for able time during the first clinic visit educating
these women to have female caregivers when- women about the benefits of regular prenatal
ever possible, which would promote health, care, including emphasis on the health and
well-being, and client satisfaction with care. well-being of both the mother and the baby.
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332 S E C T I O N V Caring Theories

In 1999, Wehbeh-Alamah conducted a homes, apartments for the aged, and other
2-year ethnonursing study using the culture long-term care settings. Many residents from
care theory and studied the generic health both cultural groups participated in the care of
care beliefs, practices, and expressions of their fellow residents. Residents assisted other
Lebanese American Muslim immigrants in residents to the dining room, checked on
two Midwestern U.S. cities. Her findings, others who did not appear for meals in the
which confirmed many of Lunas from 1989, dining room (care as surveillance of others),
included the discovery of specific generic folk and assisted in ambulation of those who were
care beliefs on practices that required culture not able to walk independently. This focus on
care accommodation/negotiation in the home other care versus only self-care was a form of
as well as in the hospital. These included pro- culturally congruent care that residents desired
viding for prayer while facing east five times a in order to maintain healthy and beneficial
day; having large numbers of visitors when in lifeways in an institutional setting. Culture
the hospital or at home; and eating only halal care preservation was practiced by nursing
meat. Many gender care findings were similar staff as these generic care practices were inte-
to those from Lunas study, revealing a persist- grated into professional nursing care.
ence of many related care patterns over time Within the retirement home, both Anglo
as predicted in the culture care theory. How- and African American residents desired spiri-
ever, the women in Wehbeh-Alamahs study tual or religious care and had some diverse
believed the absence of extended family mem- aspects of such care rooted in their respective
bers in the United States had influenced male cultures. The findings of both universality and
family members thinking about the appropri- diversity within the pattern of religious or
ateness of men caring for family members. spiritual care supported Leiningers theory,
The researcher reported that acculturation had which states that culture care concepts,
changed mens view about providing care meanings, expressions, patterns, processes,
from the more traditional belief that the and structural forms of care are different
hands-on caring for the children, elderly, (diversity) and similar (toward universality)
and sick belonged to women, to the more among all cultures of the world (Leininger,
contemporary belief in cooperation and par- 1991b, p. 45). African American residents
ticipation in direct caregiving by Muslim men received care from church friends who ran
(Wehbeh-Alamah, 2006). Wehbeh-Alamah errands, did banking and laundry, paid bills,
conducted an ethnonursing study of the cul- visited, and brought communion to them.
ture care of Syrian American Muslims living Anglo American residents received a more
in a Midwestern U.S. city. In addition to dis- formal type of care from their churches, such
covering the culture care meanings, beliefs, as a minister coming to the retirement home
and practices of this group, she will compare to do a worship service or a church choir trav-
this study with her previous studies to arrive eling to the retirement home to entertain the
at universal and diverse care findings among residents. The nurses at the retirement home
Muslim immigrants from different cultures practiced culture care preservation by main-
living in the United States. taining the involvement of churches in the
daily lives of both cultural groups to help res-
Culture Care of Elderly Anglo idents face living in a retirement home with
and African Americans increasing disabilities related to aging and
In the mid-1990s, the theory of culture care handicaps, and even dealing with the prospect
was used to guide a study of the culture care of of death. With an increase in the numbers of
Anglo and African American elders in a long- elderly from both the Anglo and African
term care institution (McFarland, 1997). This American cultural groups being admitted to
study revealed care implications for nurses long-term care institutions, the knowledge of
who practice in retirement homes, nursing culture-specific care for both Anglo and
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African American elders is important for Culture care restructuring of these care-
nurses who practice in these settings. related concerns can be accomplished only
The generic care pattern of families help- when nurses assume an advocacy role for the
ing their elderly relatives enhanced the health elderly residents and work with governmen-
and lifeways of both Anglo and African tal and private agencies that provide the
American elders in the retirement home set- funding and make the rules and regulations
ting. Anglo American residents received help that affect long-term care. The culture care
from their spouses and/or adult children. In theory, with the ethnonursing method,
contrast with the Anglo American findings, assisted the researcher in this study in
African American spouses, children, extended the discovery of action and decision modes
family members, and nonkin who were con- that were culturally specific for Anglo and
sidered family reflected the care pattern of African American elders residing in a long-
families helping elderly residents. Grandchil- term care institution.
dren, great grandchildren, nieces, nephews,
grandnieces, and grandnephews, as well as Culture Care of German Americans
church members or friends who were consid- In 2000, McFarland and Zehnder (2006)
ered family and were referred to as brothers, conducted a 2-year ethnonursing study of the
sisters, or daughters, were involved in caring culture care of German American elders liv-
for African American elders. The nursing ing in a nursing home in a small Midwestern
staff recognized the importance of family city in the United States. Their findings,
involvement in the care of residents and prac- which confirmed many of McFarlands (1997)
ticed culture care preservation to maintain earlier findings, included many care beliefs
culture-specific family care practices for resi- and practices that required culture care
dents from each cultural group. preservation. German American elder care
The care pattern of protection was impor- practices included caring for fellow residents
tant to African American residents but not to by assisting confused residents to find their
Anglo American residents. Most African assigned seat in the dining room or making
American residents had left homes that were items for the annual bazaar to raise money to
in unsafe neighborhoods and had moved into buy flowers for the nursing home courtyard
the facility partly for that reason. African garden, thereby benefitting all of the resi-
American nursing staff recognized the impor- dents. The finding of the important care of
tance of protective care and often accompa- doing for others versus an emphasis on self-
nied African American residents when they care was previously discovered in McFarlands
wanted to go outside. The nursing staff made earlier study in 1997 with Anglo American
efforts to practice culture care accommoda- and African American elders and was con-
tion by negotiating to take the residents out- firmed in this German American study.
side to sit on the small grass strip around the German American elders received spiritual
perimeter of the parking lot of the home. care from the local German American church
McFarland (1997) also discovered that and pastor. The pastor conducted a worship
the nursing care and the lifeways of elderly service and a Bible class in German each
residents in the nursing home setting were week. Spiritual religious care, provided by
less satisfying than in the apartment setting connections with the Lutheran Church, was
within the retirement home context. Profes- essential to German American elders in
sional nurses need to be more actively maintaining their traditional lifeways and
involved in culture care repatterning as health in the nursing home setting. This find-
coparticipants with elders to restructure life- ing had also been discovered with Anglo
way practices, care routines, and the environ- American elders in McFarlands (1997) previ-
mental context of nursing homes (including ous study and was confirmed with German
room designs and privacy considerations). American elders.
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334 S E C T I O N V Caring Theories

McFarland is currently comparatively syn- universal and diverse care meanings, beliefs, and
thesizing culture care findings from ethnonurs- practices to meet the needs of the increasing
ing studies of elder care conducted by transcul- numbers of elders worldwide who value gener-
tural nurses with diverse cultures worldwide. ic culture-specific care to reaffirm their cultural
This will hopefully lead to the discovery of identities in the latter phase of their lives.

Summary
The purpose of the culture care theory and in the numerous books and articles by
(along with the ethnonursing method) has Dr. Madeleine Leininger. Nurses in clinical
been to discover culture care with the goal of practice are advised to consult a list of
using the knowledge to combine generic and research studies and doctoral dissertations
professional care. The goal is to provide conceptualized within the culture care theory
culturally congruent nursing care using the for additional detailed nursing implications
three modes of nursing actions and deci- for clients from diverse cultures (Leininger &
sions that are meaningful, safe, and benefi- McFarland, 2002).
cial to people of similar and diverse cultures The Theory of Culture Care Diversity and
worldwide (Leininger, 1991b, 1995). The Universality is one of the most comprehensive
clinical use of the three major care modes yet practical theories to advance transcultural
(culture care preservation or maintenance; and general nursing knowledge with con-
culture care accommodation or negotiation; comitant ways for practicing nurses to estab-
and culture care repatterning or restructur- lish or improve care to people. Nursing
ing) by nurses to guide nursing judgments, students and practicing nurses have remained
decisions, and actions is essential in order to the strongest advocates of the culture care
provide culturally congruent care that is theory (Leininger, 2002). The theory focuses
beneficial, satisfying, and meaningful to the on a long-neglected area in nursing practice
people nurses serve. The studies of the four culture carethat is most relevant to our
cultures just reviewed (Lebanese Muslim, multicultural world.
Anglo American, African American, and The Theory of Culture Care Diversity
German Americans) substantiate that the and Universality is depicted in the sunrise
three modes are care-centered and are based enabler as a rising sun. This visual metaphor
on the use of generic care (emic) knowledge is particularly apt. The future of the culture
along with professional care (etic) knowl- care theory shines brightly indeed, because
edge obtained from research using the cul- it is holistic, comprehensive, and facilitates
ture care theory along with the ethnonurs- discovering care related to diverse and simi-
ing method. This chapter has reviewed only lar cultures, contexts, and ages of people
a small selection of the culture care findings in familiar and naturalistic ways. The theory
from ethnonursing research studies con- is useful to nurses and to nursing and to
ducted over the past four decades. There is a professionals in other disciplines such as
wealth of additional findings of interest to physical, occupational, and speech therapy,
practicing nurses who care for clients of all medicine, social work, and pharmacy. Health
ages from diverse and similar cultural groups care practitioners in other disciplines are
in many different institutional and commu- beginning to use this theory, because they
nity contexts around the world. More in- also need to become knowledgeable about
depth culture care findings, along with the and sensitive and responsible to people of
use of the three modes, can be found in the diverse cultures who need care (Leininger,
Journal of Transcultural Nursing (19892004) 2002).
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C H A P T E R 1 8 Madeleine Leiningers Theory of Culture Care Diversity and Universality 335

References

Berry, A. (1996). Culture care expression, meanings, and Leininger, M. (1991c). Ethnonursing: A research
experiences of pregnant Mexican American women method with enablers to study the theory of culture
within Leiningers culture care theory. (UMI No. care. In: M. Leininger (Ed.), Culture care diversity
9628875). Ann Arbor, MI: UMI Microfilm. and universality: A theory of nursing (pp. 73118).
Berry, A. (1999). Mexican American womens expressions New York: National League for Nursing Press.
of the meaning of culturally congruent prenatal care. Leininger, M. (1995). Transcultural nursing: Concepts,
Journal of Transcultural Nursing, 103, 203212. theories, research, and practice. Columbus, OH:
Leininger, M. (1970). Nursing and anthropology: Two McGraw Hill College Custom Series.
worlds to blend. New York: John Wiley & Sons. Leininger, M. (1997a). Overview and reflection of the
Leininger, M. (1976). Transcultural nursing presents an theory of culture care and the ethnonursing research
exciting challenge. The American Nurse, 5(5), 69. method. Journal of Transcultural Nursing, 8(2),
Leininger, M. (1977). Caring: The essence and central 3251.
focus of nursing. Nursing Research Foundation Report, Leininger, M. (1997b). Overview of the theory of culture
12(1), 214. care with the ethnonursing research method. Journal
Leininger, M. (1978). Transcultural nursing: Concepts, of Transcultural Nursing, 8(2), 3253.
theories, and practices. New York: John Wiley & Leininger, M. (1997c). Transcultural nursing research to
Sons. transform nursing education and practice: 40 years.
Leininger, M. (1981). Caring: An essential human need. Image: Journal of Nursing Scholarship, 29(4), 341347.
Thorofare, NJ: Slack. Leininger, M. (1998). Special research report: Dominant
Leininger, M. (1984). Care: The essence of nursing and culture care (emic) meanings and practice findings
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Leininger, M. (1985). Qualitative research methods in Nursing, 9(2), 4447.
nursing (pp. 3373). Orlando, FL: Grune & Leininger, M. M. (2002). Part I: The theory of culture
Stratton. care and the ethnonursing research method. In:
Leininger, M. (1988). Care: Discovery and uses in clinical M. M. Leininger & M. R. McFarland (Eds.),
and community nursing. Detroit: Wayne State Transcultural nursing: concepts, theories, and practice
University Press. (3rd ed., pp. 7198). Sudbury, MA: Jones and
Leininger, M. (1989a). Transcultural nursing: Quo vadis Bartlett.
(where goeth the field)? Journal of Transcultural Leininger, M., & Hofling, C. (1960). Basic psychiatric
Nursing, 1(1), 3345. concepts in nursing. Philadelphia: Lippincott.
Leininger, M. (1989b). Transcultural nurse specialists Leininger, M. M., & McFarland, M. R. (Eds). (2002).
and generalists: New practitioners in nursing. Transcultural nursing: Concepts, theories, and practice
Journal of Transcultural Nursing, 1(1), 416. (3rd ed.). New York: McGraw-Hill.
Leininger, M. (1990a). Transcultural nursing: A world- Leininger, M. M., & McFarland, M. R. (Eds.) (2006).
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Current issues in nursing. St. Louis, MO: C. V. Luna, L. (1989). Care and cultural context of Lebanese
Mosby. Muslims in an urban U.S. community: An ethnographic
Leininger, M. (1990b). Culture: The conspicuous miss- and ethnonursing study conceptualized within
ing link to understand ethical and moral dimensions Leiningers theory. (UMI No. 9022423). Ann Arbor,
of human care. In: M. Leininger (Ed.), Ethical MI: UMI Microfilm.
and moral dimensions of care. Detroit: Wayne State Luna, L. (1994). Care and cultural context of Lebanese
University Press. Muslim immigrants with Leiningers theory. Journal
Leininger, M. (1990c). Ethnomethods: The philosophic of Transcultural Nursing, 5(2), 1220.
and epistemic basis to explicate transcultural nursing McFarland, M. R. (1995). Cultural care of Anglo and
knowledge. Journal of Transcultural Nursing, 1(2), African American elderly residents within the environ-
4051. mental context of a long-term care institution. (UMI
Leininger, M. (1990d). Ethical and moral dimensions of No. 9530568). Ann Arbor, MI: UMI Microfilm.
care. Detroit: Wayne State University Press. McFarland, M. R. (1997). Use of culture care theory
Leininger, M. (1991a). Culture care diversity and with Anglo and African American elders in a long
universality: A theory of nursing. New York: term care setting. Nursing Science Quarterly, 10(4),
National League for Nursing Press. 186192.
Leininger, M. (1991b). The theory of culture care diver- McFarland, M. R. (2002). Part II: Selected research
sity and universality. In: M. Leininger (Ed.), Culture findings from the culture care theory. In: M. M.
care diversity and universality: A theory of nursing Leininger & M. R. McFarland (Eds.), Transcultural
(pp. 568). New York: National League for Nursing nursing: Concepts, theories, and practice (3rd ed.,
Press. pp. 99116). New York: McGraw-Hill.
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McFarland, M. R., & Zehnder, N. (2006). The culture USA. In: M. M. Leininger & M. R. McFarland
care of German American elders within a nursing (Eds.), Culture care universality and diversity:
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McFarland (Eds.), Culture care universality and MA: Jones and Bartlett.
diversity: A worldwide theory of nursing (2nd ed.). Zoucha, R. (1998). The experiences of Mexican
Sudbury, MA: Jones and Bartlett. Americans receiving professional nursing care:
Qualitative Solutions and Research. (1997). QSR An ethnonursing study. Journal of Transcultural
NUD*IST 4. Thousand Oaks, CA: Sage. Nursing, 9(2), 3343.
Wehbeh-Alamah, H. (2006). Generic care of
Lebanese Muslim women in the Midwestern
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Chapter
19
Josephine Paterson
and Loretta Zderads
Humanistic Nursing Theory
S USAN K LEIMAN

Introducing the Theorists Introducing the Theorists


Overview of the Theory Dr. Josephine Paterson is originally from the
Applications of the Theory East Coast, where she attended a diploma
Practice Exemplar school of nursing in New York City. She
Summary subsequently earned her bachelors degree in
References nursing education from St. Johns University.
In her graduate work at Johns Hopkins
University, she focused on public health
nursing and then earned her doctor of nurs-
ing science degree from Boston University.
Her doctoral dissertation focused on patient
comfort.
Dr. Loretta Zderad is from the Midwest,
where she attended a diploma school of nurs-
ing. She later earned her bachelors degree in
nursing education from Loyola University of
Josephine Paterson
Susan Kleiman Chicago and pursued graduate work in psy-
Loretta Zderad chiatric nursing at the Catholic University of
America. She subsequently earned her PhD
from Georgetown University. Her disserta-
tion research focused on empathy.
Josephine Paterson and Loretta Zderad
met in the mid-1950s while working at
Catholic University. As a joint project they
created a new program that synthesized the
community health and mental health compo-
nents of the graduate program. This project
launched a collaboration and friendship that
has lasted for more than 50 years. They shared
ideas and developed concepts, approaches,
and experiences related to existential phenome-
nology, which evolved into their Theory of
Humanistic Nursing.
In 1971, after their work in academia,
Drs. Paterson and Zderad were hired by the
Veterans Administration (VA) hospital in

337
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338 S E C T I O N V Caring Theories

Northport, NY. They accepted positions as nursing, can be heard where nursing is offered,
nursologists created by a forward-thinking coming to our attention as a subtle murmur of
administrator who recognized the need for pain, sorrow, anxiety, desperation, joy, laughter,
staff support during a period of change in even silence, that expresses the state-of-being of
the VA system. The position of nursologist the protagonists in the drama of health-care
involved a three-pronged approach to the delivery, our patients and ourselves.
improvement of patient care through clinical Unlike the sounds that signal the arrival of
practice, education, and research. As part of equipment or activity, these subtle sounds are
this project they implemented workshops for always present and can be sensed, even when
the nurses at Northport from 1971 until they fall outside the range of human hearing.
1978. In 1978, there was a change in hospital It is as if they are awaiting amplification,
administration that resulted in a reorganiza- ready to be transmitted by some mystical
tion of services. force to those who would or would not hear
Dr. Paterson was assigned to the Mental them. When they come into current aware-
Hygiene Clinic to work as a psychotherapist ness, they overwhelm the surrounding sounds
while Dr. Zderad became the associate chief of the environment, directing our immediate
of nursing service for education. These were attention to a call for the human touch of a
the positions they held when I encountered nurse.
them as a graduate student in psychiatric Consider, for example, the calls of a mother
mental-health nursing. Dr. Paterson agreed to for her newborn baby:
work with me as my clinical supervisor.
Where is my baby?
The following 2 years brought me a world
What happened to my baby?
of enrichment. For Drs. Paterson and Zderad,
Whats wrong with my baby?
those years culminated in their retirement and
Where is my baby?
relocation to the South, while I continued
the work that they started as fellow theorist, These calls intensify and bring into the
colleague, and friend. They have inspired me foreground of a nurses awareness his or her
to carry on their work, using it in my nursing own inner calling to offer that human touch.
situations in clinical, administrative, and edu- When a nurse responds to a call of a
cational roles, and to share what I have come health-related concern, she enters the world
to know with others. of another, offering to, metaphorically speak-
For more details about the historical and ing, go through life with that person. An
personal backgrounds of Josephine Paterson occasion of humanistic nursing thereby comes
and Loretta Zderad, told in their own words, into being. From these moments, nurses can
refer to the chapter on Dialogues with help patients or their loved ones be as much as
Paterson and Zderad in Human-Centered they can be in the situations in which they
Nursing: The Foundation of Quality Care find themselves: birth, death, sickness, dis-
(Kleiman, 2008). ability, or health. Helping others to be as
much as they can be regardless of their per-
sonal situation is the fundamental outcome of
Overview of the Theory humanistic nursing (Kleiman, 2008).
The Humanistic Nursing Theory emerged Humanistic Nursing Theory offers nurses a
from Patersons and Zderads search for a way to way to illuminate the values and meanings cen-
make things better for nurses and their patients tral to their lived experiences so that they may
as they engaged in the daily activities of nursing share them with other nurses and integrate
practice; in existential terms, being in the them into their nursing practice. Bringing into
world of nursing. They wanted to offer a presence the values and meanings central to
way of responding to the call of human needs. these lived experiences helps nurses to realize
This call, a foundational concept of humanistic their self-actualizing potential.
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C H A P T E R 1 9 Josephine Paterson and Loretta Zderads Humanistic Nursing Theory 339

Paterson and Zderad called this process of terms and phrases awkward. When I spoke to
bringing into presence the essential values and a colleague of the moreness and of relating
meanings of ones life world phenomenological all-at-once, she remarked, Uh-oh, youre
reflection on experiences. The process empha- beginning to sound just like them (Paterson
sizes synthesis and wholeness rather than & Zderad). But this vocabulary reflects a
reduction and logical analysis. Challenging grasp of nursing as an ever-changing process.
the notion that the reductionistic approach is Just as nursing in actual practice is never inert,
the touchstone of explanatory power, they pos- so Humanistic Nursing Theory is dynamic.
tulated an all-at-once character of existence in Consider the description of humanistic nurs-
nurses experiences of being in the world. They ing: Our here and now stage of Humanistic
led the way for many of the contemporary nurs- Nursing Theory development at times is
ing theories that emphasize these existential, experienced as an all-at-once octopus at a
phenomenologic, and caring aspects of nursing discotheque, stimulation personified, gyrat-
(Benner, 1984; Parse, 1981; Watson, 1988). ing in many colors (Paterson & Zderad,
1976, p. 4).
Highlights of the Theory If asked to conceptualize Humanistic Nurs-
Humanistic Nursing Theory is multidimen- ing Theory succinctly, I would say, call and
sional. It speaks to the essences of nursing and response. These three words encapsulate
embraces the dynamics of being, becoming, the core themes of this elegant and very pro-
and change. It is an interactive nursing theory found theory. Through this dialogic move-
that provides a methodology for reflection and ment Paterson and Zderad have presented a
articulation of nursing essences. It also provides vision of nursing that is amenable to variation
a methodological bridge between theory and in practice settings and to the changing pat-
practice by providing a broad guide for nursing terns of nursing over time.
dialogue in a myriad of settings. According to Humanistic Nursing Theory,
Nursing, as seen through Humanistic there is a call from a person, a family, a
Nursing Theory, is the ability to struggle with community, or from humanity for help with
another through peak experiences related to some health-related issue. A nurse, a group of
health and suffering in which the participants nurses, or the community of nurses hearing
are and become in accordance with their and recognizing that call respond in a manner
human potential (Paterson & Zderad, 1976, that is intended to help the caller with the
p. 7). The struggle evolves within a dialogue health-related need. What happens during
between the participants, illuminating the this dialogue, the and in the call and
possibility for each to become in concert response, the between, is nursing.
with the other. According to Paterson and There is a call from a person, a family, a
Zderad (1976), in nursing, the purpose of community, or from humanity for help with
this dialogue, or intersubjective relating, is, some health-related issue. A nurse, a group of
nurturing the well-being and more-being of nurses, or the community of nurses hearing
persons in need (p. 4). and recognizing that call respond in a manner
Humanistic Nursing Theory is grounded that is intended to help the caller with the
in existentialism and emphasizes the lived health-related need. What happens during
experience of nursing. One of the existential this dialogue, the and in the call and
themes that it builds on is the affirmation of response, the between, is nursing.
being and becoming of both the patient and In their book, Humanistic Nursing (1976),
the nurse, who are actualized through the Drs. Paterson and Zderad share with other
choices they make and the intersubjective nurses their method for exploring the
relationships in which they engage. between, again emphasizing that it is the
The new adventurer in Humanistic Nurs- between that they conceive of as nursing.
ing Theory may at first find some of these The method is phenomenological inquiry
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340 S E C T I O N V Caring Theories

(Paterson & Zderad, 1976). Engaging in is (education, skills, life experiences, intu-
the phenomenological process sensitizes the ition, etc.) and integrates it into her or his
inquiring nurse to the excitement, anticipa- response. A common misconception that
tion, and uncertainty of approaching the students of Humanistic Nursing Theory may
nursing situation openly. Through a spirit of have is that it asserts that the nurse must
receptivity, a readiness for surprise, and the provide what it is that the patient is calling
courage to experience the unknown, there is for. Remember the response of the nurse is
an opportunity for authentic relating and guided by all that she or he is. This includes
intersubjectivity. The process leads one natu- his or her professional role, ethics, and com-
rally to repeated experiences of and reflective petencies. A particular nurse may not actual-
immersion in the lived phenomena (Zderad, ly be able or willing to provide what is being
1978, p. 8). called for, but the process of being heard,
This immersion into the intersubjective according to this theory, is in itself a human-
experience and the phenomenological izing experience.
process helps to guide the nurse in the The conceptual framework of Humanistic
responsive interchange. During this inter- Nursing Theory in Figure 19-1 may illumi-
change, the nurse calls forth all that she or he nate and illustrate some of its basic concepts

HUMANISTIC NURSING

a r d we l l - b e i n g a
g t ow nd
r in m or
tu e
ur
-b
n

ein

Gestalt Gestalt
g

Incarnate Incarnate
in time PATIENT well-being and NURSE in time
and space Call more-being Response and space

DIALOGUE

being and becoming


through intersubjective relating
(being with and doing with)

The body knows


(a being in a body)
gut feeling
Figure 19 1 World of others and things.
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C H A P T E R 1 9 Josephine Paterson and Loretta Zderads Humanistic Nursing Theory 341

and assumptions. Humanistic nursing is a experienced in ones own spacetime dimen-


dynamic process that occurs in the living con- sion. As illustrated, this gestalt includes past
text of human beings, human beings who and current social relationships, as well as
interface and interact with others and other gender, race, religion, education, work, and
things in the world. In the world of Human- all of the individualized patterns for coping
istic Nursing Theory, when we speak of that a person has developed. It also includes
human beings, we mean patients (e.g., indi- past experiences with persons in the health
viduals, members of families, members of care system and a patients images and
communities, or members of the human race) expectations of those persons.
and nurses (Fig. 19-2). A person becomes a Our gestalt is the unique expression of our
patient when he or she sends a call for help individuality as incarnate human beings who
with some health-related problem. The per- exist in this particular space at this particular
son hearing and recognizing the call is a time, with circumscribed resources and in
nurse. A nurse, by intentionally choosing to a physical body that senses, filters, and
become a nurse, has made a commitment to processes our experiences to which we assign
help others with health-related needs. subjective meanings. Accordingly, a nurse and
It is important to emphasize that in a patient perceive and respond to each other
Humanistic Nursing Theory, each nurse and as a gestalt, not just as the presentation of a
each patient is taken to be a unique human sum of attributes. In humanistic nursing we
being with his or her own particular gestalt say that each person is perceived as existing
(Fig. 19-3). Gestalt, representing all that the all-at-once. In the process of interacting
particular human being is, includes all past with patients, nurses interweave professional
experiences, all current being, and all hopes, identity, education, intuition, and experience
dreams, and fears of the future that are with all their other life experiences, creating

Nursing Is Transactional

age nu
e im
nurs ctations ness ex rse
expe of being sta pec im
state te tat age
of ion
CALLANDRESPONSE be s
ing
ne
ss
PATIENT NURSE
e liv
nc ed
r ie ex
pe per
ex ien
ed ce
liv ente
r int
o th
e ex
I need help peri I am prepared to give you help
ence
of th
e pa
tient educational preparation

nursing professional development


expressed in

being withdoing with


(presence) (procedures)
bridges or barriers
Figure 19 2 Shared human experience.
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342 S E C T I O N V Caring Theories

n
pa tio
st
exp u ca
eri ed
en
ce
sw
ith
he
lpe
rs el igion
ce, r
r, ra
ge nde

interweaves

past experiences "all-at-once" his current being

so
cia
l re
g lat
pin ion
co sh
er

or ips
sf
oth

rn

his
tte
of

pa
ho
d
ion

lize
pe
a
tat

idu
s,
iv
ec

d
ind
re
p
ex

am
nd

s,
ea

a
nd
ag

fea
im

rs

Figure 19 3 Patient and nurse gestalts.

their own tapestry, which unfolds during their the patient. Comfort in this instance refers to
responses. the idea that through the relationship engen-
One has only to observe nurses going dered and nurtured in intersubjective dia-
about their nursing to see this process of logue, there arises the possibility for persons
interrelating as subjective human beings. to become all that they can be in particular
Consider for example, performing the task of lived situations.
suctioning a patient. This task can be done
with tenderness, dignity, and with masterful Philosophical and Methodological
technical skills that make the procedure Background
almost unnoticeable. I once watched as a The phenomenological movement of the
nurse performed the task of positioning and 19th century was a response to what its
suctioning a patient; she made sure she also proponents called the dehumanization and
repositioned the small basket of flowers objectification of the world by the logical
placed by the patients bedside. The reposi- positivists. Phenomenologists proposed that
tioning of the flowers was not needed to per- human beings, the world, and their experi-
form the technique of suctioning. However, it ences of their world are inseparable. One can
showed that the nurse recognized the patient easily see that a nursing theory based in the
as a unique human being, and she did some- human context lends itself to phenomenolog-
thing special to make the experience less ical inquiry rather than reductionism, which
stressful and as comfortable as possible for attempts to remove subjective humanness
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C H A P T E R 1 9 Josephine Paterson and Loretta Zderads Humanistic Nursing Theory 343

and strives to achieve detached objectivity. Nursing Theory: bracketing, angular view,
The early phenomenologists saw their goal as and noetic loci. These will be taken up as we
the examination and description of all things, discuss the phases of inquiry.
including the human experience of those
things, in the particular way they reveal Preparation of the Nurse Knower
themselves. for Coming to Know
Phenomenology is not only a philosophy, In the first phase, the inquirer tries to open
but also a methoda method that can be him- or herself up to the unknown and to the
integrated into a general approach or way possibly different. The nurse consciously and
of viewing the world. Nurses who can relate conscientiously struggles with understanding
to this method are inclined to cultivate it and identifying her or his own angular view.
and make it a part of their everyday Angular view involves the gestalt of the
approach to nursing. This method is no less unique person mentioned earlier. It includes
rigorous in its application than methods the conceptual and experiential framework
used in experimental research to build theo- that we bring into any situation, a framework
ries. The phenomenological approach is that is usually unexamined and casually
based on description, intuition, analysis, and accepted as we negotiate our everyday world.
synthesis. Training and conscientious self- Later in the process angular view is called
criticism on the part of the unbiased inquir- upon to help make sense of and give meaning
er are essential as he or she investigates the to the phenomena being studied.
phenomenon as it reveals itself. In phenom- By intentionally bringing into conscious-
enology, a statements validity is based on ness and acknowledging our angular view we
whether or not it describes the phenomenon are then able to bracket it purposefully so that
accurately. The truth of all the statements we do not superimpose it on the lived experi-
resulting from the critical analysis of each ence of the other. When we bracket, we hold
phenomenon described can be verified by our own thoughts, experiences, and beliefs in
examining the phenomenon itself. abeyance. This holding in abeyance does not
Drs. Paterson and Zderad describe five deny our unique selves but suspends them
phases to their phenomenological study of temporarily.
nursing. Phenomenology underpins the prac- A personal experience that helped me grasp
tice of nursing and study of nursing phenom- the concept of bracketing and the desired state
ena. These phases are presented sequentially it aims to achieve occurred when I was travel-
but are actually interwoven because, as with ing in Europe. As I entered each new country,
all of Humanistic Nursing Theory, there is a I experienced the excitement of the unknown.
constant flow between, in all directions, and I realized at the same time how alert, open,
all-at-once emanating toward a center that is and other-directed I was in this uncharted
nursing. The phases of humanistic nursing world as compared to my own daily routine at
inquiry are: home. In my familiar surroundings, I would
often fill in the blanks left by my inattentive-
Preparation of the nurse knower for com-
ness to a routine experience, sometimes antic-
ing to know
ipating and answering questions even before
Nurse knowing the other intuitively
they were asked.
Nurse knowing the other scientifically
Bracketing prepares the inquirer to enter
Nurse complementarily synthesizing known
the uncharted world of the other without
others
expectations and preconceived ideas. It helps
Succession within the nurse from the many
one to be open to the authentic, to the true
to the paradoxical one
experience of the other. Even temporarily
Enfolded in these five phases are three letting go of that which shapes our own
concepts that are very basic to Humanistic identity, however, causes anxiety, fear, and
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344 S E C T I O N V Caring Theories

uncertainty. Labeling, diagnosing, and rou-


tine add a necessary and very valuable pre-
dictability, sense of security, and means of
impressions the
conserving energy to our everyday existence nurse becomes
and practice. However, as a consequence we aware of in
may become less open to the new and differ- herself sudden
insights
ent in a situation. Being open to the new and
different is a necessary stance in being able a new
to know the other intuitively. overall grasp

Nurse Knowing the Other Intuitively recollected


real experience
Knowing the other intuitively is described by
Paterson and Zderad (1976) as moving back
and forth between the impressions the nurse
becomes aware of in herself and the recollect- At this time the nurses general impressions
ed real experience of the other (pp. 8889), are in a dialogue with her unbracketed view
which was obtained through the unbiased Figure 19 4 Nurse knowing the other intuitively.
being with the other. Bracketing and intuiting (Adapted from Briggs, J., & Peat, D. [1989]. Turbulent
are not contradictory processes. Both are nec- Mirror [p. 176]. New York: Harper & Row.)
essary and interwoven parts of the phenome-
nological process. The rigor and validity of and categorizes (Paterson & Zderad, 1976,
phenomenology are based on the continually p. 79). Patterns and themes are reflective of
referring back to the phenomenon itself. It and rigorously validated by the authentic
is conceptualized as dialectic between the experience (Fig. 19-5).
impression and the real. This shifting back
and forth allows for sudden insights on the Nurse Complementarily Synthesizing
nurses part, a new overall grasp, which mani- Known Others
fests itself in a clearer, or perhaps a new, At this point, the nurse personifies what has
understanding. These understandings gen- been described by Paterson and Zderad as
erate further development of the process. At a noetic locus, a knowing place (1976,
this time, the nurses general impressions are p. 43). According to this concept, the greatest
in a dialogue with her or his unbracketed view gift a human being can have is the ability to
(Fig. 194). relate to others, to wonder, search, and
imagine about experience, and to create out
Nurse Knowing the Other of what has become known. Seeing them-
Scientifically selves as knowing places inspires nurses to
In the next phase, objectivity is needed as continue to develop and expand their com-
the nurse comes to know the other scientif- munity of world thinkers through their
ically. Standing outside the phenomenon, educative and practical experiences, which
the nurse examines the other through analy- then becomes a part of their angular view.
sis. She or he comes to know the other This self-expansion, through the internal-
through parts or elements that are symbolic ization of what others have come to know,
and known. This phase incorporates the dynamically interrelates with the nurses
nurses ability to be conscious of her- or human capacity to be conscious of her own
himself and that which she or he has taken lived experiences. Through this interrela-
in, merged with, and made part of her- or tionship, the subjective and objective world
himself. This is the time when the nurse of nursing can be reflected upon by each
mulls over, analyzes, sorts out, compares, nurse, who is aware of and values herself as
contrasts, relates, interprets, gives a name to, a knowing place (Fig. 19-6).
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C H A P T E R 1 9 Josephine Paterson and Loretta Zderads Humanistic Nursing Theory 345

Standing outside the phenomenon, the nurse


examines it through analysis
and comes to know
Concepts from
written literature
evaluation

mulls over Alternative


elements

Structure
Mental and Model
written
information relates

compares

Discrepancies
contrasts

interprets

nurse conscious of herself


Figure 19 5 Nurses knowing the other scientifically. (Adapted from illustration in Briggs, J., & Peat, D.
[1989]. Turbulent Mirror [p. 176]. New York: Harper & Row.)

Dialectic
Succession Within the Nurse from the
a new overall grasp Many to the Paradoxical One
sudden insights This is the birth of the new from the exist-
ing patterns, themes, and categories. It is in
this phase that the nurse comes up with a
conception or abstraction that is inclusive of
and beyond the multiplicities and contradic-
tions (Paterson & Zderad, 1976, p. 81) in a
process that augments and expands her or
Synthesizes his own angular view. This is the pattern of
the dialectic process, which is reflected
throughout Humanistic Nursing Theory.
In the dialectic process there is a repetitive
pattern of organizing the dissimilar into a
Subjective Objective
higher level (Barnum, 1990, p. 44). At this
higher level, differences are assimilated to
create the new. This repetitive dialectic
process of humanistic nursing is an approach
Noetic Loci
that feels comfortable and natural for those
"knowing place" who think inductively. The pervasive theme
Figure 19 6 Nurses complementarily synthesizing of dialectic assimilation speaks to universal
knowing others. interrelatedness from the simplest to the
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346 S E C T I O N V Caring Theories

most complex level. Humans, by virtue of Applications of the Theory


their ability to self-observe, have the unique
These descriptive explorations illuminate
capacity to transcend themselves and reflect
the concepts of empathy, comfort, and pres-
on their relationship to the universe.
ence innate in applying Humanistic Nursing
This dialectic process has a pattern similar
theory to a clinical setting. Paterson (1977)
to that of the call-and-response dialogic
shared a personal experience in a nursing
movement of Humanistic Nursing Theory.
situation with a person terminally ill with
The movement speaks to the interactive dia-
cancer:
logue between two different humans from
which a unique yet universal instance of nurs- For a while I really beat on myself. I felt nothing, just
ing emerges. The nursing interaction is limited a kind of indifference and numbness, as Dominic
in time and space, but the internalization of expressed his miseries, fears, and anger. I pride
that experience adds something new to each myself on my empathic ability. I felt so inadequate.
persons angular view. Neither is the same as I could not believe I could not feel with him what
before. Each is more because of that coming he was experiencing. Intellectually I knew his
together. The coming together of the nurse words, his expressions were pain-filled. My feelings
and the patient, the between in the lived of inadequacy, helplessness, and inability to control
world, is nursing. Just as in the double helix of myself, came through strong. [As] I mulled reflec-
the DNA molecule whose interweaving pat- tively about this, suddenly a light dawned amidst
tern gives structure to the individual, in the my puzzlement. I was experiencing what Dominic
fabric of Humanistic Nursing Theory this was expressing. At this time I was feeling his inad-
intentional interweaving between patient and equacy, helplessness, and inability to control his
nurse is what gives nursing its structure, form, cancer. (p. 13)
and meaning.
This insight brought a greater understand-
ing between Dr. Paterson and this patient, an
The Concept of Community understanding that brought them closer so
The definition of community presented by that she could endure with him in his fear-
Paterson and Zderad (1976) is: Two or filled knowing and unknowing of dying. As
more persons struggling together toward a his condition deteriorated, she continued to
center (1976, p. 131). In any community visit at his bedside.
there is the individual and the collective.
Plato points to the microcosm and the Often after greeting me and saying what he
macrocosm and proposes that the one is needed he would fall asleep. First, I thought, It
reflective of the many. Humanistic Nursing doesnt matter whether I come or not. Then I
Theory similarly proposes that the interac- noticed and validated that when I moved his eyes
tion of one nurse is a reflection of the recur- flew open. I reevaluated his sleeping during my
rent pattern of nursing, and is therefore visit. I discussed this with him. He felt safe when
worth reflecting upon and valuing. Accord- I sat with him. He was exhausted, staying awake,
ing to Humanistic Nursing Theory, there is watching himself to be sure he did not die. When
an inherent obligation of nurses to one I was there I watched him, and he could sleep.
another and to the community of nurses. I no longer made any move to leave before my
That which enhances one of us, enhances all time with him was up. I told him of this intention
of us. Through openness, sharing, and car- so that he could relax more deeply. To alleviate
ing, we each will expand our angular views, aloneness; this is a most expensive gift. To give
each becoming more than before. Subse- this gift of time and presence in the patients
quently, we take back into our nursing com- space, a person has to value the outcomes of
munity these expanded selves, which in turn relating. (p. 13)
will touch our patients, other colleagues, and This gift of presence is poetically described by
the world of health care. Dr. Zderad (1978)
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Death lifts his scythe concerned about my family and what they
to swipe down the young man were struggling with, I began to experience
misdressed in hospital gown some of my own feelings. I felt so alone. Then
displaced in hospital bed. the evening nurse who had been working with
The cruel cold blade slashes me over the last two days of testing came in.
the hard mask of his nurse We looked at each otherneither of us said a
silently standing there word and she just gently touched my hand. I
bleeding forth her presence. (p. 48) cried. She stayed there for I dont know
how long, until I placed my other hand on top
At an interdisciplinary conference on love, of hers and gently gave it a pat. She left and I
intimacy, and connectedness that I attended, was able to go to sleep. This was one of the
one of the opening speakers described the fol- most intimate moments in my life. This nurse
lowing experience that had been related to offered to be with me in the known, and
him by a dear friend. unknown; somehow she also conveyed a reas-
His friend had just been diagnosed with a surance that I did not have to go through what
serious form of cancer. The speaker described was coming, whatever that was, alone.
his friend telling him, In the early evening the This ability to be with and endure with a
family was all around. We talked, but there patient in the process of living and dying is
was the awkwardness of not knowing what to frequently taken for granted by us, yet it is
say or what to expect. Later that night, I was what many times differentiates us from other
in my room all alone. No longer having to be professionals.

Practice Exemplar
The humanistic nursing approach is useful in terms of what the patient was reaching for.
clinical supervision. In the process of supervi- The patient had received clear explanations
sion I try to understand the call of the nurse that she did not have AIDS, but at some
when she brings up a clinical issue. This usu- point, she might acquire the disease. The
ally is connected to the call of the patient to patient was told that there were treatments
him or her, and some issue that has arisen to retard the disease process, but that there
around the nurses not being able to hear or were no cures yet. Given this, the doctor,
respond to that call. whose primary function was to treat and
Consider this example. Ms. L. was work- cure, was feeling ill-prepared to deal with
ing with a patient who had recently been told this patient. Perhaps this sense of inadequa-
that her HIV test was positive. Although she cy fostered avoidant behavior on his part. But
did not have AIDS, she had been exposed to as the nurse and I dialogued together, we
the AIDS virus, probably through her cur- came to realize that, in fact, the patient was
rent boyfriend, who was purportedly an IV not calling for doctoring; she was calling for
drug abuser. The nurse was concerned that nursing. She was calling for someone to help
the doctor on the interdisciplinary team, who her get through and grow through this expe-
was also the patients therapist, was not giv- rience in her life. With this clarified, the
ing the patient the support that the nurse felt nurse and I began to explore the nurses
the patient was calling out for. The nurse and experience of hearing this call. The nurse
I explored her perception that the patient did spoke of the pain of knowing that this young
in fact seem to be reaching out. We ask our- woman might die prematurely. She spoke of
selves about the meaning of reaching out in how a friend, who reminded her of this
Continued
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348 S E C T I O N V Caring Theories

Practice Exemplar cont.


patient, had also died, and that when she The nurse in the hospital grew from her
associated the two, she felt sad. experience of working with this patient.
As we explored the nurses angular view, we Although she is usually quite reserved and
were able to identify areas that were unknown. shies away from public forums, with encour-
The nurse had difficulty understanding the agement she was able to share the experience
need or the role of the patients relationship with this patient in a large public forum. She
with her current boyfriend. We worked on not only shared with other professionals the
helping the nurse to bracket her own thoughts role that she as a nurse played in the care of
and judgments, so that she could be more this patient, but also acknowledged herself
open to the patients experience of this rela- in a group of professionals as a knowing
tionship. Subsequently, the nurse was able to place.
understand the patients intense fear of being The process enfolded in Humanistic
alone. As the nurse began to understand that Nursing Theory is beneficial to supervisors
choices are humanizing, she began to explore and self-reflective practitioners in all areas of
the need for support systems. To expand her nursing. Patients call to us both verbally and
own capability of being a knowing place and nonverbally, with all sorts of health-related
expanding her angular view, she sought out needs. It is important to hear the calls and
the help of the nurse practitioner in our gyne- know the process that lets us understand
cology clinic. They worked well together with them. In hearing the calls and searching our
this patient, who eventually was able to leave own experiences of who we are, our personal
the hospital, get a part-time job, and be all angular view, we may progress as humanistic
that she could in her current life situation. nurses.

Policy: Developing a Community of called to the community of nurses where I


Nurses work, and we joined together to struggle with
Another group experience in which Human- this challenge. While the importance of
istic Nursing Theory was utilized was the organized nursing power cannot be overem-
formation of a community of nurses who phasized, it is the individual nurse in her or his
were mutually struggling with changes in day-to-day practice who can actualize or
their nursing roles. In Humanistic Nursing undermine the power of the profession. As a
Theory, sharing within the community of group, we strove to acknowledge and support
nurses allows each nurse and the community one another as individuals of worth so that
to become more. I became aware of a com- we in turn could maximize our influence as a
mon call issued forth by nurses from my own profession.
experiences as a nurse manager. In settings such as hospitals, the time pres-
In the report of the secretary of Health and sure, the unending tasks, the emotional strain,
Human Services Commission on Nursing and the conflicts do not allow nurses to relate,
(December, 1988) we were told that the per- reflect, and support one another in their
spective and expertise of nurses are a necessary struggle toward a center that is nursing. This
adjunct to that of other health-care profes- isolation and alienation does not allow for the
sionals in the policy-making, and regulatory, development of either a personal or profes-
and standard setting process (p. 31). This sional voice. Within our community of nurses,
mandate is still echoed in todays nursing liter- it became clear that developing individual
ature (Wick, 2003), confirming the belief that voices was our first task. Talking and listening
nurses are challenged to help bring about to one another about our nursing worlds
needed change in the health care system. I allowed us to become more articulate and
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C H A P T E R 1 9 Josephine Paterson and Loretta Zderads Humanistic Nursing Theory 349

clear about function and value as nurses. The and has a potential resource for expanding
theme of developing an articulate voice has herself as a knowing place.
pervaded and continues to pervade this group. Through openness and sharing we were able
There is an ever-increasing awareness of both to differentiate our strengths. Once the mem-
manner and language as we interact with one bers could truly appreciate the unique compe-
another and those outside the group. The tencies of one another, they were able to reflect
resolve for an articulate voice is even more firm that appreciation back. Through this reflection,
as members of the group experience and share members began to internalize and then project
the empowering effect it can have on both per- a competent image of themselves. They learned
sonal and professional life. It has been said that that this positive mirroring did not have to
those that express themselves unfold in health, come from outsiders. They can reflect back
beauty, and human potential. They become to one another the image of competence and
unblocked channels through which creativity power. They, as a community of nurses, can
can flow (Hills & Stone, 1976, p. 71). empower one another. This reciprocity is a self-
Group members offered alternative enhancing process, for the degree to which I
approaches to various situations that were can create relationships which facilitate the
utilized and subsequently brought back to the growth of others as separate persons is a meas-
group. In this way, each member shared in the ure of the growth I have achieved in myself
experience. That experience therefore became (Rogers, 1976, p. 79). And so by sharing in our
available to all members as they individually community of nurses we can empower one
formulated their own knowledge base and another through mutual confirmation as we
expanded their angular view. As Paterson and help one another move toward a center that is
Zderad (1976) proposed, each person might nursing. We strive to do this with our patients.
be viewed as a community of the beings with We must also strive to do this for one another
whom she has meaningfully related (p. 45) and the profession of nursing.

Summary
Today I perceive another call. This call is asks of nursing practice is: Is this particular
resounded in and exemplified by the follow- intersubjectivetransactional nursing event
ing description of examining a pregnant humanizing or dehumanizing? Nurses as
woman: Instead of having to approach the clinicians, teachers, researchers, and admin-
woman . . . to feel her breathing, you could istrators can use the concepts and process of
now read the information [on her and her Humanistic Nursing Theory to gain a better
fetus] from across the room, from down the understanding of the calls we are hearing.
hall (Rothman, 1987, p. 28). Through this understanding we are given
The call I hear is for nursing. It is the call direction for expanding ourselves as know-
from humanity to maintain the humanness ing places so that we can fulfill our reason
in the health care system, which is becoming for being, which, according to Humanistic
increasingly sophisticated in technology, Nursing Theory, is nurturing the well-being
increasingly concerned with cost contain- and more-being of persons in need.
ment, and increasingly less aware of and For more information on the subject of
concerned with the patient as a human Humanistic Nursing see Human-Centered
being. The context of Humanistic Nursing Nursing: The Foundation of Quality Care by
Theory is humans. The basic question it Susan Kleiman.
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350 S E C T I O N V Caring Theories

References

Barnum, B. J. S. (1990). Nursing theory: Analysis, Paterson, J. G. (1977). Living until death, my perspec-
application, evaluation. Glenview, IL: Scott, tive. Paper presented at the Syracuse Veterans
Foresman. Administration Hospital, New York.
Benner, P. (1984). From novice to expert. Menlo Park, Paterson, J. G., & Zderad, L. T. (1976). Humanistic
CA: Addison-Wesley. nursing. New York: John Wiley & Sons.
Buber, M. (1965). The knowledge of man. New York: Rogers, C. R. (1976). Perceiving, behaving, and becoming:
Harper & Row. 100 ways to enhance self-concept in the classroom.
Heidegger, M. (1977). The question concerning technology. Englewood Cliffs, NJ: Prentice-Hall.
New York: Harper & Row. Rothman, B. (1987). The tentative pregnancy: Prenatal
Hills, C., & Stone, R. B. (1976). Conduct your own diagnosis and the future of motherhood. New York:
awareness sessions: 100 ways to enhance self-concept in Penguin.
the classroom. Englewood Cliffs, NJ: Prentice-Hall. U.S. Public Health Services. (1988, December). Secretarys
Husserl, L. (1970). The idea of phenomenology. The commission on nursing, final report. Washington, DC:
Hague, Netherlands: Martinus Nijhoff. Department of Health & Human Services.
Kleiman, S. (2008). Human Centered Nursing: The Watson, J. (1988). Nursing: Human science and human
foundation of quality care. Philadelphia: F. A. Davis. care. New York: National League for Nursing.
May, R. (1995). The courage to create. New York: W. W. Wick, G. (2003). A place where the spirit can grow: An
Norton. answer to recruitment and retention? Nephrology
Oliveira, N. (2003). Lived dialogue between nurse and Nursing Journal, 30(1), 15.
mothers of children with cancer. 107f. Dissertation Zderad, L. T. (1978). From here-and-now theory:
(masters degree)Centro de Cincias da Sade/ Reflections on how. In: Theory development: What?
Universidade Federal da Paraba, Joo Pessoa. Why? How? Publication no. 15-1708. New York:
Parse, R. (1981). Man-living-health: A theory of nursing. National League for Nursing.
New York: John Wiley & Sons.
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Chapter
20
Jean Watsons Theory
of Human Caring
J EAN WATSON AND T ERRI K AYE
W OODWARD

Introducing the Theorist Introducing the Theorist


Overview of the Theory Dr. Jean Watson is a distinguished professor
Applications of the Theory of nursing who holds an endowed Chair in
Practice Exemplar Caring Science at the University of Colorado
Summary Denver, College of Nursing where she formerly
References served as dean. She founded the original
Center for Human Caring at the University
of Colorado Health Sciences Center School
of Nursing. She is also a member of the
American Academy of Nursing and has
served as president of the National League
for Nursing. Dr. Watson founded and serves
as director of the nonprofit Watson Caring
Science Institute, dedicated to furthering the
work of caring, science, and heart-centered
Caritas Nursing, restoring caring and love for
Jean Watson
nurses and health care clinicians healing
practices for self and others.
Dr. Watson earned undergraduate and grad-
uate degrees in nursing and psychiatricmental
health nursing and holds a doctorate in educa-
tional psychology and counseling from the
University of Colorado at Boulder. She is a
widely published author and is the recipient of
several awards and honors, including an inter-
national Kellogg Fellowship in Australia; a
Fulbright Research Award in Sweden; and six
honorary doctoral degrees, including three
international honorary doctorates in Sweden,
the United Kingdom, and Canada.
Dr. Watsons published works on the
philosophy and theory of human caring and
the art and science of nursing are used
by clinical nurses and academic programs
throughout the world. Her caring philoso-
phy is used to guide new models of caring
and healing practices in diverse settings and
in several different countries. More recent

351
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352 S E C T I O N V Caring Theories

clinicalresearch initiatives have been under- made during the past 30 years. This latest
way in clinical agencies interested in trans- update introduces Caritas Nursing as the
forming nursing practice from the inside out, culmination of a Caring Science foundation
implementing transformative caring-healing for professional nursing. The Watson Caring
practices and models of caring, guided by Science Institute and its Faculty Associates
Watsons theory and philosophy. are developing educational, clinical, and
Dr. Watsons original book on caring was administrativeleadership and research mod-
published in 1979, 6 years after she earned her els that seek to sustain and deepen authentic
PhD and joined the faculty at the University caringhealing practices for self and other,
of Colorado. Her second book, Nursing: transforming practitioners and patients alike.
Human Science and Human Care, was written The Caring Science model is integrating
while on sabbatical in Australia and reflects Caritas with the Science of the Heart
the metaphysical, spiritual evolution of her (www.heartMath.com) as a liberating model
thinking. The third book, Postmodern Nursing to deepen the intelligent heart-centered car-
and Beyond, moves beyond theory to reflect ing for all.
the ontological foundation of nursing as
an overarching framework for transforming
caring and healing practices in education and Overview of the Theory
clinical care (Watson, 1999). The Theory of Human Caring was developed
Additional empirical and clinical caring between 1975 and 1979 while I was teaching
research foci developments include the first at the University of Colorado. It emerged
and second editions of the book on caring from my own views of nursing, combined and
instruments, Assessing and Measuring Caring informed by my doctoral studies in educa-
in Nursing and Health Sciences (2002, 2008). tional, clinical, and social psychology. It was
These works offer a critique and collation of my initial attempt to bring meaning and focus
more than 20 instruments for assessing and to nursing as an emerging discipline and dis-
measuring caring. The measurement publica- tinct health profession that had its own
tions seek to bridge modern and postmodern unique values, knowledge, and practices, and
views of caring and healing in relation to its own ethic and mission to society. The work
outcomes research and the need for clinical was also influenced by my involvement with
evidence of caring. an integrated academic nursing curriculum
Her Caring Science as Sacred Science (Watson, and efforts to find common meaning and
2004/5 American Journal of Nursing book of the order to nursing that transcended settings,
Year) makes a case for a deep moralethical, populations, specialty, and subspecialty areas.
spirit-filled foundation for caring science and From my emerging perspective, I tried
healing that is based on infinite love and to make explicit that nursings values,
an expanding cosmology. This view in turn knowledge, and practices of human caring
elicits the finest of nursing as the art, science, were geared toward subjective inner healing
and spiritual practice it is meant to be processes and the life world of the experienc-
because it reflects the highest ethical ideal ing person. This required unique caring
form of compassionate service to society and healing arts and a framework called carative
humanity. factors, which complemented conventional
The latest 2008 theoretical work, Nursing: medicine but stood in stark contrast to
The Philosophy and Science of Caring. Revised curative factors. At the same time, this
New Edition, University Press of Colorado, emerging philosophy and theory of human
revisits and reworks her first book, Nursing: caring sought to balance the cure orientation of
The Philosophy and Science of Caring (1979, medicine, giving nursing its unique disciplinary,
reprinted 1985), bringing the original publi- scientific, and professional standing with itself
cation up to date to include all the changes and its public.
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C H A P T E R 2 0 Jean Watsons Theory of Human Caring 353

Major Conceptual Elements Caring Science as a model for nursing allows


The major conceptual elements of the original nursings caringhealing core to become both
(and emergent) theory are: discipline-specific and trans-disciplinary. Thus,
nursings timeless, ancient, enduring, and most
Ten carative factors (evolving toward clini- noble contributions come of age through a
cal caritas processes) Caring Science orientationscientifically, aes-
Transpersonal caring relationship thetically, and ethically.
Caring moment/caring occasion
Caringhealing modalities Ten Carative Factors
Other dynamic aspects of the theory that The original (1979) work was organized
have emerged or are emerging as more explic- around 10 carative factors as a framework for
it components include: providing a format and focus for nursing phe-
nomena. Although carative factors is still
Expanded views of self and person the current terminology for the core of nurs-
(transpersonal mindbodyspirit unity ing, providing a structure for the initial work,
of being, embodied spirit the term factor is too stagnant for my sensi-
Caringhealing consciousness and inten- bilities today. I offer another concept that is
tionality to care and promote healing more in keeping with my own evolution and
caring consciousness as energy within the future directions for the theory, the concept
humanenvironmental field of a caring of clinical caritas and caritas processes as
moment consistent with a more fluid and contempo-
Phenomenal field/unitary consciousness: rary movement with these ideas and my
unbroken wholeness and connectedness of all expanding directions.
Advanced caringhealing modalities/nursing Caritas comes from the Latin word mean-
arts as a future model for advanced practice ing to cherish and appreciate, giving special
of nursing qua nursing (consciously guided attention to, or loving. It connotes something
by ones nursing ethicaltheoretical that is very fine; indeed, it is precious. The
philosophical orientation). word caritas is also closely related to the
original word carative from my 1979 book.
Caring Science At this time, I now make new connections
The emergence of the work is a more explicit between carative and caritas and without
development of Caring Science as a deep hesitation compare them to invoke love,
moralethical context of infinite and cosmic which caritas conveys. This allows love and
love. As soon as one is more explicit about caring to come together for a new form of
placing the human and caring within their deep transpersonal caring. This relationship
science model, it automatically forces a rela- between love and caring connotes inner heal-
tional unitary worldview and makes explicit ing for self and others, extending to nature
caring as a moral ideal to sustain humanity and the larger universe, unfolding and evolv-
across time and space, one of the gifts and ing within a cosmology that is both meta-
raison detre of nursing in the world, but yet to physical and transcendent with the coevolving
be recognized within and without. Neverthe- human in the universe. This emerging model
less a Caring Science orientation is necessary of transpersonal caring moves from carative to
for the survival of nursing as well as humanity caritas. This integrative expanded perspective
at this crossroads in human evolution. is postmodern, in that it transcends conven-
This view takes nursing and healing work tional industrial, static models of nursing
beyond conventional thinking. The latest while simultaneously evoking both the past
orientation is located within the ageless wisdom and the future. For example, the future of
traditions and perennial ingredients of the dis- nursing is tied to Nightingales sense of call-
cipline of nursing, while transcending nursing. ing, guided by a deep sense of commitment
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354 S E C T I O N V Caring Theories

and a covenantal ethic of human service, cher- professional ethic and mission to societyits
ishing our phenomena, our subject matter, raison dtre for the public. That is where nurs-
and those we serve. ing theory comes into play, and transpersonal
It is when we include caring and love in our caring theory offers another way that both dif-
work and in our life that we discover and fers from and complements that which has
affirm that nursing, like teaching, is more come to be known as modern nursing and
than just a job; it is also a life-giving and life- conventional medicalnursing frameworks.
receiving career for a lifetime of growth and The 10 carative factors included in the
learning. Such maturity and integration of original work are the following:
past with present and future now require
1. Formation of a humanisticaltruistic
transforming self and those we serve, includ-
system of values.
ing our institutions and the profession itself.
2. Instillation of faithhope.
As we more publicly and professionally assert
3. Cultivation of sensitivity to ones self and
these positions for our theories, our ethics, and
to others.
our practiceseven for our sciencewe also
4. Development of a helpingtrusting,
locate ourselves and our profession and disci-
human caring relationship.
pline within a new, emerging cosmology. Such
5. Promotion and acceptance of the expres-
thinking calls for a sense of reverence and
sion of positive and negative feelings.
sacredness with regard to life and all living
6. Systematic use of a creative problem-
things. It incorporates both art and science, as
solving caring process.
they are also being redefined, acknowledging a
7. Promotion of transpersonal
convergence among art, science, and spiritual-
teachinglearning.
ity. As we enter into the transpersonal caring
8. Provision for a supportive, protective,
theory and philosophy, we simultaneously are
and/or corrective mental, physical, socie-
challenged to relocate ourselves in these
tal, and spiritual environment.
emerging ideas and to question for ourselves
9. Assistance with gratification of human
how the theory speaks to us. This invites us
needs.
into a new relationship with ourselves and our
10. Allowance for existential
ideas about life, nursing, and theory.
phenomenologicalspiritual forces.
(Watson, 1979/1985)
Original Carative Factors
Although some of the basic tenets of the
The original carative factors served as a guide
original carative factors still hold, and indeed
to what was referred to as the core of nursing,
are used as the basis for some theory-guided
in contrast to nursings trim. Core pointed to
practice models and research, what I am
those aspects of nursing that potentiate thera-
proposing here, as part of my evolution and
peutic healing processes and relationships
the evolution of these ideas and the theory
they affect the one caring and the one being
itself, is to transpose the carative factors into
cared for. Further, the basic core was grounded
clinical caritas processes. For example, con-
in what I referred to as the philosophy, science,
sider the following within the context of clin-
and even art of caring. Carative is that deeper
ical caritas and emerging transpersonal caring
and larger dimension of nursing that goes
theory.
beyond the trim of changing times, setting,
procedures, functional tasks, specialized focus
around disease, and treatment and technology. From Carative Factor to Clinical
Although the trim is important and not Caritas Processes
expendable, the point is that nursing cannot be As carative factors evolve within an expand-
defined around its trim and what it does in a ing perspective, and as my ideas and values
given setting and at a given point in time. Nor evolve, I now offer the following translation
can nursings trim define and clarify its larger of the original carative factors into clinical
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caritas processes, suggesting more open which potentiate alignment of mind-


ways in which they can be considered. For body-spirit, wholeness, and unity of
example: being in all aspects of care, tending to
both embodied spirit and evolving
1. Formation of a humanisticaltruistic
spiritual emergence.
system of values becomes the practice of
10. Allowance for existential-
loving kindness and equanimity within the
phenomenological-spiritual forces
context of caring consciousness.
becomes opening and attending to
2. Instillation of faithhope becomes being
spiritual-mysterious and existential
authentically present and enabling and
dimensions of ones own life-death;
sustaining the deep belief system and sub-
soul care for self and the one being
jective life world of self and one being
cared for.
cared for.
3. Cultivation of sensitivity to ones self and What differs in the clinical caritas frame-
to others becomes cultivation of ones own work is that a decidedly spiritual dimension
spiritual practices and transpersonal self, and an overt evocation of love and caring are
going beyond ego self, opening to others merged for a new paradigm for this millen-
with sensitivity and compassion. nium. Such a perspective ironically places
4. Development of a helpingtrusting, human nursing within its most mature framework
caring relationship becomes developing and is consistent with the Nightingale model
and sustaining a helpingtrusting, of nursingyet to be actualized but await-
authentic caring relationship. ing its evolution. This direction, while
5. Promotion and acceptance of the expres- embedded in theory, goes beyond theory
sion of positive and negative feelings and becomes a converging paradigm for
becomes being present to, and supportive nursings future.
of, the expression of positive and negative Thus, I consider my work more a philo-
feelings as a connection with deeper spirit sophical, ethical, intellectual blueprint for
of self and the one being cared for. nursings evolving disciplinary/professional
6. Systematic use of a creative problem- matrix, rather than a specific theory per se.
solving caring process becomes creative Nevertheless, others interact with the original
use of self and all ways of knowing as part work at levels of concreteness or abstractness.
of the caring process; to engage in artistry The caring theory has been, and is still being
of caring-healing practices. used as a guide for educational curricula, clin-
7. Promotion of transpersonal teaching- ical practice models, methods for research and
learning becomes engaging in genuine inquiry, and administrative directions for
teaching-learning experience that attends nursing and health-care delivery.
to unity of being and meaning, attempting
to stay within others frames of reference. Reading the Theory
8. Provision for a supportive, protective, The theory can be read as a philosophy, an
and/or corrective mental, physical, societal, ethic, a paradigm, an expanded science model or
and spiritual environment becomes creat- a theory. If read as a theory, it can be read as
ing a healing environment at all levels grand theory within the unitarytransformative
(a physical and nonphysical, subtle envi- paradigm when understood at the transpersonal
ronment of energy and consciousness, energetic field level of Caritas-Universal Love,
whereby wholeness, beauty, comfort, and evolving consciousness.
dignity, and peace are potentiated). It can be read as middle range theory when
9. Assistance with gratification of human read at the Carative factors/Caritas process,
needs becomes assisting with basic needs, which provides the structure and language of
with an intentional caring consciousness, the theory, as both middle range and specific.
administering human care essentials, When used in clinical settings nurses are
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356 S E C T I O N V Caring Theories

framing their experiences around the caritas latest research based upon the Science of the
processes to sustain the caring science focus, as Heart has demonstrated that the loving
well as developing language systems including heart-centered person is radiating love that
computerized documentation systems to doc- can be measured eight to ten feet beyond
ument and study caring within a designated themselves, affecting the subtle environment
language system (Rosenberg, 2006, p. 55). of all. Moreover, this research affirms that
The middle range focus also is congruent the heart is actually sending messages to the
with clinical caring research projects, utilizing brain, rather than the other way around. For
caring language of carative/caritas. Indeed, more information, please visit www.heart-
many of the more formalized caring assess- Math.com; www.heartMath.org
ment tools are based on the language of this This work posits a values explicit moral
structure. Several multisite research projects foundation and takes a specific position with
are now underway using consistent caring respect to the centrality of human caring, car-
assessment tools. For example, Dr. Joanne itas, and love as an ethic and ontology. It
Duffys: Caring Assessment Tool and the John is also a critical starting point for nursings
Nelson, Jean Watson, Inova Health Instru- existence, broad societal mission, and the basis
ment: Caring Factor Survey (Persky, Nelson, for further advancement for caringhealing
Watson, & Bent, 2008; www.nursing.ucdenver. practices. Nevertheless, its use and evolution
edu/caring). For more complete access to all are dependent on critical, reflective practices
the Caring Assessment tools see Assessing and that must be continuously questioned and
Measuring Caring in Nursing and Health Sci- critiqued in order to remain dynamic, flexible,
ences, 2nd ed. (Watson, 2008b). and endlessly self-revising and emergent
(Watson, 1996, p. 143).
Heart-Centered Transpersonal
Caring Moment: Caritas Field Transpersonal Caring Relationship
Whether the theory is read at different lev- The terms transpersonal and a transpersonal
els, used as a language system for documenta- caring relationship are foundational to the
tion, used as a guide for professional nursing work. Transpersonal conveys a concern for the
practice models, or the focus of multisite or inner life world and subjective meaning of
individual clinical caring research studies, the another who is fully embodied. But transper-
essence of the lived theory is in the Caring sonal also energetically goes beyond the ego
Moment. The Caring Moment can be located self and beyond the given moment, reaching
within any caring occasion, as a concept with- to the deeper connections to spirit and with
in middle-range or even prescriptive or prac- the broader universe. Thus, a transpersonal
tice level theory. caring relationship moves beyond ego self and
However, the Caring Moment is most radiates to spiritual, even cosmic, concerns
evident within the transpersonal Caritas and connections that tap into healing possi-
energetic field model, in that ones con- bilities and potentials.
sciousness, intentionality, energetic heart- Transpersonal caring seeks to connect
centered presence is radiating a field beyond with and embrace the spirit or soul of the other
the two people or the situation, affecting through the processes of caring and healing
the larger field. Thus nurses can become and being in authentic relation, in the
more aware, more awake, more conscious of moment. Such a transpersonal relationship is
manifesting/radiating a Caritas field of love influenced by the caring consciousness and
and healing for self and others, helping intentionality, and energetic presence of the
to transform self and system. For more com- nurse as she or he enters into the life space or
prehensive understanding of this work, see phenomenal field of another person and is
Nursing: The Philosophy and Science of Caring, able to detect the other persons condition of
revised 2nd ed. (Watson, 2008a). Indeed, the being (at the soul or spirit level). It implies a
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C H A P T E R 2 0 Jean Watsons Theory of Human Caring 357

focus on the uniqueness of self and other and Assumptions of the Transpersonal
the uniqueness of the moment, wherein the Caring Relationship
coming together is mutual and reciprocal, The nurses moral commitment, intentionality,
each fully embodied in the moment, while and caritas consciousness exists to protect,
paradoxically capable of transcending the enhance, promote, and potentiate human dig-
moment, open to new possibilities. nity, wholeness, and healing, wherein a person
The transpersonal Caritas consciousness creates or co-creates his or her own meaning
nurse seeks to see who is that spirit- for existence, healing, wholeness, and living
filled person behind the patient/behind the and dying.
colleague/behind the disease, diagnosis, the The nurses will and consciousness affirm
behavior or personality one may not like and the subjective-spiritual significance of the per-
connect with the spirit filled individual son while seeking to sustain caring in the midst
behind the illusion. This is heart-centered of threat and despairbiological, institutional,
Caritas practice guided by the very first or otherwise. This honors the IThou rela-
Caritas process: cultivation of loving kindness tionship versus an IIt relationship.
and equanimity with self and other, allowing The nurse seeks to recognize, accurately
for development of more caring, love, com- detect, and connect with the inner condition
passion, and authentic caring moments. of spirit of another through genuine presenc-
Transpersonal caring calls for an authen- ing and being centered in the caring moment.
ticity of being and becoming, an ability to be Actions, words, behaviors, cognition, body
present to self and others in a reflective frame. language, feelings, intuition, thought, senses,
The transpersonal nurse has the ability to the energy field, and so on all contribute to
center consciousness and intentionality on transpersonal caring connection. The nurses
caring, healing, and wholeness, rather than on ability to connect with another at this
disease, illness, and pathology. transpersonal spirit-to-spirit level is translated
Transpersonal caring competencies are via movements, gestures, facial expressions,
related to ontological development of the procedures, information, touch, sound, verbal
nurses human caring literacy and ways of expressions, and other scientific, technical,
being and becoming. Thus, ontological car- aesthetic, and human means of communica-
ing competencies become as critical in this tion, into nursing human art/acts or inten-
model as technological curing competencies tional caring-healing modalities.
to the conventional modern, Western nurs- The caringhealing modalities within the
ing-medicine model, which is now coming to context of transpersonal caring/caritas con-
an end. sciousness potentiate harmony, wholeness,
Within the model of transpersonal car- and unity of being by releasing some of the
ing, clinical caritas consciousness is engaged disharmony, the blocked energy that inter-
at a foundational ethical level for entry into feres with the natural healing processes. As a
this framework. The nurse attempts to enter result, the nurse helps another through this
into and stay within the others frame of ref- process to access the healer within, in the
erence for connecting with the inner life fullest sense of Nightingales view of nursing.
world of meaning and spirit of the other. Ongoing personalprofessional develop-
Together, they join in a mutual search for ment and spiritual growth and personal spiri-
meaning and wholeness of being and becom- tual practice assist the nurse in entering into
ing, to potentiate comfort measures, pain this deeper level of professional healing
control, a sense of well-being, wholeness, or practice, allowing the nurse to awaken to the
even a spiritual transcendence of suffering. transpersonal condition of the world and to
The person is viewed as whole and complete, actualize more fully ontological competen-
regardless of illness or disease (Watson, cies necessary for this level of advanced prac-
1996, p. 153). tice of nursing. Valuable teachers for this work
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358 S E C T I O N V Caring Theories

include the nurses own life history and previ- connection at a deeper level than that of phys-
ous experiences, which provide opportunities ical interaction. For example:
for focused studies, as the nurse has lived
[W]e learn from one another how to be human by
through or experienced various human condi-
identifying ourselves with others, finding their
tions and has imagined others feelings in
dilemmas in ourselves. What we all learn from it is
various circumstances. To some degree, the
self-knowledge. The self we learn about is every
necessary knowledge and consciousness can
self. IT is universalthe human self. We learn to rec-
be gained through work with other cultures
ognize ourselves in others [it] keeps alive our
and the study of the humanities (art, drama,
common humanity and avoids reducing self or oth-
literature, personal story, narratives of illness
er to the moral status of object. (Watson, 1985,
journeys), along with an exploration of ones
pp. 5960)
own values, deep beliefs, relationship with self
and others, and ones world. Other facilitators
include personal-growth experiences such Caring (Healing) Consciousness
as psychotherapy, transpersonal psychology,
The dynamic of transpersonal caring (heal-
meditation, bioenergetics work, and other
ing) within a caring moment is manifest in a
models for spiritual awakening. Continuous
field of consciousness. The transpersonal
growth is ongoing for developing and matur-
dimensions of a caring moment are affected
ing within a transpersonal caring model. The
by the nurses consciousness in the caring
notion of health professionals as wounded
moment, which in turn affects the field of the
healers is acknowledged as part of the neces-
whole. The role of consciousness with respect
sary growth and compassion called forth
to a holographic view of science has been
within this theory/philosophy.
discussed in earlier writings (Watson, 1992,
p. 148) and includes the following points:
Caring Moment/Caring Occasion
The whole caringhealingloving con-
A caring occasion occurs whenever the nurse sciousness is contained within a single
and another come together with their unique caring moment.
life histories and phenomenal fields in a The one caring and the one being cared for
human-to-human transaction. The coming are interconnected; the caring-healing
together in a given moment becomes a focal process is connected with the other
point in space and time. It becomes transcen- human(s) and with the higher energy of
dent, whereby experience and perception take the universe.
place, but the actual caring occasion has a The caringhealingloving consciousness of
greater field of its own, in a given moment. the nurse is communicated to the one
The process goes beyond itself yet arises from being cared for.
aspects of itself that become part of the life Caringhealingloving consciousness exists
history of each person, as well as part of a through and transcends time and space and
larger, more complex pattern of life (Watson, can be dominant over physical dimensions.
1985, p. 59; 1996, p. 157).
A caring moment involves an action and Within this context, it is acknowledged
choice by both the nurse and other. The that the process is relational and connected. It
moment of coming together presents the two transcends time, space, and physicality. The
with the opportunity to decide how to be in process is intersubjective with transcendent
the moment, in the relationshipwhat to do possibilities that go beyond the given caring
with and in the moment. If the caring moment.
moment is transpersonal, each feels a connec-
tion with the other at the spirit level; thus, the Implications of the Caring Model
moment transcends time and space, opening The Caring Model or Theory can be con-
up new possibilities for healing and human sidered a philosophical and moral/ethical
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C H A P T E R 2 0 Jean Watsons Theory of Human Caring 359

foundation for professional nursing and is part having a human experience? Such thinking
of the central focus for nursing at the discipli- in regard to this philosophical question can
nary level. A model of caring includes a call guide ones worldview and help to clarify
for both art and science. It offers a framework where one may locate self within the caring
that embraces and intersects with art, science, framework.
humanities, spirituality, and new dimensions Are those interacting and engaging in the
of mindbodyspirit medicine and nursing model interested in their own personal
evolving openly as central to human phenom- evolution: Are they committed to seeking
ena of nursing practice. authentic connections and caringhealing
I emphasize that it is possible to read, relationships with self and others?
study, learn about, and even teach and research Are those involved conscious of their
the caring theory. However, to truly get it, caring caritas or noncaring consciousness
one has to experience it personally. The model and intentionally in a given moment, at
is both an invitation and an opportunity to individual and system level? Are they
interact with the ideas, experiment with and interested and committed to expanding
grow within the philosophy, and to live it out their caring consciousness and actions to
in ones personal/professional life. self, other, environment, nature, and wider
universe?
Are those working within the model inter-
Applications of the Theory ested in shifting their focus from a modern
The ideas as originally developed, as well as medical sciencetechnocure orientation to
in the current evolving phase (Watson, 1979, a true heart-centered authentic caring
1985, 1999, 2003, 2005, 2008), provide us healingloving model?
with a chance to assess, critique, and see This work, in both its original and evolving
where or how, or even if, we may locate forms, seeks to develop caring as an ontological
ourselves within a framework of Caring epistemological foundation for a theoretical
Science/Caritas as a basis for the emerging philosophicalethical framework for the pro-
ideas in relation to our own theories and fession and discipline of nursing and to clarify
philosophies of professional nursing and/or its mature relationship and distinct intersec-
caring practice. If one chooses to use the tion with other health sciences. Nursing
caring-science perspective as theory, model, caring theorybased activities as guides to
philosophy, ethic, or ethos for transforming practice, education, and research have devel-
self and practice, or self and system, the oped throughout the United States and other
following questions may help (Watson, parts of the world. The Caring/Caritas model
1996, p. 161): is consistently one of the nursing caring theo-
Is there congruence between the values and ries used as a guide in Magnet Hospitals in the
major concepts and beliefs in the model United States, as found to be culturally consis-
and the given nurse, group, system, organi- tent with nursing in many other cultures,
zation, curriculum, population needs, clini- nations, and countries. Nurses reflective-critical
cal administrative setting, or other entity practice models are increasingly adhering to a
that is considering interacting with the car- caring ethic and ethos as moral and scientific
ing model to transform and/or improve foundation for a profession that is coming of
practice? age for a new global era in human history.
What is ones view of human? And what
does it mean to be human, caring, healing, Latest Developments
becoming, growing, transforming, and so The Watson Caring Science Institute was
on? For example, in the words of Teilhard established in 2007 as a nonprofit founda-
de Chardin: Are we humans having a spir- tion. The following statements define and
itual experience, or are we spiritual beings describe the goals, missions, and purposes of
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360 S E C T I O N V Caring Theories

the International Caritas Consortium and of caring inquiry, and model caringhealing
the WCSI as two interrelated entities. practices.
The general goals and objectives of the Mentor self and others in using, extending
Watson Caring Science Institute (WCSI) are the Theory of Human Caring to transform
to steward and serve the ICC its activities, education and clinical practices.
and more specifically to: Develop and disseminate Caring Science
models of clinical scholarship and profes-
Transform the dominant model of medical
sional excellence in the various settings in
science to a model of caring science by
the world.
reintroducing the ethic of caring and love,
necessary for healing. Activities for Caritas Consortium
Deepen the authentic caringhealing rela- Gatherings
tionships between practitioner and patient
Provide a safe forum to explore, create,
to restore love and heart-centered human
renew self and system through reflective
compassion as the ethical foundation of
time out.
healthcare.
Share ideas, inspire each other, and learn
Translate the model of CaringHealing/
together.
Caritas into more systematic programs and
Participate in use of Appreciative Inquiry
services to help transform health care one
whereby each member is facilitative of each
nurse, one practitioner, one educator, and
others work, each learning from others.
one system at a time.
Create opportunities for original scholar-
Ensure caring and healing for the public,
ship and new models of caring science
reduce nurse turnover, and decrease costs to
based clinical and educational practices.
the system.
Generate and share multi-site projects in
caring theory/caring science scholarship.
International Caritas Consortium Network for educational and professional
Charter models of advancing caringhealing prac-
The main purposes of the unfolding and tices and transformative models of nursing.
emerging International Caritas Consortium Share unique experiences for authentic self-
(Watson, 2008a, pp. 278280) are: growth within the Caring Science context.
Educate, implement, and disseminate
1. To explore diverse ways to bring the caring
exemplary experiences and findings to
theory to life in academic and clinical
broader professional audiences through
practice settings by supporting and learn-
scholarly publications, research and formal
ing from each other
presentations.
2. To share knowledge and experiences so that
Envision new possibilities for transforming
we might help guide self and others in the
nursing and health care.
journey to live the caring philosophy and
theory in our personal and professional lives Because of the many national and interna-
tional developments and sincere desire for
The Consortium gatherings, sponsored by
authentic change, new projects using Caring
systems implementing Caring Theory in
Science; Caritas Theory and Philosophy of
practice:
Human Caring are now underway in many
Provide an intimate forum to renew, systems. The Watson Caring Science Institute
restore, and deepen each persons, and each and the International Caritas Consortium are
systems, commitment and authentic prac- examples of individuals and representatives of
tices of human caring in their personal/ systems convening (in these cases, twice a
professional life and work. year) to deepen and sustain what is referred to
Learn from each other through shared as Caritas Nursingthat is, bringing caring
work of original scholarship, diverse forms and love and heart-centered human to human
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C H A P T E R 2 0 Jean Watsons Theory of Human Caring 361

practices back into our personal life and work Cultivation of own spiritual heart-centered
world (Watson, 2008a). practices of loving kindness and equanimity
to self and others
Caring Indicators and Programs Intentionally pausing and breathing,
While these above-named systems are iden- preparing self to be present before entering
tified as sponsors of the growing Internation- patients room
al Caritas Consortium, examples of how Centering exercises and mindfulness prac-
these systems are implementing the theory tices, individually and collectively
are captured through identified acts and Placing magnets on patients door with
processes depicting such transformative positive affirmations, and reminders of
changes. caring practices
Caring theory-in-action reflects transfor- Exploring documentation of caring
mative processes that are representative of language and integration in computerized
actions taking place in many of the systems in documentation systems
the Caritas Consortium and other systems Participation in multisite research assessing
guided by Caring Science and caring theory caring among staff and patients.
as a guide. The following are examples of such Creating healing environmentsattending
caring-in-action indicators: to the subtle environment or Caritas field
Displaying healing objects, stones, blessing
Making human caring integral to the orga-
basket
nizational vision and culture through new
Creating Caritas Circles to share caring
language and documentation of caring,
moments
such as posters
Caring Rounds at bedside with patients
Introducing and naming new professional
Interviewing and selecting staff on basis of
caring practice models, leading to new
caring orientation. Asking candidates to
patterns of delivery of caring/care, for
describe Caring Moment
example, Attending Caring Nursing
Development of caring competencies
Project, Patient Care Facilitator Role,
caritas literacy as guide to assess and
the 12-Bed Hospital
promote staff development and assure
Conscious intentional meaningful rituals.
caring
For example, hand washing is for infec-
tion control, but also may be a meaning- These and other practices are occurring in
ful ritual of self-caring-energetically a variety of hospitals across the United States,
cleansing, blessing, and releasing last situ- often in Magnet hospitals or those seeking
ation or encounter, and being open to the Magnet recognition, where Caring Theory
next situation. and models of human caring are used to
Selected use of caringhealing modalities transform nursing and health care for staff
for self and patients, for example, mas- and patients alike.
sage, therapeutic touch, reflexology, The names of other health care national and
aromatherapy, calmative oil of essences; international clinical and educational systems
sound, music, arts, variety of energetic incorporating Caring Theory into professional
modalities nursing practice models (many hospitals are
Dimming the unit lights and having desig- Magnet hospitals or preparing to become
nated quiet time for patients/families/staff Magnet hospitals) can be found on the follow-
alike, to soften, slow down, and calm the ing Web sites: www.watsoncaringscience.org;
environment. www.nursing.ucdenver.edu/caring
Creating healing spaces for nurses; These identified system examples are
sanctuaries for their own time out; may exemplars of the changing momentum today,
include meditation or relaxation rooms and are guided by a shift toward an evolved
for quiet time consciousness. They rely on moral, ethical,
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362 S E C T I O N V Caring Theories

philosophical, and theoretical foundations Such a values guided relational ontology


to restore human caring and healing and and expanded epistemology and ethic is
health in a system that has gone astray embodied in Caring Science as the discipli-
educationally, economically, clinically, and nary ground for nursing, now and the future.
socially. This shift is in a hopeful direction, The advancement of nursing theory, which
and is based on a grass roots transformation of includes both ideals and practical guidance, is
nursing, one that is from the inside out. The increasingly evident as nursing makes its
dedicated leaders who are ushering in these major contribution to health care and matures
changes serve as an inspiration for sustaining as a distinct caringhealing professionone
nursing and human caring for practitioners that balances and complements conventional,
and patients alike. medicalinstitutional practices and processes.
Nevertheless, much work remains to be done.
Conclusion New transformative, human-spiritinspired
Consistent with the wisdom and vision of approaches are required to reverse institution-
Florence Nightingale, nursing is a lifetime al and system lethargy and darkness. To create
journey of caring and healing, seeking to the necessary cultural change, the human
understand and preserve the wholeness spirit has to be invited back into our health
of human existence across time and space care systems. Professional and personal mod-
and national/geographic boundaries, to offer els are required that open the hearts of nurses
heart-centered compassionate, informed knowl- and other practitioners. New horizons of pos-
edgeable human caring to society and sibilities have to be explored to create space
humankind. This timeless view of nursing whereby compassionate, intentional, heart-
transcends conventional minds and mindsets centered human caring can be practiced. Such
of illness, pathology, and disease that are authentic personal/professional practice mod-
located in the body physical with curing els of Caring Science are capable of leading us,
as end, often at all costs. In nursings timeless locally and globally, toward a moral commu-
model, caring, kindness, love, and heart-centered nity of caring. This community will restore
compassionate service to humankind are healing and health at a level that honors and
restored. The unifying focus and process is on sustains the dignity and humanity of practi-
connectedness with self, other, nature, and tioners and patients alike.
God/the Life Force/the Absolute. This vision The Watson Caring Science Institute is
and wisdom is being reignited today through dedicated to create, conduct, and sponsor
a blend of old and new values, ethics, and Caring Science/Caritas education, training,
theories and practices of human caring and and support to serve the current and future
healing. These Caritas Consciousness prac- generations of health care professionals glob-
tices preserve humanity and human dignity ally (www.watsoncaringscience.org
and wholeness, and are the very foundation WCSI, 4405 Arapahoe Avenue, Suite 100,
of transformed thinking and actions. Boulder, CO 80303).

Practice Exemplar
Transpersonal Caring Theory and the caring 1996, p. 160). This is an exemplar of the
model can be read, taught, learned about, Transpersonal Caring Theory in action.
studied, researched and even practiced: howev- October 2002 presented the opportunity
er, to truly get it, one has to personally experi- for 17 interdisciplinary health-care profes-
ence itinteract and grow within the philoso- sionals at The Childrens Hospital in Denver,
phy and intention of the model (Watson, Colorado, to participate in a pilot study
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C H A P T E R 2 0 Jean Watsons Theory of Human Caring 363

designed to: (1) explore the effect of integrat- (Watson, 1996). Gadow (1995) describes nurs-
ing Caring Theory into comprehensive pedi- ing as a lived world of interdependency and
atric pain management and (2) examine the shared knowledge, rather than as a service pro-
Attending Nurse Caring Model (ANCM) as vided. Caring praxis within this lived world is a
a care delivery model for hospitalized chil- praxis that offers a combination of action and
dren in pain. A 3-day retreat launched the reflection . . . praxis is about a relationship with
pilot study. Participants were invited to self, and a relationship with the wider commu-
explore Transpersonal Human Caring Theory nity (Penny & Warelow, 1999, p. 260). Caring
(Caring Theory), as taught and modeled by praxis, therefore, is collaborative praxis.
Dr. Jean Watson, through experiential inter- Collaboration and co-creation are key ele-
actions with caringhealing modalities. The ments in our endeavors to translate Caring
end of the retreat opened opportunities for Theory into practice. They reveal the nonlin-
participants to merge Caring Theory and pain ear process and relational aspect of caring
theory into an emerging caring-healing praxis. praxis. Both require openness to unknown
Returning from the retreat to the preexist- possibilities, honor the unique contributions
ing schedules, customs, and habits of hospital of self and other(s), and acknowledge growth
routine was both daunting and exciting. We and transformation as inherent to life experi-
had lived Caring Theory, and not as a remote ence. These key elements support the evolu-
and abstract philosophical ideal; rather, we tion of praxis away from predetermined
had experienced caring as the very core of our goals and set outcomes toward authentic
true selves, and it was the call that led us into caringhealing expressions. Through collabo-
the health care professions. Invigorated by ration and co-creation, we can build on existing
the retreat, we returned to our 37-bed acute foundations to nurture evolution from what is
care inpatient pediatric unit, eager to apply to what can be.
Caring Theory to improve pediatric pain Our mission, to translate Caring Theory
management. Our experiences throughout into praxis, has strong foundational support.
the retreat had accentuated caring as our core Building on this supportive base, we have
value. Caring Theory could not be restricted committed our intentions and energies
to a single area of practice. toward creating a caring culture. The follow-
Wheeler and Chinn (1991) define praxis ing is not intended as an algorithm to guide
as values made visible through deliberate one through varied steps until caring is
action (p. 2). This definition unites the ontol- achieved but is rather a description of our
ogy or the essence of nursing to nursing ongoing processes and growth toward an
actions, to what nurses do. Nursing within ever-evolving caring praxis. These processes
acute care inpatient hospital settings is prac- are co-creations that emerged from collabora-
ticed dependently, collaboratively, and inde- tion with other ANCM participants, fellow
pendently (Bernardo, 1998). Bernardo describes health professionals, patients and families,
dependent practice as energy directed by and our environment, and our caring intentions.
requiring physician orders, collaborative prac-
tice as interdependent energy directed toward
activities with other health care professionals,
First Steps
and independent practice as where the mean- One of our first challenges was to make the
ingful role and impact of nursing may evolve ANCM visible. Six tangible exhibits have
(p. 43). Our vision of nursing practice was been displayed on the unit as evidence of our
based in the caring paradigm of deep respect commitment to caring values. First, a large,
for humanity and all life, of wonder and awe of colorful poster titled CARING is posi-
lifes mystery, and the interconnectedness from tioned at the entrance to our unit. Depicting
mindbodyspirit unity into cosmic oneness pictures of diverse families at the center, the
Continued
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364 S E C T I O N V Caring Theories

Practice Exemplar cont.


poster states our three initial goals for theory- Fifth, a booklet has been written and pub-
guided practice: (1) create caringhealing lished to welcome families and patients to
environments, (2) optimize pain management our unit, to introduce health team members,
through pharmacological and caringhealing unit routines, available activities, and define
measures, and (3) prepare children and fami- frequently used medical terms. This book
lies for procedures and interventions. Watsons emphasizes that patients, parents, and families
clinical caritas processes are listed, as well as are members of the health team. A description
an abbreviated version of her guidelines for of our caring attending team is also included.
cultivating caringhealing throughout the day Sixth and most recently, the unit chaplain,
(Watson, 2002). This poster, written in Car- child-life specialist, and social worker have
ing Theory language, expresses our intention organized a weekly support session called
to all and reminds us that caring is the core of Goodies and Gathering, offered every
our praxis. Thursday morning. It is held in our healing
Second, a shallow bowl of smooth, rounded rooma conference room painted to resem-
river stones is located in a prominent position ble a cozy room with a beautiful outdoor view
at each nursing desk. A sign posted by and redecorated with comfortable armchairs,
the stones identify them as CaringHealing soft lighting, and plants. Goodies and Gath-
Touch Stones inviting one to select a stone as ering extends a safe retreat within the hospi-
every human being has the ability to share tal setting. Offering one hour to parents and
their incredible gift of lovinghealing. These another to staff, these professionals provide
stones serve as a reminder of our capacity to snacks to feed the body, a sacred space to
love and heal. Pick up a stone, feel its smooth nourish emotions, and their caring presence
cool surface, let its weight remind you of your to nurture the spirit.
own gifts of love and healing. Share in the love
and healing of all who have touched this stone Attending Caring Team (ACT)
before you and pass on your love and healing To honor the collaborative partnership of our
to all who will hold this stone after you. ANCM participants, to include patients and
Third, latched wicker blessing baskets families as equal partners in the health care
have been placed adjacent to the caring team, and open participations to all, we have
healing touch stones. Written instructions adopted the name Attending Caring Team
invite families, visitors, and staff to offer (ACT). The acronym ACT reinforces that
names for a blessing by writing the persons our actions are opportunities to make caring
initials on a slip of paper and placing the visible. Care as the core of praxis differs from
paper in the basket. Every Monday through the centrality of cure in the medical model.
Friday, the unit chaplain, holistic clinical To describe our intentions to others we com-
nurse specialist (CNS), and interested staff piled the following elevator description of
devote thirty minutes of meditative silence ACT, a terse, thirty-second summary that
within a healing space to ask for peace and renders the meaning of ACT in the time
hope for all names contained within the frame of a shared elevator ride:
baskets. The core of the Attending Caring Team
Fourth, signs picturing a snoozing cartoon- (ACT) is caring-healing for patients, families
styled tiger have been posted on each patients and ourselves. ACT co-creates relationships
door announcing Quiet Time. Quiet time and collaborative practices between patients,
is a midday, half-hour pause from hospital families and health care providers. ACT prac-
hustle-bustle. Lights in the hall are dimmed, tice enables health care providers to redefine
voices are hushed, and steps are softened to themselves as caregivers rather than taskmas-
allow a pause for reflection. Staff tries not to ters. We provide Health Care not Health
enter patient rooms unless summoned. Tasks.
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C H A P T E R 2 0 Jean Watsons Theory of Human Caring 365

Large signs have been professionally pro- personal healing and support self-growth.
duced and are hung at various locations on The unit on pain management has been
our unit. These signs serve a dual purpose. expanded to include use of caringhealing
The largest, posted conspicuously at our modalities. A new interactive session on the
threshold, identifies our unit as the home of caritas processes has been added that asks
the Attending Caring Team. Smaller signs, participants to reflect on how these processes
posted at each nurses station, spell out the are already evident in their praxis and to
above ACT definition, inviting everyone explore ways they can deepen caring praxis
entering our unit to participate in the collab- both individually and collectively as a unit.
orative co-creation of caringhealing. The tracking tool used to assess a new
Giving ourselves a name and making our employees progress through orientation now
caring intentions visible contribute to estab- includes an area for reflection on growing in
lishing an identity, yet may be perceived as caring competencies. In addition to changes
peripheral activities. For these expressions in phase classes, informal clock hours are
to be deliberate actions of praxis, the central- offered monthly. Clock hours are designed to
ity of caring as our core value was clearly respond to the immediate needs of the unit
articulated. Caring Theory is the flexible and encompass a diverse range of topics, from
framework guiding our unit goals and unit conflict resolution, debriefing after specific
education and has been integrated into our events, and professional development, to
implementation of an institutional customer health treatment plans, physiology of medical
service initiative. diagnosis, and in-services on new technolo-
Unit goals are written yearly. Reflective of gies and pharmacological interventions.
the broader institutional mission statement, Offered on the unit at varying hours to
each unit is encouraged to develop a mission accommodate all work shifts, clock hours
statement and outline goals designed to provide a way for staff members to fulfill con-
achieve that mission. In 2003, our mission tinuing educational requirements during
statement was rewritten to focus on provision work days.
of quality family-centered care, defined as an
environment of caring-healing recognizing Customer Service
families as equal partners in collaboration Caring Theory has provided depth to an insti-
with all health care providers. One of the tutional initiative to use FISH philosophy to
goals to achieve this mission literally spells enhance customer service (Lundin, Paul, &
out caring. We promote a caring-healing Christensen, 2000). Imported from Pikes
environment for patients, families, and staff Fish Market in Seattle, FISH advocates four
through: premises to improve employee and customer
Compassion, competence, commitment satisfaction: presence, make their day, play,
Advocacy and choose your attitude. Briefly summarized,
Respect, research FISH advocates that when employees bring
Individuality their full awareness through presence, focus
Nurturing on customers to make their day, invoke fun
Generosity into the day through appropriate play, and
through conscious awareness choose their
Education attitude, work environments improve for all.
Unit educational offerings have also been When the four FISH premises are viewed
revised to reflect Caring Theory. Phase classes, from the perspective of transpersonal caring,
a 2-year curriculum of serial seminars they become opportunities for authentic
designed to support new hires in their clini- human-to-human connectedness through
cal, educational, and professional growth, IThou relationships. The merger of Caring
now include a unit on self-care to promote Theory with FISH philosophy has inspired

Continued
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366 S E C T I O N V Caring Theories

Practice Exemplar cont.


the following activities. A parade composed of Building practice on caring relationships has
patients, their families, nurses, and volunteers led to an increase in both the type and volume
complete with marching music, hats, stream- of care conferences held on our unit. Previ-
ers, flags, and noise makersis celebrated two ously, care conferences were called as a way to
to three times a week just before the playroom disseminate information to families when
closes for lunch. This flamboyant display lasts complicated issues arose or when communi-
less than five minutes but invigorates partici- cation between multiple teams faltered and
pants and bystanders alike. In addition to families were receiving conflicting reports,
being vital for children and especially appro- plans, and instructions. Now, these confer-
priate in a pediatric setting, play unites us all in ences are offered proactively as a way to coor-
the life and joy of each moment. When our dinate team efforts and to ensure we are
parade marches, visitors, rounding doctors, all working toward the families goals. Transi-
present on the unit pause to watch, wave, and tional conferences provide an opportunity to
cheer us on. A weekly bedtime story is read in coordinate continuity of care, share insight
our healing room. Patients are invited to bring into the unique personality and preferences of
their pillows and favorite stuffed animal or doll the child, coordinate team effort, meet fami-
and come dressed in pajamas. Night- and day- lies, provide them with tours of our unit, and
shift staff have honored one another with sur- collaborate with families. Other caringheal-
prise beginning-of-the-shift meals, staying ing arts offered on our unit are therapeutic
late to care for patients and families, and refus- touch, guided imagery, relaxation, visualiza-
ing to give off-going report until their on- tion, aromatherapy, and massage. As ACT
coming co-workers had eaten. Colorful caring participants, our challenge is to express our
stickers are awarded when one staff member caring values through every activity and inter-
catches another in the ACT of caring, being action. Caring Theory guides us and mani-
present, making anothers day, playing, and fests in innumerable ways. Our interview
choosing a positive attitude. process, meeting format, and Clinical Nurse
Specialist (CNS) role have been transfigured
ACT Guidelines through Caring Theory. Our interview
Placing Caring Theory at the core of our process has transformed from an interrogative
praxis supports practicing caringhealing arts three-step procedure into more of a sharing
to promote wholeness, comfort, harmony, and dialogue. We are adopting another meeting
inner healing. The intentional conscious pres- style that expresses caring values.
ence of our authentic being to provide a Our unit director had the foresight to
caringhealing environment is the most budget a position for a CNS to support the
essential of these arts. Presence as the founda- co-creation of caring praxis. The traditional
tion for co-creating caring relationships has CNS rolesresearcher, clinical expert, collab-
led to writing ACT guidelines. Written in the orator, educator, and change agenthave
doctor order section of the chart, ACT guide- allowed the integration of Caring Theory
lines provide a formal way to honor unique development into all aspects of our unit pro-
families values and beliefs. Preferred ways of gram. The CNS role advocates self-care and
having dressing changes performed, most facilitates staff members to incorporate caring-
helpful comfort measures, home schedules, healing arts into their practice through model-
and special needs or requests are examples of ing and hands-on support. In addition to pro-
what these guidelines might address. ACT viding assistance, searching for resources, acting
members purposefully use the word guide- as liaison with other health care teams, and
line as opposed to order as more congruent promoting staff in their efforts, the very pres-
with co-creative collaborate praxis and to ence of the CNS on the unit reinforces our
encourage critical thinking and flexibility. commitment to caring praxis.
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C H A P T E R 2 0 Jean Watsons Theory of Human Caring 367

Summary tasks and skills. Building relationships for


Caringhealing co-creation is fluid, not supportive collaborative practice is the most
static. More than 100 years ago, Florence exciting and most challenging endeavor we
Nightingale wrote, I entirely repudiate the are now facing as old roles are reevaluated in
distinction usually drawn between the man light of co-creating caring-healing relation-
of thought and the man of action (Vivinus ships. Watson and Foster (2003) describe
& Nergaard, 1990, p. 310). Nightingale the potential of such collaboration: The
rejected the separation of the ideal (theory) new caring-healing practice environment
from action (practice). For Nightingale, is increasingly dependent on partnerships,
nursing is not a profession or a job one per- negotiation, coordination, new forms of
forms, but rather is a calling. Dedicating her communication pattern and authentic rela-
life toward achieving the ideal, she chal- tionships. The new emphasis is on a change
lenged others to let the Ideal go if you are of consciousness, a focused intentionality
not trying to incorporate it in your daily towards caring and healing relationships
life (Vivinus & Nergaard, 1990, p. 310). and modalities, a shift towards a spiritual-
We continue to work toward incorporating ization of health vs. a limited medicalized
caring ideals in every action. Currently, we view (p. 361). Our ACT commitment is to
are modifying our competency-based guide- authentic relationships and the creation of
lines to emphasize caring competency within caringhealing environments.

Summary
Nursings future and nursing in the future and processes and the spiritual dimensions
will depend on nursing maturing as the dis- of care much more completely.
tinct health, healing, and caring profession Thus, nursing is at its own crossroad of pos-
that it has always represented across time sibilities, between worldviews and paradigms.
but has yet to fully actualize. Nursing thus Nursing has entered a new era; it is invited and
ironically is now challenged to stand and required to build upon its heritage and latest
mature within its own Caring Science para- evolution in science and technology but must
digm, while simultaneously having to tran- transcend itself for a postmodern future yet to
scend it and share with others. The future be known. However, nursings future holds
already reveals that all health care practi- promises of caring and healing mysteries and
tioners will need to work within a shared models yet to unfold, as opportunities for
framework of caringhealing relationships offering compassionate caritas services at indi-
and humanenvironmental energetic field vidual, system, societal, national, and global
modalities. Practitioners of the future pay levels for self, for profession, and for the
attention to consciousness, intentionality, broader world community. Nursing has a criti-
energetic human presence, transformed cal role to play in sustaining caring in human-
mindbodyspirit medicine, and will need ity and making new connections between car-
to embrace healing arts and caring practices ing, love, healing, and peace in the world.

References

Bernardo, A. (1998). Technology and true presence in Lundin, S. C., Paul, H., & Christensen, J. (2000). Fish!
nursing. Holistic Nursing Practice, 12(4), 4049. A remarkable way to boost morale and improve results.
Gadow, S. (1995). Narrative and exploration: Toward a New York: Hyperion.
poetics of knowledge in nursing. Nursing Inquiry, Penny, W., & Warelow, P. J. (1999). Understanding the
2, 211214. prattle of praxis. Nursing Inquiry, 6(4), 259268.
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Persky, G., Nelson, J.W., Watson, J., & Bent, K. (2008). Watson, J. (1999). Postmodern nursing and beyond.
Profile of a nurse effective in caring. Nursing New York: Churchill Livingstone.
Administration Quarterly, 32(1), 1520. Watson, J. (2001). Post-hospital nursing: Shortage,
Rosenberg, S. (2006). Utilizing the language of Jean shifts and scripts. Nursing Administration Quarterly,
Watsons Caring Theory within a computerized 25(3), 7782.
documentation system. CIN: Computers, Informatics, Watson, J. (2002). Intentionality and caring-healing
Nursing, 24(1), 5356. consciousness: A practice of transpersonal nursing.
Swanson, K. M. (1991). Empirical development of a Holistic Nursing Practice, 16(4), 1219.
middle range nursing theory. Nursing Research, Watson, J. (2003). Assessing and measuring caring in
40(3), 161166. nursing and health sciences. New York: Springer.
Vivinus, M., & Nergaard, B. (1990). Ever yours, Florence Watson, J. (2005). Caring science as sacred science.
Nightingale. Cambridge, MA: Harvard University Philadelphia: F. A. Davis.
Press. Watson, J. (2008a). Nursing: The philosophy and science of
Watson, J. (1979). Nursing. The philosophy and science of caring (rev. 2nd ed. with Caritas Meditation CD).
caring. Boston: Little Brown. Reprinted. (1985) Boulder, CO: University Press of Colorado; www.
Boulder, CO: University Press of Colorado. upcolorado.com
Watson, J. (1985). Nursing: Human science and human Watson, J. (2008b). Assessing and measuring caring in nurs-
care. Norwalk, CT: Appleton Century. Reprinted ing and health sciences (2nd ed.). New York: Springer.
(1988, 1999, 2008) New York: National League Watson, J., & Foster, R. (2003). The Attending Nurse
for Nursing Press; Sudbury, MA: Jones and Caring Model: Integrating theory, evidence and
Bartlett. advanced caring-healing therapeutics for transform-
Watson, J. (1996). Watsons theory of transpersonal ing professional practice. Journal of Clinical Nursing,
caring. In: P. H. Walker & B. Newman (Eds.), 12, 360365.
Blueprint for use of nursing models: Education, research, Wheeler, C. E., & Chinn, P. L. (1991). Peace and power:
practice and administration. New York: National A handbook of feminist process (3rd ed.). New York:
League for Nursing Press. National League for Nursing Press.

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www.nursing.ucdenver.edu/caring and/or www. ( Japanese translation), Translated into Portuguese.
watsoncaringscience.org Edinburgh: Churchill Livingstone/W. B. Saunders/
Elsevier.
Publications/Audiovisuals Watson, J. (2002). Instruments for assessing and measuring
Bevis, E. O., & Watson, J. (1989). Toward a caring cur-
caring in nursing and health sciences. New York:
riculum. A new pedagogy for nursing (reprinted 2000).
Springer. (American Journal of Nursing Book of the
Sudbury, MA: Jones and Bartlett.
Year Award, 2002. Japanese translation 2003.)
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Revised 2nd edition. 2008.
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Philadelphia: F. A. Davis. (American Journal of
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Nursing Book of the Year award).
imperative in education. New York: National League
Watson, J., & Ray, M. (Eds.). (1988). The ethics of care
for Nursing Press.
and the ethics of cure: Synthesis in chronicity. New
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York: National League for Nursing Press.
hurt: Human suffering and human caring. Boulder,
CO: Colorado Associated University Press. Journal Articles
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Chinese, Korean, German, Norwegian, and Danish. Alternative Therapies, 9(3), A6579.
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way of non-caring. Australian Journal of Holistic with music by Gary Malkin. In J. Watson (2008).
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source and survival. ICU NURS WEB J 9, 17. www. caring [videotape]. University of Colorado Health
nursing.gr/J.W.editorial.pdf Science Center, School of Nursing, Denver, CO.
Watson, J. (2002). Holistic nursing and caring: A values Contact: ellen.janasko@uchsc.edu.
based approach. Journal of Japan Academy of Nursing Watson, J. (1988). The power of caring: The power to make
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Watson, J. (2002). Intentionality and caring-healing Video, University of Colorado Health Sciences
consciousness: A theory of transpersonal nursing. Center, School of Nursing, Denver, CO. Contact:
Holistic Nursing Journal, 16(4), 1219. ellen.janasko@uchsc.edu.
Watson, J. (2002). Metaphysics of virtual caring communi- Watson, J. (1989). Theories at work [videotape]. New York:
ties. International Journal of Human Caring, 6(1), 4145. National League for Nursing. In conjunction with
Watson, J. (2003). Love and caring: Ethics of face and University of Colorado HSC/SoN Chair in Caring
hand. Nursing Administrative Quarterly, 27(3), 197202. Science. Contact ellen.janasko@uchsc.edu.
Watson, J., & Foster, R. (2003). The attending nurse car- Watson, J. (1994). Applying the art and science of human
ing model: Integrating theory, evidence and advanced caring, Parts I and II [videotape]. New York:
caring-healing therapeutics for transforming profes- National League for Nursing. In conjunction with
sional practice. Journal of Clinical Nursing, 12, 360365. the University of Colorado HSC/SoN, Chair in
Watson, J., & Smith, M. C. (2002). Caring science and Caring Science. Contact: ellen.janasko@uchsc.edu.
the science of unitary human beings: A trans- Watson, J. (1999). A meta-reflection on nursings present
theoretical discourse for nursing knowledge develop- [audiotape]. American Holistic Nurses Association.
ment. Journal of Advanced Nursing, 37(5), 452461. Boulder, CO: SoundsTrue Production.
Watson, J. (1994). A frog, a rock, a ritual: An eco-caring Watson, J. (1999). Private psalms. A mantra and meditation
cosmology. In: E. Schuster & C. Brown (Eds.), for healing [CD]. Music by Dallas Smith and
Caring and environmental connection. New York: Susan Mazer. To obtain: e-mail University of
National League for Nursing Press. Colorado Health Sciences Center Bookstore at
Watson, J. (1996). Artistry and caring: Heart and soul of traci.mathis@uchsc.edu. (All proceeds from bookstore
nursing. In: D. Marks-Maran & M. Rose (Eds.), CDs sales go to support activities of the Murchinson-
Reconstructing nursing: Beyond art & science Scoville Endowed Chair in Caring Science.)
(pp. 5463). London: Baillire Tindall. Watson, J. (2001). Creating a culture of caring [audiotape].
Watson, J. (1996). Poeticizing as truth on nursing At the Creative Healthcare Management 9th Annual
inquiry. In: J. Kikuchi, H. Simmons, & D. Romyn CHCM, Minneapolis, MN.
(Eds.), Truth in nursing inquiry (pp. 125139). Watson, J. (2000). Importance of story and health care.
Thousand Oaks, CA: Sage. Second National Gathering on Relationship-Centered
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caring. In: P. H. Walker & B. Neuman (Eds.), Watson, J. (2001). Reconnecting with spirit: Caring and
Blueprint for use of nursing models: Education, research, healing our living and dying. International Parish
practice, & administration (pp. 141184). New York: Nursing Conference. Westberg Symposium.
National League for Nursing Press. September, 2001. Allenspark, CO.
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Chapter
21
Anne Boykin and
Savina O. Schoenhofers
Nursing as Caring Theory
A NNE B OYKIN , S AVINA O. S CHOENHOFER ,
AND D ANIELLE L INDEN

Introducing the Theorists Introducing the Theorists


Overview of the Theory Anne Boykin serves as professor and dean of
Applications of the Theory the College of Nursing at Florida Atlantic
Questions Nurses Ask About the Theory University where she has demonstrated a
of Nursing as Caring
long-standing commitment to the Interna-
Practice Exemplar
tional Association for Human Caring, hold-
References
ing the following positions: president-elect
(19901993), president (19931996), and mem-
ber of the nominating committee (19971999).
As immediate past president, she served as
coeditor of the International Journal for Human
Caring from 1996 to 1999.
Her scholarly work centers on caring as
the grounding for nursing as evidenced in
Nursing as Caring: A Model for Transforming
Practice (coauthored with S. O. Schoenhofer,
Anne Boykin Savina O. Schoenhofer
1993), and Living a Caring-based Program
(1994). The latter book illustrates how caring
grounds all aspects of a nursing education pro-
gram. Dr. Boykin has also authored numerous
book chapters and articles. She serves as a
local, regional, national, and international
consultant on the topic of caring.
Dr. Boykin is a graduate of Alverno
College in Milwaukee, Wisconsin. She
received her masters degree from Emory
University in Atlanta, Georgia and her
doctorate from Vanderbilt University in
Nashville, Tennessee.
Savina Schoenhofer initially studied nurs-
ing at Wichita State University, where she
earned undergraduate and graduate degrees in
nursing, psychology, and counseling. She com-
pleted a PhD in educational foundations and
administration at Kansas State University in
1983. In 1990, Dr. Schoenhofer cofounded
Nightingale Songs, an early venue for
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communicating the beauty of nursing in the faculty group revising the caring-based
poetry and prose. In addition to her work on curriculum. When the revised curriculum was
caring, including coauthorship of Nursing As in place, each of us recognized the potential
Caring: A Model for Transforming Practice, and even the necessity of continuing to develop
she has written on nursing values, primary and structure ideas and themes toward a com-
care, nursing education, support, touch, per- prehensive expression of the meaning and
sonnel management in nursing homes, and purpose of nursing as a discipline and a pro-
mentoring. Her career in nursing has been fession. The point of departure was the
significantly influenced by three colleagues: acceptance that caring is the end, rather than
Lt. Col. Ann Ashjian (Ret.), whose commu- the means, of nursing, and that caring is the
nity nursing practice in Brazil presented intention of nursing rather than merely its
an inspiring model of nursing; Marilyn E. instrument. This work led to the statement of
Parker, RN, PhD, a faculty colleague who focus of nursing as nurturing persons living
mentored her in the idea of nursing as a caring and growing in caring. Further work
discipline, the academic role in higher edu- to identify foundational assumptions about
cation, and the world of nursing theories nursing clarified the idea of the nursing situa-
and theorists; and Anne Boykin, PhD, who tion, a shared lived experience in which the
introduced her to caring as a substantive caring between enhances personhood, with
field of nursing study. Schoenhofer created personhood understood as living grounded in
and manages the website and discussion caring. The clarified focus and the idea of the
forum on the theory of nursing as caring nursing situation are the key themes that draw
(www.nursingascaring.com). forth the meaning of the assumptions under-
lying the theory and permit the practical
understanding of nursing as both a discipline
Overview of the Theory and a profession. As critique of the theory and
This chapter provides an overview of the study of nursing situations progressed, the
Theory of Nursing as Caring, a general theory, notion of nursing being primarily concerned
framework, or disciplinary view of nursing. The with health was seen as limiting, and we now
Theory of Nursing as Caring offers a view that understand nursing to be concerned with
permits a broad, encompassing understanding human living.
of any and all situations of nursing practice Three bodies of work significantly influ-
(Boykin & Schoenhofer, 1993). It serves as an enced the initial development of nursing
organizing framework for nursing scholars in as caring. Roachs (1987/2002) basic thesis that
the various roles of practitioner, researcher, caring is the human mode of being was incor-
administrator, teacher, and developer. porated into the most basic assumption of the
We first present the theory in its most theory. We view Paterson and Zderads (1988)
abstract form, addressing assumptions and key existential phenomenological theory of human-
themes. We then discuss the meaning of the istic nursing as the historical antecedent of
theory in relation to practice and other nursing nursing as caring. Seminal ideas such as the
roles. In the second part of this chapter, between, call for nursing, nursing response,
Danielle Linden further describes the theory and personhood served as substantive and
by illustrating its use as a guide to practice. structural bases for our conceptualization of
nursing as caring. Mayeroff s (1971) work, On
Nursing as Caring: Historical Caring, provided a language that facilitated the
Perspective and Current recognition and description of the practical
Development meaning of caring in nursing situations. In
The Theory of Nursing as Caring is an out- addition to the work of these thinkers, both
growth of the curriculum development work authors are long-standing members of the
in the College of Nursing at Florida Atlantic community of nursing scholars whose study
University, where both authors were among focuses on caring and who are supported
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372 S E C T I O N V Caring Theories

and undoubtedly influenced in many subtle Caring


ways by the members of this community and Caring is an altruistic, active expression of
their work. love and is the intentional and embodied
Fledgling forms of the Theory of Nursing recognition of value and connectedness.
as Caring were first published in 1990 Caring is not the unique province of nurs-
and 1991, with the first complete exposition ing; however, as a discipline and a profes-
of the theory presented at a conference in sion, nursing uniquely focuses on caring as
1992 (Boykin & Schoenhofer, 1990, 1991; its central value, its primary interest, and the
Schoenhofer & Boykin, 1993), followed by direct intention of its practice. The full
the publication of Nursing as Caring: A meaning of caring cannot be restricted to a
Model for Transforming Practice in 1993 definition but is illuminated in the experi-
(Boykin & Schoenhofer, 1993), which was ence of caring and in the reflection on that
re-released with an epilogue in 2001 (Boykin experience.
& Schoenhofer, 2001a).
Research and development efforts at the Focus and Intention of Nursing
time of this writing are concentrated on
expanding the language of caring by uncovering Disciplines as identifiable entities or branch-
personal ways of living caring in everyday life es of knowledge grow from the holistic tree
(Schoenhofer, Bingham, & Hutchins, 1998); of knowledge as need and purpose develop.
reconceptualizing nursing outcomes as value A discipline is a community of scholars
experienced in nursing situations (Boykin & (King & Brownell, 1976) with a particular
Schoenhofer, 1997; Schoenhofer & Boykin, perspective on the world and what it means
1998a, 1998b); and in consultation with gradu- to be in the world. The disciplinary com-
ate students, nursing faculties, and health-care munity represents a value system that is
agencies who are using aspects of the theory to expressed in its unique focus on knowledge
ground research, teaching, and practice. and practice.
The focus of nursing, from the perspective
of the Theory of Nursing as Caring, is person
Assumptions and Key Themes as living in caring and growing in caring. The
Certain fundamental beliefs about what it general intention of nursing as a practiced
means to be human underlie the Theory discipline is nurturing persons living caring
of Nursing as Caring. These assumptions, and growing in caring.
which are illustrated later, reflect a particular
set of values and key themes that provide a Nursing Situation
basis for understanding and explicating the
The practice of nursing, and thus the practi-
meaning of nursing, listed as follows and
cal knowledge of nursing, lives in the con-
detailed here:
text of person-with-person caring. The
Persons are caring by virtue of their nursing situation involves particular values,
humanness. intentions, and actions of two or more per-
Persons are whole and complete in the sons choosing to live a nursing relationship.
moment. The nursing situation is understood to mean
Persons live caring from moment to the shared lived experience in which caring
moment. between nurse and nursed enhances person-
Personhood is a way of living grounded in hood. Nursing is created in the caring
caring. between. All knowledge of nursing is created
Personhood is enhanced through participa- and understood within the nursing situation.
tion in nurturing relationships with caring Any single nursing situation has the poten-
others. tial to illuminate the depth and complexity
Nursing is both a discipline and a profession. of nursing knowledge. Nursing situations are
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best communicated through aesthetic media commitment of knowing the other as a car-
to preserve the lived meaning of the situa- ing person, and in that knowing, acknowl-
tion and the openness of the situation as edging, affirming, and celebrating the person
text. Storytelling, poetry, graphic arts, and as caring. The nursing response is a specific
dance are examples of effective modes of expression of caring nurturance to sustain
representing the lived experience and allow- and enhance the other as he or she lives
ing for reflection and creativity in advancing caring and grows in caring in the situation of
understanding. concern. Nursing responses to calls for car-
ing evolve as nurses clarify their understand-
Personhood ings of calls through presence and dialogue.
Personhood is understood to mean living Nursing responses are uniquely created for
grounded in caring. From the perspective of the moment and cannot be predicted or
the Theory of Nursing as Caring, personhood applied as preplanned protocols (Boykin &
is the universal human call. A profound Schoenhofer, 1997). Sensitivity and skill in
understanding of personhood communicates creating unique and effective ways of com-
the paradox of person-as-person and person- municating caring are developed through
in-communion all at once. intention, experience, study, and reflection in a
broad range of human situations.
Call for Nursing
A call for nursing is a call for acknowledg- The Caring Between
ment and affirmation of the person living The caring between is the source and
caring in specific ways in the immediate ground of nursing. It is the loving relation
situation (Boykin & Schoenhofer, 1993, into which nurse and nursed enter and co-
p. 24). Calls for nursing are calls for nurtu- create by living the intention to care. With-
rance through personal expressions of car- out the loving relation of the caring between,
ing. These calls originate within persons unidirectional activity or reciprocal exchange
as they live out caring uniquely, expressing can occur, but nursing in its fullest sense
personally meaningful dreams and aspira- does not occur. It is in the context of the car-
tions for growing in caring. Calls for nursing ing between that personhood is enhanced,
are individually relevant ways of saying, each expressing self and recognizing the oth-
Know me as a caring person in the moment er as a caring person.
and be with me as I try to live fully who
I truly am. Intentionality (Schoenhofer, Lived Meaning of Nursing as Caring
2002a) and authentic presence open the
Abstract presentations of assumptions and
nurse to hearing calls for nursing. Because
themes lay the groundwork and provide an
calls for nursing are unique situated person-
orienting point. However, the lived meaning
al expressions, they cannot be predicted, as
of nursing as caring can best be understood by
in a diagnosis. Nurses develop sensitivity
the study of a nursing situation. The following
and expertise in hearing calls through inten-
poem is one nurses expression of the meaning
tion, experience, study, and reflection in a
of nursing, situated in one particular experi-
broad range of human situations.
ence of nursing and linked to a general con-
Nursing Response ception of nursing.
As an expression of nursing, caring is the I Care for Him
intentional and authentic presence of the My hands are moist,
nurse with another who is recognized My heart is quick,
as living caring and growing in caring My nerves are taut,
(Boykin & Schoenhofer, 1993, p. 25). The Hes in the next room,
nurse enters the nursing situation with the I care for him.
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374 S E C T I O N V Caring Theories

The room is tense, nursed live and grow in their understanding


Its anger-filled, and expressions of caring.
The air seems thick, In the first stanza, the nurse prepares to
Im with him now, enter the nursing relationship with the formed
I care for him. intention of offering caring in authentic pres-
ence. Perhaps he has heard a report that the
Time goes slowly by, person he is about to encounter is a difficult
As our fears subside, patient, and this is a part of his awareness;
I can sense his calm, however, his nursing intention to care reminds
He softens now, him that he and his patient are, above all, car-
I care for him. ing persons. In the second stanza, the nurse
His eyes meet mine, enters the room, experiences the challenge
Unable to speak, that his intention to nurse has presented, and
I feel his trust, responds to the call for authentic presence and
I open my heart, caring: Im with him now/I care for him.
I care for him. Patterns of knowing are called into play as the
nurse brings together intuitive, personal
Its time to leave. knowing, empirical knowing, and the ethical
Our bond is made, knowing that it is right to offer care, creating
Unspoken thoughts, the integrated understanding of aesthetic
But understood, knowing that enables him to act on his nurs-
I care for him! ing intention (Boykin, Parker, & Schoenhofer,
J. M. C OLLINS (1993) 1994; Carper, 1978). Mayeroff s (1971) car-
ing ingredients of courage, trust, and alternat-
Each encountereach nursing experience ing rhythm are clearly evident.
brings with it the unknown. In Collinss reflec- Clarity of the call for nursing emerges as
tions, he shares a story of practice that illu- the nurse begins to understand that this
minates the opportunity to live and grow in particular man in this particular moment is
caring. calling to be known as a uniquely caring per-
In the nursing situation that inspired this son, a person of value, worthy of respect and
poem, the nurse and nursed live caring regard. The nurse listens intently and recog-
uniquely. Initially, the nurse experiences the nizes the unadorned honesty that sounds
familiar human dilemma, aware of separate- angry and demanding but is a personal
ness while choosing connectedness as he expression of a heartfelt desire to be truly
responds to a yet-unknown call for nursing: known and worthy of care. The nurse
My hands are moist/my heart is quick/ responds with steadfast presence and caring,
my nerves are taut . . . I care for him. As he communicated in his way of being and of
enters the situation and encounters the doing. The caring ingredient of hope is drawn
patient as person, he is able to let go of forth as the man softens and the nurse takes
his presumptive knowing of the patient as notice.
angry. The nurse enters with the guiding In the fourth stanza, the caring between
perspective that all persons are caring. This develops, and personhood is enhanced as
allows him to see past the anger-filled room dreams and aspirations for growing in caring
and to be with him (second stanza). As they are realized: His eyes meet mine I open
connect through their humanness, the beauty my heart. In the last stanza, the nursing
and wholeness of other is uncovered and situation is completed in linear time. But each
nurtured. By living caring moment to one, nurse and nursed, goes forward, newly
moment, hope emerges and fear subsides. affirmed and celebrated as caring persons,
Through this experience, both nurse and and the nursing situation continues to be a
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source of inspiration for living caring and surveillance techniques. Still, in our eyes, that
growing in caring. is an insufficient responseit certainly is not
the nursing we advocate. The theory of nurs-
Assumptions in the Context ing as caring calls upon the nurse to reach
of the Nursing Situation deep within a well-developed knowledge base
In Collinss poem, the power of the basic that has been structured using all available
assumption that all persons are caring by patterns of knowing, grounded in the obliga-
virtue of their humanness enabled the nurse tions and intentionality inherent in the com-
to find the courage to live his intentions. The mitment to know persons as caring. These
idea that persons are whole and complete in patterns of knowing may develop knowledge
the moment permits the nurse to accept con- as intuition; scientifically quantifiable data
flicting feelings and to be open to the nursed emerging from research; and related knowl-
as a person, not merely as an entity with edge from a variety of disciplines, ethical
a diagnosis and superficially or normatively beliefs, and many other types of knowing. All
understood behavior. The nurse demonstrated knowledge held by the nurse that may be
an understanding of the assumption that per- relevant to understanding the situation at
sons live caring from moment to moment, hand is drawn forward and integrated as
striving to know self and other as caring in the understanding that guides practice in particu-
moment with a growing repertoire of ways lar nursing situations (aesthetic knowing).
of expressing caring. Personhood, a way of liv- Although the degree of challenge presented
ing grounded in caring that can be enhanced from situation to situation varies, the commit-
in relationship with caring others, comes ment to know self and other as caring persons
through; the nurse is successfully living his is steadfast.
commitment to caring in the face of difficulty The nursing as caring theory, grounded
and in the mutuality and connectedness that in the assumption that all persons are car-
emerged in the situation. The assumption ing, has as its focus a general call to nurture
that nursing is both a discipline and a profes- persons in their unique ways of living caring
sion is affirmed as the nurse draws on a set of and growing as caring persons. The chal-
values and a developed knowledge of nursing lenge for nursing, then, is not to discover
as caring to actively offer his presence in serv- what is missing, weakened, or needed in
ice to the nursed. another, but to come to know the other as a
caring person and to nurture that person in
situation-specific, creative ways and to
Applications of the Theory acknowledge, support, and celebrate the car-
The commitment of the nurse practicing ing that is. We no longer understand nurs-
nursing as caring is to nurture persons living ing as a process in the sense of a complex
caring and growing in caring. This implies sequence of predictable acts resulting in
that the nurse comes to know the other as a some predetermined desirable end product.
caring person in the moment. Difficult to Nursing, we believe, is inherently processu-
care situations are those that demonstrate the al, in the sense that it is always unfolding
extent of knowledge and commitment needed and is guided by intentionality and the
to nurse effectively. An everyday understand- commitment to care.
ing of the meaning of caring is obviously chal- The nurse practicing within the caring
lenged when the nurse is presented with context described here will most often be
someone for whom it is difficult to care. In interfacing with the health care system in two
these extreme (though not unusual) situa- ways: first, communicating nursing so that it
tions, a task-oriented, nondiscipline-based can be understood with clarity and richness;
concept of nursing may be adequate to assure and second, articulating nursing service as a
the completion of certain treatment and unique contribution within the system in
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376 S E C T I O N V Caring Theories

such a way that the system itself grows to and often walks a very precarious tightrope
support nursing. between direct caregivers and corporate
executives. The nurse administrator, whether
Nursing as Caring in Nursing at the executive or managerial level of the
Administration organizational chart, is held accountable for
From the viewpoint of nursing as caring, the customer satisfaction as well as for the
nurse administrator makes decisions through bottom line. Nurses who move up the exec-
a lens in which the focus of nursing is on nur- utive ladder may, on the one hand, be sus-
turing persons as they live caring and grow in pected of disassociating from their nursing
caring. All activities in the practice of nursing colleagues, and, on the other hand, of not
administration are grounded in a concern for being sufficiently cognizant of the harsh
creating, maintaining, and supporting an envi- realities of fiscal constraint. Administrative
ronment in which calls for nursing are heard practice guided by the assumptions and
and nurturing responses are given (Boykin & themes of nursing as caring can enhance elo-
Schoenhofer, 2001b). From this point of view, quence in articulating the connection
the expectation arises that nursing administra- between caregiver and institutional mission:
tors participate in shaping a culture that the person seeking care.
evolves from the values articulated within Nursing practice leaders who recognize
nursing as caring. their care role, indirect as it may be, are in an
Although often perceived to be removed excellent position to act on their committed
from the direct care of the nursed, the nurs- intention to promote caring environments.
ing administrator is intimately involved in Participating in rigorous negotiations for fiscal,
multiple nursing situations simultaneously, material, and human resources and for improve-
hearing calls for nursing and participating in ments in nursing practice calls for special
responses to these calls. As calls for nursing skill on the part of the nurse administrator
are known, one of the unique responses of the skill in recognizing, acknowledging, and
nursing administrator is to enter the world of celebrating the other (e.g., CEO, CFO,
the nursed either directly or indirectly, to nurse manager, or staff nurse) as a caring
understand special calls when they occur, and person. The nurse administrator who under-
to assist in securing the resources needed by stands the caring ingredients (Mayeroff,
each nurse to nurture persons as they live and 1971) recognizes that caring is neither soft
grow in caring (Boykin & Schoenhofer, nor fixed in its expression. A developed
1993). All administrative activities should be understanding of the caring ingredients helps
approached with this goal in mind. Here, the the nurse administrator mobilize the courage
nurse administrator reflects on the obliga- to be honest with self and other, to trust
tions inherent in the role in relation to the patience, and to value alternating rhythm with
nursed. The presiding moral basis for deter- true humility while living a hope-filled com-
mining right action is the belief that all per- mitment to knowing self and other as caring
sons are caring. Frequently, the nurse admin- persons.
istrator may enter the world of the nursed
through the stories of colleagues who are Nursing as Caring in Nursing
assuming another role, such as that of nurse Education
manager. The nursing administrator assists From the perspective of nursing as caring, all
others within the organization to understand structures and activities should reflect the
the focus of nursing and to secure the fundamental assumption that persons are car-
resources necessary to achieve the goals of ing by virtue of their humanness. Other
nursing. assumptions and values reflected in the educa-
The nurse administrator is subject to tion program include knowing the person as
challenges similar to those of the practitioner whole and complete in the moment and living
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caring uniquely; understanding that person- search to discover greater meaning of caring
hood is a way of living grounded in caring as uniquely expressed in nursing. Examples of
and is enhanced through participation in a nursing education program based on values
nurturing relationships with caring others; similar to those of nursing as caring are illus-
and affirming nursing as a discipline and trated in the book Living a Caring-based
profession. Program (Boykin, 1994).
The curriculum, the foundation of the Mentoring students as co-learners and
education program, asserts the focus and creating caring learning environments while
domain of nursing as nurturing persons living concomitantly accepting responsibility for
caring and growing in caring: summative evaluation calls for the integrat-
ed foundation provided by the guiding
The model for organizational design of nursing
intention to know and nurture persons as
education is analogous to the dancing circle.
caring. This intention helps the nurse tran-
Members of the circle include administrators, fac-
scend limiting historical practices while cre-
ulty, colleagues, students, staff, community, and
atively inventing ways to inspire. The
the nursed. What this circle represents is the com-
humility of unknowing, joined with courage
mitment of each dancer to understand and sup-
and hope, helps the nurse educator guide the
port the study of the discipline of nursing. The role
study of nursing as a commitment to know-
of education administrators in the circle, represent-
ing and nurturing persons as caring. Many
ed by deans and department chairpersons is more
nurse educators are struck with the incon-
clearly understood when the origin of the word is
gruity of instilling a commitment to nursing
reflected upon. The term administrator derives
as an opportunity to care through means
from the Latin ad ministrare, to serve (according to
that seem to view the student as an object
Websters, cited in Guralnik, 1976). This definition and view the discipline as a preexisting set of
connotes the idea of rendering service. Administra- operating rules. Nursing education practiced
tors within the circle are by nature of [their] role from the perspective of nursing as caring
obligated to ministering, to securing, and to provid- opens the way for faculty to truly value the
ing resources needed by faculty, students, and discipline and the student.
staff to meet program objectives. Faculty, students,
and administrators dance together in the study of
nursing. Faculty support an environment that val- Questions Nurses Ask About
ues the uniqueness of each person and sustains
each persons unique way of living and growing in
the Theory of Nursing as
caring. This process requires trust, hope, courage, Caring
and patience. Because the purpose of nursing The following presents several common
education is to study the discipline and practice of questionsand responsesthat nurses ask
nursing, the nursed must be in the circle, and the about nursing as caring.
focus of study must be the nursing situation, the
shared lived experience of caring between nurse How Does the Nurse Come to Know
and nursed and all those who participate in the Self and Other as Caring Persons?
dance of caring persons. The community created is
Nursing practice guided by the Theory of
that of persons living caring in the moment and
Nursing as Caring entails living the commit-
growing in personhood, each person valued as
ment to know self and other as living caring in
special and unique. (Boykin & Schoenhofer, 1993,
the moment and growing in caring. Living
pp. 7374)
this commitment requires intention, formal
In teaching nursing as caring, faculty assist study, and reflection on experience. Mayeroff s
students to come to know, appreciate, and cel- (1971) caring ingredients offer a useful starting
ebrate both self and other as caring persons. point for the nurse committed to knowing self
Students, as well as faculty, are in a continual and other as caring persons. These ingredients
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378 S E C T I O N V Caring Theories

include knowing, alternating rhythm, honesty, What About Nursing a Person for
courage, trust, patience, humility, and hope. Whom It Is Difficult to Care?
Roachs (1987/2002) five Cscommitment,
Related to the previous dilemma, this ques-
confidence, conscience, competence, and
tion presents the crucible within which ones
compassionoffer another conceptual frame-
commitment to the assumptions and themes
work that is helpful in providing a language
of nursing as caring is tested to the limit. The
of caring. Coming to know self as caring is
underlying question is, Does the person to be
facilitated by:
nursed deserve or merit my care? Again, as
Trusting in self, freeing self up to become before, the simple answer is yes. All persons
what one can truly become, and valuing are caring, even when not all chosen actions of
self. the person live up to the ideal to which we are
Learning to let go, to transcendto let go all called by virtue of our humanness. In dis-
of problems, difficulties, in order to cussions of hypothetical situations involving
remember the interconnectedness that child molesters, serial killers, and even politi-
enables us to know self and other as living cal figures who have attempted mass destruc-
caring, even in suffering and in seeking tion and racial annihilation, certain ethical
relief from suffering. systems permit and even call for making judg-
Being open and humble enough to experi- ments. However, when such a person presents
ence and know self, to be at home with to the nurse for care, the nursing ethic of car-
ones feelings. ing supersedes all other values. The Theory of
Continuously calling to consciousness that Nursing as Caring asserts that it is only
each person is living caring in the moment through recognizing and responding to the
and that we are each developing uniquely other as a caring person that nursing is creat-
in our personhood. ed and personhood enhanced in that nursing
Taking time to experience our human- situation. This question and the previous one
ness fully; one can only truly understand make it clear that caring is much more than
in another what one can understand in sweetness and light; caring effectively in
self. difficult to care situations is the most chal-
Finding hope in the moment. (Schoenhofer lenging prospect a nurse can face. It is only
& Boykin, 1993, pp. 8586) with sustained intentionality, commitment,
study, and reflection that the nurse is able to
Must I Like My Patients to Nurse offer nursing in these situations. Falling short
Them? in ones commitment does not necessitate
self-deprecation nor does it warrant condem-
The simple answer to this question is yes. To
nation by others, rather, it presents an oppor-
know the other as caring, the nurse must find
tunity to care for self and other and to grow in
some basis for respectful human connection
personhood. Making real the potential of
with the person. Does this mean that the
such an opportunity calls for seeing with clar-
nurse must like everything about the person,
ity, reaffirming commitment, and engaging in
including personal life choices? Perhaps not;
study and reflection, individually and in con-
however, the nurse as nurse is not called upon
cert with caring others.
to judge the other, only to care for the other.
A concern with judging or censuring anoth-
ers actions is a distraction from the real pur-
Is It Impossible to Nurse Someone
pose for nursingthat is, coming to know the Who Is in an Unconscious or Altered
other as caring person, as one with dreams State of Awareness?
and aspirations of growing in caring, and The key point here is the caring between
responding to calls for caring in ways that that is the nursing creation: When nursing a
nurture personhood. person who is unconscious, the nurse lives the
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commitment to know the other as caring How Does the Nursing Process
person. How is that commitment lived? It Fit with this Theory?
requires that all ways of knowing be brought
into action. The nurse must make self as car- Process, as it is understood in the term nursing
ing person available to the one nursed. The process, connotes a systematic and sequential
fullness of the nurse as caring person is called series of steps resulting in a predetermined,
forth. This requires use of Mayeroff s caring specifiable product. Nursing process, as intro-
ingredients: the alternating rhythm of duced into nursing by Orlando (1961), is a lin-
knowing about the other and knowing the ear stepwise decision-making tool based on
other directly through authentic presence and rational analysis of empirical data (known in
attunement; the hope and courage to risk other disciplines as the problem-solving process)
opening self to one who cannot communicate and is a key structural theme of many nursing
verbally; patiently trusting in self to under- theories developed in past decades. Propo-
stand the others mode of living caring in the nents of the theory of nursing as caring view
moment; honest humility as one brings all nursing not as a process with an endpoint, but
that one knows and remains open to learning as an ongoing process, that is, as dynamic and
from the other. The nurse attuned to the oth- unfolding, guided by intentionality, although
er as person might, for example, experience not directed by a pre-envisioned outcome or
the vulnerability of the person who lies product. Nursing responses of care arise in
unconscious from surgical anesthetic or trau- aesthetic knowing, in the creative and evolv-
matic injury. In that vulnerability, the nurse ing patterns of appreciation and understand-
recognizes that the one nursed is living caring ing, and in the context of a shared lived expe-
in humility, hope, and trust. Instead of rience of caring. Instead of preselected and
responding to the vulnerability, merely taking quantifiable outcomes, the value of nursing to
care of the other, the nurse practicing nurs- the nursed and to others is that which is expe-
ing as caring might respond by honoring the rienced as valuable arising in and evolving
others humility, by participating in the others through the caring between of the nursing
hopefulness, and by steadfast trustworthiness. situation. Much of that value is neither meas-
Creating caring in the moment in this situa- urable nor empirically verifiable. That which
tion might come from the nurse resonating is measurable and empirically verifiable is rel-
with past and present experiences of vulnera- evant in the situation, however, and may be
bility. Connected to this form of personal called upon at any time to contribute to and
knowing might be an ethical knowing that through the nurses empirical knowing. Infor-
power as a reciprocal of vulnerability has the mation that the nurse has available becomes
potential to develop undesirable status differ- knowledge within the nursing situation.
ential in the nursepatient role relationship. Knowing the person directly is what guides
As the nurse sifts through a myriad of empir- the selection and patterning of relevant points
ical data, the most significant information of factual information in a nursing situation.
emergesthis is a person with whom I am That is, any fact or set of facts from nursing
called to care. Ethical knowing again merges research or related bodies of information can
with other pathways as the nurse forms the be considered for relevance and drawn into
decision to go beyond vulnerability and the supporting knowledge base. This knowl-
engage the other as caring person, rather edge base remains open and evolving as the
than as helpless object of anothers concern. nurse employs an alternating rhythm of scan-
Aesthetic knowing comes in the praxis of car- ning and considering facts for relevance while
ing, in living chosen ways of honoring humil- remaining grounded in the nursing situation
ity, joining in hope, and demonstrating trust- (Schoenhofer & Boykin, 1993, pp. 8990).
worthiness in the moment (Schoenhofer & In addition to empirical knowing, knowing
Boykin, 1993, pp. 8687). for nursing purposes also requires personal
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380 S E C T I O N V Caring Theories

knowing, including intuition and ethical know- proposing his model of machine technologies
ing, all converging in aesthetic knowing with- and caring in nursing, Locsin (1995, 2001)
in each unique nursing situation. distinguishes between mere technological
competence and technological competence as
How Practical Is This Theory in the an intentional expression of caring in nursing.
Real World of Nursing? Simply avowing an intention to care is not
Nurses are frequently heard to say they have sufficient. The committed intention to care is
no time for caring, given the demands of the supported by serious study of caring and
role. All nursing roles are lived out in the con- ongoing reflection. As Locsin (1995, p. 203)
text of a contemporary environment. At the so aptly states:
beginning of the twenty-first century, the
[A]s people seriously involved in giving care know,
environment for practice, administration, edu-
there are various ways of expressing caring. Profes-
cation, and research is fraught with many chal-
sional nurses will continue to find meaning in their
lenges, such as
technological caring competencies, expressed
Technological advancement and prolifera- intentionally and authentically, to know another as
tion that can promote routinization and a whole person. Through the harmonious coexis-
depersonalization on the part of the care- tence of machine technology and caring technolo-
giver as well as the one seeking care gy the practice of nursing is transformed into an
Demands for immediate and measurable experience of caring.
outcomes that favor a focus on the simplis-
The practicality of the theory of nursing as
tic and the superficial
caring has been tested in various nursing
Organizational and occupational configura-
practice settings. Nursing practice models
tions that tend to promote fragmentation
have been developed in acute and long-term
and alienation
care settings. Research studies focused on
Economic focus and profit motive (time is
designing, implementing, and evaluating a
money) as the apparent prime institutional
theory-based practice model using nursing as
value
caring on a telemetry unit of a for-profit hos-
Nurses express frustration when evaluating pital and in the emergency department of a
their own caring efforts against an idealized, community hospital demonstrated that when
rule-driven conception of caring. Practice nursing practice is intentionally focused on
guided by the theory of nursing as caring coming to know a person as caring and on
reflects the assumption that caring is created nurturing and supporting those nursed as they
from moment to moment and does not live their caring, transformation of care
demand idealized patterns of caring. Caring occurs. Within this new model, those nursed
in the moment (and moment to moment) could articulate the experience of being cared
occurs when the nurse is living a committed for; patient and nurse satisfaction increased
intention to know and nurture the other as dramatically; retention increased; and the
caring person (Boykin & Schoenhofer, 2000). environment for care became grounded in the
No predetermined ideal amount of time or values of and respect for person (Boykin,
form of dialogue is prescribed. A simple Schoenhofer, Smith, St. Jean, & Aleman, 2003;
example of living this intention to care is the Boykin, Bulfin, Baldwin, & Southern, 2004;
nurse who goes to the IV or the monitor Boykin, Schoenhofer, Bulfin, Baldwin, &
through the person, rather than going directly McCarthy, 2005).
to the technology and failing to acknowledge Current research is focused on transforming
the person. When the nurse goes through an entire for-profit health care organization by
the person, it becomes clear that the use of intentionally grounding it in Nursing as Car-
technology is one way the nurse expresses ing. Caring from the hearta model for
caring for the person (Schoenhofer, 2001). In interdisciplinary practice in a long-term care
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facility and based on the theory of nursing as Strews, & Brown, 2003). The major building
caringwas designed through collaboration blocks of the nursing models for an acute care
between project personnel and all stakehold- hospital and for a long-term care facility each
ers. Foundational values of respect and com- reflect central themes of nursing as caring, but
ing to know grounded the model, which those themes are drawn out in ways unique to
revolves around the major themes of respond- the setting and to the persons involved in each
ing to that which matters; caring as a way of setting. The differences and similarities in
expressing spiritual commitment; devotion these two practice models demonstrate the
inspired by love for others; commitment to power of nursing as caring to transform prac-
creating a home environment; and coming to tice in a way that reflects unity without con-
know and respect person as person (Touhy, formity, uniqueness within oneness.

Practice Exemplar
The application of nursing as caring in my situation, serving as a framework in my
practice has been fulfilling both professionally patient encounters. I walk in the room with
and personally. I have been invited to share the intent of coming to know other as a holis-
this experience. tic being with a body, mind, and spirit. The
Nursing as caring requires the nurse to use call for nursing then begins to unfold and
many different ways of knowing to come to reveals itself to me. My presence with other is
know other in the fullness of ones existence. authentic, and there exists a genuine respon-
Each domain contains a vast amount of siveness to come to know other. Authentic
knowledge. The nurse must be knowledgeable presence allows one to know that which is not
of each and artfully apply this knowledge in spoken. A person can speak ones mind. A
an effort to transcend the physical boundaries physical assessment can reveal an ailment.
of the human body to come to know others The spirit, however, must be attended to as
complex existence. Personally, this effort is well. Everything is revealed in ones spirit.
rewarded by enhancing who I am as a person. When you are in authentic presence with
As an advanced registered nurse practi- other, the call for nursing unfolds before you.
tioner (ARNP) in family practice, I see These are the profound encounters that never
patients in a primary care setting. Grounded leave you.
in nursing as caring, I borrow knowledge Then there are the more frequent encoun-
from other disciplines such as pathophysiolo- ters where reflection becomes a useful tool to
gy, microbiology, pharmacology, and philoso- uncover the deeper meaning behind these
phy and use this knowledge to come to know chance nursing situations. Sometimes the
other in each moment of our visit. Some patients call for nursing is physical. I recognize
patients have immediate acute needs. Others it and treat accordingly. Reflection allows me
have chronic problems that require mainte- to answer these questions: Was I nursing?
nance therapy. All of them need to be recog- What did I do differently from another
nized as holistic and complex humans with a health-care provider? My answer is the per-
unique existence in this world, living in car- spective from which I practice. I walked into
ing and growing in caring. I am a facilitator of the room with the willingness to come to
this process and risk entering into anothers know other, whatever may have been revealed
world with the intent of living caring in that in that moment. It was the way I touched the
nursing situation. patient, my tone of voice, my unhurried pace,
In practice, I emphasize wellness and pre- and my smileall the tools I use to convey
vention. Nursing as caring guides the nursing to other that I am there and that I care. The
Continued
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382 S E C T I O N V Caring Theories

Practice Exemplar cont.


goal is to enhance other as he or she lives wanted to share with me a precious gift the
and grows in caring. Lord had given herher voice. There, in the
I take time regularly to reflect upon the office, I sat with her labs in my lap as she ser-
profound and not-so-profound nursing situa- enaded me with a song. I dont remember the
tions in my life. Reflection uncovers those name of the song, but the verse told me Jesus
hidden meanings that are not readily appar- was calling her home and she was not afraid.
ent in the moment. It is also a time for self- When she was done, we discussed the find-
growth and validationa process of coming ings. I advised her that although the blood test
to know self and others as caring persons. was not diagnostic, the possibility of cancer did
Another form of reflection is the sharing exist and she needed to see an oncological
of nursing situations with others. There are gynecologist. She cried and we hugged.
many different ways one can present a nurs- After a month of invasive testing at the
ing situation, such as case presentations, familys prompting, exploratory surgery and
poems, projects, and various other art forms. biopsies confirmed the diagnosis of ovarian
When one shares a nursing situation with cancer with extensive metastasis. The patient
others, new possibilities for knowing other underwent a total abdominal hysterectomy
unfold exponentially. Each practitioner and bilateral salpingo-oophorectomy with
brings the wealth of his or her education and debulking, and she died shortly thereafter.
experiences. New revelations come to life. There is much one can learn from a case
I share with you here a nursing situation I presentation such as this one, but it does not
encountered. First, I will present it in the tra- reflect the essence of what occurred between
ditional medical model, and then I will pres- the nurse and the one nursed. The reader is
ent the same story in a nursing perspective left wondering what the nurse did that
grounded in the nursing as caring theory. prompted such a special present in return.
Through comparison, the lived experience of
both of these models will make clearer the Nursing as Caring Perspective
difference between practice perspectives. As the morning rolled along, I began to
dream. I dreamed I was a tree. My roots
Medical Model Perspective entwined deep within the foundation upon
E. S. was a 76-year-old white woman who which I stood. I took from the Earth what
came to the office with the complaint of a I needed to nourish and strengthen me. My
lump in her abdomen. She remarked that she roots drank from the spring of knowledge
did not like going to the doctor and had neg- beneath me. I felt strong. I grew tall. My arms
lected to have any checkups in quite a few outstretched, reached for the sun, found the
years. A comprehensive history and physical sky, and in it, a gentle breeze that surrounded
exam was unremarkable with the exception of and calmed me. I stood in awe of the suns
her abdomen, which revealed a small, palpa- beauty as its rays poured over me and warmed
ble, nontender mass in the right lower quad- my spirit. I felt connected. I felt whole.
rant. I ordered blood tests, all of which were I saw a glow on the horizon, unlike the sun
unremarkable with the exception of the and different from the moon and stars. An
Ca125, which was 625, well above normal ember, the residue of a fire that had burned
parameters. My suspicion for ovarian cancer through the night, tirelessly, provided
was confirmed. warmth. I was drawn to it. Unafraid that my
Three days after our initial visit, I asked her branches might catch fire and burn, I reached
to return to the office so we could discuss the for her abdomen. I searched. As my hands
results. She did so, and brought a gift. She said pressed on, I began to feel the Earth slipping
I had done so much for her in our visit, she from the sky. I reached upward, grasping for
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the restoration of harmonious interconnect- that reverberates beyond the room, city, state,
edness, but in the sky, there is nothing to grab country, world, and galaxy. It brings with it
onto. You may grow into it, enjoy its beauty, the wisdom of the universe.
bask in its breezes, and breathe in its life- The first three basic assumptions inherent
giving oxygen, but you cannot hold on to it or in nursing as caring facilitate the lived experi-
possess it. ence of authentic presence in this moment.
My arms grew weary, my leaves were wilt- The assumption that this person is a caring
ed, so I drank from the spring beneath my person by virtue of her humanness, complete
foundation. My roots nourished me with in that moment, gave me the courage to enter
courage, patience, trust, and humility. She into authentic presence to come to know her
reached for my hand. Her spirit filled me and as a complete, caring person in that moment.
strengthened me as she ascended toward the As the moment unfolded, our mutual trust
sky. I began to feel stronger and reached enhanced and supported who we were as we
toward the sky, hoping to catch one last lived and grew in that caring encounter.
glimpse of her ember and saw her reflection The patients need to share with me a spe-
in the sun. Her rays poured over me and cial gift was validation that she felt it, too.
warmed my spirit. I felt whole once again. The fifth basic assumption of the theory of
This nursing story is a reflection of a nurs- nursing as caring is personhood, which is
ing situation grounded in caring. It demon- enhanced through participation in nurturing
strates the perspective of enhancing other as relationships. As the patient demonstrated in
one lives and grows in caring, which subse- the words of her song, she knew that her
quently results in the enhancement of self as physical existence was coming to an end and
the nurse lives and grows in caring. she was not afraid. There was a mutual know-
ingness that was unspoken, even without the
Ways of Knowing lab work or biopsies. Her lack of fear and her
I chose this story as the medium with which courage allowed her spirit to soar free in the
to share. Nursing as caring encourages nurses open sky, giving me a glimpse of the spiritual
to choose various art forms as media for shar- existence.
ing and reflection. This is aesthetic knowing. This is not to devalue the importance of
It is the artful integration of all the ways of empirical knowledge. It, too, is an important
knowing to create a meaningful, caring part of coming to know other. Empirical
moment that is born in a nursing situation. knowledge is the information that is organ-
Personal knowing is that which is known ized into laws and theories to describe,
intuitively by encountering self and other. explain, or predict phenomena. This knowl-
Authentic presence is a key component for edge is acquired through the senses. Based in
my intuitive experiences when I just know. the sciences, it is our understanding of anato-
This patient trusted me and humbled herself my and physiology, diagnostic processes, and
to ask me to validate her concern that the treatment regimens. For me, it is the concrete
mass in her belly was of grave concern. The form of the foundation upon which my prac-
patient knew, intuitively, before I laid my tice is built.
hands on her. There is a lot to be gained by Empirical knowledge is essential to be rec-
learning to trust our intuition, and we can ognized as a profession. The sixth assumption
know more by engaging in authentic pres- of nursing as caring is that nursing is both a
ence. Authentic presence, for me, removes all discipline and a profession. The scientific evi-
physical boundaries to my coming to know dence that lends theory-based knowledge to
other. It is a spiritual connectedness that has our profession gives us the diagnostic reason-
no time limits or physical boundaries. It is a ing we need to address the physical needs that
feeling of interconnectedness with the patient people have. In this particular situation, the

Continued
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384 S E C T I O N V Caring Theories

Practice Exemplar cont.


laboratory findings confirmed that which we beyond the received view of traditional sci-
knew personally. Often the bereaved loved ence. Nursing as caring guides the use of
ones need a diagnosis to help cope with the nursing knowledge and information from
grief of losing a family member. other disciplines in ways appropriate to nurs-
This brings us to ethical knowingthe ing. Through the application of this theory,
patience and compassion to be with grieving I have come to know new possibilities for
family members when they are not ready nursing practice.
to let go of a loved one who is ready to die. I believe now more than ever that, with
Ethical knowing is also the recognition that the advancing roles of nurses, we need to be
these family members are caring persons as clear on what it is that we do that is different
well, coping in the only way they know how, from other practitioners. As advanced prac-
through their experiences. Humility has tice nurses (APNs) we assume more respon-
allowed me to come to know and respect the sibilities and perform tasks that were tradi-
familys perspective. Patience is needed to tionally reserved for those of the medical
allow other to come to know hope in the profession; the overlapping further blurs the
moment a loved one is diagnosed with a termi- boundaries of our professions. We need to
nal illness. Hope for a spiritual existence maintain our nursing perspective. As nurse
beyond this world was revealed to me in this practitioners continue to be lumped into cat-
nursing situation. egories with other midlevel practitioners, we
Each of the patterns of knowing need to demonstrate to our patients that our
aesthetic, personal, empirical, and ethicalis profession was born of a need from society, a
borrowed from Carper (1978). They serve as need that only nurses can fill. If there is no
conceptual tools to help us understand and call to nursing, our profession will dissolve
implement the theory of nursing as caring. into the sea of midlevel practitioners.
Nursing as caring provides a theoretical Nursing theory sets apart what nurse prac-
perspective with an organizing framework titioners do from any other profession. To
that guides practice and allows for the gener- ensure that our practice maintains its identi-
ation of new knowledge. In addition, it lends ty, the practice must be built upon research-
a methodological process to define, explain, based nursing theory. The theory of nursing
and verify this knowledge. This theory reaches as caring is one such theory.

References

Boykin, A. (Ed.). (1994). Living a caring-based program. Boykin, A., & Schoenhofer, S. O. (1993). Nursing as
New York: National League for Nursing Press. caring: A model for transforming practice. New York:
Boykin, A., Bulfin, S., Baldwin, J., & Southern, B. National League for Nursing Press.
(2004). Transforming care in the emergency depart- Boykin, A., & Schoenhofer, S. O. (1997). Reframing
ment. Topics in Emergency Medicine, 26(4), 331336. nursing outcomes. Advanced Practice Nursing Quar-
Boykin, A., Parker, M. E., & Schoenhofer, S. O. (1994). terly, 1(3), 6065.
Aesthetic knowing grounded in an explicit conception Boykin, A., & Schoenhofer, S. O. (2000). Invest in
of nursing. Nursing Science Quarterly, 7, 158161. yourself. Is there really time to care? Nursing Forum,
Boykin, A., & Raines, D. (2006). Design and structure: 35(4), 3638.
An expression of caring. International Journal for Boykin, A., & Schoenhofer, S. O. (2001a). Nursing as
Human Caring, 10(4), 4549. caring: A model for transforming practice. Sudbury,
Boykin, A., & Schoenhofer, S. O. (1990). Caring in MA: Jones and Bartlett.
nursing: Analysis of extant theory. Nursing Science Boykin, A., & Schoenhofer, S. O. (2001b). The role of
Quarterly, 3(4), 149155. nursing leadership in creating caring environments
Boykin, A., & Schoenhofer, S. O. (1991). Story as link in health care delivery systems. Nursing Administra-
between nursing practice, ontology, epistemology. tion Quarterly, 25(1), 17.
Image, 23, 245248.
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Boykin, A., Schoenhofer, S., Bulfin, S., Baldwin, J., & Schoenhofer, S. O. (1995). Rethinking primary care:
McCarthy, D. (2005). Living caring in practice: The Connections to nursing. Advances in Nursing Science,
transformative power of the theory of nursing as 17(4), 1221.
caring. International Journal for Human Caring, 9(3), Schoenhofer, S. O. (2001). A framework for caring in a
1519. technologically dependent nursing practice environ-
Boykin, A., Schoenhofer, S. O., Smith, N., St. Jean, J., ment. In: R. C. Locsin (Ed.), Advancing technology,
& Aleman, D. (2003). Transforming practice using a caring and nursing (pp. 311). Westport, CT: Auburn
caring-based nursing model. Nursing Administration House.
Quarterly, 27, 223230. Schoenhofer, S. O. (2002a). Choosing personhood:
Carper, B. A. (1978). Fundamental patterns of knowing Intentionality and the theory of nursing as caring.
in nursing. Advances in Nursing Science, 1(1), 1324. Holistic Nursing Practice, 16, 3640.
Collins, J. M. (1993). I care for him. Nightingale Songs, Schoenhofer, S. O. (2002b). Considering philosophical
2(4), 3. Retrieved from underpinnings of an emergent methodology for
http://www.fau.edu/divdept/nursing/ngsongs/ nursing as caring inquiry. Nursing Science Quarterly,
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Gaut, D., & Boykin, A. (Eds.). (1994). Caring as heal- Schoenhofer, S. O., Bingham, V., & Hutchins, G. C.
ing: Renewal through hope. New York: National (1998). Giving of oneself on anothers behalf: The
League for Nursing Press. phenomenology of everyday caring. International
Guralnik, D. (1976). Websters new world dictionary of the Journal for Human Caring, 2(1), 2329.
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King, A., & Brownell, J. (1976). The curriculum and the Parker, M. E. (Ed.), Patterns of nursing theories in
disciplines of knowledge. Huntington, NY: Robert E. practice (pp. 8392). New York: National League for
Krieger. Nursing Press.
Locsin, R. C. (1995). Machine technologies and caring Schoenhofer, S. O., & Boykin, A. (1998a). The value of
in nursing. Image, 27, 201203. caring experienced in nursing. International Journal
Locsin, R. C. (2001). Advancing technology, caring and for Human Caring, 2(3), 915.
nursing. Westport, CT: Auburn House. Schoenhofer, S. O., & Boykin, A. (1998b). Discovering
Mayeroff, M. (1971). On caring. New York: Harper & the value of nursing in high-technology environ-
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ship: Function, process and principles. New York: Touhy, T., & Boykin, A. (2008). Caring as the central
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Paterson, J. G., & Zderad, L. T. (1988). Humanistic nurs- Touhy, T., Strews, W., & Brown, C. (2003). Caring from
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Roach, S. (1987/2002). Caring, the human mode of being. Touhy, Christine E. Lynn College of Nursing,
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Section
VI
Middle-Range Theories
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Section

VI Middle-Range Theories

Nine middle-range theories in nursing are presented in the final section. Each chapter is written
by the scholars who developed the theory. Although we determine all to be at the middle range
because of their more circumscribed focus on a phenomenon and more immediate relation-
ship to practice and research, they still vary in level of abstraction. Comfort is an important con-
cept to nursing practice. Kolcabas middle-range theory of comfort is presented in Chapter 22.
She defines comfort as to strengthen greatly and identifies relief, ease, and transcendence as
types of comfort and physical, psychospiritual, environmental, and sociocultural as contexts in
which comfort occurs. Duffys Quality-Caring Model, described in Chapter 23, is a relatively new
theory that is being used in many healthcare settings to address the issues of patient satisfac-
tion and the lack of patients feeling cared for in the acute care environment. In this model the
goal of nursing is to engage in a caring relationship with self and others to engender feeling
cared for. Reeds Theory of Self-Transcendence is presented in Chapter 24. The focus of the
theory is on facilitating self-transcendence for the purpose of enhancing well-being. Reed
defines self-transcendence as the capacity to expand the self-boundary intrapersonally (toward
greater awareness of one's beliefs, values, and dreams), interpersonally (to connect with
others, nature, and surrounding environment), transpersonally (to relate in some way to dimen-
sions beyond the ordinary and observable world), and temporally (to integrate one's past and
future in a way that expands and gives meaning to the present). In Chapter 25 Swanson
describes her trajectory and the process of developing of her middle-range theory of caring
from research. The theory includes the concepts of knowing, being with, doing for, enabling,
and maintaining belief. Smith and Liehr present story theory in Chapter 26. They posit that
story is a narrative happening wherein a person connects with self-in-relation through
nurseperson intentional dialogue to create ease. This theory has already been applied in a
number of practice and research initiatives. Parker and Barrys Community Nursing Practice
Model has guided nursing practice in community settings in several countries. The model is rep-
resented by concentric circles with the nursing situation as core and connected with the outer
spheres of influence in the community and environment. Chapter 28 contains Locsins Theory
of Technological Competency-Caring. This theory dissolves the artificial and often assumed
dichotomy between technology and caring, and asserts that technology is a way of coming to
know the person as whole. Ray and Turkel authored Chapter 29 on Rays Theory of Bureaucratic
Caring. The theory uses a multidimensional, holographic model to facilitate the understanding
of caring within the complex environment of healthcare systems. In Chapter 30 Smith presents
her theory of unitary caring for the first time. The theory evolved from viewing caring through
the lens of Rogers Science of Unitary Human Beings.

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Chapter
22
Katharine Kolcabas
Comfort Theory
K ATHARINE KOLCABA

Introducing the Theorist Introducing the Theorist


Overview of the Theory Katharine Kolcaba was born and educated in
Application of the Theory in Cleveland, Ohio. In 1965, she received a diplo-
Practice
ma in nursing and practiced part time for many
Practice Exemplar
years in the operating room, medicalsurgical
References
units, long-term care, and home care before
returning to school. In 1987, she graduated
with the first R.N. to M.S.N. class at the
Frances Payne Bolton School of Nursing, Case
Western Reserve University (CWRU), with
a specialty in gerontology. While attending
graduate school, Kolcaba maintained a head
nurse position on a dementia unit. In the con-
text of that unit, she began theorizing about
comfort.
Katharine Kolcaba After graduating with her masters degree
in nursing, Kolcaba joined the faculty at the
University of Akron (UA) College of Nursing,
where her clinical expertise was gerontology
and dementia care. She returned to CWRU to
pursue her doctorate in nursing on a part-time
basis while teaching full time. Over the next
10 years, she used course work from her doc-
toral program to further develop her theory.
During that time, Kolcaba published a frame-
work for dementia care (1992a), diagrammed
the aspects of comfort (1991), operationalized
comfort as an outcome of care (1992b), con-
textualized comfort in a middle range theory
(1994), tested the theory in several interven-
tion studies (Kolcaba, 1999, 2003, 2004;
Kolcaba, Tilton & Drouin, 2006; Dowd,
Kolcaba, Steiner, & Fashinpaur, 2007), and
further refined the theory to include hospital-
based outcomes (2001). She has an extensive
series of publications to document each step
in the process, most of which have been com-
piled in her book Comfort Theory and Practice

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390 S E C T I O N VI Middle-Range Theories

(2003). Many publications and comfort assess- maintained for homeostasis. Transcendence
ments also are available on her web site at was derived from Paterson and Zderad (1976),
www.TheComfortLine.com. who believed that patients could rise above
Kolcaba taught nursing at UA for 22 years their difficulties with the help of nurses.
and is now an associate professor emeritus. The four contexts in which comfort is
Kolcaba still teaches her web-based theory experienced by patients are physical, psycho-
course once a year and she represents her own spiritual, sociocultural, and environmental
company, The Comfort Line, as a consultant. and came from a further review of literature
In this capacity, she works with health care regarding holism in nursing (Kolcaba, 1991,
agencies and hospitals who choose to apply 2003). When these four contexts of experi-
Comfort Theory on an institutional-wide ence are juxtaposed with the three types of
basis. She also is founder and member of her comfort, a taxonomic structure (TS) or grid is
local parish nurse program and is a member of created that covers the nursing meaning
ANA and Sigma Theta Tau. Kolcaba contin- of comfort as a patient outcome. This TS,
ues to work with students at all levels and with definitions of each type and context of
with nurses who are conducting comfort stud- comfort, provides a map of the content of
ies. She resides in the Cleveland area with her comfort so that nurses can use it to pattern
husband, near her two daughters, their chil- their care for each patient and family member.
dren, and her mother. One other daughter Kolcaba's technical definition of the outcome
resides in Chicago. of comfort is: The immediate experience of
being strengthened when needs for relief,
ease, and transcendence are addressed in four
Overview of the Theory contexts of experience. Figure 22-1 contains
In Comfort Theory (CT), comfort is a noun or the TS of comfort with the corresponding
an adjective, and an outcome of intentional, definitions of relief, ease, transcendence and
patient/family focused, quality care. In spite of the physical, psychospiritual, environmental
everyones familiarity with the idea of comfort, and sociocultural contexts.
it is a very complex term that has several mean- Other uses of the TS of comfort are (1) for
ings and usages in ordinary language. The use determining the existence and extent of unmet
of comfort as a noun and an outcome is specif- comfort needs in patients or family members;
ic to CT and different from its alternative (2) for designing comforting interventions,
usages as a verb, adverb, and process (Kolcaba, which often can be "bundled" in a single
1995). From a search of the literature, Kolcaba patient interaction; and (3) for creating meas-
learned that the original definition of comfort urements of holistic comfort for documenta-
meant to strengthen greatly. From other dis- tion in practice and research; such measure-
ciplines, she learned that (1) the need for com- ments would be conducted before and after
fort is basic, (2) persons experience comfort comfort interventions and/or interactions.
holistically, (3) self-comforting measures can (A place to note the nature and time of the
be healthy or unhealthy, and (4) enhanced nursing intervention next to baseline and sub-
comfort (when achieved in healthy ways) leads sequent comfort measurements is essential in
to greater productivity. medical records. These strategies are discussed
Kolcaba used three nursing theories to further in a later section of this chapter.)
describe three distinct types of comfort One way to think about the grid is that
(Kolcaba, 2003). Relief was synthesized from comfort is an umbrella outcome that entails
the work of Orlando (1961/1990), who stated relief from discomforts such as anxiety, pain,
that nurses relieved the needs expressed environmental stressors, and/or social isola-
by patients. Ease was synthesized from the tion. Because the TS represents a holistic
work of Henderson (1978), who described 13 definition of comfort, the cells on the grid
basic functions of humans that needed to be are interrelated and as a whole, comfort
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C H A P T E R 2 2 Katharine Kolcabas Comfort Theory 391

Relief Ease Transcendence

Physical Pain

Psychospiritual Anxiety

Environmental

Sociocultural

Figure 22 1 Taxonomic
structure of comfort.

interventions directed to one part of the grid comfort interventions are often nontechnical
have effects on all parts of the grid. Total and complement delivery of technical care.
comfort is also greater than the sum of its Care providers, such as nurses, may also be
individual parts. Therefore, comfort interven- considered recipients if the institution makes
tions to treat anxiety also may reduce the a commitment to improving comfort in its
dosage of analgesia needed for adequate pain work setting (discussed later).
relief. On a comfort continuum, the concept When comfort is not enhanced to the
of Total Comfort (as much as can be expected fullest extent possible, nurses consider inter-
given the circumstances) is at one extreme vening variables for as possible explanations as
end, and Suffering is at the other end. to why comfort interventions did not work.
Abusive homes, lack of financial resources,
Propositions of Comfort Theory devastating diagnoses, or cognitive/psycho-
CT contains three intuitive parts that can be logical impairments may render ineffective
applied or tested separately or as a whole. The the most appropriate interventions and com-
first part states that comforting interventions, forting actions. The aspect of transcendence,
when effective, result in increased however, guides nurses to help patients rise
comfort for recipients (patients and fami- above or be inspired to achieve mutually
lies), compared to a pre-intervention baseline. determined goals regardless of life circum-
Increased comfort is the immediate desired stances. Nurses who practice CT never give
outcome for this kind of care. Comfort inter- up being with and inspiring their patients.
ventions address basic human needs, such as Thus, this focus on comfort is proactive, ener-
rest, homeostasis, therapeutic communica- gized, intentional, and longed for by recipi-
tion, and viewing patients holistically. These ents of care in all settings.
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392 S E C T I O N VI Middle-Range Theories

The second part states that increased com- TS, includes more than relief of pain or
fort of recipients results in their being strength- anxiety. Thus, when nurses adopt CT as their
ened for their tasks ahead, which are called personal philosophy for practice, they are uti-
health-seeking behaviors (HSBs). HSBs are lizing a simple pattern for individualized care
subsequent recipient goals and are negotiated that is efficient, creative, and satisfying to
between nurses and the recipients. In the prac- themselves and recipients of their care. When
tice of nursing administration, when the in- enhanced comfort is documented, nurses can
tended recipients are bedside nurses, HSBs are also demonstrate their real contributions to
negotiated with nursing staff. better institutional outcomes such as higher
The third part states that increased engage- patient satisfaction, fewer readmissions, or
ment in HSBs results in increased Institutional shorter length of stay. The diagram of CT
Integrity (InI). Enhanced InI strengthens the shows the relationships between the simple
institution and its ability to gather evidence concepts (Fig. 22-2). Definitions of the con-
for best practices and best policies. Best prac- cepts are below the diagram.
tices and policies lead to quality care, which, in
many ways, benefits the bottom financial line Theoretical Definitions for Diagram
of the institution. Concepts
Kolcaba believes that nurses already know In the context of comfort theory, health care
how and want to practice comforting care, needs are defined as needs for comfort, aris-
and that it can be easily incorporated into ing from stressful health care situations that
every nursing action. Many nurses deliver cannot be met by recipients traditional support
comforting care intuitively, but do not docu- systems. They include physical, psychospiritual,
ment its total effects of patients as enhanced sociocultural, and environmental needs made
comfort. The explicit focus on and documen- apparent through monitoring and verbal or
tation of this type of holistic care is called nonverbal reports, needs related to pathophysi-
comfort management and, as shown in the ological parameters, needs for education and

Conceptual framework for Comfort Theory

Best
practices

Health Intervening Health-


Nursing Enhanced Institutional
care + interventions
+ variables comfort
seeking
integrity
needs behaviors

Internal External Best


behaviors behaviors policies

Peaceful
death

Figure 22 2 Conceptual framework for comfort theory.


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C H A P T E R 2 2 Katharine Kolcabas Comfort Theory 393

support, and needs for financial counseling and policies are also determined from empirical
intervention. evidence.
Comfort interventions are defined as As stated previously, the diagram and specific
intentional actions designed to address specific definitions for the concepts in CT provide a
comfort needs of recipients, including physio- pattern and practical rationale for practicing
logical, social, cultural, financial, psychological, comfort management. This kind of care is indi-
spiritual, environmental, and physical interven- vidualized, efficient, holistic, and therapeutic.
tions. Within these contexts of experience, there Importantly, the nurturing aspect of nursing
are three types of comfort interventions provides the altruistic motivation for practicing
described later: technical, coaching, and com- comfort management. It is the traditional mis-
fort food for the soul. sion and passion of nursing (Kolcaba, 2003;
Intervening variables are defined as inter- Morse, 1992). But the practical rationale is
acting forces that influence recipients percep- important at the institutional level, because
tions of total comfort. These consist of variables without administrative support for optimum
such as past experiences, age, attitude, emotion- staffing and employment practices, nurses often
al state, support system, prognosis, finances, cannot give the kind of care to which they were
education, cultural background, and the totality born or for which they were educated.
of elements in recipients experience. For teaching and learning purposes, care
Comfort was defined technically earlier plans based on CT are provided on Kolcabas
in this chapter. It is the state that is experi- website and in her book (Kolcaba, 2003). One
enced immediately by recipients of comfort is for patients and one is for patients and
interventions. It entails the holistic experi- family members, as defined by the patient.
ence of being strengthened through having Note, for teaching and learning, it is not nec-
comfort needs addressed. essary to distinguish among relief, ease, and
The concept of health-seeking behaviors transcendence when assessing and interven-
was developed by Dr. Rozella Schlotfeldt ing for unmet comfort needs. Institutional
(1975) and represents the broad category of outcomes are not included in the care plans,
subsequent outcomes related to the pursuit of because these data are not accessible to students
health. Schlotfeldt stated that HSBs could be and beginning nurses. An additional column
internal or external. She was ahead of her can be added to the care plans, especially for the
time in thinking that a peaceful death could InI outcome of patient satisfaction so that
also be an HSB. Realistic HSBs are deter- learners can see the relationship between their
mined by recipients of care in collaboration comforting interventions and the broader
with their health care team. integrity of the institution (Kolcaba, 1995).
Institutional integrity is defined as These care plans can also be applied in home
those corporations, communities, schools, care and in long-term care.
hospitals, regions, states, and countries that
possess qualities of being complete, whole, Application of the Theory
sound, upright, appealing, ethical, and sin-
cere. When an institution displays this type in Practice
of integrity, it can produce valuable evidence According to CT, there are three types of
for best practices and best policies. Best comforting interventions: technical, coaching,
practices are health care interventions that and comfort food for the soul. Technical inter-
produce the best possible patient and family ventions are those that are specified by other
outcomes based on empirical evidence. Best disciplines or by nursing protocols; they
policies are institutional or regional policies include medications, treatments, monitoring
ranging from basic protocols for procedures schedules, insertion of lines, and so forth. For
and medical conditions, to systems for patients, competency in the administration
access and delivery of health care. Best and documentation of technical interventions
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394 S E C T I O N VI Middle-Range Theories

is the minimum expectation for nurses. Coach- was looking only at their rates of medication
ing consists of supportive nursing actions, active errors or failures to rescue?)
listening, referrals to other members of the
health care team, advocacy, reassurance, and so How to BE a Nurse
forth. Comfort Food for the Soul are those extra CT guides nurses to detect comfort needs of
special, holistic, and more time-consuming patients and families that are not being
nursing interventions such as back or hand addressed and to develop interventions to
massage, guided imagery, music or art therapy, meet those needs. Their caring actions are
a walk outside, or special arrangements for intuitive, but in this theory, caring is a com-
family members. The latter two types of inter- fort intervention in and of itself. CT describes
ventions require considerably more expertise how to care and how to BE a nurse, what is
and confidence by nurses and are what patients important to patients and families, and factors
most remember. And they are what Benner that facilitate healing. In addition, all techni-
(1984) would ascribe to expert nurses. cal nursing interventions are delivered in a
However, most nurses focus on technical comforting way.
interventions first, and when time permits, Nurses and patients want to experience
implement coaching techniques. Interesting- intentional and meaningful moments with
ly, charting usually accounts only for technical each other and with family members, the kind
interventions and the effects of analgesia; that patients might call wow moments.
there are no places in traditional hospital (Wow! Ill always remember that nurse.)
records to record the more important healing Nurses usually sense when this happens, and
interventions. But, patients rarely remember these instances are sustaining, satisfying, and
the technical interventions; the important profound for them as well as for their
interventions to patients and their families are patients. But nurses often fail to understand
those that are not documented such as: coach- and share how the moment intentionally
ing and comfort food for the soul, the most came to be created, especially if they practice
important work of expert nurses. Thus, there without a theory. These special instances
is a perpetual disconnect between legal chart- require appropriate theories to add both per-
ing and actions that patients want and need sonal and disciplinary structure and meaning
from their nurses, and which we claim to be to such experiences (Chinn, 1997). When
the essence of nursing. It is no wonder that, nurses are able to describe their wow
when pressed, nurses cannot describe the moments in terms of CT, the nature of their
impact they make with patients and their interactions becomes purposeful and repeat-
familiescoaching and comfort food inter- able, and these transformative interactions
ventions are not valued by administrators and become associated with the power of nursing
are not even visible in patient care records. in general, not just with one nurse. The cumu-
CT provides the language and rationale to lative power of these moments strengthens
once again claim and document essential not only the recipients, but also nurses who
nursing activities that are most beneficial to create the moments, and the discipline that
patients and family members in stressful lays claim to them.
health care situations. It is also important to CT states that the process of comforting a
remember that the outcome of enhanced patient entails the intention to comfort, to be
comfort is a value-added outcome; that is, it is present, and to deliver comforting interventions
a positive measure of quality care rather than based on the patients and loved ones unmet
a measure of what is not quality care such as comfort needs (Kolcaba, 2003; Kolcaba, on
the currently measured outcomes of nosoco- line). If the patient needs time to voice concerns
mial infections, falls, decubitus ulcers, med- and questions, the nurse listens attentively and
ication errors, and failure to rescue. (Note, provides culturally appropriate encouragement
would YOU want to go to a hospital which and body language (a comforting intervention).
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C H A P T E R 2 2 Katharine Kolcabas Comfort Theory 395

The nurse knows exactly why and when to do research, without permission, because the web-
this, because he or she is tuned into the whole site is in the public domain. The address is
person as patient and because the nurse wants www.TheComfortLine.com (Appendix B).
to provide comfort, to soothe in times of dis- In addition to providing methods for doc-
tress and sorrow. Such an explanation of how to umentation of comfort needs and comforting
BE a nurse is lacking in most other theories. measures, there are other ways that institu-
tions can demonstrate their commitment to
Institutional Advocacy comfort management. These include building
It is not enough for institution administrators comfort management into orientation, inser-
to state that they want nurses and other care vice programs, performance reviews, and
providers to practice comforting carethey methods for nursing assignments (based in
need to implement documentation and rein- part on comfort needs of patients and family
forcement strategies to ensure this is done and members). An example of an institution that
to show that they value this kind of care. If has implemented such strategies across all
administrators do not take on this responsi- departments is The Mount Sinai Hospital,
bility, practicing nurses can be self-advocates New York City (contact person: Carol Porter,
and begin to document comforting interven- chief nursing officer).
tions and their effects in narrative charting.
Whether top-down and/or from the grass Institutional Awards
roots, the institutional ideal is for health care Institutions have adopted CT to enhance nurses
institutions to provide ways in which comfort work environments, such as in the quest for
needs of patients and family members are national recognition including Magnet Status,
routinely charted, beginning with baseline the Baldrich Award, and the Beacon Award.
comfort levels. Comforting interventions are Many institutions discover that the application
described and implemented, and comfort lev- process for these types of awards is simplified
els are reassessed and charted. Modifications when a theoretical framework is adopted. The
to the interventions are made, until comfort main benefit of doing so is that employees are
levels are sufficiently increased. Preferences of on the same page, in the case of CT, comfort-
patients and families are honored wherever ing patients and family members in their own
possible. In appropriate settings, comfort con- personalized styles and capacities. Moreover,
tracts (Appendix A) can be instituted and fol- and perhaps most importantly, is that adminis-
lowed throughout a defined clinical situation trative commitment to a philosophy of comfort
such as surgery, labor and delivery, or an acute management includes sufficient staffing levels
psychiatric episode. in all departments to support this type of holis-
According to CT, technical interventions tic health care. A large hospital system that
should be documented as usual (often on a adopted CT to undergird their application
checklist including times), but methods of for Magnet Status, and was successful in
intentional caring also should be documented achieving Magnet Status shortly thereafter, is
in the same way that administration of Southern New Hampshire Medical Center
pain medication is noted in two places. There (SNHMC) (contact person, Collette Tilton,
are many suggestions for documentation on CNO) (Kolcaba, Tilton, & Drouin, 2006).
the instrument section at Kolcabas website, When SNHMC decided to apply for
including a verbal rating scale, a numeric dia- Magnet Status, nurses from middle man-
gram, comfort daisies for children, a comfort agement formed a committee and reviewed
behaviors checklist for nonverbal or unrespon- several nursing theories. They chose CT
sive patients, and several questionnaires about because it most accurately reflected their
patient comfort for different research settings. values and goals. Kolcaba was contacted to
These instruments can be downloaded from arrange a consultative visit, which occurred
the website and utilized in practice and/or after a sufficient time to prepare the other
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396 S E C T I O N VI Middle-Range Theories

departments, including upper administra- are precious. Each is an example of a holistic


tive levels, for the visit. comfort intervention that has greater positive
As part of this consultation, Kolcaba and effects on the patients total comfort than could
the CNO visited all departments. They be imagined by the caregiver. These comforting
requested suggestions from the staff for ideas interventions are examples of wow moments
that would increase their comfort at work. The for receivers, and the exchange also renews the
many suggestions that were given came to be givers of such acts in existential ways. Moreover,
added to comfort wish lists on each unit. One such comforting interventions can be delivered
astute young nurse asked where to send the by any member of the health care team or
items on the wish list. The CNO replied, department within the context of their job
Most of your suggestions will not require description.
additional funds, and you can implement those
items on your own units. For items that do How Comfort Theory
require more money, please send them to me. Lives in Practice
Another strategy adopted during this visit Best Practices
consisted of brief instructions about designing
and implementing small comfort studies Currently, there is administrative interest in
specific to each unit and to common clinical improving the patient experiencea factor
problems. The diagram of CT (see Fig. 22-2) that typically is measured by items on patient
defines the research process when comfort satisfaction instruments, the results of which
studies are undertaken, often a requirement are posted on public websites. The quality of
for national awards. Strategies for publicizing the patient experience, as rated by patients
the results of these studies, as well as the insti- after a hospital stay, determines choices by
tutional commitment to comfort manage- insurance companies for future coverage of
ment, were also suggested. their enrollees. Often, these items are nursing
sensitive, meaning that if nurses demonstrate
simple comforting techniques, patients will
The Meaning of Comfort respond favorably to those patient experi-
Theory for Practice ence questions.
Kolcaba routinely asks nurses and students in One administrative approach to enhancing
her audiences about their experiences during the patient experience has been to imple-
past hospitalizations, either as a patient or a ment scripting, whereby members of the
family member. She asks if they remember any health care team memorize specific prewrit-
of their nurses, and if so, what do they remem- ten statements to use during common patient
ber? The stories that emerge are usually about encounters. An example is a standard script to
nurses who demonstrated small, nontechnical, be delivered on first introducing oneself to the
but very comforting acts of compassion and patient such as, Hello, I am Nurse Thomas
understanding. Examples of these interven- and I will be in charge of your care for today.
tions are: a brief back massage, helping a child If you need anything at all, please let me
make a phone call, sitting beside an anxious know. This approach may negate individual-
patient, making eye contact during an interac- ized care, the special needs of the patient and
tion, gently encouraging ambulation, listening family, and the particular communication
attentively to role change issues, holding a skills of the team member. And most patients
dying patients hand, washing a patients hair, can determine when such statements are pre-
making a family member comfortable during scripted, especially when they hear the same
an overnight stay, and so forth. These types of statements several times from different care-
interventions are remembered by patients for givers over the course of a hospital stay.
years after a stressful health care episode A different approach is to undergird all
because emotions run high and kind encounters patient interactions with principles of CT,
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C H A P T E R 2 2 Katharine Kolcabas Comfort Theory 397

which caregivers learn in orientation and number of foreign language comfort instru-
in-service programs. Principles of CT that ments available on Kolcabas website.
are relevant to the patient experience are that
Best Policies
(1) each interaction entails therapeutic use of
self; (2) caregivers assess for comfort needs of An example of how CT is used in practice is the
patients and family members and design their creation of a policy for Comfort Management
interaction to meet those needs; (3) care- by the American Society of Peri-Anesthesia
givers approach each patient and family Nurses (ASPAN). This national association is
member with the intent to comfort and make composed of nurses who work in the following
a personal, culturally appropriate connection; areas: ambulatory surgery, perioperative staging,
and (4) caregivers regularly reassess comfort operating room, postanesthesia recovery, and
of patients and family members and docu- step-down. ASPAN decided collectively to
ment comfort levels routinely. Utilizing this apply CT in an explicit way throughout patients
approach facilitates individualized and effi- surgical experiences. Kolcaba served as consult-
cient care and a more positive patient experi- ant and facilitator in this process.
ence. Two examples of how CT is being used First, they achieved national consensus
to enhance the patient experience are at the about the development of Guidelines for Com-
Mount Sinai Hospital, New York City (Carol fort Management that would complement their
Porter, CNO, contact person) and at Kaiser existing Guidelines for Pain Management. The
Permanente Hospital in San Francisco (Katy process proceeded with a survey of its member-
Kennedy, contact person). ship about providing comfort to patients, then
with a report of findings, then the conference
Electronic Database about components of Comfort Management,
To support CT in practice, components have and finally the composition of the guidelines
been incorporated into national electronic data- (Kolcaba & Wilson, 2002; Wilson & Kolcaba,
bases, such as the National Interventions Clas- 2004).
sification (NIC) and the National Outcomes The guidelines contain information
Classification (NOC) systems (The Iowa about how to (1) perform a comfort assess-
Taxonomy) as well as the North American ment, (2) create a comfort contract with
Nursing Diagnosis Association (NANDA). patients before surgery, (3) discover the
Comforting interventions, comfort outcomes, interventions that patients and families use
and comfort diagnoses are included in these at home for specific discomforts, (4) use a
data systems, meaning that individualized com- checklist for comfort common management
fort needs and the effectiveness of interventions strategies, (5) document changes in comfort,
to meet those needs can be charted electroni- and (6) implement pre- and post-testing for
cally and entered into larger databases by a hos- contact hours in comfort management. The
pital system, at the local, state, region, or coun- completed Guidelines for Comfort Man-
try level. While there are at least 13 national agement are available on ASPANs website
databases for nursing, and others for medicine, (www.ASPAN.org). This is an example of a
when hospital systems select and contribute grassroots change (within a national associ-
data to a mainstream system, documentation of ation of nurses) that was disseminated to all
patient care problems, interventions, and out- perianesthesia settings and soon became a
comes can be more widely compared, leading practice expectation. This example could be
to more consistent and higher quality patient followed by any nursing specialty, at the
care practices. In this regard, an important fea- macro level, or any patient care unit, at the
ture of CT is the universality of its main con- micro level. The important point is that the
cept, comfort. This is a word that is understood model was initiated by nurses and is now an
by all health-related disciplines and is translat- expectation that the Joint Commission
able into most languages, as evident with the reviews on recertification.
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398 S E C T I O N VI Middle-Range Theories

Practice Exemplar
Nurse Smith worked for approximately 15 years episode that the patient experience could be
in a single large hospital system. Because of her greatly improved and she had an idea about
strong work ethic and creative ideas, she had how to make that happen. Her vision was for
been promoted over the years from staff nurse her hospital to adopt CT for its multidiscipli-
to positions in upper management. In addition nary framework to undergird the patient
to her BSN, she had her MBA and was also experience. Every encounter with patients
enrolled in a DNP program. While attending and families would be a comforting and con-
graduate school at the age of 45, she developed necting experience. There would be no need
breast cancer and was a patient in her own sys- for scripting because each encounter would
tem. She was full of anxiety about her progno- be based on comforting the patient and family
sis, treatment, and role change and spent many in some way and would be individualized, sin-
days in various settings including in-patient, cere, and unique to the skills of the caregiver.
out-patient, surgery, radiation therapy, and She believed that such encounters would take
chemotherapy. Her treatment spanned several the same amount of time, or less, than imper-
months in close contact with the nurses from sonal ones and indeed, they would help allay
her own organization. anxiety almost immediately. She was hired.
To her chagrin, during this time of high CT was officially adopted by this institu-
comfort needs, Nurse Smith received little or tion, integrating the following components:
no comfort from the nurses with whom she commitment by administration, retelling of
came in contact. She recalled that no person- the CNOs story, redefining quality care in
al connections were made by these nurses, terms of comfort for patients and families,
who delivered their interventions mechani- orientation to CT for all personnel, an intro-
cally, with a noticeable lack of personalized duction of CT to the academic community
eye contact. Nurse Smith felt lonely, scared, including nursing students, small changes in
and in more objective moments, deeply con- the way care would be delivered, comfort
cerned for her profession. rounds, comfort charting (electronic and
Shortly after her recovery from intensive paper based), performance review/clinical
therapies, Nurse Smith applied for the Chief ladders, and marketing strategiesputting
Nursing Officer (CNO) position. As part their commitment to comforting care out
of her interview, she told the administrators there. Data are currently being collected
who would be choosing the next CNO about regarding the extent to which the patient
her experience as a patient in their organi- experience was improved following the
zation. She knew from her own personal rollout of CT.
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C H A P T E R 2 2 Katharine Kolcabas Comfort Theory 399

References

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Appendix A: Example of a 5. The following medications I had taken


have resulted in undesirable outcomes
Comfort Contract _________________________________
Thank you for taking the time to complete The undesirable outcomes have included
the comfort contract. The purpose of this _________________________________
contract is to increase your comfort and pain _________________________________
management while you are hospitalized. _________________________________
Please rate your expectation of comfort from
0 to 10 (10 is highest) for each situation list- Nursing Interventions
ed. Please use the comfort scale as directed for 6. I prefer personal hygiene to be performed
all items except when indicated otherwise and during the (morning, afternoon, evening).
take your time and complete the following 7. I prefer my family to be present (all the
questions. time, occasionally, not at all) during my
Use Comfort Scale as directed in figure 22-3. recovery.
8. I wish to have the following family mem-
Extreme Extreme ber(s) present:_____________________.
discomfort Comfort comfort 9. I prefer to exclude the following persons
1 2 3 4 5 6 7 8 9 10 from visiting my room______________.
Figure 22 3 Comfort scale. 10. I prefer to have a fan present in my room.
(Yes/No)
11. I prefer updates regarding my status (only
The Comfort Experience when asked, daily, not at all).
1. I expect a comfort level of:

a. _______ when the anesthesia wears off. Appendix B


b. _______ on postoperative day 1 Comfort is a concept that has a strong associ-
c. _______ on postoperative day 3 (when ation with nursing. Nurses traditionally pro-
ambulating) vide comfort to patients and their families
d. _______ on postoperative day 5 (study through interventions that can be called com-
conclusion day) fort measures. The intentional comforting
actions of nurses strengthen patients and their
2. These interventions might assist to
families (who can be found in their own
increase my comfort:
homes, in hospitals, agencies, communities,
Warming blanket (recovery room) states, and nations). When patients and fam-
Pet visitation ilies are strengthened by actions of health care
Family visits (when anesthesia wears off ) personnel (nurses!), they can better engage in
Music health-seeking behaviors. The positive relation-
Cold washcloth ships between these deliberate nursing actions
Pillowslocation: ___________ and comfort is entailed in the first part of
Massage Kolcabas middle-range Theory of Comfort.
Other ________________ Enhanced comfort is an immediate desirable
(Circle All that Apply.) outcome of nursing care, according to Comfort
Theory. In addition, it theoretically and posi-
3. In the past, I have required (small, moder-
tively correlates with desired health-seeking
ate, large) amounts of pain medication to
keep me comfortable.
Developed by students at The University of Akron and
4. I have had success with the following distributed with their permission: Robert Bearss, Brent
medications during my previous Ferroni, Ryan Hartnett, Kristy Kuzmiak, Brittney
admissions to the hospital ____________ Stover, Spring 2006.
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C H A P T E R 2 2 Katharine Kolcabas Comfort Theory 401

behaviors (HSBs). The concept was first intro- comfort, HSBs, and InI constitute the third
duced by Schlotfeldt (1975). HSBs can be part of the theory. Tests of the theory can be
internal (healing, immune function, number of on the first part, the second part, the third
T cells, etc.), external (health-related activities, part, or the whole theory.
functional outcomes, etc.), or a peaceful death. Types of comfort:
The relationships between comfort and health-
seeking behaviors are considered in the second Relief: The state of having a specific comfort
part of Kolcabas comfort theory. need met.
Health-Seeking Behaviors (HSBs) are in Ease: The state of calm or contentment.
reference to the small or large group of Transcendence: The state in which one can
patients being analyzed. HSBs of patients or rise above problems or pain.
larger groups, in turn, are positively related to Context in which comfort occurs:
Institutional Integrity.
Institutional Integrity (InI) is NEWLY Physical: Pertaining to bodily sensations and
(Kolcaba, 2007) defined as the values, financial homeostatic mechanisms.
stability, and wholeness of health care organi- Psychospiritual: Pertaining to internal aware-
zations at local, regional, state, and national ness of self, including esteem, concept,
levels. In addition to hospital systems, the def- sexuality, meaning in ones life, and ones
inition of institutions includes public health relationship to a higher order or being.
agencies, Medicare and Medicaid programs, Environmental: Pertaining to the external
home care agencies, and nursing home consor- background of human experience (tem-
tiums. Examples of variables related to this perature, light, sound, odor, color, furni-
expanded definition of InI include cost sav- ture, landscape, etc.)
ings, improved access, decreased morbidity Sociocultural: Pertaining to interpersonal,
rates, decreased hospitalizations and readmis- family, and societal relationships (finances,
sions, improved health-related outcomes, effi- teaching, health care personnel, etc.), as
ciency of services and billing, and positive well as to family traditions, rituals, and
costbenefit ratios. Relationships among religious practices.
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Chapter
23
Joanne Duffys Quality
Caring Model
J OANNE R. D UFFY

Introducing the Theorist Introducing the Theorist


Introducing the Model Joanne R. Duffy, PhD, RN, FAAN, has more
Applications of the Model than 35 years of experience in clinical, admin-
Practice Exemplar istrative, and academic nursing. She is at pres-
Summary ent a professor at Indiana University School
References of Nursing where she teaches at the graduate
level and conducts research in relationship-
centered caring. Dr. Duffy graduated from
St. Josephs Hospital School of Nursing
in Providence, RI, completed her BSN at
Salve Regina College in Newport, RI and her
masters and doctoral degrees at the Catholic
University of America in Washington, DC.
She is a Fellow of the American Academy of
Nursing, a Magnet Hospital appraiser, and an
international consultant.
Joanne R. Duffy
Dr. Duffy has held associate director of
nursing positions at two academic medical
centersGeorge Washington University Med-
ical Center and Georgetown University
Medical Centerand has simultaneously
served in academic appointments. She devel-
oped the Cardiovascular Center for Out-
comes Analysis and administrated the Trans-
plant Center at INOVA Fairfax Hospital in
Virginia. She has special expertise in out-
comes measurement, and the focus of her
work has been on maximizing outcomes of
health care recipients, particularly those with
cardiovascular disease. She was a nursing con-
sultant to the multidisciplinary study team for
the national APACHE study of outcomes
from intensive care and received the First
Annual Health Care Research Award from
the National Institute of Health Care Man-
agement for this work.
Dr. Duffy was the first to examine the link
between nurse caring behaviors and patient
outcomes and developed the caring assessment

402
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C H A P T E R 2 3 Joanne Duffys Quality Caring Model 403

tool in multiple versions. She is especially hidden, in the daily work of nursing. This
interested in the hidden value of nursings form of caring was considered different from
work. Dr. Duffy assisted the American Nurses the caring that occurs between family and
Association in the development and implemen- friends because nurse caring requires special-
tation of acute care and community nursing- ized knowledge, attitudes, and behaviors
sensitive quality indicators and is leading that are directed toward health and healing.
a national demonstration project to ensure Through this specialized knowledge recipi-
caringhealingprotective environments for ents feel cared for, which was theorized
hospitalized older adults and nurses. Dr. Duffy to free them to take risks, to learn new healthy
is an outspoken proponent of quality health behaviors, or to participate effectively in
care, particularly for hospitalized older adults. decision-making based on evidence. This
She has exposed the significance of nursings sense of feeling cared for was considered an
work through the mid-range Quality-Caring antecedent necessary to influence improved
Model and employs innovative approaches to intermediate and terminal outcomes, particu-
educate health care providers on relationship- larly nursing-sensitive outcomes such as
building. knowledge (including self-knowledge), safety,
comfort, anxiety, adherence, human dignity,
health, and satisfaction. Furthermore, the model
Introducing the Model was considered supportive to professional
The Quality-Caring Model was initially nursing. Blending societal needs for measura-
developed in 2003 to guide practice and ble outcomes with the unique relationship-
research (Duffy & Hoskins, 2003). The seeds centered processes central to daily nursing
of the model were sown during discussions practice represented a practical, postmodern
concerning nursing interventions, but it was approach.
informed from earlier work on caring (Duffy, The major purposes of the Quality-Caring
1992). While examining the outcomes vari- Model at that time were to:
able of patient satisfaction, Dr. Duffy found
Guide professional practice
that hospitalized patients who were dissatis-
Describe the conceptualtheoretical
fied often expressed, nurses just dont seem to
empirical linkages between quality of care
care. This concern was corroborated in the
and human caring
literature and represented a clinical problem
Propose a research agenda that would
that significantly impacted patient quality.
provide evidence of the value of nursing
Over time, Dr. Duffy continued to study
(Duffy & Hoskins, 2003).
human interactions during illness, developing
tools to measure caring (Duffy, 2002; Duffy, Since 2003, the Quality-Caring Model
Hoskins, & Seifert, 2007) and studying the has been revised (Fig. 23-1) to meet the
linkage between nurse caring and selected demands of a complex, interdependent, and
health care outcomes (Duffy, 1992, 1993). global health care system that requires a more
In 2002, it became apparent that there were sophisticated workforce, one that understands
few nursing theories that could guide the devel- the significance of systems thinking, whose
opment of a caring-based nursing intervention practice is based on knowledge, multiple and
while simultaneously speaking to the relation- oftentimes competing connections, and one
ship between nurse caring and quality. As part that values relationships as the basis for actions
of a research team, Drs. Duffy and Hoskins and decision-making (Duffy, 2009, p.192). In
developed and tested the model in a group of this revised version, the link between caring
heart failure patients (Duffy, Hoskins, & relationships and quality care is even more
Dudley-Brown, 2005). Caring relationships explicit, challenging the nursing profession to
were the core concept in this model, and were use this knowledge in daily practice. The
believed to be integrated, although often revised model is considered a middle-range
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404 S E C T I O N VI Middle-Range Theories

Self-
advancing
Quality-caring model systems

Feel
cared for
Relationship-centered
professional encounters

Collaborative
relationship
Health care Nurse
team Intermediate
outcomes

Independent relationship
Humans
in relationship Patients and
families

Communities

Self

Figure 23 1 Revised Quality-Caring Model. (From Duffy, J. [2009]. Quality caring in


nursing: Applying theory to clinical practice, education, and leadership [p. 198]. New York: Springer.)

theory because it draws on others work. It beings with various characteristics that make
views quality as a dynamic, nonlinear charac- them unique. Recognizing human characteris-
teristic that is influenced by caring relation- tics, including how they differ and yet are the
ships. When caring relationships are fully same, provides an understanding that influences
integrated aspects of nursing practice, human human interactions and nursing interventions.
connections are formed that may influence Humans are also social beings connected to
future interactions with health care providers; others through birth or in work, play, learning,
such interactions may enhance health out- worship, and local communities. It is through
comes for patients and families. Nurses also these connections that humans mature,
benefit from practicing in congruence with enhance their communities, and advance.
their true nature, often deriving meaning Relationship-centered professional encounters
from this work. consist of the independent relationship
between the nurse and patient/family and the
Concepts, Assumptions, collaborative relationship that nurses establish
and Propositions with members of the health care team. When
In this revision of the Quality-Caring Model, these relationships are of a caring nature, the
there are four main concepts. The first is intermediate outcome of feeling cared for is
humans in relationship. This idea refers to the generated. Embedded in this concept are the
notion that humans are multidimensional caring factors that are discussed in the next
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C H A P T E R 2 3 Joanne Duffys Quality Caring Model 405

section. Feeling cared for is a positive emotion Propositions from the revised Quality-
that signifies to patients and families that they Caring Model include:
matter. It allows one to relax and feel secure
Human caring capacity can be developed.
about health care needs. It is an important
Caring relationships are composed of dis-
antecedent to quality health outcomes, partic-
crete factors.
ularly those that are nursing-sensitive.
Caring relationships require intent, choice,
Patients and families who experience car-
specialized knowledge and skills, and time.
ing relationships with the health care team are
Engagement in communities through car-
more apt to concentrate on their health, focus
ing relationships enhances self-caring.
on learning about it, modify lifestyles, adhere
Independent caring relationships between
to the recommendations and regimens, and
patients and nurses influence feeling
actively participate in health care decisions.
cared for.
They feel understood and more confident in
Collaborative caring relationships among
their abilities. Over time, persons who experi-
nurses and members of the health care
ence caring interactions with health profes-
team influence feeling cared for.
sionals progress to self-caring individuals.
Feeling cared for is an antecedent to
Self-caring is the final concept in this model.
self-advancing systems.
It is a human phenomenon that is stimulated
Feeling cared for influences the attain-
by caring relationships. Self-caring is a capac-
ment of intermediate and terminal health
ity that cannot be controlled; it emerges over
outcomes.
time driven by caring connections. Self-caring
Self-advancement is a nonlinear, complex
represents quality in that it is dynamic and
process that emerges over time and in space.
enhances an individuals well-being. The over-
Self-advancing systems are naturally
all purposes of the revised Quality-Caring
self-caring or self-healing.
Model are to (1) guide professional practice
Relationships characterized as caring
and (2) provide a foundation for nursing
contribute to individual, group, and system
research. It can also be used in nursing educa-
self-advancement (Duffy, 2009).
tion (to guide curriculum development and
facilitate caring studentteacher relationships) The overall role of the nurse in this model
and in nursing leadership as a basis for human is to engage in caring relationships with self
interactions and decision-making. and others to engender feeling cared for
Assumptions of the revised Quality-Caring (Duffy, 2009, p. 199). Such actions positively
Model include the following: influence intermediate and terminal health
outcomes by easing anxieties and leveling the
Humans are multidimensional beings capa-
playing field for genuine reciprocal interac-
ble of growth and change.
tions. Feeling cared for leads the way to future
Humans exist in relationship to themselves,
interactions and may influence healing. Caring
others, communities or groups, and nature.
relationships also advantage nurses because
Humans evolve over time and in space.
sharing oneself with another authentically rais-
Humans are inherently worthy.
es awareness and promotes self-knowing. Car-
Caring is embedded in the daily work of
ing relationships enhance nursing-sensitive
nursing.
patient outcomes and may influence clinical
Caring is a tangible concept that can be
autonomy (Weston, 2008).
measured.
The revised Quality-Caring Model specif-
Caring relationships benefit both the one
ically emphasizes the following responsibilities
caring and the one being cared for.
of professional nurses:
Caring relationships benefit society.
Caring is done in relationship. Attain and continuously advance knowl-
Feeling cared for is a positive emotion. edge and expertise in the caring factors.
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406 S E C T I O N VI Middle-Range Theories

Initiate, cultivate, and sustain caring rela- universe, their fundamental nature is integrat-
tionships with patients and families. ed or whole. The many seemingly different
Initiate, cultivate, and sustain caring rela- parts relate to and depend on each other, gen-
tionships with other nurses and all mem- erating an orientation of the self that repre-
bers of the health care team. sents a source of understanding often lost in
Maintain an awareness of the patient/ the business of life. Individuals tend to go
family point of view. about their day habitually moving from one
Carry on self-caring activities, including task to another without noticing their internal
professional development. bodily processes, feelings, or connections with
Integrate caring relationships with specific others. This externally driven focus separates
evidence-based nursing interventions to individuals from those internal forces that
positively influence health. hold a special knowledge of self. In nursing,
Advance quality health care through professionals care for others and their families
research and continuous improvement. with ease, frequently forgetting to connect
Using the expertise of caring relationships with self. Yet, allowing oneself to slow down
embedded in nursing, actively participate in enough to access his or her own genuineness
community groups. offers a clarity that is life-enhancing. Some
Contribute to the knowledge of caring and would say such inner awareness is necessary
ultimately the profession of nursing, using for authentic interaction and health (Davidson
varied approaches of inquiry. et al., 2003), while others (Siegel, 2007) believe
Maintain an open, flexible approach. it is necessary to adequately care for others. As
human beings, professional nurses who are
Caring Relationships regularly in touch with themselves set up the
conditions for self-caring, a state that offers a
There are four caring relationships essential
rich supply of energy and renewal.
to quality caring (Fig. 23-2). The first is the
In nursing, remaining self aware is a neces-
relationship with self. Because humans are
sary prerequisite for caring relationships
multidimensional (comprised of biopsycho
because in knowing the self, it is possible
socialculturalspiritual components) that
to know others. Regular mindfulness activities
continuously interact in concert with the
such as prayer, meditation, quiet time, atten-
tion to physical health through regular exercise
and proper nutrition, and creative activities,
when performed in a conscious manner, pro-
mote insight. Likewise in the work environ-
ment, short pauses, consciously remembering
to center on the person being cared for,
attending to bodily needs such as nourish-
Health ment and elimination, and even short time
Self
care team
outs ensures that the caring focus of nursing
remains the priority. Reflective awareness by
actively soliciting feedback about ones per-
Patients
and formance is another method of attaining self-
Families knowledge that may offer professional nurses
a boost in self-confidence or specific learning
Communities opportunities. Reflective analysis in which
thoughts are actually documented in written
or taped format and then analyzed for their
Figure 23 2 Four relationships necessary for quality subjective meanings can be used to inform
caring. clinical practice. Professional nurses need to
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C H A P T E R 2 3 Joanne Duffys Quality Caring Model 407

acknowledge and reflect on the important work environment that may increase work
work they do in order to value themselves and satisfaction.
nursing, a precondition for caring relation- Finally, caring for the communities nurses
ships (Foster, 2004). live and work in reflects a caring relation-
As the primary focus of nursing, patients ship essential to the revised Quality-Caring
and families who are ill are vulnerable and Model. This relationship is predicated on
dependent on nurses for caring. Initiating, cul- the belief that humans interact with groups
tivating, and sustaining caring relationships beyond the family to connect, share similar
with patients and families is an independent history and customs, and enhance the lives of
function of professional nursing that involves each other. Engaging in communities pro-
intention, choice, specific knowledge and skills, vides professional nurses opportunities to use
and time (Duffy, 2009). Intending to care caring relationships as the basis for improving
depends on ones attitudes and beliefs; it shapes health or decreasing disease. Such activities
a nurses choice and resulting behaviors, specif- contribute to the ongoing vitality of the
ically whether to care for another. Such community and enrich nurses personal lives.
choice is a conscious decision that is required The four relationships essential to quality car-
for effective caring relationships. Deep aware- ing when well-developed and practiced with
ness of the self enhances caring intention and knowledge of the caring factors meets the
consequential behaviors become more positively needs of patients and families for quality
focused toward the patient/family. health care.
Collaborative relationships with members
of the health care team are essential to quali- The Caring Factors
ty health care (Knaus, Draper, Wagner, &
Caring is not just a mind-set or simple acts
Zimmerman, 1986) and are depicted as an
of kindness; rather, clinical caring requires
important relationship in the Quality-Caring
knowledge (Mayerhoff, 1971) and skills.
Model. Nurses are already connected to one
Many have theorized about the qualities nec-
another by the work they do, and with other
essary for therapeutic relationships (Rogers,
members of the health team by the common-
1961; Yalom, 1975), but Watson (1979, 1985)
ality of simultaneously providing services
identified 10 factors necessary for human
to patients and families. But collaboration
caring in the patientnurse relationship.
connotes mutual respect for the work of other
Through empirical testing, eight factors
health professionals and occurs in relationship.
were identified in a sample of 557 medical
Ongoing interaction is key to collaboration to
surgical patients that represented caring
seek the others point of view, validate the
(Duffy, Hoskins, & Seifert, 2007). These
work, share responsibilities, and evaluate the
factors point to the specific knowledge and
care. The Quality-Caring Model maintains
skills necessary for caring relationships. The
that professional nurses have a responsibility
following represent the caring factors (as
for implementing collegial, caring interper-
defined by this group of medical-surgical
sonal relationships with each other and mem-
patients):
bers of the health care team. Discussing
specific clinical issues pertinent to patients, Mutual problem-solving
participating in joint rounds, improving Attentive reassurance
quality or research projects, holding family Human respect
conferences, and discharging rounds are all Encouraging manner
examples of positive collaboration that benefit Appreciation of unique meaning
not only patients and families but the health- Healing environment
care team as well. Affirming each others Affiliation needs
unique contribution to patient care through Basic human needs (Duffy, Hoskins, &
genuine collaboration contributes to a healthy Seifert, 2007)
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408 S E C T I O N VI Middle-Range Theories

The caring factors relate to Watsons origi- healing environment, including appealing sur-
nal Carative Factors (Watson, 1979, 1985), but roundings, decreasing stressors (noise, light-
also are consistent with aspects of other nurs- ing), ensuring patient privacy and confiden-
ing theorists work (Swanson, 1991; Peplau, tiality, and practicing in a safe manner are
1988; Roach, 1984; Boykin & Schoenhofer, included in this factor. The particular norms
1993; Leininger, 1981; Nightingale, 1992; and customs of a department to which a
Johnson, 1990; King, 1981; Orem, 2001; patient is admitted also have impact on the
Henderson, 1980; Roy, 1980) and empirical environment. This factor is receiving renewed
research (Cossette, Cote, Pepin, Ricard, interest today as professional nurses are being
& DAoust, 2006; Boudreaux, Francis, & viewed as crucial to patient safety (Institute of
Loyacano, 2002; Campbell & Rudisill, 2006; Medicine, 2004). Ensuring that basic human
Mangurten et al., 2006; Paul, Hendry, & needs are attended to during an illness
Cabrelli, 2004; Wolf, Zuzelo, Goldberg, (including the higher order needs [Maslow,
Crothers, & Jacobson, 2006). Mutual problem- 1954]) has been a major role of the profes-
solving represents the largest factor and refers sional nurse that today is often delegated to
to assisting patients and families to learn unlicensed assistive personnel. Often this fac-
about, question, and participate in their tor is blended with other nursing activities
health or illness. This is accomplished recip- such as assessments, teaching and learning,
rocally and requires professional interaction and emotional support. Providing for basic
that is informed and engaging. This factor human needs is an opportunity to further the
recognizes that patients and families are the development of caring relationships. Finally,
decision-makers. Facilitating informed alter- appreciating the significance of affiliation
natives is crucial. Attentive reassurance refers to needs refers to making sure that patients are
being available and offering a positive outlook not only allowed access to their families, but
to patients and families that helps them feel also that families are included in care deci-
secure. Professional nurses who use this factor sions. Being open and approachable to fami-
are able to be with their patients long lies and keeping them informed is important
enough to focus on their needs, listen, and to patients well-being and should be a normal
present some cheerful dialog. Human respect part of nursing care.
implies valuing the person of the other by The caring factors are used in relation-
acting in such a way that demonstrates that ship with others and comprise the knowl-
value. For example, calling a patient by his or edge and skills required for caring relation-
her preferred name, performing tasks in a ships. Using them is dependent on patient
gentle manner, and maintaining eye contact needs and the context of the situation. Not all
show regard for the other. Using an encourag- factors are necessarily used at once; rather, the
ing manner or a supportive demeanor during professional nurse uses his or her judgment to
interactions conveys confidence in the patient make use of them. When applied with expert-
and is expressed verbally and nonverbally. It ise, these factors are theorized to positively
is especially important to maintain uniformi- impact recipients such that they feel cared
ty between messages expressed and those for. In fact, feeling cared for is calming to
implied by body language. Appreciation of the patient, leaving him or her to concentrate
unique meanings helps a patient feel under- on the meaning of illness and the require-
stood because the nurse uses this factor to ments for health and healing. Feeling cared
acknowledge what is significant to patients for also sets up the conditions for future inter-
and families. In other words, nurses aim to actions that eventually lead to outcomes of
see things from the patients point of view care. In other words, the patients ability to
including his or her sociocultural meanings. progress is mediated somewhat by the feelings
In this way, nurses tailor interventions in the generated as a consequence of caring relation-
patients frame of reference. Cultivating a ships (Duffy, 2009). Performing nursing in
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C H A P T E R 2 3 Joanne Duffys Quality Caring Model 409

such a way that valuable time is spent predom- Applications of the Model
inantly in caring relationships with patients
and families (i.e., using the caring factors) The Quality-Caring Model provides the
ensures that patients and families feel cared clinician with a way of practicing nursing
for and that health outcomes are positively that is primarily relationship-centered. In
impacted. doing so, it honors the interdependencies
The caring factors are applicable to the necessary for human advancement. It pro-
other three relationships pertinent to the vides a way of being with patients and fam-
Quality-Caring Model. For example, col- ilies through the caring factors that can be
laborative relationships founded on the car- used to guide nursing interventions and
ing factors enhance teamwork and coopera- ongoing learning about the self. The model
tion. As experts in caring, professional nurses offers a way to relate to and engage with other
are in a unique position to profoundly bene- health care providers and the community. In
fit the health care system. Uniting caring addition, because caring relationships can be
knowledge and caring action/s in relation- measured and their consequences assessed,
ships with self, patients and families, co- the model affords an evaluation design for
workers, and the community provides oppor- improvement of services. Specific nursing-
tunities for creative innovations, improvements sensitive outcomes are likely to be influenced
in practice, and a source of energy for future through use of the model so it becomes use-
interactions. Furthermore, some nurses who ful as a foundation for research. Lastly, using
practice this way describe richer work experi- the Quality-Caring Model purports to bene-
ences that are naturally renewing (DAntonio, fit professional nurses as well as patients and
2008). families.

Practice Exemplar
Mr. N is a 56-year-old man with amyotroph- 7:30 A.M. to have this surgery performed. He
ic lateral sclerosis who lives at home with his arrived in his wheelchair accompanied by his
wife. He has been living with the disease for wife. He was nervous about the procedure,
several years and is a quadriplegic who is not only related to the surgery itself, but also
wheelchair bound. Mr. N and his wife invest- because he knew he would not be able to talk
ed in an expensive electronic wheelchair that afterwards. The admitting office was busy so
can support his computer system, which he the technician took his time gathering insur-
uses for communication and work activities. ance information and then wheeled Mr. N
Mr. N is a computer programmer who still down to the preop area. He sat in the wheel-
works at home through this system. He com- chair for 45 minutes until a nurse, who was
municates a little verbally, but mostly he uses busy on the phone, arrived. She introduced
his eyes in a signaling system that his wife herself and stated that he should undress and
taught him. His secretions have been gradu- get in bed so she could begin her assessment.
ally getting worse (despite medications) and Mr. Ns wife undressed him, as she always
he had a gastrostomy tube placed 4 months does at home, and then asked for help getting
ago because swallowing was becoming him in bed. A tech came to help and Mr. N
unbearable. His pulmonary function studies was placed safely in the hospital bed.
were normal and his neurologist suggested The nurse returned with a clipboard and
that he consider an elective tracheostomy began her assessment, collecting pertinent
to avert an emergency. Mr. N subsequently history. Then she began a physical assess-
entered a large teaching magnet hospital at ment. Her resultant problem list consisted
Continued
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410 S E C T I O N VI Middle-Range Theories

Practice Exemplar cont.


of two problems: shortness of breath due to look. The wife asked the PACU nurses for
inadequate airway clearance and inadequate help in figuring out what was wrong, but they
mobility. She told Mr. N a little about the saw that his vital signs, blood gasses, and dress-
upcoming surgery and asked his wife to sign ing were normal. One nurse decided to suc-
the consent papers. The anesthesiologist tion him but there were few secretions. Her
arrived to start the anesthesia, so Mrs. N technique was rather rough, Mr. N grimaced
kissed her husband and he was wheeled into with pain, and Mrs. N asked if it would
the OR. In an hour, he was in the recovery always be this way. The nurse said it would
area and when Mrs. N saw her husband, he get better with time and went over to talk to
was swollen around the eyes, teary, and the other nurse. Mr. N remained anxious
extremely anxious. He was attached to a ven- throughout the night while his wife sat by his
tilator, but he was able to take his own breath side. Neither of them slept. He was taken to
some of the time. He was looking around, the intermediate care unit at 8:30 A.M.
eyes darting from person to person with obvi- On this unit, Mr. N was cared for by a
ous fright. Since he could not move on his young nurse named Molly who had graduated
own, his wife, who understood his anxiety, sat 2 years earlier. Molly stopped briefly to slow
by his side and used their communication herself down and readjust her thoughts
system to talk to him. He told her he felt toward Mr. N before she entered his room.
like he couldnt breathe. Mrs. N, in turn, relayed Taking a couple of slow deep breaths, Molly
this to the nurse who asked her to tell him that entered the room and quickly scanned the
this was a normal feeling after a trach. Mr. N environment and the patient to notice any-
continued to experience anxiety, often cough- thing significant. She introduced herself by
ing, and was eventually placed in the farthest name and then looked Mr. N in the eyes,
bed so as to not disturb the other patients. smiled, and squeezed his hand lightly (human
Unfortunately, Mrs. N could not allay his con- respect). Then she asked what he would like to
cerns and he continued to feel anxious and be called while he stayed with them and
distressed. wrote that name on a board on the wall oppo-
It was 5:00 P.M. and Mr. N was doing well site his bed. Since he couldnt talk, Molly
according to the nurses in the post-anesthesia asked Mrs. N to explain the communication
care unit (PACU); they began his discharge system they used at home and she tried it
by searching for an ICU bed, but there were with Mr. N to better understand his needs.
no available beds in this busy teaching hospi- Using the Quality Caring Model as a frame
tal. Unfortunately, Mr. N had to stay in the of reference, Molly completed a physical
PACU overnight until an ICU bed became assessment that included physiological, emo-
available. Two other patients were also staying tional, sociocultural, and spiritual compo-
overnight. The PACU nurses were unhappy nents. Her goal was to use this opportunity to
with this arrangement because it meant two initiate a caring relationship with Mr. N and
of them would have to stay on call to staff the his wife that could grow and be sustained
unit. They were overheard talking to each throughout the hospitalization experience.
other, saying, If I had wanted to work on a Through this process, Molly came to know
surgical floor, I wouldnt have applied to the Mr. N as a software engineer who still worked
PACU. Mr. N continued to display anxiety, from home, had a married adult daughter and
often gagging and looking fearful with his two grandchildren, is an avid tennis fan (had
eyes. His wife could not help him because she been a player before his illness), and who was
didnt know enough about the procedure to anxious and tired. She also learned he
answer his questions. She thought maybe he received his diagnosis 8 years earlier and had
was in pain, but he denied this. He continued progressively become weaker and eventually
to remain lying in the bed with his frightened wheelchair bound. His father had died of
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C H A P T E R 2 3 Joanne Duffys Quality Caring Model 411

a heart attack at 63 years of age and his assured them that they had the capacity to
mother was alive and well, living in upstate live well with this chronic disease, using
New York. Mr. N was taking a diuretic and examples of what she had already observed
an angiotensin-converting enzyme (ACE) about the couple (attentive reassurance). Molly
inhibitor for hypertension and medication to then asked Mrs. N if she wanted something
reduce his pulmonary secretions. His vital to drink and made sure Mr. N was hydrated
signs were good. Although he was slightly as well. Then she offered him mouth care and
tachycardic with a heart rate of 112, his neck turned him slightly to the side with a pillow
dressing was dry and his back showed behind his back. Molly closed the blinds
evidence of a beginning pressure ulcer at and offered Mrs. N a pillow and a reclining
the coccyx region. Mrs. N, who was all of chair and let them sleep for 2 hours, as they
110 pounds, relayed her difficulty in caring had been up all night (healing environment).
for Mr. N while she worked full time as a She put a sign on the door reminding others
security analyst. This couple regularly visited that the patient was sleeping (basic human needs
with a Lutheran minister who had been a and affiliation needs). For the first time in more
family friend for years. This physical assess- than 24 hours, Mr. N was able to relax and
ment time provided Molly the opportunity to shut his eyes, showing evidence of feeling
understand the unique human being (Mr. N) cared for.
in relationship to his family, his work, and life Mollys professional encounter with this
role (appreciation of unique meanings) and couple was relaxed, genuine, and distinguished
to begin a relationship-centered professional by the caring factors. With only 2 years experi-
encounter that was based on these findings. ence, Molly was competent in their use. Mollys
She documented the results of the assess- focus and knowledge of herself provided the
ment in the computer, looking frequently at strength to meet this couples needs. During
Mr. N so he could see her. The problem list the time they were resting, Molly checked
Molly came up with included issues such as on the couple quietly and frequently (healing
airway maintenance, anxiety, impaired com- environment). At one of these opportunities,
munication, altered family processes, impaired Mrs. N sought out Molly to relay her anxieties
physical mobility, potential skin breakdown, about taking Mr. N home with the trach.
inadequate knowledge, and hypertension. Molly listened and encouraged Mrs. N to
Then she sat down and using the caring fac- adjust first to this new environment while she
tor, mutual problem solving, explained to (Molly) would come back later to help them
Mr. and Mrs. N what would happen on this understand how to live with a trach (affiliation
unit, including how long the couple might needs).
stay, and how and when to contact her. She Molly also spent some time completing
engaged participation by inviting questions Mr. Ns care plan. She listed his problems and
and asked them for guidance regarding developed some interventions based on her
Mr. Ns normal routines. She relayed that she knowledge of his family situation, his own
would be there all day and gave them her routines, and their joint interactions. When
telephone number. Then she asked them the surgeon came for rounds, Molly accom-
what they knew about recovering from a trach panied him and they conversed about Mr. Ns
and listened attentively to their responses. vital signs, dressing, and secretions. Including
She sat a little toward the patient and looked Mr. N in the discussions, they asked how
at him as he talked. This took longer he was feeling and he communicated with
than usual because he used the alphabet to Mollys help. During a conversation at the
spell out words (encouraging manner). She nurses station, both professionals agreed that
explained a little about living with a trach, but Mr. N could go home with support the next
together they decided to wait until after they day. The surgeon relied on Mollys judgment
had some sleep to review trach care. Molly about Nr. Ns readiness for discharge because
Continued
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412 S E C T I O N VI Middle-Range Theories

Practice Exemplar cont.


he had come to know her these last 2 years as about not wanting to be there, was treated
a competent and caring nurse. Molly trusted roughly, and was not turned for 12 hours
her recommendations; their encounter was despite the fact that he was paralyzed. On the
collaborative and friendly. intermediate care unit, the nurse used the
Later that day, Molly returned with a caring factors to initiate and cultivate a caring
written set of instructions about caring for relationship with him from admission. She
trachs. She reviewed the instructions with used this relationship as the basis for care that
both Mr. and Mrs. N, answering questions, included attention to his basic needs for sleep,
allowing Mrs. N to practice with the suction comfort, and nutrition. Molly helped Mr. N
catheters. She used a positive approach, reas- understand his new situation and included
suring Mrs. N that she could do this and that his wife, who would be his caretaker. She was
she would be there in a couple of hours to collaborative with the physician and positive
review the procedure again (attentive reassur- in her demeanor. She referred to the patient
ance and encouraging manner). Molly then as Mr. N and used her time appropriately to
called the social worker and the home care ensure that his transition to home would
team to get things rolling for discharge. Dur- occur safely. In essence, this nurse saw the
ing report, Molly reviewed Mr. Ns problem patient as a whole person, not a physical body
list and her recommended interventions to with a trach, and used her caring knowledge
the oncoming nurse, including those she had and skills to build a relationship that generated
initiated. She felt good that Mr. and Mrs. N trust and security. Through ongoing interac-
were learning about the trach and pleased tion, a connection developed between the
that she had relieved some of their anxiety. nurse and patient that provided the insight
She said good-bye to all her patients and necessary for effectively following the nursing
went to her weekly yoga class to unwind. The process including specific interventions and
next morning, Molly had the same assign- evaluation. Although the tasks she performed
ment and worked with Mr. and Mrs. N to were routine in nature, this nurse balanced
ensure their self-caring needs were met. doing with being caring. The caring relation-
Although this case is typical in many ship she established created a higher quality
acute care facilities, Mr. N is a unique indi- nursing care that benefited both the patient
vidual who experienced two different nurs- and the nurse.
ing encounters. In the first instance, one Acknowledging the unique caring nature
might say that his physical needs were met, of nursing and demonstrating a professional
yet he was not affirmed as the one being commitment to it offers a way for nursing to
treated (the nurses talked to his wife about help patients make sense of their illnesses. It
him), he was not adequately assessed by the also provides an opportunity for nursing to
preop nurse, he remained anxious for many claim a unique place in the health care system
hours postop, was isolated from others, didnt by generating evidence of the value of caring
sleep, overheard professional nurses talking through research.

Evaluating and Improving nurses must be competent in evaluating their


Caring Practice practice, critically appraising caring research in
order to judge its trustworthiness and partici-
The Quality-Caring Model maintains that pate in ongoing evaluation and research con-
quality nursing care is based on the use of best cerning caring.
evidence and asserts that it is a nursing Evaluation of nursing practice is an ongo-
responsibility to gather and use such evidence ing process that is usually based on perform-
in daily practice. This means that professional ance behaviors or competency statements. It
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C H A P T E R 2 3 Joanne Duffys Quality Caring Model 413

is important to begin evaluation by first artic- study effects on specific patient outcomes
ulating the caring factors because they provide (Duffy, Hoskins, & Dudley-Brown, 2005;
the attitudes and behaviors required in caring Erci et al., 2003). Such research adds to the
relationships. The caring factors can be used knowledge base and offers implications for
to develop competency statements or per- the improvement of nursing practice. Study-
formance expectations from which individual ing caring through research is important to
nurses can complete self-evaluations or gather provide evidence of nursings contribution to
peer evaluations that nursing leaders can use health care and to advance the profession.
in annual evaluations. A more comprehensive Such evidence provides policymakers with
approach using the 360 method (Edwards & documentation of nursings value that may
Ewen, 1996; London & Smither, 1995) pro- impact important decisions such as funding,
vides assessments from the perspective of the job descriptions, promotion and advance-
one being evaluated (nurse self-evaluation), ment, and staffing. To that end, the Quality-
those being cared for (patients and families), Caring Model provides a foundation for
the supervisor, and colleagues (other nurses, research. Ensuring that results are disseminated
physicians, other members of the health care quickly to the nursing community through
team). Using the perspective of the patient publications and presentations is a nursing
(the one being cared for) directly points to responsibility that can advance caring science.
ways nurses can improve their practice. The At the systems level, assessing caring on a
360 approach to evaluating caring compe- unit or organizational basis provides some
tence is thorough and relationship centered; it evidence of how well professional practice
takes advantage of multiple sources and per- models are integrated into practice and points
spectives to provide important feedback about to performance improvement recommenda-
nursing practice. tions. Many tools exist that are available to
Effectively appraising caring research assist this process (Watson, 2002). However,
informs nursing practice by providing evi- they vary in terms of how they define caring,
dence that can guide nursing interventions. the approach, how they are administered and
Unit-based journal clubs, nursing rounds, or scored, whose view they are obtaining (e.g.,
even quality improvement data can provide patients, nurses, or others), and validity and
forums for such appraisal. Translating find- reliability. Only a few directly gather informa-
ings of such research into practice and evalu- tion from patients. This is an important
ating the outcomes provide opportunities for component of assessment because the one
improvement. being cared for is the direct source of knowl-
Because the model provides a set of con- edge and others opinions may not be consis-
cepts, assumptions, and propositions, ques- tent. One instrument, the Caring Assessment
tions generated from these theoretical ideas Tool (CAT) (Duffy, Hoskins, & Seifert,
can provide the basis for research. For example, 2007), a 36-item instrument designed to cap-
the proposition, feeling cared for influences ture patients perceptions of nurse caring, has
the attainment of ...health outcomes (Duffy, been used with success in many health care
2009, p. 199) could be tested by linking the institutions. This tool has established validity
results of an instrument measuring caring and reliability and is available in English,
with a set of specific patient outcomes. In fact, Spanish, and Japanese. Using this tool pro-
nurse researchers have investigated this and vides an evaluation of nurse caring behaviors
found some evidence that caring is linked to as perceived by patients that can be used for
patient satisfaction, postoperative recovery, performance improvement and practice revi-
and decreased anxiety (Burt, 2007; Swan, sions. Another instrument that was adapted
1998; Wolf, Zuzelo, Goldberg, Crothers, & from the CAT is the Caring Assessment
Jacobson, 1998). Others have developed car- Tool for Administration (Duffy, 2002). This
ing nursing interventions and used them to tool is a 39-item questionnaire that assesses
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414 S E C T I O N VI Middle-Range Theories

how nurses perceive nurse manager caring processes with nursing-sensitive outcomes
behaviors and has become important in the measures, and assess how structural indicators
assessment of caring practice environments. such as staffing patterns or nurse credentials
Many other instruments exist to measure car- affect caring processes.
ing, however, ensuring that the conceptual Up until now, weaknesses in caring evalua-
base, population and setting, and perspective tion and research including the lag behind new
of the respondent are consistent with your caring theories, the vagueness between findings
own are vital to successful evaluation. and components of theory, measurement issues,
A recent innovative project that allows and poorly designed studies with small and/or
multiple institutions to benchmark their car- nonprobability samples have created gaps in
ing knowledge is the International Caring caring knowledge. Linking caring to nursing-
Comparative Database (ICCD) (Duffy & sensitive patient outcomes, improving existing
Brewer, in press). This ongoing quality caring instruments, caring-based interventional
improvement initiative includes several acute research, educational caring, and costbenefit
care institutions that routinely (quarterly) col- analyses are urgently needed to provide evi-
lect patient level caring data. The participat- dence of nursings value. Using rigorous meth-
ing institutions receive reports that allow cli- ods, research that builds on the work of others
nicians and administrators to benchmark and includes multiple patient populations and
themselves with other institutions, monitor settings would test the validity of caring theo-
improvements in nursing practice, link caring ries and advance nursing practice.

Summary
Practice-based knowledge is a hallmark of a the health care system. Theory-guided,
profession; therefore, a strong alignment evidence-based professional practice that is
between a theory and the practice of it holistic and meaningful can make a pro-
enhances its significance to society. Caring found impact on patient outcomes.
and quality in health care are implicitly tied Implications of the revised Quality-Caring
together. Because humans exist in relation Model exist for educators to help students
to others, caring relationships facilitate learn caring. Using values-based methods with
human advancement and the future interac- meaningful evaluation techniques and fre-
tions so necessary for excellent health care. quent caring studentteacher interactions,
Independent and collaborative caring rela- nurse educators can greatly enhance learning
tionships in health care contribute to outcomes. Clinical courses in which caring
patients welfare in that they promote com- behaviors are valued and role-modeled by fac-
fort, safety, consistent communication, and ulty are essential. It is crucial that those nurses
learning. Professional nurses who regularly in leadership positions create caringhealing
relate to themselves and their communities protective environments for staff and patients
are more equipped to engage in genuine in a cost-effective manner. Redesigning pro-
independent and collaborative caring rela- fessional work so that its primary function is
tionships with patients and families as well relationship centered and decisions are partic-
as advance their own self-caring. Spending ipative is paramount to quality caring. Finally,
time in relationship focuses attention on showing evidence of nursings foremost pro-
the patient versus the disease or task and fessional purpose (caring) through ordinary
generates a meaningful practice that is the everyday caring actions blended with a culture
basis for joy. In essence, the model benefits of continuous inquiry creates novel possibili-
both patients and nurses, the profession, and ties for advancing the profession.
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C H A P T E R 2 3 Joanne Duffys Quality Caring Model 415

Institutions Using the QualityCaring Model as the Institutions Participating in the International Caring Compar-
Foundation for Professional Practice ative Database (ICCD)
Holy Cross Hospital, Silver Spring, MD John C. Lincoln Memorial Hospital,
St. Alphonsus Medical Center, Boise, ID Scottsdale, AZ
Childrens Mercy Hospital, Kansas Scottsdale Healthcare, Scottsdale, AZ
City, MO St. Marys Bon Secours Hospital, Richmond, VA
St. Josephs Medical Center, Towson, MD Memorial Regional Hospital, Mechan-
Johns HopkinsBayview, Baltimore, MD icsville, VA
Virginia Hospital Center Emergency St. Francis Hospital, Charleston, SC
Department, Arlington, VA Wake Forest Baptist Medical Center,
Spectrum Health, Grand Rapids, MI Winston-Salem, NC
Nashoba Valley Hospital, Ayer, MA Mayo Hospitals and Clinics, Scottsdale, AZ
Lowell General Hospital, Lowell, MA Miami Baptist Hospital, Miami, FL
Northern Michigan Medical Center, Jacksonville Baptist Health System (five
Petrosky, MI hospitals), Jacksonville, FL

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Chapter
24
Pamela Reeds Theory
of Self-transcendence
PAMELA G. R EED

Introducing the Theorist Introducing the Theorist


Overview of the Theory Pamela G. Reed is a professor at the University
Practice Exemplar of Arizona College of Nursing in Tucson. She
Summary received her academic degrees from Wayne
References State University in Detroit, Michigan: a BSN
and an MSN with a double major in Child &
Adolescent PsychiatricMental Health Nurs-
ing and Nursing Education, which prepared her
both as a clinical nurse specialist and nurse edu-
cator. In 1982, Dr. Reed received her PhD from
Wayne State University, majoring in nursing
research and theory with a minor in lifespan
development and aging.
Dr. Reed was one of the first in the disci-
pline to study spirituality as an area of scien-
Pamela G. Reed
tific inquiry in nursing. She developed two
widely used research instruments, the Spiritual
Perspective Scale and the Self-Transcendence
Scale. Her research in spirituality, mental
health and well-being, and end of life has
been strongly influenced by Martha Rogers
perspective of nursing and by lifespan devel-
opment theories. She developed her nursing
theory of self-transcendence based on her
research and her developmental perspective of
correlates of well-being. Her theory has been
widely published and is used by many nursing
students and researchers.
Dr. Reed is a fellow in the American
Academy of Nursing and is a member of a
number of professional organizations including
Sigma Theta Tau International, the American
Nurses Association, and the Society of Rogerian
Scholars. She serves on editorial review boards
of numerous journals and as contributing
editor for a Nursing Science Quarterly column,
Scholarly Dialogue. Reed is co-editor of a
nursing theory text, Perspectives on Nursing
Theory, now in its 5th edition.

417
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418 S E C T I O N VI Middle-Range Theories

Since January 1983 Dr. Reed has been on integrate those changes in order to achieve a
the University of Arizona faculty, where she sense of well-being. Individuals often do this
teaches, writes, conducts research, and has themselves, but in times of difficulty nurses
served as Associate Dean for Academic Affairs and other health professionals can help in this
for 7 years. She has received many teaching process.
awards from faculty peers and students. In The original thinking for the theory of self-
addition to her research publications, she fre- transcendence derived from a life-span devel-
quently writes about the philosophical and opmental view of aging and mental health
theoretical dimensions of nursing with a focus (Reed, 1983) coupled with Martha Rogers
on practice-based knowledge development. (1970, 1980) conceptual system that describes
She lives with her husband and two daughters the living processes of humans. When Reeds
in the Tucson, Arizona desert. theory was first developed more than 15 years
ago, it focused on self-transcendence as it
emerges in later adulthood. However, the
Overview of the Theory scope of the theory has been extended beyond
The theory of self-transcendence, like theories this focus to address self-transcendence as a
in general, is a compressed description of a phe- resource for well-being across the lifespan,
nomenon or process, which in this case is self- particularly in times of serious health events
transcendence. The theory does not provide where there is a heightened sense of vulnera-
every instance and detail of self-transcendence. bility or mortality. This change in scope was
As it was once stated about Keplers theory of suggested by findings of studies in which self-
planetary motion, the theory does not catalog transcendence was measured in adolescents,
every position of every planet at every moment young and middle-aged adults, as well as old-
in time (Kauffman, 1995, p. 22). Similarly, er adults. Chronological age is important in
humans are too complex and unpredictable for self-transcendence only insofar as advanced
a nursing theory to catalog all instances of self- age, like health experiences at any age, may
transcendence. Rather, the theory consists of influence an expanded awareness of self in
key concepts and propositions that describe the relation to human mortality and the greater
process of self-transcendence. In addition, the- environment and universe.
ories are open systems that thrive in disequilib-
rium and need continued input to sustain their Assumptions
dynamic structure and usefulness. As such, I All theories are built upon various beliefs and
invite you to consider new ideas that you may philosophic ideas called assumptions that are
have about how to apply, refine, or extend the considered to be generally true and accepted
theory of self-transcendence. by the discipline. Unlike the propositions of a
The focus of the theory of self-transcendence theory, assumptions are neither directly tested
for nursing practice is on facilitating self- nor applied in research and practice. Instead,
transcendence for the purpose of enhancing they support the development of ideas in a
well-being. Theories from other sciences, theory. Two key assumptions underlie the
such as psychology, may also address self- theory of self-transcendence and reflect ideas
transcendence. However, what distinguishes about humans as dynamic, open living sys-
this particular theory as a nursing theory is its tems. They derive from lifespan developmen-
inclusion of well-being of the whole person in tal theory and nursing theory.
the context of health experiences.
The theory proposes that when people face Potential for Well-Being:
life-threatening illness or undergo health-related A Nursing Process
changes that intensify ones awareness of vul- The first major assumption of the self-transcen-
nerability, there may be a readiness or need to dence theory is that humans possess an inner
expand (or transcend) the self-boundary to potential for healing, growth and well-being
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C H A P T E R 2 4 Pamela Reeds Theory of Self-transcendence 419

throughout the lifespan. This inner potential events as well as other crises tend to increase
for well-being has been described most broad- complexity in life that can diminish well-being
ly as a nursing process (Reed, 1997), arguing unless the individual is able to integrate and
that nurses focus their practice and study on organize the complexity. For example, serious
nursing processes, much like chemists study health events confront the individual and fam-
chemical processes, sociologists study social ily with new people and technology, new choic-
processes, and developmentalists study devel- es, lifestyle changes, new worries and fears, new
opmental processes. decisions to be made, and new self-image. As
An underlying mechanism useful in explain- health crises increase the complexity in persons
ing this inner potential for well-being is called lives, a role of nursing is to help them organize
self-organization, referring to a pattern in living and integrate this complexity by (1) providing
systems of increasing complexity and organiza- critical information; (2) guiding them in ways
tion over time (Kauffman, 1995; Reed, 1983). to integrate the needed changes into their lives;
Self-organization occurs across living systems. and (3) supporting their efforts to find mean-
According to the lifespan developmental per- ing in the situation by being a good listener,
spective (Lerner, 2002), increasing complexity validating their feelings, and guiding them in
and organization is a fundamental pattern of identifying their strengths as well as areas
change in developmental processes. Similarly, it where professional help may be needed.
is assumed that self-organization is fundamen- To conclude, a basic assumption of the the-
tal in what I have called nursing processes, by ory is that people possess a self-organizing
which individuals and groups attain healing and potential that, when applied to nursing situa-
well-being (Reed, 1997). What promotes tions, is interpreted as a nursing process that
human development is assumed to also facili- promotes well-being. Self-transcendence is an
tate a sense of well-being. example of humans inherent nursing processes
Martha Rogers (1970, 1980) principle of of well-being; it is one means of integrating and
helicy supports this idea of an inner nursing organizing complexity in life to promote well-
process of well-being: her principle proposes being. Nurses in practice may discover other
that human change is innovative, as well nursing processes by which healing and sense of
as irreversible and often unpredictable. This well-being occur in patients. Ideas about other
capacity for innovation is reflected in individ- nursing processes can generate new nursing
uals ability to undergo positive changes and theories.
experience well-being, even in difficult health
experiences such as facing a terminal illness or The Self-Boundary and
end-of-life caregiving. Acknowledging an Pandimensionality
inner potential for well-being can be a source Self-transcendence involves expanding the
of hope in illness and end of life. self-boundary. Underlying this idea is a second
This idea of inherent nursing processes of assumption that humans, as open systems,
well-being is related to familiar concepts like impose a conceptual boundary on their open-
inner healing and self-healing described in ness to define their reality and provide a sense
other disciplines. But the nursing perspective of identity and security. This assumption is
emphasizes a potential for healing independ- based on ideas from developmental psychology
ent of biophysical perfection or medical cure. on the development of self-identity and from
Biophysical health may play an important role Rogers (1970) early writings about human
in the process, but it is not essential. For exam- well-being and perceived boundaries.
ple, sense of well-being may be experienced In reference to developmental science, it is
among dying or chronically ill individuals. known that perceptions of self and the world
Although people possess this innovative change across the lifespan as persons become
capacity for well-being, the process may be more differentiated, more complex, and
difficult and require others help. Serious health define their identity. For example, theorists
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420 S E C T I O N VI Middle-Range Theories

have identified the diffuse boundary between may be considered in terms of how they are
infant and parent: the increased sense of iden- reflected in individuals self-boundaries. For
tity and self-consciousness in children and example, people may perceive death as a wall
adolescents as they clarify their boundary or a window. Dr. Rogers refrained from
between self and others; the increased differ- using the term death to describe the changes
entiation of self and more secure sense of iden- witnessed at end of life because the word
tity in middle adulthood; and the complex death implied a boundary she thought was
forms of self and connections to others in later artificial and misrepresented the nature of
adulthood and end of life. human beings. Nevertheless, people impose
In reference to nursing science, the theory boundaries on themselves in their journey
of self-transcendence focuses on the per- through life in ways that can influence well-
ceived self-boundary that fluctuates during being. A persons self-boundary influences
health-related events, which are like mini- how she or he perceives self and the world
developmental events in life. While develop- and imagines the mysteries beyond this
mental psychologists focus their theories world.
and research on ontogenetic changes (change
From Assumptions to the Theory
across decades), nurses focus their theories
and practice on microgenetic change (changes The theory of self-transcendence is built on
that occur during health experiences in terms the assumption that humans possess an inner
of hours, days, weeks, or months). capacitytheir own inner nursing processes
The self-boundary is reflected in perspec- to integrate lifes complexities in a way that
tives regarding the inner-self: the relatedness facilitates well-being during health-related
of self to others, environment and nature, problems. This capacity is realized in part by
machines and technology; and the percep- expanding or adjusting ones self-boundary.
tions about relationships between bodymind The individual expands or alters the self-
spirit, life, and death. boundary by bringing in new perspectives,
Rogers (1970, 1980, 1990) ideas challenged revising old beliefs, reaching out to others,
nurses thinking about the usual boundaries and connecting to something greater than
between person and environment, and among oneself. These perspectives help integrate
past, present, and future. She proposed that and organize the complexity of life in a way
humans were really infinite in space and that promotes well-being. A self-boundary
time, extending beyond the discernible can also be limiting or even destructive if it
mass we identify as the human body, and restrains a persons resources for innovation,
without boundaries. She used the term pandi- organization, and ability to make meaning in
mensionality (revised from the former terms a situation. The theory of self-transcendence
four-dimensionality and multidimensionality) to acknowledges the human tendency to con-
express the unbounded nature of humans, even struct a self-boundary as well as the capacity
though she acknowledged that people per- to transcend limiting views of self and the
ceive self-boundaries. Her principle of inte- world in ways that reflect the pandimensional
grality emphasizes a fundamental connected- nature of living systems. The theory is based
ness between people and their environment. In on a pluralistic view of reality that accounts
addition, her concept of relative present chal- for multiple ways that people can expand their
lenged conventional distinctions among past, self-boundaries.
present, and future to emphasize instead the
importance of the individuals own temporal The Theory: Concepts and
perspective. Relationships
In summary, assumptions about pandi- Theories by definition consist of descriptions
mensionality and temporal perspective, which of concepts and proposals about how those
underlie the theory of self-transcendence, also concepts are related to each other. There are
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C H A P T E R 2 4 Pamela Reeds Theory of Self-transcendence 421

three major concepts in the theory: self- some way? Do they have a sense of relatedness
transcendence, well-being, and vulnerability to something greater than themselves? Do
(Fig. 24-1). The model below depicts the they dwell in the past, regret the past, fear
concepts and how they are related to each the future, or live in the present? Self-
other. transcendence provides for flexibility in ones
self-boundary to extend the person beyond
Self-Transcendence immediate and constricted views of self and
Self-transcendence is the core concept of the the world. And it provides ways to organize
theory. It refers to the capacity to expand the and make meaning out of the increasing com-
self-boundary intrapersonally (toward greater plexity that comes into ones life when faced
awareness of ones beliefs, values and dreams), with serious health-related events.
interpersonally (to connect with others, The term self-transcendence may evoke
nature, and surrounding environment), ideas about the mystical, supernatural, or oth-
transpersonally (to relate in some way to er experiences that tend to disconnect self
dimensions beyond the ordinary and observ- from others or from the present. However,
able world), and temporally (to integrate ones spiritual meanings associated with this theory
past and future in a way that expands and more often refer to terrestrial, everyday prac-
gives meaning to the present). Other dimen- tices of spirituality in terms of reaching deeper
sions may be identified. within the self and reaching out to others,
Self-transcendence is evident in psychoso- to nature, to ones God, or other means of
cial and spiritual perspectives and practices adjusting the self-boundary to attain mean-
regarding individuals perceived self-bound- ing in life and sense of connectedness. Self-
aries: Do they have an awareness of their per- transcendence embodies experiences that
sonal beliefs or dreams? Do they engage in connect rather than separate a person from
meaningful relationships with others? Do self, others, and the environment. The value
they feel connected to their environment in of connecting with family and friends and

Self-transcendence
A primary nursing process Secondary
nursing
processes

Intrapersonal

Interpersonal

Vulnerability
and a Transpersonal
Well-being
pandimensional
self Temporal

Other
dimensions

Personal
and
contextual
factors

Figure 24 1 Model of the theory of self-transcendence.


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422 S E C T I O N VI Middle-Range Theories

having social support is well understood. approach to measuring self-transcendence. It


Enjoyment found in being out in nature, tak- is possible that self-transcendence may be
ing in the beauty of the environment, appre- measured by other means and instruments
ciating the arts, caring for a pet, and feeling as well.
connected to society in some way are all rec-
ognized as important to ones well-being. Vulnerability
Nevertheless, relatedness to unseen or Illness, disability, aging, bereavement, and end
unobservable entities may be an important of life all mark times of vulnerability and
perspective within a persons self-boundary. increased awareness of mortality. A second
Religious practices and beliefs are one com- key concept in the theory is vulnerability,
mon pathway to this experience. In society which refers to an increased awareness of
today, there is increasing acknowledgment personal mortality. A wide variety of human
of and opportunity to develop nonreligious experiences can increase this awareness, par-
spiritual perspectives that provide a sense of ticularly health-related events that are life-
connection to something greater than the self. threatening or that involve deep loss. From a
This reference to the unseen or the mystery in developmental perspective, it has long been
life blurs the traditional boundary in modern accepted that events that heighten ones sense
science between the conceptual and empirical, of mortality canif they do not crush the
to allow for perspectives that may facilitate individuals inner selftrigger expansion of self
meaning and well-being. and energize ones journey into life (Becker,
Finally, expansion of the self-boundary 1973; Corless, Germino, & Pittman, 1994;
may also involve connectedness with nonliv- Erikson, 1986; Frankl, 1963; Marshall, 1980).
ing entities that influence well-being in pro- From a nursing perspective of a pandimen-
found ways. Objects can hold meaning and sional self who has potential for innovative
memories that are highly valued and included change (as described in the assumptions), it is
within the boundary of self. In addition, theorized that vulnerability may lead to or be
illness often confronts the individual with accompanied by increased self-transcendence.
technology and machines that can be difficult Health experiences are major sources of
to accept as a necessary part of ones life. increased vulnerability because they confront
However, as the contemporary philosopher individuals and their families with issues or
Donna Haraway (1991) suggested, there can questions about mortality and immortality. A
be liberating power in technologies if they list of situations that may initiate or intensify
are applied in an empowering rather than this awareness of vulnerability include serious
demeaning manner. People can expand their or life-limiting illness, disability, chronic ill-
self-boundary by fusing flesh and machine. ness, loss or anticipated loss, work with seri-
It involves helping patients perceive fluid ously ill patients, traumatic events, and cata-
boundaries between biology and machine strophic societal events. Self-transcendence
and rejecting societal pressure to accept ones may be a resource for well-being during these
limitations as natural and unfortunate. Self- events by helping the person transform loss
boundary expansion and well-being in the into a growth or healing experience. Vulnera-
midst of serious illness involves the valoriza- bility may be assessed in any number of ways
tion of humans particularly in the contexts of that reflect a persons level of awareness or
disability and end of life. nearness of his or her mortality, or being at
The Self-Transcendence Scale (STS) was increased risk for illness, disability, or death.
developed to measure self-transcendence.
The STS is described at the end of this chap- Well-Being
ter. The instrument and the theory have The concept of self-transcendence is linked
evolved together to provide a reliable and valid to the concept of well-being in that fluctuations
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C H A P T E R 2 4 Pamela Reeds Theory of Self-transcendence 423

in self-boundaries influence well-being and relationship between self-transcendence and


mental health. It is theorized that self- well-being. These concepts include the fol-
transcendence, as a nursing process, is linked lowing as possibly significant in the theory:
logically with positive, health-promoting expe- age, gender, ethnicity, years of education, ill-
riences. Self-transcendence is considered to be ness intensity, life history, social support, and
a correlate if not a predictor of well-being. other factors concerning the persons social
Well-being is the third major concept in and physical environment. For example, the
the theory. Well-being is defined broadly relationship between self-transcendence and
as a subjective feeling of health or wholeness well-being may be strengthened by advanced
as based on the persons own criteria at a given age, higher education, certain spiritual or reli-
point in time. It involves an existential gious or philosophical perspectives, and life
judgment by the individual, and is influenced experiences of significant loss. Family stress,
by ones history, culture, values, family and caregiver stress, lack of social support or oth-
other significant relationships, and biophysi- er resources that support self-transcendence
cal factors. may weaken the relationship between self-
There are many indicators of well-being transcendence and well-being.
that can be used in assessment. Nursing and The other set of concepts in the theory are
other health and social sciences have identi- called primary and secondary nursing processes
fied a wide variety of measures of well-being, that support or enhance self-transcendence.
which reveal the diversity of values for well- As a primary nursing process, self-transcendence
ness among individuals and health profes- is accessed directly by and from within the
sionals. Examples of indicators of well-being individual or family without formal external
that have been found to be significantly relat- intervention of a professional. When individ-
ed to self-transcendence include life satisfac- uals acquire self-transcendent perspectives and
tion, happiness, high morale in aging, self- behaviors on their own, self-transcendence
care agency in chronic illness, sense of functions as a primary nursing process. However,
meaning in life, and specific indicators of individuals often may require assistance or
mental health such as absence of depression interventions of professional nurses or other
and anxiety. health care providers. Nursing interventions
Dr. Martha Alligood, a scholar of nursing function as secondary nursing processes in that
theory, suggested that the theory of self- they support and supplement individuals
transcendence could be called a theory of well- and families inner nursing processes of
being (Reed, 2008). In a general sense, the healing. Secondary nursing processes originate
theory of self-transcendence is indeed a well- outside of the individual or family and are
being theory. The theory of self-transcendence designed by professional nurses to facilitate
provides an approachspecifically in refer- well-being.
ence to a persons self-boundaryto facilitat- Note that the nursing processes (primary
ing well-being in nursing practice. Other and secondary) addressed in this theory focus
nursing theories, extant and still to be devel- on self-transcendence. Other nursing theories
oped, can also be described as well-being the- have a different focus and inform nurses about
ories, each proposing a unique focus on under- other kinds of primary and secondary nursing
standing and facilitating the persons healing processes that promote well-being. Self-
potential and well-being in practice. transcendence is one of many nursing processes
that promote healing and well-being. Nursing
Additional Concepts in the Theory interventions can strengthen the relationship
One set of concepts that is important to between a persons self-transcendence and
consider in the theory refers to personal well-being, as shown in the practice exemplar
and contextual factors that may influence the below.
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424 S E C T I O N VI Middle-Range Theories

Practice Exemplar
Several years ago, Rose was diagnosed with The theory of self-transcendence provided a
emphysema. In her youth and through young useful framework for Dr. N to enact her
adulthood, Rose had been a professional assumptions about healing in concrete ways
dancer on Broadway. But she now found that to facilitate Roses well-being. Dr. N was
what were once the strongest parts of her knowledgeable of four dimensions (intraper-
bodyher legswere no longer able to carry sonal, interpersonal, transpersonal, and tem-
her around with grace and ease. Her illness poral) to apply in her work with Rose and her
had advanced to the point that she required family caregiver. The theory also allowed for
supplemental oxygen and a walker at home. the possibility that Dr. N. might discover
This made it difficult for her to get out of the another dimension of the self-boundary that
house as often as she desired. She lived alone could be significant to well-being in the
but her daughter, her family caregiver, visited unique realities of Roses situation.
her several times a week. Recently, Rose expe-
rienced a worsening of her physical symp- Vulnerability
toms and more difficulty breathing. Her The nurse first acknowledged the likelihood
daughter decided that it would be wise for that Roses worsening illness may be con-
Rose to move closer to her. Even though tributing to a heightened sense of vulnerabil-
Roses new apartment was more modern than ity. The diagnosis of a serious illness necessi-
her old house, and her daughter could visit tated relationships with new people (health
more often, Rose wasnt as happy in her new care providers) and unfamiliar routines. It
surroundings. Her daughter was puzzled as to introduced strange, new information and ter-
why Roses mood seemed a little down during minology about the illness itself, medications,
her frequent visits. devices, treatments and self-care activities.
The nurse, Dr. N, who happened to have Dr. N helped to demystify the health care
focused on the spiritual and psychosocial regimen by clarifying information and teach-
aspects of pulmonary health experiences for ing Rose and her daughter about procedures
her doctoral studies, worked together with and available resources. The nurse also pro-
Rose and her family caregiver to better vided emotional support for their questions
understand how to be of help. Roses health and concerns and helped them accept new
and well-being required attention to various elements of care into their life. Dr. N also
dimensions of her life. Together the three of worked to bolster hope and faith in them-
them designed a plan of care that addressed selves that they had the inner strength and
Roses needs regarding physical activity, ability to deal with the situation and perhaps
nutrition, and medical aspects, along with even grow in some way from the difficult
discussing Roses resources for maintaining a experience.
safe and clean home environment. But Dr. N
also knew that facilitating Roses well-being Intrapersonal
was more complex than addressing these Rose explained that she was a private person
physical aspects. and didnt like to depend on others; it sur-
prised her to find out that it felt comforting
Theory as a Framework for Practice to reach out and verbalize her concerns to
Dr. N operated from basic assumptions and another person. The nurses open attitude and
beliefs about human strengths and potential empathy gave Rose permission to express her
for transcending self-boundaries or limita- inner feelings of anger and some of the
tions to attain a sense of well-being in the regrets about her life now that she was facing
midst of vulnerability. She felt compassion, its end. Rose said that the release of emotion
but not pity, for Rose and her caregiver. made her feel better inside.
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C H A P T E R 2 4 Pamela Reeds Theory of Self-transcendence 425

Reflecting on her feelings with Dr. N also also provided her opportunities to use her
helped Rose get more in touch with her own experiences to help others. Sharing her
beliefs about quality of life, values, goals for wisdom with others was very gratifying and
herself, and dreams for her daughters future. enhanced her well-being.
This knowledge would prove useful later on
in making decisions about treatments and Transpersonal
the timing of hospice care. Their discussions Rose also admitted that she wasnt particular-
also helped Rose expand her self-boundary ly religious but found herself praying each
inward, by acknowledging and integrating morning and evening. Dr. N was aware of
difficult feelings into her life. Whether she research findings that suggested that religious
resolved all of her concerns was not as impor- beliefs once held in youth can become salient
tant as acknowledging them and accepting again at the end of life, even if they had been
them so she could move on emotionally. eschewed during adulthood. Regardless, Rose
valued her own spiritual perspectives, which
Interpersonal connected her to something beyond the ordi-
Another area of difficulty for Rose was hav- nary that was greater than her self. Even
ing to rely on a walker and oxygen on a daily though she had difficulty believing in a life
basis. Besides the fact that these objects con- after death, the idea of it as a possibility
fronted her with her mortality, Rose found it offered some comfort and helped Rose inte-
embarrassing that she had to use a walker and grate the painful awareness about her own
oxygen wherever she went. She perceived mortality and being separated from her family
these items as foreign and undignified objects and friends. Dr. N supported Roses transper-
that announced her aging and disability to sonal resources by guiding Rose through a
the world. spiritual history to help uncover other sources
In addition, Rose shared with the nurse of strength that she could draw from as she
that although the apartment was closer to her struggled with her worsening illness.
daughter and much nicer, she missed her
friends in her former home and especially Temporality
missed her mailbox neighbor who also car- The illness initiated and intensified Roses
ried an oxygen tank. They often chatted concerns about the future and fears about
at the mailbox and shared ideas with one pain and mortality. Dr. N explored these con-
another regarding their disease and use of cerns with Rose in a realistic yet empathetic
oxygen. When talking to the neighbor, Rose manner. She guided Rose through a life
didnt feel so different. review whereby Rose reflected on her past,
Dr. N suggested that Rose participate in a made connections to the present, and dis-
pulmonary rehabilitation program. This pro- cussed anticipating the unknown. The therapy
gram could help Rose get used to using her helped Rose reflect on her life in a positive
walker and oxygen, as well as meet new way and to use the past to enrich the present.
people who had similar problems. As part of The life review also helped Rose to recognize
the program, Rose attended a support group her strengths to deal with what may come
where she saw that everyone else not only had in the future. Dr. N found that by simply
the same illness and experiences, but as she reminding Rose to try to engage in positive
said, they all looked like her too! Rose self-talk was sometimes helpful in getting her
no longer felt that she looked different and through a difficult moment.
the support group became her friends. As The nurse also facilitated Roses fuller
Rose was able to expand her self-boundary to enjoyment in the present by encouraging
integrate these devices into her life, she positive experiences such as planning enjoy-
became more accepting of her illness and able activities, holding small celebrations, and
herself overall. Attending the support group taking pictures of important or memorable
Continued
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426 S E C T I O N VI Middle-Range Theories

Practice Exemplar cont.


events. These activities generated a legacy self-boundary. By nurturing connections to
and a gift that connected Roses present to her beliefs and values, her God, her support
her familys future. Expanding her self- group friends, and to her daughter and nurse,
boundary to incorporate other temporalities Rose was able to expand her self-boundaries
gave Rose access to meaningful experiences in ways that enhanced her well-being within
that often sustained her across the trajectory the context of her incurable illness.
of her illness. The theory of self-transcendence was
designed to provide a framework for assessing
Roses Self-Transcendence and studying how self-boundaries may be relat-
Rose did not expect Dr. N or her daughter to ed to mental health and well-being. Transcend-
create self-transcendent experiences for her. ing the self-boundary is not always easy and
But their support and guidance buttressed may require the support of another, even though
her own inner healing potential for healing the assumption is that self-transcendence is
through the illness experience. Roses open- inherent. The theory can help inform nurses
ness to accepting help and guidance from and patients of ways to adjust or expand self-
the nurse was a first step in expanding her boundaries to facilitate well-being.

Summary
The theory of self-transcendence comprises self-transcendence is related to an increase
three key concepts: self-transcendence, well- in level of well-being, however well-being
being, and vulnerability. The concepts are is measured.
defined broadly and fit many nursing situa- 3. The third general proposition is that per-
tions where a persons health is challenged sonal and contextual factors influence
or limited. Three propositions are derived (positively or negatively) the relationship
from the theory, which can be tested between self-transcendence and well-being.
in a diversity of nursing care contexts. The
propositions are stated using abstract terms In addition, a similar proposition can be
such as end-of-life issues, well-being, added if a nursing intervention is under
and personal factors. These general terms consideration. This proposition would
should be replaced with more specific, meas- propose that a given nursing interven-
urable terms to make the propositions appli- tion, for example, art-making, positively
cable to a specific group of patients or clini- influences the relationship between self-
cal practice setting. transcendence and well-being.

1. The first proposition of the theory, The theory of self-transcendence, as dis-


concerning vulnerability, is that self- played in Figure 24-1, is not too complex and
transcendence is greater in persons facing is straightforward in its propositions. As nurses
end-of-life issues than in persons not fac- use the theory in research and practice, they
ing such issues. End-of-life issues arise may identify nuances to the three main propo-
with life events, illness, aging, caregiving, sitions. For example, it is very possible that
and other experiences that increase aware- certain personal factors or nursing interven-
ness of personal mortality. tions may be found to relate directly to self-
2. A second proposition is that self- transcendence.
transcendence is positively related to Overall, the concepts were designed to be
well-being. An increase in level of clearly defined and easily measurable, yet to
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C H A P T E R 2 4 Pamela Reeds Theory of Self-transcendence 427

be broad enough in scope to allow nurses the Practitioners as well as researchers both
flexibility in using the theory across a variety can use the theory to contribute new knowl-
of the following components of the theory: edge about facilitating human well-being
across a variety of health experiences. The
Contexts of vulnerability
theory is dynamic and open to revision and
Expressions of self-transcendence across
further development. I invite nurses to partic-
the four (or more) dimensions
ipate in making self-transcendence a useful
Influential personal and contextual factors
part of their practice with patients and to
Interventions to promote self-transcendence
discover new dimensions and approaches to
Descriptions of well-being by patients and
facilitating well-being.
families

References

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Bartlett. Reed, P. G. (1996). Transcendence: Formulating
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Frankl, V. E. (1963). Mans search for meaning. New York: Reed, P. G. (1997). Nursing: The ontology of the disci-
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Haraway, D. (1991). Simians, cyborgs and women. Reed, P. G. (2008). Reeds theory of self-transcendence.
New York: Routledge. Nurse Theorists Portraits of Excellence Vol. 2. Athens,
Kauffman, S. (1995). At home in the universe: The search OH: Fitne Video Productions.
for laws of self-organization and complexity. Rogers, M. E. (1970). An introduction to the theoretical
New York: Oxford University Press. basis of nursing. Philadelphia: F. A. Davis.
Lerner, R. M. (2002). Concepts and theories of human Rogers, M. E. (1980). A science of unitary man. In:
development (3rd ed.). New York: Random House. J. Riehl & C. Roy (Eds.), Conceptual models for
Marshall, V. M. (1980). Last chapter: A sociology of aging nursing practice (2nd ed., pp. 329338). New York:
and dying. Monterey, CA: Brooks-Cole. Appleton-Century-Crofts.
Reed, P. G. (1983). Implications of the life-span devel- Rogers, M. E. (1990). Nursing: Science of unitary, irre-
opmental framework for well-being in adulthood ducible, human beings: Update 1990. In: E. A. M.
and aging. Advances in Nursing Science, 6, 1825. Barrett (Ed.), Visions of Rogers science based nursing
Reed, P. G. (1986). Developmental resources and depres- (pp. 512). New York: National League for Nursing
sion in the elderly. Nursing Research, 35(6), 368374. Press.
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Chapter
25
Kristen Swansons
Theory of Caring
K RISTEN M. S WANSON

The Journey of Theory The Journey of Theory


Development Begins
Evolution of a Middle-Range Theory of
Development Begins
Cari ng In this revised chapter, I update answers to
Developing and Testing Theory-Guided questions posed by students and practitioners
Practice Applications who have wanted to know more about the
Clarifying Caring Through Literary origins and progress of my research and theo-
Meta-analysis rizing on caring. I have situated myself as a
From Theory and Research Back to nurse and as a woman so that the context of
Practice
my scholarship, particularly as it pertains to
Summary
caring, may be understood. I consider myself
References
to be a second-generation nursing scholar.
I was taught by first-generation nurse scien-
tists (that is, nurses who received their doctor-
al education in fields other than nursing). My
struggles for identity as a woman, nurse, and
academician were, like many women of my
era (the baby boomers), a somewhat organic
and reflective process of self-discovery during
a rapidly changing social scene (witness the
womens and civil rights movements). Third-
Kristen M. Swanson
generation nursing scholars (those taught by
nurses whose doctoral preparation is in nurs-
ing) may find my yearning somewhat odd.
To those who might offer critique about the
egocentricity of my pondering, I offer the
defense of having been brought up during
an era in which nurses dealt with such strug-
gles as, Are we a profession? Have we a
unique body of knowledge? Are we entitled
to a space in the full (i.e., PhD-granting)
academy? I fully appreciate that questions
of uniqueness and entitlement have not
completely disappeared. Rather, they have
faded as a backdrop to the weightier concerns
of making a significant contribution to the
health of all, keeping patients safe, educating
and retaining a supply of nurses prepared
to provide comprehensive patient-centered

428
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C H A P T E R 2 5 Kristen Swansons Theory of Caring 429

care to an aging population with increasingly shaping the institutional vision for practice. It
complex and chronic health conditions, work- was phenomenal witnessing our collective
ing collaboratively with consumers and other capacity as nurses, physicians, respiratory
scientists and practitioners, practicing in a therapists, and housekeepers to collaborative-
highly technological environment, embracing ly make a profound difference in the lives of
pluralism, and acknowledging the socially- those we served. However, what I learned
constructed power differentials associated with most from that experience came from the
gender, race, poverty, and class. patients and their families. I realized that
there was a powerful force that people could
Turning Point call upon to get themselves through incredibly
In September 1982, I had no intention of difficult times. Watching patients move into
studying caring; my goal was to study what it a space of total dependency and come out
was like for women to miscarry. It was my the other side restored was like witnessing a
dissertation chair, Dr. Jean Watson, who miracle unfold. Sitting with spouses in the
guided me toward the need to examine caring waiting room while they entrusted the hearts
in the context of miscarriage. I am forever (and lives) of their partners to the surgical
grateful for her foresight and wisdom. team was awe-inspiring. It was encouraging
I believe that the key to my program of to observe the inner reserves family members
research is that I have studied human could call upon in order to hand over that
responses to a specific health problem (mis- which they could not control. I felt so privi-
carriage) in a framework (caring) that leged, humbled, and grateful to be invited
assumed from the start that a clinical thera- into the spaces that patients and families cre-
peutic had to be defined. So, hand in glove, ated in order to endure their transitions
the research has constantly gone back and through illness, recovery, and, in some instances,
forth between whats wrong and what can be death.
done about it, whats right and how can it be After a year and a half at the University of
strengthened, whats real to women (and Massachusetts, I was still a fairly new nurse
most recently their mates) who miscarry and and was unclear what all of these emotional
how might care be customized to that reality, insights had to do with nursing. I saw them as
and how can we measure the impact of something related to my spiritual beliefs and
caring-based interventions on couples healing me, rather than about my profession. At that
after miscarriage? The back-and-forth nature point, what mattered most to me as a nurse
of this line of inquiry has resulted in insights was my emerging technological savvy, under-
about the nature of miscarrying and caring standing complex pathophysiological process-
that might otherwise have remained elusive. es, and conveying that same information to
other nurses. Hence, I applied to graduate
Predoctoral Experiences schools with the intention of focusing on
My preparation for studying caring-based teaching and on the care of the acutely ill
therapeutics from a psychosocial perspective adult. Approximately 2 years after completing
began, ironically, in a cardiac critical care unit. my baccalaureate degree, I enrolled in the
After receiving my BSN at the University of Adult Health and Illness Nursing program at
Rhode Island, I was wisely coached by Dean the University of Pennsylvania.
Barbara Tate to pursue a job at the brand-new While at Penn, I served as the student rep-
University of Massachusetts Medical Center resentative to the graduate curriculum com-
(U. Mass.) in Worcester, Massachusetts. I was mittee and, as such, was invited to attend a
drawn to that institution because of the nurs- 2-day retreat to revise the masters program. I
ing administrations clear articulation of how distinctly remember listening to Dr. Jacqueline
nursing could and should be. It was exciting Fawcett and listening in amazement as she
to be there from day one. We were all part of spoke about health, environments, persons,
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430 S E C T I O N VI Middle-Range Theories

and nursing; she claimed that these four with the class assignment and the unexpected
concepts were the stuff that truly comprised circumstances surrounding his birth. It so
nursing. I was hearing someone put voice to happened that an obstetrician had been
the inner stirrings I had kept to myself back in invited to speak to the group about miscar-
Massachusetts. It really impressed me that riage at the first meeting I ever attended. I
there were nurses who studied in such arenas. found his lecture informative with regard to
Shortly after the retreat, I received my MSN the incidence, diagnosis, prognosis, and med-
and was hired at Penn on a temporary basis to ical management of spontaneous abortion.
teach undergraduate medicalsurgical nurs- However, when the physician sat down and
ing. I immediately enrolled as a postmasters the women began to talk about their personal
student in Dr. Fawcetts new course on the experiences with miscarriage and other forms
conceptual basis of nursing. It proved to be of pregnancy loss, I was suddenly over-
one of the best decisions I ever made, prima- whelmed with the realization that there had
rily because it helped me to figure out an been a one-in-six chance that I could have
answer to the constant question, Why does- miscarried my son. Up until that point, it
nt a smart girl like you enter medicine? I had never occurred to me that anything
finally knew that it was because nursing, a could have gone wrong with something so
discipline that I was now starting to under- central to my life. I was 29 years old and
stand from an experiential, personal, and aca- believed, quite naively, that anything was
demic point of view, was more suited to my possible if you were only willing to work
beliefs about serving people who were moving hard at it.
through the transitions of illness and well- Two profound insights came to me from
ness. It is safe to say that I was beginning to that meeting. First, I was acutely aware of the
understand that my gifts lay not in the diag- American Nurses Association Social Policy
nosis and treatment of illness, but in the Statement, that, Nursing is the diagnosis and
ability to understand and work with people treatment of human responses to actual and
going through transitions of health, illness, potential health problems (ANA, 1980, p. 9).
and healing. It was clear to me that whereas the physician
had talked about the health problem of spon-
Doctoral Studies taneously aborting, the women were living the
Such insights made me want more; hence, human response to miscarrying. Second,
I applied for doctoral studies and was accepted being in my last semester of course work, I
into the graduate program at the University of was desperately in need of a dissertation top-
Colorado. My area of study, psychosocial ic. From that point on it became clear to me
nursing, emphasized such concepts as loss, that I wanted to understand what it was like
stress, coping, caring, transactions, and person to miscarry. The problem, of course, was that
environment fit. Having been supported by a I was a critical care nurse and knew very little
National Institute of Mental Health (NIMH) about anything related to childbearing. An
traineeship, one requirement of our program additional concern was that during the early
was a hands-on experience with the process of 1980s, there was a strong emphasis on episte-
undergoing a health promotion activity. Our mology, ontology, and the methodologies
faculty offered us the opportunity to carry out to support multiple ways of understanding
the requirement by enrolling ourselves in nursing as a human science, however, our
some type of support or behavior-change methods courses were traditionally quantita-
program of our own choosing. Four weeks tive. Luckily, two mentors came my way.
into the same semester in which I was Dr. Jody Glittenberg, a nurse anthropologist,
required to complete that exercise, my first agreed to guide me through a pre-dissertation
son was born. I decided to enroll in a cesare- pilot study of five womens experiences with
an birth support group as a way to deal miscarriage in order that I might learn about
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C H A P T E R 2 5 Kristen Swansons Theory of Caring 431

interpretive methods. Dr. Colleen Conway- was that women felt heard, understood, and
Welch, a midwife, agreed to supervise my attended-to in a nonjudgmental fashion. In
trek up the psychology-of-pregnancy learning later years, this insight would become the
curve. grist for a series of caring-based intervention
studies.
I have often been asked if my research was
Evolution of a Middle-Range an application of Jean Watsons Theory of
Human Caring (Watson, 1979/1985, 1985/
Theory of Caring 1988). Neither Dr. Watson nor I have ever
Twenty women who had miscarried within seen my research program as an application of
16 weeks of being interviewed agreed to her work per se, but we do agree that the
participate in my phenomenological study of compatibility of our scholarship lends cre-
miscarriage and caring. These results have dence to both of our claims about the nature
been published in greater depth elsewhere of caring. I have come to view her work as
(Swanson, 1991; Swanson-Kauffman, 1985, having provided a research tradition that oth-
1986b). er scientists and I have followed. Watsons
Through that investigation, I proposed research tradition asserts that:
that caring consisted of five basic processes:
1. Caring is a central concept and way of
Knowing relating in nursing.
Being with 2. Multiple methodologies are essential to
Doing for understanding caring as a concept and way
Enabling of relating.
Maintaining belief 3. It is important to study caring so that it
At that time, the definitions were fairly may be better understood, consciously
awkward and definitely tied to the context claimed, and intentionally acted upon to
of miscarriage. In addition to naming those promote, maintain, and restore health and
five categories, I also learned some important healing.
things about studying caring:
Refining the Theory
1. If you directly ask people to describe what Through Research
caring means to them, you force them to Postdoctoral Studies
speak so abstractly that it is hard to find
any substance. Approximately 9 months after I completed
2. If you ask people to list behaviors or words the dissertation, my second son was born. He
that indicate that others care, you end up had a difficult start in life and spent a few days
with a laundry list of niceties. in the newborn intensive care unit (NICU).
3. If you ask people for detailed descriptions Through this event, I became aware that in
of what it was like for them to go through my experience of childbearing loss (having a
an event (i.e., miscarrying) and probe for not-well child at birth), I, too, wished to
their feelings and what the responses of receive the kinds of caring responses that my
others meant to them, it is much easier to miscarriage informants had described. Hence,
unearth instances of peoples caring and my next study, an individually awarded
noncaring responses. National Research Service Award postdoc-
4. I learned that although my intentions were toral fellowship (19891990), was inspired.
to gather data, many of my informants Dr. Kathryn Barnard, at the University of
thanked me for what I did for them. Washington, agreed to sponsor this investiga-
tion and ended up opening doors for me that
As it turned out, a side effect of gathering continue to open. With her guidance, I spent
detailed accounts of the informants experiences over a year hanging out in the NICU at the
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432 S E C T I O N VI Middle-Range Theories

University of Washington Medical Center experience that those more person-centered


(the staff gave me permission to acknowledge aspects of his role could not be stuffed
them and their practice site when discussing for too long and that they often came haunt-
these findings). ingly into his consciousness at 3 A.M. His
The question I answered through the remarks left me to wonder if the true origin
NICU phenomenological investigation was, of burnout is the failure of professions and
What is it like to be a provider of care to care delivery systems to adequately value,
vulnerable infants? In addition to my obser- monitor, and reward practitioners whose com-
vational data, I did in-depth interviews with prehensive care embraces caring, attaching,
some of the mothers, fathers, physicians, managing responsibilities, and avoiding bad
nurses, and other health care professionals outcomes.
who were responsible for the care of five
infants. The results of this investigation are Caring for Socially At-Risk Mothers
published elsewhere (Swanson, 1990). With While I was still a postdoctoral scholar,
respect to understanding caring, there were Dr. Barnard invited me to present my research
three main findings: on caring to a group of five masters-prepared
public health nurses. They became quite
1. Although the names of the caring cate-
excited and claimed that the early draft of the
gories were retained, they were grammati-
caring model captured what it had been like
cally edited and somewhat refined so as to
for them to care for a group of socially at-risk
be more generic.
new mothers. About 4 years before our meet-
2. It was evident that care in a complex
ing, these five advanced practice nurses had
context called upon providers to simulta-
participated in Dr. Barnards Clinical Nursing
neously balance caring (for self and other),
Models Project (Barnard et al., 1988). They
attaching (to people and roles), managing
had provided care to 68 socially at-risk expec-
responsibilities (self-, other-, and society-
tant mothers for approximately 18 months
assigned), and avoiding bad outcomes
(from shortly after conception until their
(for self, other, and society).
babies were 12 months old). The purpose of
3. What complicated everything was that
the intervention had been to help the mothers
each NICU provider (parent or profes-
take care of themselves and control of their
sional) knew only a portion of the whole
lives so they could ultimately take care of their
story surrounding the care of any one
babies. As I listened to these nurses endorsing
infant. Hence, there existed a strong
the relevance of the caring model to their
potential for conflict stemming from mis-
practice, I began to wonder what the mothers
understanding others and second-guessing
would have to say about the nurses. Would
one anothers motives.
the mothers (1) remember the nurses and (2)
While I was presenting the findings of the describe the nurses as caring?
NICU study to a group of neonatologists, I I was able to locate 8 of the original
received an interesting comment. One young 68 mothers (a group of women with highly
physician told me that it was the caring and transient lifestyles). They agreed to partici-
attaching parts of his vocation that brought pate in a study of what it had been like to
him into medicine, yet he was primarily eval- receive an intensive long-term advanced prac-
uated on and made accountable for the tice nursing intervention. The result of this
aspects of his job that dealt with managing phenomenological inquiry was that the caring
responsibilities and avoiding bad outcomes. categories were further refined and a defini-
Such a schism in his role-performance expec- tion of caring was finally derived.
tations and evaluations had forced him to Hence, as a result of the miscarriage,
hold the caring and attaching parts of doing NICU, and high-risk mothers studies, I began
his job unexpressed. Unfortunately, it was his to call the caring model a middle-range theory
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C H A P T E R 2 5 Kristen Swansons Theory of Caring 433

of caring. I define caring as a nurturing way Together we realized that, at the very least,
of relating to a valued other toward whom open-ended interviews involved aspects of
one feels a personal sense of commitment knowing, being with, and maintaining belief.
and responsibility (Swanson, 1991, p. 162). We suspected that if doing-for and enabling
Knowing, striving to understand an event as interventions specifically focused on common
it has meaning in the life of the other, involves human responses to health conditions were
avoiding assumptions, focusing on the one added, it would be possible to transform the
cared for, seeking cues, assessing thoroughly, techniques of phenomenological data gather-
and engaging the self of both the one caring ing into a caring intervention. That conversa-
and the one cared for. Being with means tion ultimately led to my design of a caring-
being emotionally present to the other. It based counseling intervention for women who
includes being there, conveying availability, miscarried.
and sharing feelings while not burdening the Soon, I was writing a proposal for a
one cared for. Doing for means doing for Solomon four-group randomized experimen-
the other what he or she would do for him-or tal design (Swanson, 1999b, 1999c). It was
herself if it were at all possible. The therapeu- funded by the National Institute of Nursing
tic acts of doing for include anticipating Research and the University of Washington
needs, comforting, performing competently Center for Womens Health Research. The
and skillfully, and protecting the other while primary purpose of the study was to examine
preserving his or her dignity. Enabling the effects of three 1-hour-long, caring-based
means facilitating the others passage through counseling sessions on the integration of loss
life transitions and unfamiliar events. It (miscarriage impact) and womens emotional
involves focusing on the event, informing, well-being (moods and self-esteem) in the
explaining, supporting, allowing and validat- first year after miscarrying. Additional aims of
ing feelings, generating alternatives, thinking the study were to (1) examine the effects of
things through, and giving feedback. The last early versus delayed measurement and the
caring category is maintaining belief, which passage of time on womens healing in the
means sustaining faith in the others capacity first year after loss and (2) develop strategies
to get through an event or transition and face to monitor caring as the intervention/process
a future with meaning. This means believing variable.
in the other and holding him or her in esteem, An assumption of the caring theory was
maintaining a hope-filled attitude, offering that the recipients well-being should be
realistic optimism, helping find meaning, and enhanced by receipt of caring from a provider
going the distance or standing by the one informed about common human responses
cared for, no matter how his or her situation to a designated health problem (Swanson,
may unfold (Swanson, 1991, 1993, 1999b, 1993). Specifically, it was proposed that if
1999c). women were guided through in-depth discus-
sion of their experience and felt understood,
informed, provided for, validated, and believed
Developing and Testing in, they would be better prepared to integrate
miscarrying into their lives. The content for
Theory-Guided Practice the three counseling sessions was derived
Applications from the miscarriage modela phenomeno-
As my postdoctoral studies were coming to an logically derived model that summarized the
end, Dr. Barnard challenged me and claimed, common human responses to miscarriage
I think youve described caring long enough. (Swanson, 1999c; Swanson-Kauffman, 1983,
Its time you did something with it! We dis- 1985, 1986a, 1986b, 1988).
cussed how data-gathering interviews were Women were randomly assigned to two lev-
often perceived by study participants as caring. els of treatment (caring-based counseling and
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434 S E C T I O N VI Middle-Range Theories

controls) and two levels of measurement circumstances. My work is further limited by


(earlycompletion of outcome measures the lack of diversity in my research partici-
immediately, 6 weeks, 4 months, and 1 year pants. Over the years, I have predominantly
postloss; or delayedcompletion of outcome worked with middle-class, married, educated,
measures at 4 months and 1 year only). Coun- Caucasian women. I am currently making a
seling took place at 1, 5, and 11 weeks post- concerted effort to rectify this situation and to
loss. ANOVA was used to analyze treatment examine what it is like for diverse groups of
effects. Outcome measures included self- women to experience both miscarriage and
esteem (Rosenberg, 1965), overall emotional caring.
disturbance, anger, depression, anxiety, and Monitoring caring as an intervention vari-
confusion (McNair, Lorr, & Droppleman, able was the second specific aim of the
1981) and overall miscarriage impact, personal Miscarriage Caring Project. Three strategies
significance, devastating event, lost baby, and were employed to document that, as claimed,
feeling of isolation (investigator-developed caring had occurred. First, approximately
Impact of Miscarriage Scale). 10 percent of the intervention sessions were
A more detailed report of these findings is transcribed. Analysis was done by research
published elsewhere (Swanson, 1999b). There associate Katherine Klaich, RN, PhD. As one
were 242 women enrolled, 185 of whom com- of the counselors in the study, she found
pleted. Participants were within five weeks of she could not approach analysis of the tran-
loss at enrollment: 89 percent were partnered, scripts naivelythat is, with no preconceived
77 percent were employed, and 94 percent notions, as would be expected in the conduct
were Caucasian. Over one year, main effects of phenomenologic analysis. Hence, she
included the following: (1) caring was effec- employed both deductive and inductive con-
tive in reducing overall emotional distur- tent analytic techniques to render the tran-
bance, anger, and depression and (2) with the scribed counseling sessions meaningful. She
passage of time, women attributed less per- began with the broad question, Is there evi-
sonal significance to miscarrying and realized dence of caring as defined by Swanson [1991]
increased self-esteem and decreased anxiety, on the part of the nurse counselors? The unit
depression, anger, and confusion. of analysis was each emic phrase that was used
In summary, the Miscarriage Caring Pro- by the nurse counselor. Phrases were coded
ject provided evidence that, although time for which (if any) of the five caring processes
had a healing effect on women after miscarry- were represented by the emic utterances. Each
ing, caring did make a difference in the counselor statement was then further coded
amount of anger, depression, and overall dis- for which subcategory of the five processes
turbed moods that women experienced after was represented by the phrase. Twenty-nine
miscarriage. This study was unique in that it subcategories of the five major processes were
employed a clinical research model to deter- defined. With few exceptions (social chitchat),
mine whether or not caring made a differ- every therapeutic utterance of the nurse coun-
ence. I believe that its greatest strength lies selor could be accounted for by one of the
in the fact that the intervention was based subcategories.
both on an empirically derived understanding The second way in which caring was mon-
of what it is like to miscarry and on a consci- itored was through the completion of paper-
entious attempt to enact caring in counseling and-pencil measures. Before each session, the
women through their loss. The greatest limita- counselor completed a Profile of Mood States
tion of that study is that I derived the caring (McNair, Lorr, & Droppleman, 1981) in
theory (developed from the intervention) order to document her pre-session moods
and conducted most of the counseling ses- (thus enabling examination of the association
sions. Hence, it is unknown whether similar between counselor pre-session mood and self
results would be derived under different or client post-session ratings of caring). After
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C H A P T E R 2 5 Kristen Swansons Theory of Caring 435

each session, women were asked to complete 4. One of the counselors was a psychiatric
Swansons Caring Professional Scale (2002). nurse by background. She knew very little
Having been left alone to complete the meas- about miscarriage before participating in
ure, women were asked to place the evalua- this study and had recently experienced a
tions in a sealed envelope. In the meantime, in death in her family. The only time her
another room, the counselor wrote out her pre-session moods (in this case, depression
counseling notes and completed the Coun- and confusion) were significantly associated
selor Rating Scale, a brief five-item rating of (p.05) with any of the post-session
how well the session went. ratings (both client caring professional
The Caring Professional Scale (2002) score and counselor self-rating) was in
originally consisted of 18 items on a 5-point Session I. During Session I, women dis-
Likert-type scale. It was developed through cussed in-depth what the actual events of
the Miscarriage Caring Project and was com- miscarrying felt like. It is possible that the
pleted by participants in order to rate the counselor was so touched by and caught
nurse counselors who conducted the interven- up in the sadness of the stories that her
tion and to evaluate the nurses, physicians, or own vulnerabilities were a bit less veiled.
midwives who took care of the women at the 5. Session II, in which the two topics
time of their miscarriage. The items included addressed were relationship oriented (who
the following: Was the health-care provider the woman could share her loss with and
that just took care of you understanding, what it felt like to go out in public as a
informative, aware of your feelings, centered woman who had miscarried), was the only
on you? The response set ranged from session in which the other counselors
1 (yes, definitely) to 5 (not at all). The vulnerabilities came through. This coun-
items were derived from the caring theory. selor had just gone through a divorce. Her
Three negatively worded items (abrupt, emo- post-session self-evaluation was signifi-
tionally distant, and insulting) were dropped cantly associated with her pre-session
due to minimal variability across all of moods: depression (p.05) and low vigor,
the data sets. For the counselors at 1, 5, and confusion, fatigue, and tension (all at
11 weeks post-loss, Cronbach alphas were p.01). Also, most notably, there was an
.80, .95, and .90 (sample sizes for the coun- association between this counselors pre-
selor reliability estimates were 80, 87, and 76). session tension and clients post-session
The lower reliability estimates were because Caring Professional scores (p.05).
the counselors caring professional scores were
consistently high and lacked variability (mean
item scores ranged from 4.52 to 5.0). Clarifying Caring Through
Noteworthy findings include the following: Literary Meta-analysis
1. Each counselor had a full range of pre- I also conducted an in-depth review of the
session feelings, and those feelings/ literature. This literary meta-analysis is pub-
moods were, as might be expected, highly lished elsewhere (Swanson, 1999a). Approxi-
intercorrelated. mately 130 data-based publications on caring
2. For the most part, counselor pre-session were reviewed for that state-of-the-science
mood was not associated with post-session paper. Through it I developed a framework
evaluations. for discourse about caring knowledge in nurs-
3. The caring professional scores were ing. Proposed were five domains (or levels)
extremely high for both counselors, indi- of knowledge about caring in nursing. I
cating that, overall, the clients were pleased believe that these domains are hierarchical
with what they received and, as claimed, and that studies conducted at any one domain
caring was delivered and received. (e.g., Level III) assume the presence of all
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436 S E C T I O N VI Middle-Range Theories

previous domains (e.g., Levels I and II). The I set the goal to leave the comfort of acade-
first domain includes descriptions of the mia and to make myself learn more about the
capacities or characteristics of caring persons. world of nursing practice. I realized that if my
Level II deals with the concerns and/or com- work on caring was going to have relevance to
mitments that lead to caring actions. These nursing I needed to understand better what
are the values nurses hold that lead them it was like to practice as a nurse in todays
to practice in a caring manner. Level III health care environment. I was delighted that
describes the conditions (nurse, patient, Susan Grant (at that time Vice President for
and organizational factors) that enhance or Patient Care at the University of Washington
diminish the likelihood of caring occurring. Medical Center) agreed to mentor me. My
Level IV summarizes caring actions. This personal mantra was that I wanted to help
summary consisted of two parts. In the first create the conditions that enable nurses to
part, a meta-analysis of 18 quantitative stud- work in accordance with their core values of
ies of caring actions was performed. It was caring, healing, and keeping their patients
demonstrated that the top five caring behav- safe. The journey I took as an Executive
iors valued by patients were that the nurse Nurse Fellow was extremely rewarding and,
(1) helps the patient to feel confident that at the same time, daunting. The world of
adequate care was provided; (2) knows how to health care is undergoing rapid change. The
give shots and manage equipment; (3) gets to vocabulary, pace, politics, technologies, loca-
know the patient as a person; (4) treats the tions, and challenges of health care are chang-
patient with respect; and (5) puts the patient ing at warp speed. I learned that in the
first, no matter what. By contrast, the top five healthiest practice settings caring must take
caring behaviors valued by nurses were: (1) place at the organizational level and at the
listens to the patient, (2) allows expression point of care. Institutional caring practices
of feelings, (3) touches when comforting is take the form of continuous quality improve-
needed, (4) perceives the patients needs, and ments that strive to achieve the Institute
(5) realizes the patient knows him- or herself of Medicines (2001) call for health care that
best. The second part of the caring actions is delivered in a safe, efficient, effective, time-
summary was a review of 67 interpretive stud- ly, equitable, and patient-centered manner.
ies of how caring is expressed (the total num- Providers experience the rewards of knowing
ber of participants was 2,314). These qualita- their work matters when they practice in
tive studies were classified under Swansons organizations that are driven to constantly
caring processes, thus lending credibility to enhance safe, effective, and compassionate care
caring theory. The last domain was labeled for patients, families, and employees. As a
consequences. These are the intentional and result of lessons learned through the RWJF
unintentional outcomes of caring and noncar- fellowship I now routinely consult with health
ing for patient and provider. In summary, this care facilities where the mission is to create
literary meta-analysis clarified what caring and sustain a culture of caring.
means, as the term is used in nursing, and val-
idated the generalizability or transferability of The Journey Continues: The Couples
Swansons caring theory beyond the perinatal Miscarriage Project
contexts from which it was originally derived. I recently completed an NIH-NINR-funded
randomized controlled trial of three caring-
based interventions against a control condi-
From Theory and tion to see if we can make a difference in
Research Back to Practice men and womens healing after miscarriage.
In 2004, I was honored to be named a Robert The purpose of this randomized trial was to
Wood Johnson Foundation (RWJF) Executive compare the effects of nurse caring (three
Nurse Fellow. When I wrote the application, nurse counseling sessions), self-caring (three
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C H A P T E R 2 5 Kristen Swansons Theory of Caring 437

home-delivered videotapes and journals), developed based on the Miscarriage Model


combined caring (one nurse counseling and the Caring Theory. We enrolled 341
plus three videotapes and journals), and no couples. Intervention findings are currently
intervention (control) on the emotional under review for publication. Similar to the
healing, integration of loss, and couple well- Miscarriage Caring Project we also focused
being of women and their partners (hus- on measuring caring as an intervention vari-
bands or male mates) in the first year after able; those findings are soon to be submitted
miscarrying. All intervention materials were for publication.

Summary
Caring, to be effective, must be sensitive to or war; and still others are committed to liv-
those involved in caring transactions to the ing healthy life practices that limit their
cultural contexts in which caring occurs, and footprint on Earth. Stepping back and ask-
to the common responses that individuals, ing what an ecological perspective on caring
families, groups, and communities experi- and health might look like, it is clear that the
ence when living with conditions of wellness work that lies ahead must focus on the polit-
and illness. Globally, we are living at a time ical, economic, social, institutional, spiritual,
where some people are living longer and and personal practices necessary to promote
with chronic health challenges; others are a world where a healthy human ecology is
dying prematurely due to genetics, poverty, possible.

References

American Nurses Association (ANA). (1980). Nursing: A. S. Hinshaw, S. Feetham, & J. Shaver (Eds).,
A social policy statement. Kansas City, MO: American Handbook of clinical nursing research. Thousand Oaks,
Nurses Association. CA: Sage.
Barnard, K. E., Magyary, D., Sumner, G., Booth, C. L., Swanson, K. M. (1999b). The effects of caring, meas-
Mitchell, S. K., & Spieker, S. (1988). Prevention of urement, and time on miscarriage impact and
parenting alterations for women with low social womens well-being in the first year subsequent to
support. Psychiatry, 51, 248253. loss. Nursing Research, 48, 6, 288298.
Institute of Medicine of the National Academies. Swanson, K. M. (1999c). Research-based practice with
(2001). Crossing the quality chasm: A new health women who miscarry. Image: Journal of Nursing
system for the 21st century. Report Brief. Retrieved Scholarship, 31, 4, 339345.
from http://www.iom.edu/CMS/8089/5432/27184. Swanson, K. M. (2002). Caring Profession Scale.
aspx (Accessed January 29, 2008). In: J. Watson (Ed.), Assessing and measuring
McNair, D. M., Lorr, M., & Droppleman, L. F. (1981). caring in nursing and health science. New York:
Profile of mood states: Manual. San Diego: Educational Springer.
and Industrial Testing Service. Swanson-Kauffman, K. M. (1983). The unborn one:
Rosenberg, M. (1965). Society and the adolescent self- The human experience of miscarriage (Doctoral dis-
image. Princeton, NJ: Princeton University Press. sertation, University of Colorado Health Sciences
Swanson, K. M. (1990). Providing care in the NICU: Center, 1983). Dissertation Abstracts International,
Sometimes an act of love. Advances in Nursing 43, AAT8404456.
Science, 13(1), 6073. Swanson-Kauffman, K. M. (1985). Miscarriage: A
Swanson, K. M. (1991). Empirical development of a new understanding of the mothers experience.
middle-range theory of caring. Nursing Research, Proceedings of the 50th anniversary celebration of
40, 161166. the University of Pennsylvania School of Nursing,
Swanson, K. M. (1993). Nursing as informed caring for 6378.
the well-being of others. Image, 25, 352357. Swanson-Kauffman, K. M. (1986a). A combined quali-
Swanson, K. M. (1999a). Whats known about caring tative methodology for nursing research. Advances in
in nursing science: A literary meta-analysis. In: Nursing Science, 8(3), 5869.
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Swanson-Kauffman, K. M. (1986b). Caring in the Watson, M. J. (1979/1985). Nursing: The philosophy and
instance of unexpected early pregnancy loss. Topics in science of caring. Boulder, CO: Colorado Associated
Clinical Nursing, 8(2), 3746. Press.
Swanson-Kauffman, K. M. (1988). The caring needs Watson, M. J. (1985/1988). Nursing: Human science and
of women who miscarry. In M. M. Leininger human care. New York: National League for Nursing
(Ed.), Care: Discovery and uses in clinical and com- Press.
munity nursing. Detroit: Wayne State University
Press.
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Chapter
26
Mary Jane Smith and Patricia
Liehrs Story Theory
M ARY J ANE S MITH AND PATRICIA LIEHR

Introducing the Theorists Introducing the Theorists


Overview of the Theory Patricia R. Liehr, PhD, RN, graduated from
Practice Exemplar: Advancing Practice Ohio Valley Hospital, School of Nursing in
Scholarship Through Story Theory
Pittsburgh, Pennsylvania. She completed her
Summary
baccalaureate degree in nursing at Villa Maria
References
College, her masters in family health nursing
at Duquesne University, and her doctorate at
the University of MarylandBaltimore, School
of Nursing, with an emphasis on psychophys-
iology. She completed postdoctoral studies at
the University of Pennsylvania as a Robert
Wood Johnson scholar. Dr. Liehr is currently
the Associate Dean for Nursing Research and
Scholarship at the Christine E. Lynn College
of Nursing at Florida Atlantic University.
Mary Jane Smith Patricia Liehr
She has taught nursing theory to masters and
doctoral students for nearly two decades.
Mary Jane Smith, PhD, RN, earned her
bachelors and masters degrees from the
University of Pittsburgh and her doctorate
from New York University. She has held
faculty positions at the following nursing
schools: University of Pittsburgh, Duquesne
University, Cornell University-New York Hos-
pital, and Ohio State University; and she is
currently Professor and Associate Dean for
Graduate Academic Affairs at West Virginia
University School of Nursing. She has been
teaching theory to nursing students for nearly
three decades.

Overview of the Theory


Stories are integral to nursing practice. Prac-
tice decisions are informed by both physiolog-
ical bodily responses and the stories that
infuse bodily responses with unique personal
meaning. To focus on one without attention
to the other contributes to less than the best
439
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440 S E C T I O N VI Middle-Range Theories

nursing care. There are times when one, either process for using the evidence from practice
physiological bodily responses or stories, is stories to grow the substantive knowledge of
foreground while the other is background; the discipline. Finally, an exemplar is used to
this foreground/background interplay dynam- highlight use of the theory in practice through
ically emerges over the course of each nurse application of the seven-phase inquiry process.
person caring interaction. For instance, when
a person, comes into the emergency room Emergence of Story as a Topic
with crushing chest pain and then suddenly of Interest
becomes unconsciousness, numbers are in the Story is not new to nursing. Nurse theorists
foreground. Heart rate, blood pressure, and (Boykin & Schoenhofer, 1991, 2001; Newman,
respiratory rate guide critical immediate 1999; Parse, 1981; Peplau, 1991; Watson,
action. Within a short time, the nurse will 1997) have called attention to the importance
want to begin to gather the story, including of listening to what matters since the time
dimensions such as what the person was of Nightingale, who implored nurses to
doing when the chest pain began, whether stop chattering and begin listening (Nightin-
this has ever happened before, and what gale, 1969). Others (Benner, 1984; Chinn &
other life/health circumstances could have Kramer, 1999; Ford & Turner, 2001) have
contributed to the chest pain. Stories are used the stories of practicing nurses to under-
essential to even the most technology-driven stand both the challenge and the essence of
nursing practice, and in some ways, the more nursing practice. In a discussion of the
technology-driven the practice, the more importance of story for research with minor-
important the place of relevant health stories. ity populations, Banks-Wallace (2002) dis-
Our linear-thinking culture often places cussed the therapeutic value of storytelling.
greater value on physiological bodily responses Story-sharing has also had a prominent
than stories. In fact, precious stories shared place in research with elders (Heliker, 2007;
during nursing practice may be heard and dis- Sierpina & Cole, 2004). It is often used by
regarded or heard and acted upon without nurse researchers focused on the art of caring
another thought about the practice-evidence for people who have dementia (Crichton &
generated. Practice stories are seldom heard Koch, 2007; Holm, Lepp, & Ringsberg,
and chronicled becoming part of the founda- 2005; Keady, Williams, & Hughes-Roberts,
tion of nursing practice evidence. The overall 2007).
intent of this chapter is to describe Story The- Recently, physicians have emphasized nar-
ory as a framework informing story-gathering rative medicine as both a way of learning clin-
and story analysis, thereby positioning story ical practice essentials and a way of approaching
as a major thread of nursing practice evidence, patients (Charon & Montello, 2002; Charon,
contributing to substantive nursing knowledge. 2006; Mehl-Medrona, 2007). Diamond, a
This chapter first addresses the emergence psychotherapist, addressed the long history
of story or narrative as a topic of interest for of using narrative, in forms such as personal
health care providers, including nurses. Then, testimony and letter-writing, to treat alco-
Story Theory is summarized, including the holism and addiction. In his book, entitled
essential theory concepts (intentional dialogue, Narrative means to sober ends (Diamond,
connecting with self-in-relation, creating ease) 2000), he describes the spirit of narrative
and discussion of ways that the theory comes therapy: Stories, not atoms, are the stuff that
alive in practice. Bringing the theory to life is hold our lives and our world together (p. 5).
described in the context of the theory method This view of stories resonates with the foun-
dimensions (complicating health challenges, dational assumptions of Story theory and
developing story plot, movement toward with a valuing of the important place of sto-
resolving) aligned respectively with each theory ries for health promotion. In Narrative medi-
concept. We discuss a seven-phase inquiry cine: The use of history and story in the healing
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C H A P T E R 2 6 Mary Jane Smith and Patricia Liehrs Story Theory 441

process, Mehl-Madrona (2007) approached The theory is based on three assumptions


the topic of narrative from a Native American that underpin the framework. The assump-
perspective, distinguishing narrative medicine tions are that people (1) change as they inter-
from conventional medicine and proceeding relate with their world in a vast array of flow-
to share Native American stories that he ing connected dimensions; (2) live in an
described as maps for healing. These writings expanded present moment where past and
and others confirm our beliefs about the future events are transformed in the here and
significance of story and remind us that this now; and (3) experience meaning as a resonat-
core dimension of nursing practice is now ing awareness in the creative unfolding of
being recognized by other disciplines (Liehr human potential (Liehr & Smith, 2008).
& Smith, 2008, p. 208). Although we, the These assumptions are consistent with a
authors, do not equate story with narrative, unitarytransformative view of the world,
we accept the place of narrative within the an inherently complex view (Newman, Sime,
context of story. Story moves beyond narra- & Corcoran-Perry, 1991), establishing a value
tive, intricately weaving remembered events, structure that creates a foundation for the
personal interpretations of the moment theory concepts.
and hopes and dreams to create the now The three concepts of the theory are inten-
moment, guiding choices in-the-moment. tional dialogue, connecting with self-in-
Story Theory is one way to conceptualize relation, and creating ease (Fig. 26-1). The
an idea that has a long history in nursing and related method dimensions are complicating
recently escalated attention from other disci- health challenge, developing story plot, and
plines. The authors believe that the structure movement toward resolving. The nurse engages
of Story Theory creates possibilities for appli- a person through intentional dialogue about
cation and evaluation that are critical to the a complicating health challenge, where con-
endeavor of building substantive disciplinary necting with self-in-relation ensues as the
knowledge. developing story plot surfaces through story-
sharing. As the storyteller makes explicit what
Foundations of the Theory may have been tacit (Polanyi, 1958), moments
of ease accompany movement toward resolv-
Story Theory proposes that story is a narrative
ing the health challenge. Figure 26-1 depicts
happening wherein a person connects with
the theory model, indicating relationships
self-in-relation through nurseperson inten-
among the theory concepts and related
tional dialogue to create ease (Liehr & Smith,
2008). Ease emerges in the midst of accepting method dimensions.
the whole story as ones owna process of The current theory model spreads a wave
attentive embracing the complexity of ones across all concepts in the theory, expressive
situation. All nursing encounters occur within of the energy essential to story-sharing through
the context of story. The stories of the nurse,
patient, family, and other health care providers
Connecting with
are woven together to create the tapestry of the self-in-relation
momentthis is the whole story in the Developing story-plot
moment. Each time a nurse engages a patient
about what matters most regarding a health Nurse
Intentional dialogue
Person
challenge, Story Theory is applicable. By Complicating health challenge
abandoning preexisting assumptions, respect-
ing the storyteller as the expert, and querying Creating Ease
Movement toward resolving
vague story directions, the nurse intentionally
engages the other, enabling connecting with
self-in-relation to create ease. Figure 26 1 Story Theory with method.
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442 S E C T I O N VI Middle-Range Theories

intentional dialogue. The heavy dotted ellipse her puppy while she is in the hospital. There
between nurse and person highlights nurse is an endless list of possibilities known only to
person intentional dialogue, the core activity the person who is living the health challenge.
enabling connecting with self-in-relation and The nurse can never assume to know what
creating ease. There are three ellipses in the matters most about a health challenge regard-
design of the model, mapping a vortex of a less of the extent of experience in a particular
continually evolving process, encompassing all practice environment. The nurse knows how
the theory concepts and associated method to proceed only by querying what matters
dimensions. The links between the essential most about a complicating health challenge.
elements of the model map the theory phe-
nomenon as an energy-laden integrated whole. Connecting with Self-in-Relation
Through Developing Story Plot
Intentional Dialogue About a Connecting with self-in-relation occurs as
Complicating Health Challenge reflective awareness on personal history (Smith
Intentional dialogue is the central activity & Liehr, 1999). It is an active process of recog-
between nurse and person that brings story nizing self as related with others in a develop-
to life; it is querying emergence of a health ing story-plot uncovered through intentional
challenge story in true presence (Smith & dialogue (Liehr & Smith, 2008). To connect
Liehr, 1999). This purposeful engagement with self-in-relation, people see themselves not
with another creates potential for embracing as isolated individuals but as existing and
the whole story in the moment as the nurse growing in a context, which includes awareness
summons the storytellers narrative focusing of other people and times, sensitivity to bodily
on what matters most about a complicating expression, and a sense of history and future in
health challenge (Liehr & Smith, 2008). The the present moment. In following the story
complicating health challenge is a life circum- path, the nurse encourages reckoning with a
stance wherein life change generates uneasi- personal history by traveling to the past to
ness. Understanding the uneasiness refines arrive at the story beginning, moving through
the health challenge to enable meaningful the middle, and into the future all in the pres-
nurseperson interaction. For instance, get- ent, thus going into the depths of the story to
ting married could be both a joyful and an find unique meanings that often lie hidden in
uneasy transition. In this case, the complicat- the ambiguity of puzzling dilemmas (Smith &
ing health challenge may be articulated as the Liehr, 2003, p. 171).
transition from being single to being married. The story path is an expression of a devel-
What matters most to the anticipatory bride oping story plot with high points, low points,
may be the uncertainty she is feeling in the and turning points. High points are times
midst of excited planning. This joyfuluneasy when things are going well by the storytellers
paradox will become the focus for the nurse evaluation; low points are times when they are
using Story Theory to guide practice; the not going so well; and turning points are
nurse will listen to the brides complaint of times when the story twists, sometimes subtly,
stomach pain within the context of joy sometimes dramatically, creating a shift in
uneasiness emerging in the transition to mar- the forward view. Often, we and our col-
ried life. leagues have used a story path approach to
In another example, for a woman facing gather stories (Hain, 2007, 2008; Williams,
the complicating health challenge of a breast 2007) for research. The story path links pres-
cancer diagnosis, it is possible that the ent, past, and future (Liehr & Smith, 2000),
thought of losing her breast matters most, or beginning with the question, What matters
it could be the threat imposed by the cancer, most to you right now about (the health chal-
or the response of her husband to her chang- lenge you are facing)? This question is fol-
ing body, or concern about who will care for lowed by one that queries the past, asking
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C H A P T E R 2 6 Mary Jane Smith and Patricia Liehrs Story Theory 443

how it contributes to the present. Finally, with Mary, so...are you saying that stress-
hopes and dreams are elicited. induced high blood pressure is your pressing
Figure 26-2 depicts a story path for Mary, concern right now? Mary says yes. What
a 29-year-old woman who has come to see the matters most to Mary about the health chal-
nurse practitioner for hypertension. Her blood lenge of hypertension on this visit is her
pressure was recorded as 180/110 mm Hg stressful work life, which she feels unable to
on the primary care visit. The nurse has drawn control. The nurse then moves to the past and
a line on a sheet of paper and asked Mary to asks Mary to identify situations and events on
tell her where she is in her life path by mark- her story path that contributed to her current
ing the present on the line. Then, she asks health challenge of stress-induced high blood
Mary what matters most in this present pressure, and then to the future, asking her
moment. Mary talks about her discomfort to note hopes and dreams related to the
with her elevated blood pressure at her young health challenge. Mary notes story path
age. She adds detail about her job as a project events related to her father and identifies her
director for a research study while having just desire to have a baby within the next 5 years.
finished full-time study for her masters Each of these markings along the story path is
degree and now beginning work on her doc- discussed with the storyteller leading the way.
toral degree in psychology. Marys home situ- The nurse makes notes on the story path so
ation is stabilized by her husband John, who that both participants are engaged in the
she describes as mellow and the strongest process, infusing the physiological indicator,
supporter for considering lifestyle changes to a blood pressure of 180/110 mm Hg, with
lower her high blood pressure. She tells the Marys unique personal story.
nurse that the only time her blood pressure is Before ending any visit where story has
normal is on weekends, when she is away been pulled into the foreground, it is impor-
from work. She provides great detail about tant that the nurse ask if there is anything
her work situation on this visit, describing else about the health challenge that the sto-
work as an out-of-control stress environ- ryteller wants to share to enhance under-
ment aggravated by people who seem to standing. What matters most about a health
enjoy her stressful frenzy. Mary believes that challenge may change from visit to visit and
work-related stress is the strongest contribu- any single visit may encompass more than one
tor to her hypertension. The nurse clarifies issue that matters the most. Detailed story

Marys Story Path


Masters work
paid for by self,
father gave credit

Married John Normal BP through


lifestyle change

5 years
Present:
down the
4 years old College Stress-induced
road
Dad always First experienced BP
dissatisfied DBP Somewhere in here
with her wants to have child
Figure 26 2 Mary's story path.
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444 S E C T I O N VI Middle-Range Theories

paths include bits of practice evidence gleaned Creating Ease While Moving
from what the storyteller emphasized. This Toward Resolving
practice evidence has the potential to guide
Creating ease is remembering disjointed story
the next steps the nurse will take during this
moments to experience flow in the midst
and upcoming visits.
of anchoring (Smith & Liehr, 1999). As a
Story path is just one approach to gathering
person anchors even for a moment, embracing
the story in a practice setting. We have sug-
the comprehensible whole, flow ensues as
gested others such as photographs, family trees,
easiness-with-self situated in a complex con-
and pain diaries (Liehr & Smith, 2008). There
text. Ease is neither assured nor pervasive
seems to be value in eliciting a story through
during story-sharing. Sometimes it is elusive;
a collaborative creation that enhances the
sometimes it is experienced as only a moment
telling and takes the story to a structure such as
in time. When story moments come together
story path. The possible approaches for story-
in a meaningful way for the person sharing a
gathering are limitless. The creative nurse will
story, there is often some movement toward
identify other unique approaches for querying
resolving the health challenge. Movement
what matters most about a health challenge.
may be minuscule or it may be a leap; it
Coming to grips with what matters most is
enables a shift in ones perspective usually
a process of embracing story, where paradoxi-
accompanied by action to address what mat-
cally, embracing releases a person from story
ters most about the health challenge.
confines, engendering a sense of ease.

Practice Exemplar
Advancing Practice Scholarship complicating health challenge. Querying
Through Story Theory what matters most about the health challenge
We have proposed seven phases of inquiry is coming to know the unique perspective of
for practicing nurses who want to develop the person sharing the story. To gather the
practice evidence as a base for knowledge story, the nurse could use a structured
development (Smith & Liehr, 2005). The approach such as story path or story-gathering
phases are: (1) gather a story about what mat- could occur over time through attentive pres-
ters most about a complicating health chal- ence with another. Irrespective of how the
lenge; (2) compose a reconstructed story; nurse gathers the story, coming to know the
(3) connect existing literature to the health other in this way culminates in a reconstructed
challenge; (4) refine the name of the compli- story. The nurse in the forthcoming story
cating health challenge; (5) describe the queried the health challenge of transitioning
developing story plot with high points, low to a nursing home environment for elders
points, and turning points; (6) identify move- who had been living independently.
ment toward resolving; and (7) collect addi- Phase two requires that the nurse compose
tional stories about the health challenge a reconstructed story. A reconstructed story is
(Liehr & Smith, 2008). For the purposes of a narrative creation with a beginning, a mid-
this chapter, we address all phases of the dle, and an end that weaves together the
inquiry process except the last, which takes nurses and the storytellers perspective of the
the nurse back to the practice environment to health challenge; the reconstructed story nat-
substantiate what emerged while completing urally incorporates what matters most about
the first six phases. the health challenge. The reconstructed story
Phase one asks the practicing nurse to shared in this chapter was written by a nurse
gather a story of what matters most about a who cared for Elizabeth during the last
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C H A P T E R 2 6 Mary Jane Smith and Patricia Liehrs Story Theory 445

months of her life in a nursing home. The approach to therapy. Throughout this time, it
nurse had practiced in this nursing home was very hard for Elizabeth to lift her left leg.
for 10 years, often witnessing the health No matter how hard she tried, she couldnt
challenge of transitioning from independent move it like she could move her right leg.
to nursing home living. The story-gathering Still, she was anticipating return to the bun-
occurred over time and story moments are galow to get on with everyday living with her
synthesized as a reconstructed story to serve husband. While Elizabeth was in the nursing
as an evidence base for understanding the home, her husband visited every day at meal-
independent living to nursing home living times and when she was ready to go to sleep.
transition. She referred to these visits as the best times
Elizabeth was an 88-year-old woman who of her day.
enjoyed independent living in her bungalow As part of the discharge plan, the physical
with her husband of 65 years. She and her therapists took Elizabeth to her bungalow to
husband resided in the independent living try out everyday activities. The difficulty
component of a continuing care community. moving her leg was magnified when she was
Elizabeth had a long history of atrial fibrilla- in her usual environment and the therapists
tion, chronic heart failure, and diabetes, but began to think that she may not be able to
she managed to remain independent, using return home. About the same time, Elizabeth
a walker to get around. She attributed her began to have dramatic blood sugar swings
independence to the devotion of her husband that were accompanied by confusion and
who watched over her medication routine, twitching that engaged all parts of her body.
diet, and the balance between her activity/rest Her husband was anxious and looking for
patterns. At the end of January, Elizabeth answers while she was consistently question-
began having difficulty moving her left leg, ing: Whats going to happen to me now?
especially when she awoke in the morning. It Her health challenge at this time was an
seemed to her that her leg had fallen asleep arduous struggle to resume normal inde-
due to positioning during the night. Then, pendent living in her bungalow with her
one February morning, Elizabeths lower leg husband, and what mattered most at this
was painful, cool to touch, and slightly discol- point was the unfamiliar, uncontrollable
ored. Her husband called the community bodily experience, and the uncertainty that
nurse, who immediately sent Elizabeth to the ensued from unfamiliarity. The question,
hospital, where a popliteal clot was found to Whats going to happen to me now? was
be occluding the artery. Amputation was con- one the nurse had heard repeatedly over her
sidered but rejected due to the complexity of years of nursing home practice as residents
Elizabeths health situation. Clot-buster began to understand that they may not return
was dripped directly into Elizabeths clot for home. She had begun to view the question as
7 hours while she lay on her back and the clot a marker of transition that demanded her
dissolved. Elizabeth was relieved because she concentrated attention to what mattered
had always feared losing her leg after wit- most for the resident.
nessing her grandmothers double amputa- Elizabeth didnt understand why her leg
tion as a result of long-standing diabetes. wouldnt move even though she worked so
After 10 days in the hospital, Elizabeth hard in therapy; she tried to hide the twitch-
returned to the nursing home component of ing, which she had never experienced before.
her continuing care community, planning to The twitching and her attempts to move her
begin rehabilitation. Shortly after admission, leg took a lot of energy and she often said
she was diagnosed with the flu, delaying the that she was tired. She never stopped saying
start of rehabilitation. Once she began, the that she wanted to go home, but at some
physical therapists referred to her as their point the nurse suspected that the meaning of
energizer bunny because of her spirited going home had changed for Elizabeth.
Continued
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446 S E C T I O N VI Middle-Range Theories

Practice Exemplar cont.


The nurse asked her Where is home? and Elizabeth was attentively present to the shift-
Elizabeth responded that she wasnt sure. ing story, following Elizabeths lead to pursue
Shortly thereafter, Elizabeth stopped asking meaning during the last months of her life.
to go to the bungalow and she expressed Phase three of the story inquiry process
wishes for a peaceful death. requires that the nurse become familiar with
It became clear that Elizabeth was not get- the existing literature about the complicating
ting better as her heart failure became more health challengein this case, transitioning
debilitating and blood sugar swings continued from independent to nursing home living.
in spite of precise insulin dosing and measured For the purposes of this chapter, only the
carbohydrate intake. At this time, the doctor beginnings of a literature review are reported.
suggested hospice. Elizabeth and her husband However, the practicing nurse interested in a
listened to the description of hospice services, particular health challenge will stay abreast
and she signed the hospice papers. While of related literature and eventually develop
under hospice care, she stopped troubling over a broad literature base informing ongoing
her failed effort to move her left leg, contin- interpretation of stories and physiological
ued to have blood sugar swings, and never bodily responses. To begin this literature
stopped trying to hide the twitching. search, the phrases nursing home transition
Appearances mattered to Elizabeth, and and elder were searched together.
she continued to care about how she looked. Brandburg (2007) conducted an integrated
One time she told the nurse that she wore literature review intended to synthesize the
her pink shirt as often as she could because state of the science regarding transition to a
her husband liked it. She asked to have nursing home for older adults. The 13 articles
her roots done, and the nurse took her to that met the inclusion criteria led to the
the beauty shop one floor away. When she creation of a transition process framework
returned, her husband took her picture. She with the foundational concepts of initial reac-
was wearing her pink shirt and her husband tion, transitional influences, adjustment, and
later included the picture in a memorial col- acceptance. Brandburg (2007) reported that
lage that was created when she died. The long the initial reaction and adjustment phases of
loving relationship between Elizabeth and the process require approximately 6 months.
her husband was most important to both of During that time, people move from disor-
them in her last days. She giggled with him ganization to reorganization and relationship
while recalling fun times they had over the building. They also move from a sense
years and she asked for hugs, an uncharacter- of homelessness to recognition of a new
istic request that became increasingly familiar home where new relationships are developed
to her husband during this time. and old ones are cultivated. She describes
Elizabeth and her roommate told each the final or acceptance phase as one where
other stories, shared chocolates, and looked reflecting on the transition experience in
out for each other as well as they could. Her light of personal values helped many older
roommate called her sweet pea. On the adults accept their new home because they
day Elizabeth died, the roommate asked could find meaning in their present situation
Elizabeths husband and the nurse if she (p. 55).
could pray with them. The theme of home that was noted by
Elizabeth had been in the nursing home Brandburg (2007) was strongly described by
about 3 months before she died. The course Heliker and Scholler-Jaquish (2006) in a
of her story shifted from one of expectation study of 10 newly admitted nursing home
for familiar normalcy in her bungalow with residents who were interviewed multiple
her husband to one of peaceful going home. times over their first 3 months of residency.
The nurse in this situation of caring for Residents responded to the directive: Tell
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C H A P T E R 2 6 Mary Jane Smith and Patricia Liehrs Story Theory 447

me a story about what it is like for you to Merging Elizabeths story with the relevant
come here and live. Data from 32 interviews literature prepared the stage for the next step
lasting from 15 to 60 minutes were analyzed of the story inquiry process, refining the
using a hermeneutical phenomenological name of the complicating health challenge.
approach. Three themes emerged: becoming Phase four suggests that the nurse refine
homeless, getting settled, learning the ropes, the name of the complicating health chal-
and creating a place. The first theme, becoming lenge, if necessary. There may be some times
homeless, contributed to the researchers when the original name is confirmed as ade-
conclusion that ...one cannot separate home, quately expressive of the challenge and there
memories, and friends from ones very identity. are other times when the convergence of the
Each continuously shapes and is shaped reconstructed story with the existing litera-
by the other (p. 41). Getting settled and ture demands that the health challenge name
learning the ropes was a theme characterized be refined. We believe that naming is most
by residents shift from unknown to known, important for the continuing work and we
invisible to visible. Creating a place was a advocate that the health challenge name be
theme related to creating meaning in this new neither too high nor too low in level of
life situation. In their conclusion, the authors abstraction. Names that are too high may be
note the important place of story: The chal- difficult to apply to practice situations and
lenge for nursing home staff is to create situ- names that are too low may be meaningful
ations, a clearing for sharing stories.....that for only a very few people. Considering
facilitate the co-creation of new mean- Elizabeths story and the existing literature,
ings....A staff that listens to what matters to the name of the complicating health chal-
residents can interpret a plan of care that is lenge was changed to struggling to go
meaningful (p. 41). home. This complicating health challenge
Listening was the major theme in a brief name is consistent with the original name of
by Maynes (2004). She shared the story of a transitioning from independent to nursing
patient she met on a short hospitalization, home living, but it captures more clearly what
during which his cancer diagnosis was con- matters most about the transition. It is nei-
firmed and he was evaluated as having a poor ther so high that it cannot be applied in
prognosis. The nurse listened to the quiet practice nor so low that it applies on only a
man and honored his wish to return home narrow subset of people. Because it is in the
to the farm country where he was raised. On middle, it may also have applicability to oth-
the day he was to be transferred, the nurse er populations, such as people who have been
went to his bedside to say good-bye, thankful evacuated from their homes due to natural
that he would be returning to the place he disasters or families of premature newborns
loved. When she approached the bed, she who demand extended hospital stays.
realized that he had died. I sat next to him, Phase five of the story inquiry process
put his hand in mine, and whispered good- focuses on the developing story plot through
bye (p. 32). identification of high points, low points, and
Elizabeths short nursing home stay fits turning points. Turning points are shifts in
most clearly with the initial reaction phase what is happening to create a revision in the
described by Brandburg (2007) and the storytellers forward view. These are situations
becoming homeless theme described by or events that move the story along. High and
Heliker and Scholler-Jaquish (2006), both of low points note times when things are going
whom call attention to the meaning of home. well or not so well. Table 26-1 records the
The idea of home emerges strongly from the turning points, high points, and low points
literature and story sources. Both Elizabeth in Elizabeths reconstructed story. Turning
and the man in Maynes (2004) brief feel points may also be high points or low points,
the pull of home as they approach death. but this is not always the case. Sometimes
Continued
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448 S E C T I O N VI Middle-Range Theories

Practice Exemplar cont.

Table 26 1 Turning Points, High Points, and Low Points in Elizabeths Story
Story Event TP HP LP
Difculty moving leg beginning in January x
Change in leg pain, temperature, and colorleading to hospitalization x x
Decision not to amputate x x
Clot was dissolved x x
Return to nursing home for rehabilitation x
Diagnosed with u x x
Couldnt move leg though she tried x
Husbands four-times-daily visits x
Inability to perform usual activities with physical therapist in bungalow x x
aware she may not return
Blood sugar swings, confusion, and twitching x
Whats going to happen to me now? x
Stopped asking about going to bungalow and began talking about x
peaceful death
Signed hospice papers x
Getting roots done, giggling with husband, sharing chocolate
with roommate x
TP = turning point; HP = high point; LP = low point.

turning points exist with no particular value resolving the health challenge. This phase
assigned by the person living the story. of practice inquiry may be most instructive
In Elizabeths story, turning points can be for the nurses continuing work with a par-
summarized as: (1) diagnosed health issues, ticular population because it taps the inher-
(2) treatment milestones, and (3) the hospice ent wisdom of people living the challenge
decision. High points are: (1) favorable to understand how they got by. The ques-
(according to Elizabeth) treatment milestones tion facing the nurse analyzing Elizabeths
and (2) relationship-centered moments of joy. reconstructed story is: How does Elizabeth
Low points are: (1) limitations in physical move toward resolving the complicating
movement, (2) unfamiliar bodily experiences health challenge of struggling to go home?
with and without diagnoses, and (3) uncer- Elizabeth put all her effort into her recovery
tainty. As the practicing nurse collected more so that her therapists called her their ener-
stories of this nature, comparison, contrast, gizer bunny. When her efforts failed and
and synthesis of turning points, high points, her bodily experience indicated that she was
and low points would be possible and the evi- on a different path, she signed the hospice
dence from stories could contribute to the papers. Finally, Elizabeth enjoyed moments
knowledge base guiding practice with people with her husband and her roommate and
who are transitioning into a nursing home. chose to do things that kept her appearance
One last phase of analysis considers the evi- as she liked. Movement toward resolving
dence from stories to identify how people get recounted in the reconstructed story included
through the health challenge. the approaches of (1) devoting energy to
Phase six asks that the practicing nurse recovery, (2) accepting hospice, (3) experi-
identify how an individual moved toward encing the joy of relationship, and (4) attending
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C H A P T E R 2 6 Mary Jane Smith and Patricia Liehrs Story Theory 449

to self through personal appearance. The person created ease and offers an invitation
range of ways Elizabeth moved toward to consider how others in similar situations
resolving reflects the dynamic and complex may create ease as they move toward resolv-
nature of story. What is characterized as ing a health challenge of struggling to go
movement toward resolving emerges as the home. Once again, there is guidance for
story unfolds. The four approaches extracted nursing practice in the wisdom of people liv-
from the reconstructed story have implica- ing health challenges. The nurse could use
tions for people who are struggling to what is learned from this story analysis to
go home, regardless of the context of their guide current practice and frame further
situation. The story describes how one inquiry.

Summary
This chapter has introduced the reader to precious contribution it can make to nurs-
story as an essential element of practice ing knowledge. Each nurse at the bedside,
evidence. In the story of Elizabeth, story in the clinic, or in the office is uniquely
theory and its related method dimensions positioned to gather and analyze practice
were addressed. The authors hope that prac- stories. The middle-range Story Theory is
ticing nurses can use the story inquiry proposed as a framework for structuring
process to mine story evidence for the story-gathering and analysis.

References

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Boykin, A., & Schoenhofer, S. (1991). Story as a link Journal of Advanced Nursing, 33, 288295.
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245248. by hemodialysis patients. American Kidney Fund:
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Charon, R. (2006). Narrative medicine: Honoring the Heliker, D., & Scholler-Jaquish, A. (2006). Transition of
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adjustment to Alzheimers disease a single case Peplau, H. (1991). Interpersonal relations in nursing.
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Liehr, P., & Smith, M. J. (2000). Using story theory to Polanyi, M. (1958). The study of man. Chicago: The
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Human Caring, 4, 1318. Sierpina, M., & Cole, T. R. (2004). Care Management
Liehr, P., & Smith, M. J. (2008). Story theory. In: Journals, 5(3), 175182.
Middle range theory for nursing (2nd ed.). New York: Smith, M. J., & Liehr, P. (1999). Attentively embrac-
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Chapter
27
The Community Nursing
Practice Model
M ARILYN E. PARKER AND
C HARLOT TE D. B ARRY

Introducing the Theorists Introducing the Theorists


Overview of the Model Marilyn E. Parker is a professor at the
Structure of Services and Activities Christine E. Lynn College of Nursing at
Practice Exemplar Florida Atlantic University, where she is
Summary founding director of the Quantum Foundation
References Center for Innovation in School and Com-
munity Well-Being. She earned degrees from
Incarnate Word College (BSN), the Catholic
University of America (MSN), and Kansas
State University (PhD). Her overall career
mission is to enhance nursing practice,
scholarship, and education through nursing
theory, using both innovative and traditional
means to improve care and advance the
discipline.
As principal investigator for a program of
Marilyn E. Parker Charlotte D. Barry
grants to create and use a new Community
Nursing Practice Model, Dr. Parker has pro-
vided leadership to develop transdisciplinary
school-based wellness centers devoted to
health and social services for children and
families from underserved multicultural com-
munities, teaching university students from
several disciplines, and developing research
and policy to promote community well-being.
Dr. Parkers active participation in nursing
education and health care in several countries
led to her 2001 Fulbright Scholar Award to
Thailand where she continues collaboration
with Thai colleagues. Her commitment to
caring for underserved populations and to
health policy evaluation led to being named a
National Public Health Leadership Institute
Fellow and to being elected a distinguished
practitioner in the National Academies of
PracticeNursing. Dr. Parker is a fellow in
the American Academy of Nursing.

451
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452 S E C T I O N VI Middle-Range Theories

Charlotte D. Barry is an associate profes- (Florida Atlantic University College of Nursing


sor and associate director at the Quantum Philosophy and Mission, 1994/2003).
Foundation Center for Innovation in School The concepts and relationships of the
and Community Well-Being at the Florida model are the guiding force for community
Atlantic University Christine E. Lynn Col- practice. Through various participatory-
lege of Nursing. Dr. Barry graduated from action approaches, including ongoing shared
Brooklyn College, where she earned an asso- reflection, intuitive insights, and discoveries,
ciate degree in nursing; she holds a bachelors the Community Nursing Practice Model has
degree in health administration, a masters evolved and continues to develop. The educa-
degree in nursing from Florida Atlantic tion of university students and the conduct
University in Boca Raton, and a PhD from of student and faculty research are integrated
the University of Miami, Florida. She is with nursing and social work practice.
nationally certified in school nursing. Throughout the early development and ongo-
The focus of Dr. Barrys scholarship and ing refinement of the model, there has been
teaching has been caring for persons in schools nurturing of collaborative community part-
and communities. Current research includes the nerships, evaluation and development of school
usefulness of the Community Nursing Practice and community health policy, and develop-
Model to guide practice in the United States ment of enriched community.
and Africa and school nursing practice issues The model has been used as a framework
including values, research, and delegation. for curriculum development for a masters
Dr. Barry provides leadership roles in many program in advanced community nursing at
organizations, including the International Naresuan University, Phitsanulok, Thailand.
Association of Human Caring (IAHC), the The faculty of nursing at Mbarara University
National Association of School Nursing of Science and Technology, Mbarara, Uganda,
(NASN), and the Florida Association of has used the model to develop study of
School Nurses (FASN). She serves on the advanced community nursing and to design
Board of the NASN and is chair of the school and operate the first school-based community
nursing education special interest group. nursing center in Uganda. The Community
Active in FASN, she has served as president, Nursing Practice Model guides a diverse,
treasurer, and board member. complex, and transdisciplinary practice of
nursing and social work in school-based com-
munity wellness centers serving children and
Overview of the Model families from diverse multicultural communi-
The Community Nursing Practice Model ties and is accepted by local communities
(CNPM) described herein began with, and and providers as essential to the health care
continues to be a blend of, the ideal and the system. The model is featured in a major
practical. The ideal was the commitment to community nursing text (Clark, 2003). The
develop and use nursing concepts to guide practice received the 2001 award for Out-
nursing practice, education, and scholarship, standing Faculty Practice from the National
and of a desire to develop a nursing practice as Organization of Nurse Practitioner Faculties.
an essential component of a nursing college.
The practical was the effort to bring this Foundations of the Model
model to life within the context and structures Essential values that form the basis of the
of a community existing health care system. model are (1) respect for person; (2) persons
The model reflects the concept of nursing are caring, and caring is understood as the
held by the faculty of nursing, nursing is essence of nursing; and (3) persons are whole
nurturing the wholeness of persons and environ- and always connected with one another in
ments through caring, and the mission of families and communities. These essential or
the Christine E. Lynn College of Nursing transcendent values are always present in
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C H A P T E R 2 7 The Community Nursing Practice Model 453

nursing situations, while other actualizing clients and families are provided essential
values guide practice in certain situations. health care while being enrolled in a local
The principles of primary health care from insurance plan that will partially support that
the World Health Organization (1978) are care. Over several weeks, clients are assisted to
the actualizing values. These additional con- enroll in long-term forms of health care
cepts of the model are (1) access, (2) essential- insurance and related benefits and are referred
ity, (3) community participation, (4) empow- to a more permanent source of health care in
erment, and (5) intersectoral collaboration. the community. Transitional care, an ideal for
These also guide health care and social nursing and social work practice, is sometimes
service practice. Concepts of practice that have not possible owing to immigration status, a
emerged include transitional care and enhanc- complex and confounding application process,
ing care. The model illuminates these values or other issues of the family.
and each of the concepts in four interrelated Enhancing care describes nursing and
themes: nursing, person, community, and social work that is intended to assist the client
environment, along with a structure of inter- and family who need care in addition to that
connecting services, activities, and communi- provided by a local health care provider.
ty partnerships (Parker & Barry, 1999). An
inquiry group method has been designed and Person
is the primary means of ongoing assessment Respect for person is present in all aspects of
and evaluation (Parker, Barry, & King, 2000; nursing, with clients, community members,
Ryan, Hawkins, Parker, & Hawkins, 2004). and colleagues. Respect includes a stance of
humility that the nurse does not know all that
Nursing can be known about a person and a situation,
The unique focus of nursing is nurturing the acknowledging that the person is the expert in
wholeness of persons and environments his/her own care and knowing his/her experi-
through caring (Florida Atlantic University ence. Respect carries with it an openness to
[FAU], 1994/2003). Nursing practice, educa- learn and grow. Values and beliefs of various
tion, and scholarship require creative integra- cultures are reflected in expressions of respect
tion of multiple ways of knowing and under- and caring. The person as whole and connected
standing through knowledge synthesis within with others, not the disease or problem, is the
a context of value and meaning. Nursing focus of nursing.
knowledge is embedded in the nursing situa- Persons are empowered by understanding
tion, the lived experience of caring between choices, how to choose, and how to live daily
the nurse and the one receiving care. The with choices made. The person defines what
nurse is authentically present for the other, to is necessary to well-being and what priorities
hear calls for caring and to create dynamic exist in daily life of the family. Nursing and
nursing responses. The school-based commu- social work practice based on practical, sound,
nity wellness centers and satellite sites in the culturally acceptable, and cost-effective meth-
community become places for persons and ods are necessary for well-being and whole-
families to access nursing and social services ness of persons, families, and communities.
where they are: in homes, work camps, Early on, Swadener and Lubecks (1995)
schools, or under trees in a community gath- work on deconstructing the discourse of risk
ering spot. Nursing is dynamic and portable; was a major influence on practice. At risk
there is no predetermined nursing and often connotes a deficiency that needs fixing; a doing
no predetermined access place (Parker, 1997; to rather than collaborating with. Thinking
Parker & Barry, 1999). about children and families at promise
Nursing practice is further described with- instead of at risk inspires an approach to
in the context of transitional care and enhanc- knowing the other as whole and filled with
ing care. Transitional care is that in which potential.
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454 S E C T I O N VI Middle-Range Theories

Respect and caring in nursing require full Practice in the model, whether unfolding
participation of persons, families, and com- in a clinic or under a tree where persons have
munities in assessment, design, and evaluation gathered, provides a welcoming and safe place
of services. Based on this concept, an inquiry for sharing stories of caring. The intention to
group method is used for ongoing appraisal of know others as experts in their self-care while
services. This method is defined as a route of listening to their hopes and dreams for well-
knowing and a route to other questions. being creates a communion between the
Each person is a coparticipant, an expert client and provider that guides the develop-
knower in their experience; the facilitator is ment of a nurturing relationship. Knowing
expert knower of the process. The facilitators the other in relationship to their communi-
role is to encourage expressions of knowing so ties, such as family, school, work, worship, or
calls for nursing and guidance for nursing play, honors the complexity of the context of
responses can be heard. In this way, the essen- persons lives and offers the opportunity to
tial care for persons and families can be understand and participate with them.
known, and care designed, offered, and evalu-
ated (Barry, 1998; Parker, Barry, & King, Environment
2000). The notion of environment within this mod-
el provides the context for understanding
Community the wholeness of interconnected lives. The
Community, as understood within the model, environment, one of the oldest concepts in
was formed from the classical definition offered nursing described by Nightingale (1859/
by Smith and Maurer (1995) and from Pecks 1992), is not only immediate effects of air,
existential, relational view (1987). According to odors, noise, and warmth on the reparative
Smith and Maurer, a community is defined by powers of the patient, but also indicates the
its members and is characterized by shared val- social settings that contribute to health and
ues. This expanded notion of community illness. Another nursing visionary, Lillian
moves away from a locale as a defining charac- Wald, witnessed the hardships of poverty
teristic and includes self-defined groups who and disenfranchisement on the residents of
share common interests and concerns and who the lower Manhattan immigrant communi-
interact with one another. ties. She developed the Henry Street Settle-
Community, offered by Peck (1987), is a ment House to provide a broad range of care
safe place for members and ensures the secu- that included direct physical care up to and
rity of being included and honored. His work including finding jobs, housing, and influ-
focuses on building community through a encing the creation of child labor laws
web of relationships grounded in acceptance (Barry, 2003).
of individual and cultural differences among Chooporian (1986) re-inspired nurses to
faculty and staff and acceptance of others expand the notion of environment to include
in the widening circles, including colleagues not only the immediate context of patients
within the practice and discipline, other health lives, but also to think of the relationship
care colleagues from varied disciplines, grant between health and social issues that influence
funders, and other collaborators. The notion human beings and hence create conditions for
of a transdisciplinary care is an exemplar of heath and illness (p. 53). Reflecting on earth
this approach to community. Another defin- caring, Schuster (1990) urged another look at
ing characteristic of community, according to the environment, inviting nurses to consider a
Peck, is willingness to risk and tolerate a cer- broader view that included nonhuman species
tain lack of structure. The practice guided by and the nonhuman world. Acknowledging the
the model reflects this in fostering a creative interrelatedness of all living things energizes
approach to program development, imple- caring from this broader perspective into a
mentation, evaluation, and research. wider circle. Kleffel (1996) described this as an
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C H A P T E R 2 7 The Community Nursing Practice Model 455

ecocentric approach grounded in the cosmos. creating, as well as the beauty in differences.
The whole environment, including inanimate The model calls into the circles others to cre-
elements such as rocks and minerals, along ate programs and environments to nurtured
with animate animals and plants, is assigned well being (Fig. 27-1).
an intrinsic value (p. 4). This directs thinking
about the interconnectedness of all elements, Core Services
both animate and inanimate. Teaching, prac- Core services are provided at each practice
tice, and scholarship require a caring context site and illuminate the focus of nursing:
that respects, explores, nurtures, and celebrates nurturing the wholeness of persons and
the interconnectedness of all living things environments through caring. The unique
and inanimate objects throughout the global experiences of staff and faculty with those
environment. receiving care create the substance of the
core: respecting self-care practice, honoring
lay and indigenous care, inviting participation
Structure of Services and listening to clients stories of health and
and Activities well-being, providing care that is essential
The model is envisioned as three concentric for the other, supporting caring for self,
circles around a core. Envisioning the model family and community, providing care that is
as a water color representation, one can appre- culturally competent, and collaborating with
ciate the vibrancy of practice within the mod- others for care. These services, provided
el, the amorphous interconnectedness of the to children, students, school staff, and fami-
core and the circles, and the certain lack of lies from the community, occur in the follow-
structure draws attention to the beauty in ing and frequently overlapping categories of

Figure 27 1 Community
nursing practive model.
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456 S E C T I O N VI Middle-Range Theories

care: (1) design and coordinate care: examples are Second Circle
making and receiving referrals, navigation to The second circle draws attention to the
other health services, and insurance enroll- wider context of concern and influence for
ment, home visits, and programs such as the well being and includes structured and organ-
Celebrity Chef Cooking Club, Senior Health ized groups whose members also share con-
Program, or Yoga for Children; the concepts cern for the education and well-being of the
of transitional and enhancing care are illumi- persons served at the centers but within a
nated here through the development of col- wider range or jurisdiction such as a district or
laborative relationships; (2) primary preven- county. Examples of these policy-making or
tion and health education: examples include advising groups include the school district
child-development milestones, pre- and post- and county public health department, the
natal wellness, breast health, testicular exami- county health-care district, Childrens Service
nation, stress reduction, chronic illness man- Council, American Lung Association, and
agement, car safety, and administration of the American Red Cross. Local funders who
immunizations; (3) secondary prevention/health offer support for use of the model include
screening/early intervention: examples include the Health Care District of Palm Beach
hearing and vision, height/weight/BMI, cho- County, which offered initial support, and the
lesterol, blood sugar, blood pressure, clinical Quantum Foundation, the ongoing sustain-
breast exams, lead levels, assessment, and ing funder. The services provided in this
early management of health issues; (4) tertiary circle include (1) consultation and collaboration:
prevention/primary care: assessment, diagno- building relationships and community with
sis, treatment, and care management for members of these groups, contributing to pol-
chronic health issues, crisis intervention and icy appraisal, development, and evaluation,
behavioral support, and collaborating with leading and serving on teams and committees
others for transitional and enhancing care. responsible for overseeing the care of students
First Circle and families, and providing school nurse
education; and (2) research and evaluation:
The first circle of the model depicts a widen- assessing school health services, describing
ing circle of concern and support for well research findings for best practices related to
being of persons and communities. This circle school and community health, and designing
includes persons and groups in each school research projects focused on school/community
and community who share concern for the health issues, and/or school/community nurs-
well-being of persons served at the centers. ing practice.
This includes participants in inquiry groups,
parents/guardians, school faculty, and nonin-
structional staff, after-school groups, parent/ Third Circle
teacher organizations, and school advisory The third circle includes state, regional,
councils. The services provided within this national, and international organizations with
circle might include: (1) consultation and col- whom we are related in various ways. Services
laboration: building relationships and commu- within this circle are focused on (1) consulta-
nity, answering inquiries on matters of health tion and collaboration: building relationships
and well-being, providing in-service and and community with members and collabo-
health education, serving on school commit- rating about scholarship, policy, outcomes,
tees, reviewing policies and procedures; (2) practice, research, educational needs of school
appraisal and evaluation: conducting commu- nurses and advanced practice nurses, and
nity assessments, appraising care provided, sustainability through ongoing and additional
evaluating outcomes, and promoting pro- funding; (2) appraisal and evaluation: school
grams that enhance well-being for individuals nursing and advanced practice faculty organi-
and communities. zations offer a milieu for discussion and
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C H A P T E R 2 7 The Community Nursing Practice Model 457

appraisal of the services provided at the colleagues in the health department, school
centers. Organizations in this circle include district, health care district, and other groups
Florida Department of Health: Office of taking the lead with school and community
School Health, Florida Association of health. Committees on which center adminis-
School Nurses, Florida Association of School trators and staff serve meet regularly to dis-
Health, National Association of School Nurs- cuss school and community health issues and
es, National Assembly of School-Based to seek consensus on possible solutions. These
Health Centers, and the National Nursing committees include the School Health Task
Centers Consortium. Force and Advisory Groups and the Access
Palm Beach County collaboration. The health
Connection of Core to Concentric department provides consultation on health
Circles and practice matters; the school district pro-
Connections of the core to the concentric cir- vides the physical space for the centers, and
cles of services illuminate the appreciation of through a collaborative agreement with the
the complexity of the practice within the health-care district, many of our clients with-
Community Nursing Practice Model. The out health insurance can be enrolled in a safety-
core service of consultation and collaboration is net program of health services. Physicians are
a primary focus of practice, beginning with consultants for medical questions and refer-
nursing and social work colleagues and rals. School nurse education is also provided
extending to participating clients, families, for nurses in the local county and in sur-
policy makers, funders, and legislators. This rounding areas of this state.
value-laden service has been essential to the Like the other circles, the third circle
viability and sustainability of this model. It depicts the breadth of relationships developed
promotes the stance of humility that guides at meetings, and through publications and
the respectful question throughout the circles: presentations at local, regional, national, and
How can we be helpful to you? The answer international conferences. Administration and
directs the creation of respectful individual- faculty have been recognized for the contribu-
ized care and program development. Essential tion made to the health and well-being of
health-care services are created within the children and families. Faculty, staff, and stu-
core and extend into the first circle. dents participate on panels, sharing their
Connections to the second circle unfold experiences in caring for underinsured and
from the collaborating relationships with uninsured persons.

Practice Exemplar
A nursing situation titled The Clothes Line is to you? And they heard We need to find
offered as an exemplar from practice illumi- jobs but dont have the right clothes, can you
nating the core values and concepts of the help us? The students reflected, conferred
CNPM, as well as collaborations developed and decided to try. They gathered clothes
in response to a call for nursing. from their closets and their friends closets
Cut-outs of cotton dresses, shirts, pants that looked like a good fit and brought them
and socks strung on a clothes line are an aes- to the shelter for the residents. Next they
thetic representation of a nursing situation explored the neighborhood for resources and
grounded in the community nursing practice found a clothes cleaner nearby the shelter.
model. A group of nursing students studying After explaining to the manager the resi-
community nursing at a homeless shelter dents need for clothes, a decision was made
asked the residents How can we be helpful to set up a clothing collection box in the shop.
Continued
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458 S E C T I O N VI Middle-Range Theories

Practice Exemplar cont.


The students hoped that the prominently to their hopes and dreams and for creating
displayed collection box would attract others a way for them to dress for success and to
to leave clothes and also be accessible for the get back on their feet. The students felt
residents of the shelter to come pick out they had responded to a call for nursing;
clothes for job hunting. The students returned they connected to community resources, left
to the shelter and explained the community behind a viable community project, and nur-
clothing collection box. The residents expressed tured the wholeness of the persons living at
their gratitude to the students for listening the shelter.

Summary
The fundamental beliefs and commitment to Nursing. Members of the faculty and center
the discipline and unique practice of nursing staff are encouraged to practice from these
provided for both creating and sustaining this beliefs and to reach out and through the con-
Community Nursing Practice Model. This centric circles, strengthening and widening
model provides the environment in which the web of relationships with colleagues,
nursing is practiced from the core beliefs of clients, and community members. Through
respect, caring, and wholeness. School-based use of this model, the ideals of the discipline
wellness centers, developed and managed by are brought into reality of care for wholeness
nurses, have demonstrated the integration of and well being of persons and families in mul-
the mission and philosophy of the College of ticultural communities.

References

Barry, C. (1994). Face painting as metaphor. In E. Nursing a school-aged child provides an insight to
Schuster, & C. Brown (Eds.), Exploring our environ- the Guatemalan culture. Florida Journal of School
mental connections (pp. 279286). New York: Health, 9(1), 2936.
National League for Nursing Press. Barry, C., & Gordon, S. (2006a). Theories and models
Barry, C. (1998). The celebrity chef cooking club: of school nursing. In J. Selekman (Ed.), Comprehen-
A peer involvement feeding program promoting sive Textbook of School Nursing. Scarborough,
cooperation and community building. Florida ME: National Association of School Nursing.
Journal of School Health, 9(1), 1720. Barry, C. D., & Gordon, S. C. (2006b). Caring for
Barry, C. (2003). A retrospective: Looking back on Linda students in school using a community nursing prac-
Rogers and the history of school nursing. Paper present- tice model. International Journal for Human Caring,
ed at the 8th annual Florida Association of 9(3), 38-42.
School Nurses Conference: Past, Present and Future: Barry, C. D., & Gordon, S. C. (2009). Coming to know
Continuing the Vision. Orlando, Florida, January the community: Going to the mountain. In: R. C.
2003. Locsin & M. J. Purnell (Eds.), A contemporary process
Barry, C. D., Blum, C. A., Eggenberger, T. L., Palmer- of nursing: The (un)bearable weight of knowing in
Hickman, C., & Mosley, R. ( July/August 2009). nursing. New York: Springer.
Understanding homelessness using a simulated Barry, C. D., Gordon, S. C., & Lange, B. (2007). The
nursing experience. Journal of Holistic Nursing usefulness of the Community Nursing Model in
Practice, 23(4), 230237. school based community wellness centers: Voices
Barry, C., Blum, C. A., & Purnell, M. (2007). Caring from the U.S. and Africa. Research and Theory for
for Individuals Displaced by Hurricanes Katrina Nursing Practice: An International Journal, 21(3),
and Wilma: The Lived Experience of Student 174184.
Nurses. International Journal for Human Caring, Chooporian, T. (1986). Reconceptualizing the environ-
11(2), 67-73. ment. In: P. Mocia (Ed.), New approaches to theory
Barry, C., Bozas, L., Carswell, J., Hurtado, M., Keller, development (pp. 3954). New York: National
M., Lewis, E., Poole, K., & Tipton, B. (1998). League for Nursing Press.
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Clark, M. J. (2003). Community health nursing: Caring Parker, M. E., Barry, C. D., & King, B. (2000). Use of
for populations. Upper Saddle River, NJ: Prentice- inquiry method for assessment and evaluation in a
Hall. school-based community nursing project. Family and
Florida Atlantic University Christine E. Lynn College Community Health, 23(2), 5461.
of Nursing. (1994/2003). Mission and philosophy. Parker, M. E., Pandya, A., Hsu, S., Noell, D., &
In: Faculty handbook. Boca Raton, FL: Florida Newlin, K. (2007), Assuring Nursings Voice in the
Atlantic University Christine E. Lynn College of Electronic Health Record. In: IEEE International
Nursing. Conference on Natural Language and Knowledge
Kleffel, D. (1996). Environmental paradigms: Moving Development Engineering, Beijing, China. Proceedings.
toward an ecocentric perspective. Advances in Institute of Electrical and Electronics Engineers,
Nursing Science, 18(4), 110. NLP-KE 107.
Nightingale, F. (1859/1992). Notes on nursing: Commem- Peck, S. (1987). The different drum: Community making
orative edition with commentaries by contemporary and peace. New York: Simon & Schuster.
nursing leaders. Philadelphia: J. B. Lippincott. Ryan, E., Hawkins, W., Parker, M. E., & Hawkins, M.
Parker, M. E. (1996). Designing a nursing model of (2004). Perceptions of access to U. S. health care of
primary health care and early intervention. Proposal Haitian immigrants in South Florida. Florida Public
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County, FL. Schuster, E. (1990). Earth caring. Advances in Nursing
Parker, M. E. (1997). Emerging innovations: Caring Science, 13(1), 2530.
in action. International Journal for Human Caring, Smith, C., & Mauer, F. (1995). Community health
1(2), 910. nursing: Theory and practice. Philadelphia: W.B.
Parker, M. E., & Barry, C. D. (1997). Love and suffer- Saunders.
ing at the margins. Paper presented at the Interna- Swadener, B., & Lubeck, S. (1995). Children and families
tional Association of Human Caring Research at promise. Deconstructing the discourse on risk.
Conference, the Primacy of Love and Existential Albany: State University of New York Press.
Suffering, Helsinki, Finland. World Health Organization, Alma-Ata. (1978). Primary
Parker, M. E., & Barry, C. D. (1999). Community prac- health care. Geneva, Switzerland: World Health
tice guided by a nursing model. Nursing Science Organization.
Quarterly, 12(2), 125131.
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Chapter
28
Rozzano Locsins Technological
Competency as Caring and the
Practice of Knowing
Persons in Nursing
R OZZANO C. L OCSIN

Introducing the Theorist Introducing the Theorist


Overview of the Theory Rozzano C. Locsin is Professor of Nursing
Application of the Theory at Florida Atlantic Universitys Christine
Practice Exemplar E. Lynn College of Nursing. Life transitions
Summary in the health-illness experience defines his
References program of research in which the model of
Technological competence as caring in nurs-
ing is illustrated as the practice of knowing
persons through technologies in nursing.
Dr. Locsin was a Fulbright Scholar to Uganda
in 2000, a recipient of the 20042006
Fulbright Alumni Initiative Award to Uganda,
and Fulbright Senior Specialist in Global and
Public Health and International Develop-
ment. He received the prestigious Edith
Moore Copeland Excellence in Creativity
Rozzano C. Locsin
Award from Sigma Theta Tau International
Honor Society of Nursing, and two lifetime
achievement awards from premier schools
of nursing in the Philippines. His edited book
Advancing Technology, Caring, and Nursing
was published in 2001. His middle-range
nursing theory, Technological Competency as
Caring in Nursing: A Model for Practice, was
released in March 2005. He co-edited the
book Technology and Nursing: Practice, Process
and Issues, published in 2007. A fourth book,
A Contemporary Process of Nursing: The
(Unbearable) Weight of Knowing in Nursing,
was published in 2009. His interest in global
nursing and care initiatives enhances his
appreciation of the dynamic nature of
humans, and of nursing as the practice of con-
tinuous knowing of persons through contem-
porary technologies within a caring in nursing

460
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C H A P T E R 2 8 Rozzano Locsins Technological Competency as Caring 461

framework. He holds baccalaureate and mas- health care demand expertise with technolo-
ters degrees in Nursing from Silliman Univer- gies. Often, such expertise is perceived as
sity in the Philippines, and a PhD in Nursing non-caring in situations where the focus of
from the University of the Philippines. He knowing is on the technology, rather than on
was inducted as a Fellow of the American the person. It is the premise of this chapter,
Academy of Nursing in 2006. however, that being technologically compe-
tent is being caring. For the purposes of this
theory, the following assumptions are posited:
Overview of the Theory
Persons are whole or complete in the
There is a great demand for a practice of nurs-
moment (Boykin & Schoenhofer, 2001).
ing based on an authentic intention to know
Knowing persons is a practice process of
humans fully as persons rather than as objects
nursing that allows for continuous appreci-
of care. Nurses want to use creative, imagina-
ation of persons moment to moment
tive, and innovative ways of affirming, appre-
(Locsin, 2005).
ciating, and celebrating humans as whole
Nursing is a discipline and a professional
persons. Often the best way to realize these
practice (Boykin & Schoenhofer, 2001)
intentions is through expert, competent use of
Technology is used to know persons fully in
nursing technologies (Locsin, 1998).
the moment (Locsin, 2005).
Frequently perceived as the practice of
using machines in nursing (Locsin, 1995), The ultimate purpose of technological
technological competency as caring in nursing competency in nursing is to acknowledge
is the practice of knowing persons as whole the person as a focus of nursing and that var-
(Locsin, 2001), frequently with the use of ious technological means can and should be
health-care technologies. Contemporary defi- used in the practice of knowing persons in
nitions of technology include a means to an nursing.
end, an instrument, a tool, or a human activity This acknowledgment of persons brings
that increases or enhances efficiency (Heideg- together the relatively abstract concept of
ger, 1977). Conceptualizing technology and wholeness of person with the more concrete
caring in nursing practice is problematic. View- concept of technology. Such acknowledg-
ing them in harmonious coexistence is crucial ment compels the redesigning of nursing
to understanding technological competency as processesways of expressing, celebrating,
an expression of caring (Locsin, 2005). and appreciating the practice of nursing as
The purpose of this chapter is to explain continuously knowing persons as whole
knowing persons through technological moment to moment. In this practice of nurs-
competency as a practice of nursing, a frame- ing, technology is used not to know what is
work of nursing that guides its practice, the person? but rather to know who is the
grounded in the theoretical construct of tech- person? Appropriately, answers to the for-
nology competency as caring in nursing (Locsin, mer question allude to an expectation of
2005). This model of practice illuminates the knowing empirical aspects and facts about
harmonious relationship between technologi- the composite person; the latter question
cal competency and caring in nursing. In this requires the understanding of an unpre-
model, the focus of nursing is the person, a dictable, irreducible person who is more than
human being whose hopes, dreams, and aspi- and different from the sum of his or her
rations are focused on living life fully as a car- empirical self. The former question alludes to
ing person (Boykin & Schoenhofer, 2001). the idea of persons as objects; the latter
As a model of practice, technological compe- addresses the uniqueness and individuality of
tency as caring in nursing (Locsin, 2005) is as persons as humans who continuously unfold
valuable today as it has been and will continue and who therefore require continuous know-
to be in the future. Advancing technologies in ing (Locsin, 2005).
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462 S E C T I O N VI Middle-Range Theories

Persons as Whole and Complete in the Campling, 2005), particularly when the sub-
Moment ject of concern is technology-dependent care
and technology competency as an expression
One of the earlier definitions of the word per-
of caring in nursing. Hudson (1988) suggests
son was evident in Hudsons 1988 publication
that false comfort may be offered whenever it
claiming that the emphasis on inclusive
is implied that this life and this body are sig-
rather than sexist language has brought into
nificantly less important than the spiritual
prominence the use of the word person
body and the next life... the time has come to
(p. 12). The origin of the word person is from
enhance an awareness of the post human or
the Greek word prosopon, which means the
spiritual future (p. 13). What structural
actors mask of Greek tragedy; in Roman ori-
requirements will the post human possess?
gin, persona indicated the role played by the
Today, some humans have anatomic and/or
individual in social or legal relationships.
physiologic components that are already elec-
Hudson (1988) also declares that an individ-
tronic and/or mechanical, such as mechanical
ual in isolation is contrary to an understand-
cardiac valves, self-injecting insulin pumps,
ing of person (p. 15). A necessary apprecia-
cardiac pacemakers, or artificial limbs, all
tion of persons is the view that humans are
appearing as excellent facsimiles of the real.
whole or complete in the moment. As such,
Yet the idea of a whole person and being nat-
there is no need to fix them or to make them
ural continues to persist as a requirement of
complete again (Boykin & Schoenhofer,
what a human being should be (Fig. 28-1).
2001). There is nothing missing that requires
nurses intervening to make persons whole or
complete again, or for nurses to assist in this How Are Persons Known?
completion. Persons are complete in the Often, questioning in order to know the per-
moment. Their varying situations of care call son is limited to inquiry about body parts. For
for creativity, innovation, and imagination example, How are your knees? instead of
from nurses so that they may come to know How are you doing with your knees? Of
the nursed as whole person. The uniqueness what purpose is the question? Is it to know
of the person emerges in the response called the person, or to know the condition of the
forth in particular situations. specific composite part? Perhaps inadvertently,
Inherent in humans as unpredictable, unconsciously, or both, one consciously
dynamic, and living beings is the regard for inquires about the body part because of a cul-
self-as-person. This appreciation is like the turally founded reason, or the customary focus
human concern for security, safety, self-esteem, on anothers bodily features that defines the
and actualization popularized by Maslow person!
(1943) in his quintessential theoretical model How are persons as human beings known?
on the hierarchy of needs. More important, Historically, humans were depicted through
however, is the understanding that being drawings and paintings. Art works using col-
human is being a person, regardless of bio- ors represented the human being in imagina-
physical parts or technological enhancements. tive ways as conceptualized by painters and
Because the future may require relative illustrators. Through colors, aesthetic repre-
appreciation of persons, if the ultimate crite- sentations provided vivid depictions of the
rion of being human today is that humans are human being. Artists and their works became
only those who are all natural, organic, and commodities, and Leonardo DaVinci topped
functional, being human may not be so easy this list as, perhaps, the most popular of illus-
to determine. The purely natural human trators and painters. Studying the human
being may be rare. The understanding that being as object allowed him to illustrate the
technology-supported life is artificial and composite of the human being through dis-
therefore is not natural stimulates discussions sected remains. Illustrations such as these may
among practitioners of nursing (Locsin & have influenced Michelangelo in his creation
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C H A P T E R 2 8 Rozzano Locsins Technological Competency as Caring 463

Caring in nursing

Human
beings as
persons

Technological
competence

Figure 28 1 Nursing as knowing persons.

of masterful artworks such as David and when there are no extremities? They may also
Moses. The clarity, definition, and fidelity of have wondered, On growing up, will this
the representation provided the utmost appre- baby be concerned about what it is like to
ciation of the human being. Yet the question have no limbs, or will he wish he had limbs so
remains: does the human being become a per- he could go places like others? (Barnard &
son, or is he a person always? Is the composi- Locsin, 2007, p. 17).
tion of the human being the ultimate descrip- Consider also the Girl with Eight Limbs
tor, characteristic, and quality of a whole and from a province in India, who was subjected to
complete person? What happens when the intense surgical intervention to remove the
human being has no limbsor at the least has other non-functional limbs which were put-
limbs which are not functional? Is this human ting her life in a precarious situation. What do
being a person? you think this girl thinks now? Am I com-
Consider the case of a baby born without plete or incomplete? Am I normal or abnor-
limbs but was alive and well. When the baby mal, just because I am like everyone else with
became ill, he was rushed to a hospital. To the two upper limbs and two lower limbs? (PBS).
chagrin of the nurses and physicians, they In an episode of the television series The
were at first unable to care for the baby. Their Twilight Zone, a woman so hideous she was
main question was How can we initiate IVs thought unworthy to be seen, had to hide her
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464 S E C T I O N VI Middle-Range Theories

face behind a veil. She was shunned and others fully as persons is integral to this cru-
denied by her family. It was an unbearable life cial positioning.
for her and for her family as well. In the end, Wholeness is the idealized condition or
the revelation focused on the adage beauty is situation of the one who is nursed. This ideal-
in the eye of the beholder (Serling, 1960). ization is held within the nurses understand-
The people who shunned the woman had ing of persons as complete human beings in
faces like those of pigs, while she had more the moment. Expressions of this complete-
human-like features. In fact, she was a beau- ness vary from moment to moment. These
tiful human woman whom everyone found to expressions are human illustrations of living
be ugly, embarrassing, pitiful, and a misfit, and and growing. Using technology alone and
was advised to move to a distant colony with focusing on the received technological data
a small population of people like her. rather than on continually knowing the oth-
In a recent Associated Press news article, er fully as person can lead to the nurse think-
The Androgynous Pharoah? Akhenated ing of the person as an object who needs to be
Had Feminine Physique (USA Today, May 2, completed and made whole again. Paradoxi-
2008), writer Alex Dominguez presented cally, because of the idea that humans are
Dr. Irwin Bravermans findings on the contro- unpredictable, it is not entirely possible for
versial feminine features of the pharaoh the nurse to fully know another human
Akhenaten. Dominguez wrote, Akhenaten beingexcept in the moment and only if the
wasnt the most manly pharaoh, even though person allows the nurse to know him or her by
he fathered at least a half-dozen children. entering into the others world.
In fact, his form was quite feminine, which In this perspective, the condition in
has puzzled experts for years. And he was a which the nurse and the other allow know-
bit of an egghead. The pharaoh had an ing each other exists as the nursing situation,
androgynous appearance. He had a female the shared lived experience between the
physique with wide hips and breasts, but he nurse and nursed (Boykin & Schoenhofer,
was male and he was fertile and he had six 2001).
daughters, Braverman is quoted as saying. In this relationship, trust is established that
But nevertheless, he looked like he had a the nurse will know the other fully as person;
female physique. Apparently, what consti- the trust that the nurse will not judge the per-
tutes knowing whether a human being is a son or categorize the person as just another
man or a woman is the physical appearance. human being or experience, but rather as a
This makes Bravermans study of the Pharoah unique person who has hopes and aspirations
Akhenaten most meaningful. that are singularly his or her own.
An example of person as object, known as It is the nurses responsibility to know the
a composite of physical elements, is the leg- persons hopes and aspirations. Technological
endary Frankenstein monster, an entity assem- competency as caring allows for this under-
bled from various human parts. The monster standing. In doing so, the nurse also sanctions
was created and made human in the sense of the other (the nursed) to know him or her as
being a composite of parts, but also in the person. The expectation is that the nurse is to
sense of his essence being energy (electricity). use multiple ways of knowing competently in
using technologies in order to know the other
The Process of Knowing Persons fully as person. The nurses responsibility is
Persons possess the prerogative and the choice immeasurable in creating conditions that
whether or not to allow nurses to know them demand technological competency and care,
fully. Entering the world of the other is a crit- much like the wish to create a computerized
ical requisite to knowing as a process of nurs- human facsimile. In creating a nursing situa-
ing. Establishing rapport, trust, confidence, tion of care, there is a requisite competency to
commitment, and the compassion to know know persons fully, to understand, and to
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C H A P T E R 2 8 Rozzano Locsins Technological Competency as Caring 465

appreciate the important nuances of the in nursing. Knowledge about the person that
persons dreams and desires. is derived from assessing, intervening, evalu-
There are many ways of interpreting the ating, and further assessing additionally
concept of person as whole. Three of informs the nurse that in knowing persons,
the popular interpretations are derivations of one comes to understand the condition of
the concept of person from dominant per- more knowing about the person and about his
spectives, those views that shape the popular or her being, in order to affirm, support, and
understanding of the concept. One of these celebrate his or her dreams and aspirations in
interpretations is the mindbody dualism the moment. Supporting this process of
popularly ascribed to Descartes, which sup- knowing is the understanding that persons are
plies the continuing citation of the connection unpredictable and simultaneously conceal and
between mind and body. At least in nursing, reveal themselves as persons from one
the mindbodyspirit connection is popular- moment to the next (Parse, 1998).
ized by Jean Watson (1985) in her theory The nurse can know the person fully only
of transpersonal caring. The simultaneity par- in the moment.
adigm (Parse, 1998) categorizes the human This knowing occurs only when the person
environmental mutual connection as the allows the nurse to enter his or her world.
relationship that best serves the human science When this happens, the nurse and nursed
nursing perspective and grounds theoretical become vulnerable as they move toward fur-
frameworks and models of practice, including ther continuous knowing.
those of the caring sciences. These contempo- Vulnerability allows participation, so that
rary and popular elucidations create concep- the nurse and nursed continue knowing each
tions of humans as the focus of nursing and of other moment to moment. In such situations,
knowing persons in their wholeness as the Daniels (1998) explains that nurses work
practice of nursing. is to ameliorate vulnerability (p. 191). The
The process of nursing is a dynamic unfold- embodiment of vulnerability in caring situa-
ing of situations encompassing knowledgeable tions enables its recognition in others, partic-
practices. The meaning of the process is char- ipating in mutual vulnerability conditions, and
acterized by listening, knowing, being with, sharing in the humanness of being vulnerable.
enabling, and maintaining belief (Swanson, Further, Daniels declares that vulnerable
1991). The following occurrences exemplify individuals seek nursing care, and nurses seek
the process: those who are vulnerable (p. 192). Allowing
the nurse to enter the world of the one nursed
Knowing and appreciating uniqueness of
is the mutual engagement of power with
persons
rather than having power over through a
Designing participation in caring
created hierarchy (Daniels, 1998). The nurse
Implementing and evaluating (a simultane-
does not know more about the person than
ous illustration and exercise of conjoining
the person knows about him- or herself. No
relationships crucial to knowing persons by
one knows the experience better than the per-
using nursing technologies)
son who encounters the situation.
Verifying knowledge of person through
Nonetheless, there is the possibility that the
continuous knowing
nurse will be able to predict and prescribe for
In this model of practice, knowing is the the one nursed. When this occurs, these situa-
primary process. Knowing nursing means tions forcibly lead the nurse to appreciate per-
knowing in the realms of personal, ethical, sons more as object than as person. Such a sit-
empirical, and aestheticall at once (Boykin uation can occur only when the nurse has
& Schoenhofer, 2001, p. 6). The continu- assumed to have known the one nursed.
ous, circular process demonstrates the ever- While it can be assumed that with the process
changing, dynamic, cyclical nature of knowing of knowing persons as whole, opportunities
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466 S E C T I O N VI Middle-Range Theories

to continuously know the other become limit- understanding for the purpose and process of
less, there is also a much greater likelihood competently using technologies in nursing.
that having already known the one nursed, These descriptions are:
the nurse will predict and prescribe activities or
To perceive directly with the senses or mind
ways for the one nursed, ultimately causing
To be certain of, regard, or accept as true
objectification of person (Fig. 28-2).
beyond doubt
To be capable of, have the skills to
To Know and Knowing To have thorough or practical understand-
It is interesting to read the 10 common ing of, as through experience of
definitions of the word know as a verb list- To be subjected to or limited by
ed in the 1987 Readers Digest Illustrated To recognize the character or quality of
Encyclopedic Dictionary (p. 932). Of these, To be able to distinguish, recognize
nine appropriately describe the intended To be acquainted or familiar with
use of the word in nursing, facilitating its To see, hear, or experience

MULTIPLE WAYS Through the lens


OF KNOWING of Nursing as
Such as Calls for Caring. Using
Empirical Nursing: technologies
Personal Affirmation, competently to
Ethical Support, appreciate persons
Aesthetic Celebration of as whole in the
who is person?, moment
and what is person?

Responses to
Calls for Nursing:
Sustaining and
enhancing who is
person and what is
person?

KNOWING
PERSONS: THE
PRACTICE OF
NURSING

What is person?
Who is person?
Figure 28 2 Framework for nursing.
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C H A P T E R 2 8 Rozzano Locsins Technological Competency as Caring 467

While the action word know sustains the physiochemical and anatomical being. Know-
notion that nursing is concerned with activity ing persons allows the nurse to know who
and that the one who acts is knowledgeable and what is the person.
(in the sense of understanding the rationales
behind the activities), the word knowing is a Knowing When Using Technology
key concept that alludes to the focus of an From such a view, it may seem that the
action from a cognitive perspective requiring process of knowing is possible only when
description. Knowing perfectly describes the using technologies in nursing. This percep-
ways of nursingtranspiring continuously as tion, which is not necessarily true, is supported
explicated from the framework of knowing by the idea that nursing is technology when
persons. It is the use of the word knowing technology is appreciated as anything that
in which the process of nursing as knowing creates efficiency, be this an instrument or a
persons is lived. The framework for practice tool, such as machines, or the activity of nurs-
clearly shows the circuitous and continuous es when nursing. Sandelowski (1993) has
process of knowing persons as a practice of argued about the metaphorical depiction of
nursing. nursing as technology, or with technology as
It is appreciated that nurses practice nurs- nursing, and the semiotic relationship of these
ing from a theoretical perspective rather concepts. Locsin and Purnell (2007) have
than from tradition or from blind obedience declared that accompanying the rapture of
to instructions and directions. Nevertheless, technologies in nursing is the consequent suf-
processes of nursing that are derived from fering or the price of advancing dependency
extant theories of nursing continue to dictate on technologies that critically influence con-
and prescribe how a nurse should nurse. Con- temporary human lives. With increased use
trary to this popular conception, knowing of technologies and ensuing technological
persons as a model of practice using tech- dependency experienced by recipients of care,
nologies of nursing achieves for the nurse an the imperative is to provide technological
appreciation of expertise and the knowledge competency as caring in nursing (Locsin,
of persons in the moment. Technologies allow 2005).
nurses to know about the person only as much Regardless, the idea of knowing persons
as the person permits the nurse to know. It guiding nursing practice is novel in the sense
can be true that technologies detect the that there is no ideal prescription; rather there
anatomical, physiological, chemical, and/or is the wholesome appreciation of an informed
biological conditions of a person. This identi- practice that allows the use of multiple ways of
fies the person as a living human being. How- knowing such as described by Phenix (1964)
ever, with knowing persons, the nurse is and expanded by Carper (1978). These ways
allowed to understand and anticipate the of knowing involve the empirical, ethical, per-
ever-changing person from moment to sonal, and aesthetic. Aesthetic expressions
moment. document, communicate, and perpetuate the
The purpose of knowing the person is appreciation of nursing as transpiring moment
derived from the nurses intention to nurse to moment. Popular aesthetic expressions
(Purnell & Locsin, 2000)a continuing include storytelling; poetry; visual expressions
appreciation of the person as ever-changing as in drawings, illustrations, and paintings; and
and never static: one who is a dynamic human aural renditions such as music. Encountering
being. The information derived from know- aesthetic expressions again allows the nurse
ing the person is only relevant for the and the nursed to relive the occasion anew.
moment, for the persons state can change Reflecting on these experiences using the fun-
moment to moment. Importantly, knowing damental patterns of knowing (Carper, 1978)
the who or what of persons helps nurses enhances learning, motivates the furtherance
realize that a person is more than simply the of knowledgeable practice, and increases the
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468 S E C T I O N VI Middle-Range Theories

valuing of nursing as a professional practice The model articulates continuous know-


grounded in a legitimate theoretical perspec- ing. Continuing to know persons deters
tive of nursing. objectification, a process that ultimately
The use of technologies in nursing is regards human beings as stuff to care
consequent to the contemporary demands for about, rather than as knowledgeable partici-
nursing actions requiring technological know- pants in their care.
ing (Locsin, 2009). Technological knowing is Participating in his or her care frees the
demanded for the ultimate purpose of knowing person from having to be assigned a care
the real person. The concept of technological that he or she may not want or need. This
knowing is construed as the practice process of relationship signifies responsiveness (Hudson,
using technologies of care to acknowledge the 1988). Continuous knowing results from the
value of knowing the one nursed through con- contention that findings through consequent
temporary technological advancements. Impor- knowing further inform the desire to know
tant along with technology use in nursing is the who is and what is the person. Doing
condition that the one nursed allows him- or so inhibits substantiation as the ultimate rea-
herself to be known as person. son for nursing. Continuous knowing over-
Technological competency in nursing fos- powers the motivation to prescribe and direct
ters the recognition and realization of persons the persons life. Rather, it affirms, supports,
as participants in their care rather than objects and celebrates his or her hopes, dreams, and
of care. The idea of participation in their aspirations as a participating human being.
care stems from active engagement, in which
the nurse enters the world of the one nursed Calls and Responses for Nursing
through available appropriate technologies, Calls for nursing are illuminations of the per-
attempting to know the nursed more fully in sons hopes, dreams, and aspirations. Calls
the moment. In this practice, the assumption for nursing are individual expressions by per-
is understood that the one nursed allows the sons who seek ways toward affirmation, sup-
nurse to enter his or her world so that togeth- port, and celebration as person. The nurse
er they may mutually support, affirm, and cel- appreciates the uniqueness of persons in his
ebrate each others being. In this relationship or her nursing. In doing so, the nurse sustains
of the knower and the one known, technolo- and enhances the wholeness of the human
gy provides the efficiency and the valuing that being, while facilitating the realization of the
marks their mutual and momentary reality persons completeness through acting for
(Locsin, 2009). or with the person. This is a way of affirm-
There is no letting up, because advancing ing, supporting, and celebrating the persons
technology currently encompasses the bulk of wholeness.
functional activities that nurses are expected The nurse relies on the person for calls for
to perform, particularly when the practice is nursing. These calls are specific mechanisms
in a clinical setting. Clinical nursing is firmly that persons use while allowing the nurse to
rooted in the clinical health model (Smith, respond with authentic intentions to know
1983) in which the organismic and mechanis- them fully as persons in the moment. Calls
tic views of humans as persons convincingly for nursing may be expressed in various ways,
dictate the practice of nursing. Nevertheless, often as hopes and dreams, such as the hope
the process of knowing persons will prevail, to be with friends while recuperating in the
for the model of technological competency as hospital, or the desire to play the piano when
caring in nursing provides the nurse the fit- fingers are well enough to function effective-
ting stimulation and motivation (and the ly, or simply the ultimate desire to go home,
prospective autonomy to judge critically) a or the wish to die peacefully. As uniquely
mode of action that desires an appreciation of as these calls for nursing are expressed, the
persons as whole. nurse knows the person continuously moment
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C H A P T E R 2 8 Rozzano Locsins Technological Competency as Caring 469

to moment. One way of communicating cre- facilitate patients recognition of their whole-
ated nursing responses may be as patterns of ness in the moment.
information, such as those derived from
machines like the EKG monitor, in order to
know the physiological status of the person in Applications of the Theory
the moment or to administer life-saving Locsins theory is relatively new. Applications
medications, institute transfer plans, or refer of the theory of Technological Competency as
patients for services to other health-care pro- Caring in Nursing has been elusive although
fessionals. anecdotal references as to its utility exist.
The entirety of nursing is to direct, focus, Through these anecdotes received in various
attain, sustain, and maintain the person. In occasions especially after presentations and
doing so, hearing calls for nursing is continu- conversations and through personal commu-
ous and momentarily complete. Knowing per- nications via electronic mails, these positive
sons allows the nurse to use technologies in declarations continue to provide the confir-
articulating calls for nursing. The empirical, mation that the theory is useful particularly in
personal, ethical, and aesthetic ways of know- nursing practice. Often during class presenta-
ing that are fundamental to understanding tions and in scholarly/academic conferences,
persons as whole increase the likelihood of students and participants express their claims
knowing persons in the moment. that the theory resonates well in their prac-
As unpredictable and dynamic, human tice, affirming their understanding of nursing,
beings are ever changing moment to moment. and confirming their appreciation of know-
This characteristic challenges the nurse to ing persons through technologies as practice.
know persons continuously as whole, rejecting However, there has been an absence of com-
the traditional conception of possibly know- ments from practitioners who have signified
ing persons completely at once, in order to that the theory has guided their practice, or of
prescribe and predict their expressions of any researcher who has claimed that he or she
wholeness. In continuously knowing persons has used the theory as framework in any
as whole through articulated technologies in study. Nevertheless, the claims that the theory
nursing, the nurse can perhaps intervene to has affirmed ones practice exist.

Practice Exemplar
In one South Florida migrant camp during the technology available required a focus on the
time of the harvest, a beautiful infant childa usual anatomical and physiological composi-
firstborn sonwas born to two proud parents. tion of a human being; that is the design
The child was healthy but he was born with- required a person to have both torso and limbs
out arms and legs. Two weeks after birth, the intact (Locsin & Barnard, 2007).
infant caught an infection suddenly and was The technological challenges expressed by
rushed to an area hospital for help. Physicians the health care personnel, especially nurses,
and nurses were stunned: How could they per- focused on how they can monitor the infants
form the needed technology-based care such vital signs when the technologies required
as drawing blood for laboratory tests, and plac- limbs which were missing? The challenge
ing a cuff on the arm or leg to measure blood was directed towards their views on knowing
pressure? Their ability to care for the infant of persons as wholeresponding to the essen-
was limited by the technological design of tiality of technological competency as caring
available medical devices and the assumed in nursing. The understanding of wholeness of
presentation of human completeness. The persons departs from the traditional view of
Continued
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470 S E C T I O N VI Middle-Range Theories

Practice Exemplar cont.


humans as composites of human parts, and technologies could not be used, deterring the
that human wholeness is the complete human nurse from knowing the infants physiological
with the standard parts. What about those responses. The ultimate question raised is
born without these composite human parts, focused on how much fullness can be known
like the infant born without all four limbs? of the person, when technologies cannot be
What about those with technological parts as used? This is an example of the realization
replacements for lost or missing parts, those that machine technologies (Locsin, 1995)
individuals with artificial limbs, electronic/ allow the nurse (rather than limits) to know
mechanical devices that make them live? They the person more fully as person. Knowing per-
continue to be human, to be whole, and son as process of nursing is synonymous with
through technological marvels, the nurse is everyday approaches to theory-based nursing
able to know these persons more fully as per- practice; that is, nursing practice guided by
sons. As with the infant without limbs, the theories of nursing.

Summary
The purpose of this chapter is to describe process of nursing grounded in the perspec-
and explain knowing persons as whole, a tive of technological competency as caring in
framework of nursing guiding a practice nursing.
grounded in the theoretical construct of tech- The process of knowing persons as whole
nological competency as caring in nursing is explicated as technological efficiency in
(Locsin, 2005). This framework of practice nursing practice. The model of practice is
illuminates the harmonious relationship illustrated through the understanding of tech-
between technological competency and car- nology and caring as coexisting in nursing.
ing in nursing. In this model, the focus of The process of knowing persons is continu-
nursing is the person. ous. In this process of nursing, with calls and
Critical to understanding the phenomenon responses, the nurse and nursed come to know
of technological competency as caring in each other more fully as persons in the
nursing are the conceptual descriptions of moment. Grounding the process is the appre-
technology, caring, and nursing. Assumptions ciation of persons as whole and complete in
about human beings as persons, nursing as the moment, of human beings as unpre-
caring, and technological competency are pre- dictable, of technological competency as an
sented as foundational to the process of expression of caring in nursing, and of nursing
knowing persons as whole in the momenta as critical to health care.

References

Barnard, A., & Locsin, R. (2007). Technology and nurs- Daniels, L. (1998). Vulnerability as a key to authenticity.
ing: Concepts, practice, and issues. London, UK, Image: Journal of Nursing Scholarship, 30(2), 191192.
Palgrave-Macmillan, Co. Heidegger, M. (1977). The question concerning technology.
Boykin, A., & Schoenhofer, S. (2001). Nursing as car- New York: Harper and Row.
ing: A model for transforming practice. Boston: Hudson, R. (1988). Whole or partsa theological
Jones and Bartlett and New York: National League perspective on person. The Australian Journal of
for Nursing Press. Advanced Nursing, 6(1), 1220.
Carper, B. (1978). Fundamental patterns of knowing Hudson, G. (1993). Empathy and technology in the
in nursing. Advances in Nursing Science, 1(1), coronary care unit. Intensive Critical Care Nursing,
1324. 9(1), 5561.
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C H A P T E R 2 8 Rozzano Locsins Technological Competency as Caring 471

Locsin, R. (1995). Machine technologies and caring in Maslow, A. H. (1943). A theory of human motivation.
nursing. Image: Journal of Nursing Scholarship, 27(3), Psychological Review, 50, 370396.
201203. Parse, R. R. (1998). The human becoming school of thought.
Locsin, R. (1998). Technologic competence as expres- Thousand Oaks, CA: Sage.
sion of caring in critical care settings. Holistic Phenix, P. H. (1964). Realms of meaning. New York:
Nursing Practice, 12(4), 5056. McGraw-Hill.
Locsin, R. (2001). Practicing nursing: Technological Purnell, M., & Locsin, R. (2000). Intentionality: Unifi-
competency as an expression of caring in nursing. cation in nursing. Unpublished manuscript. Florida
In: Advancing technology, caring, and nursing. Atlantic University College of Nursing, Boca Raton,
Westport, CT: Auburn House, Greenwood Publish- Florida.
ing Group. Readers Digest Association. (1987). Readers Digest
Locsin, R. (2005). Technological competency as caring in illustrated encyclopedic dictionary (p. 932). Pleas-
nursing: A model for practice. Indianapolis, IN: Sigma antville, NY: The Readers Digest Association.
Theta Tau International. Sandelowski, M. (1993). Toward a theory of technology
Locsin, R. (2009). Painting a clear picture: The techno- dependency. Nursing Outlook, 41(1), 3642.
logical knowing of persons as contemporary process Serling, R. (1960). Season 2, Episode 6 of The Twilight
of nursing. In: R. Locsin & M. Purnell (Eds.), Zone, Eye of the Beholder. CBS.
A contemporary process of nursing: The (un)bearable Smith, J. (1983). The idea of health: Implications for the
weight of knowing persons in nursing. New York: nursing professional. New York: Teachers College
Springer. Press.
Locsin, R., & Campling, A. (2005). Techno sapiens and Swanson, M. (1991). Dimensions of caring interven-
posthumans: Nursing, caring and technology. In: tions. Nursing Research, 40, 161166.
R. Locsin (Ed.), Technological competency as caring in Watson, J. (1985). Nursing: Human science and human
nursing: A model for practice. Indianapolis, IN: Sigma care. East Norwalk, CT: Appleton-Century-Crofts.
Theta Tau International.
Locsin, R., & Purnell, M. J. (2007). Rapture and suffer-
ing with technology in nursing. International Journal
for Human Caring, 11(1), 3843.
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Chapter
29
Marilyn Anne Rays Theory
of Bureaucratic Caring
M ARILYN A NNE R AY AND
M ARIAN C. T URKEL

Introducing the Theorist Introducing the Theorist


Overview of the Theory Marilyn Anne (Dee) Ray, RN, PhD, CTN is
Evolution of Theory Development a Professor Emeritus at Florida Atlantic
Application of the Theory University, The Christine E. Lynn College of
Practice Exemplar Nursing, in Boca Raton, Florida. She holds a
Summary bachelor of science and a master of science in
References nursing from the University of Colorado in
Denver, Colorado, a master of arts in cultural
anthropology from McMaster University in
Hamilton, Canada, and a doctorate from the
University of Utah in Transcultural Nursing.
She retired as a colonel in 1999 after 30 years
of service with the United States Air Force
Reserve Nurse Corps. As a certified transcul-
tural nurse (CTN), she has published widely
on the subjects of caring in organizational
cultures, caring theory and inquiry develop-
Marilyn Anne Ray
ment, transcultural caring, and transcultural
ethics. She has held faculty positions at
the University of California San Francisco,
University of San Francisco, McMaster
University, University of Colorado and Florida
Atlantic University, and Scholar positions at
Florida Atlantic University and Virginia
Commonwealth University. Ray has enjoyed
many diverse teaching and learning assign-
ments around the world. She is a review board
member of the Journal of Transcultural Nurs-
ing. Ray has conducted phenomenological,
ethnographic, and grounded theory research
on different topics related to nursing admin-
istration and practice, and the United States
military. Rays research has revolved around
cultural, technological, political, and econom-
ic issues related to caring in complex organi-
zations. Her latest research conducted with
Dr. Marian Turkel used both qualitative
and quantitative research methods to study

472
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C H A P T E R 2 9 Marilyn Anne Rays Theory of Bureaucratic Caring 473

the complex nursepatient relational caring illustrating caring as not only humanistic
process and its impact on economic and (physical), ethical, spiritual/religious, social-
patient outcomes in hospitals. In her role as cultural, and educational, but also as part of
professor emeritus, Ray is actively engaged in the structuralpolitical, economic, legal, and
mentoring new faculty members and guiding technologicalcharacteristics of a complex
doctoral students, both in the United States organization. These co-determining processes
and abroad, whose studies focus on the related to the thesis of caring and the
research of administrative and clinical prac- antithesis of bureaucracy were synthesized
tice, including the clinical nurse leader role, into the Theory of Bureaucratic Caring
patient safety, and the ethical practice of nurs- (Fig. 29-1). After additional research and
ing, and transcultural nursing. continued reflection on what was occurring in
science and in nursing science, Ray revisited
the theory, and discovered that the theory
Overview of the Theory itself incorporated many concepts from the
This chapter presents a discussion of contem- new sciences of complexity (the science of
porary nursing culture and shares theoretical change and wholeness). The theory, as shown
views in nursing and those related to the in Figure 29-2, was then revealed as holo-
authors theoretical vision and development of graphic (Coffman, 2006; Ray, 2006; Turkel,
professional nursing. The Theory of Bureau- 2007).
cratic Caring is discussed first as a grounded
theory (both substantive and formal) and then Theory in Nursing
as a holographic theory. Within this chapter, Theory is the intellectual life of nursing
Dr. Marian Turkel, Director of Professional (Levine, 1995). Scientific theories in the disci-
Nursing Practice, Albert Einstein Healthcare pline of nursing have developed out of the
Network, Philadelphia, Pennsylvania inte- choices and assumptions a particular theorist
grates the relevance of the theory in adminis- believes about nursing, what the basis of nurs-
trative and clinical practice. ings knowledge is, the state of the science, the
results of research, and what nurses do or how
The Generation of Bureaucratic they practice in the real world (Ray, 1998a).
Caring Theory
The Theory of Bureaucratic Caring was gen-
erated in a hospital organization from a qual-
itative research study using three research
approaches 30 years ago (Ray, 1981). Data Ethical
Spiritual/
analysis involved the description of the hospi- Religious
tal as a culture (ethnography), the meaning of
caring in the life world (phenomenology), and Educational/
the discovery of conceptual categories and Social Economic
CARING
subcategories and theories of the structure
and process of caring in the complex organi-
zation (grounded theory method). Substantive Political Technological/
theory called Differential Caring was gener- Physiological
ated from the diversity and dominant mean- Legal
ings of caring expressed by participants on
different units in the hospital. The formal
theory was developed from interpretation of
the initial qualitative data and data related to Figure 29 1 Grounded Theory of Bureaucratic
complex systems, such as bureaucracy. The Caring (Differential Caring and Bureaucratic
culture of the hospital was a dynamic unity Caring theories).
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474 S E C T I O N VI Middle-Range Theories

Watson, and Parse demonstrate a diversity of


integrated approaches to nursing based on the
Social- worldview, education, and research of an indi-
Physical
Cultural vidual theorist. Ongoing research through
testing and evaluation supports the validity
Educational
and reliability of the theories. Many grounded
SPIRITUAL-
Legal or middle-range theories also have been gen-
ETHICAL erated (Liehr & Smith, 1999). They focus on
CARING particular aspects of nursing practice and are
commonly discovered as substantive theories
Political Technological
in and from nursing practice. As such, some
scholars view middle-range theories as more
Economic
relevant and useful to nursing than the appli-
cation of grand theories (Cody, 1996). How-
ever, rather than show partiality for one
theory over another, the diversity of nursing
Figure 29 2 Holographic Theory of Bureaucratic theories that emphasize particular and holistic
Caring.
points of view actually support the new pic-
ture of reality in science that there is more
Van Manen (1982) refers to theory as wake- than one lens from which a phenomenon can
fulness of mind, awareness or the pure view- be viewed and studied.
ing of truth. Truth in this sense is from the
Greek view which is not the property of con- Complexity and Nursing Theory
sensus among concepts or the consensus Complexity theory is a scientific theory of
among theorists but the disclosure of the dynamical systems collectively referred to as
essential nature or the good of things. There- the sciences of complexity (Ray, 1998a, p. 91).
fore, theoretical truth refers to contemplating They illuminate the nature and creativity of
the good (van Manen, 1982). Collectively, the- science itself. Revolutionary approaches to new
ories in nursing have focused on the good of scientific theory development have transpired,
nursingwhat nursing is and what it does or such as quantum theory, the science of whole-
should do. Based on the assumption of nursing ness, holographic and chaos theories, fractals or
as serving the good, the locus of the discipline the idea of self-similarity, networks of relation-
centers on wholeness and the dynamics of ships and complex information systems, and
unity (body, mind, and spirit), caring for others the concepts of choice and self-organization
in the human health experience, the human- (Bar-Yam, 2004; Bassingthwaighte, Liebovitch,
environment integral relationship, energy pat- & West, 1994; Battista, 1982; Briggs &
terns, human becoming, transcultural care, Peat, 1989, 1999; Davidson & Ray, 1991;
organizational caring, and facilitating health Harmon, 1998; Lindberg, Nash, & Lindberg,
and well-being through choice and social 2008; Peat, 2003; Ray, 1998a; Wheatley, 1999;
justice (Davidson & Ray, 1991; Leininger, 1991; Wilbur, 1982).
Newman, 1992; Newman, Sime, & Corcoran- Complexity theory is replacing other theo-
Perry, 1991; Newman, Smith, Pharris, & Jones, ries, such as Newtonian physics and even
2008; Ray, 1989a,b, 2006; Roach, 2002; Einsteins beliefs and those of other scientists
Rogers, 1970; Watson, 1988, 2005). Theories as well, that the physical world is governed
in nursing are ethical, spiritual and contextual. by laws and order. New scientific views
Theories of nursing thus direct or enlighten state that phenomena that are antithetical
the good. actually coexistdeterminism with uncer-
Theories such as the classical grand theo- tainty and reversibility with irreversibility
ries in nursing of Rogers, Leininger, Newman, (Nicolis & Prigogine, 1989). Opposing things
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C H A P T E R 2 9 Marilyn Anne Rays Theory of Bureaucratic Caring 475

can happen at the same time, in the same intellectual views of scholars in the complex
space, without contradicting each other world of nursing science, research, education,
(Thoma, 2003, p. 17). Thus, both linear and and practice. Theories, as the integration of
nonlinear and simple (e.g., gravity) and com- knowledge, research, and experience, high-
plex (economic and cultural) systems exist light the way in which scholars and practi-
together. One of the tools or metaphors in the tioners of nursing interpret their world and
studies of complexity is chaos theory. Chaos the context where nursing is lived. Theories in
deals with life at the edge, or the notion that this sense are also philosophies or ideologies
the concept of order exists within disorder at that serve a practical purpose. Thus, the idea
the system communication or choice point that theories are the pure viewing of truth
phases where old patterns disintegrate or new (wakefulness or awareness) and that they
patterns emerge (Davidson & Ray, 1991; can be judged in light of their practical
Lindberg et al., 2008; Newman et al., 2008; consequences (Bohman, 2005) underscores
Ray, 1994a, 1998b; Ray et al., 1995). This new the importance of nursing theory as both a
science, which signifies interrelationship of scholarly enterprise and a wise practice that
mind and matter, interconnectedness and identifies and participates in the complexities
choice, carries with it a moral responsibility of inquiry about relationships, knowledgeable
and the quest toward wisdom, which includes caring, health, and the universe.
awareness, information systems, networks of The Theory of Bureaucratic Caring illumi-
relationships, patterns of energy and creativity, nated in this chapter is a holistic theory with a
information about the environment, and practical purpose. Substantive and formal the-
emergence (Davidson & Ray, 1991; Fox, ories (Differential Caring and the Theory of
1994). The conception of the interconnected- Bureaucratic Caring respectively) emerged
ness and relational reality of all things, the from researching the values, beliefs, attitudes
interdependence of all humanenvironmental and behaviors of health professionals and
phenomena, and the discovery of order in a patients in the complex organization of the
chaotic world demonstrate the pioneering hospital (Coffman, 2006; Ray, 1981, 1984,
story of twentieth century science and how 1989a, 2006; Turkel, 2007). The Bureaucratic
the insightful idea of belongingness and rela- Caring Theory was illustrated first as grounded
tionality (a powerful nursing concept) is shap- theory. As stated, after reflection and further
ing the science of the 21st century. research in the organizational culture, the
Within nursing, certain nursing theorists theory was illustrated as a holographic theory
have embraced the notion of nursing as showing the growth and development of the
complexity in which consciousness, human nature of nursing over time. In the holographic
environmental mutual relationship, caring, and model, caring (the center of the model) is
choice-making are central concepts (Davidson highlighted as spiritual and ethical in relation
& Ray, 1991; Lindberg et al., 2008; Newman, to the physical (humanistic), the socialcultural
1986, 1992; Newman et al., 2008; Ray, 1994a, and educational, and the more structural
1998a; Rogers, 1970). Given the nature of dimensions of a complex organization: the
nursing as unitary, holistic, relational, and car- political, economic, legal, and technological.
ing, and health as expanded consciousness Thus, spiritualethical caring honors the good
(Pharris, in Parker, 2006; Newman et al., of caring, commits to the moral position of car-
2008), there is a coherent link between the ing, respects creativity, and integrates the net-
importance of theory as wakefulness and pro- works of complex organizational or bureaucratic
fessional practice. This author holds the posi- systems. This chapter invites us to increase our
tion that nurses do need to be exposed to awareness of theory generation and application
ideas and need diverse nursing theories to in practice situations. The Theory of Bureau-
stimulate thinking. The only way that nursing cratic Caring as a holographic model will facil-
can critique itself is by understanding the itate and increase our understanding of the
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476 S E C T I O N VI Middle-Range Theories

practice of nursing in complex contemporary What distinguishes organizations as cul-


health care environments. tures from other paradigms, such as organi-
zations as machines, brains, or other images
Contemporary Nursing Practice as (Morgan, 1997), is its foundation in anthro-
Complex, Dynamic and Emergent pology or the study of how people act in com-
The practice of nursing is dynamic, always munities or formalized structures and the sig-
changing, and emerging with new possibili- nificance or meaning of work life (Brenton &
ties as people relate to each other. Contempo- Driskill, 2005; Cuilla, 2000; Louis, 1985).
rary nursing practice, however, continues Organizational cultures, therefore, are viewed
to occur in organizations that are generally as social constructions, symbolically formed
bureaucratic or systematic in nature. Although and reproduced through interaction (Smircich,
there has been much discussion about the 1985).
end of bureaucracy to cope better with The beliefs about work emerge in organi-
21st-century innovation and work life within zations through relationships, and organiza-
complex systems (Perrow, 1986; Pinchot & tional mission and policy statements. A
Pinchot, 1994; Sorbello, 2008a,b), bureaucra- nations prevailing tenets and expectations
cy remains a valuable tool to identify and about the nature of work, leisure, and
understand the fundamentally different struc- employment are pivotal to the work life of
tural principles that undergird coordinated people; hence, there is an interplay between
and relational organizational systems. Bureau- the macrocosm of a national/global culture
cracies are organizational systems that can be and the microcosm of specific organizations
viewed as cultures. Organizational cultures (Eisenberg & Goodall, 1993; Schein, 2004).
have a rich heritage and have been studied In recent years, organizational cultures have
as both formal and informal systems since emerged as globalizing corporate systems
the 1930s in the United States (Bolman, with multiple descriptions of meaning. How-
2008; Brenton & Driskill, 2005; Morgan, ever, economics or the bottom line is the
1997; Pensky, 2005; Porter-OGrady & potent equalizer of most macro- and micro-
Malloch, 2003, 2007; Ray, 1981, 1984, 1989a, cultures (Eisler, 2007; Henderson, 2006).
2006; Ray in Coffman, 2006; Smircich, 1985; There is an ever greater concentration of eco-
Swinderman, 2005; Turkel & Ray, 2000, nomic and political power in a handful of
2001). Informal organizational culture inte- corporations, which separate their interests
grates codes of ethics and conduct encom- (usually profit-driven) from the interests of
passing commitment, identity, character, coher- humans, which are life-centered (Eisler,
ence, and a sense of community in social 2007; Henderson, 2006; Korten, 1995; Turkel
interaction and the social environment. The & Ray, 2000, 2001).
informal organizational culture is considered Health care and its activities are tightly
essential to the successful functioning or interwoven into the social and economic fab-
the administering of the formal organiza- ric of nations. Values that drive a nation are
tion: political power and authority, techno- experienced in the health care arena. For
logical computation, and economic and legal example, for the most part, cost and
exchange. The formal organization thus com- profit have transformed health care in the
prises political, economic, legal, and technical United States. As health care organizations
systems (the typical phenomena of bureaucra- continually are affected by issues of cost and
cies). Bureaucracies themselves create their profit, health-care systems undergo immense
own cultural orientations, patterns, goals, rit- change. Over recent years, confidence in
uals, languages, and norms within the struc- major health-care institutions and their lead-
tural elements of the political, economic, ers have fallen so low as to put the legitimacy
legal, and technological dimensions (Britain of executives who manage health care systems
& Cohen, 1980). at risk. Trust is a major issue (Ray, Turkel, &
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C H A P T E R 2 9 Marilyn Anne Rays Theory of Bureaucratic Caring 477

Marino, 2002). Old rules of loyalty and com- Incorporating business principles and creativ-
mitment to employees, investment in the ity of caring, the work of the soul or rela-
worker, fairness in pay, and the need to tional self-organization (Ray, 1994a, 1998;
provide good benefits are in jeopardy. Health- Ray, Turkel, & Marino, 2002) means leading
care systems have fallen victim to the corpo- in a new way (Porter-OGrady & Malloch,
ratization of the human enterprise. Conse- 2007; Turkel & Ray, 2004). It is a witness to
quently, the conflict between health care as the power and depth of transformation: resee-
a business and caring as a human need has ing the good of nursing, searching for mean-
resulted in a crisis in nursing in terms of ing in life, creating caring organizations, and
shortages of professional nurses, and the qual- finding new meaning in the complexities of
ity of care provided by health-care organiza- work itself.
tions (Anderson & McDaniel, 2008; Begun
& White, 2008; Eisler, 2007; Page, 2004; Organizational Cultures as
Satterly, 2004; Sorbello, 2008b). Transformational Bureaucracies
The actual work of nurses, while underval- The transformation of nursing toward a greater
ued in terms of both cost and worth (Ray, understanding of relational self-organization
1987a; Turkel & Ray, 2000, 2001), currently is and creativity (work of the soulspiritual
being evaluated in terms of issues of patient ethical caring) is not necessarily a new pursuit
safety and clinical nurse leadership (Page, for the profession: what it reveals is a move-
2004). Since the Institute of Medicine report ment from invisibility to visibility. Identifying
(Page, 2004), a resurgence of interest is taking professional nurse caring work as having value
place in the meaningfulness of work and and an expression of ones soul or ones creative
patient safety in many hospitals. Nursing self at work replaces the notion of nursing as
education and the clinical nurse leader role are performing only machinelike tasks.
highlighted as bridges to quality (Long, 2003; Bureaucracy, still considered by some as a
Stanley, 2006). The language of trust and machinelike metaphor, as we have identified,
morally worthy work (Cuilla, 2000; Ray, continues to play a significant role in the
Turkel, & Marino, 2002; Wiggins, 2006) is meanings and symbols of organizations
beginning to replace the language of downsiz- (Coffman, 2006; Perrow, 1986; Ray, 1981,
ing and restructuring at the same time that 1989a, 2006). The social theorist Weber
mergers and acquisitions still hold sway in (1999) actually predicted that the future
contemporary corporate environments. Cuilla belonged to the bureaucracy and not to the
(2000) stated that [t]he most meaningful working class. Weber, who saw bureaucracy as
jobs are those in which people directly help an efficient and superior form of organiza-
others [provide care] or create products that tional arrangement, predicted that the
make life better for people (p. 225). bureaucratization of enterprise would domi-
Although the traditional work of nurses is nate the world (Bell, 1974; Weber, 1999).
defined as directly helping others through This, of course, is witnessed by the current
knowledgable caring (Watson, 2005), contem- globalization of commerce and technical
porary nurses work and its meaning is information systems. In terms of global com-
also defined by and in the organizational merce, recent acquisitions and mergers of
contextthe structural dimensions of politi- industrial firms and even health-care systems,
cal, economic, legal, and technological systems especially in the United States, are larger and
(Ray, 1989a, 2006; Turkel, 2007). Urging hold more power than some world govern-
nurses, physicians, and administrators to find ments. (Yet, to maintain the integrity of
cohesion among these dimensions in organi- large scale, for-profit corporations, often gov-
zations and the dynamics of unity of human ernments have to step in with increased regu-
beings (body, mind, and spirit integration) lation and infuse systems with monetary
call for the reinvention of work (Fox, 1994). guarantees.) Information technology systems
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478 S E C T I O N VI Middle-Range Theories

often are in the hands of a few who direct some as associated with red tape and inflexi-
and guide knowledge. We can see this hap- bility, continues to provide the most reason-
pening with the development of informatics able way in which to view systems and facili-
in hospitals and other health care systems tate the preservation and understanding of
(Swinderman, 2005). The concept of bureau- organizations. In the past two decades, there
cratization is thus a worldwide phenomenon has been a call for decentralization and the
(Ray, 1989). Although they considered it less flattening of organizational structuresto
effective than other forms of organization, become less bureaucratic and more participa-
Britain and Cohen (1980) stated that, Like tive or heterarchical (Porter-OGrady &
it or not, humankind is being driven to a Malloch, 2005, 2007). Many firms have
bureaucratized world whose forms and func- begun to hold to new principles that honor
tions, whose authority and power must be creativity and imagination (Morgan, 1997).
understood if they are ever to be even partially Even nursing has advanced in a more collab-
controlled (p. 27). The study of bureaucra- orative or decentralized manner by its focus
cies is, in effect, the study of the most salient on patient-centered nursing and a movement
and powerful organizations of the contempo- from more centralized control and adminis-
rary world (p. 27). As bureaucracies grow, so tration to more decentralized self-governance
too will the importance of family, kin, com- (Long, 2003; Nyberg, 1998). But creative
munity, organizational life, culture, ethnicity, views still need to be marked with under-
and what is now termed, panethnicity, an standing of structural systems of bureaucracy
understanding of diversity within wholeness as globalization, information, and economics
(Britain & Cohen, 1989; Tuan, 1998). sweep the world.
The characteristics of bureaucracies are as Leadership models, which are fundamen-
follows: tally hierarchical because of the need for
order, continue to head the short-lived partic-
A division of labor based on departments,
ipative movement toward decentralization.
leadership, and authority
Even the new Clinical Nurse Leader role sets
A hierarchy of offices [bureaus or units]
a nursing leader apart from his or her peers in
with diverse cultural orientations
terms of knowledge and authority. Power is
A set of general policies and rules that
still in the hands of a few. As local and global
govern performances
economic markets rule, there is a call for cre-
A separation of the personal from the
ating a caring economics and a need to be
official
creative and ethical in terms of the worldwide
A selection of personnel on the basis of
technological and economic transformation
technical/professional qualifications
taking place (Eisler, 2007; Ray, 1987a). We
Equal treatment of all employees or stan-
have to look at the social, psychological, and
dards of fairness and reimbursement
spiritual factors that shape our societies and
Employment viewed as a career by
organizations. As a result, the concept of
participants
bureaucracy does not seem as bad as was once
Protection of dismissal by tenure or evalua-
thought because it addresses human, and in
tion (from Perrow, 1986; Eisenberg &
many respects, humane action. It can be con-
Goodall, 1993).
sidered as a much less radical paradigm than
Bureaucracy thus incorporates within the the business paradigm that focuses only on
human and ethical dimension the political competition and response to market forces,
(power and authority), legal (policies and subsequently eradicating standards of fairness
rules), economic (cost systems), and technical or social justice for humans in the workplace.
(professional, informational, and computa-
tional) dimensions. At the same time, bureau- Caring as the Unifying Focus of Nursing
cracies integrate the whole social and cultural Caring in nursing speaks of relationships,
system. Bureaucracy, while condemned by compassion, human dignity, ethics, justice,
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C H A P T E R 2 9 Marilyn Anne Rays Theory of Bureaucratic Caring 479

and competent and knowledgeable caring interaction with the larger whole. Health is
practice (Ray, 1981, 1989b; Roach 2002; considered expanded consciousness (Newman
Watson, 2005). It is holistic, humane, and et al., 2008). Health in the face of illness
dynamic; thus, it facilitates growth and devel- [prevention of disease or dis-ease] derives
opment of human persons and helps to make meaning through a caring nursepatient rela-
things work in health care agencies. As such, tionship (Newman et al., 2008, p. E1718).
caring is considered by many nurse scholars Many caring theories correspond to one or all
to be the essence of nursing (Boykin & of these paradigms (Morse et al., 1990). The
Schoenhofer, 2001; Leininger, 1981b, 1991, Theory of Bureaucratic Caring has its roots
1997; Morse, Solberg, Neander, Bottorff, & in all these paradigms and most specifically
Johnson, 1990; Ray, 1989a,b, 1994a,b; in the unitarytransformative paradigm by
Swanson, 1991; Watson, 1985, 1988, 1997, its synthesis of caring and the organizational
2005). Although not uniformly accepted, (bureaucratic) context, holism, and the dynam-
Newman, Sime, and Corcoran-Perry (1991) ics and relational self-organizing emergent
and Newman (1992) characterized the social process of the humanenvironmental integral
mandate of the discipline of nursing as caring relationship.
in the human health experience. Newman
et al. (2008) further emphasized her initial Description of Bureaucratic
idea that health is the focus, the rhythmic Caring Theory
fluctuations of the life process, as well as The Theory of Bureaucratic Caring, as report-
caring, consciousness, mutual process, pat- ed, originated as a grounded theory from a
terning, presence, and meaning (Newman qualitative study using phenomenology,
et al., 2008). Caring and health thus are influ- ethnography, and grounded theory methods of
ential concepts. The expression caring in the caring in the organizational culture, and
human health experience emphasizes the social appeared first as the authors dissertation in
mandate to which nursing has responded 1981 and as a chapter and article in 1984 and
throughout its history and encompasses the 1989, respectively. In the qualitative study of
scope of the discipline (Roach, 2002; Watson, caring in the organizational context, the
2005). Caring, with multiple meanings, how- research revealed that nurses and other profes-
ever, is manifested in different and complex sionals struggled with the paradox of serving
ways in the nursing discipline and profession the bureaucracy and serving humans, especially
(Morse et al., 1990; Newman, 1992; Ray, patients, through caring. Caring, however, had
1981, 1989a,b). multiple meanings and was expressed differ-
Various paradigms that enfold the care ently in terms of the way a particular unit was
and caring ideal exist in nursing. The totality organized. The system phenomena of politi-
(Fawcett, 1993), the simultaneity (Parse, 1987), cal, economic, legal, and technological became
and the unitarytransformative (Newman, integrated into the meaning system of caring
1992; Newman et al., 2008) paradigms have just as the humanistic, social, educational, eth-
been the prevailing worldviews in nursing and ical, and spiritual. The discovery of bureau-
have directed nursing theories. The totality cratic caring resulted in both substantive theory
paradigm demonstrates that nursing, person, (grounded in the context of meaning) and for-
society, environment, and health characterize mal theory (integrated from the substantive
the nature of nursing. The simultaneity para- theory and general understanding of dimen-
digm illuminates the humanenvironmental sions of complex bureaucracies) (Ray, 1981,
integral nature of nursing. The unitary 1984, 1989a).
transformative paradigm states that what The bureaucracy represented a living
constitutes nursings reality is the view that system. Caring was portrayed not only as the
the human being is unitary and evolving as a more interpersonal relational patterns of
self-organizing field embedded in a larger humanness and compassion, but also as how
self-organizing field identified by pattern and the official structures of the bureaucracy,
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480 S E C T I O N VI Middle-Range Theories

especially the political and economic, were Subsequently, the theory was revealed as holo-
infused into the meaning system of profes- graphic, showing that caring is complex, holis-
sionals. Even patients saw the system as tic, and dynamic. Interactions and symbolic
affecting how they understood caring in their systems of meaning by nurses and others are
own health care experiences (Ray, 1981, formed and reproduced from the construc-
1989a; Ray & Turkel, 20012004). The tions or dominant values held and evolving
substantive theory (grounded) emerged as within the organization. In some respect, we
Differential Caring Theory and showed that are the organization.
caring in the complex organization of the The theory has been embraced by educa-
hospital was complex and differentiated itself tors, researchers, technologists, nursing admin-
in terms of meaning by its specific context istrators, and clinicians who, after witnessing
dominant caring dimensions related to areas changes in health care policy in the past decade,
of practice or units wherein professionals have begun to appreciate how the context
worked and clients resided. Differential Car- micro- and macro-culturesinfluences nurs-
ing Theory showed that professionals and ing. Moving away from just centering on
patients on different units espoused different patient care to the economic justification of
and dominant caring meanings based on their nursing and health care systems has prompted
personal and organizational goals and values. professionals to desire a fuller understanding of
For example, participants in the oncology unit how to preserve humanistic caring within the
espoused caring as intimate and spiritual; in business or corporate (economic and political)
contrast, participants in the Intensive Care culture (Miller, 1989; Nyberg, 1989, 1991,
Unit espoused caring as more technological; 1998; Turkel, 2007). The theory also has been
in the administration, participants espoused used as a foundation for additional research
caring as maintaining economic viability. The and observational studies of the nursepatient
formal Theory of Bureaucratic Caring sym- caring relationship and system issues, such as
bolized a dynamic structure of caring, which in public health administration, curriculum
was synthesized from a dialectic using the development, correctional facility health care,
tenets of the philosophy of Hegel (thesis, technology and information technology, eco-
antithesis, and synthesis); the dialectic between nomics of caring, the clinical nurse leader role,
the thesis of caring as humanistic, social, ethics and the moral community, legal caring,
educational, ethical, and religious/spiritual pediatric pain, and medication errors in com-
(dimensions of humanism, morality, and spir- plex organizations (Al-Ayed, 2008; Coffman,
ituality), and the antithesis of caring as eco- 2006; Gomez, 2008; Gibson, 2008; Manworren,
nomic, political, legal, and technological 2008; McCray-Stewart, 2008; OBrien, 2008;
(dimensions of bureaucracy) (Coffman, 2006; Ray, 1987b, 1993, 1997a, 1998a,b; Ray, Turkel
Ray, 1981, 1989a, 2006; Turkel, 2007). & Marino, 2002; Sorbello, 2008a; Swinderman,
Although the later depictions of the model 2005; Turkel, 1997, 2007; Turkel & Ray, 2000,
demonstrate that the dimensions are equal, the 2001, 2009).
initial research revealed that economic and
political patterns of meaning were more dom- Evolution of Theory
inant followed by the technical and legal
dimensions, and then the social and ethical/ Development
spiritual dimensions. Subsequently, the model Facing the challenge of the economic and
was pictured with co-equal dimensions. The patient safety crises in health care and nurs-
current holographic model shows the primacy ing, disillusionment of registered nurses about
of caring as spiritualethical and the other the disregard for their caring services, and the
dimension as equal, indicating the holistic concern of the nursing profession and the
nature of the interface between the spiritual public about the effects of the shortage of
and ethical and the bureaucratic dimensions. nurses (Page, 2004), working for the good
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C H A P T E R 2 9 Marilyn Anne Rays Theory of Bureaucratic Caring 481

of the profession and preservation of the with researching the meaning and action of
nursepatient caring relationship is impera- caring in the bureaucratic, organizational or
tive. Running away from the chaos of hospi- institutional culture of a hospital, which
tals or misunderstanding the meaning of resulted in a substantive Theory of Differen-
work life cannot become the norm. Wherever tial Caring. Narrative responses to the mean-
nurses go, they will be haunted by bureau- ing of caring reported by different health-care
cracies, some functional, many problematic. professionals and patients produced varied
What, then, is the deeper reality of nursing beliefs and values, ranging from humanistic
practice? Why are theories in practice definitions, such as empathy, love, and ethical
important? The following is a presentation and religious delineations, to technological
of theoretical views that relate to Bureau- (patient-assist machines or other technolo-
cratic Caring Theory, culminating in a vision gies), legal (policies and rules), political (power
for understanding the deeper significance and control), and economic (money, budget)
of nursing life as holistic, the dynamics of descriptions. The formal theory evolved as a
unity. result of using the Hegelian dialectical process
of thesis, antithesis, synthesis, as an analytic
Substantive Theory and Formal tool. In this research caring was the thesis,
Theory bureaucracy was the antithesis of caring, and
Glaser and Strauss (1967; Glaser, 1978; Bureaucratic Caring Theory was the synthe-
Strauss & Corbin, 1998) were the first sociol- sis. The laws of the dialectic include:
ogists to present the perspective of social the-
Examining and connecting co-determining
ory, both substantive and formal, discovered
polar opposites (thesis and antithesis)
from inductive research processes. Substantive
Negation of each of the separate yet
and formal theories emerge from in-depth
co-determining opposites (thesis and
qualitative studies of socialcultural processes
antithesis)
action and interaction associated with the
Synthesis of the polar opposites into a new
social world. The researcher considers evi-
conceptualization (change and spiral trans-
dence about how one event affects another
formation) (Moccia, 1986; Ray, 1981).
and explains the things observed and recorded
by developing theoretical relationships about Thus, in this research, the co-determining
the data. Theoretical sampling (Glaser, 1978) opposites were the thesis of caring which
refines, elaborates, and exhausts conceptual included the humanistic, social, ethical,
categories so that an actual integration of educational, and religious/spiritual dimen-
descriptors and categories about a phenome- sions, and the antithesis, which included the
non or social process can facilitate the discov- structural dimensions of economics, politics,
ery of substantive theory. The discovery of a law, and technology of the bureaucracy.
basic social process is the foundation for Negation of both the co-determining polar
substantive theory. The formal theory is opposites became a synthesis, the dialectical,
generated from both the inductive process, formal Theory of Bureaucratic Caring
based on substantive knowledge/theory, and indicating change and transformation. The
deductive approaches, which draw upon meaning of caring in the organizational/
cumulative knowledge from the social world institutional culture was illuminated as the
to examine the initial propositions advanced. Theory of Bureaucratic Caring, which is
A formal theory reflects the structure of both simply a representation of carings integral
processes. nature (meaning) in contemporary organiza-
tional culture. The theory shows that caring
Formal Theory Analysis reached its completeness through the process
The Theory of Bureaucratic Caring integrat- of its own relevance in practice (Ray, 1981,
ed knowledge from data that are associated 1989a, 2006).
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482 S E C T I O N VI Middle-Range Theories

The Relationship Between Middle- Is the Theory of Bureaucratic Caring a


Range and Formal Theory middle-range theory as well as a grounded
substantive and formal theory? Middle-range
Middle-range theory deals with a relatively theories, especially substantive theories are
broad scope of phenomena but does not cov- abstract enough to extend beyond data gener-
er the full range of phenomena of a disci- ated in a specific space, place, and time, but
pline, as do grand theories that encompass specific enough to allow for testing the theory
the fullest range or the most global phenom- in different arenas or permitting interven-
ena in the discipline (Chinn & Kramer, 1995; tions for practice to transform nursing prac-
Liehr & Smith, 1999). As such, middle- tice (Moody, 1990). Middle-range theory
range theories are generally considered nar- embodies the perspective that these theories
rower in scope than grand theories, and to fall between the concrete world of practice
some extent not as broad as formal theory and the grand theories that guide nursing
within the grounded theory tradition. Middle research and practice (Moody, 1990; Liehr &
range theories include the following: inter- Smith, 1999). The initial dialectical theory
mediate in scope; testable; grounded in showed that the meaning of living caring in
research; neither too broad nor too narrow; organizational life with the meaning and
less concrete than practice theory; substan- symbols in an institutional/organizational
tively specific; consisting of a limited number culture reflects not only the microculture of a
of variables; focused on limited aspects of personalhealth care organization connec-
reality; and can be built on the work of other tion, but also a connection that reflects the
middle range theories (Liehr & Smith, 1999, macro or dominant culture of a nation-state.
pp. 8283). The meaning of caring in the organization
There is a paradox in viewing caring showed that meaning was constituted inter-
or the study of caring only as middle-range personally but within a larger pattern of sig-
theory. Caring in nursing, for example, may nificance. Organizations or bureaucracies are
be considered by some scholars in the disci- representations of our humanity and the
pline as having a narrow scope or a founda- social order (Bolman & Dial, 2008; Smircich,
tion for a middle-range theory from nursing 1985; Schein, 2004). They are living systems.
practice situations. However, others who Social forms and social arrangements reflect
have adopted the unitarytransformative the interplay among cultural systems of
paradigmatic view of the discipline of nursing thought, language, communication, organi-
as health and caring, see caring manifesting zations, nations and in the modern era, the
consciousness, belongingness, intentionality, globe. Bureaucratic Caring Theory reflected
seeing the self, other and environment as the symbols of the spiritual, ethical and psy-
interconnected, dynamic flow, pattern appre- chodynamics of caring in human experience,
ciation, the infinite (the quality of caring and the political and economic power and
as love or divine energy), and complexity authority, technology and the law in complex
where creative emergence unfolds through human systems. However, within the con-
intrinsic properties of living what matters crete world of human experience, caring was
and choice. Caring in this view is specific illuminated as a universal ideal, that is, not
and universal, human and transcendent only unique in nursing but universal to what
(Newman, 1992; Newman et al., 2008; it means to be human (Boykin & Schoen-
Smith, 2004; Ray, 1997b). Moreover, those hofer, 2001; Roach, 2002). Therefore, the
who have studied caring in the human health Theory of Bureaucratic Caring is a ground-
experience in complex organizations see car- ed theory and a middle-range theory. Fur-
ing as a broad enough ideal to embrace and thermore, the theory may be considered a
capture the holistic nature of nursing (body, grand or holographic theory because of the
mind, spirit, and coexistent with the context nature of caring and culture as holistic and
or environment). ubiquitous.
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C H A P T E R 2 9 Marilyn Anne Rays Theory of Bureaucratic Caring 483

Holographic Emergence in (1991), and was a foundation for other


Bureaucratic Caring Theory theories, such as those of Parse, Newman, and
Reed (Marriner Tomey & Alligood, 2006).
The holographic paradigm in science recog- This notion is seen again at a different time
nizes that the ontology or what is of the and through a different lens. In the authors
universe or creation is the interconnectedness work, the focus is on the caring patterns of the
of all things, that the epistemology or knowl- nursepatient relationship within the bureau-
edge that exists is in the relationship rather cratic context of a hospital. The Bureaucratic
than in the objective world or subjective expe- Caring Theory already considered paradoxical
rience, that uncertainty is inherent in the rela- (bureaucratic caring), identified the linkage
tionship because everything is in process, and between caring as humanistic, socialcultural,
that information and choice hold the key educational, and spiritualethical, and the
to grasping the holistic and complex nature organizational hospital system as structural:
of the meaning of holography or the whole political, economic, legal, and technological.
(Battista, 1982; Harmon, 1998). Holography Caring is a relational pattern; it is the flow of
means that the implicate order (the whole) nurses and others own experiences in the
and explicate order (the part) are intercon- structural context of the organization. This
nected, that everything is a holon, including simultaneous process illuminates the idea that
humans, in the sense that everything is a the whole and parts are one and the same; all
whole in one context and a part in another cycles of activities are linked coherently
each part being in the whole and the whole together but each may be doing different
being in the part (Cannato, 2006; Harmon, things at different paces; all the parts are
1998; Peat, 2003; Wilber, 1982). For example, participating in the whole and the whole is
The molecule depends on the atom, the participating as a part in different contexts of
cell depends on the molecule, and all depend meaning (Davidson & Ray, 1991; Rogers,
on the stability of the interconnected system 1970; Thoma, 2003). Information (caring and
in order to thrive (Cannato, 2006, p. 98). system data) unfolds and emerges at the same
All cycles of activities are linked coherently time, in the same space without contradict-
together; the more energy is stored within ing each other. Bureaucratic Caring Theory
systems, the more subcycles there are. It is as a holographic theory furthers the vision
the relational and reciprocal aspect of rela- of nursing and organizations as complex,
tionship itself, information and choice that dynamic, relational, integral, informational,
makes it holistic rather than mechanistic, and emergentopen to sets of possibilities
which subsequently opens all systems to because of the synchronicity of interacting
diversity and emergence (integrated sets of parts and the whole. Everything intercon-
possibilities) (Davidson & Ray, 1991; Ray, nects; we are all creative manifestations of the
1998,b; Thoma, 2003). Holistic science is a oneness of the environment (context), moving
humanenvironmental mutual process, and in relationship and continually transforming
a dynamic unity, and a transformative (emerginggrowing and developing) (Thoma,
process. Holistic science (and art) thus cap- 2003). Because of the knowledge of complex-
tures the idea that all systems, including ity as holography (holistic science and art), we
health care systems, are living systems, are all need to become more aware of the meaning
both wholes and parts, and depend on of participatory life and ways of relating to the
networks of relationships, information, and reality of complex organizations or bureaucra-
communication flow. cies. Rather than continuing mechanistic
The humanenvironmental mutual process approaches of prediction and control that
is not a new idea to nursing. It was a central may have worked to some extent to gain pre-
theoretical perspective of Martha Rogers cise knowledge in the past, we must now give
(1970), and central to beliefs in anthropology way to new understanding. Nurses and other
and transcultural nursing advanced by Leininger professionals must be open to change, to
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484 S E C T I O N VI Middle-Range Theories

the integral nature of the dynamic unity of Transforming the Organization


the human and environment, and to phenom- How can knowledge of holistic caring inter-
ena that are coherent and emergent wholes connectedness motivate nursing to help
(body, mind, spirit and context) that make nurses to continue to embrace the human
up our world of caring, health, healing, and dimension within the current political, eco-
well-being (Davidson & Ray, 1991; Rogers, nomic, legal, and technologic environment of
1970). health care? Can higher ground be reclaimed
for the 21st century? Higher ground requires
The Theory of Bureaucratic Caring that we make excellent choices at the edge
as Holographic Theory of chaos where possibilities exist to either
How can the Theory of Bureaucratic Caring transform or disintegrate. Understanding of
be viewed as a holographic theory? As pre- spiritual-ethical caring in the holographic
sented, the theory arose initially from inter- Theory of Bureaucratic Caring helps us to
pretations and choices that were made about connect at our deepest level. Nursing and
the meaning and structure of caring in organi- others in complex systems can reclaim higher
zational life. The process parallels ideas from ground by doing the work of the soul
complexity sciences and specifically hologra- (understanding and engaging creatively, and
phy: consciousness or awareness, intentional- taking ethical responsibility for the other and
ity of the mutual humanenvironmental car- the organizational system). The model (see
ing relationships, quality of the caring Fig. 29-2) presents a vision of nursing but it is
transactions, and the effective ability to ana- based on the reality of practice through con-
lyze, negotiate, make choices, and reconcile tinuous research and observation. The model
paradoxes between caring and the system emphasizes a direction toward the unity of
demands. The humanistic nursepatient care experience. Spirituality involves creativity and
needs and professional responsibilities in terms choice and refers to genuineness, vitality,
of the structural considerations of the system and depth. It is revealed in attachment, love,
(political, economic, legal, and technological and community and comprehended within as
dimensions) were always emerging from sets intimacy and spirit (Harmon, 1998; Secretan,
of caring possibilities. Awareness of belong- 1997). Ethics deals with our moral responsi-
ingness, the mutual humanenvironmental bility to one another and to the organizations
relationship, the implicate (the whole) and within which we work. Secretan (p. 27) states:
explicate (the part) orderthe whole is Most of us have an innate understanding of
reflected in the part, and part reveals the soul, even though each of us might define it in
whole, respect for the good of all things, and a very different and personal way.
communication, choice and emergence are Fox (1994) calls for the theology of work
central to holistic science. Similarly, these con- a redefinition of work. Because of the crisis of
cepts were central to the interpretation of car- our relationship to work, we are challenged to
ing as a whole in the complex organization. reinvent it. For nursing, this is important
The dialectic of caring (the thesis, the implic- because work puts us in touch with others, not
it order or the whole) in relation to the various only in terms of personal gain, but also at the
structures (the antithesis of the system, explic- level of service to humanity or the community
it order or part) is reconciled and transformed of patients/clients and other professionals.
by a synthesis of the polar opposites into the Work must be spiritual and ethical, with
Theory of Bureaucratic Caring. The synthesis recognition of the creative spirit at work in us.
of Bureaucratic Caring Theory shows that Nurses must be the custodians of the human
everything is interconnectedhumanistic spirit (Secretan, 1997, p. 27).
spiritualethical caring and the organizational The ethical imperatives of caring that join
systemthe whole is in the part and the part with the spiritual relate to questions or issues
is in the whole, therefore, nursing in the sys- about our moral obligations to others. The
tem is a holon. ethics of caring as edifying the good through
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C H A P T E R 2 9 Marilyn Anne Rays Theory of Bureaucratic Caring 485

communication and interaction involve never Summary


treating people simply as a means to an end The values of nursing are deepening, and as a
or as ends in themselves, but rather as beings discipline and profession, nursing is expand-
that have the capacity to make choices about ing its consciousness. Nursing is being shaped
the meaning of life, health, and caring. Ethi- by the historical revolution occurring in sci-
cal contentas principles of doing good, ence, social sciences, and theology as well as
doing no harm, allowing choice, being fair, the revolution of its own commitment to car-
and promise-keepingfunctions as the com- ing, health and understanding holism and
pass in our decisions to sustain humanity in complex systems (Davidson & Ray, 1991;
the context of political, economic, and tech- Lindberg et al., 2008; Newman et al., 2008;
nological situations within organizations. Ray, 1998a, 2006; Reed, 1997; Watson, 2005).
Roach (2002) pointed out that ethical caring Freeman (in Appell & Triloki, 1988) pointed
is operative at the level of discernment of out that human values are a function of the
principles, in the commitment needed to capacity to make choices, and called for a par-
carry them out, and in the decisions or choic- adigm giving recognition to awareness and
es to uphold human dignity through love choice. As noted, a revision toward this end is
and compassion. Furthermore, Roach (2002) taking place in science based upon a new
remarked that health is a community respon- holographic scientific worldview. Nursing has
sibility, an idea that is rooted in ancient the capacity to make creative and moral
Hebrew ethics. The expression of human choices for a preferred future. Constructs of
caring as an ethical act is inspired by spiritual consciousness and choice are central and
traditions that emphasize charity. For nursing, demonstrate that phenomena of the universe,
spiritual/ethical caring does not question including society and what happens in nurs-
whether or not to care in complex systems but ing, arise from the choices that are or are not
intimates how sincere deliberations and ulti- made (Davidson & Ray, 1991; Harmon,
mately the facilitation of choices for the good 1998; Newman et al., 2008). As the Theory
of others can or should be accomplished. By of Bureaucratic Caring has reinforced, caring
integrating knowledgeable caring creatively, is the primordial construct and consciousness
by staying intentional and conscious of of nursing. Nursing theory focuses on the
dynamic movements within the circle of life capacity to direct the good. In nursing, the
and relationships, and by leading in a new way critical task is to comprehend the meaning
in complex systems, nurses are engaging in of the networks and complexity of relation-
new and exciting work (Eisler, 2007; OGrady ship, between what is given in culture (the
& Malloch, 2007; Ray, Turkel, & Marino, norms), and what is chosen (the moral and
2002; Turkel & Ray, 2004). Holistic science spiritual). In nursing, the unitary-transforma-
and art is a witness to the power and depth of tive paradigm and the various theories of
transformation: to reseeing the good of nurs- Newman, Leininger, Parse, Rogers, and the
ing as spiritual and ethical, to believing in holographic Theory of Bureaucratic Caring
human potential, to continually searching for are challenging nursing to become aware and
meaning in life, to creating caring organiza- understand their future. The unitary-transfor-
tions, to co-creating new possibilites, and to mative paradigm of nursing and its holo-
finding new meaning in the complexities of graphic tenets are consistent with the chang-
work life itself. ing images of the new science despite the
The scientist Sheldrake (1991, p. 207) remarked: reality that nursing continues to be threatened
The recognition that we need to change the way by the business model over its long-term
we live [work] is gaining ground. It is like waking up human interests for facilitating health and
from a dream. It brings with it a spirit of repentence, well-being (Davidson & Ray, 1991; Lindberg
seeing in a new way, a change of heart. This con- et al., 2008; Ray, 1994a, 1998; Reed, 1997;
version is intensified by the sense that the end of Smith, 2004; Vicenzi, White, & Begun,
the age of oppression is at hand. 1997). The creative, intuitive, ethical, and
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486 S E C T I O N VI Middle-Range Theories

spiritual mind is unlimited, however. Through engender a new sense of hope for transforma-
authentic conscience (Harmon, 1998), we tion in the work world. This transformation
must find hope in our creative powers. toward relational caring organizations can
The latest presentation of Bureaucratic occur in the economic and politically driven
Caring Theory is a creative enterprise. The atmosphere of today. The deep values that
theory reflects incorporation of tenets of the underlie choice to do good for the many will
new sciences of complexity highlighting be felt both inside and outside organizations.
holography. Holographic theory illuminates We must awaken our consciences and act on
holistic science and art, the interconnected- this awareness and no longer surrender to
ness of all things, human-environment inte- injustices and oppressiveness of systems that
gral relationships, scientific chaos, holographic focus primarily on the good of a few. Healing
patterning (the whole is in the part and the a sick society [work world] is a part of
part in the whole), informational networks, the ministry of making whole (Fox, 1994,
relational self-organization, transformation, p. 305). The holographic Theory of Bureau-
change, choice, and emergence (Bar-Yam, cratic Caringidealistic, yet practical; vision-
2004; Davidson & Ray, 1991; Lindberg et al., ary, yet realcan give direction and impetus
2008; Ray, 1991, 1994, 1998a; Turkel & to lead the way.
Ray, 2000, 2001; Thoma, 2003). In the revised
model of the Theory of Bureaucratic Caring,
everything is infused with spiritual/ethical Application of the Theory
caring (the center of the model) by its integra- Ray (1989a, p. 31) warned that the transfor-
tive and relational connection to the struc- mation of America and other health care
tures of organizational life (relational self- systems to corporate enterprises emphasizing
organization). Spiritual/ethical caring is both competitive management and economic gain
a part and a whole, and every part secures its seriously challenges nursings humanistic
purpose and meaning from each of the parts philosophies and theories, and nursings
that can also be considered wholes. In other administrative and clinical policies. Approxi-
words, the theoretical model shows how mately 20 years later, in the current health
spiritual/ethical caring is involved with quali- care environment, there is an intense focus on
tatively different processes or systems; for operating costs and the bottom line, and car-
example, political, economic, technological, ing is often not valued within the organiza-
and legal. The systems, when integrated and tional culture. However, nurse researchers,
presented as open and interactive, are a whole nurse administrators, and nurses in practice
and must operate as such by conscious choice, can use the Theory of Bureaucratic Caring as
especially by the choice making of nursing, a framework to guide practice and decision
which always has, or should have, the interest making.
of humanity at heart. As the United States is in the midst of
Envisioning the theory as holographic from debate concerning the future of health care
its initial substantive and formal grounded access and coverage the focus is on the con-
theories shows that through creativity and cept of economics. From an economic per-
imagination, nursing can build the profession spective, health-care organizations and insur-
it wants. Nurses are calling for expression of ance companies are businesses. The competition
their own spiritual and ethical existence. for survival among organizations is becoming
Nurses are also calling for understanding of stronger, cost controls are becoming tighter,
the nurse-patient caring relationship in com- and reimbursement is declining. However, the
plex organizations. The new scientific, spiri- human dimension of health care is missing
tual and experiential approach to nursing the- from the economic discussion.
ory as holographic will have positive effects. In the economic debate, the belief in caring
The union of science, ethics, and spirit will for the patients as the goal of health-care
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C H A P T E R 2 9 Marilyn Anne Rays Theory of Bureaucratic Caring 487

organizations and insurance companies has Caring to examine the paradox between
been lost. Ray (1987a, 1989a) questioned the concept of human caring and political,
how economic caring decisions are made economic, legal and technological dimensions
related to patient care in order to enhance in complex organizations. Moreover, recently,
the human perspective within a corporate Al-Ayed (2008), Gibson (2008), Gomez
culture. When patients are hospitalized, it is (2008), McCray-Stewart (2008), OBrien
the caring and compassion of the registered (2008) and Swinderman (2005) have used
nurse that the patients perceive as quality the theory to evaluate medication errors,
care and what makes a difference in their interviews in the justice system, nursing
recovery (Turkel, 1997). education and practice, health care in correc-
Historically, nursing care delivery has not tional facilities and public health nursing,
been financed or costed out in terms of reim- and informatics respectively. For additional
bursement as a single entity. In the United information, please visit DavisPlus at http://
States, the prospective payment system of davisplus.fadavis.com. It was a challenge for
diagnostic related groups (DRGs) connected nurses to combine the science and art of car-
nursing services to the bed rate for patients ing within the complex health-care environ-
(Shaffer, 1985). The current reimbursement ment. However, any efforts to reshape the
systems, including health maintenance organ- health-care system in the United States and
izations (HMOs), managed care, Medicare, other countries must take into account the
Medicaid, and private insurers, are reimburs- value of caring within bureaucracies.
ing hospitals at a flat capitated rate. Subse-
quently, it is hospital administrators who must Relevance of the Theory of
determine how these dollars will be allocated Bureaucratic Caring to Nursing
within their institutions. Thus, it is necessary Education
for caring nursing interactions to be viewed as The theory is relevant to nursing education
having value as an economic resource. When because of the focus on caring in nursing
professional nursing salary dollars are viewed practice and the conceptualization of the
as an economic liability that limits the poten- health care system (Coffman, 2006). When
tial profit margins of organizations they are developing the curriculum for a baccalaureate
examined closely. It is imperative to the future program, the faculty at Nevada State College
of professional nursing practice that we study combined Rays Theory of Bureaucratic
and document the economic value of caring, Caring with theoretical constructs from
so that human caring is not subsumed by the Watson (1985) and Johns (2000) as a concep-
economics of health care. Nurses, who under- taul framework. According to this framework,
stand the economics of as well as the politics the holographic theory of caring recognizes
and technical complexities of health care the interconnectedness of all things and that
organizations, will be able to synthesize this everything is a whole in one context and a
knowledge into a framework for practice that part of the whole in another context. Spiritual-
integrates the dimensions of the Theory of ethical caring, the focus for communication,
Bureaucratic Caring. Although caring and infuses all nursing phenomena including
economics may seem paradoxical, contempo- physical, socialcultural, legal, technological,
rary health-care concerns emphasize the economic, political, and educational forces
importance of understanding the cost of car- (Nevada State College, 2003, p. 2).
ing in relation to quality. Turkel (2001) used the theory to guide
Ray (1981, 1987a,b, 1989a, 1998a,b); Ray curriculum development in the masters of
and Turkel (1999, 20002004, 2001, 2003); science program in nursing administration at
Turkel and Ray (2003); Ray, Turkel, and Florida Atlantic University. Dimensions
Marino (2002); and Turkel (1997, 2001), have from the theory, including ethical, spiritual,
used dimensions of the Theory of Bureaucratic economic, technological, legal, political, and
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488 S E C T I O N VI Middle-Range Theories

social, served as a framework for the explo- were challenged to analyze the current
ration of current health care issues. The economic and reimbursement structure of
economic dimension of the theory was a cen- health care from the perspective of a
tral component in several courses. Students caring lens.

Practice Exemplar
The following exemplar from the practice nurse specialists. The CEO was reluctant to
setting was previously published by Turkel spend the additional financial resources.
(2007). The situation reflects the lived experi- Megan explained that increasing the number
ences of how the Theory of Bureaucratic Car- of registered nurses would decrease the num-
ing serves as a framework for nursing practice ber of falls and pressure ulcers and increase
and guides decision-making. compliance related to patient safety. Addi-
Megan Smith, RN, MSN, was recently tional registered nurses would increase satis-
hired as the Chief Nurse Executive (CNE) faction for both nurses and patients as the
for a 500-bed inner city hospital. The payer nurses would have more time to focus on
mix for this patient population was once pri- developing caring relationships with patients
vate insurance but now it is approximately and their families. In addition, the registered
75% Medicare and Medicaid. When Megan nurses would have time to focus on providing
met with the nursing staff, they stated, We patient teaching and discharge planning.
are not valued or treated with respect. The Megan presented the CEO with quantitative
administrators only see us as numbers. We data to demonstrate the costs associated with
are implementing a new computerized doc- falls, pressure ulcers, and patients returning to
umentation system, getting new monitors, the emergency department (ED) within 48
being told that patient safety is important hours post-discharge because of inadequate
and getting ready for a survey from The education or discharge planning. The request
Joint Commission. With all the rules and for additional registered nurses and clinical
regulations, it is stressful to find time to nurse specialists was approved. Six months
actually care for our patients. Plus we need later the number of falls, pressure ulcers,
more help. medication errors, and return visits to the ED
Megan was committed to being an advo- had decreased. Scores on the patient satisfac-
cate for nursing while realizing the profes- tion survey related to nurses informing
sional accountabilty of considering the eco- patients, showing concern, and checking
nomic, political, and technological perspectives patient identification bands increased.
of her decision-making. Megan promised The additional clinical nurse specialists
the nurses that she would review the budget served as mentors to increase the technical
and follow-up with their concerns. She skills of the inexperienced graduate nurses
explained to the nurses that providing safe, and to demonstrate how the use of technol-
high quality patient care in a caring and com- ogy in terms of cardiac monitoring would
passionate manner was the top priority for the enhance the caring interactions between the
organization. registered nurse and patient. Customized
Later that week, Megan met with the programing of the new clinical documenta-
Chief Executive Officer (CEO) to share the tion system afforded nurses the opportunity
concerns of the nursing staff. Her first priori- to document interventions related to specif-
ty was to increase the number of registered ic dimensions of the Bureaucratic Caring
nurses and to hire two additional clinical Theory.
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Dimensions of the Theory zations were identified by Ray more than two
of Bureaucratic Caring decades ago. Ray (1987a) described the prob-
lems associated with economic changes in
The economic, political, technological, and health care and the negative impact econom-
spiritual dimensions of bureaucratic caring can ics would have on nurse caring. Current
be used to guide practice. Now is the time for research (Turkel & Ray, 2000, 2001, 2003) on
professional nurses to become proactive and the economics of the nursepatient relation-
use theory-based practice to shape their future ship showed that the preservation of this rela-
instead of having the future dictated by others tionship and humanistic caring was continuing
outside the discipline. Staff nurses can hold to grow despite the heavy emphasis by admin-
close their core value that caring is the essence istrators and insurance companies on cost
of nursing and can still retain a focus on meet- control. The researchers recommend that
ing the bottom line. Empirical studies have administrators recognize and respect the con-
firmly established a link between caring and tributions nursing could make in developing
positive patient outcomes. Positive patient out- hospital organizations as politically moral,
comes are needed for organizational survival in caring organizations.
this competitive era of health care. Given this,
professional nursing practice must embrace Application of Theory to
and illuminate the caring philosophy in rela- Contemporary Nursing Practice
tion to complex organizational phenomena. The American Nurses Credentialing Center
Staff nurses value the caring relationship (ANCC) Magnet Recognition Program rec-
between nurse and patient. However, nurses ognizes excellence in professional nursing prac-
are practicing in an environment where the tice. Organizations need to provide written nar-
economics and costs of health care permeate ratives and sources of evidence related to the
discussions and clinical decisions. The focus development, dissemination, and enculturation
on costs is not a transient response to shrink- of best practices, quality care, technical skill,
ing reimbursement; instead, it has become and patient preference. This emphasis on profes-
the catalyst for change within health care sional nursing practice within the Magnet
organizations. Recognition Program has resulted in organiza-
Nurses are continuing to struggle not only tions integrating nursing research and profes-
with economic changes, but also with political sional models of care delivery using nursing
and technological changes. With a system goal theory into the practice setting.
of decreasing length of stay and increasing In the past, organizations provided sources
staffing ratios, nurses need to establish trust of evidence and written narratives illustrat-
and initiate a relationship during their first ing the dissemination, enculturation, and
encounter with a patient. As this relationship sustainability of the Fourteen Forces of
is being established, nurses need to focus Magnetism across the organization (ANCC,
on being, knowing, and doing all at once 2005). Recently, a new model was developed
(Turkel, 1997). From a patient perspective, (ANCC, 2008). The new model has five com-
being there means completing a task while ponents that contain the Forces of Magnet-
simultaneously engaging with a patient. This ism. The five components include transfor-
holistic approach to practice means not only mational leadership; structural empowerment;
viewing the patient as a person in all of his or exemplary professional nursing practice; new
her complexity, but also viewing the patient knowledge, innovation and improvements;
and the needs of professional nursing within and empirical quality results. The Theory of
the complex organizational environment. Bureaucratic Caring can be integrated into
Changes that incorporated the human car- each of these components.
ing dimension and the critical nature that Transformational leadership represents qual-
human relationships play in hospital organi- ity of nursing leadership and management
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490 S E C T I O N VI Middle-Range Theories

style. Under quality of nursing leadership ref- resources, autonomy, nurses as teachers, and
erence can be made to the nursing strategic interdisciplinary relations. Nursing situations
plan and the goal of balancing caring and eco- reflecting clinical decision making and staffing
nomics in clinical decision making. For man- patterns balancing caring and economics
agement style, reference can be made as to are examples of evidence to support a profes-
why the direct care registered nurses selected sional model of care. For consultation and
the theory for practice and how they use the resources, reference can be made to external
theory in everyday nursing situations. consultation with nursing scholars and how
Structural empowerment represents orga- attendance at professional conferences makes
nizational structure, personnel policies and a difference in nursing practice and patient
programs, community and the healthcare outcomes. Under autonomy, the component
organization, image of nursing and profes- of spiritual-ethical caring illustrates how
sional development. For organizational struc- nurses serve as advocates for patients and
ture, an example can be a direct care regis- families. The educational dimension of the
tered nurse making a presentation to the theory supports nurses as teachers as the
board of trustees on how caring makes a professional nurse develops innovative, indi-
difference in practice. Caring attributes as vidualized, evidence-based patient education
part of the professional evaluation and job initiatives. If an organization is truly focused
descriptions can be used as evidence under on transformation and excellence, the theory
personnel polices and programs. As part of can be interdisciplinary beyond nursing
community and the health care organization, and serve as the plan of care for the health-
registered nurses are involved in community care team.
caring. Being in the community requires inte- The component of new knowledge, inno-
gration of the social, political, and cultural vation, and improvements includes quality
dimensions of the theory. Having a formal improvement. Unit-based patient care projects
practice theory supports the professional and evidence-based best practice related to the
image of nursing within the organization. theory is included under this component.
On-going education including interactive The fifth component, empirical quality,
dialogue and reflective practice related to the incorporates quality of care. Examples of edu-
theory can be referenced under professional cation related to spiritual ethical caring and
development. research projects documenting the difference
Exemplary professional practice includes in patient outcomes serve as evidence for this
professional models of care, consultation and component.

Summary
The foundation for professional caring is dimensions. When caring is defined solely as
the blending of the humanistic and empirical science or as art, empirical or aesthetic nurs-
aspects of care as well as understanding caring ing respectively, neither is adequate to reflect
in complex organizations. In todays environ- the reality of current practice. Nurses must be
ment, the nurse needs to integrate caring, able to understand and articulate the politics
knowledge, and skills all at once. Given polit- and the economics of nursing practice and
ical and economic constraints, the art of health care. Classes that examine the envi-
caring cannot occur in isolation from meet- ronment of practice generally, and the politics
ing the physical needs of patients and incor- and the economics of health care in relation
porating the dimensions of the economic, to caring, must be integrated into nursing
political, technological, spiritual-ethical caring education and staff development curricula.
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C H A P T E R 2 9 Marilyn Anne Rays Theory of Bureaucratic Caring 491

Nurses need to search continually for differ- Nurses need repeated exposure to the eco-
ent approaches to professional practice that nomics and costs associated with health care as
will incorporate caring in an increasingly well as knowledge of complex technological
political, technical, and cost-driven environ- organizational environments. Lack of knowl-
ment. Doing more with less no longer works; edge in these areas means that others outside
nurses must move outside of the box to create of nursing will continue to make the political
innovative practice models based on nursing and economic decisions concerning the prac-
theory. tice of nursing. Having an in-depth knowl-
Administrative nursing research needs to edge of the politics and economics of health
continue to focus on the relationship among care will allow nurses to challenge and change
staff nursing, caring, patient outcomes, and the system. A new theory-based model can be
complex organizational economic outcomes. created for nursing practice that supports
Ongoing research is required to firmly estab- human caring in relation to the organizations
lish the nursepatient relationship as an eco- economic, technical, and political values. The
nomic resource in the new paradigm of multiple dimensions of Bureaucratic Caring
evidence-based practice of health care delivery Theory serve as a philosophical/theoretical
(Ray & Turkel, 2008). Findings from addi- framework to guide both contemporary and
tional research studies may continue to sup- futuristic research and theory-based nursing
port the Theory of Bureaucratic Caring as practice. Thus, having this in-depth knowl-
both a middle-range and holographic practice edge will allow nurses to continually challenge
theory. and transform the system.

References

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Chapter
30
Marlaine Smiths Theory of
Unitary Caring
M ARLAINE C. S MITH

Introducing the Theorist Introducing the Theorist


Overview of the Theory Marlaine C. Smith is currently the Helen K.
Practice Exemplar Persson Eminent Scholar and Associate Dean
Summary for Academic Programs at the Christine E.
References Lynn College of Nursing at Florida Atlantic
University. Dr. Smith has been a nurse since
1972, and has practiced in acute care and pub-
lic health settings in large metropolitan areas
and a rural small town. She graduated from
Duquesne University with a BSN, the
University of Pittsburgh with two masters
degrees in public health and nursing with a
specialty in oncology and nursing education,
and New York University with a PhD
in Nursing. Dr. Smith held faculty and aca-
Marlaine C. Smith
demic administrative positions at Duquesne
University, Penn State University, LaRoche
College, and University of Colorado before
her current position.
Dr. Smith is known for her work in two
areas: metatheory, or the study of nursing
theories and theoretical issues, and research
related to healing through touch therapies. She
has studied, written about, and conducted
research related to Rogers Science of Unitary
Human Beings, Parses Man-Living-Health
(now humanbecoming), Watsons Theory of
Transpersonal Caring, and Newmans Health
as Expanding Consciousness, and has written
many commentaries on issues related to nurs-
ing theory development. She conducted five
studies examining how the touch therapies of
massage, therapeutic touch, hand massage, and
simple touch can affect pain, symptom distress,
quality of life, sleep, and other important out-
comes for persons in acute and longterm care
settings. The last completed study was funded
by the National Institutes of Health, Center
for Complementary and Alternative Medicine.

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Dr. Smith has been interested in transthe- concepts of the theory, the empirical referents
oretical work, that is, looking across nursing of the theory, and a practice exemplar that
theories for points of convergence. The unitary illustrates the major concepts.
theory of caring developed while studying the
literature on caring in nursing, and then ana- Process of Theory Development
lyzing this literature through the theoretical This process of developing a middle-range
lens of the Science of Unitary Human Beings. theory was guided by the question: What
Dr. Smith was the recipient of the National is the substantive domain of caring knowl-
League for Nursings Martha E. Rogers Award edge from a unitary perspective? Through a
for the Advancement of Nursing Science, is a unitary lens the question was framed as:
Distinguished Alumna of New York University What is the quality of being in mutual process
Division of Nursing, and is a fellow in the that is called caring within other theoretical
American Academy of Nursing. contexts? This question was answered through
a process of concept clarification that evolved
from Paleys assertion that concepts were nich-
Overview of the Theory es within theories. This concept clarification
There has been a significant body of literature involved the following processes: (1) identify-
in nursing explicating caring as a phenomenon ing the existing meanings of the concept
that is central to nursings focus as a discipline in context, (2) identifying theoretical niches,
and profession (Boykin & Schoenhofer, 1993, (3) synthesis of the concept through identify-
2001; Leininger, 1977; Roach, 1987; Stevenson ing constitutive meanings, and (4) instantiation
& Tripp-Reimer, 1990; Watson, 1979, 1985). of the concept (Smith, 1999). Identification
At the same time, there has been a correspon- of the existing meanings of the concept
ding body of literature critiquing the asser- occurred through reviewing the literature on
tion that caring is an identifying concept caring that described it as a way of being.
for the discipline, and that the existing litera- Exemplar sources (Boykin & Schoenhofer,
ture related to caring is ambiguous and 1993; Eriksson, 1997; Gadow, 1980, 1985,
provides no direction for meaningful inquiry 1989; Gaut, 1983; Gendron, 1988; Leininger,
(Morse, Solberg, Neander, Bottorf, & Johnson, 1990; Mayeroff, 1971; Montgomery, 1990;
1990; Rogers in Smith, 1988; Paley, 2001; Rawnsley, 1990; Ray, 1981, 1997; Roach,
Smith, 1990). After an analysis of the caring 1987; Sherwood, 1997; Swanson, 1991;
literature, I agreed that caring was a multidi- Watson, 1979, 1985) were reviewed in this
mensional concept that assumed multiple process. From these sources semantic expres-
meanings depending on the framework sions, or phrases that captured the essential
within which it was situated or the lens from meaning of caring as a way of being, were list-
which it was viewed (Smith, 1999). Paley ed. Next, the literature written by unitary
(1996) argued that a concept acquires its scholars (Barrett, 1990; Cowling, 1990, 1993a,
meaning within the context of the theory 1997; Krieger, 1979; Madrid, 1997; Madrid
within which it resides. Concepts are theoret- & Barrett, 1992; Newman, 1994; Quinn,
ical niches, and to understand a concept fully, 1992; Rogers, 1994) was examined for exist-
the theory in which the concept lives and ing concepts that corresponded to the seman-
derives its meaning must be clearly explicated. tic expressions of caring. These were identi-
This chapter is the explication of a middle fied as theoretical niches in the unitary
range theory of caring within the perspective literature. Constitutive meanings, phrases that
of the unitarytransformative paradigm. captured the meaning of a cluster of semantic
For this reason, it is called a unitary theory expressions, were named using language
of caring. This chapter contains a description consistent with a unitary perspective. Five
of the theory development process, the constitutive meanings were developed (Smith,
assumptions underpinning the theory, the 1999). Since the initial publication, the work
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C H A P T E R 3 0 Marlaine Smiths Theory of Unitary Caring 497

was expanded with assumptions and empiri- literature on caring and similar concepts
cal referents (Cowling, Smith, & Watson, described by unitary scholars. The theoretical
2008) to form a middle range theory. The concepts have their underpinnings in each of
theory is connected philosophically to the the assumptions.
unitarytransformative paradigm, has five
concepts that describe the phenomenon of car- Manifesting Intentions
ing from a unitary perspective, and can guide Manifesting intentions is the first concept in
practice behaviors and research questions at the unitary theory of caring; it was originally
the empirical level (Smith & Liehr, 2008). defined as creating, holding, and expressing
thoughts, images, beliefs, hopes, and actions
Assumptions that affirm possibilities for human betterment
Assumptions of the unitary theory of caring and well-being (Smith, 1999, p. 21). From
come from Rogers Science of Unitary Human this point of view, the nurse is a healing envi-
Beings (1970, 1994), Newmans Theory of ronment, creating sacred space through her
Health as Expanding Consciousness (1994, thoughts, feelings, intentions, and actions
2008), and Watsons Theory of Transpersonal (Quinn, 1992). Understanding intentionality
Caring (1985, 2002, 2005). To fully under- in this way comes with an assumption that
stand the meaning of the theory, readers will underlying the world of form that is accessed
benefit from studying these sources. by sensory perception, there is the primary
reality that is pandimensional (Rogers, 1994)
1. Human beings are unitary or irreducible,
and beyond access through the five senses
in mutual process with an environment
alone. David Bohms (1980) concept of the
that is coextensive with the Universe,
holographic Universe with implicate/explicate
participating knowingly in patterning,
orders of reality is consistent with this point
and ever-evolving through expanding
of view. The implicate order is the primary,
consciousness (Newman, 1994; Rogers,
unseen pattern, while the explicate order is
1992).
the manifestation of this underlying pattern
2. Caring is a quality of participating know-
that is accessible through the senses. Caring is
ingly in humanenvironmental field pat-
engaging with both orders of reality, holding
terning (Smith, 1999).
intentions through affirmations and images,
3. Caring is the process through which
and expressing these intentions through actions.
human wholeness is affirmed, and which
Thoughts, feelings, perceptions, and images
potentiates the emergence of innovative
are as potent as our words and actions. Inten-
patterning and possibilities (Cowling,
tions are meaningful energetic blueprints
Smith, & Watson, 2008, E44).
for transformation (Smith, 1999). What we
4. Caring accompanies expanding conscious-
hold in our hearts matters. (Cowling, Smith,
ness potentiating greater meaning, insight,
& Watson, 2008, p. E46). Manifesting inten-
and transformative ways of relating to self
tions encompasses actions that create healing
and others (Cowling, Smith, & Watson,
environments, preserve dignity, humanity, and
2008).
reverence for personhood, focus attention to
5. Caring consciousness is resonating with the
and concern for the other, and facilitate
pan-dimensional Universe (Watson, 2005;
authentic presence.
Rogers, 1994; Watson & Smith, 2002).
Appreciating Pattern
Concepts Appreciating pattern is the second concept
After establishing the theoretical linkages to in this theory. This concept was referenced
the unitary-transformative paradigm, the five by both Dolores Krieger (1979) and
concepts of this theory are explicated. The five Richard Cowling (1990, 1993a, 1993b, 1997),
concepts were developed from an analysis of and defined by Cowling (1997) as seeing
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498 S E C T I O N VI Middle-Range Theories

underneath all that is fragmented to the complex synchronized integration (Gendron,


real existence of wholeness and acknowledg- 1988), and experiencing energetic resonance
ing that with awe (p. 136). Cowling (1997) (Quinn, 1992). It is hearing the call that
describes the process of approaching knowing may be spoken or unspoken. Newman (2008)
the other with gratitude and enjoyment. describes the process of resonance as a way of
This contrasts with a clinical problem- knowing that presents itself through intuitive
solving approach. While appreciating pattern insights and feelings. Intellectualization can
is an existing concept in unitary theory, it actually break this resonant field that is created
corresponds to many important meanings through true presence. Caring is not taking
within caring theories including valuing the lead and telling the person what he/she
and celebrating the wholeness and uniqueness needs to do. It is understanding where the
of persons, acknowledging pattern without other wants to go and moving with him/her
attempting to change it, recognizing the per- in the struggle to get there. It is going to the
son as perfect in the moment, being sensitive relationship without an agenda, a plan, a bag
to the unfolding pattern of the whole, and of tricks, but trusting in the transformative
coming to know the other. Pattern is reflected power of healing presence.
in meaning, so finding out what is meaning-
ful to the other becomes primary in knowing Experiencing the Infinite
pattern (Newman, 2008). Appreciating pat- The next concept in the theory is experienc-
tern is coming to know the uniqueness of the ing the infinite. This concept was defined as
other. It is grasping the wholeness of the oth- pandimensional awareness of coextensive-
er (individual, family, and community), not ness with the universe occurring in the con-
through analysis, but through sensing, co- text of human relating (Smith, 1999, p. 24).
exploring experiences, and listening to the This is described by many caring theorists as
others story. This happens through letting go spiritual union (Watson, 1985), Divine Love
of preconceptions and the need to categorize, (Ray, 1997), or an actual caring occasion
classify, diagnose, or judge. When we resist (Watson, 1985). Experiencing the Infinite
labeling and diagnosing we can glimpse the is the recognition that the nurse-person
dynamic being that is sharing this moment relationship is sacred, we meet the Holy in
with us. Appreciating pattern is being-with in it, and when we are with others in this
wonder at this work of art before us, this life way, there are no limits to the possibilities.
that reflects the diversity of creation. Miracles happen! There are miracles of heal-
ing that happen with our patients every day
Attuning to Dynamic Flow that can be potentiated through love and
Attuning to dynamic flow is the third concept caring. This can be recognizing who one
in this unitary theory of caring. Attuning to really is, appreciating the Oneness of Being
dynamic flow was originally defined as danc- with all there is, and finding hope in the
ing to the rhythms within continuous mutual darkest of hours. All of this is mediated by
process (Smith, 1999, p. 23). Caring is flow- our outlook, how we view our world, and
ing with the co-created rhythms of relating in what we entertain as possibilities. William
the moment. It happens by being truly present Blake said, The tree which moves some to
in the moment and is a back and forth move- tears of joy is in the eyes of others only a
ment of relationship building through a green thing that stands in the way. Experi-
vibrational sensing of where to place focus encing the infinite occurs in moments of
and attention (Smith, 1999, p. 23). This grace, experiencing the presence of God in
includes expressions of caring and unitary relationship with others. In those moments
relating from the literature such as: attuning to there is an experience of connectedness to
the subtle cues in the moment (Montgomery, all-that-is extending beyond space-time
1990), shifting perspectives and patterns boundaries that defies description in ordi-
of response (Mayeroff, 1971), relating in a nary language.
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C H A P T E R 3 0 Marlaine Smiths Theory of Unitary Caring 499

Inviting Creative Emergence through preparing to become the energetic


The final concept in this theory of unitary environment that potentiates healing. Nurses
caring is inviting creative emergence. This prepare by centering or connecting to the
concept was taken from Quinns (1992) descrip- True Self, going to that place within where it
tion of healing and Newmans (1994, 2008) is possible to hear the still small voice. Nurses
descriptions of transforming presence. Descrip- prepare by focusing on the present moment,
tions of caring in the literature that corre- leaving behind the thoughts racing in their
spond to this concept are a transformative heads that interfere with being truly present
experience wherein the constant birthing of with those they serve. Nurses prepare for car-
love in caring actions is the growth of spiritual ing by holding intentions that change the
life within (Roach, 1987), allowing a person vibratory pattern of the energy field. Marcus
to grow in his/her own time and way Aurelius said, The soul becomes dyed by
(Mayeroff, 1971), and calling to a deeper life, the color of its thoughts. The soul of
the spiritual life, of each person (Ray, 1997). our practice is dyed by our pattern of think-
Caring is inspiring the other to birth oneself ing. If we cultivate the habit of focusing,
anew in the moment. It might be through centering, and setting intentions before any
an activity, realization, decision, a new role, a patient encounter; we can create the space
new life pattern. The nurse creates a safe space for caring and healing. This way of being-
for this new life to emerge through support- with can be developed through self reflection,
ing, coaching, and providing confidence when expressing intentions through touch and
it is lacking. This concept relates caring to energy work, centering exercises, spiritual prac-
healing. Caring is the vehicle through which tices such as meditation and prayer, mantram
healing occurs. Caring takes trust and patience. repetition, and experiences in nature (Cowling,
People change and grow in their own ways Smith, & Watson, 2008). The development of
and in their own time. They know their way an inner life is critical for the full expression
and we journey with them. This invitation for of caring in nursing. If caring is a way of
creative emergence is gentle and encourag- being, nurses must develop these competen-
ing. Quinn (1992) calls it being a midwife to cies as much as any other in order to evolve as
healing. caring beings. Rituals can structure the
process of setting intentions that are manifest
Empirical Indicators in the nursing situation. Watson (2008) gives
An empirical indicator is a concrete and spe- an example of creating a handwashing ritual
cific real world proxy for a middle range the- where nurses use this daily practice as a way of
ory concept... (Fawcett, 2000, p. 20). It is centering and leaving behind any thoughts that
taking a conceptual abstraction and moving it might interrupt presence. Morning huddles
to a place where it lives...where it can be seen, are used in some settings as a ritual to come
heard, felt, experienced, or measured. There together as a team and set the intentions for
are empirical indicators for both practice and the day. Nurses can develop rituals related to
research. Those for practice are useful in giving report that signify the duty to care
translating the theoretical concept to guides (Cowling, Smith, & Watson, 2008).
for nursing practice. Those for research can be The concept of manifesting intentions can
used to generate research questions, develop be studied. Activities such as centering, set-
measures of the concept, or develop paths of ting an intention, affirmations, meditations,
inquiry where the concept might be explicat- prayers, values-based decision making, and
ed through experiences. Each of the concepts use of mantrams could be tested using any
is discussed at the empirical level. variety of outcomes associated with nurses or
their clients. One could explore how nurse
Manifesting Intentions centering before care influences outcomes
As far as the concept of manifesting intentions, related to patient safety or how the hand-
nurses enter a caring relationship with intention, washing ritual described above might improve
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500 S E C T I O N VI Middle-Range Theories

patient satisfaction. One could study if there meaningful events and relationships in their
were healing outcomes associated with Reiki, lives toward recognizing pattern and making
therapeutic touch, or prayer since these express choices about those patterns.
intentionality. Does our growing intention of
healing the planet result in actions and outcomes Attuning to Dynamic Flow
that reflect a healthier environment for all? Attuning to dynamic flow is lived in practice
through sensing the readiness to begin to talk
Appreciating Pattern about sensitive issues or the willingness to
In a unitary theory of caring, nurses would take on a major life change. It might be stay-
approach coming to know their patients in an ing engaged with a person and family mem-
entirely different way. The nursing process, or bers as they struggle together with the deci-
the problem-solving process, would not be sion to move to hospice care. It might be
consistent with caring from this point of view. knowing when a person needs the nurse to be
It would involve knowing the other through tough, urging him to get out of bed and walk
using the sensory and extrasensory abilities to after surgery or to be soft, facilitating some
grasp wholeness. Nursing assessments would quiet space for a person to be alone for awhile.
include exploring the unique life patterns of Nurses need to cultivate their abilities related
the person, exploring what is most important to this through sensing, hearing and moving
in the moment, and hearing the persons story. with rhythms, presencing, and focusing.
Perhaps the first questions that we ask our Learning to listen for shifts and pauses
patients should be What is important to you and learning to listen to and trust intuitive
right now? and What matters most in this insights is important. There are hospital
moment? (Boykin & Schoenhofer, 2006). myths about the nurse who walks by a
Cowling (1997) and Newman (1994, 2008) patients room and knows that the patient is
have both developed clear praxis methods that going to code. This may be an example of
focus on pattern appreciation and pattern being sensitive to changes and shifts within a
recognition. Nurses need to develop their abil- situation, attuning to the information that is
ities to appreciate pattern. Skills of pattern see- embedded in the field of consciousness.
ing, listening, grasping the essence, and art and There are research possibilities related to
music appreciation correspond to this ability this concept. It would be interesting to study
of appreciating pattern (Cowling, Smith, & how nurses attune to the dynamic flow of
Watson, 2008). In interdisciplinary team con- relationship with an unconscious person or a
ferences, nursing is the voice that represents neonate. What are the cues that they pick up
the wholeness of the person; no other disci- and act on? What are the ways that they
pline does this. Instead of describing a commu- sense beyond the senses to understand what
nity by its census and health statistics, we come is happening or what is being communicated
to know it by asking its members to describe to them? The study of intuition in practice is
the essence of the community. We can use bul- an example of an empirical indicator of this
letin boards in patient rooms as places that per- concept.
sons and families can display their uniqueness Experiencing the infinite. One example of
and what is most important to them. experiencing the infinite is seeing the sacred
Research related to pattern appreciation in mundane activities. It is recognizing the
already exists. Cowlings unitary pattern appre- extraordinary in the ordinariness of our activ-
ciation is a praxis method (combines research ities. This might be made concrete by practice
and practice) in which he and the participant/ rituals that can help us to recognize and cele-
client explore patterning together; this is then brate the work of nursing. One such ritual
captured and shared through aesthetic expres- that has been used is the blessing of the
sions. Through using Newmans praxis method, hands. Another way to experience the infi-
nurses engage persons in an exploration of the nite in practice is to validate its existence
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C H A P T E R 3 0 Marlaine Smiths Theory of Unitary Caring 501

through nursing practice stories. We dont creative emergence. This can happen when we
take the time to really appreciate the incredi- help women become mothers through teach-
ble moments experienced in caring with oth- ing them the necessary skills to care for their
ers. The sensitivity to experience the infinite babies and help them to grow, or when we
in our practice may be developed through connect people to resources in the communi-
spiritual practice or a practice that fosters ty that allow them to live with greater ease in
deep reflection. This could be meditation, the midst of a family crisis. It is helping oth-
prayer, centering, being in nature, or walking ers live their lives differently and discover new
a labyrinth (Cowling, Smith, & Watson, ways of becoming.
2008, p. E48). The empirical indicators for research
The research questions that are related to might be developing an instrument to meas-
this concept might be studying nurses and ure satisfaction or pride associated with life
patients stories of the extraordinary moments changes. Studies could be structured to
experienced in nursing practice. explore differences in outcomes when lifestyle
change is approached with a nondirective
Inviting Creative Emergence model suggested by this concept, rather than
There are many examples in nursing practice a structured directive approach to lifestyle
that can illustrate how caring can invite change.

Practice Exemplar
Sue is a family nurse practitioner working in Beth talks rapidly, wringing her hands and
a community-based family practice with a tugging on her sleeve. I was on vacation last
physician colleague. She practices from a nurs- week in North Carolina with my friends. We
ing model, using theories in the unitary- were having a relaxing time, and as I was get-
transformative paradigm as a guide for her prac- ting out of the car I felt myself go into atrial
tice. Beth is a 55-year-old attorney who has fibrillation. My heart rate went way up like it
been seeing Sue for her primary care for some does to about 270, and I felt just awful, like I
time. She is waiting in the examining room. couldnt breathe, lightheaded....I thought I
Sue has had a busy morning with time was going to die.
pressures and some difficult patient encoun- Oh, how scary....thats awful.
ters. She is backed up with two patients I know. I ended up in the Emergency
waiting for her. She approaches the examin- Room of this tiny hospital where they treated
ing room and pulls out the chart. She smiles me with IV anti-arrhythmic drugs, and finally
as she sees Beths name. In front of the door, my heart rate went down, and I converted to
she pauses, closes her eyes, takes several deep sinus rhythm in about three hours. But this is
breaths and centers herself, repeating her the third time that this has happened to me,
mantram. She sets an intention to be fully and the second time when Ive been away
and authentically present with Beth in this from home. I just need to get to the bottom
encounter and to enter a relationship with her of this. Im frustrated and scared.
that facilitates their mutual well-being. Of course you are, Sue continues. OK
Sue opens the door and finds Beth sitting tell me how things are going with you gener-
on the chair fully clothed. Sue approaches her ally and anything unusual that you were doing
warmly, holding out her hand and touching on vacation that might have precipitated this
her on the shoulder. She pulls up her chair episode.
and puts the chart aside. OK, Beth, whats Well, you know I had that episode of
going on? How are you? diverticulitis before I left for vacation, and
Continued
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502 S E C T I O N VI Middle-Range Theories

Practice Exemplar cont.


you prescribed the Cipro for me. Well, I was have triggered this event given your history.
not feeling great on vacation, the pain was And of course Dramamine and alcohol could
better, but I had constipation, but took the have contributed. And at the time this hap-
Miralax and the fiber that I always take. We pened you were just getting over diverticulitis
went on a boat trip the day before and I took and werent feeling great. But, we also need to
some Dramamine, too. Also, my friends and I focus on this distress that you are experienc-
were drinking wine every night. Thats all I ing related to your work. Id like you to do
can think of. some journaling for a period of two weeks.
What about home and work? Write down the things that you love, your
Beth looks down at her hands. Well, Bob passions, what makes your heart sing? Dont
still cant find a job, and things have been over-think it, Beth. If you have images or
crazy at work. I just cant seem to get ahead of messages that come to you, jot them down.
it. I have a major brief due in a couple of Make an appointment in two weeks, and
weeks...It was hard to leave for vacation. I well talk about what you discovered. OK?
love being with my friends, but I was torn Yes, OK. Beth nods tentatively.
about taking the time. Before you leave Im going to listen to
Sue pauses then says, Tell me more about your heart and check your blood pressure
this feeling of being torn between what you again. Hop up on the table. Sue auscultates
love and what you have to do. Beths heart sounds and measures her blood
I guess Im in that space a lot lately, Sue. pressure. Everything is fine. Your heart rate
Beth begins crying. I dont think Im doing is regular at 60, and your blood pressure is
what I love to do...I feel like Im not in con- OK, but a bit higher than wed like it to be:
trol of my life. 130/82. I know you experience some white
Sue hands Beth some tissues and sits qui- coat hypertension. Well check it again next
etly with her, gently touching her arm as Beth week. You check it too at the machine in the
sobs. In the moment Beth sobs for the loss of grocery store and keep track. Bring that back
joy in her life now, and at the memory of her in two weeks too.
mother telling her she had to go into a prac- Sue puts two hands on Beths shoulders.
tical career like law, not fiction writing. In the Im in this with you. Youll figure this out.
moment Sue imagines holding and rocking Change can be hard, but its how we grow.
Beth in the space between them. In her Anything else that we need to talk about
minds eye she whispers comforting words. In today?
silence, they both experience an intimacy that No, I feel better....thanks, Sue.
is beyond language. Thank you! Ill see you in two weeks.
When Beth stops crying she looks up and (The encounter took 15 minutes).
asks, What do I do now? The five concepts of the unitary theory of
Lets take care of the A-fib issue first, caring were evident. First, manifesting inten-
Beth. Are you still on the same dose of the beta tion was visible in the preparation before Sue
blocker that your cardiologist prescribed? entered the room. She was aware that she, as
Yes, Toprol 25 mg. nurse, is an environment for healing (Quinn,
OK. I want you to get in to see the cardi- 1992). Sue set an intention and entered the
ologist as soon as possible and discuss this nursing situation being fully present to Beth.
with him. You have some options with abla- She shared her intentions with Beth when
tion or other anti-arrhythmics. You might she said, Im in this with you, and in her use
want to talk with an electrophysiologist as of touch and eye contact to communicate her
well. Ill make a referral. Also, I just checked desire to be present and in partnership with
the side effects of Cipro, and atrial fibrillation Beth. Appreciating pattern was evident as Sue
is a rare side effect. So taking the Cipro could asks Beth about what was going on with her,
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C H A P T E R 3 0 Marlaine Smiths Theory of Unitary Caring 503

how she was, and if there was anything differ- sat with Beth as she sobbed, they both expe-
ent about the time that led up to the episode rienced an intimacy beyond words, and a
of atrial fibrillation. Sue values the unique- pandimensional awareness of pastpresent
ness of Beths experience and Beths own future in the moment. This is an example of
insights about events that led up to the the concept of experiencing the infinite. Finally,
episode, affirming that Beths knowledge of when Beth expresses that she is not doing
her own pattern had validity. Intuitively, Sue what she loves, Sue is inviting creative emer-
asked the questions, What about home and gence by asking her to attend to any cues she
work? and Tell me more about this feeling may receive about what she would love to do
of being torn between what you love to do and to record this in a journal. She asks her to
and what you have to do. This second ques- return for a follow-up visit in 2 weeks.
tion emerged from Sues tuning into meaning Often, the argument is advanced that
and resonating with the whole, illustrating there is no time to care in this way, but this
the concept of attuning to dynamic flow. This encounter took 15 minutes, no longer than a
led to the revelation of Beths life pattern that conventional, medically-focused primary care
could have remained undisclosed had Sue not visit. It isnt the time we have; it is what we do
attended to the intuitive flash. As Sue silently with that time that counts.

Summary
The unitary theory of caring provides a con- the theory were explication, each concept was
stellation of concepts that describe caring described, and examples of empirical indica-
from a unitary perspective. The theory is tors for practice and research were offered.
constituted with five concepts: manifesting The unitary theory of caring is new; it can
intentions, appreciating pattern, attuning to grow through those who invest in it through
dynamic flow, experiencing the Infinite, and testing it in practice and research.
inviting creative emergence. Assumptions of

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Index
Note: Page numbers followed by f refer to figures; page numbers followed by t refer to tables; page numbers followed
by b refer to boxes.

A Care/caring, 5
Adaptation Boykin and Schoenhofers theory of. See Nursing as
Conservation Model, 87 Caring Theory
Johnson Behavioral System Model, 106107 bureaucratic. See Theory of Bureaucratic Caring
Roy model of. See Roy Adaptation Model culture. See Theory of Culture Care Diversity and
Adaptive potential, in Modeling and Role-Modeling Universality
theory, 210211, 210f Duffys model of. See Quality Caring Model
Administration in Halls model of nursing, 60, 60f
Conservation Model application to, 91 in Human-to-Human Relationship Model, 76
Johnson Behavioral System Model application to, Leiningers theory of. See Theory of Culture Care
115, 116t Diversity and Universality
Neuman Systems Model application to, 196197 Locsins theory of. See Technological Competency
Aesthetic knowing, 2627, 231f, 232 as Caring
Affiliation, 209 in Nightingales work, 47
African American elders, culture care of, 332333 Paterson and Zderads theory of. See Humanistic
Aging Nursing Theory
culture care and, 332334 Smiths theory of. See Theory of Unitary Caring
in Theory of Accelerating Evolution, 257258 Swansons theory of. See Theory of Caring
in Theory of Goal Attainment, 155 Watsons theory of. See Theory of Human Caring
Alligood, Martha, 423 Caring Professional Scale, 435
American Holistic Nurses Association, 227 Caring Science as Sacred Science (Watson), 352
Anger, in morbid grief, 213 Caritas, 353354
Anglo elders, culture care of, 332333 Change, 10
Anti-contagionism, 43 Choice points, in Theory of Health as Expanding
Arousal, stress-related, 210, 210f Consciousness, 301303, 302f, 303f
Assessing and Measuring Caring in Nursing and Health Christian feminist, 45
Sciences (Watson), 352 Chronic illness, Conservation Model application to, 94
Attending Caring Team, 364365, 366367 Client, 5
Attending Nurse Caring Model, 362367 Client-nurse encounter, 5. See also Dynamic Nurse-
Awareness Patient Relationship Theory; Nurse-patient/client
in nursing theory selection, 2526 relationship; Nurse-Patient Relationship Theory
in Quality Caring Model, 406407 Clinical Nursing: A Helping Art (Wiedenbach), 6162
in Theory of Health as Expanding Consciousness, 296 Collected Works of Florence Nightingale, 35, 47
Comfort Theory, 389401
application of, 393396
B best policy in, 393, 397
Barry, Charlotte D., 251252. See also Community best practices in, 393, 396397
Nursing Practice Model care plans in, 393
Basic Principles of Nursing Care (Henderson), 63 coaching in, 394
Bearing witness, 240 Comfort Contract in, 400
Behavioral System Model. See Johnson Behavioral comfort definition in, 393
System Model comfort interventions in, 393
Beliefs, 6, 2122. See also Values concepts of, 391392, 392f, 400401
Bentov, Itzhak, 295, 298 contexts in, 390
Boomerang pillow, 92 ease in, 390
Boykin, Anne, 370371. See also Nursing as Caring electronic data base in, 397
Theory health care needs in, 392393
Bureaucracy, 477478. See also Theory of Bureaucratic health-seeking behaviors in, 393
Caring institutional advocacy in, 395
institutional awards in, 395396
C institutional integrity in, 393
Care, Cure, and Core Model, 5961, 60f intention in, 394395
practice application of, 63 intervening variables in, 393
505
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506 Index

Comfort Theory (Continued) health in, 88


nursing practice in, 394395, 396397 inflammatory response in, 89
practice exemplar of, 398 influences on, 85, 85b
relief in, 390 nursing process in, 90, 90t, 95, 95t96t
taxonomic structure of, 390391, 391f operational environment in, 89, 95
technical interventions in, 393394 organismic responses in, 8990
transcendence in, 390 patient-centered care in, 8485
value-added outcomes in, 394 perceptual environment in, 89, 95
wow moments in, 394 perceptual response in, 89
Comfort Theory and Practice (Kolcaba), 389390 person in, 88
Communication practice applications of, 9094
for client change, 259260 administration, 94
integral, 241 boomerang pillow use, 92
nonverbal, 219220 chronic illness, 94
nursing discipline, 6 critical care environment, 9293
Community developmentally disabled child, 91
Community Nursing Practice Model, 454, 456 education, 94
Conservation Model, 9495, 95t96t emergency room care, 93
Humanbecoming School of Thought, 283286 fatigue, 92
Humanistic Nursing Theory, 346 geriatric care, 94
Self-Care Deficit Theory, 136 Hartmans procedure, 92
Theory of Culture Care Diversity and Universality, homeless care, 9394
328 hysterectomy, 9192
Theory of Goal Attainment, 157 nursing care outcomes, 93
Theory of Health as Expanding Consciousness, ostomy care, 92
307308 pediatric care, 91
Community Nursing Practice Model, 451459 perioperative care, 93
community in, 454, 456 premature infant handling, 91
core services in, 455456, 457 preterm infant health promotion, 91
development of, 452 sleep hygiene, 93
environment in, 454455 wound care, 91, 92
evaluation and, 456457 practice exemplar of, 96100
first circle services in, 456, 457 stress response in, 89
foundations of, 452453 values of, 86
nursing in, 453 wholeness in, 88
person in, 453454, 456 Contagionism, 43
policy development and, 456 Contemporary Process of Nursing: The (Unbearable) Weight
practice exemplar of, 457458 of Knowing in Nursing (Locsin), 460461
second circle services in, 456, 457 Couples Miscarriage Project, 436437
services in, 455457, 455f Creative suspension, 260
third circle services in, 456457 Crimean War, 3841, 39f, 41f
Compassion, 240 Critical care, Conservation Model application to, 9293
Complexity theory, 474476 Cultural feminism, 45
Concept development, 149150 Culture. See also Theory of Culture Care Diversity and
Conceptual models, 1011 Universality
analysis of, 28 aging and, 332334
evaluation of, 28 nursing theory and, 13
Conceptual structures, of nursing discipline, 6 organization, 477478
Conscious dying, 240 in Theory of Goal Attainment, 157
Consciousness. See Theory of Health as Expanding in Theory of Health as Expanding Consciousness, 304
Consciousness Curiosity, 17
Conservation Model, 8490
adaptation in, 87
assumptions of, 86
D
Death, 420
in community-based care, 9495, 95t96t
grieving response to, 212213, 212f, 213t
composition of, 8689
in Theory of Integral Nursing, 240
conceptual environment in, 89, 95
Developmental processes
conservation in, 8788
in Modeling and Role-Modeling theory, 214, 214t
environment in, 8889, 95, 100
in Theory of Integral Nursing, 228, 234235, 235f
flight/fight response in, 89
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Developmentally disabled child, Conservation Model F


application to, 91 Family Health Theory, 153
Disease, origin of, 43 Fatigue, Conservation Model application to, 92
Dissipative structures, theory of, 301, 302f Feminism
Domain, 46 cultural, 45
Dossey, Barbara, 224225. See also Theory of Integral in Nightingales caring, 4446
Nursing Fermentation, 43
Drives, 207, 208t Florence Nightingale Today: Healing, Leadership, Global
Duffy, Joanne, 402403. See also Quality Caring Model Action (ANA), 35
Dying Forging resolve, 260261
conscious, 240 Formal theory, 481
in Theory of Integral Nursing, 240 Four-quadrants perspective, 232237, 232f, 233f, 235f
Dynamic Nurse-Patient Relationship: Function, Process and collective exterior (Its), 233f, 234, 235f, 236237,
Principles, The (Orlando), 78 242
Dynamic Nurse-Patient Relationship Theory, 79 collective interior (We), 233f, 234, 235f, 236, 237,
practice applications of, 7980 240241
individual exterior (It), 233f, 234, 235f, 236, 237,
E 241242
Education, 67 individual interior (I), 233f, 234, 235f, 236, 237,
Conservation Model and, 94 239240
of Florence Nightingale, 3637, 3940
Humanbecoming School of Thought and, 285 G
Johnson Behavioral System Model and, 114115 General System Theory, 148
Neuman Systems Model and, 195196 Geriatric care, Conservation Model application to, 94
on nurse-patient relationship, 70 German American elders, culture care of, 333334
Nursing as Caring Theory and, 376377 Goal attainment. See Theory of Goal Attainment
theory-guided nursing practice and, 30 Goal Attainment Scale, 151
Theory of Bureaucratic Caring and, 487488 Grand theories, 1011
Theory of Culture Care Diversity and Universality analysis of, 28
and, 328 evaluation of, 28
Theory of Goal Attainment and, 155156 interactive-integrative. See Conservation Model;
Theory of Human Caring and, 365 Johnson Behavioral System Model; Modeling and
Theory of Integral Nursing and, 242243 Role-Modeling Theory; Neuman Systems Model;
Emancipation, of women, 45 Roy Adaptation Model; Self-Care Deficit Theory;
Emancipatory knowing, 26 Theory of Goal Attainment; Theory of Integral
Emergency room care, Conservation Model application Nursing
to, 93 unitary-transformative. See Humanbecoming School
Empathy, in Human-to-Human Relationship of Thought; Science of Unitary Human Beings;
Model, 77 Theory of Health as Expanding Consciousness
Environment, 5 Grieving response, 212213, 212f, 213t
Community Nursing Practice Model, 454455 Growth needs, 211, 211t
Conservation Model, 8889, 95, 100 Guided imagery, 260
Johnson Behavioral System Model, 107, 110111
Modeling and Role-Modeling Theory, 207209
Neuman Systems Model, 188189, 188f H
Nightingale model, 4344 Hall, Lydia, 5657. See also Care, Cure, and Core Model
Quality Caring Model, 408 Hartmans procedure, Conservation Model application
Roy Adaptation Model, 173 to, 92
Theory of Integral Nursing, 230f, 231, 235f, 242 Healing
Epigenesis, in Modeling and Role-Modeling theory, Quality Caring Model, 408
215 Science of Unitary Human Beings, 262
Equanimity, 240 Theory of Human Caring, 358
Equilibrium, 210, 210f Theory of Integral Nursing, 229230, 229f230f, 238
Erickson, Helen, 202204. See also Modeling and Health, 5
Role-Modeling Theory Conservation Model, 88
Ethical knowing, 26 Johnson Behavioral System Model, 111
Ethnonursing, 318. See also Theory of Culture Care Modeling and Role-Modeling theory, 209
Diversity and Universality Neuman Systems Model, 189190
Evidence-based practice, 158 Roy Adaptation Model, 173174
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508 Index

Health (Continued) nurse knower in, 343344, 344f, 345f


Theory of Culture Care Diversity and Universality, nursing in, 339
323 phenomenology in, 339, 342343
Theory of Goal Attainment, 156 philosophical background in, 342343
Theory of Integral Nursing, 230231, 230f, 235f, in policy development, 348349
241242 practice exemplar of, 347348
Health as Expanding Consciousness (Newman), 293 scientific knowing in, 344, 345f
Henderson, Virginia, 5556 vocabulary in, 339
basic nursing care components of, 59, 64 Humanuniverse, 279
nursing definition of, 5859, 6263 Hygiene, Nightingale on, 45
Hierarchy, 107 Hyperactivity, 257
Holistic person, in Modeling and Role-Modeling Hypnotherapeutic techniques, 219
theory, 207209, 208f, 218 Hysterectomy, Conservation Model application to,
Holographic theory, 483484 9192
Home, family, 4446
Homeless care, Conservation Model application to,
9394
I
Imagination, 4
Homeorrhesis, 106
Impoverishment, stress-related, 210, 210f
Honesty, 17
Individuation, 209
Hope, 76
Instincts, 207, 208t
Human Becoming School of Thought, The (Parse), 279
Integral Nursing. See Theory of Integral Nursing
Human-Centered Nursing: The Foundation of Quality
Intention
Care (Kleinman), 338
Comfort Theory, 394395
Human-to-Human Relationship Model, 7678
Nursing as Caring Theory, 372
practice applications of, 78
Technological Competency as Caring, 467
Humanbecoming School of Thought, 277289
Theory of Integral Nursing, 228, 241
art of, 282286
Theory of Unitary Caring, 497, 499500
change in, 281
Intentional dialogue, in Story Theory, 442
community settings of, 283286
Intentionality, in Science of Unitary Human Beings,
eighty/twenty (80/20) model of, 284285
262
language in, 279
Interactive-integrative paradigm, 10
in nursing education, 285
Interdisciplinary practice, 17
nursing in, 278279
International Caritas Consortium, 360361
nursing practice in, 283, 284
Interpersonal Relations in Nursing (Peplau), 68
parish nursing in, 285
Interpretation, in Human-to-Human Relationship
philosophical assumptions of, 280
Model, 77
postulates of, 280281
Interventions
principles of, 280281
Comfort Theory, 393394
reality construction in, 280
Johnson Behavioral System Model, 112113
relating in, 280
Modeling and Role-Modeling theory, 204205,
research in, 281282
205t, 206
resources on, 285286
Neuman Systems Model, 190191
true presence in, 282283
Theory of Health as Expanding Consciousness,
Humanistic Nursing (Paterson and Zderad), 339340
305306
Humanistic Nursing Theory, 337350
Introduction to Clinical Nursing (Levine), 8485
angular view in, 343
Intuition, 209, 241
applications of, 346347
bracketing in, 343344
call and response in, 339341, 340f, 341f J
coming to know in, 343344 Johnson, Dorothy, 104105. See also Johnson Behavioral
community in, 346 System Model
community of nurses and, 348349 Johnson Behavioral System Model, 105113
dialectic process in, 345346 achievement subsystem in, 108t
existentialism in, 339 action in, 110
gestalt in, 341342, 342f in administration, 115, 116t
human needs in, 338 affiliative subsystem in, 108t
intuitive knowing in, 344, 344f aggressive/protective subsystem in, 108t
multidimensionality in, 339 applications of, 113118
noetic locus (knowing place) in, 344, 345f behavioral set in, 110
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choice in, 110 Liehr, Patricia, 439. See also Story Theory
concepts of, 107113 Life orientation, need satisfaction and, 213214
conceptual set in, 110 Listening, deep, 240
core principles of, 105107 Literature, 6. See also Research
dependency subsystem in, 109t meta-analysis of, 435436
diagnostic classifications in, 112 Living a Caring-based Program (Boykin), 370
dialectical contradiction principle of, 107 Locsin, Rozzano C., 460461. See also Technological
in education, 114115 Competency as Caring
eliminative subsystem in, 109t Loeb Center for Nursing and Rehabilitation, 63
environment in, 110111
functional requirements in, 110
goal in, 110
M
Man-Living-Health: A Theory of Nursing (Parse), 279
health in, 111
Marriage, 44
hierarchic interaction principle of, 107
Meaning, 239242
imbalance and instability in, 111
grasping of, 267268
ingestive subsystem in, 109t
in Nursing as Caring Theory, 373375
nursing interventions in, 112113
philosophical, 239
nursing process in, 112113
psychological, 239
person in, 107108
in Quality Caring Model, 408
practice exemplar of, 117118
spiritual, 239
reorganization principle of, 106107
in Theory of Health as Expanding Consciousness,
research on, 113114, 114b
300301
restorative system in, 109t
Medical model, 22
set point in, 106
Meeting the Realities in Clinical Teaching (Wiedenbach), 58
sexual system in, 109t
Meleis, Afaf I., 48
stabilization principle of, 106
Metaparadigm, 5
subsystems in, 108110, 108t109t
in Theory of Integral Nursing, 230231, 230f
wholeness and order principle of, 105106
Middle-range theories, 11. See also Comfort Theory;
Justice-making, 36
Community Nursing Practice Model; Quality Caring
Model; Story Theory; Technological Competency as
K Caring; Theory of Bureaucratic Caring; Theory of
Kaleidoscoping in Lifes Turbulence Theory, 260261 Caring; Theory of Self-Transcendence; Theory of
King, Imogene M., 146148. See also Theory of Goal Unitary Caring
Attainment analysis of, 28
Knowing, 2627 development of, 152153
aesthetic, 2627, 231f, 232 evaluation of, 2829
emancipatory, 26 Mindfulness, 239240
empirical, 231f, 232 Miscarriage Caring Project, 433435
ethical, 26, 231f, 232 Modeling and Role-Modeling Theory, 204223
Humanistic Nursing Theory, 343344, 344f, 345f adaptive potential in, 210211, 210f
paranormal, 258259 analytical propositions in, 206, 207t
personal, 26, 231232, 231f data collection in, 205206, 206t
sociopolitical, 231f, 232 data interpretation in, 218219
Technological Competency as Caring, 461, 462468, data processing in, 218219
463f, 466f developmental processes in, 214, 214t
Theory of Integral Nursing, 231232, 231f, 237, 237f drives in, 207208, 208t
Knowledge, structure of, 912 environment in, 207209
Kolcaba, Katherine, 389390. See also Comfort Theory epigenesis in, 215
Kuhn, T., 910 global applications of, 220, 220t, 221t
health in, 209
human needs in, 211214, 211t, 212f
L hypnotherapeutic techniques in, 219
Language, 6
instincts in, 207, 208t
grammatical persons of, 233
intervention aims and goals in, 204205, 205t, 206
Lebanese Muslims, ethnonursing study of, 330332
modeling process in, 205206, 206t
Legitimate nursing, 126, 133
nursing in, 209210
Leininger, Madeleine, 317318. See also Theory of
person in, 207209, 208f, 208t, 218
Culture Care Diversity and Universality
philosophical assumptions in, 206210
Levine, Myra, 8384. See also Conservation Model
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Modeling and Role-Modeling Theory (Continued) nursing definition for, 4, 49, 50f
practice applications of, 215222, 217t, 220t, 221t nursing ideas of, 4650
practice exemplar of, 216, 218219 nursings goal for, 4849
proactive nursing care in, 219220 patient for, 49
role-modeling process in, 206 spirituality of, 3738, 41
sequential development in, 215 21st century legacy of, 5051
social justice in, 210 Theory of Integral Nursing and, 226227
theoretical constructs in, 210215, 210f, 211t, 212f travel by, 37
theoretical linkages in, 215 Non-nursing functions, 62
trusting-functional relationship in, 207209, Not knowing, 231f, 232
216218, 217t Notes on Nursing: What It Is and What It Is Not
Morbid grief, 213 (Nightingale), 4, 3536, 44, 47
Nurse-patient/client relationship. See also Nurse-Patient
Relationship Theory
N Nursing as Caring Theory, 373, 378379
Narrative. See Story Theory
Orlandos theory of, 7980
Narrative means to sober ends (Diamond), 440
Quality Caring Model, 406407, 406f
Narrative medicine: The use of history and story in the
Theory of Goal Attainment, 155156
healing process (Mehl-Madrona), 440441
Theory of Health as Expanding Consciousness,
Nature of Nursing, The (Henderson), 62
303305
Needs
Theory of Human Caring, 356357
Comfort Theory, 392393
Travelbees theory of, 7678
growth, 211, 211t
Nurse-Patient Relationship Theory, 6974
Humanistic Nursing Theory, 338
communication skills in, 71
life orientation and, 213214
components of, 70
Modeling and Role-Modeling theory, 211214, 211t,
listening skills in, 7071
212f
orientation phase of, 71
Quality Caring Model, 408
phases of, 7172
Neuman, Betty, 182183. See also Neuman Systems Model
practice exemplar on, 7374
Neuman Systems Model, 182201, 186f
research on, 7273
in administration, 196197
resolution phase of, 72
archive for, 198
self-awareness in, 70
client-client system in, 185188, 186f, 187f
supervisory education for, 70
client variables in, 187188
working phase of, 72
concepts of, 184185
Nurse Performance Goal Attainment, 153
created environment in, 189
Nurse presence
in education, 195196
Humanbecoming School of Thought, 282283
environment in, 188189, 188f
Nursing as Caring Theory, 373
flexible line of defense in, 185, 186f, 187f, 188f
Theory of Health as Expanding Consciousness,
health in, 189190
298299
lines of resistance in, 185, 186f, 187, 187f, 188f
Theory of Integral Nursing, 239
normal line of defense in, 185, 186f, 187f, 188f
Nursing, 5. See also Nursing discipline; Nursing theory
nursing process in, 190192, 190f
and specific nursing theories
practice applications of, 192, 197198
caring in, 5
practice exemplar of, 193194
in Community Nursing Practice Model, 453
prevention intervention in, 190191
genderization of, 4546
spirituality in, 187188
Halls conceptualization of, 5961, 60f
website for, 198
Hendersons definition of, 5859, 6263
Newman, Margaret, 290294. See also Theory of Health
in Humanbecoming School of Thought, 278279
as Expanding Consciousness
in Humanistic Nursing Theory, 339
NICU study, 431432
legitimate, 126, 133
Nightingale, Florence, 3551, 36f, 42f
Levines definition of, 89
assumptions of, 48
in Modeling and Role-Modeling theory, 209210
biographies of, 35
Nightingales definition of, 4, 49
Crimean War nursing of, 3841, 39f, 41f
Peplaus definition of, 69
early life of, 3637
relationship in, 5
education of, 3637, 4243
in Self-Care Deficit Theory, 135
feminist context of, 4446
task-based, 34
medical milieu of, 4244
Wiedenbachs conceptualization of, 5758
nurse definition for, 49
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Nursing: Concepts of Practice (Orem), 123124 theory-guided, 89, 12, 2023, 2930
Nursing: Human Science and Human Care (Watson), 352 administrative support for, 29
Nursing: The Philosophy and Science of Caring (Watson), education for, 30
352 feedback for, 30
Nursing agency, 127, 135136 practice evaluation for, 30
Nursing and Anthropology (Leininger), 318 practice implementation for, 29
Nursing as Caring: A Model for Transforming Practice theory selection for, 29
(Boykin and Schoenhofer), 370, 372 Theory of Bureaucratic Caring, 476477, 489490
Nursing as Caring Theory, 370385 Theory of Integral Nursing, 238242
in administration, 376 Nursing process
applications of, 375377 Conservation Model, 90, 90t, 95, 95t96t
assumptions of, 372375 Johnson Behavioral System Model, 112113
call for nursing in, 373, 374 Neuman Systems Model, 190192, 190f
caring in, 372 Nursing as Caring Theory, 379380
difficult to care situation in, 378 Roy Adaptation Model, 174
in education, 376377 Self-Care Deficit Theory, 133135, 134f
historical perspective on, 371372 Technological Competency as Caring, 465
intention in, 372 Theory of Goal Attainment, 153154
lived meaning in, 373375 Theory of Self-transcendence, 419, 423
nurse-client relationship in, 373, 378379 Nursing theory, 314, 473474. See also specific theories
nursing focus in, 372 and models
nursing practice in, 380381 communication of, 6
nursing process in, 379380 complexity and, 474476
nursing response in, 373 conceptual structure and, 6
nursing situation in, 372373 contextual development of, 18
person in, 373, 375, 377379 culture and, 13
practicality of, 380381 definition of, 7
practice exemplar of, 381384 domain of, 46
unconscious patient care in, 378379 education and, 67
Nursing discipline, 47. See also Nursing theory and evaluation of, 1619, 2324, 2729
specific nursing theories criteria for, 27
communication networks of, 6 frameworks for, 2829
conceptual models in, 1011 guidelines for, 28
conceptual structures of, 6 questions for, 1719, 2324, 2829
domain of, 46 formal, 481
education of, 67 functional components of, 28
grand theories in, 1011 future development of, 1213
imagination in, 4 grand, 1011, 28
language of, 6 imagination and, 4
literature of, 6 implementation of, 2930
middle-range theories in, 11, 2829, 152153, 482 language and symbols of, 6
paradigms of, 910 middle-range, 11, 2829, 152153, 482
practice-level theories in, 1112 nursing conceptualization in, 18
relationship in, 5 practice and, 89, 12, 2021. See also Nursing
structure of knowledge in, 912 practice; Practice applications; Practice exemplar
symbols of, 6 practice-level, 1112
syntactical structures of, 6 purpose of, 79
tradition of, 6 questions for, 1719
values and beliefs of, 6 research and, 8. See also Research
Nursing education. See Education selection of, 2030
Nursing Knowledge Development and Clinical Practice evaluation and, 2729
(Roy), 168 implementation and, 2930
Nursing practice. See also Practice applications; Practice practice and, 2123
exemplar questions about, 2324
Humanbecoming School of Thought, 283, 284 reflective exercise for, 2527
Johnson Behavioral System Model, 115, 116t significance of, 19, 2123
Nursing as Caring Theory, 375376, 380381 sources for, 1819
Science of Unitary Human Beings, 262269 structural components of, 28
scope of, 17 study guide for, 1619
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Nursing theory (Continued) Conservation Model, 9094


substantive, 481 Dynamic Nurse-Patient Relationship Theory, 7980
syntactical structure and, 6 Hendersons conceptualization of nursing, 6263
tradition and, 6 Human-to-Human Relationship Model, 78
values and beliefs and, 6 Humanistic Nursing Theory, 346347
Modeling and Role-Modeling Theory, 215222,
217t, 220t, 221t
O Neuman Systems Model, 192, 197198
Object attachment, 211213, 212f
Nurse-Patient Relationship Model, 7273
Observation, in Human-to-Human Relationship
Prescriptive Theory, 6162, 62f
Model, 77
Roy Adaptation Model, 174175
Occupations, for women, 45, 46
Science of Unitary Human Beings, 261269
Ordered to Care: The Dilemma of American Nursing
Self-Care Deficit Theory, 136139, 138t
(Reverby), 44
Theory of Caring, 433435
Orem, Dorothea E., 121123. See also Self-Care Deficit
Theory of Culture Care Diversity and Universality,
Theory
329334
Organization-disorganization paradigm, 10
Theory of Goal Attainment, 152159
Orlando, Ida Jean, 7879. See also Dynamic
Theory of Health as Expanding Consciousness,
Nurse-Patient Relationship Theory
306307
Ostomy care, Conservation Model application to, 92
Theory of Human Caring, 359362
Theory of Integral Nursing, 242243
P Wiedenbachs conception of nursing, 6162, 62f
Paradigm, 910 Practice exemplar
Paranormal phenomena, 258259 Care, Cure, and Core Model, 6465
Parker, Marilyn E., 251. See also Community Nursing Comfort Theory, 398
Practice Model Conservation Model, 96100
Parse, Rosemarie Rizzo, 277279. See also Hendersons conceptualization of nursing, 64
Humanbecoming School of Thought Humanistic Nursing Theory, 347348
Particulate-deterministic paradigm, 10 Johnson Behavioral System Model, 117118
Paterson, Josephine, 337338. See also Humanistic Modeling and Role-Modeling theory, 216, 218219
Nursing Theory Neuman Systems Model, 193194
Patient-centered care, in Conservation Model, 84 Nurse-Patient Relationship Theory, 7374
Peplau, Hildegard, 6869. See also Nurse-Patient Nursing as Caring Theory, 381384
Relationship Theory Quality Caring Model, 409412
Perioperative care, Conservation Model application to, 93 Roy Adaptation Model, 175180
Person, 5 Self-Care Deficit Theory, 139143
Community Nursing Practice Model, 453454, 456 Story Theory, 444449, 448t
Conservation Model, 88 Technological Competency as Caring, 469470
Humanbecoming School of Thought, 283 Theory of Bureaucratic Caring, 488
Johnson Behavioral System Model, 107108 Theory of Goal Attainment, 159161
Modeling and Role-Modeling theory, 207209, 208f, Theory of Health as Expanding Consciousness,
208t, 218 308310
Nursing as Caring Theory, 373, 375, 377378 Theory of Human Caring, 362367
Self-Care Deficit Theory, 127 Theory of Integral Nursing, 244248
Technological Competency as Caring, 461, 462468, Theory of Self-transcendence, 424426
463f, 466f Theory of Unitary Caring, 501503
Theory of Integral Nursing, 230, 230f, 235f, 240241 Unitary Pattern-Based Praxis method, 270271
Personal knowing, 26 Wiedenbachs conceptualization of nursing, 6364
Postmodern Nursing and Beyond (Watson), 352 Prescriptive theory, 5758, 6162
Power as Knowing Participation in Change Tool, practice applications of, 6162, 62f
259260 Preterm infant health, 91
Power Theory, 259260 Prevention, in Neuman Systems Model, 190191, 190f
Practice, 5. See also Nursing practice; Practice Prigogine, Ilya, 301, 302f
applications; Practice exemplar theory and, 89, 12,
2021
Practice applications. See also Practice exemplar;
Q
Qualitative Research Methods in Nursing (Leininger), 318
Research
Quality Caring Model, 402416
Care, Cure, and Core Model, 63
affiliation needs in, 408
Comfort Theory, 393397
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applications of, 409, 412414 Theory of Culture Care Diversity and Universality,
assumptions of, 405406 324328, 325f, 330
attentive reassurance in, 408 Theory of Health as Expanding Consciousness,
Caring Assessment Tool in, 413414 304308
caring factors in, 407409 Theory of Integral Nursing, 243
caring relationships in, 406407, 406f traditions of, 12
collaborative relationships in, 407, 409 Unitary Pattern-Based Praxis method, 269
concepts of, 404405 Rhythmical Correlates of Change, 259
development of, 403404, 404f Rogers, Martha E., 253254, 295, 419. See also Science
encouraging manner in, 408 of Unitary Human Beings
feeling cared for emotion in, 405, 408 Role modeling. See Modeling and Role-Modeling Theory
healing environment in, 408 Roy, Sister Callista, 167169. See also Roy Adaptation
human needs in, 408 Model
institutional use of, 415 Roy Adaptation Model, 169181
International Caring Comparative Database in, 414 assumptions of, 170171, 170t171t
meaning in, 408 cognator-regulator processes in, 171172
mutual problem-solving in, 408 concepts of, 171174
practice evaluation in, 412414 environment in, 173
practice exemplar of, 409412 health in, 173174
propositions of, 405406 historical development of, 169170
relationship-centered professional encounters in, interdependence mode in, 172, 173
404405 modes in, 172173
research on, 413414 nursing process in, 174
self-caring in, 405 people in, 171173
Quarantine, 43 physiologic-physical mode in, 172
Queen Victoria, 46 practice applications of, 174175
practice exemplar of, 175180
role function mode in, 172, 173
R self-conceptgroup identity mode in, 172173
Rapport, in Human-to-Human Relationship Model, 77
stabilizer-innovator processes in, 171172
Ray, Marilyn Anne, 472473. See also Theory of
Roy Adaptation Model, The (Roy), 168
Bureaucratic Caring
Roy Adaptation Model-based Research: Twenty-five Years of
Reaction paradigm, 10
Contributions to Nursing Science, 168
Reciprocal interaction paradigm, 10
Redundancy, in adaptation, 87
Reed, Pamela, 417418. See also Theory of S
Self-transcendence Sadness, in morbid grief, 213
Relationship, 5. See also Nurse-patient/client relationship; Schoenhofer, Savina, 370371. See also Nursing as
Nurse-Patient Relationship Theory Caring Theory
Halls model of nursing, 61 Science of Unitary Human Beings, 253276
Modeling and Role-Modeling Theory, 207209, applications of, 261269
216218, 217t Barretts practice method and, 263264
Quality Caring Model, 406407, 406f Butchers practice method and, 265268, 266f
Theory of Human Caring, 356357 Cowlings practice constituents and, 264265
Theory of Integral Nursing, 238 energy fields in, 255256
Religion, 241. See also Spirituality healing in, 262
in elder culture care, 332 helicy in, 257, 419
Research. See also Practice applications homeodynamics in, 257
Conservation Model, 101 integrality in, 257
elder care, 332334 intentionality in, 262
Humanbecoming School of Thought, 281282 nursing leadership and, 261b
Johnson Behavioral System Model, 113114, 114b nursing practice and, 261b
Lebanese Muslim ethnonursing, 330332 openness in, 256
Neuman Systems Model, 192, 197198 pandimensionality in, 256, 420
nurse-patient relationship, 7273 pattern in, 256
Quality Caring Model, 413414 postulates of, 255256
Roy Adaptation Model, 174175 practice methods and, 262269
Science of Unitary Human Beings, 261269 resonancy in, 257
theory-based, 8 spirituality in, 262
Theory of Bureaucratic Caring, 480, 486487, 491 theories from, 257261
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Science of Unitary Human Beings (Continued) Sleep hygiene, Conservation Model application to, 93
Theory of Accelerating Evolution from, 257258 Smith, Marlaine C., 495596. See also Theory of
Theory of Emergence of Paranormal Phenomena Unitary Caring
from, 258259 Smith, Mary Jane, 439. See also Story Theory
Theory of Kaleidoscoping in Lifes Turbulence from, Social justice, in Modeling and Role-Modeling theory,
260261 210
Theory of Power from, 259260 Specificity, in adaptation, 87
Theory of Rhythmical Correlates of Change from, 259 Spinsterhood, 44, 46
therapeutic touch in, 262 Spirituality
Unitary Pattern-Based Praxis method and, 265269, elder culture care, 332
266f Florence Nightingale, 3738, 41
worldview of, 255 Modeling and Role-Modeling theory, 209
Self-boundary, in Theory of Self-transcendence, Neuman Systems Model, 187188
419420 Reeds studies of, 417. See also Theory of
Self-care, 209 Self-transcendence
integral, 239 Science of Unitary Human Beings, 262
for nurse, 238239 Theory of Integral Nursing, 240, 241
Self-Care Deficit Theory, 121145 Standardized nursing languages, 153154
agent in, 127 Story. See also Story Theory
basic conditioning factors in, 127128, 128f in Modeling and Role-Modeling theory, 217218,
caregiver in, 127 217t
community groups in, 136 Story path, 443444, 443f
concepts of, 127 Story Theory, 439450
deliberate action in, 130 assumptions of, 441
developmental self-care requisites in, 132 concepts of, 441442, 441f
estimative capabilities in, 130 ease in, 444
family in, 136 emergence of, 440441
foundational capabilities and dispositions in, 130 foundations of, 441442, 441f
health deviation self-care requisites in, 132 intentional dialogue in, 442
historical evolution of, 123125 practice exemplar of, 444449, 448t
multiperson situations and units in, 136 self-in-relation in, 442444, 443f
nursing agency in, 127, 135136 story path in, 443444, 443f
nursing system definition in, 133135, 134f Stress response, in Modeling and Role-Modeling
nursing systems theory in, 126127 theory, 210211, 210f
power components in, 130 Study guide, 1619
practice applications of, 136139, 138t Substantive theory, 481
practice exemplar of, 139143 Suffering, 76
productive operation capabilities in, 130131 in Theory of Integral Nursing, 240241
self-care agency in, 129130, 130f Suggestions for Thought (Nightingale), 41
self-care deficit definition in, 132133 Sunrise enabler, in Theory of Culture Care Diversity
self-care deficit theory in, 126 and Universality, 324327, 325f, 329330
self-care definition in, 128129 Swain, Mary Ann, 204. See also Modeling and
self-care requisites in, 131132 Role-Modeling Theory
self-care theory in, 126 Swanson, Kristen M., 428431, 436. See also Theory of
self-management in, 139 Caring
structure of, 128f Sympathy, in Human-to-Human Relationship
therapeutic self-care demand in, 131 Model, 77
transitional capabilities in, 130 Synchronicity experience, 259
universal self-care requisites in, 131132 Syntactical structures, of nursing discipline, 6
Self-care knowledge, 209
Self-care resources, 209
Self-Care Theory in Nursing: Selected Papers of Dorothea
T
Technological Competency as Caring, 460471
Orem, 123
applications of, 469
Self-transcendence, 421422, 421f. See also Theory of
calls for nursing in, 468469
Self-transcendence
change in, 469
Self-Transcendence Scale, 422
continuous knowing in, 468
Simultaneity paradigm, 10
definition of, 461
Simultaneous action paradigm, 10
intention in, 467
Skills, 22
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knowing persons in, 461, 462468, 463f, 466f generic care in, 322, 323, 327
nursing process in, 465 German American elder care research in, 333334
nursing response in, 468469 goal of, 323
practice exemplar of, 469470 health in, 323
purpose of, 461 Lebanese Muslim ethnonursing research in, 330332
situation of care in, 464466 in nurse education, 328
trust in, 464 orientational definitions in, 323324
wholeness ideal in, 464, 465 practice applications of, 329334
Textbook of the Principles and Practice of Nursing professional care in, 322, 323
(Henderson), 5859, 63 purpose of, 322323
Theory. See Nursing theory and specific nursing theories rationale for, 320321
Theory for Nursing: Systems, Concepts, Process, A (King), research in, 324328, 325f, 330
147 sunrise enabler in, 324327, 325f, 329330
Theory of Accelerating Evolution, 257258 theoretical assumptions of, 323324
Theory of Bureaucratic Caring, 472494 theoretical tenets of, 321322
applications of, 486488 worldview in, 321322, 324
caring in, 478479, 484485 Theory of dissipative structures, 301, 302f
description of, 479480 Theory of Emergence of Paranormal Phenomena,
development of, 480486 258259
dialectic in, 480, 481 Theory of Goal Attainment, 146166
formal theory analysis in, 481 conceptual framework of, 149150, 149f
generation of, 473, 473f, 474f, 475476 documentation system in, 150151
in health-care economics, 486487 Goal Attainment Scale in, 151
holographic nature of, 483484, 486 nursing process in, 153154
leadership models in, 478 philosophical foundation of, 148149
middle-range character of, 482 practice applications of, 152159
in nursing education, 487488 client perspective and, 156
nursing practice in, 476477, 489490 in client systems, 155156
organizational cultures in, 477478 with clients across life span, 155
organizational transformation in, 484485 evidence-based, 158
practical dimensions of, 489490 in multicultural settings, 157
practice exemplar of, 488 in multidisciplinary settings, 158
research on, 480, 486487, 491 within nursing specialties, 156157
Theory of Caring, 428438 recommendations for, 158159
at-risk mothers study and, 432433 in work settings, 157
caring knowledge in, 435436 practice exemplar of, 159161
Caring Professional Scale in, 435 standarized nursing languages in, 153154
Couples Miscarriage Project study and, 436437 transaction process model in, 150, 151f
evolution of, 431 Theory of Group Power within Organizations, 153
literature meta-analysis in, 435436 Theory of Health as Expanding Consciousness,
Miscarriage Caring Project study and, 433435 290313
NICU study and, 431432 applications of, 297308
practice applications of, 433435 assumptions of, 297
refinements of, 431433 community-level application of, 307308
Theory of Culture Care Diversity and Universality, consciousness stages in, 303, 303f
317336 cross-culture relevance of, 304
African American elder care research in, 332333 development of, 296297
Anglo elder care research in, 332333 disruption-related choice points in, 301303, 302f,
care modalities in, 322 303f
in community-based care, 328 expanding consciousness in, 297298
cultural commonalities in, 321 focusing process in, 304
culture care accommodation/negotiation in, 322, 324, insights in, 301303, 302f
329 levels of awareness in, 296
culture care preservation/maintenance in, 322, 324, meaning in, 300301
329 nurse-client interaction in, 303305
culture care restructuring/repatterning in, 322, 324, nurse-family interaction in, 304306
329, 333 nursing practice and, 306307
development of, 318324 pattern in, 300301
domain of inquiry in, 326 pattern recognition as intervention in, 305306
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Theory of Health as Expanding relationship-based case in, 238


Consciousness (Continued) relationship-centered case in, 238
philosophical influences on, 294296 research on, 243
practice exemplar of, 308310 structure of, 237, 237f
presence in, 298299 transpersonal dimension in, 240
resonance in, 299300 Theory of Integral Nursing (Dossey), 224, 242
time and, 298299 Theory of Kaleidoscoping in Lifes Turbulence, 260261
Toward a Theory of Health presentation and, 295296 Theory of Nursing Systems, 126127. See also Self-Care
unitary-transformative paradigm in, 296297 Deficit Theory
Theory of Human Caring, 351369 Theory of Power, 259260
Attending Nurse Caring Model and, 362365, 366367 Theory of Rhythmical Correlates of Change, 259
carative factors in, 353354 Theory of Self-Care, 126. See also Self-Care Deficit
caring (healing) consciousness in, 358 Theory
Caring Moment in, 356358 Theory of Self-transcendence, 417427
caring occasion in, 358 assumptions of, 418420
Caring Science orientation in, 353 change in, 419
clinical caritas processes in, 354355 concepts of, 420423, 421f
conceptual elements of, 353 contextual factors in, 423, 426
in customer service, 365366 nursing processes in, 419, 423
development of, 352353 pandimensionality in, 420
in education, 365 personal factors in, 423, 426
in hospitals, 361362 potential for well-being in, 418419
implications of, 358359 practice exemplar of, 424426
International Caritas Consortium and, 360361 self-boundary in, 419420
practice applications of, 359362 self-organization in, 419
practice exemplar of, 362367 self-transcendence in, 421422, 421f
reading of, 355356 vulnerability in, 421f, 422, 426
transpersonal caring relationship in, 356357 well-being in, 421f, 422423, 426
Watson Caring Science Institute and, 359360 Theory of Unitary Caring, 495504
Theory of Integral Nursing, 224250 appreciating pattern in, 497498, 500
application of, 242243 assumptions of, 497
AQAL (all quadrants, all levels) in, 234237, 235f caring concept in, 496
communication in, 241 concepts of, 497499
conference on, 243 creative emergence in, 499, 501
content components of, 229237 development of, 496497
context in, 237238 dynamic flow attunement in, 498, 500501
development in, 228, 234235, 235f empirical indicators in, 499501
development of, 227228 Infinity in, 498, 500501
in education, 242243 manifesting intentions in, 497, 499500
environment in, 230f, 231, 235f, 242 practice exemplar of, 501503
four-quadrants perspective in, 232234, 232f, 233f, Theory of well-being, 423. See also Theory of
235f, 239242 Self-transcendence
in global health, 243 Therapeutic touch, 262
healing in, 229230, 229f230f, 238 Tomlin, Evelyn, 204
health in, 230231, 230f, 235f, 241242 Totality paradigm, 10
integral dialogues in, 226 Touch, therapeutic, 262
integral process in, 226 Toward a Theory for Nursing: General Concepts of Human
integral worldview in, 226 Behavior (King), 146147
intentions of, 228, 241 Tradition, 6
meaning in, 239242 Transaction process model, 150, 151f
metaparadigm in, 230231, 230f Transcultural nursing, 320321. See also Theory of
nurse in, 230, 230f, 235f, 237238, 239240 Culture Care Diversity and Universality
nursing practice and, 238242 Transcultural Nursing: Concepts, Theories, and Practices
patterns of knowing in, 231232, 231f, 237, 237f (Leininger), 318
person in, 230, 230f, 235f, 240241 Transitional objects, 213
philosophical assumptions of, 228229 Transparency, in Theory of Integral Nursing, 240
philosophical foundation of, 225, 226227 Transpersonal Caring Theory. See Theory of Human
in policy guidance, 243 Caring
practice exemplar in, 244248 Travelbee, Joyce, 75. See also Human-to-Human
questions in, 225 Relationship Model
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True presence, in Humanbecoming School of Thought, W


282283 Watson, Jean, 351352. See also Theory of Human
Trusting-functional relationship, 207209 Caring
mind-set establishment for, 216, 217t Ways of knowing, 2627
nurturing space creation for, 216217, 217t Wholeness
story facilitation for, 217218, 217t Conservation Model, 88
Truth, 474 Johnson Behavioral System Model, 105106
Theory of Health as Expanding Consciousness,
U 299300
Unitary Pattern-Based Praxis method, 265268, 266f Wiedenbach, Ernestine, 5455
pattern manifestation knowing and appreciation in, nursing conceptualizations of, 5758
265268 prescriptive theory of, 5758, 6162, 6364
practice exemplar of, 270271 Wilber, Ken, 228
research on, 269 Women Founders of the Social Sciences, The (McDonald), 47
voluntary mutual patterning in, 268269 Wound care, Conservation Model application to, 91, 92
Unitary-transformative paradigm, 10
Z
V Zderad, Loretta, 337338. See also Humanistic Nursing
Values, 6, 2122 Theory
Conservation Model, 86
Johnson Behavioral System Model, 112
Veritivity, 170
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