Caring and Nursing’s Metapauadigm: Can They
Survive the Era of Managed Care?
Carol Montgomery, RN, PhD, CS, and Denise C. Webster, RN, PhD, CS
Considering the growing power of third-party
payers to control the length and methods of
treatment, the authors summarize alternative
treatment models of providing care. These
models are evaluated within the context of
nursing’s metaparadigm. Clinical examples are
provided to illustrate how focusing on client
strengths and alternative solutions differs from
more traditional approaches to treatment.
Perspectives in Psychiatric Care Vol. 29, No. 4, October-December, 1993
w e are at a crossroads in psychiatric nursing.
Whether psychiatric/mental health nursing can re-
main viable as a specialty area or is unique in relation
to other mental health disciplines remains an open
question (Menvin & Fox, 1992; Thomas & Wilt, 1988).
In addition, along with the other mental health dis-
ciplines, we are faced with increasing demands for
accountability and cost containment and the growing
power of third-party payers to control the length and
methods of treatment (Austad & Hoyt, 1992).
Some cause for optimism can be found in a recent
interdisciplinary survey intended to identify future
trends in psychotherapy. Results suggested that psy-
chiatric nursing would be among the professions
most likely to provide psychotherapy/counseling in
the future, with psychiatrists narrowing their contri-
bution to diagnosing disease and providing medical
interventions (Norcross, Alford, & DeMichele, 1992).
However, in order for nurses to assume this role,
methods of intervention will need to be congruent
with the demands for accountable, pragmatic, and
cost-effective treatment.
While we may mourn the loss of longer-term,
more intimate relationships with our clients, the
adoption of brief treatment approaches need not im-
ply substandard care. In fact, models of brief or in-
termittent therapy such as solution-focused (Web-
ster, 1990a), possibility-oriented (deshazer, 1988;
Friedman & Fanger, 1991), and crisis approaches
(Hoff, 1989) are, in many ways, more consistent with
the core values of nursing’s metaparadigm than are
the received views of traditional behavioral and ana-
lytical models (Tuyne, 1992; Urbanic, 1992; Webster;
Whall, 1980).
Nursing‘s Metaparadigm
The science of nursing has shown rapid growth in
the last several years. Rather than relying upon bor-
rowed knowledge from medicine and other fields,
nursing has identified its own phenomena of
interest-or metaparadigm. Nursing now has a
5
 ~ ~
~~
Caring and Nursing’s Metaparadigm: Can They Survive the Era of Managed Care?
framework from which to examine ”borrowed’ theo-
ries critically in the context of the core values within
our own metaparadigm. Nursing scholars generally
agree that the phenomena of concern for nursing con-
sist of four key concepts: person, health, environ-
ment, and nursing (Fawcett, 1989).
Person. The first area of concern addressed by
nursing’s metaparadigm is the concept of person.
Chinn and Kramer (1991)claim, “The most consistent
philosophic component of the idea of the person is
the dimension of wholeness or holism” (p. 42). Ho-
lism in nursing means that the person must be un-
derstood as a nonreducible totality that is more than
the sum of its parts. Several nursing theories attempt
to represent wholeness by using a systems paradigm
(Erickson, Iomlin, & Swain, 1983; King, 1981; Roy,
1984). Others rely on existential-phenomenological
understandings of the person (Benner & Wrubel,
1989; Parse, 1981; Watson, 1985). Still others use the
model of energy fields (Newman, 1986; Rogers,
1970).
Regardless of the particular model from which
these theories were derived, nursing theories all re-
ject mechanistic understandings that rely upon linear
causal relationships (Whall, 1980). For example, a
mechanistic model assumes that for change to occur
one must correct the deep-rooted causes of the prob-
lem. The ”problem” in psychodynamic tradition is
attributed to deficits in earlier development (Malin-
ski, 1986), and, in the medical model, to biological
dysfunction. The holistic paradigm, on the other
hand, suggests that significant and lasting change
also can occur by making sometimes minor, yet stra-
tegic changes in the system, context, or “field’ in
which the problem occurs. This holistic understand-
ing of the person provides a framework for psychiat-
ric nurses to facilitate change in their clients consis-
tent with the assumptions underlying brief therapies.
Another assumption in nursing’s metaparadigm
about human nature is the uniqueness and dignity of
each individual. The authority to intervene is derived
from the unique relationship with each client, rather
6 Perspectives in Psychiatric Care Vol. 29, No. 4, October-December, 1993
than from any theoretical dogma (Montgomery, in
press). Allegiance to any one theory would be inap-
propriate; instead, the clinician selectively draws
from theories that which is relevant to meet the needs
of each client. This expert level of practice (Benner,
1984) may even require going outside the boundaries
of existing theory to create new knowledge based on
the demands of each unique practice situation. Mod-
els of brief therapy also tend to emphasize creative
and pragmatic interventions that are unique to the
needs of each client.
Health. The second focus of nursing’s metapara-
digm is the concept of health. The definitions of
health by nurse theorists reflect far more than the
absence of pathology. Views of health in nursing
range from self-care (Orem, 1971) and adaptation
(Roy, 1984) to harmony of mind-body-spirit (Watson,
1985)and expanding consciousness (Newman, 1986).
A focus on wellness and the assumption that health
must be understood in terms of individual meaning
are consistent themes throughout these theories. A
nursing approach to mental health, then, is one that
emphasizes clients’ strengths rather than their psy-
chopathology and accepts each client’s personal
meaning of health.
~ ~
When nurses are able to see the world
from the client’s perspective, they can
appreciate as strengths what might appear
to others as psychopathology.
When nurses are able to see the world from the
client’s perspective, they can appreciate as strengths
what might appear to others as psychopathology
(e.g ., “manipulation,” ”resistance”). Models of brief/
intermittent therapy facilitate working with the
client’s own meanings of health because these mod-
els stay focused on the client’s definition of desired
outcome, rather than on that of the therapist.
For example, a woman diagnosed with suspicious
behavior patterns and social isolation may just want
to be alone so she can feel safe. A nursing goal, how-
ever, may be for the client to increase socialization
with other clients. Acknowledging this difference re-
duces the confusion about whose goals are actually
being pursued. When differences exist, negotiation
between the client’s goals and the nurse’shnit’s goals
then becomes necessary to avoid risking unintended
sleight-of-language redefinitions of ”my needs“ as
“her needs” and labeling the behavior as noncompli-
ant.
Benner and Wrubel (1989) support a health rather
than illness focus when they advocate shifting from a
view of reality that concentrates on deficits to one
that looks at possibilities. Rogers (1970) describes
health patterns as rhythmic cycles in which symp-
toms alternate with symptom-free periods. The solu-
tion-focused emphasis, by looking for exceptions to
the problem rather than focusing on the problem, is
also health focused (Tuyne, 1992). Even though ill-
ness may coexist with health, brief, solution-focused
approaches assume that successful interventions con-
centrate on solutions and client strengths (deshazer,
1988).
Environment. Environment has been a central
concept since Nightingale (1969) delineated a core
goal of nursing to create an environment that would
put the person in the best condition for healing to
occur. More recently, Rogers (1970) portrayed hu-
mans as energy fields that are integral with the envi-
ronment’s energy field. In keeping with this tradi-
tion, psychiatric nursing practice would concern itself
with understanding the unique patterns of interac-
tion between clients and their environment. With
such an understanding, nurses could mobilize their
own available resources in the service of emotional
growth and healing (Hoff, 1989; Montgomery, in
press).
Perspectives in Psychiatric Care Vol. 29, No. 4, October-December, 1993
From this perspective, the therapeutic relationship
is not seen as an end in itself or as a means to develop
“insight” about the etiology of a problem. Instead,
the nurse focuses on the resources available for pro-
moting the client’s independence and self-care
(Orem, 1971). Thus, the therapeutic relationship is
used in a way that enhances the client’s relationship
with his or her own natural environment. By empow-
ering clients in this way, nurses minimize clients’ de-
pendency on health providers and the subsequent
need for lengthy or expensive treatment. The strate-
gic use of context that is advocated in models of brief/
intermittent therapy offers more specific tools with
which to work with the client’s environment.
Benner and Wrubel (1989) advocate
shifting from a view of reality that
concentrates on deficits to one that looks
at possibilities.
Nursing. Perhaps the most significant component
of nursing’s metaparadigm is how the nature of the
profession, or nursing activity, is defined. Caring has
been identified as the essence of nursing (Leininger,
1984; Watson, 1985) and the source of excellence and
power of our discipline (Benner, 1984). Benner’s em-
phasis on caring has been cited by Krauss (1987) as
one of the cornerstones of the future of psychiatric
nursing practice. Newman, Sime and Corcoran-Perry
(1991) suggest that nursing is “caring in the human
health experience” (p. 3).
The authors assert that caring is expressed when a
nurse drops her ”professional persona” and allows
herself to be moved with compassion. These caring
moments can create remarkable effects by inspiring
clients to care about themselves, which promotes
7
Caring and Nursing’s Metaparadigm: Can They Survive the Era of Managed Care?
their own self-integrity and heals the wounds of their
loss (Montgomery, in press). However, natural feel-
ings of compassion may be devalued and viewed
with suspicion in psychiatric settings; and labeled as
countertransference, emotionality, or codependency
(Montgomery, 1992; Webster, 1990b, 1991). Simple
acts of kindness are seen by some to reinforce the
inherent dependency of the “defective” client.
Some of the most caring, creative exemplars of
nursing practice remain “underground’ because they
violate the tenets of scientific thinking, which values
detachment, distance, and objectivity (Montgomery,
1991). However, the irony of this situation is that the
mystification and the scientization of treatment, by its
very nature, creates dependency of the client for a
I,
cure.” When treatment is defined as something
mysterious and removed from the client’s own inher-
ent self-care abilities, then others, rather than one-
self, are seen as able to solve the problem. This atti-
tude weakens clients’ own resolve, for they are
taught they must depend on access to our knowledge
and our science.
Another implicit assumption of many psychother-
apy approaches is that clients are ”responsible” (of-
ten interpreted as “to blame”) for their problems and
must ”work” on them in order to get well (Corday,
1990). This “work’ is understood as developing in-
sight (Stuart & Sundeen, 1991). However, for a client
who is suffering emotionally and just wants to feel
better, the vagueness of this message may lead to
despair, noncompliance, and disillusionment with
the therapeutic process. While theoretical abstrac-
tions may be of little use to clients, traditional models
of psychotherapy have tended to view with suspicion
pragmatic strategies aimed at providing symptom re-
lief (Budman & Gurman, 1988). Models of brief ther-
apy support the active and creative involvement of
the therapist to relieve the client’s distress.
Suggested Treatment Models
The authors assert that therapies facilitating a re-
spectful, caring, health-oriented, and active focus
8 Perspectives in Psychiatric Care Vol. 29, No. 4, October-December, 1993
are most consistent with nursing’s metaparadigm.
These models include Eriksonian approaches (Dolan,
1985; Erickson, Tomlin, & Swain, 1983; OHanlon,
1987), solution-focused approaches (deshazer, 1988;
Dolan, 1985), possibility-oriented therapies (Fried-
man & Fanger, 1991), and some crisis therapies (Hoff,
1989).
Such models are consistent with nursing’s values
in that they focus on ”the health within illness,” and
respect clients’ innate ability to know what will work
best for their own situations. Rather than diagnosing
illness or problems and confronting clients with their
deficits, these approaches reflect a caring position of
working with clients within their own frames of ref-
erence. The unique resources they possess, both in-
trapsychically and in their environments, are ex-
ploited fully. Solutions are based on the client’s “real
world,” rather than a professional’s idealized view of
a preferred reality. This down-to-earth approach is
balanced with the careful use of language that will
mobilize hope for the client.
These models value reduction of human suffering
in the short run, as well as the long run. While
change is not always comfortable, therapies proclaim-
ing ”no pain, no gain” are inconsistent with nurs-
ing’s central values. The reduction of anxiety helps
clients feel better at the physiological as well as the
psychological levels of being (Friedman & Fanger,
1991; Lynch, 1985). Indeed, our holistic approach
warrants attention to these physiological dimensions
and other findings of psychoneuroimmunology
(Rossi, 1986). This perspective highlights the need to
utilize physiological, psychological, and spiritual di-
mensions of healing.
“Utilization,” a central concept of solution-
possibility-oriented therapy, involves the idea of us-
ing whatever people bring into the situation (includ-
ing their symptoms) to help them meet their goals.
As in reframing and ”positive asset search” tech-
niques, focus is placed on the possibilities inherent in
the person and situation. What some people call
“paradox” (the prescription of the symptom) may
involve nothing more than accepting the clients’ re- sponse was a sincere one, based on the age-old psy-
ality and assuming some positive intent in the activ- chiatric nursing principle of meeting clients where
ities they have found helpful. Such assumptions they are. She had an intuitive sense that the last thing
build on the belief that clients usually know what is in the world Mrs. J. needed was another person try-
best for them and that they are doing the best they ing to “convince” her to be “rational” and comply
can at any particular time (Peplau, 1952; Friedman & with her insurance company’s demands. The nurse
Fanger, 1991). basically ignored the flagrant symptoms of a phobic
disorder to focus on Mrs. J.’s more immediate con-
Clinical Illustrations cerns.
Specific changes in language and assumptions are
In her role as psychiatric-liaison nurse, one of the apparent in the comparison in Table 1, which is based
authors was asked by a frustrated physician to see a on questions used from a solution-focused frame-
medical client who refused to leave the hospital (she work (Friedman & Fanger, 1991). The problem focus
was exceeding her insurance policy’s specified length is evident in nursing diagnoses and care plans that
of stay) because her house was “full of germs.” Mrs. list only problems or deficits. Within the problem
J. offered a bizarre explanation for why her house framework, theoretical rationales are oriented toward
was dangerous to her health and why she had to stay finding causes for the problem and related problems,
in the hospital where it was “safe.” The nurse rein- rather than on understanding the context (Carpenito,
forced the notion that being safe was the most im- 1989; Paquette, Neal, & Rodemich, 1991). What are
portant thing. Mrs. J. vehemently agreed, elaborating
that after her last surgery she had been recuperating Table 1. Problem Focus Versus Health Focus
nicely when, without warning, her spleen ruptured.
“I almost died before I got to the hospital,” Mrs. J. Problem Focus Health Focus
added plaintively. The nurse replied, ”Well, I don’t
blame you for not wanting to go home. I wouldn’t What is the problem/ What do you want?
either, if I were you.” diagnosis?
What caused the problem? In what context does the
The client then disagreed, saying she really did problem occur?
want to go home because she missed her husband. What other problems are In what context does the
The nurse acknowledged this feeling, but continued related to this? problem not occur?
to worry with the client about her need to be safe. (exceptions)
Finally, Mrs. J. patiently reassured the nurse that Wholwhat is to blame? What keeps this (exception
to the problem) from
things weren’t that bad and that she could probably occurring more often
keep most of the germs out by closing her bedroom now?
door and taking other environmental precautions. Are there times when you
The nurse suggested that she not be home alone that already experience this
first week and Mrs. J. agreed that her daughter could (exception)even a little?
How long has this problem What difference will it
arrange to be home with her during the day while her been evident in family make for you (and
husband worked. The client continued to reassure history? significant others) when
the nurse that she would be fine and asked if she this problem no longer
could call her husband to pick her up. exists?
At the time of this interaction the nurse had no
knowledge of paradoxical interventions. Her re- Adapted from Friedman & Fanger, 1991

Perspectives in Psychiatric Care Vol. 29, No. 4, October-December, 1993 9

Caring and Nursing’s Metaparadigm: Can They Survive the Era of Managed Care?
identified as clients’ goals may actually be nursing’s
goals, based on the values and ideals of treatment.
More health-oriented approaches assume that suc-
cessful solutions do not always become evident as a
result of a detailed analysis of the problem, its histor-
ical development, and/or its ramifications.
~~~~~~
Health-oriented approaches assume that
successful solutions do not always become
evident as a result of a detailed analysis of
the problem.
~~ ~
A clinical example from the private practice of an-
other of the authors illustrates ways in which princi-
ples of health- oriented approaches to therapy can be
integrated within the nursing process. C.J., a 56-year-
old woman, was referred for ”problems with her chil-
dren” and ”increased physical symptoms.” A
lengthy list of physical problems included rheuma-
toid arthritis, multiple food allergies, and chronic
asthma. At the first visit the client walked with diffi-
culty with a cane and suffered from shortness of
breath. The client had a long history of psychiatric
treatment and had been given, at one time or an-
other, the following diagnoses: psychosis, schizoaf-
fective or manic-depressive disorder, somatization
disorder, and hysterical personality disorder.
Traditional nursing diagnoses would have in-
cluded (minimally): somatization, ineffective coping,
and altered family functioning. A focus on these di-
agnoses could easily have led the nurse to feel as
hopeless as had several previous therapists. How-
ever, the health-oriented framework focused on the
utilization of the client’s goals, views of reality, and
unique resources.
Client explanation of health situation. C.J. spent
10 Perspectives in Psychiatric Care Vol. 29, No. 4, October-December, 1993
most of her childhood in and out of hospitals with
life-threatening asthma. She also suffered with mul-
tiple allergies, joint pain, and fatigue all her life. High
doses of cortisone used to treat her asthma made her
feel ”crazy.” She was coping well for several years
until three of her adult children moved into the area
and began to burden her with their multiple continu-
ing crises, including demands to babysit for a “hy-
peractive toddler and sick baby.” She concluded,
”I’m thinking of changing my name and moving
where they’ll never find me.”
Client’s goal. “I want to be able to take care of
myself, to keep my job (as a secretary), be able to go
to church, and to finish the cookbook I’m writing for
people like me with multiple allergies.”
Health-focused assessment. Identified strengths
(selected): highly developed skills at assessing phys-
ical symptoms; well-developed patterns of self-care
(recently disrupted).
Sample of assessment interview questions in-
tended to further elucidate patterns of health and
coping.
Nurse: Tell me about a time in your life when you felt
most able to care for yourself.
C.J.: When I was manager of a shoe department
and was able to support my family.
Nurse: Are there times in your life now when you
are more able to care for yourself?
C.J.: I feel better when I stick to my diet and exer-
cise and when I pray and attend church ser-
vices.
Nurse: What would you be doing if your children
were less demanding?
C.J.: 1 would be dating again, working on the
cookbook, and learning computer skills so I
could work from home if I become more
physically disabled.
Nurse: What do you think would need to happen for
your children to be less demanding of you?
How could that happen?
C.J.: They would need to be more independent.
 This would require that they know how seri-
ously compromised my health is and find
other resources to help them with their prob-
lems.
Nursing interventions
Acknowledge, accept, and respect client’s per-
spectives and goals.
Identify client strengths and resources to meet
these goals (begun during assessment pro-
cess).
Utilize highly developed self-assessment of
client’s or nurse’s physiological responses (re-
framing symptom as a strength).
Suggest client pay attention to subtle changes
and notice her abilities to respond and to have
some effect on these changes.
Use autogenichiofeedback exercises to dem-
onstrate these to herself.
Homework assignments:
1) Notice what’s going on when you are feel-
ing most able to meet your self-care needs.
2) Think about what your “personal recipe”
would be to help adult children to be more
independent.
3) Listen to (self-hypnotic) relaxation/visu-
alization and autogenic healing tapes.
Evaluation. The client was seen weekly for four
visits. The third session was a family meeting in
which she shared her concerns and needs. She pre-
sented each child with a booklet that included her
hopes for their futures, some suggestions, and pack-
ets of information about community resources (all de-
veloped by her as part of her ”recipe”). Following
that meeting she was seen at intervals of approxi-
mately three months, scheduled per her request.
In subsequent meetings, C.J. focused on identify-
ing current stressors and plans for modifying and/or
continuing self-care patterns. She is now living in a
reduced-rent building for people who are retired and/
Perspectives in Psychiatric Care Vol. 29, No. 4, October-December, 1993
or have special needs. She eats one communal meal a
day and has begun to make friends among the resi-
dents. Of interest, the building has restrictions
against having young children staying in residents’
apartment. She has completed several computer
courses and is able to walk without her cane. One
daughter has obtained her GED.
Theories that distance us from the reality
of our clients’ pain and distract us from
alleviating suffering are not consistent
with our purpose.
Summary
Nursing has always been a pragmatic profession,
motivated by the desire to relieve suffering. Theories
that distance us from the reality of our clients’ pain
and distract us from alleviating suffering are not con-
sistent with our purpose. Nurses need theories that
lead to solutions to human problems so they can ac-
tualize their human compassion in a meaningful way
with clients. The shift to a health-oriented (possibil-
ity) frame is a revolutionary way to actualize caring,
as well as cost-effectiveness. The identification of
strengths is consistent with a nursing view of health,
which encourages us to value the uniqueness of each
person and hidher unique construction of reality.
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