Nursing Theories and Nursing Practice

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SECTION
I
An Introduction
to Nursing Theory
Copyright © 2019. F. A. Davis Company. All rights reserved.
Smith, M. C. (2019). Nursing theories and nursing practice. F. A. Davis Company.

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SECTION
I An Introduction to Nursing Theory

In this first section of the book you will be introduced to the purpose of nursing theory
and shown 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 evolution and context of nursing as a professional
discipline, and how to approach its study and evaluation. If you have studied nursing
theory in the past, these chapters will provide you with additional knowledge and
insight as you continue your study.
Nursing is a professional discipline focused on the study of the wholeness of
human-environment health and healing through caring. Nursing practice is based on
the knowledge of nursing, which consists of its philosophies, theories, concepts, prin-
ciples, research findings, and practice wisdom. Nursing theories are patterns that
guide the thinking about 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 diseases, diagnoses, and treatments.
This does not reflect practice from the disciplinary perspective of nursing. The major
reason for the development and study of nursing theory is to improve nursing practice
and, therefore, the health and quality of life of those we serve.
Chapter 1 focuses on nursing theory within the context of nursing as an evolving
professional discipline. The authors examine the relationship of nursing theory to the
characteristics of a discipline. You’ll learn new words that describe parts of the knowl-
edge structure of the discipline of nursing, and speculations about the future of nurs-
ing theory as nursing, health care, and our global society change. Chapter 2 is a guide
to help you study the theories in this book. Use this guide as you read and think about
how nursing theory fits in your practice. Nurses embrace theories that fit with their
values and ways of thinking. They choose theories to guide their practice and 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 eval-
uating 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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Nursing Theory and the

CHAPTER
1
Discipline of Nursing
Marlaine C. Smith and
Marilyn 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 a Professional but when it is posed to nurses, many define
Discipline
nursing by providing a litany of functions and
The Evolution of Nursing Science
activities. Some answer with the elements of
The Structure of Knowledge in the Discipline of
Nursing the nursing process: assessing, planning, im-
Nursing Theory and the Future plementing, and evaluating. Others might
Summary answer that nurses coordinate a patient’s care.
Questions for Reflection and Discussion Defining nursing in terms of the nursing
process or by functions or activities nurses
perform is problematic. The phases of the
nursing process are the same steps we might
use to solve any problem we encounter, from
a broken computer to a failing vegetable gar-
den. We assess the situation to determine
what is going on and then identify the prob-
lem; we plan what to do about it, implement
our plan, and then evaluate whether it 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, a nurse might
start IVs, administer medications, and perform
treatments in an acute care setting. In a

community-based clinic, a nurse might teach
a young mother the principles of infant feeding
or place phone calls to arrange community re-
sources for a child with special needs. Multiple
professionals and nonprofessionals may per-
form 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
might do discharge planning. Both nurses and
family members might change dressings, mon-
itor vital signs, and administer medications, so
3
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4 S E C T IO N I ■ An Introduction to Nursing Theory
defining nursing based solely on functions or The classic work of King and Brownell
activities performed is not useful. (1976) is consistent with the thinking of nurs-
To answer the question “What is nursing?” ing scholars (Donaldson & Crowley, 1978;
we must formulate nursing’s unique identity as Meleis, 1997, 2018) about the discipline of
a field of study or discipline. Florence Nightin- nursing. These authors have elaborated attrib-
gale is credited as the founder of modern nurs- utes that characterize all disciplines. As you will
ing, the one who articulated its distinctive focus. see in the discussion that follows, the attributes
In her book Notes on Nursing: What It Is and of King and Brownell provide a framework that
What It Is Not (Nightingale, 1859/1992), she contextualizes nursing theory within the disci-
differentiated nursing from medicine, stating pline of nursing.
that the two were distinct practices. She defined
nursing as putting the person in the best condi- Expression of Human Imagination
tion for nature to act, insisting that the focus of Members of any discipline imagine and create
nursing was on health and the natural healing structures that offer descriptions and explana-
process, not on disease and reparation. For her, tions of the phenomena that are of concern to
creating an environment that provided the con- that discipline. These structures are the theories
ditions for natural healing to occur was the focus of that discipline. Nursing theory is dependent
of nursing. Her beginning conceptualizations on the imagination of nurses in practice, ad-
were the seeds for the theoretical development ministration, research, and teaching, as they
of nursing as a professional discipline. create and apply theories to improve nursing
In this chapter, we situate the understand- practice and ultimately the lives of those they
ing of nursing theory within the context of the serve. To remain dynamic and useful, the dis-
discipline of nursing. We define the discipline cipline requires openness to new ideas and in-
of nursing, describe the purpose of theory for novative approaches that grow out of members’
the discipline of nursing, review the evolution reflections and insights.
of nursing science, identify the structure of the
discipline of nursing, and speculate on the fu- Domain
ture place of nursing theory in the discipline. A professional discipline must be clearly defined
by a statement of its domain—the boundaries or
focus of that discipline. The domain of nursing
The Discipline of Nursing includes the phenomena of interest, problems to
be addressed, main content and methods used,
Every discipline has a unique focus that directs
and roles required of the discipline’s members
the inquiry within it and distinguishes it from
(Kim, 1997; Meleis, 2018). The processes and
other fields of study (Smith, 2018, p. 3). Nurs-
practices claimed by members of the disciplinary
ing knowledge guides its professional practice;

community grow out of these domain statements.
therefore, it is classified as a professional dis-
Nightingale provided some direction for the do-
cipline. Donaldson and Crowley (1978) stated
main of the discipline of nursing. Although the
that a discipline “offers a unique perspective, a
disciplinary focus has been debated, there is some
distinct way of viewing … phenomena, which
degree of consensus (Chinn, 2019; Smith, 2019).
ultimately defines the limits and nature of its
Donaldson and Crowley (1978, p. 113)
inquiry” (p. 113). Any discipline includes net-
identified the following as the domain of the
works of philosophies, theories, concepts, ap-
discipline of nursing:
proaches to inquiry, research findings, and
practices that both reflect and illuminate its 1. Concern with principles and laws that
distinct perspective. The discipline of nursing govern the life processes, well-being, and
is formed by a community of scholars, includ- optimal functioning of human beings, sick
ing nurses in all nursing venues, who share a or well
commitment to values, knowledge, and 2. Concern with the patterning of human
processes to guide the thought and work of the behavior in interactions with the environ-
discipline. ment in critical life situations

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C H APTER 1 ■ Nursing Theory and the Discipline of Nursing 5
3. Concern with the processes through structure to organize knowledge and

which positive changes in health status illuminate nursing practice.
are affected ■ The essence of nursing practice is the
nurse–patient relationship.
Fawcett (1984) described the metaparadigm
as a way to distinguish nursing from other dis- In 2008, Newman, Smith, Dexheimer-
ciplines. The metaparadigm is very general and Pharris, and Jones revisited the disciplinary
intended to reflect agreement among members focus asserting that relationship was central
of the discipline about the field of nursing. This to the discipline, and the convergence of
is the most abstract level of nursing knowledge seven concepts—health, consciousness, car-
and closely mirrors beliefs held about nursing. ing, mutual process, presence, patterning,
By virtue of being nurses, all nurses have some and meaning—specified relationship in the
awareness of nursing’s metaparadigm. How- professional discipline of nursing. Willis,
ever, because the term may not be familiar, it Grace, and Roy (2008) posited that the
offers no direct guidance for research and prac- central unifying focus for the discipline is fa-
tice (Kim, 1997; Walker & Avant, 2011). The cilitating humanization, meaning, choice,
metaparadigm consists of four concepts: per- quality of life, and healing in living and dying
sons, environment, health, and nursing. Ac- (p. e28). Litchfield and Jonsdottir (2008)
cording to Fawcett, nursing is the study of the defined the discipline as the study of human-
interrelationship among these four concepts. ness in the health circumstance. Smith
Modifications and alternative concepts for (1994) defined the domain of the discipline
this framework have been explored throughout of nursing as “the study of human health and
the discipline (Fawcett, 2000). For example, healing through caring” (p. 50). For Smith
some nursing scholars have suggested that (2018), “nursing knowledge focuses on the
“caring” replace “nursing” in the metaparadigm wholeness of human life and experience and
(Stevenson & Tripp-Reimer, 1989). Kim the processes that support relationship, inte-
(1998) set forth four domains: client, client– gration, and transformation” (p. 4). Smith’s
nurse encounters, practice, and environment. (2019) analysis of the disciplinary perspective
Others have defined nursing as the study of identified four concepts that delineate nurs-
“the health or wholeness of human beings as ing’s disciplinary perspective: 1) human
they interact with their environment” (Donald- wholeness (the unitary or integrative per-
son & Crowley, 1978, p. 113), the life process spective on human beings reflecting the
of unitary human beings (Rogers, 1970), care or fullness and complexity of the human condi-
caring (Leininger, 1978; Watson, 1985, 2008), tion); 2) health, healing, well-being (the
and human–universe–health interrelationships dynamic and transformative experiences
(Parse, 1998). A widely accepted focus and manifestations of living and dying);
statement for the discipline was published by 3) human–environment–health relationship
Newman, Sime, and Corcoran-Perry (1991), (the interconnectedness of human health
“Nursing is the study of caring in the human with the multidimensional environment); and
health experience” (p. 3). A consensus state- 4) caring (the intentions, expressions, behav-
ment of philosophical unity in the discipline was iors, actions and experiences grounded in a
published by Roy and Jones (2007) and in- moral–ethical–spiritual foundation that nur-
cluded statements such as the following: ture humanization, health, healing and well-
being). Nursing conceptual models, grand
■ The human being is characterized by theories, middle-range theories, and practice
wholeness, complexity, and consciousness. theories explicate the phenomena within the
■ The essence of nursing involves the nurse’s domain of nursing. In addition, the focus of
true presence in the process of human-to- the nursing discipline is a clear statement of
human engagement. social mandate and service used to direct
■ Nursing theory expresses the values the study and practice of nursing (Newman
and beliefs of the discipline, creating a et al., 1991).

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Syntactical and Conceptual Structures links. Nursing theories are part of this heritage
Syntactical and conceptual structures are es- of literature, and those working with these
sential to any discipline and are inherent in theories present their work at conferences, soci-
nursing theories. The conceptual structure de- eties, and other communication networks of the
lineates the proper concerns of nursing, guides nursing discipline. A new website, nursology.net,
what is to be studied, and clarifies accepted provides a comprehensive compendium of re-
ways of knowing and using content of the dis- sources related to nursing knowledge.
cipline. This structure is grounded in the focus
of the discipline. The conceptual structure re-
Tradition
lates concepts within nursing theories. The The tradition and history of the discipline are
syntactical structures help nurses and other evident in the study of nursing over time.
professionals to understand the talents, skills, There is recognition that theories most useful
and abilities that must be developed within the today often have threads of connection with
community. This structure directs descriptions ideas originating in the past. For example,
of data needed from research, as well as evi- many theorists have acknowledged the influ-
dence required to demonstrate the effect on ence of Florence Nightingale and have ac-
nursing practice. In addition, these structures claimed her leadership in influencing nursing
guide nursing’s use of knowledge in research theories of today. In addition, nursing has a
and practice approaches developed by related rich heritage of practice. Nursing’s practical
disciplines. It is only by being thoroughly experience and knowledge have been shared
grounded in the substantive knowledge of and transformed as the content of the disci-
the discipline and modes of inquiry that the pline and are evident in many nursing theories.
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
strong commitments to compassionate and
Specialized Language and Symbols knowledgeable care of persons. Fundamental
As nursing theory has evolved, so has the need nursing values and beliefs include a holistic
for concepts, language, and forms of data that view of person, the dignity and uniqueness of
reflect new ways of thinking and knowing spe- persons, and the call to care. There are both
cific to nursing. The complex concepts used in shared and differing values and beliefs within
nursing scholarship and practice require lan- the discipline. The metaparadigm reflects the
guage that can be specific and understood. The shared beliefs, and the paradigms reflect the
language of nursing theory facilitates commu- differences.
nication among members of the discipline.

Expert knowledge of the discipline is often re- Systems of Education
quired for full understanding of the meaning A distinguishing mark of any discipline is the
of these theoretical terms. education of future and current members of
the community. Nursing is recognized as a
Heritage of Literature and Networks professional discipline within institutions of
of Communication higher education because it has an identifiable
This attribute calls attention to the array of body of knowledge that is studied, advanced,
books, periodicals, artifacts, and aesthetic ex- and used to underpin its practice. Students of
pressions, as well as audio, visual, and electronic any professional discipline study its theories
media that have developed over centuries to and learn its methods of inquiry and practice.
communicate the nature of nursing knowledge Nursing theories, by setting directions for the
and practice. Conferences and forums on every substance and methods of inquiry for the dis-
aspect of nursing held throughout the world are cipline, should provide the basis for nursing
part of this network. Nursing organizations and education and the framework for organizing
societies also provide critical communication nursing curricula.

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Definitions of Nursing Theory of science. The following definitions of theory

are consistent with general ideas of theory in
A theory is a notion or an idea that explains ex-
nursing practice, education, administration, or
perience, interprets observation, describes re-
research:
lationships, and suggests outcomes. Parsons
(1949), often quoted by nursing theorists, ■ Theory is a “set of concepts, definitions,
wrote that theories help us know what we and propositions that project a systematic
know and decide what we need to know. The- view of phenomena by designating specific
ories are mental patterns or frameworks cre- interrelationships among concepts for
ated to help understand and create meaning purposes of describing, explaining, pre-
from our experience, organize and articulate dicting, and/or controlling phenomena”
our knowing, and ask questions leading to new (Chinn & Jacobs, 1987, p. 71).
insights. As such, theories are not discovered ■ Theory is a “creative and rigorous structur-
in nature but are human inventions. ing of ideas that projects a tentative,
Theories are organizing structures of our re- purposeful, and systematic view of phe-
flections, observations, projections, and infer- nomena” (Chinn & Kramer, 2004, p. 268).
ences. Many describe theories as lenses because ■ Nursing theory is “an organized, coherent,
they color and shape what is seen. The same and systematic articulation of a set of state-
phenomena will be seen differently depending ments related to significant questions in a
on the theoretical perspective assumed. For discipline and communicated as a mean-
these reasons, “theory” and related terms have ingful whole” (Meleis, 2018, pp. 29–30).
been defined and described in a number of ■ Nursing theory is an “inductively and/or
ways according to individual experience and deductively derived collage of coherent, cre-
what is useful at the time. Theories, as reflec- ative, and focused nursing phenomena that
tions of understanding, guide our actions, help frame, give meaning to, and help explain
us set forth desired outcomes, and give evi- specific and selective aspects of nursing
dence of what has been achieved. A theory, by research and practice” (Silva, 1997, p. 55).
traditional definition, is an organized, coherent ■ A theory is an “imaginative grouping of
set of concepts and their relationships to each knowledge, ideas, and experiences that
other that offers descriptions, explanations, are represented symbolically and seek to
and predictions about phenomena. illuminate a given phenomenon.”
Early writers on nursing theory brought def- (Watson, 1985, p. 1).
initions of theory from other disciplines to di-
rect future work within nursing. Dickoff and
James (1968, p. 198) defined theory as a “con-
The Purpose of Theory in a
Professional Discipline
ceptual system or framework invented for some

purpose.” Ellis (1968, p. 217) defined theory as All professional disciplines have a body of
“a coherent set of hypothetical, conceptual, and knowledge consisting of theories, research, and
pragmatic principles forming a general frame methods of inquiry and practice. They organize
of reference for a field of inquiry.” McKay knowledge, guide inquiry to advance science,
(1969, p. 394) asserted that theories are the guide practice, and enhance the care of
capstone of scientific work, and that the term patients. Nursing theories address the phe-
refers to “logically interconnected sets of con- nomena of interest to nursing: human beings,
firmed hypotheses.” Barnum (1998, p. 1) later health, and caring in the context of the nurse–
offered a more open definition of theory as a person relationship.1 On the basis of strongly
“construct that accounts for or organizes some held values and beliefs about nursing, and
phenomenon” and simply stated that a nursing within contexts of various worldviews, theo-
theory describes or explains nursing. ries are patterns that guide the thinking about,
Definitions of theory emphasize its various being, and doing of (in) nursing.
aspects. Those developed in recent years are
more open and conform to a broader conception 1“Person” refers to individual, family, group, or community.

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Theories provide structures for making ideas that lead to the development of nursing
sense of the complexities of reality for both theories.
practice and research. Research based in nurs- At the empirical level of theory, abstract
ing theory is needed to explain and predict concepts are operationalized, or made con-
nursing outcomes essential to the delivery of crete, for practice and research (Fawcett, 2012;
nursing care that are both humane and cost- Smith & Liehr, 2018). Empirical indicators
effective (Gioiella, 1996). Some conceptual provide specific examples of how the theory is
structure, either implicitly or explicitly, directs experienced in reality; they are important for
all avenues of nursing, including nursing bringing theoretical knowledge to the practice
education and administration. Nursing theo- level. These indicators include procedures,
ries provide concepts and designs that define tools, and instruments to determine the effects
the place of nursing in health care. Through of nursing practice and are essential to re-
theories, nurses are offered perspectives for search and management of outcomes of practice
relating with professionals from other disci- (Jennings & Staggers, 1998). The resulting
plines, who join with nurses to provide human data form the basis for improving the quality
services. Nursing has great expectations of its of nursing care and influencing health-care
theories. At the same time, theories must pro- policy. Empirical indicators, grounded care-
vide structure and substance to ground the fully in nursing concepts, provide clear demon-
practice and scholarship of nursing and must stration of the utility of nursing theory in
also be flexible and dynamic to keep pace with practice, research, administration, and other
the 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 ad- Meeting the challenges of systems of care
vancing nursing knowledge is for the sake of delivery and interprofessional work demands
nursing practice. The primary purpose of nurs- practice from a theoretical perspective. Nurs-
ing theories is to further the development and ing’s disciplinary focus is important within the
understanding of nursing practice. Because interprofessional healthcare environment (Al-
nursing theory exists to improve practice, the lison & McLaughlin-Renpenning, 1999);
test of nursing theory is a test of its usefulness otherwise, its unique contribution to the in-
in professional practice. The work of nursing terprofessional team is unclear. Nursing ac-
theory is moving from an academic exercise tions reflect nursing concepts from a nursing
into the realm of nursing practice. Chapters perspective. Careful, reflective, and critical
throughout this book highlight the use of thinking are the hallmarks of expert nursing,
nursing theories in nursing practice. and nursing theories should undergird these
Nursing practice is both the source and the processes. Appreciation and use of nursing
goal of nursing theory. From the viewpoint of theory offer opportunities for successful col-
practice, Gray and Forsstrom (1991) suggested laboration with colleagues from other disci-
that theory provides nurses with different ways plines and provide definition for nursing’s
of looking at and assessing phenomena, ratio- overall contribution to health care. Nurses
nales for their practice, and criteria for evalu- must know what they are doing, why they are
ating outcomes. Many of the theories in this doing it, and what the range of outcomes of
book have been used to guide nursing practice, nursing may be, as well as indicators for doc-
stimulate creative thinking, facilitate commu- umenting nursing’s effects. These theoretical
nication, and clarify purposes and processes in frameworks serve as powerful guides for artic-
practice. The practicing nurse has an ethical re- ulating, reporting, and recording nursing
sponsibility to use the discipline’s theoretical thought and action.
knowledge base, just as it is the nurse scholar’s One of the assertions referred to often in
ethical responsibility to develop the knowledge the nursing-theory literature is that theory is
base specific to nursing practice (Cody, 1997, born of nursing practice and, after examina-
2003). Engagement in practice generates the tion and refinement through research, must be

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returned to practice. Nursing theory is stimu- for their importance to the history of nursing,
lated by questions and curiosities arising from Florence Nightingale holds the title of the
nursing practice. Development of nursing “mother of modern nursing” and the person re-
knowledge is a result of theory-based nursing sponsible for setting Western nursing on a path
inquiry. The circle continues as data, conclu- toward scientific advancement. She not only
sions, and recommendations from nursing redefined nursing as “putting the person in the
search are evaluated and developed for use in best condition for nature to act,” she also estab-
practice. Nursing theory must be seen as prac- lished a phenomenological focus of nursing as
tical and useful to practice, and the insights of caring for and about the human–environment
practice must in turn continue to enrich nurs- relationship to health. While nursing soldiers
ing theory. during the Crimean War, Nightingale began
to study the distribution of disease by gather-
ing data, so she was arguably the first nurse-
The Evolution of Nursing scientist in that she established a rudimentary
Science theory and tested that theory through her prac-
Disciplines can be classified as belonging to tice and research.
the sciences or humanities. In any science, Nightingale schools were established in the
there is a search for an understanding about West at the turn of the 20th century, but
specified phenomena through creating some Nightingale’s influence on the nursing profes-
organizing frameworks (theories) about the sion waned as student nurses in hospital-based
nature of those phenomena. These organizing training schools were taught nursing primarily
frameworks (theories) are evaluated for their by physicians. Nursing became strongly influ-
empirical accuracy through research. So, sci- enced by the “medical model” and for some
ence is composed of theories developed and time lost its identity as a distinct profession.
tested through research (Smith, 1994). Slowly, nursing education moved into in-
The evolution of nursing as a science has stitutions of higher learning where students
occurred within the past 70 years; however, be- were taught by nurses with higher degrees. By
fore nursing became a discipline or field of 1936, 66 colleges and universities had bac-
study, it was a healing art. Throughout the calaureate programs (Peplau, 1987). Graduate
world, nursing emerged as a healing ministry programs began in the 1940s and grew signifi-
to those who were ill or in need of support. cantly from the 1950s through the 1970s.
Knowledge about caring for the sick, the in- The publication of the journal Nursing Re-
jured, and those birthing, dying, or experienc- search in 1952 was a milestone, signifying the
ing normal developmental transitions was birth of nursing as a fledgling science (Peplau,
handed down, frequently in oral traditions, 1987). But well into the 1940s, “many text-
and comprised folk remedies and practices that books for nurses, often written by physicians,
were found to be effective through a process of clergy or psychologists, reminded nurses that
trial and error. In most societies, the responsi- theory was too much for them, that nurses did
bility for nursing fell to women, members of not need to think but rather merely to follow
religious orders, or those with spiritual author- rules, be obedient, be compassionate, do their
ity in the community. With the ascendency of ‘duty’, and carry out medical orders” (Peplau,
science, those who were engaged in the voca- 1987, p. 18). We’ve come a long way in less
tions of healing lost their authority over heal- than a hundred years.
ing to medicine. Traditional approaches to The development of nursing curricula stim-
healing were marginalized, as the germ theory ulated discussion about the nature of nursing
and the development of pharmaceuticals and as distinct from medicine. In the 1950s, early
surgical procedures were legitimized because nursing scholars such as Hildegard Peplau,
of their grounding in science. Virginia Henderson, Dorothy Johnson, and
Although there were influential healers Lydia Hall established the distinct character-
from other countries who can be acknowledged istics of nursing as a profession and field of

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study. Faye Abdellah, Ida Jean Orlando, Joyce Rogerian Scholars held the first Rogerian
Travelbee, Ernestine Wiedenbach, Myra Conference; the Transcultural Nursing Society
Levine, and Imogene King followed during was formed; and the International Association
the 1960s, elaborating their conceptualizations for Human Caring was formed. Some of these
of nursing. During the early 1960s, the feder- organizations developed journals publishing
ally funded Nurse Scientist Program was ini- the work of scholars advancing these concep-
tiated to educate nurses in pursuit of doctoral tual models and grand theories. Metatheorists
degrees in the basic sciences. Through this pro- such as Jacqueline Fawcett, Peggy Chinn, Afaf
gram nurses received doctorates in education, Meleis, Joyce Fitzpatrick, and Ann Whall
sociology, physiology, and psychology. These published books on nursing theory, making
graduates brought the scientific traditions of nursing theories more accessible to students.
these disciplines into nursing as they assumed Theory courses were established in graduate
faculty positions in schools of nursing. programs in nursing. The Fuld Foundation
By the 1970s, nursing theory development supported a series of videotaped interviews of
became a priority for the profession, and the many theorists, and the National League for
discipline of nursing was becoming estab- Nursing disseminated videos promoting theory
lished. Martha Rogers, Callista Roy, Dorothea within nursing. Nursing Science Quarterly, a
Orem, Betty Newman, Josephine Paterson, journal focused exclusively on advancing extant
and Loraine Zderad published their theories nursing theories, published its first issue in
and graduate students began studying and 1988.
advancing these theories through research. During the 1990s, the expansion of concep-
During this time, the National League for tual models and grand theories in nursing con-
Nursing required a theory-based curriculum as tinued to deepen, and forces within nursing
a standard for accreditation, so schools of nurs- both promoted and inhibited this expansion.
ing were expected to select, develop, and im- The theorists and their students began con-
plement a conceptual framework for their ducting research and developing practice
curricula. This propelled the advancement of models that made the theories more visible.
theoretical thinking in nursing (Meleis, 2018). Nursing regulatory bodies in Ontario Province
A national conference on nursing theory and in Canada required that nursing practice was
the Nursing Theory Think Tanks were formed theoretically grounded. This accelerated the
to engage nursing leaders in dialogue about the development of nursing theory–guided prac-
place of theory in the evolution of nursing sci- tice within Canada and the United States. The
ence. The linkages between theory, research, accrediting bodies of nursing programs in the
and philosophy were debated in the literature, United States pulled back on their requirement
and Advances in Nursing Science, the premiere of a specified conceptual framework guiding
journal for publishing theoretical articles, was nursing curricula. Because of this, there were
launched. fewer programs guided by specific conceptual-
In the 1980s additional grand theories such izations of nursing, and possibly fewer students
as Parse’s man–living–health (later changed had a strong grounding in the theoretical foun-
to human becoming); Newman’s health as ex- dations of nursing. Fewer grand theories
panding consciousness; Leininger’s transcul- emerged; only Boykin and Schoenhofer’s nurs-
tural nursing; Erickson, Tomlinson, and ing as caring grand theory was published dur-
Swain’s modeling and role modeling; and ing this time. Middle-range theories emerged
Watson’s transpersonal caring were dissemi- to provide more descriptive, explanatory, and
nated. Nursing theory conferences were con- predictive models around circumscribed phe-
vened, frequently attracting large numbers of nomena of interest to nursing. For example,
participants. Those scholars working with the Meleis’s transition theory, Mishel’s uncertainty
published theories in research and practice for- theory, Barrett’s power theory, and Pender’s
malized networks into organizations and held health promotion model were generating
conferences. For example, the Society for interest.

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From 2000 to the present, there has been If nursing is to advance as a science in its
accelerated development of middle-range the- own right, future generations of nurses must
ories with less interest in conceptual models respect and advance the theoretical legacy of
and grand theories. There seems to be a de- our discipline. Scientific growth happens
valuing of nursing theory; many graduate pro- through cumulative knowledge development
grams have eliminated their required nursing with current research building on previous
theory courses, and baccalaureate programs findings. To survive and thrive, nursing the-
may not include the development of concep- ories must be used in nursing practice and
tualizations of nursing into their curricula. This research.
has the potential for creating generations of
nurses who have no comprehension of the im-
portance of theory for understanding the focus The Structure of Knowledge
of the discipline and the diverse, rich legacy in the Discipline of Nursing
of nursing knowledge from these theoretical Theories are part of the knowledge structure of
perspectives. any discipline. The domain of inquiry (also
On the other hand, health-care organiza- called the metaparadigm or focus of the disci-
tions have been more active in promoting at- pline) is the foundation of the structure. The
tention to theoretical applications in nursing knowledge of the discipline is related to its
practice. For example, those hospitals on the general domain or focus. For example, knowl-
magnet journey are required to select a guiding edge of biology relates to the study of living
nursing framework as a practice model. For ex- things; psychology is the study of the mind;
ample, Watson’s theory of human caring is sociology is the study of social structures and
guiding nursing practice in a group of acute behaviors. Nursing’s domain was described
care hospitals. These hospitals have formed a earlier as the disciplinary focus statement or
consortium so that best practices can be shared metaparadigm. Other levels of the knowledge
across settings. structure include paradigms, conceptual mod-
Although nursing research is advancing and els or grand theories, middle-range theories,
making a difference in people’s lives, the re- practice theories, and research and practice tra-
search may not be linked explicitly to theory, ditions. These levels of nursing knowledge are
and probably not linked to nursing theory. This interrelated; each level of development is in-
compromises the advancement of nursing sci- fluenced by other levels. Theoretical work in
ence. All other disciplines teach their founda- nursing is dynamic; that is, it is continually in
tional theories to their students, and their process of development and use. It is open to
scientists test or develop their theories through adapting and extending to guide nursing en-
research. deavors and to reflect development within
There is a trend toward valuing theories nursing. Although there is diversity of opinion
from other disciplines over nursing theories. among nurses about the terms used to describe
For example, motivational interviewing is a the levels of theory, the following discussion
practice theory out of psychology that nurse re- of theoretical development in nursing is of-
searchers and practitioners are gravitating to in fered as a context for further understanding
large numbers. Arguably, there are several sim- nursing theory.
ilar nursing theoretical approaches that de-
scribe approaches to health promotion that Paradigm
preceded motivational interviewing, yet these Paradigm is the next level of the disciplinary
are used less by nurse researchers. Interprofes- structure of nursing. The notion of paradigm
sional practice and interdisciplinary research can be useful as a basis for understanding nurs-
are essential for the future of health care, but ing knowledge. A paradigm is a global, general
we do not do justice to this concept by aban- framework composed of assumptions about the
doning the rich, distinguishing features of nature of the phenomena of concern to the dis-
nursing science over others. cipline. Paradigms offer particular perspectives

7991_Ch01_001-016 12/08/19 5:19 PM Page 12
on the metaparadigm or disciplinary domain. two paradigms, or worldviews, outside the

The concept of paradigm comes from the work medical model. These are now described.
of Kuhn (1970, 1977), who used the term to Several nursing scholars have named the
describe models that guide scientific activity existing paradigms in the discipline of nurs-
and knowledge development in disciplines. Be- ing (Fawcett, 1995; Newman et al., 1991;
cause paradigms are broad, shared perspectives Parse, 1987). Parse (1987) described two par-
held by members of the discipline, they are adigms: the totality and the simultaneity. The
often called “worldviews.” Kuhn set forth the totality paradigm reflects a worldview that
view that science does not always evolve as a humans are integrated beings with biological,
smooth, regular, continuing path of knowledge psychological, sociocultural, and spiritual di-
development over time, but that periodically mensions. Humans adapt to their environ-
there are times of revolution when traditional ments, and health and illness are states on a
thought is challenged by new ideas, and “para- continuum. In the simultaneity paradigm,
digm shifts” occur. humans are unitary, irreducible, and in con-
Kuhn’s ideas provide a way to think about tinuous mutual process with the environment
the development of science. Before any dis- (Rogers, 1970, 1992). Health is subjectively
cipline engages in the development of theory defined and reflects a process of becoming or
and research to advance its knowledge, it is evolving. In her most recent work, Parse
in a pre-paradigmatic period of development. (2014) added a third paradigm, the human
Typically, this is followed by a period of time becoming paradigm. In contrast to Parse,
when a single paradigm emerges to guide Newman and her colleagues (1991) identi-
knowledge development. Research activities fied three paradigms in nursing: particulate–
initiated around this paradigm advance its deterministic, integrative–interactive, and
theories. This is a time during which knowl- unitary–transformative. From the perspective
edge advances at a regular pace; Kuhn refers of the particulate–deterministic paradigm,
to this as “normal science.” Sometimes, a humans are known through parts; health is
new paradigm can emerge to challenge the the absence of disease; and predictability and
worldview of the existing paradigm. It can be control are essential for health management.
revolutionary, overthrowing the previous In the integrative–interactive paradigm, hu-
paradigm, or multiple paradigms can coexist mans are viewed as systems with interrelated
in a discipline, providing different world- dimensions interacting with the environment,
views that guide the scientific development and change is probabilistic. From the world-
of the discipline. view of the unitary–transformative paradigm
Kuhn’s work has meaning for nursing and humans are patterned, self-organizing fields
other scientific disciplines because of his recog- within larger patterned, self-organizing fields.
nition that science is the work of a community Change is characterized by fluctuating

of scholars in the context of society. Paradigms rhythms of organization–disorganization to-
and worldviews in nursing are subtle and pow- ward more complex organization. Health is a
erful, reflecting different values and beliefs reflection of this continuous change. Fawcett
about the nature of human beings, human– (1995, 2000) provided yet another model of
environment relationships, health, and caring. nursing paradigms: reaction, reciprocal inter-
Kuhn’s (1970, 1977) description of scientific action, and simultaneous action. In the reac-
development is particularly relevant to nursing tion paradigm, humans are the sum of their
today as new perspectives are being articulated, parts, reaction is causal, and stability is val-
some traditional views are being strengthened, ued. In the reciprocal interaction worldview,
and some views are taking their places as part the parts are seen within the context of a
of our history. As we continue to move away larger whole, there is a reciprocal nature to
from the historical conception of nursing as a the relationship with the environment, and
part of biomedical science, developments in change is based on multiple factors. Finally,
the discipline of nursing are directed by at least the simultaneous action worldview includes

7991_Ch01_001-016 12/08/19 5:19 PM Page 13
a belief that humans are known by pattern Middle-Range Theories

and are in an open, ever-changing process Middle-range theories are the next level in the
with the environment. Change is unpre- structure of the discipline. Robert Merton
dictable and evolving toward greater com- (1968) described this level of theory in the
plexity and organization (Fawcett, 2000, field of sociology, stating that they are theories
pp. 11–12). broad enough to be useful in complex situa-
It may help you to think of theories as clus- tions and appropriate for empirical testing.
tered within these nursing paradigms. Many Nursing scholars proposed using this level of
theories share the worldview established by a theory because of the difficulty in testing
particular paradigm. At present, multiple par- grand theory (Jacox, 1974). Middle-range
adigms coexist within nursing. theories are narrower in scope than grand the-
Grand Theories and Conceptual ories and offer an effective bridge between
Models grand theories and the description and expla-
nation of specific nursing phenomena. They
Grand theories and conceptual models are at present concepts and propositions at a lower
the next level in the structure of the disci- level of abstraction and hold great promise for
pline. They are less abstract than the focus of increasing theory-based research and nursing
the discipline and paradigms but more ab- practice strategies (Smith & Liehr, 2018).
stract than middle-range theories. Concep- Fourteen middle-range theories are included
tual models and grand theories focus on the in this book. Middle-range theories may have
phenomena of concern to the discipline such their foundations in a particular paradigmatic
as persons as adaptive systems, self-care perspective or may be derived from a grand
deficits, unitary human beings, human be- theory or conceptual model. The literature
coming, or health as expanding conscious- presents a growing number of middle-range
ness. The grand theories, or conceptual theories. This level of theory is expanding
models, are composed of concepts and rela- most rapidly in the discipline and represents
tional statements. Relational statements on some of the most exciting work published in
which the theories are built are called as- nursing today. Some of these new theories are
sumptions and often reflect the foundational synthesized from knowledge from related dis-
philosophies of the conceptual model or ciplines and transformed through a nursing
grand theory. These philosophies are state- lens (see Chapters 20, 27, and 28). The liter-
ments of enduring values and beliefs; they ature also offers middle-range nursing theories
may be practical guides for the conduct of that are directly related to grand theories of
nurses applying the theory, and can be used nursing (see Chapters 26, 29, and 30). Re-
to determine the compatibility of the model
ports of nursing theory developed at this level

or theory with personal, professional, organi- include implications for instrument develop-
zational, and societal beliefs and values. ment, theory testing through research, and
Fawcett (2000) differentiated conceptual mod- nursing practice strategies.
els and grand theories. For her, conceptual
models, also called conceptual frameworks or Practice-Level Theories
conceptual systems, are sets of general con- Practice-level theories have the most limited
cepts and propositions that provide perspec- scope and level of abstraction and are devel-
tives on the major concepts of the metaparadigm: oped for use within a specific range of nursing
person, environment, health, and nursing. situations. Theories developed at this level have
Fawcett (1993, 2000) pointed out that direction a more direct effect on nursing practice than
for research must be described as part of the do more abstract theories. Nursing practice
conceptual model to guide development and theories provide frameworks for nursing
testing of nursing theories. We do not differen- interventions/activities and suggest outcomes
tiate between conceptual models and grand the- and/or the effect of nursing practice. Nursing
ories and use the terms interchangeably. actions may be described or developed as

7991_Ch01_001-016 12/08/19 5:19 PM Page 14
nursing practice theories. Ideally, nursing activities, protocols, processes, tools, and prac-
practice theories are interrelated with concepts tice wisdom emerging from the theory. Several
from middle-range theories or developed conceptual models and grand theories have
under the framework of grand theories. A the- specific associated practice methods.
ory developed at this level has been called a
prescriptive theory (Crowley, 1968; Dickoff,
James, & Wiedenbach, 1968), a situation-
Nursing Theory and the
specific theory (Im, 2005; Meleis, 1997), and Future
a micro-theory (Chinn & Kramer, 2011). The Nursing theory is essential to the continuing
day-to-day experience of nurses is a major evolution of the discipline of nursing. Several
source of nursing practice theory. trends are evident in the development and use
The depth and complexity of nursing prac- of nursing theory. First, there seems to be
tice may be fully appreciated as nursing phe- more agreement on the focus of the discipline
nomena and relations among aspects of of nursing that provides a meaningful direction
particular nursing situations are described and for our study and inquiry. This disciplinary
explained. Dialogue with expert nurses in dialogue has extended beyond the confines of
practice can be fruitful for discovery and de- Fawcett’s metaparadigm and explicates the im-
velopment of practice theory. Research find- portance of caring and relationship as central
ings on various nursing problems offer data to to the discipline of nursing (Meleis, 2018;
develop nursing practice theories. Nursing Newman et al., 2008; Roy & Jones, 2007;
practice theory has been articulated using mul- Willis et al., 2008; Smith, 2019). The develop-
tiple ways of knowing through reflective prac- ment of new grand theories and conceptual
tice (Johns & Freshwater, 1998; Sherwood & models has decreased. Dossey’s (2008) theory
Horton-Deutsch, 2012). The process includes of integral nursing, included in this book, is
quiet reflection on practice, remembering and the only new theory at this level that has been
noting features of nursing situations, attending developed in nearly 20 years. Instead, the growth
to one’s own feelings, reevaluating the experi- in theory development is at the middle-range
ence, and integrating new knowing with other and practice or situation-specific levels. There
experience (Gray & Forsstrom, 1991). Exam- has been a significant increase in middle-range
ples of practice-level and situation-specific theories, and many practice scholars are work-
theories include the LIGHT model (Andersen ing on developing and implementing practice
& Smereck, 1989), the attendant nurse caring models or situation-specific theories that guide
model (Watson & Foster, 2003), migration practice in specific situations or with specific
transition for migrant farmworker women populations.
(Clingerman, 2007), and maintaining hope in Several changes in the teaching and learn-
transition (Davidson, Dracup, Phillips, Padilla ing of nursing theory are troubling. Many bac-
& Daly, 2007). calaureate programs include little nursing
theory in their curricula. Similarly, some grad-
Associated Research and Practice uate programs are eliminating or decreasing
Traditions their emphasis on nursing theory. This alarm-
Research traditions are the associated meth- ing trend deserves our attention. Smith and
ods, procedures, and empirical indicators that McCarthy (2010, p. 49) analyzed several of the
guide inquiry related to the theory. For exam- documents from the American Association of
ple, the theories of health as expanding con- Colleges of Nursing that guide curriculum de-
sciousness, human becoming, and cultural care velopment and inform accreditation; the
diversity and universality have specific associ- analysis revealed that nursing knowledge in the
ated research methods. Other theories have form of philosophies, theories, and the re-
specific tools that have been developed to search and practice models based on them
measure constructs related to the theories. The were not prominent or central, and rarely ex-
practice tradition of the theory consists of the plicit. Grace, Willis, Ray, and Jones (2016)

7991_Ch01_001-016 12/08/19 5:19 PM Page 15
described the imbalance in PhD education in their disciplines in their courses of study. We
nursing, with too much emphasis placed on must continue to include the study of nursing
the empirical at the expense of the philosoph- theories within our baccalaureate, master’s,
ical and conceptual/theoretical dimensions of and doctoral programs. Baccalaureate students
the discipline. If nursing is to continue to need to understand the foundations for the
thrive and to make a difference in the lives of discipline, our historical development, and the
people, our practitioners and researchers need place of nursing theory in its history and fu-
to practice and expand knowledge within the ture. They should learn about conceptual mod-
structure of the discipline. As health care be- els and grand theories. Didactic and practice
comes more interprofessional, the focus of courses should reflect theoretical values and
nursing becomes even more important. If concepts so that students learn to practice nurs-
nurses do not learn and practice based on the ing from a theoretical perspective. Middle-
knowledge of their discipline, they may be co- range theories should be included in the
opted into the practice of another discipline. study of particular phenomena such as self-
Even worse, another discipline could emerge transcendence, sorrow, and uncertainty. As
that will assume practices associated with the they prepare to become practice leaders of the
discipline of nursing. For example, health discipline, doctor of nursing practice stu-
coaching is emerging as an area of practice fo- dents should learn to develop and test nursing
cused on providing people with help as they theory–guided models. PhD students will learn
make health-related changes in their lives. to develop and extend nursing theories in their
However, this is the practice of nursing, as research. New and expanded nursing special-
articulated by many nursing theories. If re- ties, such as nursing informatics, call for devel-
searchers are not grounded in nursing knowl- opment and use of nursing theory (Effken,
edge, nursing science cannot advance. 2003). New, more open and inclusive ways to
On a positive note, nursing theories are theorize about nursing will be developed.
being embraced by health-care organizations These new ways will acknowledge the history
to structure nursing practice. For example, or- and traditions of nursing but will move nursing
ganizations embarking on the journey toward forward into new realms of thinking and
magnet status (www.nursingworld.org) iden- being. Reed (1995) noted the “ground shift-
tify a model that guides nursing practice, and ing” with the reforming of philosophies of
many are choosing existing nursing models. nursing science and called for a more open
This work has great potential to refine and philosophy, grounded in nursing’s values,
extend nursing theories. which connects science, philosophy, and prac-
The use of nursing theory in research is in- tice. Gray and Pratt (1991, p. 454) projected
consistent at best. Often, outcomes research is that nursing scholars will continue to develop
not contextualized within any theoretical per- theories at all levels of abstraction and that the-
spective; however, reviewers of proposals for ories will be increasingly interdependent with
most funding agencies request theoretical other disciplines such as politics, economics,
frameworks, and scoring criteria give points for and ethics. These authors expect a continuing
having one. This encourages theoretical think- emphasis on unifying theory and practice that
ing and organizing findings within a broader will contribute to the validation of the nursing
perspective. Nurses often use theories from discipline. Theorists will work in groups to de-
other disciplines instead of their own, and this velop knowledge in an area of concern to nurs-
expands the knowledge of another discipline. ing, and these phenomena of interest, rather
We are hopeful about the growth, contin- than the name of the author, will define the
uing development, and expanded use of nurs- theory (Meleis, 1992). Newman (2003) called
ing theory. We hope that there will be for a future in which we transcend competition
continued growth in the development of all and boundaries that have been constructed be-
levels of nursing theory. The students of all tween nursing theories and instead appreciate
professional disciplines study the theories of the links among theories, thus moving toward

7991_Ch01_001-016 12/08/19 5:19 PM Page 16
a fuller, more inclusive, and richer understand- nursing theory how to come to know those we
ing of nursing knowledge. care for, how to be with them, to truly listen?
Nursing’s philosophies and theories must Can these questions be recognized as appro-
increasingly reflect nursing’s values for under- priate for scholarly work and practice for grad-
standing, respect, and commitment to health uate students in nursing? Will these issues
beliefs and practices of cultures throughout the offer direction for studies of doctoral students?
world. It is important to question to what ex- If so, nursing theory will prepare nurses for
tent theories developed and used in one major humane leadership in national and global
culture are appropriate for use in other cul- health policy. Abdellah (McAuliffe, 1998)
tures. To what extent must nursing theory be proposed an international electronic “think
relevant in multicultural contexts? Despite ef- tank” for nurses around the globe to dialogue
forts of many international scholarly societies, about nursing theory. The 2019 launch of nur-
how relevant are American nursing theories for sology.net offers this opportunity. Such oppor-
the global community? Can nursing theories tunities could lead nurses to truly listen, learn,
inform us about how to stand with and learn and adapt theoretical perspectives to accommo-
from peoples of the world? Can we learn from date cultural variations.
Summary
This chapter focused on the place of nursing time, it is useful for the purposes and work of
theory within the discipline of nursing. The the discipline. This paradox may be seen as
relationship and importance of nursing theory ambiguous or as full of possibilities. Continu-
to the characteristics of a professional disci- ing students of the discipline are required to
pline were reviewed. A variety of definitions of study and know the basis for their contribu-
theory were offered, and the evolution and tions to nursing and to those we serve; at the
structure of knowledge in the discipline was same time, they must be open to new ways of
outlined. Finally, we reviewed trends and spec- thinking, knowing, and being in nursing. Ex-
ulated about the future of nursing theory de- ploring structures of nursing knowledge and
velopment and application. One challenge of understanding the nature of nursing as a pro-
nursing theory is that theory is always in the fessional discipline provide a frame of refer-
process of developing and that, at the same ence to clarify nursing theory.
Questions for Reflection middle-range theories, and practice-level

or situation-specific theories?
and Discussion
■ In your own words, define “theory” and

■ What differentiates nursing from the describe its purposes.
focus of other disciplines? Complete this ■ Explore the website Nursology.net.
sentence: Nursing is the study of … Identify the value of this site for nurses
■ What are the differences between para- studying nursing theory.
digms, conceptual models/grand theories,
The reference list for this chapter can be found in the online resources included with your textbook.

7991_Ch02_017-020 12/08/19 5:19 PM Page 17
A Guide for the Study of

CHAPTER
2
Nursing Theories for
Practice
Marilyn E. Parker and
Marlaine C. Smith
Nursing is a professional discipline, a field
Study of Theory for Nursing Practice of study focused on the wholeness of human-
A Guide for Study of Nursing Theory for Use in environment health and healing through car-
Practice ing (Smith, 1994). The knowledge of the
Summary discipline includes nursing science, art, philos-
Questions for Reflection and Discussion ophy, and ethics. Nursing science includes the
conceptual models, theories, and research spe-
cific to the discipline. As in other sciences such
as biology, psychology, or sociology, 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 facilitates reflection, explo-
ration, and a deeper study of the selected nurs-
ing theories.
As you read the chapters in this book, use
the questions in the guide to direct your study.
These chapters offer you an introduction to a
variety of nursing theories, which we hope will
ignite interest in deeper exploration of some of
the theories through reading the books written
by the theorists and other published articles re-
lated to the use of the theories in practice and
research. This book’s online resources can pro-
vide additional materials as you continue your
exploration.1 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. Healthcare delivery systems
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 Cre-
dentialing Center (www.nursecredentialing.org/
magnet) includes the selection of a practice
1For additional information, see the bonus chapter content
available at http://davisplus.fadavis.com.
17
7991_Ch02_017-020 12/08/19 5:19 PM Page 18
model. The list of questions in this chapter can Groups of nurses working together as col-
be useful to nurses as they select theories to guide leagues to provide care often realize that they
practice. share the same values and beliefs about nurs-
Increasingly, nurses are practicing in diverse ing. The study of nursing theories can clarify
settings and often develop organized nursing the purposes of nursing and facilitate build-
practices through which accessible healthcare ing a cohesive practice to meet them. Re-
to communities can be provided. Community gardless of the setting of nursing practice,
members may be active participants in selecting, nurses may choose to study nursing theories
designing, and evaluating the nursing they re- together to design and articulate theory-
ceive. In these situations, it is important for guided practice.
nurses and the communities they serve to iden- The study of nursing theory precedes the
tify the approach to nursing that is most consis- activities of analysis and evaluation. The
tent with the community’s values. The questions evaluation of a theory involves preparation,
in this chapter can be helpful in the mutual ex- judgment, and justification (Smith, 2018).
ploration of theoretical approaches to practice. In the preparation phase, the student of the
In the current healthcare environment, in- theory spends time coming to know it by
terprofessional practice is the desired standard. reading and reflecting on it. The best ap-
This does not mean that practicing from a proach involves intellectual empathy, curios-
nursing theoretical base is any less important. ity, honesty, and responsibility (Smith,
Interprofessional practice means that each dis- 2018). Through reading and dwelling with
cipline brings its own lens or perspective to the theory, the student tries to understand it
the patient care situation toward the goal of from the point of view of the theorist. Cu-
greater coordination and quality of care. Nurs- riosity leads to raising questions in the quest
ing’s lens is essential for a holistic picture of for greater understanding. It involves imag-
the person’s health and for the goals of caring ining ways the theory might work in prac-
and healing. The nursing theory selected will tice, as well as the challenges it might
provide this lens, and the questions in this present. Honesty involves knowing oneself
chapter can assist nurses in selecting the theory and being true to one’s own values and be-
or theories that will guide their unique contri- liefs in the process of understanding. Some
bution to the interprofessional team. theories may resonate with deeply held val-
Theories and practices from a variety of dis- ues; others may conflict with them. It is im-
ciplines inform the practice of nursing. The portant to listen to these inner messages
scope of nursing practice is continually being of comfort or discomfort, for they will be
expanded to include additional knowledge and important in the selection of theories for
skills from related disciplines, such as medicine practice.
and psychology. Again, this does not diminish Each member of a professional discipline
the need for practice based on a nursing theory, has a responsibility to take the time and put
and these guiding questions help to differenti- in the effort to understand the theories of
ate the knowledge and practice of nursing from that discipline. In nursing, there is an even
those of other disciplines. For example, nurse greater responsibility to understand and be
practitioners may draw on their knowledge of true to those that are selected to guide nurs-
pathophysiology, pharmacology, and psychol- ing practice.
ogy as they provide primary care. Nursing the- Responses to questions offered and points
ories will guide the way of viewing the person,2 summarized in the guides may be found in
inform the way of relating with the person, and nursing literature, as well as in audiovisual
direct the goals of practice with the person. and electronic resources. Primary source ma-
terial, including the work of nurses who are
recognized authorities in specific nursing
2“Person” refers to individuals, families, groups, and com- theories and the use of nursing theory, should
munities throughout the chapter. be used.

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CHAPTER 2 ■ A Guide for the Study of Nursing Theories for Practice 19
Study of Theory for Nursing ■ What is the place of nursing in interpro-

fessional practice?
Practice ■ What is the range of nursing situations in
Four main questions (described in the next which the theory is useful?
section) have been developed and refined to fa-
cilitate the study of nursing theories for use in How can nursing situations be described?
nursing practice (Parker, 1993). They focus on ■ What are the attributes of the recipient of
concepts within the theories, as well as on nursing care?

points of interest and general information ■ What are characteristics of the nurse?
about each theory. This guide was developed ■ How can interactions between the nurse
for use by practicing nurses and students in un- and the recipient of nursing be described?
dergraduate and graduate nursing education ■ Are there environmental requirements for
programs. Many nurses and students have used the practice of nursing? If so, what are they?
these questions and contributed to their con- 2. What is the context of the theory
tinuing development. As you study each the- development?
ory, answer the questions and address the Who is the nursing theorist as person and as nurse?
points in the following guide. You will find the ■ Why did the theorist develop the theory?
information you need in the chapters of this ■ What is the background of the theorist as
book; other literature, such as books and jour- a nursing scholar?

nal articles authored by the theorists and other ■ What central values and beliefs does the
scholars working with the theories; and audio- theorist set forth?
visual and electronic resources.
What are major theoretical influences
on this theory?
A Guide for Study of Nursing ■ What previous knowledge influenced the
Theory for Use in Practice development of this theory?

■ What are the relationships between this
1. How is nursing conceptualized in the theory and other theories?
theory? ■ What nursing-related theories and
Is the focus of nursing stated? philosophies influenced this theory?
■ What does the nurse attend to when
practicing nursing? What were major external influences

■ What guides nursing observations, on development of the theory?
reflections, decisions, and actions? ■ What were the social, economic, and po-
■ What illustrations or examples show how litical influences that informed the theory?
the theory is used to guide practice? ■ What images of nurses and nursing influ-
enced the development of the theory?

What is the purpose of nursing?
■ What was the status of nursing as a disci-
■ What do nurses do when they are practic-
pline and profession at the time of the
ing nursing based on the theory?
■ What are exemplars of nursing assess-
theory’s development?
3. Who are authoritative sources for information
ments, designs, plans, and evaluations?
■ What indicators give evidence of the qual-
about development, evaluation, and use of this
theory?
ity of nursing practice?
■ Is the richness and complexity of nursing
Which nursing authorities speak about, write about,
and use the theory?
practice evident?
■ What are the professional attributes of
What are the boundaries or limits for nursing? these persons?

■ How is nursing distinguished from other ■ What are the attributes of authorities, and
health-related professions? how does one become one?

■ How is nursing related to other disciplines ■ Which others can be considered
and services? authorities?

7991_Ch02_017-020 12/08/19 5:19 PM Page 20
What major resources are authoritative sources ■ Has nursing research led to further
on the theory? theoretical formulations?
■ What books, articles, and audiovisual and ■ Has the theory been used to develop
electronic media exist to elucidate the theory? new nursing practices?
■ What websites and social media sites ■ Has the theory influenced the design
exist to share information about the the- of methods of nursing inquiry?
ory and create a community of scholars? ■ What has been the influence of the theory
■ What nursing organizations share and on nursing and health policy?
support work related to the theory?
■ What service and academic programs are What are projected influences of the theory on
authoritative sources for practicing and nursing’s future?
■ How has the theory influenced the com-
teaching the theory?
4. How can the overall significance of the nursing munity of scholars?
■ In what ways has nursing as a profes-
theory be described?
What is the importance of the nursing theory over time? sional practice been strengthened by
■ What are exemplars of the theory’s use that the theory?
■ What future possibilities for nursing have
structure and guide individual practice?
■ How has the theory been used to guide been revealed because of this theory?
■ What will be the continuing social value
programs of nursing education?
■ How has the theory been used to guide of the theory?
nursing administration and organizations? Nursology.net is a new resource for stu-
■ How does published nursing scholarship
dents of nursing theory. Nursology was formed
reflect the significance of the theory? with the goal of creating a central repository
What is the experience of nurses who report for nursing knowledge with the proposed
consistent use of the theory? name of nursology. The site provides a wealth
■ What is the range of reports from of information and resources and can be ac-
practice? cessed at http://nursology.net.
Summary
This chapter contains a guide designed for the journey from a beginning to a deeper under-
study of nursing theory for use in practice. As standing of nursing theory. The study of nursing
members of the professional discipline of nurs- theory precedes its analysis and evaluation. Stu-
ing, nurses must engage in the serious study of dents should approach the study of nursing the-
the theories of nursing. The implementation of ory with intellectual empathy, curiosity, honesty,
theory-guided practice models is important for and responsibility. This guide is composed of
nursing practice in all settings. The guide pre- four main questions to foster reflection and fa-
sented in this chapter can lead students on a cilitate the study of nursing theory for practice.
Questions for Reflection ■ Describe in your own words how you

would approach the study of a nursing
and Discussion theory with intellectual empathy,
■ What are the resources that you would ac- curiosity, honesty, and responsibility.
cess to study a particular nursing theory? ■ Access nursology.net and share one re-
■ How would you discern if a secondary source that you found to be interesting
source related to a nursing theory (an and valuable to your study of nursing
author writing about the theory who isn’t theories.
the author of the theory) is credible?

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Choosing, Evaluating, and

CHAPTER
3
Implementing Nursing
Theories for Practice
Marlaine C. Smith and
Marilyn E. Parker
The primary purpose of nursing theory is to
Significance of Nursing Theory for Practice improve nursing practice and, therefore, the
Responses to Questions from Practicing Nurses health and quality of life of the persons, fami-
About Using Nursing Theory lies, and communities served. Nursing theories
Choosing a Nursing Theory to Study provide coherent ways of viewing and ap-
A Reflective Exercise for Choosing a Nursing proaching the care of persons in their environ-
Theory for Practice ment. When a theoretical model is used to
Evaluation of Nursing Theory organize care in any setting, it strengthens the
Implementing Theory-Guided Practice nursing focus of care and provides consistency
Summary to the communication and activities related to
Questions for Reflection and Discussion nursing care. The development of nursing the-
ories and theory-guided practice models ad-
vances the discipline and professional practice
of nursing.
One of the most important issues facing
the discipline of nursing is the artificial sepa-
ration of nursing theory and practice. Nursing
can no longer afford to see these dimensions
as disconnected territories, belonging to either
scholars or practitioners. The examination and
use of nursing theories are essential for closing
the gap between nursing theory and nursing
practice. Nurses in practice have a responsibil-
ity 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 nursing practice informs and
guides the process of developing theory.
The theories of any professional discipline
are useless if they have no effect on practice.
Just as psychotherapists, educators, and econ-
omists base their approaches and decisions on
particular theories, so should nurses be guided
by selected nursing theories.
When practicing nurses and nurse scholars
work together, both the discipline and practice
of nursing benefit, and nursing service to our
clients is enhanced. There are many examples
throughout this book of how nursing theories
21
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have been, or can be, used to guide nursing The purpose of this chapter is to describe
practice. Many of the nursing theorists in this the processes leading to implementation of
book developed or refined their theories based nursing theory–guided practice models. These
on dialogue with nurses who shared descrip- processes include choosing possible theories
tions of their practice. This kind of work must for use in practice, analyzing and evaluating
continue for nursing theories to be relevant these theories, and implementing theory-
and meaningful to the discipline. guided practice models. The chapter begins
The need to bridge the gap between nursing with responses to the following questions:
theory and practice is highlighted by consid- Why study nursing theory? What do practic-
ering the following brief encounter during a ing nurses gain from nursing theory? Then,
question-and-answer period at a conference. methods of analysis and evaluation of nursing
A nurse in practice, reflecting her experience, theory set forth in the literature are presented.
asked a nurse theorist, “What is the meaning Finally, steps in implementing nursing theory
of this theory to my practice? I’m in the real in practice are described.
world! I want to connect—but how can con-
nections be made between your ideas and my
reality?” The nurse theorist responded by de-
Significance of Nursing
scribing the essential values and assumptions Theory for Practice
of her theory. The practicing nurse said, “Yes, Nursing practice is essential for developing,
I know what you are talking about. I just didn’t testing, and refining nursing theory. The de-
know I knew it, and I need help to use it in my velopment of many nursing theories has been
practice” (Parker, 1993, p. 4). Another exam- enhanced by reflection and dialogue about ac-
ple that just occurred in a conference in 2018 tual nursing situations. The everyday practice
was the comment from a participant: “We of nursing enriches nursing theories. When
work in interprofessional teams. The language nurses think about nursing, they consider the
used in nursing theory isn’t familiar to other content and structure of the discipline of nurs-
health professions. It is too abstract.” The re- ing. Even if nurses do not conceptualize these
sponse was, “The nurses’ practice is guided or elements theoretically, their values and per-
informed by the theory. The nurse doesn’t nec- spectives are often consistent with particular
essarily teach the nursing theory to other nursing theories. Making these values and per-
health professionals. In some situations the spectives explicit through the use of a nursing
values and selected concepts of a nursing the- theory results in a more scholarly, professional
ory may be used to create a shared mental practice.
model for interprofessional practice.” To re- Creative nursing practice is the direct result
main current in the discipline, all nurses must of ongoing theory-based thinking, decision
join in community to advance nursing knowl- making, and action. Nursing practice must
edge in practice and must accept their obliga- continue to contribute to thinking and theo-
tion to engage in the continuing study of rizing in nursing, just as nursing theory must
nursing theories. Today, many health-care or- be used to advance practice.
ganizations that employ nurses adopt a nursing Nursing practice and nursing theory often
theory as a professional practice model. This reflect the same abiding values and beliefs.
decision provides an excellent opportunity for Nurses in practice are guided by their values
nurses in practice and in administration to and beliefs, as well as by knowledge. These val-
study, implement, and evaluate nursing theo- ues, beliefs, and knowledge often are reflected
ries for use in practice. Communicating the in the literature about nursing’s metaparadigm,
outcomes of this process with the community philosophies, and theories. In addition, nursing
of scholars advancing the theories is a useful theorists and nurses in practice think about and
way to initiate dialogue among nurses and to work with the same phenomena, including the
form new bridges between the theory and person, actions, and relationships in the nurse–
practice of nursing. person (family/community) relationship, and

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CHAPTER 3 ■ Choosing, Evaluating, and Implementing Nursing Theories for Practice 23
the context of nursing. It is no wonder that They ask questions, receive and process infor-
nurses often sense a connection and familiarity mation about needs for nursing differently, and
with many of the concepts in nursing theories. create nursing responses that are more holistic
They often say, “I knew this, but I didn’t have and client focused. These nurses learn to re-
the words for it.” This is another value of nurs- frame their thinking about nursing knowledge
ing theory. It provides the language for us to and practice and are then able to bring knowl-
share and communicate the important concepts edge from other disciplines within the context
within nursing practice. of their practice—not to direct their practice.
It is not possible to practice without some Nurses who practice from a nursing theo-
theoretical frame of reference. The question is retical base see beyond immediate facts and
what frame of reference is being used in prac- delivery systems; they can integrate other
tice. As stated in Chapter 1, theories are ways health sciences and technologies as the back-
to organize our thinking about the complexi- ground or context and not the essence of their
ties of any situation. Theories are lenses we se- practice. Nurses who study nursing theory
lect that will color the way that we view reality. realize that although no group actually owns
In the case of nursing, the theories we choose ideas, professional disciplines do claim a
to use will frame the way we think about a par- unique perspective that defines their practice.
ticular person and his or her health situation. In the same way, no group actually owns the
It will inform the ways that we approach the technologies of practice, although disciplines
person, how we relate, and what we do. Many do claim them for their practice. For example,
nurses practice according to ideas and direc- before World War II, nurses rarely took blood
tions from other disciplines, such as medicine, pressure readings and did not give intramus-
psychology, and public health. If your ap- cular injections. This was not because nurses
proach to a person is framed by his or her med- lacked the skill, but because they did not claim
ical diagnosis, you are influenced by the the use of these techniques within nursing
medical model that focuses your attention on practice. Such a realization can also lead to un-
diagnosis, treatment, and cure. If you are derstanding that the things nurses do that are
thinking about disease prevention as you work often called nursing are not nursing at all. The
with a community group, you are influenced skills and technologies used by nurses, such as
by public health theory and approaches. Al- taking blood pressure readings, giving injec-
though we use this knowledge in practice, tions, and auscultating heart sounds, are actu-
nursing theory focuses us on the distinctive ally activities that are part of the context, but
perspective of the discipline, which is more not the essence, of nursing practice. Nursing
than, and different from, these approaches. theories provide an organizing framework that
Historically, nursing practice has been directs nurses to the essence of their purpose
deeply rooted in the medical model, and this and places the use of knowledge from other
model continues today. The depth and scope disciplines in its proper perspective.
of the practice of nurses who follow notions If nursing theory is to be useful—or
about nursing held by other disciplines are lim- practical—it must be brought into practice. At
ited to practices understood and accepted by the same time, nurses can be guided by nursing
those disciplines. Nurses who learn to practice theory in a full range of nursing situations.
from nursing perspectives are awakened to the Nursing theory can change nursing practice: It
challenges and opportunities of practicing provides direction for new ways of being pres-
nursing more fully and with a greater sense of ent with clients, helps nurses realize ways of
autonomy, respect, and satisfaction for them- expressing caring, and provides approaches to
selves. Hopefully, they also provide different understanding needs for nursing and designing
and more expansive opportunities for health care to address these needs. The chapters of
and healing for those they serve. Nurses who this book affirm the use of nursing theory in
practice from a nursing perspective approach practice and the study and assessment of the-
clients and families in ways unique to nursing. ory to ultimately use in practice.

7991_Ch03_021-032 12/08/19 5:19 PM Page 24
Responses to Questions From ■ Will my work meet the expectations of

those I serve? Will other nurses find my
Practicing Nurses About work helpful and challenging?
Using Nursing Theory
Conceptual models and grand theories are
Study of nursing theory may either precede
not specific to any nursing specialty. Theories in
or follow selection of a nursing theory for use
any discipline introduce new terminology that
in nursing practice. Analysis and evaluation
is not part of general language. For example, the
of nursing theory follow the study of a nurs-
id, ego, and superego are familiar terms in a par-
ing theory. These activities are demanding
ticular psychological theory but were unknown
and deserve the full commitment of nurses
at the time of the theory’s introduction. The
who undertake the work. Because it is under-
language of the theory facilitates thinking dif-
stood that the study of nursing theory is not
ferently through naming new concepts or ideas.
a simple, short-term endeavor, nurses often
Members of disciplines do share specific lan-
question doing such work. The following
guage that may be less familiar to members
questions about studying and using nursing
outside the discipline. In interprofessional com-
theory have been collected from many con-
munication, new terms should be defined
versations with nurses about nursing theory.
and explained to facilitate communication as
These queries also identify specific issues that
needed. Nursing’s unique perspective needs to
are important to nurses who consider the
be represented clearly within the interprofes-
study of nursing theory.
sional team. The diversity of each discipline’s
perspective is important to provide the best care
My Nursing Practice possible for patients. People deserve and expect
■ Does this theory reflect nursing practice high-quality care. Nursing theory has the po-
as I know it? Can it be understood in tential to bring to bear the importance of rela-
relation to my nursing practice? Will it tionship and caring in the process of health and
support what I believe to be excellent healing; the interrelationship of the environ-
nursing practice? ment and health; an understanding of the
Conceptual models and grand theories can wholeness of persons in their life situations; and
guide practice in any setting and situation. an appreciation of the person’s experiences, val-
Middle-range theories address circumscribed ues, and choices in care. These are essential con-
phenomena in nursing that are directly re- tributions to a multidisciplinary perspective.
lated to practice. These levels of theory can
enrich perspectives on practice and should My Personal Interests, Abilities,
foster an excellent professional level of and Experiences
practice. ■ Is the study of nursing theories consistent

with my talents, interests, and goals? Is
■ Is the theory specific to my area of
this something I want to do?
nursing? Can the language of the theory
■ Will I be stimulated by thinking about
help me explain, plan, and evaluate my
and trying to use this theory? Will my
nursing? Will I be able to use the terms
study of nursing be enhanced by use of
to communicate with others?
this theory?
■ Can this theory be considered in relation
■ What will it be like to think about nursing
to a wide range of nursing situations?
theory in nursing practice?
How does it relate to more general views
■ Will my work with nursing theory be
of nursing people in other settings?
worth the effort?
■ Will my study and use of this theory
support nursing in my interprofessional The study of nursing theory does take an in-
setting? vestment in time and attention. It is a respon-
■ Will those from other disciplines be able sibility of a professional nurse who engages in
to understand, facilitating cooperation? a scholarly level of practice. Learning about

7991_Ch03_021-032 12/08/19 5:19 PM Page 25
nursing theory is a conceptual activity that can Did the theory grow out of research
be challenging and intellectually stimulating. findings or out of practice issues and
We need nurses who will invest in these activ- concerns?
ities so that knowledgeable theory-guided ■ Does the theory reflect the latest thinking
practice is the standard in all health-care in nursing? Has the theory kept pace with
settings. the times in nursing? Is this a nursing the-
ory for the future?
Resources and Support
Approaching the study of nursing theory
■ Will this be useful to me outside the
with openness, curiosity, imagination, and
classroom?
skepticism is important. Evaluation of any the-
■ What resources will I need to understand
ory should include evidence that practicing
fully the terms of the theory?
based on the theory makes a difference in the
■ Will I be able to find the support I
lives of people. Theories must have pragmatic
need to study and use the theory in my
value; that is, they need to generate research
practice?
questions and provide models that can be ap-
The purpose of nursing theory goes beyond plied in practice. In the nursing literature, you
its study within courses. Nursing theory be- will find examples of how a theory has been
comes alive when the ideas are brought to used in research and in practice. In some cases,
practice. The usefulness of theory in practice especially with newly formed theories, this ev-
is one way that we judge its value and worth. idence may be unavailable. In these situations,
It is helpful to read about the theory from pri- you will need to imagine how the theory might
mary sources or the most notable scholars and work in practice. Theories have heuristic, or
practitioners who have studied the theory. problem-solving, value in that they can lead to
Nurses interested in particular theories can new ways of thinking about situations. Con-
join online discussion groups where issues re- sider the heuristic value of the theory as you
lated to the theory are discussed. Many of the read it. The theory should ignite your passion
theory groups have formed professional so- about nursing.
cieties and hold conferences that support
lifelong learning and growing with those ap- Choosing a Nursing Theory
plying the theory in practice, administration,
research, and education. to Study
It is important to give adequate attention to
The Theorist, Evidence, and Opinion the selection of theories. Results of this deci-
■ Who is the author of this theory? What sion will have lasting influences on your nurs-
background of nursing education and ing practice. It is not unusual for nurses who
experience does the theorist bring to begin to work with nursing theory to realize
this work? Is the author an authoritative that their practice is changing and that their
nursing scholar? future efforts in the discipline and practice of
■ How is the theorist’s background of nursing are markedly altered.
nursing education and experience brought There is always some measure of hope mixed
to this work? with anxiety as nurses seriously explore nursing
■ What is the evidence that use of the theory for the first time. Individual nurses who
theory may lead to improved nursing care? practice with a group of colleagues often won-
Has the theory been useful to guide nurs- der how to select and study nursing theories.
ing organizations and administrations? Nurses in practice and nursing students in the-
What about influencing nursing and ory courses have similar questions. Nurses in
health-care policy? new practice settings designed and developed
■ What is the evidence that this nursing by nurses have the same concerns about getting
theory has led to nursing research, includ- started as do nurses in hospital organizations
ing questions and methods of inquiry? who want more from their practice.

7991_Ch03_021-032 12/08/19 5:19 PM Page 26
The following exercise is grounded in the for nursing purposes. This can be a situation from
belief that the study and use of nursing theory your current practice or may be from your nurs-
in nursing practice must have roots in the ing in years past. Consider the purpose or hoped-
practice of the nurses involved. Moreover, the for outcome.
nursing theory used by particular nurses must
reflect elements of practice that are essential Nursing Situations
to those nurses, while at the same time bring- ■ Who was this person, family, or commu-
ing focus and freshness to that practice. This nity? How did I come to know him, her,
exercise calls on the nurse to think about the or them as unique?
major components of nursing and bring forth ■ What were the person’s, family’s, or com-
the values and beliefs most important to munity’s hopes and dreams for their own
nurses. In these ways, the exercise begins to health and healing?
parallel knowledge development reflected in ■ Who was I as a person in the nursing
the nursing metaparadigm (focus of the dis- situation?
cipline) and nursing philosophies described ■ Who was I as a nurse in the situation?
in Chapter 1. Throughout the rest of this ■ What was the relationship between the
book, the reader is guided to connect nursing person, family, or community and myself?
theory and nursing practice in the context of ■ What nursing actions emerged in the
nursing situations. context of the relationship?
■ What other nursing actions might have
been possible?
A Reflective Exercise for ■ What was the environment of the nursing
Choosing a Nursing Theory situation?
for Practice ■ What about the environment was impor-
Select a comfortable, private, and quiet place tant to the person’s, family’s, or commu-
to reflect and write. Relax by taking some nity’s hopes and dreams for health and
deep, slow breaths. Think about the reasons healing and my nursing actions?
you went into nursing in the first place. Bring Nursing can change when we consciously
your nursing practice into focus. Consider connect values and beliefs to nursing situa-
your practice today. Continue to reflect and, tions. Consider that values and beliefs are the
while avoiding distractions, make notes to basis for our nursing. Briefly describe the con-
record your thoughts and feelings. When you nections of your values and beliefs with your
have been thinking for a time and have taken chosen nursing situation.
the opportunity to reflect on your practice,
proceed with the following questions. Con- Connecting Values and the Nursing
tinue to reflect and to make notes as you con- Situation
sider each one. ■ How are my values and beliefs reflected in
any nursing situation?
Enduring Values ■ Are my values and beliefs in conflict or
■ What are the enduring values and beliefs frustrated in this situation?
that brought me to nursing? ■ Do my values come to life in the nursing
■ What beliefs and values keep me in nurs- situation?
ing today?
■ What are the personal values that I hold Cultivating Awareness
most dear? and Appreciation
■ How do my personal and nursing values
In reflecting and writing about values and
connect with what is important to society?
nursing situations that are important to us, we
Reflect on an instance of nursing in which you often come to a fuller awareness and appreci-
interacted with a person, family, or community ation of our practice. Make notes about your

7991_Ch03_021-032 12/08/19 5:19 PM Page 27
insights. You might consider these initial notes Personal knowing is about striving to know
the beginning of a journal in which you record the self and to actualize authentic relationships
your study of nursing theories and their use in between the nurse and person. Using this pat-
nursing practice. This is a valuable way to fol- tern of knowing in nursing, the client is not
low your progress and is a source of nursing seen as an object but as a person moving to-
questions for future study. You may want to ward fulfillment of potential (Carper, 1978).
share this process and experience with your The nurse is recognized as continuously learn-
colleagues. Sharing is a way to explore and ing and growing as a person and practitioner.
clarify views about nursing and to seek and Reflecting on a person as a client and a person
offer support for nursing values and situations as a nurse in the nursing situation can enhance
that are critical to your practice. If you are understanding of nursing practice and the cen-
doing this exercise in a group, share your es- trality of relationships in nursing. These in-
sential values and beliefs with your colleagues. sights are useful for choosing and studying
nursing theory. Knowing the self is essential in
Multiple Ways of Knowing and selecting a nursing theory to guide practice.
Reflecting on Nursing Theory Ultimately, the choice of theoretical perspec-
Multiple ways of knowing are used in theory- tive reflects personal values and beliefs.
guided nursing practice. Carper (1978) studied Ethical knowing is increasingly important to
the nursing literature and described four essen- the study and practice of nursing today. Ac-
tial patterns of knowing in nursing. Using the cording to Carper (1978), ethics in nursing is
Phenix’s (1964) model of realms of meaning, the moral component guiding choices within
Carper described personal, empirical, ethical, the complexity of health care. Ethical knowing
and aesthetic ways of knowing in nursing. informs us of what is right, what is obligatory,
Chinn and Kramer (2015) use Carper’s pat- and what is desirable in any nursing situation.
terns of knowing and a fifth pattern, called Ethical knowing is essential in every action of
emancipatory knowing, to develop an inte- the nurse in day-to-day practice.
grated framework for nursing knowledge de- Aesthetic knowing is described by Carper
velopment. Additional patterns of knowing in (1978) as the art of nursing; it is the creative
nursing have been explored and described, and and imaginative use of nursing knowledge in
the initial four patterns have been the focus of practice (Rogers, 1988). Although nursing is
much consideration in nursing (Boykin, often referred to as art, this aspect of nursing
Parker, & Schoenhofer, 1994; Leight, 2002; may not be as highly valued as the science and
Munhall, 1993; Parker, 2002; Pierson, 1999; ethics of nursing. Each nurse is an artist, ex-
Ruth-Sahd, 2003; Thompson, 1999; White, pressing and interpreting the guiding theory
1995). Each of the patterns of knowing and its uniquely in practice. Reflecting on the experi-
relationship to theory-guided practice is artic- ence of nursing is primary in understanding

ulated in the following paragraphs. aesthetic knowing. Through such reflection,
Empirical knowing is the most familiar of the nurse understands that nursing practice has
the ways of knowing in nursing. Empirical in fact been created, that each instance of nurs-
knowing is how we come to know the science ing is unique, and that outcomes of nursing
of nursing and other disciplines that are used cannot be precisely predicted. Besides the art
in nursing practice. This includes knowing the of nursing, knowing through artistic forms is
actual theories, concepts, principles, and re- part of aesthetic knowing. Often human expe-
search findings from nursing, pathophysiology, riences and relationships can best be appreci-
pharmacology, psychology, sociology, epi- ated and understood through art forms such
demiology, and other fields. Nursing theory is as stories, paintings, music, or poetry. Some
within the pattern of empirical knowing. The assert that aesthetic knowing allows for under-
theoretical framework for practice integrates standing the wholeness of experience. Ex-
the concepts, principles, laws, and facts essen- amples of this most complete knowing are
tial for practice. frequent in nursing situations in which even

7991_Ch03_021-032 12/08/19 5:19 PM Page 28
momentary connection and genuine presence significance (Smith, 2018). There are many
between the nurse and the person, family, or sets of criteria for evaluating conceptual
community is realized. models and grand theories (Chinn & Kramer,
Emancipatory knowing as described by 2015; Fawcett, 2004; Fawcett & DeSanto-
Chinn and Kramer (2015) is realized in praxis, Madeya, 2013; Fitzpatrick & Whall, 2004;
the integration of knowing, doing, and being. Parse, 1987; Stevens, 1998). Smith (2018)
Paulo Freire’s (2007, p. 88) definition of has published criteria for evaluating middle-
praxis is simultaneous reflection and action in- range theories. After reading and studying
tended to transform the world. In this pattern the primary sources of the theory, the re-
knowing is inseparable from action and is in- search and practice applications of the the-
tegral to the being of the nurse. The transfor- ory, and other critiques and evaluations of
mative action alters the power dynamics that the theory, it is important for the evaluator
maintain disadvantage for some and privilege to come to his or her own judgments sup-
for others and is directed toward goals for so- ported by logical analysis and examples from
cial justice (Kagan, Smith, & Chinn, 2014). the theory.
The nurse using this pattern cultivates aware- The whole theory must be studied. Parts of
ness of how social, political, and economic the theory without the whole will not be fully
forces shape assumptions and opinions about meaningful and may lead to misunderstanding.
knowledge and truth. Unveiling the dynamics Before selecting a guide for theory evalu-
that sustain inequity creates freedom to see ation, consider the level and scope of the
and act in a way that improves the health of theory. Is the theory a conceptual model or
all. Emancipatory knowing reminds us of grand nursing theory? A middle-range nurs-
the contextual nature of knowing, and that ing theory? A practice theory? Not all aspects
through praxis (reflection and action) all pat- of theory described in an evaluation guide
terns of knowing are integrated. will be appropriate for all levels of theory.
Whall (2004) recognized this in offering
Using Insights to Choose Theory particular guides for analysis and evaluation
The notes describing your experience will help that vary according to three types of nursing
in selecting a nursing theory to study and con- theory: models, middle-range theories, and
sider for guiding practice. You will want to an- practice theories. Fawcett’s (2004; Fawcett &
swer these questions: DeSanto-Madeya, 2014) criteria for analysis
and evaluation pertain to conceptual models
■ What nursing theory seems consistent and grand theories. Smith’s (2018) criteria
with the values and beliefs that guide my specifically address the evaluation of middle-
practice? range theories.
■ What theories are consistent with my per- Theory analysis and evaluation may be con-
sonal values and beliefs? ceptualized as one process or as a two-step se-
■ What do I hope to achieve from the use of quence. It may be helpful to think of analysis
nursing theory? of theory as necessary for in-depth study of a
■ Given my reflection on a nursing situa- nursing theory and evaluation of theory as the
tion, how can I use theory to support this assessment of a theory’s significance, structure,
description of my practice? and utility. Guides for theory evaluation are
■ How can I use nursing theory to improve intended as tools to inform us about theories
my practice for myself and for my patients? and to encourage further development, refine-
ment, and use of theory. No guide for theory
analysis and evaluation is adequate and appro-
Evaluation of Nursing Theory priate for every nursing theory.
Evaluation of nursing theory follows its study Johnson (1974) wrote about three basic
and analysis and is the process of making a criteria to guide evaluation of nursing theory.
determination about its value, worth, and These have continued in use over time and

7991_Ch03_021-032 12/08/19 5:19 PM Page 29
offer direction today. These criteria state that The questions for evaluation of conceptual
the theory should: models address:
■ Define the congruence of nursing practice ■ Explication of origins
with societal expectations of nursing ■ Comprehensiveness of content
decisions and actions ■ Logical congruence
■ Clarify the social significance of nursing, ■ Generation of theory
or the effect of nursing on persons receiv- ■ Credibility of nursing model
ing nursing
The framework for analysis of grand and
■ Describe social utility, or usefulness,
middle-range theories includes:
of the theory in practice, research, and
education ■ Theory scope
■ Theory context
Following are summaries of the most fre- ■ Theory content
quently used guides for theory evaluation. These
guides are components of the entire work about The questions for evaluation of grand and
nursing theory of the individual nursing scholar middle-range theories address:
and offer various interesting approaches to the-
ory evaluation. Each guide should be studied in
■ Significance
more detail than is offered in this introduction
■ Internal consistency
and should be examined in context of the whole
■ Parsimony
work of the individual nurse scholar.
■ Testability
The approach to theory evaluation set forth
■ Empirical adequacy
by Chinn and Kramer (2011) is to use guide-
■ Pragmatic adequacy
lines for describing nursing theory that are Meleis (2011) stated that the structural
based on their definition of theory as “a cre- and functional components of a theory should
ative and rigorous structuring of ideas that be studied before evaluation. The structural
projects a tentative, purposeful, and systematic components are assumptions, concepts, and
view of phenomena” (p. 58). The guidelines set propositions of the theory. Functional com-
forth questions that clarify the facts about as- ponents include descriptions of the following:
pects of theory: purpose, concepts, definitions, focus, client, nursing, health, nurse–client in-
relationships and structure, and assumptions. teractions, environment, nursing problems,
These authors suggest that the next step in the and interventions. After studying these di-
evaluation process is critical reflection about mensions of the theory, critical examination
whether and how the nursing theory works. of these elements may take place, summarized
Questions are posed to guide this reflection: as follows:

■ How clear is this theory? ■ Relations between structure and function
■ How simple is this theory? of the theory, including clarity, consis-
■ How general is this theory? tency, and simplicity
■ How accessible is this theory? ■ Diagram of theory to elucidate the theory
■ How important is this theory? by creating a visual representation
Fawcett (2004; Fawcett & DeSanto-
■ Contagiousness, or adoption of the
Madeya, 2013) developed two frameworks for theory by a wide variety of students,
the analysis and evaluation of conceptual mod- researchers, and practitioners, as reflected
els and theories. The questions for analysis of in the literature
conceptual models address:
■ Usefulness in practice, education,
research, and administration
■ Origins of the nursing model ■ External components of personal values,
■ Unique focus of the nursing model professional values, social values, and
■ Content of the nursing model significance

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Smith (2018, p. 39) developed a framework a model that guides nursing practice within
for the evaluation of middle-range theories their unit or organization. The following are
that includes the following criteria: suggestions that can facilitate this process of
adoption and implementation of theory-guided
■ Substantive foundation relates to meaning
practice within units or organizations:
or how the theory corresponds to existing
knowledge in the discipline. The questions 1. Gaining administrative support. Organiza-
for evaluation ask about its fit with the tional leaders need to support the initiative
disciplinary focus of nursing; its specifica- to begin the process of implementing nurs-
tion of assumptions; its substantive meaning theory–guided practice. Although the
ing of a phenomenon; and its origins in impetus to begin this initiative might not
practice and/or research. originate in formal leadership, the organi-
■ Structural integrity relates to the structure zational leaders and managers need to be
or internal organization of the theory. on board. If it is to succeed, the implemen-
Questions for evaluation ask about the tation of a model for practice requires the
clarity of definitions of concepts, the support of administration at the highest
consistency of level of abstraction, the levels.
simplicity of the theory, and the logical 2. Selecting the theory or model to be used in
representation of relationships among practice. The entire nursing staff should be
concepts. fully involved and invested in the process
■ Functional adequacy refers to the ability of of deciding on the theoretical model that
the theory to be used in practice and re- will guide practice. This can be done in
search. Questions are related to its appli- several ways. An organization’s governance
cability to practice and client groups, the structure can be used to develop the most
identification of empirical indicators, the appropriate selection process. As stated
presence of published examples of prac- previously, the selection of a nursing theory
tice, and research using the theory and or model is based on values. Some nursing
the evolution of the theory through organizations have used their mission, val-
inquiry. ues, and vision statements as a blueprint
that helps them select nursing theories
that are most consistent with these values.
Implementing Theory-Guided Another approach is to survey all nurses
Practice about the practice models they would like
Every nurse should develop a practice that is to see implemented. The nursing staff can
guided by nursing theory. Most conceptual then study the top three or four in greater
models or grand theories have actual practice detail so that an informed decision can be
methods or processes that can be adopted. The made. Staff development can be involved
scope and generality of middle-range theories in planning educational offerings related
make them less appropriate to guide nursing to the models. A process of voting or gain-
practice within a unit or hospital. Instead, they ing consensus can be used for the final
can be used to understand and respond to phe- selection.
nomena that are encountered in nursing situa- 3. Launching the initiative. Once the model
tions. For example, Boykin and Schoenhofer’s has been selected, the leaders (formal and
Nursing as Caring theory has been adopted as informal) begin to plan for its implemen-
a practice model by several hospitals (Boykin, tation. This involves creating a timeline;
Schoenhofer, & Valentine, 2013). Reed’s mid- planning the phases and stages of imple-
dle-range theory of self-transcendence can be mentation, including activities; and using
used to guide a nurse who is leading a support all methods of communication to be
group for women with breast cancer. Hospital sure that all are informed of these plans.
units or entire nursing departments may adopt Unit champions, informal leaders who are

7991_Ch03_021-032 12/08/19 5:19 PM Page 31
enthusiastic and positive about the initia- suggestions, so resident experts should be
tive, can be key to building excitement for available for this education and support.
the initiative. A structure to lead and Those working with the model will grow
manage the implementation is essential. in their expertise, and their experiences
Consultants who are experts in the theory need to be recorded and shared with the
itself or who have experience in imple- community of scholars advancing the the-
menting the theory-guided practice ory in practice. Ways to foster staying
model can be very helpful. For example, on track must be developed. Some hos-
Watson’s National Caring Science Affili- pitals have created unit bulletin boards,
ates1 are healthcare systems that have newsletters, or signage to prevent revert-
experience implementing the theory in ing to old behaviors and to cement new
practice. New hospitals can join as an ones. Staff members need opportunities
affiliate for consultation and support as to dialogue about their experiences: what
they launch initiatives. A kickoff event, is working and what is not. They need
such as an inspirational presentation, can the freedom to develop new ways of im-
build excitement and visibility for the ini- plementing the model so that their schol-
tiative. (For additional information, visit arship and creativity flourish.
http://watsoncaringscience.org.) Periodic feedback on outcomes and oppor-
4. Creating a plan for evaluation. It is impor- tunities for reenergizing is essential. Planned
tant to build in a systematic plan for evalua- change involves anticipating the ebb and flow
tion of the new model from the beginning. of enthusiasm. In the stressful health-care en-
An evaluation study should be designed to vironment, it is important to find opportuni-
track process and outcome indicators. Con- ties to provide feedback on how the project is
sultation from an evaluation researcher is going, to reward and celebrate the successes,
essential. For example, outcomes of nurse and to fan any dying embers of enthusiasm for
satisfaction, patient satisfaction, nurse re- the project. This can be accomplished by invit-
tention, and core measures might be con- ing study champions to attend regional or na-
sidered as outcomes to be measured before tional conferences, bringing in speakers, or
and after the implementation of the model. holding recognition events.
Focus groups might be held at intervals to 6. Re-visioning of the theory-guided practice
identify nurses’ experiences and attitudes model based on feedback. Any theory-guided
related to implementation of the model. practice model will become richer through
5. Consistent and constant support and educa- its testing in practice. The nurses working
tion. As the model is implemented, a with the model will help to modify and
process to support continuing learning revise the model based on evaluation
and growth with the theory needs to data. This re-visioning should be done
be in place. The nurses implementing in partnership with theorists and other
the model will have questions and practice scholars working 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.

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Questions for Reflection not defined, and you do not understand

how they are related to each other. What
and Discussion criterion for theory evaluation would you
■ A nurse is interested in selecting a nursing use to share your critique of this theory?
theory to guide her practice. She asks ■ One of your friends hears that you are
you, “How do I get started? How do I taking a course on nursing theory and asks
approach this?” How would you advise the question, “How is nursing theory im-
this nurse? portant anyway? Nobody uses nursing
■ You read a particular nursing theory and theories in the real world.” How would
it is very confusing. The concepts are you respond?

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SE C T I O N
II
Conceptual Influences
on the 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 influ-
ences on the development of nursing theory. Thomas Kuhn refers to the stage of sci-
entific 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 conceptualizations of the nature of nursing
and the nurse–patient relationship. In Chapter 4 Lynne Dunphy, a noted historian and
Nightingale scholar, illuminates the core ideas from Nightingale’s 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 development
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 healing through attending to the person–environment relationship. She said that
the goal of nursing was to put the patient in the best condition for nature to act, and
she identified five environmental components essential to health. Nightingale saw
nursing and medicine as separate fields, and emphasized the importance of system-
atic inquiry. Her spiritual nature and vision of nursing as an art continue to influence
practice today.
In Chapter 5, Shirley Gordon summarizes the work of Ernestine Wiedenbach, Vir-
ginia Henderson, and Lydia Hall. Wiedenbach emphasized the importance of rever-
ence for life; respect for the dignity, autonomy, 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 envision
nursing as an autonomous discipline and practice. She created a model of nursing
consisting 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 admitted the patients for nursing care. Nurses worked independ-
ently with patients to foster learning, growth, and healing.
Chapter 6 focuses on three nursing leaders who described the nurse–patient re-
lationship: Hildegard Peplau, Ida Jean Orlando, and Joyce Travelbee. A psychiatric
nurse, Peplau viewed the purpose of nursing as helping the patient gain the intellec-
tual and interpersonal competencies necessary to heal. She articulated stages of the
nurse–patient relationship, a framework for anxiety, and nursing interventions to de-
crease anxiety. Travelbee emphasized the human-to-human relationship between
nurse and person nursed, and spoke of the purpose of nursing as assisting the per-
son(s) to prevent or cope with the experience of illness and suffering. Orlando de-
scribed attributes of the nurse–patient 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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Florence Nightingale’s
CHAPTER
4
Conceptualizations of
Nursing
Lynne M. Hektor Dunphy
Introducing the Theorist Introducing the Theorist

Overview of Nightingale’s Ideas About Nursing Florence Nightingale, the acknowledged founder
Applications of the Theory of modern nursing, remains a compelling and
Practice Exemplar written by Marlaine C. Smith transformative figure. Not a year goes by in
Summary which new scholarship on Nightingale does not
Questions for Reflection and Discussion emerge. Florence Nightingale and the Health of
the Raj was published in 2003 documenting
Nightingale’s 40-year-long interest and in-
volvement in Indian affairs, a previously not
well explored area of scholarship (Gourley,
2003). In 2004, a biography of Nightingale,
Nightingales: The Extraordinary Upbringing and
Curious Life of Miss Florence Nightingale by
Gillian Gill, was published. In 2008, another
biography, Florence Nightingale: The Making of
an Icon by Mark Bostridge, was published. In
2013, a very well written biography by Judith
Lissauer Cromwell, Florence Nightingale, Fem-
inist, presented Nightingale as a “feminist”—
a term that was nonexistent during the years
that Nightingale was alive. It is a fine work,
told from a post-feminist perspective. Lynn
McDonald’s (2002–2012) prodigious, ambitious,
and long overdue Collected Works of Florence
Nightingale consists of 16 volumes and provides
an in-depth scholarly analysis of Nightingale’s

legacy (http://www.uoguelph.ca/~cwfn/); in
2018, McDonald published Florence Nightin-
gale, Nursing and Health Care Today for nursing
students and the general reader. In 2005, the
American Nurses Association (Dossey, Se-
landers, Beck, & Attewell) published Florence
Nightingale Today: Healing, Leadership, Global
Action, an ambitious casting of Nightingale as
21st-century nursing’s inspiration and savior.
Catherine Reef (2016) published the biogra-
phy, Florence Nightingale: The Courageous Life of
the Legendary Nurse, which introduces Nightin-
gale as a woman, grounded by her faith, who
defies Victorian era expectations about women
35
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36 S E C T IO N II ■ Conceptual Influences on the Evolution of Nursing Theory
and becomes the founder of the profession of nursing as we recall them today. Part of what
nursing. In 2018, the A & E television network follows is a well-known tale, yet it remains one
created the Florence Nightingale Biography web- that is irresistible, casting an age-old spell on
site on biography.com (https://www.biography. the reader, like the flickering shadow of
com/people/florence-nightingale-9423539) Nightingale and her famous lamp in the dark
along with two short videos, Florence Nightingale— and dreary halls of the Barrack Hospital,
Mini Biography (https://www.biography.com/ Scutari, on the outskirts of Constantinople,
video/florence-nightingale-mini-biography- circa 1854 to 1856. It is a tale that carries even
35737155976) and Florence Nightingale—Lady more relevance for nursing practice today.
With the Lamp (https://www.biography.com/
video/florence-nightingale-lady-with-the-
lamp-30951491805). At the time you are pe- Overview of Nightingale’s
rusing this chapter, it will be more than a
century since the death of Florence Nightingale
Ideas About Nursing
in 1910 and nearly 200 hundred years since her Early Life and Education
birth on May 12 in 1820. A profession, a trade, a necessary occupation,
Nightingale transformed a “calling from something to fill and employ all my faculties,
God” and an intense spirituality into a new so- I have always felt essential to me, I have always
cial role for women: that of nurse. Her caring longed for, consciously or not. … The first thought
was a public one. “Work your true work,” she I can remember, and the last, was nursing work.
wrote, “and you will find God within you” —FLORENCE NIGHTINGALE, CITED IN
(Woodham-Smith, 1983, p. 74). A reflection COOK (1913, p. 106)
on this statement appears in a well-known
quote from Notes on Nursing (Nightingale, Nightingale was born in 1820 in Florence,
1859/1992): “Nature [i.e., the manifestation of Italy—the city for which she was named. The
God] alone cures … what nursing has to do … Nightingales were on an extended European
is put the patient in the best condition for na- tour, begun in 1818 shortly after their mar-
ture to act upon him” (Macrae, 1995, p. 10). riage. This was a common journey for those of
Although Nightingale never defined human their class and wealth. Their first daughter,
care or caring in Notes on Nursing, there is no Parthenope, had been born in the city of that
doubt that her life in nursing exemplified and name in the previous year.
personified an ethos of caring. Jean Watson A legacy of humanism, liberal thinking, and
(1992, p. 83), in the 1992 commemorative edi- love of speculative thought was bequeathed to
tion of Notes on Nursing, observed, “Although Nightingale by her father. His views on the
Nightingale’s feminine-based caring-healing education of women were far ahead of his
model has transcended time and is prophetic time. W. E. N.—as her father, William, was
for this century’s health reform, the model is called—undertook the education of both his
yet to truly come of age in nursing or the daughters. Florence and her sister studied
health care system.” In a reflective essay, music; grammar; composition; modern lan-
Boykin and Dunphy (2002) extended this guages; classical Greek and Latin; constitu-
thinking and related Nightingale’s life, rooted tional history; Roman, Italian, German, and
in compassion and caring, as an exemplar of Turkish history; and mathematics (Barritt,
justice making (p. 14). Justice making is under- 1973).
stood as a manifestation of compassion and From an early age, Florence exhibited in-
caring, “for it is our actions that bring about dependence of thought and action. The sketch
justice” (p. 16). (Fig. 4-1) of W. E. N. and his daughters was
This chapter reiterates Nightingale’s life done by Nightingale’s beloved aunt, Julia
from the years 1820 to 1860, delineating the Smith. It is Parthenope, the older sister, who
formative influences on her thinking and pro- clutches her father’s hand and Florence who,
viding historical context for her ideas about as described by her aunt, “independently

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CHAPTER 4 ■ Florence Nightingale’s Conceptualizations of Nursing 37
Life at Kaiserswerth was spartan. The

trainees were up at 5 A.M., ate bread and
gruel, and then worked on the hospital wards
until noon. Then they had a 10-minute break
for broth with vegetables. Three P.M. saw an-
other 10-minute break for tea and bread. They
worked until 7 P.M., had some broth, and
then Bible lessons until bed. What the Kaiser-
swerth training lacked in expertise it made up
for in a spirit of reverence and dedication. Flo-
rence wrote, “The world here fills my life with
interest and strengthens me in body and mind”
(Huxley, 1975, p. 24).
In 1852, Nightingale visited Ireland, tour-
ing hospitals and keeping notes on various in-
stitutions along the way. Nightingale took two
trips to Paris in 1853; hospital training again
was the goal, this time with the sisters of
St. Vincent de Paul, an order of nursing nuns.
In August 1853, she accepted her first “official”
nursing post as superintendent of an “Estab-
lishment for Gentlewomen in Distressed
FIG 4-1 ■ A sketch of W. E. N. and his daughters Circumstances during Illness,” located at
by one of his wife Fanny’s sisters, Julia Smith. 1 Harley Street, London. Selanders, Lake, and
Source: Woodham-Smith (1983), p. 9, with permission of Crane (2010) conducted a historical and the-
Sir Henry Verney, Bart. matic analysis using primary documents from
Nightingale’s work during this time and iden-
stumps along by herself” (Woodham-Smith, tified specific themes, “considered essential to
1983, p. 7). Nightingale’s professional and philosophical
Travel also played a part in Nightingale’s development” (p. 284). After 6 months at
education. Eighteen years after Florence’s Harley Street, Nightingale wrote in a letter
birth, the Nightingales and both daughters to her father: “I am in the hey-day of my
made an extended tour of France, Italy, and power” (Nightingale, cited in Woodham-
Switzerland between the years 1837 and 1838, Smith, 1983, p. 77). By October 1854, larger
and later Egypt and Greece (Sattin, 1987). horizons beckoned.
From there, Nightingale visited Germany,

making her first acquaintance with Kaiser- Spirituality
swerth, a Protestant religious community that Today I am 30—the age Christ began his Mis-
contained the Institution for the Training of sion. Now no more childish things, no more vain
Deaconesses, with a hospital school, peniten- things, no more love, no more marriage. Now,
tiary, and orphanage. A Protestant pastor, Lord let me think only of Thy will, what Thou
Theodore Fleidner, and his young wife had es- willest me to do. O, Lord, Thy will, Thy will.
tablished this community in 1836, in part to —FLORENCE NIGHTINGALE, PRIVATE
provide training for women deaconesses NOTE, 1850, CITED IN WOODHAM-SMITH
(Protestant “nuns”) who wished to nurse. (1983, p. 130)
Nightingale was to return there in 1851
against much family opposition to stay from By all accounts, Nightingale was an intense
July through October, participating in a period and serious child, always concerned with the
of “nurse’s training” (Cook, Vol. I, 1913; poor and the ill, mature far beyond her years.
Woodham-Smith, 1983). A few months before her 17th birthday,

7991_Ch04_033-054 14/08/19 1:39 PM Page 38
Nightingale recorded in a personal note dated Influenced by the Unitarian ideas of her
February 7, 1837, that she had been called to father and her extended family, as well as by
God’s service. What that service was to be was the more traditional Anglican Church she at-
unknown at that point in time. This was to be tended, Nightingale remained for her entire
the first of four such experiences that Nightin- life a searcher of religious truth, studying a va-
gale documented. riety of religions and reading widely. She was
The fundamental nature of her religious a devout believer in God. Nightingale wrote:
convictions made her service to God, through “I believe that there is a Perfect Being, of
service to humankind, a driving force in whose thought the universe in eternity is the
her life. She wrote: “The kingdom of Heaven incarnation” (Calabria & Macrae, 1994, p. 20).
is within; but we must make it without” Dossey (1998) recast Nightingale in the mode
(Nightingale, private note, cited in Woodham- of “religious mystic.” However, to Nightingale,
Smith, 1983). mystical union with God was not an end in it-
It would take 16 long and torturous years, self but was the source of strength and guid-
from 1837 to 1853, for Nightingale to actual- ance for doing one’s work in life. For
ize her calling to the role of nurse. This was a Nightingale, service to God was service to hu-
revolutionary choice for a woman of her social manity (Calabria & Macrae, 1994, p. xviii).
standing and position, and her desire to nurse In Nightingale’s view, nursing should be a
met with vigorous family opposition for many search for the truth; it should be a discovery of
years. Along the way, she turned down pro- God’s laws of healing and their proper appli-
posals of marriage, potentially, in her mother’s cation. This is what she was referring to in
view, “brilliant matches,” such as that of Notes on Nursing when she wrote about the
Richard Monckton Milnes. However, her Laws of Health, as yet unidentified. It was the
need to serve God and to demonstrate her car- Crimean War that provided the stage for her
ing through meaningful activity proved to actualize these foundational beliefs, rooting
stronger. She did not think that she could be forever in her mind certain “truths.” In the
married and also do God’s will. Crimea, she was drawn closer to those suffer-
Calabria and Macrae (1994) noted that for ing injustices. It was in the Barracks Hospital
Nightingale, there was no conflict between sci- of Scutari that Nightingale acted justly and re-
ence and spirituality; in her view, science is sponded to a call for nursing from the pro-
necessary for the development of a mature longed cries of the British soldiers (Boykin &
concept of God. The development of science Dunphy, 2002, p. 17).
allows for the concept of one perfect God
Who regulates the universe through universal War
laws as opposed to random happenings. I stand at the altar of those murdered men and
Nightingale referred to these laws, or the or- while I live I fight their cause.
ganizing principles of the universe, as —NIGHTINGALE, CITED IN WOODHAM-
“Thoughts of God” (Macrae, 1995, p. 9). As SMITH (1951, p. 182)
part of God’s plan of evolution, it was the re-
sponsibility of human beings to discover the Nightingale had powerful friends and had
laws inherent in the universe and apply them gained prominence through her study of hospi-
to achieve well-being. In Notes on Nursing tals and health matters during her travels. When
(1860/1969, p. 25), she wrote: Great Britain became involved in the Crimean
War in 1854, Nightingale was ensconced in her
God lays down certain physical laws. Upon his car- first official nursing post at 1 Harley Street.
rying out such laws depends our responsibility Britain had joined France and Turkey to ward
(that much abused word). … Yet we seem to be off an aggressive Russian advance in the Crimea
continually expecting that He will work a miracle— (Fig. 4-2). A successful advance of Russia
i.e. break his own laws expressly to relieve us of through Turkey could threaten the peace and
responsibility. stability of the European continent.

7991_Ch04_033-054 14/08/19 1:39 PM Page 39

FIG 4-2 ■ The Crimea and the Black Sea, 1854 to 1856. Source: Huxley, E. (1975). Designed by Manuel Lopez
Parras.
The first actual battle of the war, the Battle of wounded men, disease, and illness abounded.
of Alma, was fought in September 1854. It was Who was to care for these men? The French
written of that battle that it was a “glorious and had the Sisters of Charity to care for their sick
bloody victory.” The best communication tech- and wounded. What were the British to do
nology of the times, the telegraph, was to have (Goldie, 1987; Woodham-Smith, 1951)?
an effect on what was to follow. In previous The minister of war was Sidney Herbert,
wars, news from the battlefields trickled home Lord Herbert of Lea, who was the husband of
slowly. However, the telegraph enabled war Liz Herbert; both were close friends of
correspondents to transmit reports home with Nightingale. Herbert had an innovative solu-
rapid speed. The horror of the battlefields was tion: appoint Miss Nightingale and charge her
relayed to a concerned citizenry. Descriptions to head a contingent of nurses to the Crimea

7991_Ch04_033-054 14/08/19 1:39 PM Page 40
to provide help and organization to the deteri- On her arrival in the Crimea, the immedi-
orating battlefield situation. It was a brave ate priority of Nightingale and her small band
move on the part of Herbert. Medicine and war of nurses was not in the sphere of medical or
were exclusively male domains. To send a surgical nursing as currently known; rather,
woman into these hitherto uncharted waters their order of business was domestic manage-
was risky at best. But, as is well known, ment. This is evidenced in the following ex-
Nightingale was no ordinary woman, and she change between Nightingale and one of her
more than rose to the occasion. In a passionate party as they approached Constantinople: “Oh,
letter to Nightingale, requesting her to accept Miss Nightingale, when we land don’t let there
this post, Herbert wrote: “Your own personal be any red-tape delays, let us get straight to
qualities, your knowledge and your power of nursing the poor fellows!” Nightingale’s reply:
administration, and among greater things, your “The strongest will be wanted at the wash tub”
rank and position in society, give you advan- (Cook, 1913; Dolan, 1971).
tages in such a work that no other person pos- Although the bulk of this work continued
sesses” (Dolan, 1971, p. 2). At the same time, to be done by orderlies after Nightingale’s
such that their letters actually crossed, Nightin- arrival (with the laundry farmed out to the
gale wrote to Herbert, offering her services. Ac- soldiers’ wives), it was accomplished under
companied by 38 handpicked “nurses” who had Nightingale’s eagle eye:
no formal training, she arrived on November 4,
1854, to “take charge” and did not return to She insisted on the huge wooden tubs in the
England until August 1856. wards being emptied, standing [obstinately] by
Biographer Woodham-Smith and Nightin- the side of each one, sometimes for an hour at a
gale’s own correspondence, as cited in a num- time, never scolding, never raising her voice, until
ber of sources (Cook, 1913; Goldie, 1987; the orderlies gave way and the tub was emptied.
Huxley, 1975; Summers, 1988; Vicinus & (Woodham-Smith, 1951, p. 116)
Nergaard, 1990), paint the most vivid picture Nightingale set up her own extra “diet
of the experiences that Nightingale sustained kitchen.” Small portions, helpings of such things
there, experiences that cemented her views on as arrowroot, port wine, lemonade, rice pudding,
disease and contagion, as well as her commit- jelly, and beef tea, whose purpose was to tempt
ment to an environmental approach to health and revive the appetite, were provided to the
and illness: men. It was therefore a logical sequence from
cooking to feeding, from administering food to
The filth became indescribable. The men in the cor-
administering medicines. Because no antidote to
ridors lay on unwashed floors crawling with vermin.
infection existed at this time, the provision—by
As the Rev. Sidney Osborne knelt to take down
Nightingale and her nurses—of cleanliness,

dying messages, his paper became thickly covered
order, encouragement to eat, feeding, clean bed
with lice. There were no pillows, no blankets; the
linen, clean bodies, and clean wards was essential
men lay, with their heads on their boots, wrapped
to recovery (Summers, 1988).
in the blanket or greatcoat stiff with blood and filth
Mortality rates at the Barrack Hospital in
which had been their sole covering for more than a
Scutari fell. In February, at Nightingale’s insis-
week … [S]he [Miss Nightingale] estimated …
tence, the prime minister had sent to the Crimea
there were more than 1000 men suffering from
a sanitary commission to investigate the high
acute diarrhea and only 20 chamber pots. …
mortality rates. Beginning their work in March,
[T]here was liquid filth which floated over the floor
they described the conditions at the Barrack
an inch deep. Huge wooden tubs stood in the halls
Hospital as “murderous.” Setting to work im-
and corridors for the men to use. In this filth lay the
mediately, they opened the channel through
men’s food—Miss Nightingale saw the skinned car-
which the water supplying the hospital flowed,
cass of a sheep lie in a ward all night … the stench
where a dead horse was found. The commission
from the hospital could be smelled outside the
cleared “556 handcarts and large baskets full of
walls. (Woodham-Smith, 1983)
rubbish … 24 dead animals and 2 dead horses

7991_Ch04_033-054 14/08/19 1:39 PM Page 41
buried.” In addition, they flushed and cleansed Rosenberg, 1979; Slater, 1994; Welch, 1986;
sewers, lime-washed walls, tore out shelves that Widerquist, 1992).
harbored rats, and got rid of vermin. The com- There were four miles of beds in the
mission, Nightingale said, “saved the British Barrack Hospital at Scutari, a suburb of Con-
Army.” Miss Nightingale’s anti-contagionism stantinople. A letter to the London Times dated
was sealed as the mortality rates began showing February 24, 1855, reported the following:
dramatic declines (Rosenberg, 1979). “When all the medical officers have retired for
Figure 4-3 illustrates Nightingale’s own the night and silence and darkness have settled
hand-drawn “coxcombs” (as they were referred upon those miles of prostrate sick, she may
to), as Nightingale, always aware of the neces- be observed, alone with a little lamp in her
sity of documenting outcomes of care, kept hand, making her solitary rounds” (Kalisch &
copious records of all sorts (Cook, 1913; Kalisch, 1987, p. 46).
Rosenberg, 1979; Woodham-Smith, 1951). In April 1855, after having been in Scutari
Florence Nightingale possessed moral au- for 6 months, Florence wrote to her mother,
thority, so firm because it was grounded in car- “[A]m in sympathy with God, fulfilling
ing and was in a larger mission that came from the purpose I came into the world for”
her spirituality. For Miss Nightingale, spiritu- (Woodham-Smith, 1983, p. 97). Henry
ality was a much broader, more unifying con- Wadsworth Longfellow authored “Santa Filom-
cept than that of religion. Her spirituality ena” to commemorate Miss Nightingale.
involved the sense of a presence higher than
humanity, the divine intelligence that creates, Lo! In That House of Misery
sustains, and organizes the universe, and an A lady with a lamp I see
awareness of our inner connection to this Pass through the glimmering gloom
higher reality. Through this inner connection And flit from room to room
flows creative endeavors and insight, a sense of And slow as if in a dream of bliss
purpose and direction. For Miss Nightingale, The speechless sufferer turns to kiss
spirituality was intrinsic to human nature and Her shadow as it falls
was the deepest, most potent resource for heal- Upon the darkening walls
ing. In Suggestions for Thought (Calabria & As if a door in heaven should be
Macrae, 1994, p. 58), Nightingale wrote that Opened and then closed suddenly
“human consciousness is tending to become The vision came and went
what God’s consciousness is—to become One The light shone and was spent.
with the consciousness of God.” This progres- A lady with a lamp shall stand
sion of consciousness to unity with the divine In the great history of the land
was an evolutionary view and not typical of A noble type of good
either the Anglican or Unitarian views of the Heroic womanhood

time (Calabria & Macrae, 1994; Macrae, 1995; (Longfellow, cited in Dolan, 1971, p. 5)
Diagram Representing the Mortality in the Hospitals

at Scutari and Kulali from Oct. 1st 1854 to Sept. 30th 1855
May 20 to June 9
June 10 to June 30
Apr. 29 to May 19 48 per
100 22
52 per per
100 100 July 1 to Sept. 30, 1855
Apr. 8 to Apr. 28 107 per 100 22 per 100
1854
Mar. 18 to Apr.7 144 per 100 22 per 100
Oct. 1 to Oct.10
Commencement of Sanitary Improvements 85 per 100
315 per 100

Oct. 15 to Nov. 11
155 per 100
Feb. 25 to Mar. 17
427 per 100 179 per 100

321 per 100 Nov. 12 to Dec. 9
FIG 4-3 ■ Diagram by Florence Nightingale Dec. 10 to Jan. 6, 1855

Feb. 1 to Feb. 28
showing declining mortality rates. Source:
Cohen (1981). Jan. 7 to Jan. 31

7991_Ch04_033-054 14/08/19 1:39 PM Page 42
Miss Nightingale slipped home quietly, the Crimea and in the graveyards of Scutari”
arriving at Lea Hurst in Derbyshire on Au- (Huxley, 1975, p. 147).
gust 7, 1856, after 22 months in the Crimea
and after sustained illness from which she was The Medical Milieu
never to recover, after ceaseless work and after In watching disease, both in private homes and
witnessing suffering, death, and despair that public hospitals, the thing which strikes the ex-
would haunt her for the remainder of her life. perienced observer most forcefully is this, that the
Her hair was shorn; she was pale and drawn symptoms or the sufferings generally considered
(Fig. 4-4). She took her family by surprise. to be inevitable and incident to the disease are
The next morning, a peal of the village very often not symptoms of the disease at all, but
church bells and a prayer of Thanksgiving of something quite different—of the want of
were, her sister wrote, “‘all the innocent greet- fresh air, or light, or of warmth, or of quiet, or
ing’ except for those provided by the spoils of of cleanliness, or of punctuality and care in the
war that had proceeded her—a one-legged administration of diet, of each or of all of these.
sailor boy, a small Russian orphan, and a large —FLORENCE NIGHTINGALE, NOTES ON
puppy found in some rocks near Balaclava. NURSING (1860/1969, p. 8)
All England was ringing with her name, but
she had left her heart on the battlefields of To gain a better understanding of Nightin-
gale’s ideas on nursing, one must enter the
particular 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 ex-
isted. 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 dis-
appeared. The crude death rate in western
Europe was falling, largely related to decreas-
ing infant mortality as a result of improvement
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 out-
look on the nature of disease: from belief in
general states common to all illnesses to an un-
derstanding of disease-specificity symptoms. It
was this shift in thought—a paradigm shift of
the first order—that gave us the triumph of
20th-century medicine, with all its attendant
FIG 4-4 ■ A rare photograph of Florence taken on glories and concurrent sterility.
her return from the Crimea. Although greatly The 18th century was host to two major tra-
weakened by her illness, she refused to accept her
friends’ advice to rest, and pressed on relentlessly ditions or paradigms in the healing arts: one
with her plans to reform the army medical based on “empirics” or “experience,” trial and
services. Source: Huxley (1975), p. 139. error, with an emphasis on curative remedies;

7991_Ch04_033-054 14/08/19 1:39 PM Page 43
the other based on Hippocratic notions and infectious diseases as zygomatic, meaning per-
learning. Evidence of both these trends pertaining to or caused by the process of fermen-
sisted into the 19th century and can be found tation. The debate as to whether fermentation
in Nightingale’s philosophy. was a chemical process or a “vitalistic” one had
Consistent with the philosophical nature been raging for some time (Swazey & Reed,
of her superior education (Barritt, 1973), 1978). The familiarity of the process of fer-
Nightingale, like many of the physicians of her mentation helps to explain its appeal. Anyone
time, continued to emphatically disavow the re- who had seen bread rise could immediately
ality of specific states of disease. She insisted on grasp how a minute amount of some con-
a view of sickness as an “adjective,” not a sub- taminating substance could in turn “pollute”
stantive noun. Sickness was not an “entity” the entire atmosphere, the very air that was
somehow separable from the body. Consistent breathed. What was at issue was the specificity
with her more holistic view, sickness was an as- of the contaminating substance. Nightingale,
pect or quality of the body as a whole. Some and the anti-contagionists, endorsed the po-
physicians, as she phrased it, taught that dis- sition that a “sufficiently intense level of at-
eases were like cats and dogs, distinct species mospheric contamination could induce both
necessarily descended from other cats and dogs. endemic and epidemic ills in the crowded hos-
She found such views misleading (Nightingale, pital wards [with particular configurations of en-
1860/1969). vironmental circumstances determining which]”
At this point in time, in the mid-19th cen- (Rosenberg, 1979).
tury, there were two competing theories re- Anti-contagionism reached its peak before
garding the nature and origin of disease. One the political revolutions of 1848; the resulting
view was known as “contagionism,” postulat- wave of conservatism and reaction brought con-
ing that some diseases were communicable, tagionism back into dominance, where it re-
spread via commerce and population migra- mained until its reformulation into the germ
tion. A strategic consequence of this explana- theory in the 1870s. Leaders of the contagion-
tory model was quarantine, and its attendant ists were primarily high-ranking military
bureaucracy aimed at shutting down com- physicians, politically united. These divergent
merce and trade to keep disease away from worldviews accounted in some part for Nightin-
noninfected areas. To the new and rapidly gale’s clashes with the military physicians she
emerging merchant classes, quarantine repre- encountered during the Crimean War.
sented government interference and control Given the intellectual and social milieu in
(Ackernecht, 1982; Arnstein, 1988). which Nightingale was raised and educated,
The second school of thought on the nature her stance on contagionism seems preordained
and origin of disease, of which Nightingale and logically consistent (Rosenberg, 1979).
was an ardent champion, was known as “anti- Likewise, the eclectic religious philosophy she
contagionism.” It postulated that disease re- evolved contained attributes of the philosophy
sulted from local environmental sources and of Unitarianism with the fervor of Evangeli-
arose out of “miasmas”—clouds of rotting filth calism, all based on an organic view of humans
and matter, activated by a variety of things as part of nature. The treatment of disease and
such as meteorological conditions (note the dysfunction was inseparable from the nature of
similarity to elements of water, fire, air, and man as a whole, and likewise, the environ-
earth on humors); the filth must be eliminated ment. And all were linked to God.
from local areas to prevent the spread of dis- The emphasis on “atmosphere” (or “envi-
ease. Commerce and “infected” individuals ronment”) in the Nightingale model is consis-
were left alone (Rosenberg, 1979). tent with the views of the “anti-contagionists”
William Farr, another Nightingale associ- of her time. This worldview was reinforced by
ate and avid anti-contagionist, was Britain’s Nightingale’s Crimean experiences, as well as
statistical superintendent of the General Reg- her liberal and progressive political thought. In
ister Office. Farr categorized epidemic and addition, she viewed all ideas as being distilled

7991_Ch04_033-054 14/08/19 1:39 PM Page 44
through a distinctly moral lens (Rosenberg, essay about the census titled “Why Are Women
1979). As such, Nightingale was typical of a Redundant?” (Widerquist, 1992, p. 52). Many
number of her generation’s intellectuals. These of these women had no acceptable means
thinkers struggled to come to grips with an in- of support, and Nightingale’s development
creasingly complex and changing world order of a suitable occupation for women, that of
and frequently combined a language of two nursing, was a significant historical develop-
disparate realms of authority: the moral realm ment and a major contribution by Nightingale
and the emerging scientific paradigm that has to women’s plight in the 19th century. How-
assumed dominance in the 20th century. Tra- ever, in other ways, her views on women and
ditional religious and moral assumptions were the question of women’s rights were quite
garbed in a mantle of “scientific objectivity,” mixed.
often spurious at best, but more in keeping Notes on Nursing: What It Is and What It Is
with the increasingly rationalized and bureau- Not (1859/1969) was written not as a manual
cratic society accompanying the growth of to teach nurses to nurse but rather to help all
science. women to learn how to nurse. Nightingale be-
lieved all women required this knowledge to
The Feminist Context of Nightingale’s take proper care of their families during times
Caring of sickness and to promote health—specifically
I have an intellectual nature which requires sat- what Nightingale referred to as “the health of
isfaction and that would find it in him. I have a houses,” that is, the “health” of the environ-
passionate nature which requires satisfaction and ment, which she espoused. Nursing, to her,
that would find it in him. I have a moral, an ac- was clearly situated within the context of
tive nature which requires satisfaction and that female duty.
would not find it in his life. In Ordered to Care: The Dilemma of Ameri-
—FLORENCE NIGHTINGALE, PRIVATE can Nursing, historian Susan Reverby (1987)
NOTE , 1849, CITED IN WOODHAM-SMITH traces contemporary conflicts within the nurs-
(1983, p. 51) ing profession back to Nightingale herself.
She asserts that Nightingale’s ideas about fe-
Florence Nightingale wrote the following male duty and authority, along with her views
tortured note upon her final refusal of Richard on disease causality, brought about an inde-
Monckton Milnes’s proposal of marriage: “I pendent field—that of nursing—that was sep-
know I could not bear his life,” she wrote, “that arate, and in the view of Nightingale, equal, if
to be nailed to a continuation, an exaggeration not superior, to that of medicine. But this field
of my present life without hope of another was dominated by a female hierarchy and in-
would be intolerable to me—that voluntarily sisted on both deference and loyalty to the
to put it out of my power ever to be able to physician’s authority. Reverby (1987) sums it
seize the chance of forming for myself a true up as follows: “Although Nightingale sought
and rich life would seem to be like suicide” to free women from the bonds of familial de-
(Nightingale, personal note cited in Wood- mand, in her nursing model she rebound them
ham-Smith, 1983, p. 52). For Miss Nightin- in a new context” (p. 43).
gale there was no compromise. Marriage and Does the record support this evidence? Was
pursuit of her “mission” were not compatible. Nightingale a champion for women’s rights or
She chose the mission, a clear repudiation of a regressive force? As noted earlier, the answer
the mores of her time, which were rooted in is far from clear.
the time-honored role of family and “female The shelter for all moral and spiritual val-
duty.” ues, threatened by the crass commercialism
The census of 1851 revealed that there were that was flourishing in the land, as well as the
365,159 “excess women” in England, meaning spirit of critical inquiry that accompanied this
women who were not married. These women age of expanding scientific progress, was
were viewed as redundant, as described in an agreed upon: the home. All considered this to

7991_Ch04_033-054 14/08/19 1:39 PM Page 45
be a “sacred place, a Temple” (Houghton, a useful occupation for other women to pursue
1957, p. 343). And who was the head of this was founded. Although Nightingale approved
home? Woman. Although the Victorian fam- of this occupation outside of the home for
ily was patriarchal in nature in that women had other women, certain other occupations—that
virtually no economic and/or legal rights, they of doctor, for example—she viewed with hos-
nonetheless yielded a major moral authority tility and as inappropriate for women. Why
(Arnstein, 1988; Houghton, 1957; Perkins, should these women not be nurses or nurse
1987). midwives, a far superior calling in Nightingale’s
There was hostility on the part of men as view than that of a medicine “man” (Monteiro,
well as some women toward women’s emanci- 1984)?
pation. Many intelligent women—for exam- Welch (1990) termed Nightingale a
ple, Beatrice Webb, George Eliot, and, at “Christian feminist” on the eve of her depar-
times, Nightingale herself—viewed their gen- ture to the Crimea. She returned even more
der’s emancipation with apprehension. In skeptical of women. Writing to her close
Nightingale’s case, the best word might be friend Mary Clarke Mohl, she described
“ambivalence.” There was a fear of weakening women whom she worked with in the Crimea
women’s moral influence, coarsening the fem- as being incompetent and incapable of inde-
inine nature itself. pendent thought (Welch, 1990; Woodham-
This stance is best equated with cultural Smith, 1983). According to Palmer (1977), by
feminism, defined as a belief in inherent gender this time in her life, the concerns of the British
differences. Women, in contrast to men, are people and the demands of service to God took
viewed as morally superior, the holders of fam- precedence over any concern she had ever had
ily values and continuity; they are refined, del- about women’s rights.
icate, and in need of protection. This school of In other words, Nightingale, despite the
thought, important in the 19th century, used clear freedom in which she lived her own
arguments for women’s suffrage such as the life, nonetheless genderized the nursing role,
following: “[W]omen must make themselves leaving it rooted in 19th-century morality.
felt in the public sphere because their moral Nightingale is seen constantly trying to im-
perspective would improve corrupt masculine prove the existing order and to work within
politics.” In the case of Nightingale, these cul- that order; she was above all a reformer, seek-
tural feminist attitudes “made her impatient ing to improve the existing order, not to
with the idea of women seeking rights and ac- change the terrain radically.
tivities just because men valued these entities” In Nightingale’s mind, the specific “scien-
(Bunting & Campbell, 1990, p. 21). tific” activity of nursing—hygiene—was the
Nightingale had chafed at the limitations central element in health care, without which
and restrictions placed on women, especially medicine and surgery would be ineffective:
“wealthy” women with nothing to do: “What “The Life and Death, recovery or invaliding of
these [women] suffer—even physically—from patients generally depends not on any great
the want of such work no one can tell. The and isolated act, but on the unremitting and
accumulation of nervous energy, which has had thorough performance of every minute’s prac-
nothing to do during the day, makes them feel tical duty.” (Nightingale, 1860/1969).
every night, when they go to bed, as if they This “practical duty” was the work of
were going mad.” Despite these vivid words, women, and the conception of the proper divi-
authored by Nightingale (1852/1979) in the sion of labor resting on work demands internal
fiery polemic “Cassandra,” which was used as a to each respective “science,” nursing and med-
rallying cry in many feminist circles, her view icine, obscured the professional inequality. The
of the solution was measured. Her own resolu- later successes of medical science heightened
tion, painfully arrived at, was to break from her this inequity. The scientific grounding espoused
family and actualize her caring mission, that of by Nightingale for nursing was ephemeral at
nurse. One of the many results of this was that best, as later 19th-century discoveries proved

7991_Ch04_033-054 14/08/19 1:39 PM Page 46
much of her analysis wrong, although nonethe- woman alone and in command (Auerbach,
less powerful. Much of her strength was in her 1982, pp. 120–121).
rhetoric; if not always logically consistent, it Nightingale’s decision to remain single re-
certainly was morally resonant (Rosenberg, pudiated the Victorian family. Her unmarried
1979). life provides a vision of a powerful life lived on
Despite exceptional anomalies, such as her own terms. This is not the spinsterhood of
women physicians, what Nightingale effec- convention—one to be pitied, one of broken
tively accomplished was a genderization of the hearts—but a radically new image. She is freed
division of labor in health care: male physicians from the trivia of family complaints and scorns
and female nurses. This appears to be a division the feminist collectivity; yet in this seemingly
that Nightingale supported. Because this “nat- solitary life, she finds union not with one man
ural” division of labor was rooted in the family, but with all men, personified by the British
women’s work outside the home ought to re- soldier.
semble domestic tasks and complement the Lytton Strachey’s well-known evocation of
“male principle” with the “female.” Thus, nurs- Nightingale, iconoclastic and bold, is perhaps
ing was left on the shifting sands of a soon- closest to the decidedly masculine imagery she
outmoded “science”; the main focus of its selected to describe herself, as evidenced in this
authority grounded in an equally shaky moral imaginary speech to her mother written in
sphere, also subject to change and devaluation 1852:
in an increasingly secularized, rationalized, and
technological 20th century. Well, my dear, you don’t imagine with my “tal-
Nightingale failed to provide institutional- ents,” and my “European reputation” and my
ized nursing with an autonomous future, on an “beautiful letters” and all that, I’m going to stay
equal parity with medicine. She did, however, dangling around my mother’s drawing room all
succeed in providing women’s work in the my life! … [Y]ou must look upon me as your
public sphere, establishing for numerous vagabond son … I shan’t cost you nearly as much
women an identity and source of employment. as a son would have done, or had I married. You
Although that public identity grew out of must consider me married or a son. (Woodham-
women’s domestic and nurturing roles in the Smith, 1983, p. 66)
family, the conditions of a modern society re-
quired public as well as private forms of care. Ideas about Nursing
It is questionable whether more could have Every day sanitary knowledge, or the knowledge
been achieved at that point in time (King, of nursing, or in other words, of how to put the
1988). constitution in such a state as that it will have
A woman, Queen Victoria, presided over no disease, or that it can recover from disease,
the age: “Ironically, Queen Victoria, that takes a higher place.

panoply of family happiness and stubborn ad- —FLORENCE NIGHTINGALE, NOTES ON
versary of female independence, could not help NURSING (1860/1969), PREFACE
but shed her aura upon single women.” The
queen’s early and lengthy widowhood, her “re- Evelyn R. Barritt, professor of nursing and
lentlessly spreading figure and commensurately Nightingale scholar, suggested that nursing
increasing empire, her obstinate longevity became a science when Nightingale identified
which engorged generations of men and the the laws of nursing, also referred to as the laws
collective shocks of history, lent an epic quality of health, or nature (Barritt, 1973; Nightin-
to the lives of solitary women” (Auerbach, gale, 1860/1969). The remainder of all nursing
1982, pp. 120–121). Both Nightingale and the theory may be viewed as mere branches and
queen saw themselves as working through “acorns,” all fruit of the roots of Nightingale’s
men, yet their lives added new, unexpected, ideas. Early writings of Nightingale, compiled
and powerful dimensions to the myth of in Notes on Nursing: What It Is and What It
Victorian womanhood, particularly that of a Is Not (1860/1969), provided the earliest

7991_Ch04_033-054 14/08/19 1:39 PM Page 47
systematic perspective for defining nursing. Nightingale was firmly committed to “a de-
According to Nightingale, analysis and appli- termined, probabilistic social science” and
cation of universal “laws” would promote well- goes on to state that “Indeed, she [Nightin-
being and relieve the suffering of humanity. gale] described the laws of social science as
This was the goal of nursing. God’s laws for the right operation of the
As noted by the caring theorist Madeline world” (p. 186). Nightingale was convinced
Leininger, Nightingale never defined human of the necessity for evaluative statistics to
care or caring in Nightingale’s Notes on Nurs- underpin rational approaches to public ad-
ing (1859/1992, p. 31), and she goes on to ministrations. Consistently she used the pres-
wonder if Nightingale considered “compo- entation of statistical data to prove her case
nents of care such as comfort, support, nur- that the cost of disease, crime, and excess
turance, and many other care constructs and mortality was greater than the cost of sanitary
characteristics and how they would influence improvements. In later life, Nightingale en-
the reparative process.” Although Nightin- deavored to establish a chair or readership at
gale’s conceptualizations of nursing, hygiene, Oxford University to teach Quetelet’s statis-
the laws of health, and the environment never tical approaches and probability theory. In
explicitly identify the construct of caring, an today’s world, this would translate to a com-
underlying ethos of care and commitment to mitment to evidence-based practice as justi-
others echoes in her words and, most impor- fication for nursing’s value.
tant, resides in her actions and the drama of Karen Dennis and Patricia Prescott (1985)
her life. noted that including Nightingale among the
Nightingale did not theorize in the way nurse theorists has been a recent development.
to which we are accustomed today. Patricia They make the case that nurses today continue
Winstead-Fry (1993), in a review of the 1992 to incorporate in their practice the insight,
commemorative edition of Nightingale’s Notes foresight, and, most important, the clinical
on Nursing (1859/1992), states: acumen of Nightingale’s more than century
and a half vision of nursing. As part of a larger
Given that theory is the interrelationship of con- study, they collected a large base of descrip-
cepts which forms a system of propositions that tions from both nurses and physicians describ-
can be tested and used for predicting practice, ing “good” nursing practice. More than 300
Nightingale was not a theorist. None of her major individual interviews were subjected to content
biographers present her as a theorist. She was a analysis; categories were named inductively
consummate politician and health care reformer. and validated separately by four members of
(p. 161) the project staff.
Additionally, our emerging 21st century has Noting no marked differences in the de-
never been more in need of nurses who are scriptions obtained from either the nurses or
consummate politicians and health-care re- physicians, the authors report that despite
formers. Her words and ideas, contextualized their independent derivation, the categories
in the earlier portion of this chapter, ring dif- that emerged during the study bore a striking
ferently than those of the other nursing theo- resemblance to nursing practice as described
rists you will study in this book. However, her by Nightingale: prevention of illness and
underlying ideas continue to be relevant and, promotion of health, observation of the sick,
some would argue, prescient. and attention to the physical environment.
Lynn McDonald, Canadian professor of Also referred to by Nightingale as the “health
sociology and editor of the Collected Works of of houses,” this physical environment in-
Florence Nightingale, a 16-volume collection, cluded ventilation of both the patient’s rooms
places Nightingale among the most promi- and the larger environment of the “house”:
nent “Women Methodologists” identified in light, cleanliness, and the taking of food;
The Women Founders of the Social Sciences attention to the interpersonal milieu, which
(McDonald, 1994). McDonald notes that included variety; and not indulging in

7991_Ch04_033-054 14/08/19 1:39 PM Page 48
superficialities with the sick or giving them Nightingale’s Assumptions

false encouragement. 1. Nursing is separate from medicine.
The authors noted that “the words change 2. Nurses should be trained.
but the concepts do not” (Dennis & Prescott, 3. The environment is important to the
1985, p. 80). In keeping with the tradition es- health of the patient.
tablished by Nightingale, they noted that 4. The disease process is not important to
nurses continue to foster an interpersonal mi- nursing.
lieu that focuses on the person while manipu- 5. Nursing should support the environment
lating and mediating the environment to “put to assist the patient in healing.
the patient in the best condition for nature to 6. Research should be used through observa-
act upon him (sic)” (Nightingale, 1860/1969, tion and empirics to define the nursing
p. 133). discipline.
Afaf I. Meleis (1997), nurse scholar, does 7. Nursing is both an empirical science and
not compare Nightingale to contemporary an art.
nurse theorists; nonetheless, she refers to 8. Nursing’s concern is with the person in
her frequently. Meleis stated that it was the environment.
Nightingale’s conceptualization of environ- 9. The person is interacting with the
ment as the focus of nursing activity and her environment.
de-emphasis of pathology, emphasizing in- 10. Sickness and wellness are governed by
stead the “laws of health” (which she said the same laws of health.
were yet to be identified) that were the ear- 11. The nurse should be observant and
liest differentiation of nursing and medicine. confidential.
Meleis (1997) described Nightingale’s con-
cept of nursing as including “the proper use The goal of nursing as described by
of fresh air, light, warmth, cleanliness, quiet, Nightingale is assisting the patient in his or
and the proper selection and administration her retention of “vital powers” by meeting
of diet, all with the least expense of vital his or her needs, and thus, putting the pa-
power to the patient” (pp. 114–116). These tient in the best condition for nature to act
ideas clearly had evolved from Nightingale’s upon (Nightingale, 1860/1969). This must
observations and experiences. The art of not be interpreted as a “passive state” but
observation was identified as an important rather one that reflects the patient’s capacity
nursing function in the Nightingale model, for self-healing facilitated by nurses’ ability
and this observation was what should form to create an environment conducive to
the basis for nursing ideas. Meleis speculates health. The focus of this nursing activity was
on how differently the theoretical base of the proper use of fresh air, light, warmth,
nursing might have evolved if we had contin- cleanliness, quiet, proper selection and ad-
ued to consider extant nursing practice as a ministration of diet, monitoring the patient’s
source of ideas. expenditure of energy, and observing. This
Pamela Reed and Tamara Zurakowski (1983/ activity was directed toward the environ-
1989, p. 33) called the Nightingale model ment and the patient (see Nightingale’s
“visionary.” They stated: “At the core of all the- Assumptions).
ory development activities in nursing today is Health was viewed as an additive process—
the tradition of Florence Nightingale.” They the result of environmental, physical, and psy-
also suggest four major factors that influenced chological factors, not just the absence of
her model of nursing: religion, science, war, disease. Disease was the reparative process of
and feminism, all of which are discussed in this the body to correct a problem and could pro-
chapter. vide an opportunity for spiritual growth. The
The following assumptions were identified laws of health, as defined by Nightingale, were
by Victoria Fondriest and Joan Osborne those to do with keeping the person, and the
(1994). population, healthy. They were dependent on

7991_Ch04_033-054 14/08/19 1:39 PM Page 49
proper environmental control, for example, this marriage flows directly from Nightingale’s
sanitation. The environment was what the underlying religious and philosophical views,
nurse manipulated; it included the physical el- which were operationalized in her nursing prac-
ements external to the patient. tice. Nightingale was an empiricist, valuing the
Nightingale isolated five environmental “science” of observation with the intent of using
components essential to an individual’s that knowledge to better the life of humankind.
health: clean air, pure water, efficient The application of that knowledge required an
drainage, cleanliness, and light. The patient artist’s skill, far greater than that of the painter
is at the center of the Nightingale model, or sculptor:
which incorporates a holistic view of the per-
son as someone with psychological, intellec- Nursing is an art; and if it is to be made an art, it
tual, and spiritual components. This is requires as exclusive a devotion, as hard a prepa-
evidenced in her acknowledgment of the im- ration, as any painter’s or sculptor’s work; for
portance of “variety.” For example, she wrote what is the having to do with dead canvas or cold
of “the degree … to which the nerves of the marble, compared with having to do with the liv-
sick suffer from seeing the same walls, the ing body—the Temple of God’s spirit? It is one of
same ceiling, the same surroundings” the Fine Arts; I had almost said, the finest of the
(Nightingale, 1860/1969). Likewise, her Fine Arts. (Florence Nightingale, cited in Donahue,
chapter on “chattering hopes and advice” il- 1985, p. 469)
lustrates an astute grasp of human nature and Nightingale’s ideas about nursing health, the
of interpersonal relationships. She remarked environment, and the person were grounded in
on the spiritual component of disease and ill- experience; she regarded one’s sense observa-
ness, and she felt they could present an options as the only reliable means of obtaining and
portunity for spiritual growth. In this, all verifying knowledge. Theory must be reformu-
persons were viewed as equal. lated if inconsistent with empirical evidence.
A nurse was defined as any woman who This experiential knowledge was then to be
had “charge of the personal health of some- transformed into empirically based generaliza-
body,” whether well, as in caring for babies tions, an inductive process, to arrive at, for
and children, or sick, as an “invalid” example, the laws of health. Regardless of
(Nightingale, 1860/1969). It was assumed Nightingale’s commitment to empiricism and
that all women, at one time or another in experiential knowledge, her early education and
their lives, would nurse. Thus, all women religious experience also shaped this emerging
needed to know the laws of health. Nursing knowledge (Hektor, 1992).
proper, or “sick” nursing, was both an art and According to Nightingale’s model, nursing
a science and required organized, formal ed- contributes to the ability of persons to main-
ucation to care for those suffering from dis- tain and restore health directly or indirectly
ease. Above all, nursing was “service to God through managing the environment. The
in relief of man”; it was a “calling” and person has a key role in his or her own health,
“God’s work” (Barritt, 1973). Nursing activ- and this health is a function of the interaction
ities served as an “art form” through which among person, nurse, and environment.
spiritual development might occur (Reed & However, neither the person nor the environ-
Zurakowski, 1983/1989). All nursing actions ment is discussed as influencing the nurse
were guided by the nurses’ caring, which was (Fig. 4-5).
guided by underlying ideas about God. Although it is difficult to describe the inter-
Consistent with this caring base is Nightin- relationship of the concepts in the Nightingale
gale’s views on nursing as an art and a science. model, Figure 4-6 is a schema that attempts to
Again, this was a reflection of the marriage, es- delineate this. Note the prominence of “obser-
sential to Nightingale’s underlying worldview, of vation” on the outer circle (important to all
science and spirituality. On the surface, these nursing functions) and the interrelationship of
might appear to be odd bedfellows; however, the specifics of the interventions, such as “bed

7991_Ch04_033-054 14/08/19 1:39 PM Page 50
Observation
by Nelson and Rafferty (2010), Notes on
Nightingale: The Influence and Legacy of a Nurs-
Personal cleanliness ing Icon, compares problems and issues faced
Petty management by Nightingale with those of modern-day
nursing practice. Additionally, Johnson (2017)
Light
published Nightingale’s Vision: Advancing the
Health of houses Nursing Profession Beyond 2020, a book detail-
ing ways Nightingale’s vision aligns with the
Cleanliness of rooms
2010 Institute of Medicine’s (IOM) Future of
Ventilation and warming Nursing recommendations, while serving as a
reference to guide nurses in the advancement
Bed and bedding
of their profession over the next decade.
Taking food Nightingale never explicitly identified her
What food?
work as a theory according to modern stan-
dards; however, she has in recent years been
Noise included among nursing theorists, as noted by
Order
of Chattering hopes Dennis and Prescott (1985). Multiple nurse
significance and advices
scholars, however, have conducted analyses of
Variety
Nightingale’s writings using various frame-
works for defining theory and confirm that
FIG 4-5 ■ Perspective on Nightingale’s 13 canons.
Illustration developed by V. Fondriest, RN, BSN,
Nightingale developed “the original theory of
and J. Osborne, RN, C BSN, in October 1994. nursing theory” (Selander, 2010, p. 87). Even
though Nightingale did not specifically write
in terms of the paradigm of nursing, her
and bedding” and “cleanliness of rooms and written documents contain her philosophical
walls,” that go into making up the “health of assumptions and beliefs and contain “all ele-
houses” (Fondriest & Osborne, 1994). ments found in the metaparadigm of nursing”
(Selander, p. 81). Hegge (2013) extracts En-
vironmental Theory from the writings and
Applications to Practice recorded experiences of Nightingale and writes
Philip Kalisch and Beatrice Kalisch (1987, that although Nightingale herself did not
p. 26) described the popular and glorified im- “distill her philosophical beliefs into a theory,
ages that arose out of the portrayals of Florence yet rudimentary elements of a grand theory
Nightingale during and after the Crimean emerge from her writings” (p. 211). Aswalkhan
War—that of nurse as self-sacrificing, refined, and Muhammad (2016) systematically analyze
virginal, and an “angel of mercy,” a far less Nightingale’s writings and claim that Nightin-
threatening image than one of educated and gale was a “pioneer nurse theorist and founder
skilled professional nurses. They attribute of modern nursing.” Another systematic analy-
nurses’ low pay to the perception of nursing as sis of Nightingale’s Environmental Theory was
a “calling,” a way of life for devoted women conducted using both primary and secondary
with private means, such as Florence Nightin- sources to judge the utility of the theory to the
gale (Kalisch & Kalisch, 1987, p. 20). Well practice of nursing (Medeiros, Enders, & Lira,
over 100 years later, the amount of scholarship 2015). The authors conclude that Nightingale’s
on Nightingale provides a more realistic por- Environmental Theory contains concepts that
trait of a complex and brilliant woman. Other are relevant and meet parameters applicable to
publications and initiatives demonstrate ways the practice of nursing in today’s health-care
Nightingale’s basic tenets of professional nurs- environment.
ing practice remain relevant to issues faced by Florence Nightingale’s legacy of caring and
nurses in today’s health-care environment the activism it implies is carried on in nursing
(Attewell, 2010; Beck, 2010). A book edited today. There is a resurgence and inclusion of

7991_Ch04_033-054 14/08/19 1:39 PM Page 51
“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
FIG 4-6 ■ Nightingale’s model of nursing and the environment. Illustration developed by V. Fondriest, RN,
BSN, and J. Osborne, RN, C BSN.
concepts of spirituality in current nursing genuine—that are congruent with Nightin-

practice and a delineation of nursing’s caring gale’s threefold concept of nursing and then
base that in essence began with the nursing cross-validated the findings using Watson’s
life of Florence Nightingale. Nightingale’s caritive factors. These findings revealed that
caring, as demonstrated in this chapter, ex- “the phenomenon of caring relationships in
tended beyond the individual patient, beyond nursing has been part of our professional lan-
the individual person. She herself said that the guage since Victorian times” (p. 225). Arnone
specific business of nursing was the least im- and Fitzsimons (2015) provide a historical
portant of the functions into which she had perspective exploring the writings of Plato and
been forced in the Crimea. Her caring encom- ways his philosophy influenced Nightingale’s
passed a broadened sphere—that of the holistic concepts of person, health, and the
British Army and, indeed, the entire British environment, claiming, “Plato’s and Nightin-
Commonwealth. Wagner and Whaite (2010) gale’s holistic, scientific, and humanistic ap-
conducted a qualitative, historical field study proach to living, and to care practice in all its
using a latent content analysis of selected dimensions, grounds the discipline of nursing”
Nightingale works to identify the nature and (p. 156). Nightingale’s role in establishing
attributes of caring relations as depicted in her nursing as a learned discipline is grounded in
writings. The analysis identified five themes her understanding of human beings and the
that represented a caring relationship—attend environment (Koffi & Fawcett, 2016; Hegge
to, attention to, nurture, competent, and & Bunkers, 2017).

7991_Ch04_033-054 14/08/19 1:39 PM Page 52
Nightingale envisioned a modern public Theory of Nursing and the Environment can be
health-care system that included not only nurs- applied in resource-poor areas of the world with
ing but a system based on health promotion diverse populations and conditions (Awalkhan
and disease prevention which was grounded in & Muhammad, 2016; Kamau, Rotich, Cheruiyot,
her statistical arguments and powers of obser- & Ng’eno, 2015; Pirani, 2016; Rahim, 2013;
vation (Lee, Clark, & Thompson, 2013). The Sayani, 2017). Original research done by Roque
BBC (2018) provides a webpage exploring and Carraro (2015) uses Nightingale’s Theory
ways Florence Nightingale saved lives through of Nursing and the Environment to explore the
statistics presented using a timeline from 1820 perceptions of high-risk postpartum mothers
to 1910 situating Nightingale’s work within the about the hospital environment during the hos-
backdrop of the time period. McDonald (2010) pitalization of their newborn infants in the
describes how Nightingale’s holistic approach southern region of Brazil. The study emphasizes
to health care was grounded in statistics, “for it that both external and internal (psychological)
was statistical analysis that taught her the im- environments are important in the recovery of
portance of the environment, social, and bio- these women and both should be taken into
physical, both in regard to susceptibility to consideration as a way of providing holistic and
disease and treatment outcomes” (p. 92). effective nursing care.
Themes in contemporary nursing practice Nightingale’s writings have generated a
focusing on evidence-based practice and cur- wealth of knowledge solidifying and extending
ricula championing cultures of safety and qual- Nightingale’s model and philosophy of nursing
ity are all found in the life and works of as foundational to contemporary nursing prac-
Florence Nightingale. I would venture to say tice (Norman, 2013; Stichler, 2014). Perhaps
that almost all contemporary nursing practice another indicator of the relevance of Nightin-
settings echo some aspect of the ideas—and gale’s work to contemporary nursing practice
ideals—of Nightingale. Themes of Nightingale, is connected to the Nightingale Initiative for
the environmentalist, are critical to nursing Global Health (NIGH, 2017). The NIGH
practice for the individual, the community, was started in 2014 and is a “grassroots, nurse-
and global health. Cleanliness and lack of hy- inspired movement to increase global public
giene, especially hand hygiene, remain a lead- concern for and commitment to the priority of
ing cause of hospital-acquired infections in human health” (http://www.nighvision.net/).
addition to poor standards in cleaning effec- Another tribute to the enduring legacy left by
tiveness, which support the relevance of Florence Nightingale is evident in the collab-
Nightingale’s philosophy on nursing and the orative effort initiated in 2014 to establish a
environment to current nursing practice digital collection of Nightingale’s work. The
(Davies, 2012; Lee, Clark, & Thompson, Florence Nightingale Digitization Project: An
2013). A review of the literature identified International Digital Collaborative contains a

67 health-care design–related articles from collection of over 2,300 handwritten or nar-
25 nursing journals to discover the impact of rated letters by Florence Nightingale that are
health-care environments that have resonance accessible to the public through a portal hosted
with aspects of Florence Nightingale’s Envi- by Boston University (http://hgar-srv3.bu.edu/
ronmental Theory (Zborowsky, 2014). The au- web/florence-nightingale/home).
thor used descriptive statistics to reveal that the An exemplar of practice personifying
most frequently cited topics were in patient Nightingale’s approach and practice would be
care quality and safety in acute and intensive a larger-than-life nurse hero or heroine cham-
care environments. pioning current health-care reform by de-
The environmental tenets put forth by signing health-care systems that are truly
Nightingale continue to have relevance to the responsive to the needs of the populace and
current/modern practice of nursing. For exam- that extend cross-culturally and globally. To
ple, many articles utilizing case studies have quote Auerbach (1982) and Strachey (1918),
been written to demonstrate ways Nightingale’s she was “a demon, a rebel.”

7991_Ch04_033-054 14/08/19 1:39 PM Page 53
Practice Exemplar
Written by Marlaine C. Smith, RN, PhD, AHN-BC, Ms. Sheffield assessed that the environ-
HWNC-BC, FAAN ment was not conducive to Mr. Martin’s
Mr. Martin, a 68-year old man, lived alone healing. She asked Mr. Martin about the
in a small one-room apartment located in a condition of the apartment and he said that
run-down tenement complex in the middle he just “couldn’t keep up.” After asking him
of the city. He was referred to receive home- some questions, she was concerned that he
care services after a mild myocardial infarc- could be clinically depressed. She asked
tion. He had type II diabetes mellitus and Mr. Martin if he would like her to help with
had damage to his right leg from an injury getting the apartment cleaned, organized,
sustained in combat. He walked hesitantly and stocked with the food and supplies that
with a walker. He had a history of alcohol use he needed. He said he’d be very grateful for
and he smoked two packs of cigarettes a day. the help.
Mr. Martin’s income was Social Security It was a beautiful spring day and Ms. Sheffield
and a small check from the VA for a service- opened the two screened windows to ventilate
connected disability. the apartment. The fresh air and sunshine
Ms. Sheffield, the home-care nurse, visited warmed the room. Ms. Sheffield began mak-
Mr. Martin the first day after his discharge ing calls. First, she called the social work de-
from the hospital. When she entered the one- partment and asked for a social worker to join
room apartment she was shocked at what she her in the apartment for an urgent consulta-
observed. Mr. Martin was seated in a chair tion. She called the apartment manager and
watching TV. Around him were piles of dirty requested immediate pest control services,
dishes, paper plates, and Styrofoam contain- and then called “Meals on Wheels” so that
ers. Ashtrays piled with cigarette butts were in Mr. Martin could have meals delivered to his
several locations. The bed had no linens on it; home at a reasonable cost to him. When the
the mattress was visibly stained. The kitchen social worker arrived they both talked with
area consisted of a small sink, microwave, and Mr. Martin about bringing in a cleaning serv-
cooktop. There were dishes piled up in the ice that was offered through the Area Agency
sink. The bathroom consisted of a toilet and on Aging. This was an affordable service to
small shower; both were dirty and with visible him. Mr. Lewis, the social worker, made the
mold. A cat roamed around the apartment; it calls and requested a “heavy cleaning.” He
appeared that the litter hadn’t been emptied asked the service to bring linens for the bed,
for weeks. The smell of the apartment was and explained the conditions in the apart-
overwhelming, and there were cockroaches ment. He called for a laundry service to come
crawling on the floor and countertops. by and pick up soiled clothing and made an
Ms. Sheffield first attended to Mr. Martin. appointment to return to review Mr. Martin’s
She asked how he was doing since his dis- finances and eligibility for any other services.
charge. He told her that he was very tired and Ms. Sheffield made referrals for a home
couldn’t get out to get food. His medications health aide to visit two days a week to assist
were delivered from the pharmacy and he was Mr. Martin with bathing and other activities
taking them as prescribed. His vital signs were of daily living. She encouraged Mr. Martin to
normal for him and his lungs were clear. There call if he needed any other assistance and that
were no signs of dependent edema. He re- she would return in several days to check on
ported that he was comfortable, but needed him again.
help getting food for him and his cat. He told When Ms. Sheffield returned to the office,
her that he loved listening to his favorite CDs, she contacted the Goodwill resale shop and
but his CD player was broken. explained the situation to them. They had a
(continued)

7991_Ch04_033-054 14/08/19 1:39 PM Page 54
Practice Exemplar (continued)

CD player and a few framed pictures and smiled and thanked her for arranging for
accessories that they were willing to donate. Meals on Wheels to come. His vital signs
Ms. Sheffield picked them up and brought were within his normal range, lungs clear, no
them to her next home visit to Mr. Martin’s dependent edema, and he was taking his med-
apartment four days later. ications as prescribed. She showed him the
When she entered the apartment, she was CD player, framed pictures, and vases with
surprised at the difference. The apartment was some silk flowers. He liked the pictures and
orderly and cleaned. The window was open flowers and was extremely grateful for the CD
with sunlight streaming in. Mr. Martin was player. He immediately put one of his favorite
eating his lunch from Meals on Wheels. CDs in and they listened to it together. He
Mr. Martin seemed to have more energy. He said he felt better than he had in a long time.
Summary
The unique aspects of Florence Nightingale’s values of caring in an unjust health-care system
personality and social position, combined with that does not value caring. Let us look again to
historical circumstances, laid the groundwork Florence Nightingale for inspiration, for she
for the evolution of the modern discipline of remains a role model par excellence on the
nursing. Are the challenges and obstacles that transformation of values of caring into an ac-
we face today any more daunting than what tivism that could potentially transform our cur-
confronted Nightingale when she arrived in rent health-care system into a more humanistic
the Crimea in 1854? Nursing for Florence and just one. Her activism situates her in the
Nightingale was what we might call today her context of justice making. Justice making is un-
“centering force.” It allowed her to express her derstood as a manifestation of compassion and
spiritual values and enabled her to fulfill her caring, for it is actions that bring about justice
needs for leadership and authority. As historian (Boykin & Dunphy, 2002, p. 16). Florence
Susan Reverby noted, today we are challenged Nightingale’s legacy of connecting caring with
with the dilemma of how to practice our integral activism can then truly be said to continue.
Questions for Reflection ■ How do Nightingale’s ideas about nursing

relate to the metaparadigm of nursing?
and Discussion ■ How do Nightingale’s ideas about the
■ How do Nightingale’s ideas about spiri- environment apply to contemporary

tuality relate to contemporary nursing nursing practice?
theories?

7991_Ch05_055-066 12/08/19 5:18 PM Page 55
Early Conceptualizations
CHAPTER
5
About Nursing
Shirley C. Gordon
Introducing the Theorists

Overview of the Conceptualizations of Nursing
Applications of the Theories Introducing the Theorists
Practice Exemplars Ernestine Wiedenbach, Virginia Henderson,
Summary and Lydia Hall were three of the most important
Questions for Reflection and Discussion nursing scholars to influence the development
of nursing theory during the mid-20th century.
Their work, based on insights and reflec-
tions from the practice of nursing, continues to
ground nursing thought throughout the current
century. Concepts and terms first used in their
practice theories continue to echo around the
globe.
This chapter provides a brief introduction
to the theorists Wiedenbach, Henderson, and
Hall; an overview of their nursing conceptual-
izations; sections on practice applications and
practice exemplars based on their published
works; and questions for reflection and discus-
sion. The content of this chapter is partially
based on work from scholars who have studied
or worked with these theorists in addition to
those individuals who wrote this chapter in
earlier versions of this text (Gesse, Dombro,
Gordon, & Rittman, 2006, 2010; Gordon,
2001; Touhy & Birnbach, 2006, 2010).1
Ernestine Wiedenbach
Wiedenbach was born in 1900 in Germany to
an American mother and a German father, who
immigrated to the United States when Ernes-
tine was a child. She received a Bachelor of Arts
degree from Wellesley College in 1922 and
graduated from Johns Hopkins School of Nurs-
ing in 1925 (Nickel, Gesse, & MacLaren,
1992). After completing a master of arts at
Columbia University in 1934, she became a
professional writer for the American Journal
of Nursing and played a critical role in the
1For additional information, see the bonus chapter content
available at http://davisplus.fadavis.com.
55
7991_Ch05_055-066 12/08/19 5:18 PM Page 56
recruitment of nursing students and military lived it: focusing on what nurses do, how
nurses during World War II. At age 45, nurses function, and nursing’s unique role in
she began her studies in nurse-midwifery. health care.
Wiedenbach’s roles as practitioner, teacher, Henderson entered Teachers College at
author, and theorist were strengthened as a Columbia University, earning her baccalaure-
member of the Yale University School of Nurs- ate degree in 1932 and her master’s degree in
ing. While at Yale, Wiedenbach’s colleagues 1934. She continued at Teachers College as an
William Dickoff and Patricia James encouraged instructor and associate professor of nursing
her to further develop Prescriptive Theory for the next 20 years.
(Dickoff, James, & Wiedenbach, 1968). Even In the 1950s, there was an increasing inter-
after Wiedenbach retired in 1966, she and her est on the part of the profession to establish a
lifelong friend Caroline Falls offered informal research basis for nursing practice. It was also
seminars in Miami, always reminding students recognized that the body of nursing knowledge
and faculty of the need for clarity of purpose, was unstructured and therefore inaccessible
based on reality. Wiedenbach even continued to practicing nurses and educators. In 1955,
to use her gift for writing by transcribing books Henderson moved to Yale University and
for the blind, including a Lamaze childbirth began what would become a distinguished ca-
manual, which she prepared on her Braille reer in library science research.
typewriter. Ernestine Wiedenbach died in Henderson encouraged nurses to become
April 1998 at the age of 98. active in the work of classifying nursing liter-
ature. Of all her contributions to nursing,
Virginia Henderson Henderson’s work on the identification and
Born in Kansas City, Missouri, in 1897, control of nursing literature is perhaps her
Virginia Avenel Henderson was the fifth of greatest. In 1990, the Sigma Theta Tau Inter-
eight children. With two of her brothers serv- national Library was named in her honor.
ing in the armed forces during World War I
and in anticipation of a critical shortage of Lydia Hall
nurses, Virginia Henderson entered the Army Lydia Hall, born in 1906, was a visionary and
School of Nursing at Walter Reed Army Hos- risk taker. A 1927 graduate of the York Hos-
pital. It was there that she began to question pital School of Nursing in Pennsylvania, Hall
the regimentation of patient care and the held various nursing positions during the early
concept of nursing as ancillary to medicine years of her career. In the mid-1930s, she en-
(Henderson, 1991). rolled at Teachers College, Columbia Univer-
Henderson considered it a privilege to care sity, where she earned a Bachelor of Science
for sick and wounded soldiers (Henderson, degree (1937) and a Master of Arts degree
1960). This wartime experience forever influ- (1942). She worked with the Visiting Nurse
enced her ethical understanding of nursing and Service of New York from 1941 to 1947 and
her appreciation of the importance and com- was a member of the nursing faculty at Ford-
plexity of the nurse–patient relationship. ham Hospital School of Nursing from 1947 to
During a summer spent with the Henry 1950. Hall joined the faculty at Teachers Col-
Street Visiting Nurse Agency in New York lege, where she developed and implemented a
City, Henderson gained an appreciation of the nursing consultation program and engaged in
importance of getting to know patients and research activities for the U.S. Public Health
their environments and began to question the Service (Birnbach, 1988).
ability of hospital regimens to alter patients’ Hall’s most significant contribution to
unhealthy ways of living upon returning home nursing practice was the patient-centered prac-
(Henderson, 1991). Virginia Henderson was tice model she designed and put into place
one of the first to venture into describing in the Loeb Center for Nursing and Rehabil-
the complex phenomena of modern nursing. itation at Montefiore Medical Center in
Henderson wrote about nursing the way she New York. The Loeb Center opened in 1963

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C H APTER 5 ■ Early Conceptualizations About Nursing 57
under Hall’s direction and in collaboration of nursing practice and scholarship, all focus-
with Dr. Martin Cherkasky. A unique feature ing on the essential question of “What is
of the Center was a separate board of trustees, nursing?”
which afforded Hall considerable autonomy in
developing the Center’s policies and proce- Wiedenbach’s Prescriptive Theory
dures. As a result, she increased the role of Wiedenbach’s initial work on Prescriptive The-
nurses in decision making and encouraged ory is presented in her article in the American
nurses to work with patients as active partici- Journal of Nursing (1963) and her book Meeting
pants in achieving desired outcomes that were the Realities in Clinical Teaching (1969).
meaningful to the patients. A significant de- Wiedenbach’s explanation of Prescriptive
cline in the number of readmissions among Theory stated: “Account must be taken of the
former Loeb patients as compared with those motivating factors that influence the nurse not
who received other types of posthospital care only in doing what she [sic] does, but also in
(“Montefiore cuts,” 1966) validated the effec- doing it the way she [sic] does it with the real-
tiveness of Hall’s practice model. ities that exist in the situation in which she [sic]
Hall, who died in 1969, is remembered is functioning” (Wiedenbach, 1970, p. 2).
for successfully implementing a professional Three ingredients are essential to the Prescrip-
nursing patient-centered framework at a time tive Theory:
when task-oriented team nursing was the pre-
ferred practice model in most institutions. The 1. The nurse’s central purpose in nursing is
American Nurses’ Association (ANA) in- the nurse’s professional commitment. For
ducted Hall posthumously into the ANA Hall Wiedenbach, the central purpose in nurs-
of Fame in 1984. ing is to motivate the individual and/or
facilitate efforts to overcome the obstacles
that may interfere with the ability to
Overview of the respond capably to the demands made
by the realities within the situation
Conceptualizations (Wiedenbach, 1970, p. 4). She empha-
of Nursing sized that the nurse’s goals are grounded
Each of the theorists in this chapter challenged in the nurse’s philosophy, “those beliefs
nurses to think about nursing in new and ex- and values that shape her [sic] attitude
citing ways. Ernestine Wiedenbach provided toward life, toward fellow human beings
new ways for nurses to think about nursing and toward herself [sic]” (Wiedenbach,
practice and nursing scholarship by introduc- 1970, p. 4). The three concepts that epit-
ing nurses to the ideas of nursing as a profes- omize the essence of such a philosophy
sional practice discipline and nursing are (1) reverence for the gift of life;
practice theory. Virginia Henderson, some- (2) respect for the dignity, autonomy,
times known as the modern-day Florence worth, and individuality of each
Nightingale, developed the definition of nurs- human being; and (3) resolution to act
ing that is most well known internationally. dynamically in relation to one’s beliefs
Lydia Hall challenged nurses to think concep- (Wiedenbach, 1970, p. 4).
tually about the key role of professional nurs- 2. The “prescription” indicates the broad general
ing. Each of these nurse scholars helped action that the nurse deems appropriate to
nursing focus on the patient, instead of on the fulfillment of his or her central purpose. The
tasks to be done, and to plan care to meet the nurse will have thought through the kind
needs of the person. Each emphasized nursing of results to be sought and will act to ob-
as caring, from the perspective of the individ- tain these results, accepting accountability
ual being cared for—through observing, com- for what he or she does and for the out-
municating, designing, and reporting. Each comes of any action. Nursing action,
scholar was concerned with the unique aspects then, is deliberate action that is mutually

7991_Ch05_055-066 12/08/19 5:18 PM Page 58
understood and agreed on and that is textbook that her often-quoted definition of
both patient directed and nurse directed nursing first appeared:
(Wiedenbach, 1970, p. 5).
3. The realities are the aspects of the immediate Nursing is primarily assisting the individual (sick
nursing situation that influence the results the or well) in the performance of those activities
nurse achieves through what he or she does contributing to health or its recovery (or to a
(Wiedenbach, 1970, p. 3). These include peaceful death), that he [sic] would perform un-
the physical, psychological, emotional, and aided if he [sic] had the necessary strength, will,
spiritual factors in which nursing action or knowledge. It is likewise the unique contribu-
occurs. Within the situation are these tion of nursing to help people be independent of
components: such assistance as soon as possible. (Harmer &
■ The agent, who is the nurse supplying Henderson, 1955, p. 4)
the nursing action In presenting her definition of nursing, Hen-
■ The recipient, or the patient receiving derson hoped to encourage others to develop
this action or on whose behalf the ac- their own working concept of nursing and nurs-
tion is taken ing’s unique function in society. She believed the
■ The framework, comprising situational definitions of the day were too general and failed
factors that affect the nurse’s ability to to differentiate nurses from other members of
achieve nursing results the health-care team, which led to the following
■ The goal, or the end to be attained questions: “What is nursing that is not also med-
through nursing activity on behalf of icine, physical therapy, social work, etc.?” and
the patient “What is the unique function of the nurse?”
■ The means, that is, the actions and (Harmer & Henderson, 1955, p. 4).
devices through which the nurse is Based on her definition of nursing and
enabled to reach the goal after coining the term basic nursing care,
Henderson identified 14 components of basic
Wiedenbach recognized that nurses have
nursing care that reflect needs pertaining to
different values and various commitments to
personal hygiene and healthful living, includ-
nursing and that to formulate one’s purpose in
ing helping the patient carry out the physi-
nursing is a “soul-searching experience.” She
cian’s therapeutic plan (Henderson, 1960;
encouraged each nurse to undergo this experi-
1966, pp. 16–17):
ence and be “willing and ready to present your
1. Breathe normally.
central purpose in nursing for examination and
2. Eat and drink adequately.
discussion when appropriate” (Wiedenbach,
3. Eliminate bodily wastes.
1970, p. 5).
4. Move and maintain desirable postures.
5. Sleep and rest.

Henderson’s Definition of Nursing 6. Select suitable clothes—dress and
and Components of Basic Nursing undress.
Care 7. Maintain body temperature within normal
While working on the revision of the Textbook range by adjusting clothing and modifying
of the Principles and Practice of Nursing (Harmer the environment.
& Henderson, 1955), Henderson focused on 8. Keep the body clean and well-groomed
the need to be clear about the function of and protect the integument.
nurses. She opened the first chapter with the 9. Avoid dangers in the environment and
following questions: “What is nursing and what avoid injuring others.
is the function of the nurse?” (Harmer & 10. Communicate with others in expressing
Henderson, 1955, p. 1). Henderson believed emotions, needs, fears, or opinions.
these questions were fundamental to anyone 11. Worship according to one’s faith.
choosing to pursue the study and practice 12. Work in such a way that there is a sense
of nursing. It is in the fifth revision of this of accomplishment.

7991_Ch05_055-066 12/08/19 5:18 PM Page 59
13. Play or participate in various forms of

recreation.
14. Learn, discover, or satisfy the curiosity The Person
that leads to normal development and Social sciences
Therapeutic use of self—
health and use the available health aspects of nursing
facilities. "The Core"
Hall’s Care, Core, and Cure Model

The Disease
Hall enumerated three aspects of the person as The Body Pathological and
patient: the person, the body, and the disease Natural and biological therapeutic sciences
sciences Seeing the patient and
(Hall, 1965). She envisioned these aspects as family through the
Intimate bodily care—
overlapping circles of Care, Core, and Cure aspects of nursing medical care—
"The Care" aspects of nursing
that influence each other. It was her belief that "The Cure"
Everyone in the health professions either neglects

or takes into consideration any or all of these, but FIG 5-1 ■ Care, Core, and Cure model. (From
each profession, to be a profession, must have an Hall, L. [1964, February]. Nursing: What is it? The
exclusive area of expertness with which it practices, Canadian Nurse, 60[2], 151. Reproduced with permission
from The Canadian Nurse.)
creates new practices, new theories, and intro-
duces newcomers to its practice. (Hall, 1965, p. 4)
Hall believed that medicine’s exclusive area overlap and change in size as the patient pro-
of expertness was disease, which includes gresses through a medical crisis to the reha-
pathology and treatment. The area of person, bilitative phase of the illness. In the acute care
which, according to Hall, had been sadly neg- phase, the Cure circle is the largest. During
lected, belongs to many professions, including the evaluation and follow-up phase, the Care
psychiatry, social work, and the ministry, among circle is predominant. Hall’s framework for
others. In contrast, she saw nursing’s expertise nursing has been described as the Care, Core,
as the area of the body. Hall clearly stated that and Cure Model.
the focus of nursing is the provision of intimate
bodily care. She reflected that the public has Care
long recognized this as belonging exclusively to Hall suggested that the part of nursing that is
nursing (Hall, 1958, 1964, 1965). In Hall’s concerned with intimate bodily care (e.g.,
opinion, to be expert, the nurse must know how bathing, feeding, toileting, positioning, moving,
to modify the care depending on the pathology dressing, undressing, and maintaining a health-
and treatment while considering the patient’s ful environment) belongs exclusively to nursing.
unique needs and personality. From her perspective, nursing is required when
Based on her view of the person as patient, people are not able to undertake bodily care ac-
Hall conceptualized nursing as having three tivities for themselves. Care provided the op-
aspects, and she delineated the area that is the portunity for closeness and required seeing the
specific domain of nursing and those areas nursing process as an interpersonal relationship
that are shared with other professions and (Hall, 1958). For Hall, the intent of bodily care
shown in Figure 5-1 (Hall, 1955, 1958, 1964, was to comfort the patient. Through comfort-
1965). ing, the patient as a person, as well as his or her
Hall believed that this model reflected the body, responds to the physical care. Hall cau-
nature of nursing as a professional interpersonal tioned against viewing intimate bodily care as a
process. She visualized each of the three over- task that can be performed by anyone:
lapping circles as an “aspect of the nursing
process related to the patient, to the support- To make the distinction between a trade and a
ing sciences and to the underlying philosoph- profession, let me say that the laying on of hands
ical dynamics” (Hall, 1958, p. 1). The circles to wash around a body is an activity, it is a trade;

7991_Ch05_055-066 12/08/19 5:18 PM Page 60
but if you look behind the activity for the rationale doctoring; and from practical nurses, second class
and intent, look beyond it for the opportunities nursing. Some nurses would like the public to get
that the activity opens up for something more en- first class nursing. Seeing the patient through [his
riching in growth, learning and healing produc- or her] medical care without giving up the nurtur-
tion on the part of the patient—you have got a ing will keep the unique opportunity that personal
profession. Our intent when we lay hands on the closeness provides to further [the] patient’s growth
patient in bodily care is to comfort. While the pa- and rehabilitation. (Hall, 1958, p. 3)
tient is being comforted, he [sic] feels close to the
comforting one. At this time, his [sic] person talks Core
out and acts out those things that concern him The third area, which Hall believed nursing
[sic]—good, bad, and indifferent. If nothing more shared with all the helping professions, was the
is done with these, what the patient gets is venti- core. Hall defined the core as using relation-
lation or catharsis, if you will. This may bring relief ships for therapeutic effect. This area empha-
of anxiety and tension but not necessarily learn- sized the social, emotional, spiritual, and
ing. If the individual who is in the comforting role intellectual needs of the patient in relation to
has in her [sic] preparation all of the sciences family, institution, community, and the world
whose principles she [sic] can offer a teaching- (Hall, 1955, 1958, 1965). Knowledge that
learning experience around his [sic] concerns, is foundational to the core is based on the so-
the ones that are most effective in teaching cial sciences and on therapeutic use of self.
and learning, then the comforter proceeds to Through the closeness offered by the provision
something beyond—to what I call “nurturer”— of intimate bodily care, the patient will feel
someone who fosters learning, someone who fos- comfortable enough to explore with the nurse
ters growing up emotionally, someone who even “who he [sic] is, where he [sic] is, where he [sic]
fosters healing. (Hall, 1969, p. 86) wants to go, and will take or refuse help in get-
ting there—the patient will make amazingly
Cure more rapid progress toward recovery and reha-
Hall (1958) viewed cure as being shared with bilitation” (Hall, 1958, p. 3). Hall believed that
medicine and asserted that this aspect of nurs- through this process, the patient would emerge
ing may be viewed as the nurse assisting the as a whole person.
doctor by assuming medical tasks/functions or The knowledge and skills necessary for the
as the nurse helping the patient through his or nurse to use self therapeutically include know-
her medical, surgical, and rehabilitative care in ing self and learning interpersonal skills. The
the role of comforter and nurturer. Hall was goals of the interpersonal process are to help
concerned that the nursing profession was as- patients to understand themselves as they par-
suming more and more of the medical aspects ticipate in problem focusing and problem solv-
of care while at the same time relinquishing ing. Hall discussed the importance of nursing
the nurturing process of nursing to less-well- with the patient as opposed to nursing at, to,
prepared persons. She expressed this concern or for the patient. Hall reflected on the value
by stating: of the therapeutic use of self by the profes-
sional nurse when she stated:
Interestingly enough, physicians do not have prac-
tical doctors. They don’t need them … they have The nurse who knows self by the same token can
nurses. Interesting, too, is the fact that most love and trust the patient enough to work with
nurses show by their delegation of nurturing to oth- him [sic] professionally, rather than for him tech-
ers, that they prefer being second class doctors to nically, or at him vocationally. Her [sic] goals
being first class nurses. This is the prerogative of cease being tied up with “where can I throw my
any nurse. If she [sic] feels better in this role, why nursing stuff around,” or “how can I explain my
not? One good reason why not for more and more nursing stuff to get the patient to do what we want
nurses is that with this increasing trend, patients him to do,” or “how can I understand my patient
receive from professional nurses second class so that I can handle him better.” Instead her

7991_Ch05_055-066 12/08/19 5:18 PM Page 61
goals are linked up with “what is the problem?” arch

and “how can I help the patient understand him- Rese
self?” as he participates in problem facing and Nu
rs
in
solving. In this way, the nurse recognizes that the
on llaboration g
Co
ti
power to heal lies in the patient and not in the
Ad
Ad
ca
n
tio m
edu
mi
nurse, unless she is healing herself. She takes
in
nist
fic
Nursing
ist
satisfaction and pride in her ability to help the pa-
Identi
ration
ration
tient tap this source of power in his continuous Experiencing
tion
Co-o
growth and development. She becomes comfort- individual
Adva
ruc
able working cooperatively and consistently with
on
din r
st
nc
members of other professions, as she meshes her
ati
n
Val
idation
a
tio
ed
C
ic
contributions with theirs in a concerted program n
bl
st
ns Nu
of care and rehabilitation. (Hall, 1958, p. 5)
u
io
u
rsi dy
P ng Organizat
Hall believed that the role of professional
nursing was enacted through the provision of
care that facilitates the interpersonal process
FIG 5-2 ■ Professional nursing practice focus and
and invites the patient to learn to reach the core
components. (Reprinted with permission from the
of his difficulties while seeing him through the Wiedenbach Reading Room [1962], Yale University School
cure that is possible. Through the professional of Nursing.)
nursing process, the patient has the opportu-
nity to see the illness as a learning experience
and conferring; consultation, i.e., conferencing,
from which he or she may emerge even health-
and seeking help or advice; and collaboration, i.e.,
ier than before the illness (Hall, 1965).
giving assistance or cooperation with members of
other professional or nonprofessional groups con-
cerned with the individual’s welfare. The content
Applications of the Theories of the fourth circle represents activities which are
Wiedenbach essential to the ultimate well-being of the experi-
Wiedenbach stated that “the practice of clini- encing individual, but only indirectly related to him
cal nursing is goal directed, deliberately carried [sic]: nursing education, nursing administration,
out, and patient centered” (Wiedenbach, 1964, and nursing organizations. The outermost circle
p. 23). Figure 5-2 represents a spherical model comprises research in nursing, publication, and
depicting the “experiencing individual” as the advanced study, the key ways to progress in every
central focus (Wiedenbach, 1964). This model area of practice. (Wiedenbach, 1962, p. 7)
and detailed chart were later edited and pub- Application of Wiedenbach’s Prescriptive
lished in Clinical Nursing: A Helping Art Theory was evident in her practice examples,
(Wiedenbach, 1964). In a paper titled “A which often related to general basic nursing
Concept of Dynamic Nursing” (Wiedenbach, procedures and to maternity nursing practice.
1962), the model is described as follows: VandeVusse (1997) describes an educational
project designed to guide the nurse midwife in
In its broadest sense, Practice of Dynamic Nursing articulating a professional philosophy of nurs-
may be envisioned as a set of concentric circles, ing using Wiedenbach’s theory and reflects
with the experiencing individual in the circle at its current publication of her theory in the nursing
core. Direct service, with its three components, literature.
identification of the individual’s experienced need
for help, ministration of help needed, and valida- Henderson
tion that the help provided fulfilled its purpose, fills Based on the assumption that nursing has a
the circle adjacent to the core. The next circle unique function, Henderson believed that
holds the essential concomitants of direct service: nursing independently initiates and controls
coordination, i.e., charting, recording, reporting, activities related to basic nursing care. Relating

7991_Ch05_055-066 12/08/19 5:18 PM Page 62
the conceptualization of basic care components Based on the success of the fifth edition
with the unique functions of nursing provided of the Textbook of the Principles and Practice
the initial foundation for introducing the con- of Nursing (Harmer & Henderson, 1955),
cept of independent nursing practice. In her Henderson was asked by the International
1966 publication The Nature of Nursing, Hen- Council of Nurses to prepare a short essay that
derson stated: could be used as a guide for nursing practice in
any part of the world. Despite Henderson’s be-
It is my contention that the nurse is, and should lief that it was difficult to promote a universal
be legally, an independent practitioner and able definition of nursing, Basic Principles of Nursing
to make independent judgments as long as he, or Care (Henderson, 1960) became an interna-
she, is not diagnosing, prescribing treatment for tional sensation. To date, it has been published
disease, or making a prognosis, for these are the in 29 languages and is referred to as the
physician’s functions. (Henderson, 1966, p. 22) 20th-century equivalent of Florence Nightin-
Furthermore, Henderson believed that func- gale’s Notes on Nursing (Nightingale, 1860,
tions pertaining to patient care could be catego- 1969). After visiting countries worldwide,
rized as nursing and non-nursing. She believed Henderson concluded that nursing varied from
that limiting nursing activities to “nursing care” country to country and rigorous attempts to
was a useful method of conserving professional define nursing have been unsuccessful, leaving
nurse power (Harmer & Henderson, 1955). She the “nature of nursing” largely an unanswered
defined non-nursing functions as those that are question (Henderson, 1991).
not a service to the person (mind and body) Henderson’s definition of nursing has had
(Harmer & Henderson, 1955). For Henderson, a lasting influence on the way nursing is prac-
examples of non-nursing functions included or- ticed around the globe. She was one of the first
dering supplies, cleaning and sterilizing equip- nurses to articulate that nursing had a unique
ment, and serving food (Harmer & Henderson, function yielding a valuable contribution to the
1955). health care of individuals. In the writing of
At the same time, Henderson was not in the Nature of Nursing (Henderson, 1966),
favor of the practice of assigning patients to Henderson stated her conceptualization of
lesser trained workers based on patient com- nursing within a universally available health-
plexity level. For Henderson, “all ‘nursing care system with partnerships among doctors,
care’ is essentially complex because it involves nurses, and other health-care workers.
constant adaptation of procedures to the needs Halloran (1996) considered the sixth edi-
of the individual” (Harmer & Henderson, tion of Principles and Practice of Nursing
1955, p. 9). (Henderson & Nite, 1978) to be “the most im-
As the authority on basic nursing care, portant single professional document written
Henderson believed that the nurse has the rein the 20th century” (p. 17). In this book, the
sponsibility to assess the needs of the individ- synthesis of nursing practice, education, the-
ual patient, help individuals meet their health ory, and research clearly demonstrated the
needs, and/or provide an environment in functions of professional nursing practice.
which the individual can perform activities Henderson was a lifelong supporter of
unaided. It is the nurse’s role, according to nursing research. In 1964, she published an in-
Henderson, “to ‘get inside the patient’s skin’ fluential review of nursing research highlight-
and supplement his [sic] strength, will or knowl- ing the need to increase research studies
edge according to his needs” (Harmer & focusing on the effect of nursing practice on
Henderson, 1955, p. 5). Conceptualizing the patients (Simmons & Henderson, 1964). This
nurse as a substitute for the patient’s lack of nec- publication resulted in a renewed interest in re-
essary will, strength, or knowledge to attain search studies focusing on the effects of nurs-
good health and to complete or make the pa- ing care on patient outcomes and the need for
tient whole highlights the complexity and research guided by nursing theory (Halloran,
uniqueness of nursing. 1996). Most recently, Henderson’s nursing

7991_Ch05_055-066 12/08/19 5:18 PM Page 63
theory has been applied to nursing situations if further care was needed. Doctors referred pa-
such as the following: (1) guiding the care of tients to the Center, and a professional nurse
patients who donate organs after brain death made admitting decisions. Criteria for admis-
and their families (Nicely & Delario, 2011); sion were based on the patient’s need for reha-
and (2) demonstrating the use of Henderson’s bilitation nursing. What made the Loeb Center
theory in clinical practice settings using a case unique was the model of professional nursing
scenario approach set in Pakistan featuring a implemented under Lydia Hall’s guidance. The
woman admitted to the hospital following two Center’s guiding philosophy used Hall’s philos-
failed suicide attempts (Ahtisham & Jacoline, ophy that during the rehabilitation phase of
2015). The case scenario emphasized how an illness experience, professional nurses were
Henderson’s theory provided the clinical nurse the best prepared to foster the rehabilitation
with the “framework to recognize care needs, process, decrease complications and recurrences,
deliver and evaluate holistic nursing care” and promote health and prevent new illnesses.
(Ahtisham & Jacoline, 2015, p. 449). Hall watched these outcomes being accom-
plished through the special and unique way
Hall nurses work with patients in a close interper-
In 1963, Lydia Hall was able to actualize her vi- sonal process focused on fostering learning,
sion of nursing through the creation of the Loeb growth, and healing. A 2007 publication apply-
Center for Nursing and Rehabilitation at Mon- ing Hall’s theory described the role of home
tefiore Medical Center. The Center’s major health nurse management of patients with heart
focus was rehabilitation and subsequent dis- failure and hospital readmissions (McCoy,
charge to home or to long-term care institutions Davidhizar, & Gillum, 2007).
Practice Exemplar
Wiedenbach encouraged her to compare her current ex-
For Wiedenbach, the focus of nursing prac- perience with that of her sister. When the
tice is the individual for whom the nurse is mother did this, she recognized gross differ-
caring and the way this person perceives his ences between her experience and that of her
or her condition or situation. The following sister, and accepted the nurse’s explanation
description serves as a practice exemplar of that the discharge was normal. The mother
the use of Wiedenbach’s conceptual model: voiced her relief and validated it by getting
Mrs. A was experiencing a red vaginal out of bed without further encouragement
discharge on her first postpartum day. The (Wiedenbach, 1962, pp. 6–7). Wiedenbach
doctor recognized it as lochia, a normal con- considered nursing a “practical phenomenon”

comitant of the phenomenon of involution, that involved action. She believed that this
and left an order for her to be up and move was necessary to understand the theory that
about. Instead of trying to get up, Mrs. A re- underlies the “nurse’s way of nursing.” This
mained immobile in her bed. The nurse, who involved “knowing what the nurse wanted to
wanted to help her out of bed, expressed sur- accomplish, how she [sic] went about accom-
prise at Mrs. A’s unwillingness to get up. plishing it, and in what context she did what
Mrs. A explained to the nurse that her sister she did” (Wiedenbach, 1970, p. 1,058).
had had a red discharge the day after giving
birth 2 years ago and had almost died of Henderson
hemorrhage. Therefore, to Mrs. A, a red dis- Henderson’s definition of nursing and the
charge was evidence of the onset of a poten- 14 components of basic nursing care can be
tially lethal hemorrhage. The nurse expressed useful in guiding the assessment and care of
her understanding of the mother’s fear and patients preparing for surgical procedures. The
(continued)

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following description serves as a practice ex- the total health program for the patient and was
emplar of the use of Henderson’s conceptual responsible for integrating all aspects of care.
model: Only registered professional nurses were hired.
In assessing Mr. G’s preoperative vital The 80-bed unit was staffed with 44 profes-
signs, the nurse noticed he seemed anxious. sional nurses employed around the clock. Pro-
The nurse encouraged Mr. G to express his fessional nurses gave direct patient care and
concerns about the surgery. Mr. G told the teaching, and each nurse was responsible for
nurse that he had a fear of not being able to eight patients and their families. Senior staff
control his body and that he felt general anes- nurses were available on each ward as resources
thesia represented the extreme limit of loss of and mentors for staff nurses. For every two pro-
bodily control. The nurse recognized this con- fessional nurses, there was one nonprofessional
cern as being directly related to Henderson’s worker called a “messenger-attendant.” The
fourth component of basic nursing care: Move messenger-attendants did not provide hands-
and maintain desirable postures. The nurse ex- on care to the patients. Instead, they performed
plained to Mr. G that her role was to “per- such tasks as getting linen and supplies, thus
form those acts he would do for himself if he freeing the nurse to nurse the patient (Hall,
was not under the influence of anesthesia” 1964). In addition, there were four ward secre-
(Gillette, 1996, p. 267), and that she would taries. Morning and evening shifts were staffed
be responsible for maintaining his body in a at the same ratio. Night-shift staffing was less;
comfortable and dignified position. She ex- however, Hall (1965) noted that there were
plained how he would need to be positioned “enough nurses at night to make rounds every
during the surgical procedure, what part of his hour and to nurse those patients who are awake
body would be exposed, and how long the around the concerns that may be keeping them
procedure was expected to take. Mr. G also awake” (p. 2). In most institutions of that time,
told the nurse about an experience he had the number of nurses was decreased during the
after an earlier surgical procedure in which he evening and night shifts because it was felt that
experienced pain in his right shoulder. Mr. G larger numbers of nurses were needed during
expressed concern that being in one position the day to get the work done. Hall took excep-
too long during the surgery would damage his tion to the idea that nursing service was organ-
shoulder and result in waking up with shoul- ized around work to be done rather than the
der pain again. Together they discussed posi- needs of the patients.
tions that would be most comfortable for his The patient was the center of care at the
shoulder during the upcoming procedure, and Loeb Center, and actively participated in all
the nurse assured Mr. G that she would be as- care decisions. Families were free to visit at
sessing his position throughout the procedure. any hour of the day or night. Rather than
strictly adhering to institutional routines and
Hall schedules, patients at the Loeb Center were
Hall envisioned that outcomes were accom- encouraged to maintain their own usual pat-
plished by the special and unique way nurses terns of daily activities, thus promoting inde-
work with patients in a close interpersonal pendence and an easier transition to home.
process with the goal of fostering learning, There was no chart section labeled “Doctor’s
growth, and healing. Her work at the Loeb Orders.” Hall believed that to order a patient
Center serves as an administrative exemplar to do something violated the right of the pa-
of the application of her theory. tient to participate in his or her treatment
At the Loeb Center, nursing was the chief plan. Instead, nurses shared the treatment
therapy, with medicine and the other disci- plan with the patient and helped him or her
plines ancillary to nursing. In this new model to discuss concerns and become an active
of organizing nursing services, nursing oversaw learner in the rehabilitation process. In addition,

7991_Ch05_055-066 12/08/19 5:18 PM Page 65

there were no doctor’s progress notes or problems, or questions. A collaborative prac-
nursing notes. Instead, all charting was done tice model between physicians and nurses
on a form titled “Patient’s Progress Notes.” evolved, and the shared knowledge of the two
These notes included patients’ reactions to professions led to more effective team plan-
care, their concerns and feelings, their un- ning (Isler, 1964). The nursing stories pub-
derstanding of the problems, the goals they lished by nurses who worked at the Loeb
had identified, and how they saw their Center described the positive effect this model
progress toward those goals. Patients were of professional nursing had on patient out-
also encouraged to keep their own notes to comes. In addition, these stories reflect the
share with their caregivers. nursing satisfaction derived from practicing in
Staff conferences were held at least a truly professional role (Alfano, 1971; Bowar,
twice weekly as forums to discuss concerns, 1971; Bowar-Ferres, 1975; Englert, 1971).
Summary
Among other theorists featured in Section II ways. Their contributions significantly influ-
of this book, Wiedenbach, Henderson, and enced the way nursing was practiced and stud-
Hall introduced conceptualizations about the ied, both in the United States and in other
nature of nursing to the profession in the mid- countries around the world. Perhaps most
20th century. Each of the nursing leaders pre- important, each of these scholars stated and
sented in this chapter began by reflecting on responded to the question, “What is nursing?”
her own personal practice experience to explore Their responses helped all who followed under-
the definition of nursing and the importance of stand that the individual being nursed is a
nurse–patient interactions. These nurse scholars person, not an object, and how the relationship
challenged us to think about nursing in new between nurse and patient is valuable to all.
Questions for Reflection systems and within an area of specialty

practice.
and Discussion ■ How would the approach to patient care
■ How have the early conceptualizations of differ if you as the nurse were practicing
nursing by Wiedenbach, Henderson, and from within the nursing conceptual model
Hall influenced the work of other nursing developed by Wiedenbach, Henderson,
theorists who followed them? or Hall?

■ Describe how these early conceptualiza-
tions might fit within current health-care

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7991_Ch06_067-088 13/08/19 3:35 PM Page 67
Nurse–Patient Relationship
CHAPTER
6
Theories
Ann R. Peden, Nicole Poellet,
Jacqueline Staal, Diane Lee Gullett and
Maude Rittman
Introduction Introduction
The nurse–patient relationship was a signifi-
cant focus of early conceptualizations of nurs-
Hildegard Peplau’s
Part One ing. Hildegard Peplau, Joyce Travelbee, and
Nurse–Patient Relationship Ida Jean Orlando were three early nursing
and Its Applications scholars who explicated the nature of this
relationship. Their work shifted the focus of
Introducing the Theorist nursing from the performance of tasks to
Overview of the Theory engagement in a therapeutic relationship de-
Applications of the Theory signed to facilitate health and healing. Each of
Practice Exemplar these conceptualizations will be described in
Summary Parts One, Two, and Three of the chapter.
Questions for Reflection and Discussion
Part One Hildegard Peplau’s Nurse–Patient

Joyce Travelbee’s
Part Two Relationship and Its Applications
Human-to-Human Relationship Ann R. Peden and Nicole Poellet
Model and Its Applications
Introducing the Theorist
Overview of the Theory Hildegard Peplau was an outstanding leader
Applications of the Theory and pioneer in psychiatric nursing whose ca-
Practice Exemplar reer spanned seven decades. A review of the
Summary events in her life also serves as an introduction
Questions for Reflection and Discussion to the history of modern psychiatric nursing.
With the publication of Interpersonal Relations

in Nursing in 1952, Peplau provided a frame-
Part Three Ida Jean Orlando’s work for the practice of psychiatric nursing
Dynamic Nurse–Patient that would result in a paradigm shift in this
field of nursing. Before this, patients were
Relationship viewed as objects to be observed. Peplau taught
Introducing the Theorist that patients were not objects, but were
Overview of the Theory subjects, and that psychiatric nurses must par-
Applications of the Theory ticipate with the patients, engaging in the
Practice Exemplar nurse–patient relationship. This was a revolu-
Summary tionary idea. Although Interpersonal Relations
Questions for Reflection and Discussion in Nursing was not well received when it was
first published in 1952, the book’s influence
was widespread later, and it was reprinted in
1988 and has been translated into at least six
languages.
67
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Peplau served as the college head nurse and individually with Peplau to go over the interac-
later as executive officer of the Health Service tion in detail. Through this process, both Peplau
at Bennington College, Vermont. While work- and her students began to learn what was helpful
ing there, she began taking courses that would and what was harmful in the interaction.
lead to a Bachelor of Arts degree in interper- In 1955, Peplau left Columbia to teach at
sonal psychology. Dr. Erich Fromm was one of Rutgers, where she began the Clinical Nurse
her teachers at Bennington. An experience Specialist program in psychiatric–mental health
while working in the Health Service piqued nursing. The students were prepared as nurse
Peplau’s interest in psychiatric nursing. On psychotherapists, developing expertise in indi-
graduation from Bennington, Peplau joined the vidual, group, and family therapies.
Army Nurse Corps. She was assigned to the During her career as a nursing educator, a
School of Military Neuropsychiatry in Eng- total of 100 students had the opportunity to study
land. This experience introduced her to the psy- with Peplau. These students have become leaders
chiatric problems of soldiers at war and allowed in psychiatric nursing. Many went on to earn
her to work with many great psychiatrists. doctoral degrees, becoming psychoanalysts, writ-
After the war, Peplau attended Columbia Uni- ing prolifically in the field of psychiatric nursing,
versity on the GI Bill and earned her master’s and entering and influencing the academic
degree in psychiatric–mental health nursing. world. Their influence has resulted in the inte-
After her graduation in 1948, Peplau was in- gration of the nurse–patient relationship and the
vited to remain at Columbia and teach in their concept of anxiety into the culture of nursing. In
master’s program. She immediately searched 1974, Peplau retired from Rutgers, which al-
the library for books to use with students, but lowed her more time to devote to the larger pro-
found very few. At that time, the psychiatric fession of nursing. Throughout her career, Peplau
nurse was viewed as a companion to patients, actively contributed to the American Nurses’ As-
someone who would play games and take walks, sociation (ANA) by serving on various commit-
but talk about nothing substantial. In fact, tees and task forces. She was the only person who
nurses were instructed not to talk to patients had been both the executive director and presi-
about their problems, thoughts, or feelings. Pe- dent of ANA. Peplau served on the ANA com-
plau began teaching at Columbia, knowing that mittee that wrote the Social Policy Statement.
she wanted to change the education and prac- For the first time in nursing’s history, nursing had
tice of psychiatric nursing. There was no direc- a phenomenological focus—human responses.
tion for what to include in graduate nursing Peplau held 11 honorary degrees. In 1994,
programs. She took educational experiences she was inducted into the American Academy
from psychiatry and psychology and adapted of Nursing’s Living Legends Hall of Fame,
them to her conceptualization of nursing. named one of the 50 great Americans by Mar-
Her goal was to prepare nurse psychother- quis Who’s Who, and was inducted into the ANA
apists, referring to this training as “talking to Hall of Fame. Internationally, Peplau was an
patients” (Peplau, 1960, 1962). She arranged advisor to the World Health Organization
clinical experiences for her students at Brook- (WHO) and served two terms on the Interna-
lyn State Hospital, the only hospital in the tional Council of Nurses’ Board of Directors.
New York City area that would take them. At Even after her retirement, she continued to
the hospital, students were assigned to back mentor nurses in many countries. Hildegard
wards, working with the most chronic and se- Peplau died in March 1999 at her home in
verely ill patients. Sherman Oaks, California.
Each student met twice weekly with the same
patient, for a session lasting 1 hour. According
to Peplau (1998), the nurses resisted this practice Overview of the Theory
tremendously and thought it was an awful thing Peplau (1952) defined nursing as a “significant,
to do. Using carbon paper, verbatim notes were therapeutic, interpersonal process” that is an “ed-
taken during the session. Students then met ucative instrument, a maturing force, that aims

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C H APTER 6 ■ Nurse–Patient Relationship Theories 69
to promote forward movement of personality in sharing a meal with psychiatric patients can be
the direction of creative, constructive, produc- a therapeutic encounter.
tive, personal, and community living” (p. 16). The nurse–patient relationship, viewed as
Peplau was the first nursing theorist to identify growth-promoting with forward movement, is
the nurse–patient relationship as being central enhanced when nurses are aware of how their
to all nursing care. In fact, nursing cannot occur own behavior affects the patient. The “behavior
if there is no relationship, or connection, be- of the nurse-as-a-person interacting with the
tween the patient and the nurse. Her work, patient-as-a person has significant impact on
while written for all nursing specialties, provides the patient’s well-being and the quality and
specific guidelines for the psychiatric nurse. outcome of nursing care” (Peplau, 1992, p. 14).
The nurse brings to the relationship profes- An essential component of this relationship is
sional expertise, which includes clinical the continuing process of the nurse becoming
knowledge. Peplau (1987) valued knowledge, more self-aware. This occurs via supervision.
believing that the psychiatric nurse must pos- Peplau (1989) recommended that nurses par-
sess extensive knowledge about the potential ticipate in weekly supervision meetings with an
problems that emerge during a nurse–patient expert nurse clinician. The focus of the supervi-
interaction. The nurse must understand psychi- sory meetings is on the nurses’ interactions with
atric illnesses and their treatments. The nurse patients. The primary purpose is to review ob-
interacts with the patients as both a resource servations and interpersonal patterns that the
person and a teacher (Peplau, 1952). Through nurse has made or used. The goal is always to de-
education and supervision, the nurse develops velop the nurse’s skills as an expert in interper-
the knowledge base required to select the most sonal relations. Peplau (1989) emphasized “the
appropriate nursing intervention. In order to slow but sure growth of nurses” (p. 166) as they
fully engage in the nurse–patient relationship, developed their competencies in working with
the nurse must possess intellectual, interper- patients. Not only are patient problems reviewed
sonal, and social skills. These are the same skills but treatment options and the nurse’s own pat-
often diminished or lacking in psychiatric tern of responding to the patient are explored. If
patients. For nurses to promote growth in an interaction between a nurse and a patient has
patients, they must themselves use these skills not gone well, the nurse’s response is to examine
competently (Peplau, 1987). her or his own behavior first. Asking questions
There are four components of the nurse– such as, “Did my own anxiety interfere with this
patient relationship: two individuals (nurse and interaction?” or “Is there something in my expe-
patient), professional expertise, and patient riences that influenced how I interacted with this
need (Peplau, 1992). The goal of the nurse– patient?” leads to continual growth and devel-
patient relationship is to further the personal opment as a skilled clinician. This process also
development of the patient (Peplau, 1960). assures the delivery of quality care in psychiatric
Nurse and patient meet as “strangers” who in- settings. Supervision continues to be an impor-
teract differently than friends would. The role tant aspect in advanced practice psychiatric nurs-
of stranger implies respect and positive interest ing and is a requirement for certification as a
in the patient as an individual. The nurse “ac- psychiatric clinical specialist or nurse practi-
cepts the patients as they are and interacts with tioner. Supervision is essential as the nurse as-
them as emotionally able strangers and relating sumes the role of counselor. In this role, the
on this basis until evidence shows otherwise” nurse assists the patient to integrate the thoughts
(Peplau, 1992, p. 44). Peplau valued therapeu- and feelings associated with the illness into the
tic communication as a key component of patient’s own life experiences (Lakeman, 1999).
nurse–patient interactions. She advised strongly The nurse–patient relationship is objective
against the use of “social chit-chat.” In fact, she and its focus is on the needs of the patient. To
would view this as wasting valuable time with focus on the patient’s needs, the nurse must be
your patient. Every interaction must focus on a skilled listener and able to respond in ways
being therapeutic. Even something as simple as that foster the patient’s growth and return to

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health. Active listening facilitates the nurse– is interpersonal in nature and has a starting
patient relationship. As Peplau wrote in 1960, point, proceeds through identifiable phases, and
nursing is an “opportunity to further the pa- ends. Initially, Peplau included four phases in
tient’s learning about himself [sic], the focus in the relationship: orientation, identification, ex-
the nurse-patient relationship will be upon the ploitation, and resolution. In 1991, Forchuk, a
patient—his [sic] needs, difficulties, lack in in- Canadian researcher who has tested and refined
terpersonal competence, interest in living” some of Peplau’s work, proposed three phases:
(p. 966). Within the nurse–patient relationship, orientation, working, and resolution (Peplau,
the nurse works “to create a mood that encour- 1992). Forchuk’s recommendation of a three-
ages clients to reflect, to restructure percep- phase nurse–patient relationship resolves the
tions and views of situations as needed, to get lack of easy differentiation between the identifi-
in touch with their feelings, and to connect in- cation and exploitation stages. These two phases
terpersonally with other people” (Peplau, 1988, were collapsed into the working phase. By re-
p. 10). While the nurse-patient relationship is naming these two phases the working phase, a
“time-limited in both duration and frequency, more accurate reflection of what actually occurs
the aim is to create an interpersonally intimate in this important aspect of the nurse–patient
encounter, however brief, as if two whole per- relationship is provided. Although the nurse–
sons are involved in a purposive, enduring re- patient relationship is time limited in nature,
lationship; this requires discipline and skill on much of this relationship is spent “working.”
the part of the nurse” (p. 11). Peplau continued
to emphasize that nurses must possess “well- Orientation Phase
developed intellectual competencies, and dis- The relationship begins with the orientation
ciplined attention to the work at hand” (p. 13). phase (Peplau, 1952). This phase is particularly
Communication, both verbal and nonver- important because it sets the stage for the
bal, is an essential component of the nurse– development of the relationship. During the
patient relationship. However, in Peplau’s (1989) orientation period, the nurse and patient’s re-
view, verbal communication is required in order lationship is still new and unfamiliar. Nurse
for the nurse-patient relationship to develop. and patient get to know each other as people;
She writes, “anything clients act out with nurses their expectations and roles are understood.
will most probably not be talked about, and During this first phase, the patient expresses a
that which is not discussed cannot be under- “felt need” and seeks professional assistance
stood” (p. 197). One objective of the nurse– from the nurse. In reaction to this need, the
patient relationship is to talk about the problem nurse helps the individual by recognizing and
or need that has resulted in the patient inter- assessing his or her situation. It is during the
acting with the nurse. Peplau provided descrip- assessment that the patient’s needs are evalu-
tions of phrases commonly used by patients ated by the patient and nurse working together
that require clarification on the part of the as a team. Through this process, trust develops
nurse. These included referring to “they,” using between the patient and the nurse. Also, the
the phrase, “you know,” and overgeneralizing parameters for the relationship are clarified.
responses to situations. The nurse clarifies who Based on the assessment information, nursing
“they” are, responds that she or he does not diagnoses, goals, and outcomes for the patient
know and needs further information, and as- are created. Nursing interventions are imple-
sists patients to be more specific as they de- mented and the evaluations of the patient’s
scribe their experiences (Forchuk, 1993). goals are also incorporated (Peplau, 1992).
Phases of the Nurse–Patient Working Phase

Relationship The working phase incorporates identification
Peplau (1952) introduced the phases of the and exploitation. The focus of the working
nurse–patient relationship in her Interpersonal phase is twofold: first is the patient, who “ex-
Relations Theory. This time-limited relationship ploits” resources to improve health; second is

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the nurse, who enacts the roles of “resource with their patients. She wanted nurses to “do
person, counselor, surrogate, and teacher in fa- with” clients rather than “do to” (Forchuk,
cilitating … development toward well-being” 1993). The majority of the work that has
(Fitzpatrick & Wallace, 2005, p. 460). This tested Peplau’s nurse–patient relationship has
phase of the relationship is meant to be flexi- been conducted with individuals with severe
ble, so that the patient is able to function “de- mental illness, many of them in psychiatric
pendently, independently, or interdependently hospitals. In these studies, patients did move
with the nurse, based on … developmental ca- through the phases of the nurse–patient
pacity, level of anxiety, self-awareness, and relationship.
needs” (p. 460). A balance between independ- Almost all of the research that has tested
ence and dependence must exist here, and it is Peplau’s nurse–patient relationship has been
the nurse who must aid the patient in its de- conducted by Forchuk (1994; 1995) and
velopment (Lakeman, 1999). colleagues (Forchuk & Brown, 1989; Forchuk,
During the exploitation phase of the Jewell, Schofield, Sircelj, & Valledor, 1998;
working phase, the client assumes an active Forchuk, Westwell, Martin, Azzapardi,
role in the health team by taking advantage Kosterewa-Tolman, & Hux, 1998). Much of
of available services and determining the de- Forchuk’s work has focused on the orientation
gree to which they are used. Within this phase. Forchuk and Brown (1989) emphasized
phase, the client begins to develop responsi- the importance of being able to identify the
bility and independence, becoming better orientation phase and not rush movement into
able to face new challenges in the future the working phase. To assist in this, Forchuk
(Erci, 2008). Peplau (1992) writes that “ex- and Brown developed a one-page instrument,
ploiting what a situation offers gives rise to the Relationship Form, which they have used
new differentiations of the problem and the to determine the current phase of the relation-
development and improvement of skill in ship and overall progression from phase to
interpersonal relations” (pp. 41–42). phase. Building on Forchuk and Brown’s
work, Yuko and Sugita (2015) developed the
Resolution Phase Intervention Scale for Forming Nurse-Patient
The resolution phase is the last phase and in- Relationships.
volves the patient’s continual movement from Hagarty, Samuels, Norcini-Pala, and
dependence to independence, based on both a Gigliotti (2017) acknowledged the impor-
distancing from the nurse and a strengthening tance of the nurse-patient relationship on the
of the individual’s ability to manage care (Peplau, patient experience in the health-care system.
1952). Resolution can take place only when the With the increased emphasis on patient ex-
patient has gained the ability to be free from periences in hospitals as indicators of quality
nursing assistance and act independently (Lloyd, care, a confirmatory factor analysis of the
Hancock, & Campbell, 2007); at this point, old Consumer Assessment of Healthcare Providers
needs are abandoned and new goals are adopted and Systems-Hospitals (HCAHPS) data was
(p. 8). The completion of the resolution phase conducted. The Institute of Medicine (IOM)
results in the mutual termination of the nurse– Framework (IOM, 2001), which guided the
patient relationship and involves planning for fu- development of the HCAHPS survey, and
ture sources of support. Completion of this final Peplau’s Theory of Interpersonal Relations
phase “is one measure of the success of … all the in nursing were used to compare the factor
other phases” (Lloyd et al., 2007, p. 50). structure of HCAHPS data. The IOM
model emphasizes patient-centered care and
patient preferences, expressed needs, physical
Applications of the Theory comfort, and emotional support. Using the
Peplau first wrote about the nurse–patient re- HCAHPS survey, the three phases of the
lationship in 1952. She hoped that through this nurse–patient relationship were operational-
work nurses would change how they interacted ized by measuring the ratings on specific

7991_Ch06_067-088 13/08/19 3:35 PM Page 72
HCAHPS items. In the confirmatory factor Hochberger and Lingham (2017) used
analysis, the fit of the three phases of the Pe- Peplau’s interpersonal approach to promote
plau model was close to the fit of the IOM- medication self-management in psychiatric
based model. The Root Mean Square Error patients. Shared decision making, which is
of Approximation (RMSEA) for Peplau’s embedded in the three phases of the nurse–
theory was 0.039, which is within the excel- patient relationship, is critical to successful
lent to good score range of 0.01 to 0.05. The medication self-management. In shared deci-
IOM RMSEA was 0.027. The study empha- sion making, two experts, the clinician and the
sized the importance of nursing on the pa- person living with the illness, come together
tient’s overall experience. It also added to determine mutual goals for wellness. In the
support for the usefulness of Peplau’s theory Orientation Phase, the focus is on deciding to-
to improve the experiences of hospitalized gether on the patient’s needs related to med-
patients. ication management. In the Working Phase,
Moving beyond application of Peplau’s their shared expertise allows them to move
theory in psychiatric settings with psychiatric toward meeting the goal. In the Resolution
patients, Merritt and Proctor (2010) used Phase, the focus is on maintaining progress
Peplau’s four phases of the nurse–patient re- and continuing to move toward health.
lationship to guide their practice as mental The authors concluded that Peplau’s Theory
health consultation liaison nurses. Working of Interpersonal Relations uses both patient
with patients experiencing psychiatric symp- education and interpersonal skills to assist pa-
toms, but who did not have a psychiatric dis- tients to function at their highest capabilities.
order, Peplau’s four phases of the nurse–patient Partnering with patients as they move toward
relationship guided their work. This clinical optimum wellness and recovery is foundational
application led to better engagement with pa- to the application of Peplau’s Theory of Inter-
tients, provided patients with the tools needed personal Relations.
to address life changes that precipitated their Deane and Fain (2016) proposed using
illness, and finally resulted in movement to- Peplau’s Theory of Interpersonal Relations as
ward health that included meaningful, pro- a framework to assist nursing students in com-
ductive living. They concluded that Peplau’s municating with older adults. The three phases
work provided a model to ensure successful of the nurse–patient relationship were used to
engagement with patients requiring consulta- guide development of communication skills.
tion liaison nursing interventions. Classrooms, conferences, and skills laborato-
As psychiatric nurses have changed the lo- ries provided content on these phases and the
cation of their practice from hospital to com- nursing interventions that supported each
munity, they have carried Peplau’s work to this phase of the relationship. The authors con-
new arena. Unfortunately, there has been lim- cluded that Peplau’s interpersonal theory could
ited testing of the nurse–patient relationship assist nursing students in developing holistic
in community settings. Parrish, Peden, and communication.
Staten (2008) explored strategies used by ad- There has been a resurgence of interest in
vanced practice psychiatric nurses treating Peplau’s work (Adams, 2017; Dean & Fain,
individuals with depression. All the partici- 2017; Senn, 2019; Smith, 2018). Perhaps this
pants in this study practiced in community is related to nursing, especially psychiatric–
settings. When describing the strategies used, mental health nursing, not wanting to forget
the nurse–patient relationship was the primary the contributions of Peplau. It also is an indi-
vehicle by which strategies were delivered. cation of the timelessness of her work, espe-
These strategies included active listening, part- cially that nursing practice is grounded in the
nering with the client, and a holistic view of the nurse–patient relationship. Antonio, Beeber,
client. This work supports the integration of Sills, and Naegle (2014) remind us that while
Peplau’s nurse–patient relationship into the 21st-century psychiatric nursing relies on pa-
work of the psychiatric nurse. tient engagement, the use of self-management

7991_Ch06_067-088 13/08/19 3:35 PM Page 73
strategies, and interactions to promote behav- biology of psychiatric illness and manual-
ioral change, such as motivational interview- ized mental health interventions, without the
ing, none of these is effective without Peplau’s nurse–patient relationship this work does not
interpersonal process. While we embrace the advance.
Practice Exemplar
David Robinson is a 35-year-old married fa- plan that would work. Instead of contradicting
ther of two. His care was being transferred to his statement, she invited him to share more
a psychiatric nurse practitioner (NP) for psy- of his background with his illness and with
chopharmacological management of bipolar previous treatment, listening openly and non-
disorder, complicated by alcohol and mari- judgmentally to his story. Despite his initial
juana abuse. He had seen multiple providers reticence, David began to articulately describe
over several years. He was distrustful about his symptoms and how much he was suffering.
prescribed psychopharmacological interven- He also described his deep sense of duty to
tions and consistently refused to engage in protect his family from his bipolar disorder.
psychotherapy. On review of his chart, the NP It quickly became evident that his frustra-
noted that he struggled to form relationships tion stemmed from his sense that previous
with previous providers. Documentation re- providers were not helping him with this pri-
ferred to his irritability and defensiveness dur- mary goal, protecting his family, which to him
ing appointments, as well as resistance to was more important than not suffering with
engaging in behaviors that may help improve exacerbations of symptoms. Specifically, he
his symptoms, such as avoiding drugs and al- described that at times his irritability would
cohol and connecting with a psychotherapist. become so intense during hypomanic episodes
that he would begin to envision harming
Orientation Phase: During this phase, the
members of his family. Despite never having
nurse helps the patient become familiar with
acted on these thoughts, he was so fearful that
the relationship dynamics and comfortable
he might, that he would use alcohol and mar-
with the nurse specifically. This involves
ijuana to calm himself down.
identification of each of their roles and
After about an hour with David, the NP
negotiation of the role functions in the
had made significant headway in getting
relationship. The nurse also helps the patient
David to relax and start to trust in the care re-
negotiate individualized treatment goals.
lationship. David articulated that despite his
When the NP initially approached David initial skepticism with a new provider, he was
in the waiting room for his first visit he was feeling good about this visit. At this point, the
slouched in a chair, frowning, and appeared NP shared her thoughts with David that al-
angry. The NP was aware that David had cohol and marijuana appeared to be worsening
struggled with developing trusting relation- his symptoms. David quickly became loud,
ships with clinicians in the past; therefore, angry, and agitated.
she purposefully opted to approach him The NP asked David to have a seat and
openly and setting aside a priori judgments help her understand his frustration. He angrily
about him and his potential for successfully expressed that, like other providers, she did
managing his symptoms. not respect that he was using substances to
During this first visit with the NP, David keep his family safe and that this was non-
was initially quiet and wary. The NP ac- negotiable. The NP recognized that joining
knowledged that she had reviewed his chart. David around this entirely appropriate goal of
David articulated how much he had disliked keeping his family safe was essential to main-
some of his previous providers and his sense taining the relationship between them. She
that providers never suggested a treatment proposed a negotiation to David: that he
(continued)

7991_Ch06_067-088 13/08/19 3:35 PM Page 74

would understand that her job was to share relationship. Gradually, David began to find
with him an evidence-based treatment plan that he could disagree with his provider with-
for managing bipolar disorder, and that in- out getting frustrated or angry, that he could
cluded getting away from using substances to expect the same in return, and that the rela-
control symptoms. However, she would not tionship could tolerate open discussion of
expect him to stop abusing drugs and alcohol varying perspectives. Further, both David and
now. Instead, she would work with him to the NP recognized that this led to better out-
find alternative treatment options for his comes for David.
symptoms that would control symptoms Eventually, David expressed to the NP
without putting his family at risk from his that he felt ready to try not using alcohol and
symptoms. David was wary again, but agreed marijuana to manage exacerbation in symp-
to start a new mood-stabilizing agent and toms. He expressed that his symptoms were
check back in after 1 month. under moderate control pharmacologically;
he recognized in discussions with the NP that
Working Phase: The working phase is
the final element of control over symptoms
characterized by identification of resources and
would likely come in the form of stopping
moving the patient toward independence. The
substance abuse.
nurse must recognize and support the interplay
He was anxious about cutting down and
of dependence and independence that is
eliminating these substances from his “cop-
characteristic of this phase, while moving the
ing toolbox”; however, he explained to the
patient closer to as much independence as
NP that as long as she would be “with him”
possible. This requires that the patient also play
while he tried stopping, he was ready to try.
an active role in the care relationship.
Over several months of slightly more inten-
Over the course of several years and mul- sive work, he and the NP worked to cut back
tiple episodes of mood instability, David on alcohol and marijuana while expressing
continued to work with the NP to find a confidence in his coping ability and adjusting
mood stabilization combination that con- in his medications to cover exacerbations of
trolled his symptoms. Visits alternated be- symptoms. David was ultimately able to stop
tween successful forward momentum in using alcohol and marijuana; this was the
controlling symptoms, calm psychoeducation final component of achieving recovery for
about his illness, and intermittent episodes David, and he could achieve a highly func-
of David becoming angry and leaving ap- tional, and primarily independent, baseline
pointments early in anger. However, David with his disorder.
and the NP both remained focused on the

Resolution Phase: In the final phase of the
mutual goal of first keeping his family safe
nurse–patient relationship, the patient has
and second finding ways to control his symp-
achieved a level of independence that includes
toms. David worked with the NP to find
successful distancing from the nurse, as well as
ways to identify phases of his illness and early
the patient’s ability to self-manage care.
indicators of decline so that acute pharma-
cological intervention could be initiated. Once symptoms were controlled, David
David initially approached discussions was able to extend times between seeing the
around medication side effects skeptically. NP, until he was ultimately only coming to
Recognizing this, the NP identified that en- appointments for medication refills. David
gaging David as a mutual partner in decision eventually began to do public speaking about
making around his medications was essen- his disorder and to talk to patients and other
tial. Respecting David’s personal experience providers about bipolar illness and the difficult
and input continued to build trust in the journey of getting symptoms under control.

7991_Ch06_067-088 13/08/19 3:35 PM Page 75
Summary
Peplau is considered the first modern-day nurse nursing profession forward. She also believed
theorist. Her clinical work provided direction that nursing research should be grounded in
for the practice of psychiatric–mental health clinical problems. She worked tirelessly to ad-
nursing. This occurred at a time when there vance the profession of nursing, as both an ed-
were few innovations in the care of the men- ucator and a leader at national and international
tally ill. She valued education, believing that levels. Her contributions continue to have an
attaining advanced degrees would move the influence today.
Questions for Reflection patient experiences and overall satisfaction

with hospital care? Using the three phases,
and Discussion give specific examples of how patient
■ Each phase of the nurse–patient relation- experience can be improved.
ship is important. Thinking about your ■ Reflect on your first introduction to anxi-
area of practice, how do you apply these ety as an important concept that nursing
three phases as you work with patients? students needed to understand. How did
■ Can an emphasis on the nurse–patient re- your anxiety and your patient’s anxiety
lationship and the application of Peplau’s affect the nurse–patient relationship?
Theory of Interpersonal Relations improve
Part Two Joyce Travelbee’s Human-to-Human of Nursing in New Orleans, Louisiana, in

Relationship Model Theory and Its 1943. Her early clinical practice at Charity
Applications Hospital, combined with her faith, spirituality,
Jacqueline Staal, updated by Diane L. Gullett and religious background, influenced her view
on nursing and later the development of her
Introducing the Theorist theoretical model. She received her bachelor
Joyce Travelbee (1926–1973) practiced of science degree in nursing from Louisiana
psychiatric–mental health nursing for more State University in 1956 and later her master
than 30 years both in the clinical setting and of science degree in nursing with a focus on
as a nurse educator. She is best known for her psychiatric–mental health nursing in 1959
Human-to-Human Relationship Model, a from Yale University. Travelbee taught psychi-
middle-range theory that guides the nurse– atric and mental health nursing at Louisiana
patient interaction with emphasis on helping State University, New Orleans; the Depart-
the patient find hope and meaning in the ment of Nursing Education at New York
illness experience (Travelbee, 1971). The University; the University of Mississippi School
Human-to-Human Relationship Model pro- of Nursing in Jackson; and the Hotel Dieu
vided an early framework for delivering pa- School of Nursing in New Orleans, Louisiana
tient-centered care, keeping with current (Meleis, 1997; Travelbee, 1971). As a clinical
guidelines established and set forth by agen- instructor and later a professor of nursing,
cies such as the National Academy of Medi- Travelbee (1972) incorporated her philosophy
cine, the American Nurses Association, and of caring into her teaching methods, challeng-
the Joint Commission for Hospital Accredi- ing students to learn not only from their text-
tation Care and as promoted today by the books and nursing colleagues but rather from
Agency for Healthcare Research and Quality the patients and their relatives themselves. She
with the U.S. Department of Health and later served as a nursing consultant for the
Human Services. Veteran’s Administration Hospital in Mississippi
Travelbee graduated from the diploma and was enrolled in doctoral study at the time of
nursing program at Charity Hospital School her death at age 47. Travelbee was Director

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of Graduate Education at the Louisiana State nurse is to “enable (the individual) to help
University School of Nursing when she died. themselves … in prevention of illness and pro-
She was posthumously inducted into the motion of health, and in assisting those who
Louisiana Nursing Hall of Fame in 2012 are incapable, or unable, to help themselves”
(Louisiana State Nurses Association, 2012). (Travelbee, 1969, p. 7).
Travelbee’s first book, Interpersonal Aspects The human-to-human relationship “refers
of Nursing (1966), identified the purpose of to an experience or series of experiences be-
nursing and the role of nursing to achieve this tween the human being who is nurse and an ill
purpose. The delicate balance between scientific person,” culminating in the nurse meeting the
knowledge and the ability to apply evidence- ill person’s unique needs (Travelbee, 1971,
based interventions through the therapeutic use pp. 16–17). The term patient is not used in
of self was described, along with the goal of Travelbee’s model, because patient refers to a
helping the patient find hope and meaning in label or category of people, rather than a
the illness experience. In Travelbee’s second unique individual in need of nursing care. The
book, Intervention in Psychiatric Nursing: Process purpose of nursing, according to Travelbee
in the One-to-One Relationship (1969), the role (1971), is “to assist an individual, family or
of the psychiatric nurse in patient care is de- community to prevent or cope with the expe-
scribed; the concept of communication in the rience of illness and suffering and, if necessary,
Human-to-Human Relationship is examined; to find meaning in these experiences” (p. 16).
and the process of establishing, maintaining, Simply caring about an individual is not suffi-
and terminating a relationship is described. cient for providing quality care but rather the
integration of a broad knowledge base with the
therapeutic use of self is needed. To effect
Overview of the Theory change in the human relationship, the nurse
Travelbee’s Human-to-Human Relationship must transcend his or her sense of self to focus
Model was based on the work of nurse theo- on the recipient of care (Travelbee, 1969).
rists Hildegard Peplau and Ida Jean Orlando Transcendence of the traditional titles of
(Tomey & Alligood, 2006), as well as her own nurse and patient is necessary to prevent dehu-
experience in practice. Viktor E. Frankl’s manization of the ill person. With the rapid
logotherapy guided Travelbee’s (1971) concept expansion of health technology, combined
of nursing intervention and the role of the with financial constraints leading to restruc-
nurse in helping patients and their families turing of nurse–patient ratios, competing de-
find meaning in the illness experience. Trav- mands are placed on the nurse’s time and
elbee (1971) identified three main concepts in attention. An emotional detachment between
her theory: human being, suffering, and hope the nurse and ill person is created when the
(Jones & Fitzpatrick, 2012). nurse views the ill person as simply a “patient,”
Caring, in the Human-to-Human Rela- rather than as a unique individual with her or
tionship Model, involves the dynamic, recip- his own understanding of the illness experi-
rocal, interpersonal connection between the ence. By performing nursing tasks without an
nurse and patient, developed through commu- emotional investment in the nurse–patient re-
nication and the mutual commitment to per- lationship, the ill person’s physical needs are
ceive self and other as unique and valued. met. However, the ill person recognizes the
Through the therapeutic use of self and the in- lack of caring in the transaction and is left
tegration of evidence-based knowledge, the alone to suffer with the symptoms of illness.
nurse provides quality patient care that can fos- Dehumanization occurs when the ill person is
ter the patient’s trust and confidence in the left alone to find meaning in her or his illness
nurse (Travelbee, 1971). The meaning of the experience.
illness experience becomes self-actualizing for Many ill persons and their family members
the patient as the nurse helps the patient find may ask questions such as “Why me?” or
meaning in the experience. The purpose of the “Why my loved one?” By inquiring into the

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individual’s perception of her or his illness and nursing, and requires the nurse to “assist ill
how she or he has derived meaning from the persons to find meaning in the experience of
illness experience, the nurse can assess the in- illness, suffering, and pain” (Travelbee, 1971,
dividual’s coping ability and provide nursing p. 158). However, the nurse may not assume
interventions to prevent suffering and despair. that he or she understands the meaning of the
Hope and motivation are important nursing illness experience to the ill person without
tasks in caring for an ill person in despair. first inquiring into this meaning. To do so
However, the nurse “cannot ‘give’ hope to an- would communicate to the ill person that her
other person; the nurse can, however, strive to or his experience is not of value to the nurse,
provide some ways and means for an ill person resulting in dehumanization. The nurse eval-
to experience hope” (Travelbee, 1971, p. 83). uates the outcomes of his or her nursing in-
All human beings endure suffering, al- tervention based on objectives developed
though the experience of suffering differs from before the phase of appraisal.
one individual to another (Travelbee, 1971). In meeting the ill person’s needs through
Suffering may be inevitable, but one’s attitude the human-to-human relationship, the nurse
toward it affects how an individual copes with employs a disciplined intellectual approach or
illness. If the person’s needs are not met, she a logical approach consistent with nursing
or he may develop “despairful not-caring,” in standards and clinical practice guidelines to
which the person does not care whether she or identify, manage, and evaluate the ill person’s
he dies or recovers, or “apathetic indifference,” problem (Travelbee, 1971). Each stage in the
in which the person has “lost the will to live” nursing process may be employed without the
(Travelbee, 1971, pp. 180–181). Hope helps establishment of a human-to-human relation-
the suffering person to cope, and it is an as- ship. An acute medical need may be met, but
sumption of Travelbee’s (1971) that “the role the patient’s deeper spiritual and emotional
of the nurse … [is] to assist the ill person [to] needs are neglected. These spiritual and emo-
experience hope in order to cope with the tional needs are addressed in the human-to-
stress of illness and suffering” (p. 77). human relationship in the progression through
To relieve the suffering and to foster hope, five phases: the original encounter, emerging
the nurse provides care based on the individ- identities, empathy, sympathy, and rapport.
ual’s unique needs. Nursing care, according to
Travelbee (1971), is delivered through five Five Phases in the Human-to-
stages: observation, interpretation, decision Human Relationship Model
making, action (or nursing intervention), and In the phase of the original encounter, the nurse
appraisal (or evaluation). The nursing interven- and ill person form judgments about each other
tion is designed to achieve the purpose of nurs- that will guide and shape future nurse–person
ing and is communicated to the suffering interactions. Past experiences, the media, and
individual. The goals of communication in the stereotypes may influence one’s perception of
nursing process are “to know (the) person, (to) another, blocking the development of a
ascertain and meet the nursing needs of ill per- human-to-human relationship. In the phase of
sons, and (to) fulfill the purpose of nursing” emerging identities, a bond begins to form be-
(Travelbee, 1971, p. 96). tween nurse and person as each individual be-
In the observation stage of nursing care, gins to “appreciate the uniqueness of the other”
the nurse “does not observe signs of illness” (Travelbee, 1971, p. 132). The bond is created
but rather collects sensory data to identify a and shaped through each nurse–person inter-
problem or need (Travelbee, 1971, p. 99). action and is facilitated by the therapeutic use
The nurse validates his or her interpretation of self, combined with nursing knowledge. The
of the problem or need with the ill person and nurse must recognize how he or she perceives
decides whether or not to act on this inter- the person to create a foundation of empathy.
pretation. A nursing intervention is devel- The phases of original encounter and emerging
oped in alignment with the purpose of identities can be integrated into the assessment

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phase of the nursing process as this is when the being cared for awards an opportunity for both
nurse begins to form first impressions of an in- to evaluate the effectiveness of the interven-
dividual and begins collecting information tions within a trusting relationship. Rapport is
while a mutual sense of the problems of the in- not established in every nurse–person en-
dividual is identified (Jones & Fitzpatrick, counter; however, emotional involvement is
2012). required from the nurse. To establish this
In the phase of empathy, the nurse begins to emotional bond with one’s patient, the nurse
see the individual “beyond outward behavior must first ensure that his or her own emotional
and sense accurately another’s inner experience needs are met.
at a given point in time” (Travelbee, 1971, In Travelbee’s second book, Intervention in
p. 136). Empathy enables the nurse to predict Psychiatric Nursing, implementation of the
what the person is experiencing and requires Human-to-Human Relationship Model is ex-
acceptance because empathy involves the “in- plained through the stages of selecting and es-
tellectual and … emotional comprehension of tablishing a patient relationship, the process of
another person” (Travelbee, 1964) and closely maintaining the relationship, and ultimate ter-
correlates with the diagnosis/planning phase mination of the relationship. Patients in the
of the nursing process where the nurse can acute care facility are typically assigned to a
begin to consider interventions based on hav- nurse based on acuity, skill level, and experi-
ing an emotional understanding of the indi- ence of the nurse. However, nurses can select
vidual’s situation. Empathy is the precursor to patients with whom to develop a one-on-one
sympathy, or the desire, almost an urge, to help relationship based on availability and willing-
or aid an individual to relieve her or his distress ness of the nurse and patient.
(Travelbee, 1964). Sympathy is not pity, but During the pre-interaction phase, the
rather a demonstration to the person that she nurse and patient relationship is chosen or as-
or he is not carrying the burden of illness alone signed. The nurse may have preconceived
and correlates to the implementation phase of thoughts and feelings toward the patient and
the nursing process in which the nurse can must identify these prejudices before the next
begin to actively implement interventions for- phase of their relationship. Goals and objec-
mulated during the empathy phase. Trust de- tives for the interaction are established before
velops between the nurse and person in the the first meeting and may evolve over time
phase of sympathy, and the person’s distress is (Travelbee, 1969, p. 143). Once the nurse and
diminished. patient are acquainted, both the nurse and pa-
Rapport is essential in the nurse–patient tient begin to assess each other and make an
relationship. Travelbee (1971) defined rapport assumption about the other. The nurse should
as “a process, a happening, and experience, or clarify to the patient that the nurse is not there
series of experiences, undergone simultane- simply to collect data but rather to get to
ously by nurse and the recipient of her [sic] “know” the patient (p. 151). Data should be
care” (p. 150). Rapport “is composed of a clus- collected in a manner that is sensitive to the
ter of interrelated thoughts and feelings: inpatient’s privacy and comfort level. The nurse’s
terest in and concern for, others; empathy, own thoughts and feelings of the interaction
compassion, and sympathy; a non-judgmental must be considered following a one-on-one
attitude, and respect for each individual as a interaction to determine whether the nurse’s
unique human being” (Travelbee, 1963, p. 70). own behavior may have affected the patient
Through the establishment of rapport, the interaction (Travelbee, 1969, p. 132). Like-
nurse is able to foster a meaningful relationship wise, the nurse must evaluate whether the in-
with the ill person during multiple points of teraction met previously established objectives
contact in the care setting and correlates with and set goals for future interactions. The nurse
the evaluation phase of the nursing process. In and patient affect each other’s thoughts and
the rapport phase, a close human-to-human feelings during each encounter, based on “the
relationship between the nurse and individual nurse’s knowledge and her [sic] ability to use

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it, the ill person’s willingness or capacity to a sense of meaning and purpose related to
respond to the nurse’s effort, and the kind their professional identity.
of problem experienced by the ill person” Participants shared their perceptions of their
(Travelbee, 1969, p. 139). work environment during the initial encounter.
The phase of emerging identities occurs Support group members discussed the similar-
when the nurse and the patient have over- ities and differences in their work perceptions
come their own anxieties about the interac- during the phase of emerging identities. Empa-
tion, stereotypes, and past experiences. The thy and trust developed as nurses became more
nurse and patient come to see each other as accepting and nonjudgmental of each other’s
unique, and the nurse works to transcend his perceptions, culminating in the establishment
or her view of the situation. The nurse helps of rapport as group members could “recapture”
the patient to identify problems and helps the the meaning of nursing (Cook, 1989).
patient change her or his own behaviors. Cook (1989) found that nurses who had
During this stage of development, the nurse threatened to quit earlier had remained in the
helps the patient find meaning in the illness system by the end of the support group. Nurse
experience “whether this suffering be pre- productivity had increased over time, and the
dominately mental, physical, or spiritual in number of sick days taken by the nurses had
origin” (Travelbee, 1969, p 157). Eventually, diminished over the 6-month period after pro-
the relationship is terminated, and prepara- gram cessation. Nurses regained a sense of
tion for termination of the relationship meaning of their work and reported increased
should begin early in the phase of emerging job satisfaction after completion of the pro-
identities. Patients may feel abandoned or gram. Travelbee’s ideas hold potential as an
angry regarding the termination if remaining effective nursing intervention for improv-
in the facility. In some cases, the nurse may ing nurse retention rates. However, further
be able to elicit their thoughts and feelings. research is necessary because the exact number
Those to be discharged from the facility of nurses recruited into the support group and
should be encouraged to express their fears the actual number of nurses who completed
and be assisted in problem-solving solutions. the program are unknown.
Critical appraisal of Travelbee’s Human-to-
Human Relationship Model was completed by
Applications of the Theory Shelton (2016) to explicate the philosophical
Cook (1989) used Travelbee’s nursing con- and theoretical assumptions of the model. This
cepts to design a support group for nurses critical appraisal included reviewing Travel-
facing organizational restructuring at a New bee’s constructs and concepts in relation to
York hospital. The purpose of the support the criteria of clarity or brilliance, simplicity or
group was to help nurses develop more mean- parsimony, generalizability, accessibility, im-
ingful perceptions of their roles during a portance, and theory applications. Shelton
nursing shortage created during a financial (2016) states, “Travelbee’s grand theory of
crisis that resulted in a restructuring of pa- Human-to-Human Relationships provides
tient care delivery and nurse/patient ratios. nurses with a foundation necessary to connect
Group morale was low in the beginning, and therapeutically with other human beings”
nurses were frustrated with higher nurse/ (p. 661) and emphasizes how Travelbee’s the-
patient ratios. The support group met over ory should inform the scientific foundation to
2 weeks, and the group intervention was de- further nursing theory, research, and evidence-
signed by incorporating Hoff’s theory on cri- based practice for advanced practice nurses in
sis intervention with Travelbee’s phases of oncology and other settings.
observation and communication. Travelbee’s Concepts and constructs found in Travelbee’s
Human-to-Human Relationship Model was Human-to-Human Relationship Model con-
used to guide supportive discussions and tinue to have relevance to current nursing the-
problem solving as nurses struggled to regain ory and research. For example, Brown (2015)

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examines challenges faced by carers’ of early theory of Spiritual Well-Being in Illness

onset Alzheimer patients and the role nurses (O’Brien, 2014). Travelbee’s theory in psychi-
play in alleviating these challenges; while atric–mental health nursing practice has been
Falkenstrom (2016) explores nurse-patient en- applied “most easily and readily when working
counters from the perspective of home health with patients who are suffering from depressive
care nurses to better understand the context of disorders” (Jones & Fitzpatrick, 2012, p. 28), as
‘difficult’ patient encounters. Additionally, Trav- well as by hospice nurses caring for terminally ill
elbee’s work on the ability of persons to finding patients. The applications of Travelbee’s work
meaning in their experience of illness and suffer- detailed above support the relevance of the the-
ing served as the basis for the middle-range orists work to modern nursing practice.
Practice Exemplar
Luciana came into nurse practitioner Janice’s Luciana’s calm face, as though she knew she
office for her annual well-woman examina- had breast cancer all along. Janice gave her a
tion. A 53-year-old mother of three without big hug and whispered softly into her left ear,
insurance, Luciana had delayed her visit for “It will be alright. I am going to help you.”
several months due to lack of money. De- Luciana explained that she did not work and
spite a nagging feeling that the pain in her did not have either health insurance or Med-
breasts might be serious, Luciana waited icaid. Janice explained that programs were
until she could no longer tolerate the pain available to help provide financial assistance
and the redness and swelling of the breasts and that she would help her contact a repre-
that had since developed. sentative from a state-run breast cancer pro-
When Janice explained to Luciana that gram. Janice carefully finished performing
she was a nurse practitioner and would be her physical examination, taking care to doc-
performing her examination today and ad- ument the extent of her swelling and the size,
dressing any concerns she may have, Luciana shape, smoothness, mobility, and location of
sat silently, looking slightly below Janice’s any lumps palpated during the clinical breast
eyes as she spoke. She avoided eye contact examination.
until asked if something was wrong. Unable Once the examination was finished, Jan-
to wait for Janice to complete the history, ice excused herself and sought out the office
Luciana lifted her shirt and showed the manager. She pulled Sophia aside in private
nurse practitioner her erythematous, swollen and explained the situation. They contacted
breasts. The most significant swelling noted their local representative from the health de-
was located in the upper left quadrant, where partment in charge of a grant that allocated
Janice’s own mother-in-law had experienced money for diagnostic mammography and
her most significant swelling and lesions arranged for the patient to obtain the mam-
from her breast cancer 5 years earlier—a cancer mography through the program. Janice re-
she hid from her family until it was too late turned to the examination room with the
to intervene. referral form, prescription for the diagnostic
“What do you think this means?” Luciana imaging, and contact information for the
asked. “Do you think this is cancer?” Stunned program representative. The patient began
by her bluntness, Janice took a closer look to cry softly as she expressed concern for her
at the swelling and warm, red skin across three children and wondered who would
Luciana’s chest. Dread quickly filled Janice. take care of them. Janice hugged Luciana as
Trying to think back to what she had been she cried and shared her story of working as
taught to say in her nursing education, her a stay-at-home mom while her husband
mind drew a blank and honesty was the only worked for low wages. She felt lonely and
thought to come to mind. “Yes,” Janice missed her family, who lived abroad. She
replied softly. “I do.” Tears began to fall from had not shared her breast pain with anyone,

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wanting to protect her family from worry- of an oncologist with experience in treating
ing about her. Tears began to fall from Jan- breast cancer. Luciana returned to the clinic a
ice’s own eyes, as she remembered her couple weeks later and expressed her gratitude
mother-in-law lying in a hospice bed when for their help in getting her the health care she
she finally shared the gaping wounds where needed. She had started chemotherapy treat-
her own breast cancer had eaten away at ment and her mother had come to stay with
her skin. Dread had filled Janice then, too, her to help take care of her children.
as she knew she was powerless to help her. Travelbee’s concepts are evident in this
As Janice hugged Luciana, a shimmer of exemplar. Janice, the nurse practitioner, col-
hope radiated from somewhere in that ex- lected the preliminary patient history and ex-
amination room as she realized she could amination findings needed to formulate a
actually do something to help Luciana. diagnosis during the Stage of Observation.
Even though she did not have a back- However, Janice’s interpretation of unspoken
ground in oncology, Janice knew how to cues and body language led her to the purpose of
connect her with providers that could fur- Luciana’s visit and to identify Luciana’s fear
ther evaluate and manage her breast cancer. related to the breast cancer. By identifying bar-
Janice showed Luciana the documents that riers to care and existing sources of support for
she had carried into the examination room the patient (Concept of Decision Making),
and explained how she could obtain the Janice developed a care plan that involved a re-
mammogram at no charge. Janice described ferral to the health department for access to a
the program being offered through the state grant available to fund Luciana’s mam-
health department and gave her the name mogram and to a representative with the state
of the woman who would now help facili- Medicaid program for financial assistance with
tate the care she needed. Luciana looked breast cancer treatment (Concept of Action, or
her in the eyes, appearing to have been em- Nursing Intervention). By caring for her as a
powered by the information Janice had person, Luciana was able to express her story
given her, and said “Thank you.” freely and let go of her feelings of powerless-
Several days later, Janice received the ra- ness and fear that had built up inside her
diologist’s report from Luciana’s diagnostic since she first noticed her breast pain. The bar-
mammography. The report confirmed that rier between Janice-as-clinician and Luciana-
Luciana did indeed have breast cancer. For- as-patient blurred as they connected in that ex-
tunately, Sophia, the assistant office man- amination room, their stories intertwining as
ager, had spoken with Jan at the health they came together as woman-to-woman, each
department and learned Luciana had re- affected by breast cancer differently and yet
ceived Medicaid and was now under the care somehow the same (Concept of Appraisal).
Summary
Travelbee’s conceptualizations of the human- concept of therapeutic use of self to effect
to-human relationship guide the nurse–patient change in patient-centered care. Patients are
interaction with an emphasis on helping the viewed as unique, and nursing care is delivered
patient find hope and meaning in the illness over five stages: observation, interpretation,
experience. Scientific knowledge and clinical decision making, action (or nursing interven-
competence are incorporated into Travelbee’s tion), and appraisal (or evaluation).

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Questions for Reflection ■ Explain why the term patient is not philo-
sophically congruent with Travelbee’s
and Discussion Human-to-Human Relationship Model.
■ Describe the phases in the Human-to- ■ What is the significance of suffering in
Human Relationship Model and how Travelbee’s model? What role does the
these can be applied to the nursing nurse play in an individual’s suffering?
process.
Part Three Ida Jean Orlando’s Dynamic Nurse–Patient the Massachusetts chapter of the American
Relationship Nurses Association in 2006. She passed away
Diane L. Gullett and Maude Rittman on November 28, 2007.

Ida Jean Orlando was born in 1926 in Overview of the Theory
New York. Her nursing education began at Ida Jean Orlando-Pelletier was an internation-
New York Medical College School of Nursing ally known psychiatric health nurse, theorist,
where she received a diploma in nursing. In and researcher who developed the Deliberative
1951, she received a bachelor of science degree Nursing Process Theory. She was one of the
in public health nursing from St. John’s Uni- first theorists to develop her theory inductively
versity in Brooklyn, New York, and in 1954, through empirical research (Schumacher, Fisher,
she completed a master’s degree in nursing Tomey, Mills, & Sauter, 1998). Orlando’s
from Columbia University. Orlando’s early (1961) original research examined nursing sit-
nursing practice experience included obstetrics, uations to determine the process and outcome
medicine, and emergency room nursing. Her of nurse–patient interactions, stating that “the
first book, The Dynamic Nurse–Patient Rela- purpose of nursing is to supply the help a pa-
tionship: Function, Process and Principles (1961), tient requires in order for his [sic] needs to be
was based on her research and blended nursing met” (p. 8). Orlando’s theory is credited with
practice, psychiatric–mental health nursing, defining the professional role of the nurse and
and nursing education. It was published when understanding the nurse–patient relationship
she was director of the graduate program in (Fawcett, 1993). Orlando (1961/1990) outlined
mental health and psychiatric nursing at Yale three elements of a nursing encounter: the be-
University School of Nursing. havior of the patient, the reaction of the nurse,
Orlando’s theoretical work is both practice and the nursing action undertaken to benefit the
and research based. She received funding from patient.
the National Institute of Mental Health to im- Orlando’s theory has been categorized by
prove education of nurses about interpersonal other theorists in a variety of ways, including as
relationships. As a consultant at McLean Hos- a prescriptive theory (Woolridge, Skipper, &
pital in Belmont, Massachusetts, Orlando con- Leonard, 1968), an interaction theory (Barnum,
tinued to study nursing practice and developed 1998; Crane, 1980), and a middle-range the-
an educational program and nursing service ory (Fawcett, 1993). However, it is important
department based on her theory. From evalu- to recognize that Orlando (1972) described
ation of this program, she published her sec- her theory as a nursing process theory rooted
ond book, The Discipline and Teaching of in the interaction between a nurse and a pa-
Nursing Process (Orlando, 1972). Orlando’s The tient at a specific time and place. Orlando-
Dynamic Nurse-Patient Relationship: Function, Pelletier’s Nursing Process Theory is guided by
Process, and Principles was reprinted in 1990 the following five major interrelated concepts,
and has been translated into five languages. as derived from Schmieding’s (1983, 1987)
Orlando retired in 1992. She was honored analysis of Orlando’s theory using the writings
with a Living Legends in Nursing award by of John Dewey (1933) and Thomas Kuhn

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(1970): functions of professional nursing (the Immediate Reaction

organizing principle), presenting behavior (pa- The problematic situation generates an im-
tient’s problematic situation), immediate reac- mediate reaction, which involves an internal
tion (patient’s internal process), deliberative response in the nurse. Appropriate nursing
nursing process (reflective inquiry), and im- reactions follow specific steps: (1) perceiving
provement (resolution). and interpreting the patient’s behavior
Organizing Principle through the senses; (2) this perception leads
to automatic thought; and (3) the thought
The organizing principle, as conceptualized by generates an automatic feeling (Orlando,
Orlando (1972), is finding out and meeting 1972, p. 25). The nurse’s immediate reaction
the patient’s immediate needs for help, mak- is unique to each situation and reflects the
ing the patient the focus of the nurse’s func- nurse’s individuality.
tion. According to Orlando (1961), “need is
situationally defined as a requirement of the
Reflective Inquiry
patient which, if supplied, relieves or dimin-
ishes his [sic] immediate distress or improves A deliberate nursing process has elements of con-
his [sic] immediate sense of adequacy or well- tinuous reflection as the nurse tries to under-
being” (p. 5). This is done through focusing stand the meaning of the patient’s behavior and
on the process of care to an immediate indi- investigates what the patient needs from the
vidual’s experience for the purpose of alleviat- nurse in order to be helped. The deliberative
ing and diminishing an individual’s sense of nursing process has five stages—assessment,
helplessness. Professional nurses function in diagnosis, planning, implementation, and
an independent role from physicians and other evaluation—and includes identifying the needs
health-care providers. of patients, responses of the nurse, and nursing
action set in motion by patient behavior. The
Presenting Behavior nursing process, as envisioned and practiced by
The presenting behavior reflects distress or a Orlando, is not the linear model often taught
problematic situation in which the patient ex- today but is more reflexive and circular (May,
periences a need that he or she cannot resolve, 2014). Nurses use the standard nursing process
and a sense of helplessness occurs. Patient be- within Orlando’s Process Discipline Theory to
havior communicates the need for help when produce positive outcomes or patient improve-
the patient cannot meet her or his own need. ment (George, 2002). The nurse consciously
It is this behavior that stimulates a nurse’s re- assesses personal reactions and patient feedback
action, which indicates the beginning of the to perform professional deliberate nursing in-
nursing process (May, 2014). The behavior terventions grounded in mindful assessment
could be verbal or nonverbal or seemingly in- rather than automatic reactions. Responses
significant. The nurse focuses on the various comprising this process are stimulated by the
verbal and nonverbal behaviors of patients, in- nurse’s unfolding awareness of the individual
cluding language, motor activity, and physio- situation (Orlando, 1961).
logical symptoms, to provide insight into the
true nature of a patient’s need for help. Failing Improvement
to correctly understand and address the pa- The openness of the nurse to share his or her
tient’s need for help may result in an ineffective reaction safeguards the patient’s need for res-
nurse–patient relationship where the nurse is olution to the patient’s situation and improves
unable to meet the care needs of the patient. the patient’s behavior. A nurse using Orlando’s
Nurse–patient interactions are unique, com- theory prioritizes resolution or the clear under-
plex, and dynamic processes. Nurses help pa- standing of effective patient behavior. Once
tients express and understand the meaning of the patient’s immediate needs for help have
behavior. The basis for nursing action is the dis- been determined and met, there is improve-
tress experienced and expressed by the patient. ment to the patient’s situation (Orlando, 1961).

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Resolution involves determining if the pa- 2015). The Kissick Framework not only melds
tient’s sense of helplessness has been relieved together Orlando’s theory, but also the National
or diminished (Orlando, 1972). Organization of Nurse (NONPF) Core Com-
The essence of Orlando’s theory, the dy- petencies and the DNP Essentials, to develop a
namic nurse–patient relationship, reflects her practice model for family nurse practitioners
beliefs that practice should be based on needs (Kissick, 2015). These DNP projects illustrate
of the patient and that communication with the application of nursing theory with advanced
the patient is essential to understanding needs practice nurses situated in the disciplinary
and providing effective nursing care. knowledge of nursing. Tolino’s (2016) DNP
capstone project focused on improving nurse-
patient communication through sustainable
Applications of the Theory workshops utilizing role-play. The workshops
Orlando’s theoretical work was based on educated unit nurses on the use of standardized
analysis of thousands of nurse–patient interac- bedside reporting in the form of SBAR. The
tions to describe major attributes of the rela- standardized use of SBAR by the nurses im-
tionship. Based on this work, her later book proved nurse-patient communication at the
provided direction for understanding and bedside grounded in Orlando’s Nurse-Patient
using the nursing process (Orlando, 1972). Relationship Theory.
This has been known as the first theory of Aponte (2009) employed Orlando’s Dy-
nursing process and has been widely used in namic Nurse–Patient Relationship as a con-
nursing education and practice in the United ceptual framework for the Influenza Initiative
States and across the globe. Orlando consid- in New York City to address the linguistic dis-
ered her overall work to be a theoretical frame- parities within communities. A needs survey
work for the practice of professional nursing, identified unmet linguistic needs and gaps ex-
emphasizing the essentiality of the nurse– isting within the city; nursing students, many
patient relationship. Orlando’s theoretical work of whom were bilingual, served as translators
reveals and bears witness to the essence of nurs- for non–English-speaking residents of the city.
ing as a practice discipline. Orlando’s theoretical framework was used to
Orlando’s theoretical foundation serves as a describe the communication among the nurs-
foundation for bachelor’s and master’s degree ing students, home-care nurses, and city resi-
theses, and more recently has seen a resurgence dents (Aponte, 2009, p. 326). Dufault et al.
as the foundation for doctor of nursing prac- (2010) developed a cost-effective, easy-to-use,
tice (DNP) capstone projects (Grove, 2008; best-practice protocol for nurse-to-nurse shift
Haapoja, 2014; Hendren, 2012; Jin, 2017). A handoffs at Newport Hospital, using specific
DNP project done by Dalton (2016) used a ret- components of Orlando’s theory of delibera-
rospective chart review guided by Orlando’s tive nursing process. Abraham (2011) pro-
theoretical focus on determining and meeting posed addressing fall risk in hospitals using
patients’ immediate needs to demonstrate how Orlando’s conceptualizations. The author as-
the use of telemedicine by nurse practitioners in serts that three elements (patient’s behavior,
a rural emergency department improved patient nurse’s reaction, and anything the nurse does
outcomes, decreased mortality rates, and re- to alleviate the distress) can effectively act as a
duced transfers. The Kissick Framework for roadmap for decreasing fall risk.
DNP education and practice was derived from The New Hampshire Hospital, a university-
a literature review as part of a DNP project. The affiliated psychiatric facility, adopted Orlando’s
Kissick Framework, unlike other advanced framework for nursing practice (Potter, Vitale-
nursing practice frameworks, specifically focuses Nolen, & Dawson, 2005; Potter, Williams, &
on the nurse-patient relationship emphasizing Constanzo, 2004). Two nursing interventions
the patient as the primary concern of the nurse stemmed directly from the adoption of Or-
through the integration of Orlando’s Theory of lando’s ideas. Potter, Williams, and Constanzo
Dynamic Nurse-Patient Relationship (Kissick, (2004) developed a structured group curriculum

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for nurse-led psychoeducational groups in an assessed nursing students’ responses to simu-

inpatient setting. Both nurses and patients lated client scenarios (Abdoli & Safayi, 2010).
demonstrated improved comfort, active involve- Sixty nursing students enrolled in bachelor’s
ment, and learning from combining Orlando’s degree programs across Tehran were selected
dynamic nurse–patient relationship and a psy- to participate in the study. A dimensional con-
choeducational curriculum with training in tent analysis revealed six categories of students’
group leadership. Orlando’s Nursing Process immediate responses to the physical and men-
Theory served as a guide for developing a tal health problems of simulated distressed pa-
health-care administration analysis system to tients. The results indicated students’ responses
aid health-care administrators in performing were automatic and ineffective in addressing
outcome analysis, according to individual needs the mental health problems of the “patients”
(Adegboyega & Aniefiok, 2014). The study because they failed to consider the patients’
used a descriptive survey design to collect pri- decision making in the process. This study
mary and cross-sectional data. The study pro- reinforced the need to integrate Orlando’s the-
vided a demonstration of how the application ory into the nursing curriculum throughout
of information and communication technology Tehran as a means to reinforce the importance
guided by Orlando’s nursing process in health- of patients as participants in their care and en-
care services utilizes healthcare information sys- hance students’ communication skills. Another
tems as effective lifesaving systems that “can quasi-experimental study investigated anxiety
influence and enhance health-workers’ quality levels of patients undergoing an endoscopy
of services, timely precision decision making procedure using an experimental group and a
process and reduced cost of health care signifi- control group (Yekefallah, Ashktorab, Ghorbani,
cantly through effective healthcare manage- Pazokian, & Samimi, 2017). The experimen-
ment” (Adegboyega & Aniefiok, 2014, p. 56). tal group received standard hospital interven-
Sheldon and Ellington (2008) conducted a tions along with Orlando’s nursing process
pilot study to expand Orlando’s process into while the control group received only hospi-
sequential steps that further define the delib- tal interventions. The results revealed a statis-
erative nursing process. The authors used cog- tically significant lower mean anxiety level
nitive interviews with a convenience sample of among the experimental group compared to
five experienced nurses to gain insight into the the control group. Orlando’s theory as a prac-
process of nurse communication with patients tice and conceptual framework continues to be
and the strategies nurses use when respond- relevant and applicable to nursing situations in
ing to patient concerns. An exploratory study, today’s health-care environment (Sampoornam,
using Orlando’s Nursing Process Theory, 2015).
Practice Exemplar
Krystal, a 23-year-old woman with a history air. Assessment reveals no increased work of
of asthma, presents to the emergency depart- breathing with slight, bilateral, expiratory
ment with her boyfriend. She states, “I just wheezing. The nurse, employing standing
can’t seem to catch my breath, I just can’t orders, places the patient on 2 L of oxygen
seem to relax”; she appears extremely agi- per nasal cannula and initiates a respiratory
tated. Avoiding eye contact, Krystal fearfully treatment.
explains to the nurse that she has not been Seeking privacy with the patient, the nurse
able to obtain any of her regular medications kindly asks the boyfriend to wait in the patient
for approximately 4 months. The nurse ob- lounge. He becomes argumentative and reluc-
tains vital signs, including a blood pressure tant to leave; the nurse calmly states that she
of 113/68; pulse of 98; respiratory rate of 22; simply needs to complete her assessment with
an oral temperature of 37.0 degrees Celsius; the patient and again asks again for him to
and an oxygen saturation of 95% on room wait in the lounge; this time he complies.
(continued)

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Further investigation by the nurse reveals and begins crying, telling the nurse she had a
that Krystal normally uses albuterol and Ad- fight with her boyfriend today and he hit her.
vair to control her asthma, but she has been “He always makes sure to hit me where people
unable to obtain her medications over the past can’t see, and he is always sorry.” The nurse
4 months because of “personal problems.” asks if Krystal is injured in any way right now.
In this example, the nurse formulates an Krystal pulls up her shirt to reveal extensive
immediate hypothesis based on direct and bruising at various stages of healing to her
indirect observations and attempts to validate torso and what looks like several fresh ciga-
this hypothesis by collecting additional data rette burns to both her breasts. The nurse asks
(questioning the patient about her normal Krystal if it would be okay to perform some
medications, observing the boyfriend’s reluc- additional assessments to ensure no further in-
tance to leave the room, assessing the pa- ternal injury has occurred. Krystal nods her
tient’s agitated state and refusal to make eye head yes, and the nurse asks if this has hap-
contact, and obtaining vital signs). From the pened before. Krystal tells the nurse that these
patient data, the nurse formulates several ad- days it happens almost daily but that she de-
ditional hypotheses about the patient. The serves it because she doesn’t have a job and he
nurse may hypothesize that Krystal needs fi- is the only one who loves her. “I want to leave.
nancial assistance in obtaining her medica- I really do, but I am afraid he will kill me, and
tions and additional education about asthma I don’t have anywhere else to go.” The nurse
and the role of medications in managing the acknowledges Krystal’s distress, clarifying that
disease. A nurse not using Orlando’s theory Krystal does not deserve this type of treatment
might administer the necessary asthma med- and that she fears for her safety, emphasizing
ications; provide asthma education; and pro- abuse is a crime and only worsens over time.
vide resources for obtaining free or low-cost At this point, the nurse discusses how the
medications. A nurse using Orlando’s theo- patient wishes to address this concern, ensuring
retical framework, however, understands that there is a dynamic interaction occurring be-
no nursing action should be taken without tween the patient and the nurse. Offering the
first validating each hypothesis with the pa- patient the resources and opportunity to express
tient as a means of determining the patient’s and understand the meaning of her own behav-
immediate needs. The nurse in this situation ior inspires Krystal to find meaning in the ex-
validates with the patient the source of her perience and ownership in the choices needed
anxiety and inability to catch her breath. In to address these concerns. Using her nursing
doing so, the nurse learns that the patient’s knowledge of domestic abuse, the nurse en-
concern now is not with her wheezing or ob- gages Krystal in a conversation about the cycle
taining her asthma medication but rather of violence and empowers Krystal by providing
with her boyfriend. her with choices and resources to address her
The nurse hypothesizes that Krystal is a current situation. After the nurse–patient in-
victim of intimate partner violence. Again, teraction, Krystal decides to go to a local do-
the nurse seeks to validate this with the pa- mestic abuse shelter for women (the nurse
tient, asking Krystal if her boyfriend is phys- assists by calling the shelter and providing
ically or emotionally harming her. Krystal transportation), to file a police report (the nurse
continues to look fearfully at the door and arranges for an officer to come to the hospital),
states, “He is going to kill me if I tell you and to allow for photos and documentation of
anything.” The nurse assures Krystal that she her injuries to be charted (documentation fol-
is in a safe place right now, that she is not lows the guidelines needed to be admissible in
alone, and that there are safety measures that a court of law if necessary). The nurse also pro-
can be taken to remove the boyfriend from vides Krystal with the number for the National
the premises if that would make Krystal feel Resource Center on Domestic Violence, and
safer. Krystal requests the nurse to do this with two websites, the Violence Against

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Women Network (www.vawnet.org) and the based on an invalid hypothesis. The nurse in
Florida Coalition Against Domestic Violence this situation used her perception and knowl-
(www.fcadv.org). The nurse calls the shelter a edge of the nursing situation to explore the
few days later to check that Krystal is safe and meaning of Krystal’s behavior. Through
learns that Krystal will be remaining at the communication and validation with the pa-
shelter and has not had any further contact tient of the nurse’s hypotheses, perceptions,
with her boyfriend. and supporting data, the nurse was able to
Through mutual engagement, the pa- elicit the nature of the patient’s problem and
tient and nurse were able to create a dy- mutually engage the patient in identifying
namic environment that fostered effective what help was needed. After mutual decision
communication and the ability to address making, the nurse took deliberative nursing
the immediate needs of the patient. Provid- actions to meet Krystal’s immediate needs,
ing asthma education and financial re- including initiating safety protocols, provid-
sources would not have addressed Krystal’s ing resources, gathering additional data, and
need for physical safety related to domestic creating a supportive and encouraging envi-
abuse because the plan would have been ronment for the patient.
Summary
The most important contribution of Or- Orlando’s writings can serve as a philosophy
lando’s theoretical work is the primacy of the as well as a theory, because it is the founda-
nurse–client relationship. Inherent in this tion on which nursing’s profession has been
theory is a strong statement: What transpires built. With all of the benefits that modern
between the patient and the nurse is of the technology and modern health care bring—
highest value. The true worth of Orlando’s and there are many—we need to pause and
ideas is that it clearly states what nursing is ask the question, what is at risk in health care
or should be today. Regardless of the changes today? The answer to that question may lead
in the health-care system, the human trans- to reconsideration of the value of Orlando’s
action between the nurse and the patient in theory as perhaps the critical link for enhanc-
any setting holds the greatest value—not ing relationships between nursing and patient
only for nursing, but also for society at large. today (Rittman, 1991).
Questions for Reflection ■ What is the significance of nurse–patient

relationships and how is this important to
and Discussion nursing practice?
■ What are the major interrelated concepts ■ How would you compare current defini-
within Orlando’s theory and how can tions of professional nursing with that as
these be applied to nursing practice to described by Orlando?
improve patient care?

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SE C T I O N
III
Conceptual Models/
Grand Theories in the
Integrative-Interactive
Paradigm

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SECTION
III Conceptual Models/Grand Theories in the

Integrative-Interactive Paradigm
Section III includes seven chapters on the conceptual models or grand theories situ-
ated in the integrative-interactive 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 integrative-
interactive paradigm view persons1 as integrated wholes or systems interacting with
the larger environment. The integrated dimensions of the person are influenced by
environmental factors leading to some change that affects health or well-being. The
subjectivity of the person and the multidimensional nature of any outcome are con-
sidered. Most of the theories are based explicitly on a systems perspective.
In Chapter 7, Bonnie Holaday presents Johnson’s Behavioral System Model. The
model includes principles of wholeness and order, stabilization, reorganization, hier-
archic 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 balance and stability at the highest possible level.
Chapter 8 features Orem’s Self-Care Deficit Nursing Theory, written by expert
Donna Hartweg. This conceptual model has four constituent theories associated with
it: the Theory of Self-Care, the Theory of Dependent Care, the Theory of Self-Care
Deficit, and the Theory of Nursing Systems. 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.
King’s Theory of Goal Attainment, presented in Chapter 9, offers a view that the goal
of nursing is to help persons maintain health or regain health. This is accomplished
through a transaction, setting a mutually agreed-upon goal with the patient. Christina
Sieloff and Mary Louanne Friend updated the chapter originally written by King herself.
In Chapter 10, Callista Roy and her colleague Pamela Senesac describe the Roy
Adaptation Model and its applications. In this model, the person is viewed as a holistic
adaptive system with coping processes to maintain adaptation and promote person–
environment transformations. The adaptive system can be integrated, compensatory,
or compromised depending on the level of adaptation. Nurses promote coping and
adaptation within health and illness.
Sarah Beckman and Jaqueline Fawcett authored Chapter 11 on the Neuman Sys-
tems Model. The model includes the client–client system with a basic structure pro-
tected 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 as-
sisting client adjustments for optimal wellness.
In Chapter 12, Erickson, Tomlin, and Swain’s Modeling and Role-Modeling Theory
is written by Helen and Margaret Erickson. Modeling and Role-Modeling Theory pro-
vides 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 resolution.
The final chapter in this section is Dossey’s Theory of Integral Nursing, a relatively
new grand theory that posits an integral worldview and body–mind–spirit connected-
ness. The theory is informed by a variety of ideas, including Nightingale’s tenets,
holism, multidimensionality, spiral dynamics, chaos theory, and complexity. It includes
the major concepts of healing, the metaparadigm of nursing, patterns of knowing,
and Wilber’s integral theory and Wilber’s all quadrants, all levels, all lines.
90
1“Person” refers
Smith, M. C. (2019). Nursing theories and nursing practice. F. A.toDavis
individuals,
Company.families, groups, or communities.
7991_Ch07_089-108 12/08/19 5:15 PM Page 91
Dorothy Johnson’s
CHAPTER
7
Behavioral System Model
Bonnie Holaday

Overview of the Theory
Applications of the Model Introducing the Theorist
Practice Exemplar Dorothy Johnson’s earliest publications per-
Summary tained to the knowledge base nurses needed for
Questions for Reflection and Discussion nursing care (Johnson, 1959, 1961). Through-
out her career, Johnson (1919–1999) stressed
that nursing had a unique, independent con-
tribution to health care that was distinct from
“delegated medical care.” Johnson was one of
the first “grand theorists” to present her views
as a conceptual model. Her model was the first
to provide a guide to both understanding and
action. These two ideas, understanding seen
first as a holistic, behavioral system process
mediated by a complex framework and second
as an active process of encounter and response,
are central to the work of other theorists who
followed her lead and developed conceptual
models for nursing practice.
Dorothy Johnson 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 practiced briefly as a
staff nurse at the Chatham-Savannah Health
Council before attending Harvard University,
where she received her master of public

health in 1948. She began her academic ca-
reer at Vanderbilt University School of
Nursing. A call from Lulu Hassenplug, Dean
of the School of Nursing, enticed her to
the University of California, Los Angeles
(UCLA), in 1949. She also served for a year
as a pediatric nursing advisor at the Christian
Medical College School of Nursing in Vel-
lare, South India, and while there she wrote
a series of clinical articles for the Nursing
Journal of India (Johnson, 1956, 1957). She
served at UCLA as an assistant, associate,
and professor of pediatric nursing until her
retirement in 1978. During her career,
91
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92 S E C T IO N III ■ Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm
Dorothy Johnson addressed issues related make it possible to test hypotheses and con-
to nursing practice, education, and science. duct critical experiments.
Johnson is recognized as one of the founders
of modern systems-based nursing theory Five Core Principles
(Meleis, 2012). Johnson’s model incorporates five core princi-
Dorothy Johnson took an early retirement ples of system thinking: wholeness and order,
at age 59 following open-heart surgery. She stabilization, reorganization, hierarchic inter-
retired just as her theoretical work was begin- action, and dialectical contradiction. Each of
ning to be widely recognized. Her retirement these general systems principles has analogs in
was an occasion for several honors, including developmental theories that Johnson used to
the Lulu Hassenplug Award from the Cali- verify the validity of her model (Johnson, 1980,
fornia Nurses Association, and she was also 1990). Wholeness and order provide the basis
named a Fellow of the American Academy of for continuity and identity, stabilization for de-
Nursing. Today her work is globally recog- velopment, reorganization for growth and/or
nized for its seminal contributions to the de- change, hierarchic interaction for discontinu-
velopment of a theoretical knowledge base for ity, and dialectical contradiction for motiva-
nursing practice and research. Her influence tion. Johnson conceptualized a person as an
continues to be strong and her legacy is evi- open system with organized, interrelated, and
dent in the continued use of her theory and interdependent subsystems. By subsystem in-
citations of her publications. teraction and independence, the whole of the
human organism (system) is greater than the
sum of its parts (subsystems). Wholes and their
Overview of the Theory parts create a system with dual constraints:
Johnson noted that her theory, the Johnson Neither has continuity and identity without
Behavioral System Model (JBSM), evolved the other.
from philosophical ideas, theory, and research; The overall representation of the model can
her clinical background; and many years of also be viewed as a behavioral system within
thought, discussions, and writing (Johnson, an environment. The behavioral system and
1968). She cited a number of sources for her the environment are linked by interactions
theory. From Florence Nightingale came the and transactions. We define the person (be-
belief that nursing’s concern is a focus on the havioral system) as comprising subsystems and
person rather than the disease. Systems theo- the environment as comprising physical, in-
rists (Buckley, 1968; Chin, 1961; Parsons & terpersonal (e.g., father, friend, mother, sib-
Shils, 1951; Rapoport, 1968; Von Bertalanffy, ling), and sociocultural (e.g., rules and mores
1968) were all sources for her model. Johnson’s of home, school, country, and other cultural
background as a pediatric nurse is also evident contexts) components that supply the sustenal
in the development of her model. In her pa- imperatives (Grubbs, 1980; Holaday, 1997;
pers, Johnson cited developmental literature Johnson, 1990; Meleis, 2012). Sustenal im-
to support the validity of the Behavioral peratives are the necessary prerequisites for the
System Model (Ainsworth, 1964; Crandal, optimal functioning of the behavioral system.
1963; Gerwitz, 1972; Kagan, 1964; Sears, The environment must supply the sustenal im-
Maccoby, & Levin, 1954). Johnson also noted peratives of protection, nurturance, and stim-
that several of her subsystems had biological ulation to all subsystems to allow them to
underpinnings. develop and to maintain stability. Some ex-
Johnson’s theory and her related writings amples of conditions that protect, stimulate,
reflect her knowledge about both development and nurture related to achievement would in-
and general systems theories. The combination clude encouragement from parents and peers;
of nursing, development, and general systems enriched, stimulating environments, awards,
introduces some of the specifics into the rhet- and recognition; and increased autonomy and
oric about nursing theory development that responsibility.

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C H APTER 7 ■ Dorothy Johnson’s Behavioral System Model 93
Wholeness and Order stabilizes around a trajectory rather than a set

The developmental analogy of wholeness and point. A toddler placed in a body cast may show
order is continuity and identity. Given the be- motor lags when the cast is removed but may
havioral system’s potential for plasticity, a basic soon show age-appropriate motor skills. An
feature of the system is that both continuity and adult newly diagnosed with asthma who does
change can exist across the life span. The pres- not receive proper education until a year after di-
ence of or potentiality for at least some plasticity agnosis can successfully incorporate the material
means that the key way of casting the issue of into his or her daily activities. These are examples
continuity is not a matter of deciding what exists of homeorhetic processes or self-righting ten-
for a given process or function of a subsystem. dencies that can occur over time.
Instead, the issue should be cast in terms of de- What nurses observe as development or
termining patterns of interactions among levels adaptation of the behavioral system is a prod-
of the behavioral system that may promote con- uct of stabilization. When a person is ill or
tinuity for a subsystem at a given point in time. threatened with illness, he or she is subject to
Johnson’s work implies that continuity is in the biopsychosocial perturbations. The nurse, ac-
relationship of the parts rather than in their in- cording to Johnson (1980, 1990), acts as the
dividuality. Johnson (1990) noted that at the external regulator and monitors the person’s
psychological level, attachment (affiliation) and response, looking for successful adaptation to
dependency are examples of important specific occur. If behavioral system balance returns,
behaviors that change over time, although the there is no need for intervention. If not, the
representation (meaning) may remain the same. nurse intervenes to help restore behavioral sys-
Johnson stated: “Developmentally, dependence tem balance. It is hoped that the person ma-
behavior in the socially optimum case evolves tures, and with additional hospitalizations, the
from almost total dependence on others to a previous patterns of response have been assim-
greater degree of dependence on self, with a cer- ilated, and there are few disturbances.
tain amount of interdependence essential to the
Reorganization
survival of social groups” (1990, p. 28). In terms
of behavioral system balance, this pattern of de- Adaptive reorganization occurs when the be-
pendence to independence may be repeated as havioral system encounters new experiences in
the behavioral system engages in new situations the environment that cannot be balanced by
during a lifetime. existing system mechanisms. Adaptation is de-
fined as change that permits the behavioral sys-
Stabilization tem to maintain its set points best in new
Stabilization or behavioral system balance is situations. To the extent that the behavioral sys-
another core principle of the JBSM. Dynamic tem cannot assimilate the new conditions with
systems respond to contextual changes by existing regulatory mechanisms, accommoda-

either a homeostatic or homeorhetic process. tion must occur either as a new relationship be-
Systems have a set point (like a thermostat) tween subsystems or by the establishment of a
that they try to maintain by altering internal higher order or different cognitive schema (set,
conditions to compensate for changes in exter- choice). The nurse acts to provide conditions or
nal conditions. Human thermoregulation is an resources essential to help the accommodation
example of a homeostatic process that is pri- process, imposes regulatory or control mecha-
marily biological but is also behavioral (turning nisms to stimulate or reinforce certain behav-
on the heater). The use of attribution of ability iors, or attempts to repair structural components
or effort is a behavioral homeostatic process we (Johnson, 1980). If the focus is on a structural
use to interpret activities so that they are con- part of the subsystem, the nurse will focus on
sistent with our mental organization. the goal, set, choice, or action of a specific sub-
From a behavioral system perspective, home- system. The nurse might provide an educational
orhesis is a more important stabilizing process intervention to alter the client’s set and broaden
than is homeostasis. In homeorhesis, the system the range of choices available.

7991_Ch07_089-108 12/08/19 5:15 PM Page 94
The difference between stabilization and re- physical setting. The person needs to resolve
organization is that the latter involves change (maintain behavioral system balance of) a cas-
or evolution. A behavioral system is embedded cade of contradictions between goals related to
in an environment, but it is capable of oper- physical status, social roles, and cognitive sta-
ating independently of environmental con- tus when faced with illness or the threat of
straints through the process of adaptation. The illness. Nurses’ interventions during these pe-
diagnosis of a chronic illness, the birth of a riods can make a significant difference in the
child, or the development of a healthy lifestyle lives of the persons involved because the nurse
regimen to prevent problems in later years are can help clients compare opposing proposi-
all examples in which accommodation not only tions and make decisions. Dealing with these
promotes behavioral system balance but also contradictions can be viewed as the “driving
involves a developmental process that results force” of development as resolution brings
in the establishment of a higher order or more about a higher level of understanding of the
complex behavioral system. issue at hand. This may also alter the person’s
set, choice and action. Behavioral system bal-
Hierarchic Interaction ance is restored and a new level of develop-
Each behavioral system exists in a context of ment is attained.
hierarchic relationships and environmental re- Johnson’s model is unique in part because
lationships. From the perspective of General it is informed by both general systems and de-
Systems Theory, a behavioral system that has velopmental theories. One may analyze the pa-
the properties of wholeness and order, stabi- tient’s response in terms of behavioral system
lization, and reorganization will also demon- balance, and from a developmental perspec-
strate a hierarchic structure (Buckley, 1968). tive, ask, “Where did this come from, and
Hierarchies, or a pattern of relying on subsys- where is it going?” The developmental compo-
tems, lead to a degree of stability. A disruption nent necessitates that we identify and under-
or failure will not destroy the whole system but stand the processes of stabilization and sources
instead will lead to decomposition to the next of disturbances that lead to reorganization.
level of stability. These need to be evaluated by age, gender, and
The judgment that a discontinuity has oc- culture. The combination of systems theory
curred is typically based on a lack of correlation and development identifies “nursing’s unique
between assessments at two points of time. For social mission and our special realm of original
example, one’s lifestyle before surgery is not a responsibility in patient care” (Johnson, 1990,
good fit postoperatively. These discontinuities p. 32).
can provide opportunities for reorganization
and development. Major Concepts of the Model
Next, we review the model as a behavioral

Dialectical Contradiction system within an environment.
The last core principle is the motivational force
for behavioral change. Johnson (1980) de- Person
scribed these as drives and noted that these re- Johnson conceptualized a nursing client as a
sponses are developed and modified over time behavioral system. The behavioral system is or-
through maturation, experience, and learning. derly, repetitive, and organized with interrelated
A person’s activities in the environment lead and interdependent biological and behavioral
to knowledge and development. However, by subsystems. The client is seen as a collection of
acting on the world, each person is constantly behavioral subsystems that interrelate to form
changing it and his or her goals, and therefore the behavioral system. The system may be de-
changing what he or she needs to know. The fined as “those complex, overt actions or re-
number of environmental domains that the sponses to a variety of stimuli present in the
person is responding to includes the biologi- surrounding environment that are purposeful
cal, psychological, cultural, familial, social, and and functional” (Auger, 1976, p. 22). These

7991_Ch07_089-108 12/08/19 5:15 PM Page 95
ways of behaving form an organized and inte- the whole behavioral system and manage its
grated functional unit that determines and lim- relationship to the environment. Each of these
its the interaction between the person and subsystems has a set of behavioral responses
environment and establishes the relationship of that is developed and modified through moti-
the person to the objects, events, and situations vation, experience, and learning.
in the environment. Johnson (1980, p. 209) Johnson identified seven subsystems. How-
considered such “behavior to be orderly, pur- ever, in this author’s operationalization of the
poseful and predictable; that is, it is functionally model, as in Grubbs (1980), eight subsystems
efficient and effective most of the time and is are included. These eight subsystems and their
sufficiently stable and recurrent to be amenable goals and functions are described in Table 7-1.
to description and exploration.” Johnson noted that these subsystems are found
cross-culturally and across a broad range of the
Subsystems phylogenetic scale. She also noted the signifi-
The parts of the behavioral system are called cance of social and cultural factors involved in
subsystems. They carry out specialized tasks or the development of the subsystems. She did
functions needed to maintain the integrity of not consider the seven subsystems as complete,
Table 7-1 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
Affiliative 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 definite 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 identified as threats
To use resources or feedback mechanisms to alter biological, environmental, or health input or
human responses to diminish threats to self or others
To protect one’s achievement goals
To protect one’s beliefs
To protect one’s identity or self-concept
Continued

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Table 7-1 The Subsystems of Behavior—cont’d

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 on 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 one’s 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, gratify, or attract; to fulfill expectations associated with one’s 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 gratification and/or procreation
To establish meaningful relationships in which sexual gratification 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. 217–254). 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. 207–216). New York: Appleton-Century-Crofts; D. Wilkie (1987). Operationalization of the JBSM. Unpublished
paper, University of California, San Francisco; and B. Holaday (1972). Operationalization of the JBSM. Unpublished paper,
University of California, Los Angeles.

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because “the ultimate group of response sys- information, and knowledge are examined
tems to be identified in the behavioral system before a choice is made. There are three levels
will undoubtedly change as research reveals of processing: an inadequate conceptual set,
new subsystems or indicated changes in the a developing conceptual set, and a sophisti-
structure, functions, or behavioral groupings in cated conceptual set.
the original set” (Johnson, 1980, p. 214). The third and fourth components of each
Each subsystem has functions that serve to subsystem are choice and action. Choice refers
meet the conceptual goal. Functional behaviors to the individual’s repertoire of alternative be-
are the activities carried out to meet these haviors in a situation that will best meet the
goals. These behaviors may vary with each in- goal and attain the desired outcome. The larger
dividual, depending on the person’s age, sex, the behavioral repertoire of alternative behav-
motives, cultural values, social norms, and iors in a situation, the more adaptable is the
self-concepts. For the subsystem goals to be individual. The fourth structural component of
accomplished, behavioral system structural each subsystem is the observable action of the
components must meet functional require- individual. The concern is with the efficiency
ments of the behavioral system. and effectiveness of the behavior in goal attain-
Each subsystem is composed of at least four ment. Actions are any observable responses to
structural components that interact in a spe- stimuli.
cific pattern: goal, set, choice, and action. The For the eight subsystems to develop and
goal of a subsystem is defined as the desired maintain stability, each must have a constant
result or consequence of the behavior. The supply of functional requirements (sustenal
basis for the goal is a universal drive that can imperatives). The concept of functional re-
be shown to exist through scientific research. quirements tends to be confined to conditions
In general, the drive of each subsystem is the of the system’s survival, and it includes biolog-
same for all people, but there are variations ical as well as psychosocial needs. The prob-
among individuals (and within individuals over lems are related to establishing the types of
time) in the specific objects or events that are functional requirements (universal vs. highly
drive-fulfilling, in the value placed on goal at- specific) and finding procedures for validating
tainment, and in drive strength. With drives the assumptions of these requirements. It also
as the impetus for the behavior, goals can be suggests a classification of the various states
identified and are considered universal. or processes on the basis of some principle
The behavioral set is a predisposition to act and perhaps the establishment of a hierarchy
in a certain way in each situation. The behav- among them. The Johnson Model proposes
ioral set represents a relatively stable and habit- that for the behavior to be maintained, it must
ual behavioral pattern of responses to drives or be protected, nurtured, and stimulated. It re-
stimuli. It is learned behavior and is influenced quires protection from noxious stimuli that
by knowledge, attitudes, and beliefs. The set threaten the survival of the behavioral system;
contains two components: perseveration and nurturance, which provides adequate input to
preparation. The perseveratory set refers to a sustain behavior; and stimulation, which con-
consistent tendency to react to certain stimuli tributes to continued growth of the behavior
with the same pattern of behavior. The prepara- and counteracts stagnation. A deficiency in any
tory set is contingent on the function of the or all of these functional requirements threat-
perseveratory set. The preparatory set functions ens the behavioral system as a whole, or the
to establish priorities for attending or not at- effective functioning of the particular subsys-
tending to various stimuli. tem with which it is directly involved.
The conceptual set is an additional com-
ponent to the model (Holaday, 1982). It is a Environment
process of ordering that serves as the mediat- In General System Theory, the term environ-
ing link between stimuli from the preparatory ment is defined as the set of all objects for
and perseveratory sets. Here attitudes, beliefs, which a change in attributes will affect the

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system as well as those objects whose attrib- needs of an acutely ill hospitalized 6-year-old
utes are changed by the behavior of the system would need to know something about the de-
(von Bertalanffy, 1968). Johnson referred to velopmental capacities of a 6-year-old and
the internal and external environment of the about self-concept and ego development to
system. She also referred to the interaction be- understand the child’s behavior.
tween the person and the environment and to
the objects, events, and situations in the envi- Health
ronment. She further noted that there are Johnson viewed health as efficient and effective
forces in the environment that impinge on the functioning of the system and as behavioral
person and to which the person adjusts. Thus, system balance and stability. Behavioral system
in the JBSM environment consists of all ele- balance and stability are demonstrated by ob-
ments that are not a part of the individual’s served behavior that is purposeful, orderly, and
behavioral system but that influence the sys- predictable. Such behavior is maintained when
tem and can also serve as a source of sustenal it is efficient and effective in managing the per-
imperatives. Some of these elements can be son’s relationship to the environment.
manipulated by the nurse to achieve health Behavior changes when efficiency and ef-
(behavioral system balance or stability) for the fectiveness are no longer evident or when a
patient. Johnson provided no other specific more optimal level of functioning is perceived.
definition of the environment, nor did she Individuals are said to achieve efficient and ef-
identify what she considered internal versus fective behavioral functioning when their be-
external environment. But much can be in- havior is commensurate with social demands;
ferred from her writings, and system theory when they are able to modify their behavior in
also provides additional insights into the en- ways that support biological imperatives; when
vironment component of the model. they are able to benefit to the fullest extent
The external environment may include peo- during illness from a health professional’s
ple, objects, and phenomena that can poten- knowledge and skill; and when their behavior
tially permeate the boundary of the behavioral does not reveal unnecessary trauma as a con-
system. This external stimulus forms an organ- sequence of illness (Johnson, 1980, p. 207).
ized or meaningful pattern that elicits a re- Behavior system imbalance and instability
sponse from the individual. The behavioral are not described explicitly but can be inferred
system attempts to maintain equilibrium in re- from the following statement to be a malfunc-
sponse to environmental factors by assimilating tion of the behavioral system:
and accommodating to the forces that impinge
on it. Areas of external environment of interest The subsystems and the system tend to be self-
to nurses include the physical settings, people, maintaining and self-perpetuating so long as con-
objects, phenomena, and psychosocial–cultural ditions in the internal and external environment
attributes of an environment. of the system remain orderly and predictable, the
Johnson provided detailed information conditions and resources necessary to their func-
about the internal structure and how it functional requirements are met, and the interrela-
tions. She also noted that “illness or other sud- tionships among the subsystems are harmonious.
den internal or external environmental change If these conditions are not met, malfunction be-
is most frequently responsible for system mal- comes apparent in behavior that is in part disor-
function” (Johnson, 1980, p. 212). Such factors ganized, erratic, and dysfunctional. Illness or
as physiology, temperament, ego, age and re- other sudden internal or external environmental
lated developmental capacities, attitudes, and change is most frequently responsible for such
self-concept are general regulators that may be malfunctions. (Johnson, 1980, p. 212)
viewed as a class of internalized intervening Thus, Johnson equated behavioral system
variables that influence set, choice, and action. imbalance and instability with illness. How-
They are key areas for nursing assessment. For ever, as Meleis (2012) has pointed out, we
example, a nurse attempting to respond to the must consider that illness may be separate

7991_Ch07_089-108 12/08/19 5:15 PM Page 99
from behavioral system functioning. Johnson functioning than is evident at the present time,
also referred to physical and social health but the final judgment of the desired level of function-
did not specifically define wellness. Just as the ing is the right of the individual. (Johnson, 1980,
inference about illness may be made, it may be p. 215)
inferred that wellness is behavioral system bal- The source of difficulty arises from struc-
ance and stability, as well as efficient and effec- tural and functional stresses. Structural and
tive behavioral functioning. functional problems develop when the sys-
tem is unable to meet its own functional re-
Nursing and Nursing Therapeutics quirements. As a result of the inability to
Nursing is viewed as “a service that is comple- meet functional requirements, structural im-
mentary to that of medicine and other health pairments may take place. In addition, func-
professions, but which makes its own distinc- tional stress may be found as a result of
tive contribution to the health and well-being structural damage or from the dysfunctional
of people” (Johnson, 1980, p. 207). She distin- consequences of the behavior. Other prob-
guished nursing from medicine by noting that lems develop when the system’s control and
nursing views the patient as a behavioral sys- regulatory mechanisms fail to develop or be-
tem, and medicine views the patient as a bio- come defective.
logical system. In her view, the specific goal of Four diagnostic classifications to delineate
nursing action is “to restore, maintain, or attain these disturbances are differentiated in the
behavioral system balance and stability at the model. A disorder originating within any one
highest possible level for the individual” (John- subsystem is classified as either an insuffi-
son, 1980, p. 214). This goal may be expanded ciency, which exists when a subsystem is not
to include helping the person achieve an opti- functioning or developed to its fullest capacity
mal level of balance and functioning when this due to inadequacy of functional requirements,
is possible and desired. or as a discrepancy, which exists when a be-
The goal of the system’s action is behavioral havior does not meet the intended conceptual
system balance. For the nurse, the area of con- goal. Disorders found between more than one
cern is a behavioral system threatened by the subsystem are classified either as an incompat-
loss of order and predictability through illness ibility, which exists when the behaviors of two
or the threat of illness. The goal of a nurse’s ac- or more subsystems in the same situation con-
tion is to maintain or restore the individual’s flict with each other to the detriment of the in-
behavioral system balance and stability or to dividual, or as dominance, which exists when
help the individual achieve a more optimal the behavior of one subsystem is used more
level of balance and functioning. than any other, regardless of the situation or
Johnson did not specify the steps of the to the detriment of the other subsystems. This
nursing process but clearly identified the role is also an area where Johnson believed addi-
of the nurse as an external regulatory force. She tional diagnostic classifications would be de-
also identified questions to be asked when an- veloped. Nursing therapeutics address these
alyzing system functioning, and she provided four areas.
diagnostic classifications to delineate distur- The next critical element is the nature of the
bances and guidelines for interventions. interventions the nurse would use to respond
Johnson (1980) expected the nurse to base to the behavioral system imbalance. The first
judgments about behavioral system balance step is a thorough assessment to find the
and stability on knowledge and an explicit source of the difficulty or the origin of the
value system. One important point she made problem. There are at least three types of in-
about the value system is that: terventions that the nurse can use to bring
about change. The nurse may attempt to repair
given that the person has been provided with an
damaged structural units by altering the indi-
adequate understanding of the potential for and
vidual’s set and choice. The second would be
means to obtain a more optimal level of behavioral
for the nurse to impose regulatory and control

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measures. The nurse acts outside the patient health and affect the consequences of illness”
environment to provide the conditions, re- (1986, p. 6). This position focuses efforts in
sources, and controls necessary to restore be- nursing science on the expansion of knowledge
havioral system balance. The nurse also acts about clients’ health problems and nursing
within and upon the external environment and therapeutics. Nurse researchers have demon-
the internal interactions of the subsystem to strated the usefulness of Johnson’s model in a
create change and restore stability. The third, clinical practice in a variety of ways. The ma-
and most common, treatment modality is to jority of the research focuses on clients’ func-
supply or to help the client find his or her own tioning in terms of maintaining or restoring
supplies of essential functional requirements. behavioral system balance, understanding the
The nurse may provide nurturance (resources system and/or subsystems by focusing on the
and conditions necessary for survival and basic sciences, or focusing on the nurse as an
growth, including training the client to cope agent of action who uses the JBSM to gather
with new stimuli and encouraging effective be- diagnostic data or to provide care that influ-
haviors), stimulation (provision of stimuli that ences behavioral system balance.
bring forth new behaviors or increase behav- Derdiarian (1990, 1991) examined the
iors, provide motivation for a particular behav- nurse as an action agent within the practice
ior, and provide opportunities for appropriate domain. She focused on the nurse’s assessment
behaviors), and protection (safeguarding from of the patient using the JBSM and the effect
noxious stimuli, defending from unnecessary of using this instrument on the quality of care
threats, and coping with a threat on the indi- (Derdiarian, 1990, 1991). This approach ex-
vidual’s behalf). The nurse and the client ne- panded the view of nursing knowledge from
gotiate the treatment plan. exclusively client based to knowledge about the
context and practice of nursing that is model
based. The results of these studies found a sig-
Applications of the Model nificant increase in patient and nurse satisfac-
Fundamental to any professional discipline is tion when the JBSM was used. Derdiarian
the development of a scientific body of knowl- (1983, 1988) and Derdiarian and Forsythe
edge that can be used to guide its practice. (1983) also found that a model-based, valid,
JBSM has served as a means for identifying, and reliable instrument could improve the
labeling, and classifying phenomena important comprehensiveness and the quality of assess-
to the nursing discipline. Nurses have used the ment data, the method of assessment, and the
JBSM model since the early 1970s, and the quality of nursing diagnosis, interventions, and
model has demonstrated its ability to provide outcome. Derdiarian’s body of work reflects
a medium for theoretical growth; organization the complexity of nursing’s knowledge as well
of nurses’ thinking, observations, and interpre- as the strategic problem-solving capabilities of

tations of what was observed; a systematic the JBSM. Her 1991 article demonstrated the
structure and rationale for activities; direction clear relationship between Johnson’s theory
to the search for relevant research questions; and nursing practice.
solutions for patient care problems; and, fi- Others have demonstrated the utility of
nally, criteria to determine whether a problem Johnson’s model for clinical practice. Tamila-
has been solved. rasi and Kanimozhi (2009) used the JBSM to
develop interventions to improve the quality of
Practice-Focused Research life of breast cancer survivors. Oyedele,
Stevenson and Woods (1986) stated: “Nursing Wright, and Maja (2013) used the JBSM to
science is the domain of knowledge concerned develop and test nursing interventions to pre-
with the adaptation of individuals and groups vent teen pregnancy in South African teens.
to actual or potential health problems, the en- Box 7-1 highlights other JBSM research.
vironments that influence health in humans, Talerico (1999) found that the JBSM demon-
and the therapeutic interventions that promote strated utility in accounting for differences in

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BOX 7-1 Bonnie Holaday’s Research Highlighted student would need a background in systems
theory and in the biological, psychological, and
My program of research has examined normal sociological sciences, as well as genetics. The
and atypical patterns of behavior of children mapping of the human genome and clinical
with a chronic illness and the behavior of their exome and genome sequencing have provided
parents and the interrelationship between the
children and the environment. My goal was to
evidence that genes serve as general regulators
determine the causes of instability within and of behavioral system activity.
between subsystems (e.g., breakdown in inter-
nal regulatory or control mechanisms) and to Nursing Practice and Administration
identify the source of problems in behavioral Johnson has influenced nursing practice be-
system balance.
cause she enabled nurses to make statements
about the links between nursing input and
health outcomes for clients. The model has
the expression of aggressive behavioral actions been useful in practice because it identifies an
in elders with dementia in a way that was not end product (behavioral system balance),
possible from the perspective of the biomedical which is nursing’s goal. Nursing’s specific ob-
model. Wang and Palmer (2010) and Wang jective is to maintain or restore the person’s
(2016) used the JBSM to gain a better under- behavioral system balance and stability, or to
standing of women’s toileting behavior, and help the person achieve a more optimum level
Colling, Owen, McCreedy, and Newman of functioning. The model provides a means
(2003) used it to study the effectiveness of a for identifying the source of the problem in the
continence program for frail elders. Poster, system. Nursing is the external regulatory force
Dee, and Randell (1997) found the JBSM was that acts to restore balance (Johnson, 1980).
an effective framework to evaluate patient out- One of the best examples of the model’s
comes. Tineh (2016) used the JBSM to de- use in practice has been at the University of
velop nursing interventions to enhance the California, Los Angeles, Neuropsychiatric In-
quality of life for Alzheimer’s patients. stitute. Auger and Dee (1983) designed a pa-
tient classification system using the JBSM.
Education Each subsystem of behavior was operationalized
Johnson’s model was used as the basis for unin terms of critical adaptive and maladaptive be-
dergraduate education at the UCLA School of haviors. The behavioral statements were de-
Nursing. The curriculum was developed by the signed to be measurable, relevant to the clinical
faculty; however, no published material is avail- setting, observable, and specific to the subsys-
able that describes this process. Texts by Wu tem. The use of the model has had a major effect
(1973) and Auger (1976) extended Johnson’s on all phases of the nursing process, including
model and provided some idea of the content a more systematic assessment process, identifi-
of that curriculum. Later, in the 1980s, Harris cation of patient strengths and problem areas,
(1986) described the use of Johnson’s theory as and an objective means for evaluating the qual-
a framework for UCLA’s curriculum. The Uni- ity of nursing care (Dee & Auger, 1983).
versities of Hawaii, Alaska, and Colorado also The early works of Dee and Auger led to
used the JBSM as a basis for their undergrad- further refinement in the patient classification
uate curricula. Puntil (2005) incorporated the system. Behavioral indices for each subsystem
JBSM into the curriculum of a new graduate have been further operationalized in terms of
orientation program for nurses working in a critical adaptive and maladaptive behaviors.
geriatric psychiatric inpatient setting. Behavioral data are gathered to determine the
Loveland-Cherry and Wilkerson (1983) an- effectiveness of each subsystem (Dee, 1990;
alyzed Johnson’s model and concluded that the Dee & Randell, 1989).
model could be used to develop a curriculum. The scores serve as an acuity rating system
The primary focus of the program would be the and provide a basis for allocating resources.
study of the person as a behavioral system. The These resources are allocated based on the

7991_Ch07_089-108 12/08/19 5:15 PM Page 102
assigned levels of nursing intervention, and re- needs, level of patient functioning on admis-
source needs are calculated based on the total sion and discharge, and length of stay (Dee,
number of patients assigned according to levels Van Servellen, & Brecht, 1998).1
of nursing interventions and the hours of nurs- The work of Vivien Dee and her colleagues
ing care associated with each of the levels (Dee has demonstrated the validity and usefulness
& Randell, 1989). The development of this of the JBSM as a basis for clinical practice
system has provided nursing administration within a health-care setting. From the findings
with the ability to identify the levels of staff of their work, the JBSM established a system-
needed to provide care (licensed vocational atic framework for patient assessment and
nurse vs. registered nurse), bill patients for ac- nursing interventions, provided a common
tual nursing care services, and identify nursing frame of reference for all practitioners in the
services that are absolutely necessary in times clinical setting, provided a framework for
of budgetary restraint. Recent research has the integration of staff knowledge about the
demonstrated the importance of a model- clients, and promoted continuity in the deliv-
based nursing database in medical records ery of care. These findings should be general-
(Poster et al., 1997) and the effectiveness of izable to a variety of clinical settings.
using a model to identify the characteristics of
a large hospital’s managed behavioral health 1For additional information, see the bonus chapter content
population in relation to observed nursing care available at http://davisplus.fadavis.com.
Practice Exemplar
Written by Diane Gullett, RN, PhD, MSN, MPH school (could be a communication issue).
Three weeks ago, I received an admission Francine started complaining of light sensitiv-
from the emergency department. Francine, a ity, headaches, shortness of breath, cough,
15-year-old adolescent, was admitted with fever (103.8 F), sore throat, and rash to her
HIV encephalitis, bilateral lower lobe face, neck, and arms 2 weeks ago. Francine’s
pneumonia, generalized weakness, fatigue, aunt and uncle explained that although they
HIV-1 positive, neutropenia, CD4 counts of both worked full-time they did not currently
120 cells/mm3, severe anemia, toxoplasmo- have any medical insurance. Additionally,
sis, molluscum contagiosum, unexpected Francine was not “legally” in the United
weight loss, amenorrhea, and petechial rash. States, explaining why they delayed bringing
During the admission process I learned Francine to see a medical provider and at-
that Francine had only seen a physician once tempted home remedies initially (environ-
in her life, which occurred approximately mental factors—external financial delay in

2 months ago as part of the high school en- care and fear of deportation if seen by medical
rollment requirements. Francine moved to personnel).
the United States from Haiti 3 months ago Francine weighed 38.6 kg (85 lb), was
to live with her Auntie Martha and Uncle 63 inches tall, and had a body mass index
Julian and their two children (Emily, 6 years (BMI) of 15.1. She has no known drug aller-
old, and Shareen, 9 years old). Her aunt and gies. Last menstrual period unknown. Both of
uncle explained to me that they had brought Francine’s parents are deceased; her mother
Francine to the emergency room for several died 6 months ago, and the cause of death was
reasons, but their major concern was her lack not known. Uncle Julian is Francine’s mater-
of appetite and extreme weight loss (losing nal uncle, and the remaining family felt
approximately 22 pounds over the last 6 Francine would be best living with him and
weeks). Initially her family believed she his family in the United States. According to
might be dieting to fit in with her friends at Francine, she liked living in her new home

7991_Ch07_089-108 12/08/19 5:15 PM Page 103

and had made friends at school, even partic- Francine’s uncle made it very clear
ipating in social activities such as gymnastics that Francine was not to be informed of her
and cheerleading. Her aunt and uncle stated AIDS status because he felt it would impede
she had been making friends at school and her healing. He indicated that he and his
was doing well in her classes. Francine loved family would address this at a later time.
her aunt’s cooking but did not care much for While HIV/AIDS is stigmatizing in general,
American food (cultural factor). Francine’s family has particularly strong feel-
Upon admission to the floor Francine was ings about the disease. For this reason, her
placed on neutropenic, contact, and droplet aunt and uncle have not told anyone about
precautions. Over the past 3 weeks, Francine Francine’s illness and do not wish for their
has continued to lose weight, her cell counts own children to visit Francine in the hospital.
decreased even further, and she seemed to be Francine’s aunt and uncle have visited only
getting worse rather than better. The medical twice since her admission. Francine does not
team decided to change her diet status to currently have access to a cell phone or com-
nothing by mouth (NPO) except for medica- puter and has not been able to contact any of
tions and ice chips, started total parenteral nu- her friends.
trition (TPN) and lipids, placed a central line, Francine’s uncle called the nurses’ station
ordered daily weights and laboratory draws, yesterday and talked with her assigned nurse.
changed her antibiotics, and placed her on The uncle informed the nurse that he had de-
higher doses of antivirals and antifungals. cided Francine would be returning to Haiti
Francine required pain medications every after discharge from the hospital because he
2 hours and there was consideration for and his family felt they could not provide the
patient-controlled analgesia (PCA). Francine necessary care for Francine and he was wor-
was weak; complained of difficulty breathing ried for the safety of his family. He also stated
with activity; was unable to perform any of her that he and his family would not be visiting
activities of daily living (ADLs) independ- the hospital but that they would call Francine
ently, including toileting; and had frequent daily and wanted to be contacted frequently
bouts of nausea, vomiting, and diarrhea. by the health-care team about her condition.
Francine continued to ask when she was
going to get to go home and back to school. Assessment
She also did not understand why her aunt and Affiliative subsystem. Francine has strong so-
uncle would not let her cousins come to visit cial bonds and interpersonal relationships with
her nor why they had only been to see her others, but due to her illness and hospitaliza-
twice since she was admitted. Francine stated tion she has been separated from both her new
she was trying very hard to get better so her family and friends. Francine is at risk for fur-
family could come and see her. ther impaired social interaction related to con-
Currently the main issues facing Francine tact, droplet, and neutropenic precautions.
include frequent diarrhea, pain, lack of social Aggressive-protective subsystem. Francine is
support and interaction, fatigue, inadequate struggling to cope with changes in her life that
knowledge, immunosuppression, and inef- were brought on by her illness and hospital-
fective coping skills. Francine misses her ization. These changes make her feel alone,
family and friends and feels as if she is being without anyone to support her or be with her.
punished for becoming sick. She is also angry She is angry that her family is not there to
because she cannot do the things she is ac- protect her and is upset about the impact this
customed to doing independently, such as illness is having on her life.
using the bathroom, and has become incon- Dependency subsystem. Francine is losing
tinent of urine and stool. her ability to perform her own self-care or
(continued)

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ADLs due to pain, fatigue, anemia, and antibiotics, which destroy good intestinal flora
lethargy associated with her underlying di- and contribute to her frequent diarrheal stools.
agnosis of HIV/AIDS and immunosuppres- Restorative subsystem. Francine currently
sion. As an adolescent she is very concerned experiences fatigue, shortness of breath, and
with her body image and being incontinent pain, associated with anemia, pneumonia, and
of urine and stool, causing her to have de- immunosuppression.
creased self-esteem, self-concept, and self- Sexual. The patient is not sexually active.
confidence.
Achievement subsystem. Since admission Second Level of Assessment
to the hospital, Francine feels she has lost Each subsystem suspected is analyzed for
control over her individual decision-making structure and function (Tables 7.2 and 7.3).
abilities, but more important, she feels she
has lost the relationship that mattered most Internal/External Environmental
to her as a developing person—her new fam- Factors
ily and friends. She believes this because her As the nurse, I had several environmental fac-
aunt and uncle have only visited twice since tors to consider as potential sources of “system
her admission. Francine begins focusing on malfunction” concerns regarding Francine.
short-term rather than long-term goals, Francine is experiencing loss of independence,
demonstrating regression in her mental de- loss of identity, body image disturbances, and
velopmental achievement due to feelings of rejection by others; all of these are age-
stress, anxiety, and loss. appropriate fears for an adolescent in the hos-
Ingestive. Francine has lost 22 lb in 6 weeks, pital. As the nurse, I need to recognize how
has a BMI of 15.1, and is malnourished. these fears affect Francine’s ability to establish
This is due to decreased appetite secondary meaningful self-concept. Francine is an adoles-
to pain from her mouth ulcers, headaches, cent (age: internal) and is in Erickson’s devel-
immunosuppression, and underlying diag- opmental stage (developmental capacity: internal)
nosis of HIV/AIDS. of identity versus role confusion and is having
Eliminative. The patient has had frequent difficulty achieving self-confidence because she
diarrhea due to her immunocompromised feels threatened and unable to cope with her
state related to the underlying diagnosis of symptoms and illness. Additionally, Francine’s
HIV/AIDS. In addition, she is on multiple altered physical appearance has lowered
Table 7-2 General Assessment of Johnson’s Functional Components
Functional Components Patient Behavior: Assessment Data

Protection Lack of knowledge regarding illness (dependency)
Decreased coping skills and strategies due to developmental age
(achievement)
Impaired social interactions (affiliative)
Imbalanced nutrition (ingestive)
Nurturance Loss of control (achievement)
Mobilization of feelings (aggressive-protective)
Alteration in body systems (eliminative)
Stimulation Inadequate problem-solving ability (dependency)
Impaired coping skills (aggressive-protective)

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Table 7-3 General Assessment of Johnson’s Structural Components

Structural Components Caregiver’s Behaviors: Assessment Data
Goal or Drive (Survival and Seeking assistance from others (dependency)
Adaptiveness) Need to achieve control (achievement)
Identifying source of threat to interpersonal relationships (aggressive-
protective)
Set (Consistency of Response) Desire for support from others/family (affiliative)
Determination to be self-sufficient (dependency)
Lacking previous experience related to potential or real threats to self or
others (aggressive-protective)
Choice (Available Alternatives) Utilizing available help (achievement)
Increasing knowledge and problem solving (dependency)
Improving social interactions (affiliative)
Improving coping behaviors (aggressive-protective)
Action (Observable Behavior) Discussing feelings about loss of control and setting goals (achievement)
Utilizing bedside commode (dependency)
Difficulty asking for help (dependency)
Francine’s self-image and self-concept (self- types of nursing interventions to provide nurtu-
concept: internal). Francine does not possess rance, stimulation, and protection. Negotiation
the developmental level (developmental capac- between myself and Francine is important to
ity: internal) to cope with her illness alone but the overall nursing process. See Table 7-4 for
rather requires a support system in the way of nursing diagnoses, goals, interventions, and
family and friends (people: external). Addition- outcomes.
ally, being in the hospital (external: physical),
isolation precautions (physical setting: external), Epilogue
and lack of contact with her family and friends Francine continues to live with her family
(people: external) and inability to perform her in the United States 4 months later. The
own ADLs (physiology: external) is contribut- health-care team worked with Francine’s
ing to Francine’s feelings of decreased self- family, developing the resources that ad-
concept, loss of individual identity, role dressed the needs of both Francine and the
confusion, social isolation, low self-esteem, family. The family contacted me soon after-
and poor body image. All of these factors may ward to communicate with me that the nurs-
slow her healing progress. The absence of her ing care Francine received during her initial
new family is especially significant and worri- stay on the unit fundamentally affected how
some to Francine. the family would come to perceive the disease
condition and ultimately their decision to
Diagnostic Classifications have Francine live with them. In the end,
Based on the assessment data, I am able to they flourished as a family, creating a sup-
identify the source and origin of the behavioral portive transition for Francine and the entire
system imbalance and implement appropriate family.
(continued)

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Table 7-4 Nursing Diagnoses, Goals, Interventions, and Outcomes

Affiliative Subsystem
Nursing Diagnosis
Impaired social interaction related to (r/t) environmental barrier and illness as evidenced by (AEB)
impaired social functioning and dissatisfaction with social engagement.
Client Goals/Outcomes
1. The patient and nurse will identify and utilize two available support systems to enhance social
interactions by the end of the shift.
2. The patient will verbalize an awareness of feelings leading to decreased social interactions with
others by end of the shift
3. The patient will demonstrate and discuss social behaviors with others before discharge.
Interventions
1. Assess patient interests and encourage participation in social networks related to same interests.
2. The nurse will assess the patient’s patterns relating to social behaviors and assess family patterns
of relating.
3. Employ facility resources to provide patient with opportunities to increase social interactions and
situations such as use of child life specialists, volunteers, and other resources.
Evaluation
1. The patient demonstrated two positive changes in social behaviors and relationships.
2. The patient and family utilized available support services to facilitate their patterns of relating to
one another and encourage open communication.
3. The patient verbalized an awareness of feelings leading to decreased versus improved social
interactions.
Behavioral Subsystem: Aggressive-Protective Subsystem
Nursing Diagnosis
Ineffective coping r/t insufficient sense of control and inadequate opportunity to prepare for stressor AEB
insufficient access to social support.
1. The patient will identify and develop three appropriate coping behaviors by the end of the shift.
2. The patient will verbalize three actions that provide increased control over the present situation.
3. The patient will identify and utilize three available facility support systems before discharge.
Interventions
1. Assist the patient in identifying and developing coping behavior. Help the patient evaluate previous
behavior, identify inappropriate behavior, and encourage appropriate alternatives.
2. Assist the patient in setting realistic goals and developing a plan to meet these goals.
3. Assist the patient in identifying available, appropriate support systems.
Evaluation
1. The patient identified and demonstrated the three appropriate coping behaviors with the nurse.
2. The patient verbalized feelings of increased control over the present situation.
3. The patient utilized interdisciplinary counseling, social work, and other support systems to identify
source of threat.
Nursing Diagnosis
Toileting self-care deficit r/t weakness and fatigue AEB impaired ability to reach toilet and impaired
ability to complete toilet hygiene.
1. The patient will verbalize feelings and concerns over difficulty with toileting self-care before the end
of the shift.
2. The patient will verbalize three interventions that will demonstrate appropriate ability to perform
toileting self-care by the end of the shift.
3. The patient will maintain continence of bowel and urine during shift.

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Table 7-4 Nursing Diagnoses, Goals, Interventions, and Outcomes—cont’d

Interventions
1. Assess the patient’s functional, perceptual, and cognitive ability in meeting toileting needs.
2. Use assistive devices such as bedside commode and provide teaching to patient to achieve toileting
self-care activity.
3. Assist with toileting by providing patient with contact numbers for nurse and tech for immediate
assistance with toileting care.
Evaluation
1. The patient verbalized feelings and concerns over difficulty with self-care.
2. The patient used bedside commode as indicated without episodes of toileting self-care deficit during
shift.
3. The patient maintained continence of urine and stool throughout shift.
Achievement Subsystem
Nursing Diagnosis
Disturbed personal identity r/t low self-esteem and alteration in family social role AEB ineffective
relationship with family, confusion about goals, and ineffective coping strategies.
1. The patient will demonstrate ability to set two appropriate short-term and long-term goals related to
care before discharge.
2. The patient will verbalize feelings toward family issues with assistance from health-care team before
discharge.
3. The patient will verbalize three personal identity choices, along with a plan of action and consequences
for each choice before discharge.
Interventions
1. Nurturing: Help patient identify appropriate immediate goals regarding care and outcomes versus
long-term goals.
2. Assist the patient in identifying and using positive coping behaviors.
3. Explore and identify possible consequences of the patient’s personal choices regarding personal
identity.
4. Contact appropriate clergy or spiritual support to help patient.
Evaluation
1. The patient distinguished and identified appropriate short-term versus long-term goals for care.
2. Patient verbalized feelings related to family and illness and identified positive coping strategies to
address.
3. Patient differentiated her or his personal identity choices, given opportunity to make choice and follow
up with consequences of choice using effective coping skills.
Ingestive Subsystem
Nursing Diagnosis
Imbalanced nutrition (less than body requirements) r/t immunodeficiency AEB decreased appetite, unin-
tentional weight loss, and body mass index (BMI) of 15.1.
Eliminative Subsystem
Nursing Diagnosis
Diarrhea r/t extensive antibiotic usage AEB hyperactive bowel sounds and frequent liquid stools
Restorative Subsystem
Nursing Diagnosis
Fatigue r/t malnutrition and stressors AEB lethargy and impaired ability to perform activities of daily living
(ADLs) and insufficient energy.
(continued)

7991_Ch07_089-108 12/08/19 5:15 PM Page 108

Conclusion family. Framing the JBSM using modern
Though Johnson did not specify the steps of taxonomy facilitates the “development, refine-
the nursing process, the role of the nurse as an ment, dissemination, and use of standardized
external regulatory force is implicit throughout nursing diagnostic terminology” (Herdman &
her model. The practice exemplar uses current Kamitsuru, 2018, p. 29), thereby facilitating a
North American Nursing Diagnosis Associa- shared language by which nurses can come to
tion (NANDA; Herdman & Kamitsuru, understand Johnson’s theoretical and practical
2018) definitions and criteria to promote the approach to nursing care.
health and well-being of Francine and her
Summary
The Johnson Behavioral System Model cap- website (http://davisplus.fadavis.com). Exam-
tures the richness and complexity of nursing. ples include examining the levels of integration
The JBSM addresses the interdependent func- (biological, psychological, and sociocultural)
tional biological, psychological, and sociolog- within and between the subsystems. For exam-
ical components within the behavioral system ple, a study could examine the way a person deals
and locates these components within a larger with the transition from health to illness with
social system. The JBSM focuses on the person the onset of asthma. There is concern with the
as a whole, as well as on the complex interre- relations between one’s biological system (e.g.,
lationships among the subsystems. Nursing di- unstable, problems breathing), one’s psycholog-
agnosis proceeds inward to the subsystem and ical system (e.g., achievement goals, need for as-
outward to the environment. The nurse is sistance, self-concept), the physical environment
called to be a systems thinker in formulating (e.g., allergens, being away from home), and the
an assessment plan, making a nursing diagno- sociocultural context (e.g., attitudes and values
sis, and planning interventions. The JBSM about the sick). The study of transitions (e.g., the
provides nurses with a clear conception of their onset of puberty, menopause, death of a spouse,
unique goal and mission within the health-care onset of acute illness) also represents many pos-
team. sible research questions within the JBSM. Find-
Johnson expected the theory’s further de- ings obtained from these studies will not only
velopment in the future, and that it would un- provide an opportunity to revise and advance the
cover and shape significant research problems theoretical conceptualization of the JBSM but
that could have both theoretical and practical will also provide information about nursing in-
value to the discipline. There are a variety of terventions. The JBSM approach leads us to seek
problem areas worthy of investigation that common organizational parameters in every sci-
are suggested by the JBSM assumptions and entific explanation and does so using a shared
from previous studies described on this book’s language about nursing and nursing care.
Questions for Reflection ■ What are four diagnostic classifications

for identifying system imbalances?
and Discussion ■ What are the three types of nursing
■ How does the Johnson Behavioral System interventions that can bring about
Model provide a guide for the nursing system balance?
assessment?

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Dorothea Orem’s Self-Care

CHAPTER
8
Deficit Nursing Theory
Donna L. Hartweg

Applications of the Theory Introducing the Theorist
Practice Exemplar by Sharie A. Metcalfe Dorothea E. Orem (1914–2007) dedicated her
Summary life to creating and developing a theoretical
Questions for Reflection and Discussion structure to improve nursing practice. As a
voracious reader and extraordinary thinker, she
framed her ideas in both theoretical and prac-
tical terms. 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).
Orem’s personal life experiences, formal
education, employment, and reading of
philosophers such as Aristotle, Aquinas, and
Harre (1970) directed her thinking (Orem,
2006). She sought to understand the phe-
nomena she observed, creating conceptual-
izations of nursing education, disciplinary
knowledge, and, finally, a general theory of
nursing, the SCDNT.
Orem worked independently and then col-
laboratively until her death at age 93, provid-
ing a lifetime of contributions to nursing
science and practice. Orem received honors
from organizations such as Sigma Theta Tau

International, the American Academy of
Nursing, the National League for Nursing,
and Catholic University of America, as well as
four honorary doctorates.
Orem received her initial nursing education
at Providence Hospital School of Nursing in
Washington, DC (1934), and completed her
baccalaureate degree from Catholic University
of America in 1939, which led to a faculty
position. After completing her master’s degree
at Catholic University (1946), Orem became
Director of Nursing Service and Education
at Provident Hospital School of Nursing in
Detroit (Taylor, 2007).
109
7991_Ch08_109-134 13/08/19 3:34 PM Page 110
Orem’s early formulations about the nature articulation with the science of self-care”
of nursing occurred while she was working for (oreminternationalsociety.org). This mission
the Indiana State Board of Health between has been realized through the publication of
1949 and 1957 (Hartweg, 1991). She became newsletters (1993–2001) and a peer-reviewed
aware of nurses’ ability to “do nursing,” but journal, Self-Care, Dependent-Care & Nursing
their inability to “describe nursing.” Without begun in 2002 (see OIS website under Publi-
this understanding, Orem believed nurses cations). Twelve biennial Orem congresses
could not improve practice. She made an ini- have been held throughout the world. The ma-
tial effort to define nursing in a report titled jority of these conference papers and abstracts
The Art of Nursing in Hospital Service: An are available on the OIS website.
Analysis (Orem, 1956). The language of the Many of Orem’s original papers are pub-
patient doing-for-self or the nurse helping to- lished in Self-Care Theory in Nursing: Selected
do-for-self appears in this report as antecedent Papers of Dorothea Orem (Renpenning &
language for the concept of self-care. Taylor, 2003) and are also available in
During her tenure at the Office of Educa- the Mason Chesney Archives of the Johns
tion, Vocational Section in Washington, DC, Hopkins Medical Institutions for the Orem
Orem generated a simple yet important ques- Collection (www.medicalarchives.jhmi.edu/
tion: Why do people need nursing? In Guides papers/orem.html) and in the archives of the OIS
for Developing Curriculum for the Education of website. Two additional theory development/
Practical Nurses (Orem, 1959), she expanded practice resources are Self-Care Science, Nursing
the question to what she termed “the proper Theory, and Evidence-based Practice (Taylor
object of nursing”: “What condition exists in a & Renpenning, 2011) and Foundations of
person when judgments are made that a Professional Nursing: Care of Self and Others
nurse(s) should be brought into the situation?” (Renpenning, Taylor, & Pickens, 2016).1
(Orem, 2001, p. 20). Her answer was the in-
ability of persons to provide continuously for them-
selves the amount and quality of required self-care Overview of the Theory
because of situations of personal health. Orem’s General Theory of Nursing is correctly
Although Orem worked independently, referred to as Self-Care Deficit Nursing The-
two groups contributed to the theory’s early ory (SCDNT). Orem believed a general model
development (Taylor, 2007). The first group or theory created for a practical science such as
was the Nursing Model Committee at nursing encompasses not only the What and
Catholic University of America. In 1968, the Why, but also the Who and How (Orem,
Nursing Development Conference Group 2006). Therefore, this action theory includes
(NDCG) was formed and continued the work clear specifications for nurse and patient roles.
of the Nursing Model Committee. The collab- The grand theory originally comprised three
orative process and outcomes were published interrelated theories: the Theory of Self-Care,
in Concept Formalization: Process and Product the Theory of Self-Care Deficit, and the The-
(NDCG, 1973, 1979), edited by Orem. Con- ory of Nursing Systems. A fourth, the Theory
current with this group work, Orem published of Dependent Care, emerged over time to ad-
the first of six editions of Nursing: Concepts of dress the complexity not only of the individual
Practice (1971), which has been translated into in need of care but also of the caregivers whose
many languages. requisites and capabilities influence the design
In 1991, the International Orem Society of the nursing system (Taylor & Renpenning,
(IOS) for Nursing Science and Scholarship 2011). The building blocks of these theories
was founded by a group of international schol- consist of six major concepts, with parallel
ars (Note: IOS was renamed Orem Interna- concepts from the Theory of Dependent
tional Society or OIS in 2016). Its mission
continues: “To disseminate information re- 1For additional information, see the bonus chapter content
lated to development of nursing science and its available at http://davisplus.fadavis.com.

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C H A P TER 8 ■ Dorothea Orem’s Self-Care Deficit Nursing Theory 111
Care, as well as one peripheral concept. The Orem (2001) expanded two sets of propo-
following is a brief overview of each theory sitions from previous writings. She introduced
and its concepts. Readers are encouraged to requirements necessary for life, health, and
study relevant sections in Orem’s Concepts of well-being and explained the complexity of a
Practice (2001) or other citations to enhance self-care system. A person performing self-care
understanding. must first estimate or investigate what can and
Foundational to learning any theory is ex- should be done. This is a complex action of
ploration of its underlying assumptions. Five knowing and seeking information on specific
general assumptions/principles about human care measures. The self-care sequence contin-
beings grounded Orem’s conceptualizations ues by deciding what can be done and finally pro-
(Orem, 2001, p. 140). When thinking about ducing the care (Orem, 2001, pp. 143–145).
human beings within the context of the theory,
Orem viewed two types: those who need nurs- Theory of Dependent Care
ing care and those who produce it (Orem, Taylor and others (2001) formalized the The-
2006). In the simplest terms, this is the patient ory of Dependent Care as a corollary theory to
and the nurse, respectively. These assumptions the Theory of Self-Care. Concepts within the
also reveal human powers and properties nec- Theory of Dependent Care (TDC) parallel
essary for self-care. Consistent with most those in the Theory of Self-Care. Assumptions
Orem writings, the term patient is used to refer relate to the nature of interpersonal action sys-
to the recipient of care. tems and social dependency. Within a partic-
ular social unit such as a family, the self-care
Four Constituent Theories Within agent (the patient) is in a socially dependent
Self-Care Deficit Nursing Theory relationship with the person or persons pro-
Each theory includes a central idea, presupposi- viding care, such as a parent (the dependent-
tions, and propositions. The central idea presents care agent). The presence of a self-care deficit
the general focus of the theory, the presupposi- of the dependent also gives rise to the need for
tions are assumptions specific to this theory, and nursing (Taylor & Renpenning, 2011).
the propositions are statements about the con-
cepts and their interrelationships. The proposi- Theory of Self-Care Deficit
tions have changed over time with SCDNT The central idea of the Theory of Self-Care
refinement. These occurred in part through the- Deficit (TSCD) describes why people need
ory testing that validated or invalidated hypothe- nursing (Orem, 2001, pp. 146–147). Require-
ses generated from the relationships. As Orem ments for nursing are health-related limita-
used terminology at various levels of abstraction tions for knowing, deciding, and producing
within constituent theories, the reader is advised care to self. Orem presents two sets of presup-
to thoroughly study SCDNT concepts, includ- positions that articulate this theory with the
ing the synonyms. For example, agency is also Theory of Self-Care and what she calls the idea
called capability, ability, and/or power. of social dependency. To engage in self-care,
persons must have values and capabilities to
Theory of Self-Care learn (to know), to decide, and to manage self
The central idea of the Theory of Self-Care (to produce and regulate care). The second set
(TSC) describes self-care in contrast to other presents the context of nursing as a health
forms of care. Self-care, or care for oneself, service when people are in a state of social
must be learned and be deliberately performed dependency.
for life, human functioning, and well-being. The TSCD includes nine propositions
Six presuppositions articulate Orem’s notions called principles or guides for future develop-
about necessary resources, capabilities for ment and theory testing. These statements are
learning, and motivation for self-care. How- essential ideas of the larger SCDNT. Orem
ever, there are situational variations that affect describes the situations that affect legitimate
self-care, such as culture. nursing. Nursing is legitimate or needed when

7991_Ch08_109-134 13/08/19 3:34 PM Page 112
the individual’s self-care capabilities and care Orem proposes that nursing systems are deter-
demands are equal to, less than, or more than at mined by the person’s (or dependent-care
a point in time. With the existence of this in- agent’s) self-care limitations (capabilities in rela-
equity, a self-care deficit exists, and nursing is tionship to health-related self-care or dependent-
needed. In a dependent-care system, a self-care care demand). Therefore, nursing systems vary
deficit exists in the patient as well as a by the amount of care the nurse must provide,
dependent-care deficit in a caregiver. The lat- such as a total care system, or wholly compen-
ter is an inequity between the dependent-care satory system (e.g., unconscious critical care
demand and agency (abilities) to care for the patient); partial care, or partially compensa-
person in need of health care. Legitimate nurs- tory system (e.g., patient in rehabilitation); or
ing also occurs when a future deficit relation- supportive–educative system (e.g., patient
ship is predicted such as an upcoming surgery. needing teaching).
Theory of Nursing Systems Concepts

The fourth theory, the Theory of Nursing Sys- SCDNT is constructed from six basic concepts
tems (TNS), encompasses the three others. and a peripheral concept. Four concepts are
The central focus is the product of nursing, patient-related: self-care/dependent care, self-
establishing both structure and content for care agency/dependent-care agency, therapeu-
nursing practice, as well as the nursing role (see tic self-care demand/dependent-care demand,
Orem, 2001, pp. 111, 147–149). The four pre- and self-care deficit/dependent-care deficit.
suppositions direct the nurse to major com- Two concepts relate to the nurse: nursing
plexities of nursing practice. For example, agency and nursing system. Basic conditioning
Orem stated that “nursing has results— factors, the peripheral concept, is related to
achieving operations that must be articulated both the self-care agent (person receiving
with the interpersonal and societal features of care)/dependent-care agent (family member/
nursing” (Orem, 2001, p. 147). Although friend providing care) and also to the nurse
much of the theory relates to diagnosis, ac- (nurse agent). Orem defines agent as the “per-
tions, and outcomes based on a deficit relation- son who engages in a course of action or has
ship between self-care capabilities and self-care the power to do so” (Orem, 2001, p. 514).
demand, Orem also presents theoretical work Hence there is a self-care agent, a dependent-
related to the interpersonal relationship be- care agent, and a nurse agent. The unit of
tween nurse and person(s) receiving nursing service is a person(s), whether the individual
and a social contract between the nurse and (self-care agent) or another, on whom the per-
patient(s) (Orem, 2001, pp. 314–317). These son is socially dependent (dependent-care
components are often overlooked when study- agent). Orem also addresses multiple-person
ing the SCDNT and are important antecedents situations and multiple-person units such as
and concurrent actions in the process of entire families, groups, or communities.
nursing. Each concept is defined and presented with
The Theory of Nursing Systems includes levels of abstraction. Varied constructs within
seven propositions related to most SCDNT each concept allow theoretical testing at the
concepts but adds nursing agency (capabilities level of middle-range theory or at the practice
of the nurse) and nursing systems (complex ac- application level whether with the individual or
tions). Nursing agency and nursing systems are multiple-person situations. All constructs and
linked to the concepts of the person receiving concepts build on decades of Orem’s independ-
care or dependent care, such as self-care capa- ent and collaborative work. A “kite-like” model
bilities (agency), self-care demands (therapeu- provides a visual guide for the six concepts and
tic self-care demand), and limitations (deficits) their interrelationships (Fig. 8-1). For models
for self-care. Through this, the general theory of concepts and relationships of dependent care
or SCDNT becomes concrete to the practic- and multiple-person structure, see Taylor and
ing nurse. Although the language is implicit, Renpenning (2001).

7991_Ch08_109-134 13/08/19 3:34 PM Page 113
Self-care
R R
Self-care R Self-care
Conditioning Conditioning
agency demands
factors factors
Deficit R
R
Conditioning Nursing
factors agency
FIG 8-1 ■ Structure of SCDNT.
Basic Conditioning Factors continue to be developed. For example, socio-

A peripheral concept, basic conditioning factors cultural orientation refers to culture with its
(BCFs), is related to three major concepts. For various components such as values and prac-
simplicity, only the patient component is pre- tices. Sociocultural includes economic condi-
sented here rather than the parallel dependent- tions as well as others. The BCFs related to
care components. In general, BCFs relate to nursing agency include those such as age but
the patient concepts (self-care agency and expand to include nursing experience and ed-
therapeutic self-care demand) and one nurse ucation. A certified nurse educator usually has
concept (nursing agency). These conditioning more capabilities in caring for the self-care
factors are values that affect the constructs: agent with type 2 diabetes than one without
age, gender, developmental state, health state, such credentials. All these affect the parame-
sociocultural orientation, health-care system ters of the nurse’s capability to provide care.
factors, family system factors, pattern of living,
environmental factors, and resource availability Self-Care (Dependent Care)
and adequacy (Orem, 2001, p. 245). For ex- Orem (2001) defined self-care as the “practice
ample, the family system factor such as living of activities that individuals initiate and perform
alone or with others may affect the person’s on their own behalf in maintaining life, health,
ability (self-care agency) to care for self after and well-being” (p. 43). Self-care is purposeful
hospital discharge. The self-care demand (care action performed in sequence and with a pattern.
requirements) of a person taking insulin for Although engagement in purposeful self-care
type 2 diabetes will vary based on availability may not improve health or well-being, a positive
of resources and health system services (e.g., outcome is assumed. Dependent care is per-
access to medications and care services). These formed by mature, responsible persons on behalf
same BCFs apply to nursing agency, such as of socially dependent individuals or self-care
health state. A nurse with recent back surgery agents such as an infant, a child, or a cognitively
may have limitations in nursing capabilities impaired person. The purpose is to meet the per-
(nurse agency) in relationship to specific care son’s health-related demands (dependent-care
demands of the patient. demand) and/or to develop the person’s self-
These BCF categories have many subfactors care capabilities (Taylor et al., 2001; Taylor &
that have not yet been explicitly defined but Renpenning, 2011).

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Although the practice of maintaining life is Self-Care Agency (Dependent Care

self-explanatory, Orem (2001) viewed out- Agency)
comes of health and well-being as related
Orem (2001) defined self-care agency (SCA)
but different. Health is a state of physical–
as “complex acquired capability to meet one’s
psychological, structural–functional soundness
continuing requirements for care of self that
and wholeness. In contrast, well-being is con-
regulates life processes, maintains or promotes
ceived as “experiences of contentment, pleasure,
integrity of human structure and functioning
and kinds of happiness; by spiritual experiences;
[health] and human development, and pro-
by movement toward fulfilment of one’s
motes well-being” (p. 254). Capability, ability,
self-ideal; and by continuing personalization”
and power are all terms used to express agency.
(Orem, 2001, p. 186). Self-care performed
Self-care agency is therefore the mature or
deliberately for well-being versus structural–
maturing individual’s capability for deliberate
functional health was conceptualized and devel-
action to care for self. Dependent care agency
oped as health promotion self-care by Hartweg
is a “complex acquired ability of mature or
(1990, 1993).
maturing persons to know and meet some or
Key to understanding self-care and de-
all of the self-care requisites of persons who
pendent care is the concept of deliberate ac-
have health-derived or health associated lim-
tion, a voluntary behavior to achieve a goal.
itations of self-care agency, which places them
Deliberate action is preceded by investigating
in socially dependent relationships for care”
and deciding what choice to make (Orem,
(Taylor & Renpenning, 2011, p. 108). Viewed
2001). In practice, the nurse’s understanding
as the summation of all human capabilities
of each of these phases of investigating, de-
needed for performing self-care, these range from
ciding, and producing self-care is essential for
a very basic ability, such as memory, to capa-
positive health outcomes. Take one situation:
bility for a specific action in a sequence to
A woman with breast cancer determines that
meet a specific self-care demand or require-
she requires chemotherapy to sustain her life
ment. At this concrete level, the capabilities
and health. She must first know and under-
of knowing, deciding, and acting or producing
stand the relationship of self-care to her
self-care are necessary. If these capabilities do
life, health, and well-being. Decision making
not exist, the abilities of others are necessary,
follows and involves choosing a treatment
such as the family member or the nurse. A
option, in this case, chemotherapy. Finally,
three-part, hierarchical model of self-care
she must take action by undergoing the
agency provides a visualization of this struc-
chemotherapy treatment sessions. Without
ture (Fig. 8-2). Understanding these elements
each phase, self-care does not occur. The
woman may understand the health outcome
without treatment, decide to have treatment,

and then be unable to follow through because
transportation to chemotherapy sessions dis-
rupts her husband’s employment. Because
each phase of the action sequence has many Capabilities
components, nurses often provide partial sup- for self-care
port to patients neglecting the other necessary operations
self-care actions needed/required. Should the
Power components
nurse fail to anticipate patient needs for
(enabling capabilities
transportation to the cancer center, the com- for self-care)
plex self-care action sequences may not be
completed. A nurse’s inability to recognize all Foundational capabilities
phases of self-care and its many components and disposition
then affects outcomes related to life, health,
and well-being. FIG 8-2 ■ Structure of self-care agency.

7991_Ch08_109-134 13/08/19 3:34 PM Page 115
is necessary to determine the self-care agent asthma have the capability to learn about
role, the dependent-care agent role, and the regular exercise activities and rescue medica-
nurse role. tion? Does the person know how to obtain
the necessary resources? Transitional opera-
Foundational Capabilities tions relate to abilities necessary for decision
and Dispositions making, such as reflecting on the course of
Foundational capabilities and dispositions action and making an appropriate decision.
are at the most basic level (Orem, 2001, The patient may have the capabilities to learn
pp. 262–263). These are capabilities for all and obtain resources but not the ability to
types of deliberate action, not just self-care. make the decision. The patient with asthma
Included are abilities related to perception, has the capability to learn about exercise and
memory, and orientation. One example is the medication but not the capability to make
deliberate act of repairing a car. One must the decision to follow through on directions.
have perception of the concept of the car and Capabilities for productive operations are
its parts, memory of methods of repair, and those necessary for preparing the self for the
orientation of self to the equipment and ve- action, carrying out the action, monitoring
hicle. If these foundational abilities are not the effects, and evaluating the action’s effec-
present, actions cannot occur. tiveness. If the person decides to use the in-
haler, does the person have the ability to take
Power Components time to engage in the necessary self-care, to
At the midlevel of the hierarchy are the power physically push the device, to monitor the
components, or 10 powers or types of abilities changes, and determine the effectiveness of
necessary for self-care. Examples are the valu- the action? Just as the action sequence is im-
ing of health, ability to acquire knowledge portant in the self-care concept, these types
about self-care resources, and physical energy of capabilities reveal the complexity of
for self-care. At a very general level, these ca- human capability.
pabilities relate to knowledge, motivation, and At the concrete practice level, self-care
skills to produce self-care. If a mature person agency also varies by development and oper-
becomes comatose, the abilities to maintain at- ability. For example, the nurse must determine
tention, to reason, to make decisions, and to whether capabilities for learning are fully de-
physically carry out the actions are not func- veloped at the level necessary to understand and
tioning. The self-care actions necessary for life, retain information about the required actions.
health, and well-being must then be per- For example, a mature adult with late stage
formed by the dependent-care agent or the Alzheimer’s disease is not able to retain new
nurse agent. information. Therefore, the self-care agency is
developed but declining, creating the possible

Capabilities for Estimative, Transitional, need for dependent-care agency or nursing
and Productive Operations agency. A second determination is the oper-
The most concrete level of self-care agency ability of agency. Is agency fully operative, par-
is one specific to the individual’s detailed tially operative, or not operative? A comatose
components of self-care demand or require- patient may have fully developed capabilities
ments. Capabilities related to estimative op- before a motor vehicle accident; however, the
erations are those necessary to determine subsequent trauma results in inoperable cogni-
what self-care actions are needed in a specific tive functioning. SCA is therefore developed,
nursing situation at one point in time—in but not operative at that moment in time. In this
other words, capabilities of investigating and situation, the nurse agent must provide care.
estimating what needs to be done. This in- Similar variations of development and oper-
cludes capabilities of learning in situations ability occur with dependent-care agency and
related to health and well-being. For exam- must be considered by the nurse when devel-
ple, does the person newly diagnosed with oping the self-care or dependent-care system.

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Therapeutic Self-Care Demand well-being. The individual sleeps once each

(Dependent-Care Demand) day and engages in daily activities to meet
the requisite or goal of maintaining a balance
Therapeutic self-care demand (TSCD) is a
of activity and rest. Without rest, a human
complex theoretical concept that summarizes
cannot survive. Therefore, these general
all actions that should be performed over time
statements within a three-part framework
for life, health, and well-being. When first de-
provide a level of abstraction similar to the
veloped, the concept was referred to as action
power components of self-care agency.
demand or self-care demand (Orem, 2001). For
this reason, readers will see these terms used Universal Self-Care Requisites
in Orem’s writings and in the literature. De-
The eight universal self-care requisites (USCRs)
pendent care demand is the summation of all
are necessary for all human beings of all ages
care actions “for meeting the dependent care-
and in all conditions, such as air, food, activity
giver’s therapeutic self-care demand when his
and rest, solitude, and social interaction. The
or her agency is not adequate or operational”
BCFs influence the quality and quantity of the
(Taylor & Renpenning, 2011, p. 108).
action necessary to achieve the purpose. Actions
The word therapeutic is essential to one’s
to be performed over time that meet the requi-
understanding of the concept. Consideration
site, prevention of hazards to human life, human
is always on a therapeutic outcome of life,
functioning, and human well-being (the purpose),
health, and well-being. Newborn care customs
will vary for an infant (e.g., keeping crib rails
in some rural cultures may include applying
up) versus an adult (e.g., ambulation safety).
horse or cow dung to the severed umbilical
Some requisites are very general yet provide im-
cord to facilitate drying. This is a culturally ad-
portant concepts necessary for all humans. One
justed self-care measure for a newborn. With
example is the concept of normalcy, the eighth
horse or cow dung as the major carrier of
USCR. The goal is “promotion of human func-
Clostridium tetanus, this dependent-care ac-
tioning and development within social groups
tion may lead to disease and infant death, not
in accord with human potential, human limita-
a therapeutic outcome.
tions, and the human desire to be normal”
Constructing or calculating a TSCD requires
(Orem, 2001, p. 225). Two requisites, preven-
extensive nursing knowledge of evidence-based
tion of hazards and promotion of normalcy, also
practice, communication, and interpersonal
relate to the other six USCRs. For example,
skills. Both scientific nursing knowledge and
when maintaining a sufficient intake of food,
knowledge of the person and environment are
one must consider preventing hazards such as
synthesized to formulate what needs to be done
avoiding pesticides in the ingestion of food.
in a particular nursing situation (NDCG,
1979). The process of calculating the TSCD Developmental Self-Care Requisites

includes adjusting values by the basic condi-
Orem (2001) identified three types of develop-
tioning factors. For example, a patient seeking
mental self-care requisites (DSCRs). The first
mental health care will have different needs
refers to actions necessary for general human de-
based on the type of mental health condition
velopmental processes throughout the life span.
(health state), family system factors, and health-
These requisites are often met by dependent-
care resources.
care agents when caring for developing infants
and children or when disaster and serious phys-
Self-Care Requisites ical or mental illness affects adults. Engage-
To provide the framework for determining ment in self-development, the second DSCR,
the TSCD, Orem developed three types of refers to demands for action by individuals
self-care requisites (or requirements): univer- in positive roles and in positive mental
sal, developmental, and health deviation. health. Examples include self-reflection, goal-
These are the purposes or goals for which setting, and responsibility in one’s roles. The
actions are performed for life, health, and third DSCR, interferences with development,

7991_Ch08_109-134 13/08/19 3:34 PM Page 117
expresses goals achieved by actions that are nec- self-care demand (Orem, 2001). When the
essary in situational crises such as loss of friends person’s self-care agency is not adequate to
and relatives, loss of job, or terminal illness. meet all self-care requisites (TSCD), a self-
Originally subsumed under USCRs, Orem cre- care deficit exists. This qualitative and quanti-
ated the developmental self-care requisite cat- tative relationship at the conceptual level of
egory to indicate the importance of human abstraction is expressed as “equal to,” “more
development to life, health, and well-being. than,” or “less than” (see Fig. 8-1). A deficit
relationship is also described as complete or
Health Deviation Self-Care Requisites partial; a complete deficit suggests no capabil-
Health deviation self-care requisites (HD- ity to engage in self-care or dependent care.
SCRs) are situation-specific requisites or goals An example of a complete deficit may exist in
when people have disease, suffer injuries, or are a premature infant in a neonatal intensive care
under professional medical care. These six req- unit. A partial self-care deficit may exist in a
uisites guide actions when pathology exists or patient recovering from a routine bowel resec-
when medical interventions are prescribed. The tion 1 day after surgery. This person is able to
first HDSCR refers in part to a patient pur- provide some self-care.
pose: “to seek and secure appropriate medical Understanding self-care deficit is necessary
assistance for genetic, physiological, or psycho- to appreciate Orem’s concept of legitimate
logical conditions known to produce or be as- nursing. If a nurse determines that a patient
sociated with human pathology” (Orem, 2001, has self-care agency (estimative, transitional,
p. 235). For a person with history of breast can- and productive capabilities) to carry out a se-
cer, seeking regular diagnostic tests is a goal to quence of actions to meet the self-care requi-
preserve life, health, and well-being. A teenager sites, nursing is not necessary. A self-care
in treatment for severe acne takes action to deficit or anticipated self-care deficit must
meet HDSCR 5: “to modify the self-concept exist before a nursing system is designed and
(and self-image) in accepting oneself as being implemented. The nurse reflects with the pa-
in a particular state of health and in need of a tient: Is self-care agency (and/or dependent-
specific form of health care” (Orem, p. 235). care agency) adequate to meet the therapeutic
Each TSCD, through the three types of self- self-care demand? If adequate, there is no
care requisites, is individualized and adjusted by need for nursing.
the BCFs such as age, health state, and socio- A dependent-care deficit is a statement of
cultural orientation. Once adjusted to the spe- the relationship between the dependent-care
cific patient in a unique situation, the purposes demand and the powers and capabilities of the
are specific for the patient or type of patient. dependent-care agent to meet the self-care
These are called “particularized self-care requi- deficit of the socially dependent person, the
sites.” Dennis and Jesek-Hale (2003) proposed self-care agent (Taylor & Renpenning, 2011).
a list of particularized self-care requisites for a When this deficit occurs, there is a need for
nursing population of newborns. Although cre- nursing. When a parent has the capabilities to
ated for nursery newborns, a group particularized meet all health-related self-care requisites of
by age, the individual patient adjustments are an ill child, no nursing is needed.
then made. More recent nursing literature con- When an existing or potential self-care
tinues to expand the types of requisites varied by deficit is identified and legitimate nursing
specific diseases or illnesses that provide a basis is needed, an analysis by the nurse/patient/
for application to specific patients and caregivers. dependent-care agents results in identification
of types of limitations in relationship to the
Self-Care Deficit (Dependent-Care particularized self-care requisites. These are
Deficit) generally described as limitations of knowing,
As a theoretical concept, self-care deficit ex- limitations or restrictions of decision making,
presses the value of the relationship between two and limitations in ability to engage in result-
other concepts: self-care agency and therapeutic achieving courses of action. Orem classified

7991_Ch08_109-134 13/08/19 3:34 PM Page 118
these into sets of limitations (Orem, 2001, integrates all operations of this subsystem
pp. 279–282). with those of the interpersonal and the social–
contractual. This involves collecting data to
Nursing System (Dependent-Care determine existing and projected universal,
System) developmental, and health-deviation self-care
Orem describes a nursing system as an “action requisites, and methods to meet these requi-
system,” an action or a sequence of actions per- sites as adjusted by the basic conditioning
formed for a purpose. This is a composite of all factors. Using the interpersonal and social–
the nurse’s concrete actions completed or to be contractual subsystems, the nurse incorpo-
completed for or with a self-care agent to pro- rates modifications of her or his diagnosis and
mote life, health, and well-being. The compos- prescriptions in collaboration with the patient
ite of actions and their sequence produced by and family on what is possible. The nurse also
the dependent-care agent to meet the thera- identifies the patient’s usual self-care prac-
peutic dependent self-care demand is termed tices and assesses the person’s estimative,
a dependent-care system (Taylor et al., 2001). transitional, and productive capabilities for
These actions relate to three types of subsys- knowledge, skills, and motivation in rela-
tems: interpersonal, social–contractual, and tionship to the known self-care requisites.
professional–technological. That is, are the capabilities (self-care agency/
The interpersonal subsystem includes all nec- dependent-care agency) needed to meet the
essary actions or operations such as entering self-care requisites developed, operable, and
into and maintaining effective relationships adequate? Are there limitations in knowing,
with the patient and/or family or others in- deciding, or producing self-care? If no limi-
volved in care. The social–contractual subsystem tations exist, there is no need for nursing and
relates to all nursing actions/operations to reach no nursing system is developed. If there is a
agreements with the patient and others related self-care deficit or dependent-care deficit, the
to information necessary to determine the ther- nurse and patient or caregivers reach agree-
apeutic self-care demand and self-care agency ment about the patient’s role, the family’s role,
of an individual and caregivers. Within this sub- and/or the nurse’s role. Orem (2001) charted
system, the nurse, in collaboration with the pa- the progression of these steps by subsystems
tient or dependent-caregiver, determines roles (pp. 311, 314–317).
for all care participants (Orem, 2001). These are With determination of a real or potential
based on social norms and other variables such self-care deficit or dependent-care deficit, the
as basic conditioning factors. Although other nurse develops one of three types of nursing
nursing theories emphasize interpersonal inter- systems: wholly compensatory, partly compen-
actions, Orem’s general theory clearly specifies satory, or supportive–educative (developmen-
interpersonal and contractual operations as nec- tal). The nurse then continues the query: “Who
essary antecedents and concurrent components can or should perform actions that require move-
of care. This element of Orem’s model is often ment in space and controlled manipulation?”
overlooked and clarifies the decision-making (Orem, 2001, p. 350). If the answer is only the
process and collaborative relationship within the nurse, a wholly compensatory system is de-
nurse–patient–family/multiple-person roles. signed. If the patient has some capabilities to
The professional–technological subsystem perform operations or actions, the nurse and
comprises actions/operations that are diag- patient share responsibilities. If the patient
nostic, prescriptive, regulatory, evaluative, can perform all actions that control movement
and case management. The latter involves in space and controlled manipulation, but
placing all operations within a system that nurse actions are required for support (physical
uses resources effectively and efficiently with or psychological), the system is supportive–
a positive patient outcome. Orem views the educative. Note that, in all systems, the self-
professional–technological subsystem as the care deficit is the necessary element that leads
process of nursing, a nonlinear one that to the design of a nursing system. Using the

7991_Ch08_109-134 13/08/19 3:34 PM Page 119
interpersonal and social–contractual opera- Accomplishes patient’s

tions, the nurse first enters into an interpersonal therapeutic self-care
relationship and an agreement to determine
a real or potential self-care deficit, prescribe Nurse
Compensates for patient’s
roles, and implement productive operations of inability to engage in
action
self-care
self-care and/or dependent care. Regulation or
treatment operations are designed or planned Supports and protects
and then produced or performed. Control patient
operations are used to appraise and evaluate
Wholly compensatory system
the effectiveness of nursing actions and to
determine whether adjustments should be Performs some self-care
made. These appraisals emphasize validity of measures for patient
operations or actions in relationship to stan-
Compensates for self-care
dards. Selecting valid operations in the plan limitations of patient
and in evaluation incorporate evidence-based
practices. These processes, including diagnosis, Nurse Assists patient as required
prescription, designing, planning, regulat- action
ing, and controlling, can be viewed as elements
of Orem’s steps in the process of nursing Performs some self-care
measures
(Fig. 8-3).
Orem’s language of the nursing process Regulated self-care Patient
varies from the standard language of assess- agency action
ment, diagnosis, planning, implementation,
Accepts care and
and evaluation. The interaction of the three assistance from nurse
aforementioned subsystems creates a model for
true collaboration with the recipient of care or Partly compensatory system
the caregiver.
Accomplishes self-care
The three steps of Orem’s process of nurs-
Patient
ing are as follows: (1) diagnosis and prescrip- action
Regulates the exercise
tion, (2) design and plan, and (3) produce and Nurse
and development of
control. For example, Orem considers the action
self-care agency
term “assessment” too limiting. Within Orem’s
process, assessments are made throughout the Supportive-educative system
iterative social–contractual and professional– FIG 8-3 ■ Basic nursing system.
technological operations. During the first step
of diagnosis, data are collected on the basic judgments about the information within the
conditioning factors and a determination is limits of nursing agency (capabilities of the
made about their relationship to the self-care nurse, such as expertise).
requisites and to self-care agency. How does Orem describes nursing as a specialized
health state (e.g., type 2 diabetes) affect the helping service and identifies five helping
individual’s universal, developmental, and health- methods to overcome self-care limitations or
deviation self-care requirements? How does regulate functioning and development of pa-
the basic conditioning factor, or health state, tients or their dependents. Nurses employ
affect the individual’s self-care agency (capa- one or more of these methods throughout
bilities)? What, if any, are limitations for the process of nursing, including acting for
deliberate action related to the estimative or doing for another, guiding another, sup-
(investigative–knowing), transitional (decision porting another, providing for a develop-
making), and productive (performing) phases mental environment, and teaching another
of self-care (Orem, 2001, p. 312)? The nurse (Orem, 2001, pp. 56–60). Acting for or
collects information, analyzes it, and makes doing for another includes physical assistance

7991_Ch08_109-134 13/08/19 3:34 PM Page 120
such as positioning the patient. Assuming with patients and significant others. Social–con-
self-care agency that is developed and oper- tractual characteristics require the ability to
able, the nurse replaces this method with apply knowledge of variations in patients to
others that focus on cognitive development, nursing situations and to form contracts with
such as guiding and teaching. These methods patients and others for clear role boundaries.
are not unique to nursing, but are used by Desirable professional–technological character-
most health professionals. Through their istics require the ability to perform techniques
unique role functions, nurses perform a spe- related to the process of nursing: diagnosis of
cific sequence of actions in relationship to therapeutic self-care demand of an assigned pa-
the identified patient and/or dependent-care tient with consideration of all self-care requisites
agent’s self-care limitations in combination (universal, developmental, and health deviation)
with other health professionals to meet the and a concomitant diagnosis of a patient’s self-
self-care requirements. care agency.
Although comparisons are made between Other desired nurse characteristics in-
these steps and those of the general nursing clude the ability to prescribe roles: Assuming
process, Orem’s complexity is unique in ad- a self-care deficit (and therefore a legitimate
dressing an integration of interpersonal, social– patient), what are the roles and related re-
contractual, and professional–technological sponsibilities of the nurse, the patient, the
subsystems. This complexity has been criticized aide, and the family? Nurses must also have
as a weakness of the theory; however, others the ability to know and apply care measures
believe that it allows for flexibility necessary for such as general helping techniques (teaching,
application in all areas of nursing (Querios, guiding) and specialized interventions and
Vidinha, & Filho, 2014). The practice exemplar technologies such as those identified with
in this chapter provides one example of this evidence-based practice. These necessary
integrative process. nursing capabilities also have implications for
nursing education and nursing administra-
Nursing Agency tion. Knowledge of all components of nurs-
Nursing agency is the power or ability to ing agency will direct nursing curricula for
nurse. The agency or capabilities are neces- successful development of nursing compe-
sary to “know and meet patients’ therapeutic tencies. Likewise, knowledge related to nurs-
self-care demands and to protect and to reg- ing administration is critical to operability of
ulate the exercise of development of patient’s nursing agency (Banfield, 2011).
self-care agency” (Orem, 2001, p. 290).
Nursing agency is analogous to self-care Multiple-Person Situations and Units
agency but with capabilities performed on Taylor and Renpenning (2001) extended appli-
behalf of “legitimate patients.” Similar to cation of Orem’s concepts to families, groups,

self-care agency, nursing agency is affected and communities, where the recipient of nurs-
by basic conditioning factors. The nurse’s ing care is more than a single individual with a
family system, as well as nursing education self-care deficit. They distinguished among
and experience, may affect his or her ability types of multiple-person units, such as commu-
to nurse. nity groups and family or residential group units.
Orem categorizes nursing capabilities These authors present categories of multiple-
(agency) as interpersonal, social–contractual, person care systems, create family and commu-
and professional–technological. That is, the nity as basic conditioning factors, and present a
nurse must have capabilities within each of the model of community as aggregate. This model
subsystems described in the nursing system. Ca- appropriately incorporates additional basic
pabilities that result in desirable interpersonal conditioning factors such as public policy,
nurse characteristics include effective commu- health-care system changes, and community
nication skills and ability to form relationships development.

7991_Ch08_109-134 13/08/19 3:34 PM Page 121
Community groups have a selected number guiding nursing curricula (Taylor & Hartweg,
of common self-care requisites and/or limita- 2002). However, few U.S. academic institu-
tions of knowledge, decision making, and tions now use a single theory to guide the
producing care. These can be based on re- curriculum and/or practice. Personal commu-
quirements of entire communities, groups nications with faculty at universities known
within the communities, or other situations for past application, such as University of
when groups have common needs. For exam- Missouri–Columbia, revealed limited use; on
ple, the focus of a student health nurse at a the other hand, Illinois Wesleyan University
university may be a group of first-year stu- continues with application of the theory
dents and the self-care requisite, prevention of (personal communication, Dr. Vickie Folse,
the hazards of alcohol poisoning. The self-care February 28, 2018). However, increased ap-
limitations of the group may be knowledge of plication is evident in other countries such
binge-drinking outcomes and the skills to reas Japan (Tadaura et al., 2014) and Sweden
sist peer pressure at parties. This environment (Silen & Johansson, 2016).
and situation, the college milieu and new in-
dependence, creates the common set of self- Nursing Research
care requisites. The action system designed by The use of SCDNT as a framework for re-
the college health nurse is to develop the search continues to increase with application
knowledge, decision-making, and result-pro- to specific populations and conditions in
ducing skills of new students collectively so many countries. Early Orem studies concen-
life, health, and well-being are enhanced for trated on theory development and testing,
the group, as well as the college community. including creation of theory-derived research
Family or others in a communal living instruments (Gast et al., 1989), a necessary
arrangement are another type of multiple-per- process in theory building. Examples of
son unit of service. Because of the interrela- widely used concept-based instruments in-
tionship of the individuals in the living unit, clude those by Denyes (1981, 1988) on self-
the purpose of nursing varies from that for a care practices and self-care agency. The
community group. In this situation, the focus Appraisal of Self-care Agency (ASA Scale)
is often an individual, as well as the family as a by Evers, Isenberg, and Philipsen (1993)
unit. The health-related requirements of one was an early tool used in international re-
individual trigger the need for nursing but also search. This has been modified and adapted
affect the unit as a whole. In one situation, an for use in multiple countries (Sousa et al.,
elderly parent moves into the family home. 2010). A recent study found strong psycho-
Not only is the therapeutic self-care demand metric properties of the Chinese version for
of the parent involved, but also the needs of use with older Chinese adults (ASA-R-CHI;
family members as it affects their self-care req- Gue et al., 2017). Matarese, Lommi, and De
uisites. The health of the unit is therefore es- Marinis (2016) conducted a review of meas-
tablished and maintained by meeting the urement properties of seven Orem-related
therapeutic self-care demands of all members instruments used to determine self-care in
and facilitating the development and exercise adults. The authors identified the need for
of self-care agency for each group member continued development of validity and relia-
(Taylor & Renpenning, 2011). bility in these instruments.
More recent instruments derived from the
structural components of SCDNT are de-
Applications of the Theory scribed here, but it is important to recognize
Nursing Education their applicability to more specific health-
During the height of grand theory utilization related situations and populations: the Self-
in the United States, Orem’s conceptualiza- Care Requisites Scale for hospitalized patients
tion was the most frequently used theory with schizophrenia (Spain; Roldan-Merino

7991_Ch08_109-134 13/08/19 3:34 PM Page 122
et al., 2015); the Dietary Salt Reduction the concept as the “ability to manage self in
Self-Care Behavioral Scale for older adults stable or changing environments and ability
with hypertension (Thailand; Srikan & to manage one’s personal affairs” (p. 111).
Phillips, 2014); the Dietary Sodium Reduc- This definition relates to continuity of con-
tion Self-Care Agency Scale (Thailand; tacts and interactions one would expect over
Smith & Phillips, 2013); and the Self- time with nursing, especially when caring for
Performance Scale for Patients with Stomach people with chronic conditions such as dia-
Cancer after Gastrectomy (Korea; Jeon & betes. By nature, chronic disease variations
Park, 2016). over time are collaboratively managed by the
As research frameworks often use select self-care agent, the dependent-care agent,
concepts from the total reality found in con- the nurse agent, and others. The Dependent-
ceptual models, middle-range theories pro- Care Theory enhances the self-management
vide another avenue for nurses and are component, a uniqueness of SCDNT (Casida,
necessary for advancement of nursing knowl- Peters, & Magnan, 2009). With increases in
edge (Fawcett, 2005). Ideally, a middle- chronic illness and treatment, especially in re-
range theory can be a derivation from a lationship to allocation of health-care dollars,
conceptual model, retaining original assump- countries such as Thailand now emphasize
tions, such as a middle-range Theory of self-management versus self-care in health
Weight Management (Pickett, Peters, & policy decisions (personal communication,
Jarosz, 2014). Others integrate multiple the- Prof. Dr. Somchit Hanucharurnkul, January 15,
ories and concepts with elements of Orem’s 2013).
SCDNT to create middle-range theories of In addition to creating models for specific
nursing, including Self-Management Behav- health-care conditions, Orem’s SCDNT is
ior for Collaborative Research and Practice also used as a general framework for nursing
(Blok, 2017) and the Theory of Nursing in practice in specific health-care institutions.
Hypertension Care in Sweden (Drevenhorn, For example, Cedars Sinai Medical Center
2018). This combination of concepts and in Los Angeles, California, integrates SCDNT
theories in research studies is common. See with its shared governance model to promote
Table 8-1 for examples of research con- patient safety (Swanson & Tidwell, 2011).
ducted since 2013. As part of their Magnet journey, nurses
at the University of Chicago Medicine
Nursing Practice selected Orem’s SCDNT to highlight the
Nursing practice has informed development professionalism of nursing in providing ho-
of SCDNT as SCDNT has guided nursing listic care for the patient and family (Vincent,
practice and research. One change in the Pischke-Winn, Pakieser-Reed, & LaFond,
past decade has been an emphasis on self- 2016). In Germany, select institutions use
management rather than or in conjunc- SCDNT as a model in a variety of health-
tion with self-care (Ryan, Aloe, & Mason- care settings (personal communication, Gerd
Johnson, 2009; Sürücu & Kizilci, 2012; Bekel, March 8, 2018). Table 8-2 includes a
Swanlund, Scherck, Metcalfe, & Jesek-Hale, few examples of practice applications using
2008). Orem (2001) introduced the term Orem’s model or select elements, such as the
self-management in her final book, defining process of nursing.

Table 8-1 Examples of Research Applications
Author (Year), Population/ SCDNT

Country Purpose Settings Concept(s) Methods Results
Afrasiabifar, Mehri, To determine Multiple sclerosis SCR: SCA/DCA; Single blind, After the intervention, a statistically significant
Sadat, & Shirazi the effect of a patients (N = 63) SC/DC; SCD randomized difference was observed in the mean difference of

(2016), Iran self-care model Methods of clinical trial fatigue between the two groups (p < 0.05). Orem’s
on fatigue severity helping self-care model was effective in reducing the fatigue
of multiple sclerosis patients.
Altay & Cavusoglu To determine the Asthmatic SC Experimental The five self-care skills of medicine usage, peak
effect of Orem’s adolescents in design expiratory flow meter usage, applying an asthma
7991_Ch08_109-134 13/08/19 3:34 PM Page 123
(2013), Turkey and Supportive–

Spain self-care model their homes educative system action plan, keeping a daily follow-up schedule,
as guide to an (N = 80) and protecting against triggering factors differed
intervention significantly between the first and last visits in the

program experimental group, whereas the self-care skills of
adolescents in the control group did not change.
C H A P TER 8
■
Applying Orem’s self-care model increased the

self-care skills of adolescents with asthma.
Armer, Brooks, & To examine Breast cancer SCA, especially Secondary Identified types of self-care limitations in relationship
Steward (2011), patient percep- survivors, estimative, analysis of to sets of limitations. Most limitations were not related
United States tions of SC limita- post-surgery transitional, qualitative data to lack of knowledge but to energy, patterns of living,
tions to meet (N = 14) and productive from pilot study etc. Emphasized the “supportive” element in this
TSCD to reduce phases of self- (Armer et al., nursing system.
lymphedema care necessary to 2009)
decrease risk of
lymphedema;
supportive–
educative nursing
system
Arvidsson, Bergman, To describe Rheumatic Health-promoting Phenomenology Perspectives revealed that SC requires dialogues with
Arvidsson, Fridlund, the meaning disease patients SC the body and environment, power struggles with the
Dorothea Orem’s Self-Care Deficit Nursing Theory
& Tops (2011), of health- (N = 12) disease, and making choices to fight the disease. SC
Sweden promoting SC was viewed as a way of life.
Continued
123
124
Table 8-1 Examples of Research Applications—cont’d

Hauffman, Alfonsson, To describe Cancer patients TSCD; USCR, Evidence-based The result is an IHCA described as a nurse-led,
Mattsson, Forslund, development and with anxiety DSCR, HDSCR practice: Internet-based learning and self-care program that

S E C T IO N III
Bill-Axelson, Nygren, acceptance of an and depression structured helps patients to perform self-care using different
■
Supportive–
& Johansson (2017), Internet-based symptoms educative nursing collaboration types of material in interaction with patients and
Sweden program intended (N = 39) system between patients, health-care staff. The acceptance of the program
to support cancer clinicians, and is consistent with the results of similar studies.
patients with researchers to Collaboration between patients, clinicians, and
7991_Ch08_109-134 13/08/19 3:34 PM Page 124
anxiety and develop a theory researchers seems to be a fruitful approach in the

depression of evidence-based development of an IHCA aiming to support cancer
symptoms interaction health patients’ self-care strategies.
communication

application (IHCA)
based on Orem’s
SCDNT and
select aspects of
Bandura’s social
learning theory
Heinze & Williams To describe Female breast SC Cross-sectional The most often used self-care symptom alleviation
(2015), United self-care cancer survivors, Use of Orem’s study with method category was diet/nutrition/lifestyle and
States strategies used 6 months or more model to purposive the least common category was herbs/vitamins/
to alleviate after treatment conceptualize subsample complementary therapy. With few exceptions, the
symptoms and (N = 51) study reported methods were perceived as effective. The
perceptions of most important nursing implication is to ensure that
their utility every patient who receives chemotherapy is well versed
in self-care regarding symptom management.
Hornboonherm, To investigate self- Thai patients SCD; SC; SCA Exploratory case The study shows that self-care deficit nursing theory
Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm
Nanagara, Kochamat, care deficits, self- with scleroderma Supportive– study, using (Orem, 2001) and the chronic illness trajectory
& Wantha (2017), care behaviors, (N = 12) educative nursing qualitative framework (Corbin & Strauss, 1991) are useful guides
Thailand “in chronic system methods to nursing management for people with scleroderma.
illness trajectory
management
Jahanbin, Homayouni, To investigate the Elderly Iranian SCA Randomized In the treatment group, mean change scores for
Rasti, Soltani, & effect of a cardiac patients with Supportive– double-blind self-care were statistically significant before and
Keshavarzi rehabilitation congestive heart educative controlled clinical after intervention (p < 0.001) and increases in the
(2014), Iran program on failure (CHF) program, trial mean change scores were observed in responses to all
performing (N = 90) emphasizing self-care items after intervention.
self-care nonpharmaceuti- The findings showed that using such a nonpharmaceu-

cal and tical therapy (cardiac rehabilitation) and individual’s
exercise-based need-based trainings (Orem’s model) could improve
interventions self-care ability in elderly suffering from CHF.
Kim & Dee (2017), To determine Rural Hispanic SCA; SC Descriptive Social support, spirituality, and self-care ability were
United States factors that women at risk Select BCFs cross-sectional significantly correlated in women with PPD.
7991_Ch08_109-134 13/08/19 3:34 PM Page 125
affect self-care for postpartum design Social support was a strong factor in predicting
depression (PPD) self-care ability for nutrition, psychological well-being,
(N = 223) exercise, and responsible health practices in the rural
Hispanic women at risk for PPD.

C H A P TER 8
Mohammadpour, To assess the Iranian patients SCA Randomized After the intervention, patients in the experimental
■
Sharghi, Khosravan, effectiveness with myocardial Supportive– controlled trial group had higher levels of self-care knowledge,
Alami, & Akhond of a supportive infarction recently educative nursing motivation, and skills compared to the prestudy
(2015), Iran educational discharged from system readings and the control group. The supportive
intervention the intensive care educative intervention developed based on Orem’s
unit (N = 66) self-care theory can improve nonhospitalized patients’
self-care ability and positively affect public health
outcomes.
Moura, Braga, Orem’s model Diabetic and SCD; SCR; Descriptive study, Two of the most prevalent nursing diagnoses in
Domingos, Rodrigues, used as hypertensive helping methods; with convenience hypertensive and/or diabetic subjects were “ineffective
Correla, & Oliveira framework with patients in a nursing systems sample of adults self-care,” and “readiness to enhance knowledge.”
(2015), Brazil nursing diagnosis family health-care
(NANDA-I) unit using home
to identify visits (N = 30)
classifications
of self-care
requisites
Continued
125
126
Table 8-1 Examples of Research Applications—cont’d

Nazik & Eryilmaz To determine the Postpartum SCA; USCR; Quasi- Difference in self-care agency was statistically
(2013), Turkey impact of Orem’s primiparas who DSCR; HDSCR experimental significant (p < .001). The study supported that

S E C T IO N III
model and had vaginal the care given to women in the postpartum period
■
nursing diagnosis deliveries in using Orem’s self-care model prevented postpartum

on prevention hospital and who complications and increased the self-care agency of
and reduction were followed at postpartum women.
of postpartum home (N = 63)
7991_Ch08_109-134 13/08/19 3:34 PM Page 126
complications
Rosmawati, Rohana, To determine Malaysian SCA; SC; helping Quasi- The study revealed that the mean scores of total and
& Manan (2013), effectiveness patients with methods; experimental subtotal self-care practices of the experimental group,

Malaysia of a supportive– type 2 diabetes, supportive– study i.e., dietary control, exercise, medication taking, stress
developmental seen at a nurse- developmental management, and personal hygiene, were significantly
intervention on run clinic nursing system higher than those in the control group (p < 0.05).
self-care practices (N = 68) There was no significant difference in HbA1c before
and after intervention in either group. Thus, this study
suggests that the supportive developmental nursing
program is effective in helping the Type 2 diabetic
patients to improve their self-care practices.
Saleema, Panpakdee, To test SCDNT Thai patients with BCFs; SCA; SC; Descriptive, Results indicated that the modified model of self-care
Arpanantikul, & by exploring hypertension SCD cross-sectional behaviors for hypertension control was supported
Chai-Aroon (2016), the pattern of receiving study by the data and explained 49% of variance in
Thailand relationship treatment at both self-care behaviors related to hypertension control.
among BCFs, outpatient clinics Patient–provider communication had positive effects
SCA, and SC and hospitals on self-care behaviors through knowledge about
(N = 402) hypertension, knowledge about self-care demands,
and perception about hypertension.
Shahdadi, To examine the Multiple sclerosis Use of model as Randomized After the intervention, the intervention group had a
Dahmardeh, Salari, effect of a self- patients (N = 78) framework for controlled clinical significantly greater mean change in stress scores
& Ahmadidarehsima care instructional educational trial than the control group (p < 0.05). The findings
(2017), Iran program on stress program used as indicate that the implementation of Orem’s self-care
reduction the intervention instructional program has potential for reducing the
stress of patients with multiple sclerosis.
Sharifi, Majlessi, To determine Female university SCA; SCD Two-stage Mean scores for self-care agency, self-care demand,
Montazeri, the effect of an students Self-care random stratified self-care operation structures, and total self-care in the
Shojaeizadeh, & osteoporosis (N = 150) operations sampling in intervention group were significantly better after the
Sadeghi (2017), Iran prevention quasi- intervention. The educational intervention seemed to be
program using Total self-care experimental effective in promoting self-care for the prevention of
Orem’s model method osteoporosis. The control group showed no significant
improvement in any of the aforementioned variables.

The results are in favor of the effects of educational
intervention on osteoporosis preventive self-care
among female students.
White (2013), To determine African American SC Nonexperimental, This study suggests that spiritual self-care practices
7991_Ch08_109-134 13/08/19 3:34 PM Page 127
United States relationship of patients with Spiritual self-care correlational can help manage chronic illness, specifically heart
self-care practices chronic heart practices design failure and QOL.
on QOL failure (N = 142) Created White’s
Theory of

Spirituality and
C H A P TER 8
Spiritual Self-Care
■
(a middle-range
model)
Wong, Ip, Choi, & To test relationship Chinese BCFs; SC; SCA Predictive Path analysis revealed that age and received menstrual
Lam (2015), Hong between basic adolescent correlational study education had both direct and indirect effects through
Kong, China conditioning girls with self-care agency on self-care behaviors. Mother’s
factors, self-care dysmenorrhea and father’s educational level, pain intensity, and
agency, and (N = 531) self-medication used when experiencing dysmenorrhea
self-care behaviors only affected the self-care behaviors directly.
Zarandi, Raiesifar, & To determine the Iranian patients SC; SCA; SCD Randomized All dimensions of QOL including physical functioning,
Ebadi (2016), Iran effect of Orem’s with migraine Supportive– clinical trial physical role limitation, body pain, general health,
self-care nursing (N = 83) educative system vitality, social functioning, and emotional role limitation
model on QOL and mental health in the experimental group showed a
significant increase after the intervention compared to
the control group (p < 0.05). This suggests that Orem’s
self-care nursing model has potential to improve
function and overall QOL and reduce the high cost

of migraines and migraine-related disabilities.
BCFs = basic conditioning factors; DCSC = dependent self-care; HDSCR = health deviation self-care requisite; QOL = quality of life; SC = self-care or self-care practice; SCA = self-care agency;
127
SCD = self-care deficit; SCDNT = self-care deficit nursing theory; SCR = self-care requisite; TSCD = therapeutic self-care demand.
128
Table 8-2 Examples of Practice Applications
Author (Year), Health or Illness SCDNT Patient or Practice Focus

Country Focus Setting Concept(s) (Selected Examples) Other
Alspach (2011), Hypertension/ Critical care unit SC Development of checklist tool to measure Use of the theoretical
United States heart failure SC at home after critical care discharge framework to design a brief

S E C T IO N III
in elderly checklist to support self care

■
at discharge.
Green (2013), Children with School nursing SCA/DCA Demonstration of utility of SCDNT with links Proposes expansion of the
United States special needs USCR; BCFs (with to individuals and vulnerable populations theory with use of select
public health concepts to
7991_Ch08_109-134 13/08/19 3:34 PM Page 128
links to public
health concepts, better serve vulnerable
such as self- populations
determination and

intersectionality)
Hohdorf (2010), Hospitalized Acute-care SCDNT Exemplified change of focus to theory-based One hospital’s goal to improve
Germany patients settings nursing practice quality care and decrease
length of stay by moving to
theory-based practice.
Hudson & Adults with Community SCDNT as frame- Demonstration of SCDNT as guide to de- An example of application
Macdonald hemodialysis dialysis unit work; all concepts velop and update patient-teaching resources or SCDNT to arteriovenous
(2010), Canada arteriovenous including NA in preparation for home care; assisted fistula SC
fistula self- nurses with role clarification
cannulation
Kurtz & Adults with All settings, Supportive– Conceptualized elements of cognitive- Integration of nonpharmaco-
Schmidt insomnia but primarily educative system behavioral therapy within Orem’s self-care logical, evidence-based
(2016), outpatient designed for requisites and the power components of interventions aimed at
United States patients with self-care agency changing sleep behaviors
insomnia
O’Shaughnessy Elderly patients Clinical setting SC; SCD; NA Uses nursing agency to assess if patients Continuing education offering
(2014), United on home dialysis or home care are capable of decision making and of Promotion of independence in
States therapy setting self-care (peritoneal dialysis) at home the elderly
Pickens (2012), Adults with Psychiatric SCA: motivation Explored various theories of motivation to Theoretical paper incorporat-
United States schizophrenia nursing care component develop SCDNT’s foundational capability ing elements of other theories
and power component of motivation to expand supportive–
developmental technologies
in patients with serious mental
illness

Rodriguez- Patient with Application of Development of SCDNT and creating of nursing diagnosis Within the model, led to
Sandoval, osteogenesis Orem’s nursing nursing diagnosis assisted with prioritizing interventions identification of requirements
Solorzano- imperfecta process using the PES and acquisition of skills for
Garcia, & format (problem, the family to provide care
Hernandez- etiology, signs
7991_Ch08_109-134 13/08/19 3:34 PM Page 129
Cantoral and symptoms)

(2013), Mexico
Surucu & Kizilci Use of SCDNT in University BCFs; SCA; Implemented steps of general nursing This case study provides an
(2012), Turkey type 2 diabetes setting; diabetes SCD; TSCD, process using Orem-specific concepts exemplar for self-management

self-management education center with emphasis on of type 2 diabetes
C H A P TER 8
education HDSCR
■
Swanson & Integration Orem’s self-care SCA; SCD; helping Demonstrates incorporation of SCDNT as SCDNT as component of
Tidwell (2011), model of shared deficit theory as methods the theoretical guide to professional practice health system practice model
United States governance general practice at one institution and its combination
using magnet framework shared governance to enhance patient safety
components to
promote patient
safety
Wanchai, Armer, Breast cancer Multiple settings SCA SC agency enhancement through use of
& Stewart survivors based on review complementary or alternative therapies to
(2010), United of 11 studies meet HDSCR, specifically to maintain
States, Canada, from 1990 physical and emotional well-being and
and Germany through 2009 to manage side effects of treatment
Wazni & Gifford Patients with Orem’s theory Conceptual model Expands view of SCDNT to integrate
(2017), Canada schizophrenia to integrate to provide for interpretive, empirical, and crucial
theoretical necessary physical perspectives
perspectives and mental health

care
BCFs = basic conditioning factors; DCA = dependent-care agency; HDSCR = health deviation self-care requisite; NA = nursing agency; SC = self-care; SCA = self-care agency; SCD = self-care
129
deficit; SCR = self-care requisite; TSCD = therapeutic self-care demand.

7991_Ch08_109-134 13/08/19 3:34 PM Page 130
Practice Exemplar
Written by Sharie Metcalfe, PhD, RN month. Anita and her husband attend mass
Initial establishment of Interpersonal on Sunday but otherwise are not actively in-
and Social–Contractual Relationship volved in the church. Anita prepares most
of the evening meals, as they prefer home-
Anita was referred to the local health clinic
cooked dishes; however, she often eats out
.
after routine blood pressure (BP) screening

for lunch. Anita reports a diet of vegetables,
at her workplace revealed an elevated read-
beans, tortillas, and cheeses. She denies
ing on two separate occasions. The most
smoking or alcohol use but does not exercise
recent BP was 138/78 mm Hg. After in-
on a regular basis. Anita verbalizes that she
troducing herself, the Advanced Practice
knows she should exercise but just does not
Nurse (APN) explores Anita’s expectations
have the motivation to do it.
for her visit. Anita discloses that she needs
Examination of health state reveals
to find out if she has high BP. The APN
that Anita is 5 feet 2 inches tall, weighs
explains how she might assist, providing
147 pounds, and has a body mass index
Anita the opportunity to ask questions.
(BMI) of 26.8 (AHA, 2017). Her vital
Anita responds that she does not have a
signs are temperature 37°C; pulse 80 beats
regular health-care provider and only had
per minute and regular; and sitting
her BP taken as part of an office program.
BP 136/78, repeat BP 139/76, and stand-
She indicates her willingness to provide the
ing BP 132/74. She states that she is in
health information needed to explore her
good health, taking no medicines except a
health concern. With roles confirmed, the
daily vitamin. Significant past medical
APN initiates the three steps of the process
history is negative. Her mother had high
of nursing outlined by Orem.
BP but died of colon cancer at age 76.
Professional/technological (process of
She verbalizes that she is “a little over-
nursing)
weight,” wanting to know if losing weight
Step I: Diagnosis and Prescription would help her BP. The APN agrees that
weight loss would be beneficial and rec-
1. Investigation of basic conditioning factors
ommends laboratory tests at this visit to
(BCFs). Initial information gathering
determine Anita’s atherosclerotic cardio-
about Anita is framed by the BCFs as
vascular risks and overall health status
these will affect the nurse’s determination
(American College of Cardiology, 2018).
of the care needed (self-care requisites),
The APN acknowledges Anita’s concerns
her self-care abilities (self-care agency),
about her BP, explaining that it is possible

and the methods to provide care
to observe her BP readings over a period
(methods of assisting).
of several months to determine if non-
Anita is a quiet, 52-year-old woman
medication approaches would be suffi-
who is employed part time as an office
cient to lower her BP.
manager in a local insurance agency. Anita
2. Calculation of the Therapeutic Self-Care
is a community college graduate and bilin-
Demand (TSCD). Together the APN and
gual. She enjoys her job and taking care of
Anita investigate the actions needed to
her home, where she lives with her hus-
meet her universal, developmental, and
band in a safe neighborhood surrounded
health deviation self-care requisites; this
by friends. They have one son who is in
includes her usual methods of care. The
college. Anita’s husband works full time;
focus of this visit is the care requirements
their combined income covers house pay-
that are most relevant to elevated BP
ments, bills, and health insurance, but
rather than the entire TSCD. The APN
there is no money left at the end of the

7991_Ch08_109-134 13/08/19 3:34 PM Page 131

proposes weight loss through reduced 4. Health Deviation Self-Care Requisites.
calories and increased physical activity ■ Monitor and record BP each morning
that are core recommendations to reduce and evening for 3 months to establish
BP (Whelton et al., 2017). Anita indi- BP threshold for diagnoses and
cates that she is willing to try modifying appropriate treatment (Whelton
her diet and physical activity. During the et al., 2017).
interview, the APN solicits information ■ Follow prescribed dietary intake
from Anita that will help identify specific of 1,500 mg or less of sodium
methods and the actions for meeting per day.
each requisite and Anita’s preferences. Example of a Calculated HDSCR. Using
The APN particularizes the two professional knowledge (Nurse Agency), the
universal self-care requisites (USCRs): nurse mentally calculates the methods and
(a) maintaining adequate food and water actions to meet the HDSCR for HBPM.
through diet; and (b) balancing rest These are presented below as an example of
and activity. one component of Anita’s TSCD.
3. Universal Self-Care Requisites. ■ Seek and secure safe and valid equipment
■ Consult with a dietitian to select for HBPM.

and eat healthy foods following ■ Determine and judge the appropriate
the Dietary Approaches to Stop fit of the BP device.

Hypertension (DASH) diet (Whelton ■ Manipulate BP equipment correctly to
et al., 2017), limiting calories to apply and take BP.

1,400 per day to achieve a BMI of ■ Know and follow the established proce-
less than 25. dure for HBPM (Whelton et al., 2017,

■ Engage in 90 to 150 minutes of p. 30).
walking each week to reach moderate- ■ Read and interpret the BP readings
intensity physical aerobic exercise sufficient for recording purposes.

(65% to 75% heart rate reserve) to ■ Record BP readings accurately using a
help reduce BP toward a goal of less standard format that includes site, date,
than 130/80 mm Hg (Whelton et al., and time.
2017). ■ Incorporate adequate time to take BP
One health deviation self-care requi- into her daily routine.

site (HDSCR) arises from Anita’s health ■ Know when BP readings are too high
status at this time: effectively carry out and seek appropriate advice.
medically prescribed, diagnostic, and ■ Determine availability and access of
therapeutic measures. To establish the BP supplemental materials to review

threshold, determine clinical treatment, HBPM procedure and information.
and evaluate the effectiveness of the treat- 5. Determination of Self-Care Agency (SCA).
ment, the APN explains the need to After the determination of the methods/
monitor Anita’s BP over 3 to 6 months. actions to meet the HDSCR in patient
The APN prefers to use home BP moni- care situations, it is important that nurses
toring (HBPM) to confirm the category are able to make judgments about the per-
of Anita’s BP and treatment effectiveness son’s ability to care for self. Anita’s exist-
and recommends that Anita reduce her ing abilities and resources are compared to
sodium intake. The result is two state- the care that needs to be done. Some of
ments about what should be done to im- the information the APN solicits follows:
prove Anita’s health state. Is she willing to take her BP twice a day
(continued)

7991_Ch08_109-134 13/08/19 3:34 PM Page 132

and keep records? Does Anita have the computer skills and office skills will be ben-
resources to obtain BP equipment? Is she eficial for seeking information and recording
able to learn the skill of taking BP? Does BP readings. However, there are limitations
she have knowledge regarding acceptable in self-care operations.
BP readings? Does she have cultural or Summary of Self-Care Limitations (Self-
family values that will influence her Care Deficit). Anita specifically lacks knowl-
course of action? Are there indications edge and skills for HBPM. She says she does
that a specific teaching approach would not have resources to purchase the BP mon-
be effective? itoring equipment. An analysis of Anita’s
Initially the APN validates Anita’s abilities to meet the requirements to take her
general abilities (foundational capabilities own BP indicates that the demand for care
and dispositions), inferring that she is is greater that her abilities (self-care agency).
cognitively intact, has good reasoning This indicates a self-care deficit. The pres-
abilities, has no physical limitations, and ence of the self-care deficit legitimizes the
shows interest in her health. The APN role of the APN to initiate the design of a
concludes that Anita’s basic self-care nursing system.
agency is developed and operable. During
the interaction, the nurse and Anita assess Step II: Design and Plan
Anita’s ability to perform the new health The APN decides that obtaining appropriate
deviation self-care actions. They then re- BP equipment and determining who will
view actions needed in relation to specific take the BP and at what time the BP will be
self-care abilities. taken are important initial actions in the plan
Anita reveals that she has been reading of care. She acknowledges Anita’s reluctance
about the condition on the Internet. She to do HBPM but encourages Anita to choose
was surprised to discover that most people HBPM by helping her determine the advan-
do not have symptoms. She also found tages and recognize her own skills and ability
that medicine is used for treatment but to learn. Since Anita is in the process of di-
diet and exercise could help, something agnosing her BP status, she qualifies for a
she prefers to try first. As they interact, the new program the clinic offers that loans BP
APN explains basic information about the equipment for 3 months. Anita is satisfied
causes of high BP, possible treatments, that initially she does not need to purchase
and how it is diagnosed. The nurse ob- equipment. Learning that it would be neces-
serves that Anita appears uncomfortable sary to take her BP twice a day at about the
during their discussion. Anita reveals that same time Anita decides the best time is
she has concerns about taking her own morning before work and in the evening after
BP, the cost of the BP equipment, and ac- supper.
tions to take if her BP is high. These state- Their discussion progresses to gaining
ments indicate an awareness of self-care knowledge of the actual procedure for taking
with appropriate apprehension about tak- BP and developing the skills to manipulate
ing and making judgments about her BP. the equipment. The APN demonstrates the
When the nurse suggests coming to the appropriate technique, explaining each step.
clinic, Anita identifies conflicts with her She reassures Anita that at the appointment
work schedule. when she is measured for the BP cuff, the
The nurse confirms that Anita has in- nurse will teach her how to manipulate the
terest and desire to engage in self-care. She equipment, require that Anita demonstrate
has the ability to learn and is motivated to correct technique, and show her how to
control her BP without medication. Her record the readings. The APN will provide

7991_Ch08_109-134 13/08/19 3:34 PM Page 133

Anita with a written procedure for her to Step III: Production and Control
review. Anita becomes more receptive to Essential to the success of their collaborative
the idea of doing her own HBPM so the design of the nursing system, the APN knows
APN takes the opportunity to supplement that implementation of the prescribed TSCD
the basic hypertension information, such as (select USCRs and HDSCRs) requires both
the meaning of BP readings, when BP is she and Anita to use their specified abilities.
too high, and contact information if that In this supportive–educative design, it is
situation occurs. Since Anita has demon- Anita’s role to produce the self-care while the
strated good computer skills in looking for APN’s role is to develop Anita’s ability to per-
information, the APN offers some website form care and to direct her actions according
addresses with reliable information. It is to the plan.
important that Anita get the support and Anita was able to make the appointment
guidance she needs to incorporate the new to receive HBPM instructions with office
self-care requirements into her life. records, validating her satisfactory monitoring
Before Anita leaves the office, the of BP. When the APN called at the 2-week
APN reviews the design and plan for the interval, the results of the HBPM indicated
supportive–educative nursing system to a pattern consistent with findings in the of-
clarify the role and actions for each of them. fice. The APN reminded Anita that typically
Anita will make an appointment to attend the results of nonpharmacological interven-
the HBPM session. At that time, she will tions are not evident for 6 months (Whelton
be measured for the correct size cuff and et al., 2017). Anita said she was able to take
provided with the home equipment. If she her BP twice a day but had missed two morn-
is unable to make these arrangements, she ing readings and had read the written mate-
will call the APN. Following the initial ori- rial but not watched the videos. The APN
entation and skills session, Anita will take supported her progress to date. Anita agreed
her BP twice a day, accurately recording the to make an office appointment in 1 month, to
values as outlined on the daily record pro- bring records of BP readings, and to bring her
vided by the clinic. The APN will call Anita equipment to demonstrate her skill. At that
in 2 weeks to get the results of the BP mon- appointment, the APN and Anita will review
itoring and discuss the findings. In the in- the current nursing system to evaluate the
terim Anita agrees to call the APN with progress of nonpharmacological strategies in
concerns about her BP. reducing the BP to the target of less than
The APN provides her with an email ad- 130/80.
dress that can be used to submit the HBPM Throughout this interaction, the APN
readings and a telephone number to call for demonstrated specialized knowledge of the
readings of systolic BP (SBP) less than 180 clinical situation combined with interper-
and diastolic BP (DBP) less than 110. The sonal, social–contractual, and professional–
APN provides Anita with reliable resources technological operations to maintain an
for Internet videos and self-education re- effective relationship with Anita. She estab-
garding HBPM (AHA, 2017). In 1 month, lished what should be done, what can be
the APN will meet with Anita to review done, and who will perform the action. The
the written record of BP, review the labo- APN’s method of assisting was to teach,
ratory reports, and calculate Anita’s risk fac- guide, and support Anita once her self-care
tors to make the determination on further limitations were identified.
monitoring.

7991_Ch08_109-134 13/08/19 3:34 PM Page 134
Summary
This chapter provided an overview of Orem’s six major concepts and one peripheral concept.
Self-Care Deficit Nursing Theory. Orem cre- Orem’s SCDNT has been applied extensively
ated this general theory of nursing to address in nursing practice throughout the United
the proper objective of nursing through the States and internationally in diverse settings
question, What condition exists in a person when and with diverse populations. Concepts from
judgments are made that a nurse(s) should be SCDNT increasingly are used for research
brought into the situation (i.e., that a person with specific patient populations throughout
should be under nursing care; Orem, 2001, the world, including the Middle East and
p. 20)? The grand theory comprises four inter- South America. Collaboration among schol-
related theories: the Theory of Self-Care, the ars, researchers, and practitioners is necessary
Theory of Dependent Care, the Theory of Self- to provide the science of self-care useful to im-
Care Deficit, and the Theory of Nursing Sys- prove nursing practice into the future (Taylor
tems. The building blocks of these theories are & Renpenning, 2011).
Questions for Reflection ■ How is the concept of “legitimate nurs-

ing” critical to understanding the nurse’s
and Discussion role and the patient’s role? How might
■ Review the practice exemplar. Discuss the this be considered an “economics” model?
pros and cons of the complexity of ■ Describe the four constituent theories that
SCDNT. Does the detailed process of make up Orem’s Self-Care Deficit Nurs-
nursing, including determining in detail ing Theory and how these conceptually
“what needs to be done” and “what can be contribute to defining Orem’s theory as a
done by the patient,” contribute to healthy grand theory in nursing.
patient outcomes?

7991_Ch09_135-148 13/08/19 3:39 PM Page 135
Imogene King’s Conceptual

CHAPTER
9
System and Theory of Goal
Attainment
Mary Louanne Friend and
Christina L. Sieloff
Introducing the Theorist Imogene M. King was born on January 30,
Overview of the Theory 1923, in West Point, Iowa. She received a
Applications of the Theory diploma in nursing from St. John’s Hospital
Practice Exemplar by Mary B. Killeen School of Nursing, St. Louis, Missouri (1945);
Summary a bachelor of science in nursing education
Questions for Reflection and Discussion (1948) and a master of science in nursing from
St. Louis University (1957); and a doctor of
education (Ed.D.) from Teachers College,
Columbia University, New York (1961). She
held educational, administrative, and leader-
ship positions at St. John’s Hospital School of
Nursing, the Ohio State University, Loyola
University, the Division of Nursing in the
U.S. Department of Health, Education, and
Welfare, and the University of South Florida.
King’s hallmark theory publications include “A
Conceptual Frame of Reference for Nursing”
(1968), Towards a Theory for Nursing: General
Concepts of Human Behavior (1971), and A
Theory for Nursing: Systems, Concepts, Process
(1981). Since 1981, King clarified and ex-
panded her conceptual system, her middle-
range Theory of Goal Attainment, and the
transaction process model in multiple book
chapters, articles in professional journals, and

presentations. After retiring as professor
emerita from the University of South Florida
in 1990, King remained an active contributor
to nursing’s theoretical development and
worked with individuals and groups in devel-
oping additional middle-range theories, apply-
ing her theoretical formulations to various
populations and settings and implementing
the Theory of Goal Attainment in clinical
practice. King received recognition and nu-
merous awards for her distinguished career
in nursing from the American Nurses Asso-
ciation, the Florida Nurses Association, the
American Academy of Nursing, and Sigma
135
7991_Ch09_135-148 13/08/19 3:39 PM Page 136
Theta Tau International. Dr. Imogene King of human beings (ontology) and to the nature
died in December 2007. Her theoretical of knowledge (epistemology).
formulations for nursing continue to be taught
at all levels of nursing education and applied Philosophical Foundation
and extended by national and international In the late 1960s, while auditing a series of
scholars.1 courses in systems research, I was introduced
to a philosophy of science called General Sys-
tem Theory (von Bertalanffy, 1968). This
Overview of the Theory philosophy of science gained momentum in
Imogene King’s Conceptual System2 the 1950s, although its roots date to an earlier
My first theory publication pronounced the period. This philosophy refuted logical posi-
problems and prospect of knowledge develop- tivism and reductionism and proposed the
ment in nursing (King, 1964). At that time, idea of isomorphism and perspectivism in
the problems were identified as (1) a lack of a knowledge development. Von Bertalanffy,
professional nursing language, (2) lack of the- credited with originating the idea of General
oretical nursing phenomena, and (3) limited System Theory, defined this philosophy of
concept development. Today, theories and science movement as a “general science of
conceptual frameworks have identified theo- wholeness: systems of elements in mutual in-
retical approaches to knowledge development teraction” (von Bertalanffy, 1968, p. 37).
and utilization of knowledge in practice. Con- My philosophical position is rooted in
cept development is a continuous process in General System Theory, which guides the study
the nursing science movement (King, 1988). of organized complexity as whole systems. This
My rationale for developing a schematic philosophy gave me the impetus to focus on
representation of nursing phenomena was knowledge development as an information-
influenced by the Howland Systems Model processing, goal-seeking, and decision-making
(Howland, 1976) and the Howland and system. General System Theory provides a ho-
McDowell (1964) conceptual framework. The listic approach to study nursing phenomena as
levels of interaction in those works influenced an open system and frees one’s thinking from
my ideas relative to organizing a conceptual the parts-versus-whole dilemma. In any discus-
frame of reference for nursing. Because con- sion of the nature of nursing, the central ideas
cepts offer one approach to structure knowl- revolve around the nature of human beings and
edge for nursing, a thorough review of nursing their interaction with internal and external en-
literature provided me with ideas to identify vironments. During this journey, I began to
five comprehensive concepts as a basis for a conceptualize a theory for nursing. However,
because a manuscript was due in the publisher’s
conceptual system for nursing. The overall

concept is a human being, commonly referred office, I organized my ideas into a conceptual
to as an “individual” or a “person.” system (formerly called a “conceptual frame-
Initially, I selected abstract concepts of per- work”), and the result was the publication of a
ception, communication, interpersonal rela- book titled Toward a Theory of Nursing (King,
tions, health, and social institutions (King, 1971).
1968). These ideas forced me to review my
Design of a Conceptual System
knowledge of philosophy relative to the nature
A conceptual system provides structure for
organizing multiple ideas into meaningful
1For additional information about the theorist, publica- wholes. From my initial set of ideas in 1968
tions, and research using King’s conceptual model and the and 1971, my conceptual framework was re-
Theory of Goal Attainment (Tables 9-1 to 9-14), see the
fined to show some unity and relationships
bonus chapter content available at http://davisplus.fadavis.
com. Some tables are specifically referenced throughout among the concepts. The conceptual system
the text to further guide the reader. consists of individual systems, interpersonal
2This section is written by Imogene King. systems, and social systems and concepts

7991_Ch09_135-148 13/08/19 3:39 PM Page 137
CHAPTER 9 ■ Imogene King’s Conceptual System and Theory of Goal Attainment 137
that are important for understanding the in- and relationships to past experiences. Northrop
teractions within and between the systems (1969) noted that concepts fall into different
(Fig. 9-1). types according to the different of their meaning.
The next step in this process was to review Concepts are the categories in a theory. Con-
the research literature in the discipline in cepts that represent phenomena in nursing are
which the concepts had been studied. For ex- structured within a framework and theory to
ample, the concept of perception has been show relationships.
studied in psychology for many years. The lit- Multiple concepts were identified from my
erature indicated that most of the early studies analysis of nursing literature (King, 1981). The
dealt with sensory perception. Around the concepts that provided substantive knowledge
1950s, psychologists began to study interper- about human beings (self, body image, percep-
sonal perception, which related to my ideas tion, growth and development, learning, time,
about interactions. From this research litera- and personal space) were placed within the per-
ture, I identified the characteristics of personal system, those related to small groups (in-
ception and defined the concept for my teraction, communication, role, transactions,
framework. I continued searching literature for and stress) were placed within the interpersonal
knowledge of each of the concepts in my system, and those related to large groups that
framework. An update on my conceptual sys- make up a society (decision making, organiza-
tem was published in 1995 (King, 1995). tion, power, status, and authority) were placed
within the social system (King, 1995). How-
Process for Development of Concepts ever, knowledge from all the concepts is used
“Searching for scientific knowledge in nursing is in nurses’ interactions with individuals and
an ongoing dynamic process of continuous iden- groups within social organizations, such as the
tification, development, and validation of rele- family, the educational system, and the political
vant concepts” (King, 1975, p. 25). What is a system. Knowledge of these concepts came
concept? A concept is an organization of refer- from my synthesis of research in many disci-
ence points. Words are the verbal symbols used plines. Concepts, when defined from research
to explain events and things in our environment literature, give nurses knowledge that can be
applied in the concrete world of nursing. The
concepts represent basic knowledge that nurses
use in their role and functions either in practice,
Social systems
(society)
education, or administration. In addition, the
concepts provide ideas for research in nursing.
One of my goals was to identify what I call
the essence of nursing. That brought me back
Interpersonal systems
(group) to the question: What is the nature of human
beings? A vicious circle? Not really! Because
Personal nurses are first and foremost human beings
systems
(individuals) who give nursing care to other human beings,
my philosophy of the nature of human beings
has been presented along with assumptions I
have made about individuals (King, 1989a).
Recognizing that a conceptual system repre-
sents structure for a discipline, the next step in
the process of knowledge development was to
derive one or more theories from this structure.
Lo and behold, a Theory of Goal Attainment
was developed (King, 1981, 1992). More re-
cently, others have derived theories from my
FIG 9-1 ■ King’s conceptual system. conceptual system (Frey & Sieloff, 1995).

7991_Ch09_135-148 13/08/19 3:39 PM Page 138
Theory of Goal Attainment of your behavior and that of the patient after
Generally speaking, nursing care’s goal is to interacting with that patient. It is my belief
help individuals maintain health or regain that you can identify your perceptions, mental
health (King, 1990). Concepts are essential judgments, mental actions, and reactions (neg-
elements in theories. When a theory is de- ative or positive). Did you make a transaction?
rived from a conceptual system, concepts are That is, did you exchange information and set
selected from that system. Remember my a goal with the patient? Did you explore the
question: What is the essence of nursing? means for the patient to use to achieve the
The concepts of self, perception, communi- goal? Was the goal achieved? If not, why? It is
cation, interaction, transaction, role, growth my opinion that most nurses use this process
and development, stress, time, and personal but are not aware that it is based in a nursing
space were selected for the Theory of Goal theory. With knowledge of the concepts and
Attainment. of the process, nurses have a scientific base for
practice that can be clearly articulated and doc-
Transaction Process Model umented to show quality care. How can a
A transaction model, shown in Figure 9-2, was nurse document this transaction model in
developed to represent the process in which in- practice?
dividuals interact to set goals that result in goal
attainment (King, 1981, 1995). Documentation System
The model is a human process that can be A documentation system was designed to im-
observed in many situations when two or more plement the transaction process that leads to
people interact, such as in the family and in so- goal attainment (King, 1984). Most nurses
cial events (King, 1996). As nurses, we bring use the nursing process to assess, diagnose,
knowledge and skills that influence our per- plan, implement, and evaluate, which I call a
ceptions, communications, and interactions in method. My transaction process provides the
performing the functions of the role. In your theoretical knowledge base to implement this
role as a nurse, sit down and write a description method. For example, as one assesses the
Feedback
PERCEPTION
JUDGMENT
ACTION
NURSE
REACTION INTERACTION TRANSACTION
ACTION
JUDGMENT
PATIENT
PERCEPTION
Feedback
FIG 9-2 ■ Transaction process model. (From King, I. M. [1981]. A theory for nursing: Systems, concepts, process
[p. 145]. New York: Wiley.)

7991_Ch09_135-148 13/08/19 3:39 PM Page 139
patient and the environment and makes a useful purpose in delivering professional nurs-
nursing diagnosis, the concepts of perception, ing care. For instance, currently federal laws
communication, and interaction represent have been passed that indicate that patients
knowledge the nurse uses to gather informa- must be involved in decisions about their care
tion and make a judgment. A transaction is and about dying. This transaction process
made when the nurse and patient decide mu- provides a scientifically based process to help
tually on the goals to be attained, agree on the nurses implement federal laws such as the
means to attain goals that represent the plan Patient Self-Determination Act (Federal Reg-
of care, and then implement the plan. Evalu- ister, 1995). The relevance of evidence-based
ation determines whether or not goals were practice, using my theory, links the art of nurs-
attained. If not, you ask why, and the process ing found in the 20th century to the science of
begins again. The documentation is recorded nursing in the 21st century.
directly in the patient’s chart. The patient’s
record indicates the process used to achieve
goals. On discharge, the summary indicates Applications of the Theory
goals set and goals achieved. One does not Since the first publication of King’s work
need multiple forms when this documenta- (1971), nursing’s interest in the application of
tion system is in place, and the quality of her work to practice has grown. She was one
nursing care is recorded. of the few theorists who generated both a con-
ceptual system and a middle-range theory. The
Goal Attainment Scale conceptual system and theory continue to in-
At a time when there were few instruments spire nursing research and practice. Additional
designed for nursing research, I attended a middle-range theories have been generated
conference at the University of Maryland with and tested, and applications to practice have
experts in measurement and evaluation focused expanded. After her retirement, King contin-
on teaching nurses to design reliable and valid ued to publish and examine new applications
instruments. I had the privilege of participat- of the theory. The purpose of this part of the
ing in this 2-year continuing education con- chapter is to provide an updated review of the
ference, and the result was the development of state of the art and science in terms of the ap-
the Goal Attainment Scale (King, 1989b). plications of King’s conceptual system (KCS)
This instrument may be used to measure goal and middle-range theory in a variety of areas:
attainment. It may also be used as an assess- practice, administration, education, and re-
ment tool to provide patient data to plan and search. Publications, identified from a review
implement nursing care. of the literature, are summarized and briefly
discussed. Finally, recommendations are made
Vision for the Future for future knowledge development in relation

My vision for the future of nursing is that nurs- to KCS and middle-range theory, particularly
ing will provide access to health care for all cit- in relation to the importance of their applica-
izens. The United States’ health-care system tion within an evidence-based practice envi-
will be structured using my conceptual system. ronment.
Entry into the system will be via nurses’ assess- In conducting the literature review, the
ment so that individuals are directed to the authors began with the broadest category of
right place in the system for nursing care, med- application—application within KCS to nurs-
ical care, social services information, health teaching care situations. Because a conceptual frame-
ing, or rehabilitation. My transaction process work is, by nature, very broad and abstract, it
will be used by every practicing nurse so that can serve only to guide, rather than to prescrip-
goals can be achieved to demonstrate quality tively direct, nursing practice.
care that is cost-effective. My conceptual sys- Concept development within a conceptual
tem, Theory of Goal Attainment, and transac- framework is particularly valuable, as it often
tion process model will continue to serve a explicates concepts more clearly than a theorist

7991_Ch09_135-148 13/08/19 3:39 PM Page 140
may have done in his or her original work. In relation to the interpersonal system,
Concept development may also demonstrate Doornbos (2007), using her Family Health
how other concepts of interest to nursing can Theory, addressed family health in terms of
be examined through a nursing lens. Such ex- families of adults with persistent mental ill-
plication further assists the development of ness. Thomason and Lagowski (2008) used
nursing knowledge by enabling the nurse to concepts from King along with other nursing
better understand the application of the con- theorists to develop a model for collaboration
cept within specific practice situations. Exam- through reciprocation in health-care organiza-
ples of concepts developed from within King’s tions. The Interactive Theory of Breastfeeding
work include managerial coaching (Batson described, explained, and predicted factors that
& Yoder, 2012), emotional intelligence as a precede and affect the ability to breastfeed, as
crucial component in the nurse’s ability to pro- well as the influence of these factors on the
vide holistic care (Shanta & Connolly, 2013), breastfeeding process (Primo & Brandão, 2017;
functional status for client-family-centered Veira, Morais, Lima, de Pontes, Brandao,
care (Caceres, 2015), and user participation (da & Primo, 2017). In relation to social systems,
Silva & Ferreira, 2016).3 Sieloff and Bularzik (2011) revised the Theory
Development of middle-range theories is a of Group Power within Organizations to
natural extension of a conceptual framework. the Theory of Group Empowerment within
Middle-range theories, clearly developed from Organizations to explain the ability of groups
within a conceptual framework, accomplish to empower themselves within organizations.4
two goals: (1) Such theories can be directly Instruments have been designed within King’s
applied to nursing situations, whereas a con- framework to measure relevant constructs.
ceptual framework is usually too abstract King (1988) developed the Health Goal At-
for such direct application, and (2) validation tainment instrument, designed to detail the
of middle-range theories, clearly developed level of attainment of health goals by individ-
within a particular conceptual framework, ual clients. The Sieloff-King-Friend Assessment
lends validation to the conceptual framework of Group Empowerment within Educational
itself. King (1981) stated that individuals act Organizations (SKFAGEEO) was developed
to maintain their own health. Although not to measure the level of group empowerment
explicitly stated, the converse is probably true in baccalaureate and graduate nurse faculty
as well: Individuals often do things that are not and administrators (Friend, Sieloff, Shannon,
good for their health. Accordingly, it is not & Leeper, 2016). The Nursing Care Interper-
surprising that the KCS and related middle- sonal Relationship Questionnaire measured
range theory are often directed toward patient interpersonal relationships in nursing care
and group behaviors that influence health. (Borges, Moreira, & Andrade, 2018). The
In addition to the middle-range Theory of processes of advanced directives (Smith, 2017)

Goal Attainment (King, 1981), several other and medication adherence (Panozzo, 2018)
middle-range theories have been developed were also examined through the development
from within King’s interacting systems frame- of instruments.5
work. In terms of the personal system, Brooks
and Thomas (1997) used King’s framework to Applications in Nursing Practice
derive a Theory of Perceptual Awareness. The There have been many applications of King’s
focus was to develop the concepts of judgment middle-range theory to nursing practice be-
and action as core concepts in the personal cause the theory focuses on concepts relevant
system. Other concepts in the theory in- to all nursing situations—the attainment of
cluded communication, perception, and deci-
sion making. 4See Table 9-5 in the bonus chapter content available at
http://davisplus.fadavis.com.
3See Table 9-2 in the bonus chapter content available at 5See Table 9-6 in the bonus chapter content available at
http://davisplus.fadavis.com. http://davisplus.fadavis.com.

7991_Ch09_135-148 13/08/19 3:39 PM Page 141
client goals. The application of the middle- of the nursing process (Frazier-Warmack,
range Theory of Goal Attainment (King, 2017).
1981) is documented in several categories: Over time, nursing has developed nursing
(1) general application of the theory, (2) explor- terminologies used to assist the profession in
ing a particular concept within the context of improving communication both within, and
the theory of goal attainment, (3) exploring a external to, the profession. These terminolo-
particular concept related to the theory of gies include the nursing diagnoses, nursing in-
goal attainment, and (4) application of the terventions, and nursing outcomes. With the
theory in nonclinical nursing situations. For use of these standardized nursing languages
example, King (1997) described the use of the (SNLs), the nursing process is further refined.
Theory of Goal Attainment in nursing prac- Standardized terms for diagnoses, interven-
tice. Park and Oh (2012) developed an Active tions, and outcomes also potentially improve
Parenting Today (APT) program based on communication among nurses.
the Goal Attainment Theory to address Using SNLs also enables the development
parental stress in Korea. Communication ef- of middle-range theory by building on concepts
fectiveness, in various situations, was exam- unique to nursing, such as those concepts from
ined by Anyaoha (2013), Ketcham (2013), the KCS that can be directly applied to the
and Patton (2017), and patients’ perceptions nursing process: action, reaction, interaction,
of their care were explored by Senn, Needham, transaction, goal setting, and goal attainment.
and Antille (2012).6 Biegen and Tripp-Reimer (1997) suggested
that middle-range theories be constructed from
Nursing Process and Nursing the concepts in the taxonomies of the nursing
Terminologies, Including languages focusing on outcomes. Alternatively,
Standardized Nursing Languages King’s framework and theory may be used as a
The nursing process has consistently been used theoretical basis for these phenomena and may
as a tool for nursing practice. King’s frame- assist in future knowledge development in
work and middle-range Theory of Goal At- nursing.
tainment (1981) have been clearly linked to the With the advent of SNLs, “outcome iden-
process of nursing. Although many published tification” is identified as a step in the nurs-
applications have broad reference to the nursing process after assessment and diagnosis
ing process, several deserve special recognition. (McFarland & McFarland, 1997, p. 3). King’s
First, King herself (1981) clearly linked the (1981) concept of mutual goal setting is
Theory of Goal Attainment to nursing process analogous to the outcomes identification
as theory and to nursing process as method. step, because King’s concept of goal attain-
Application of King’s work to nursing curric- ment is congruent with the evaluation of
ula further strengthened this link. client outcomes.

In addition, the steps of the nursing process In addition, King’s concept of perception
have long been integrated within the KCS (1981) lends itself well to the definition of
and the middle-range Theory of Goal Attain- client outcomes. Moorhead, Johnson, and Maas
ment (Daubenmire & King, 1973; D’Souza, (2013) define a nursing-sensitive patient out-
Somayaji, & Suybrahmanya, 2011; Woods, come as “an individual, family or community
1994). Other examples include the exami- state, behavior or perception that is measured
nation of assessment as related to student along a continuum in response to nursing in-
self-reflective journals (Payne-Payne, 2017); tervention(s)” (p. 2). This is fortuitous because
research focused on the intervention aspect the development of nursing knowledge re-
through health contracting with patients ex- quires the use of client outcome measure-
periencing dialysis (Cho, 2013); and evaluation ment. Patients’ perceptions of their roles in goal
setting in a spinal cord injury regional reha-
6See Table 9-3 in the bonus chapter content available at bilitation program was the focus for Draaistra,
http://davisplus.fadavis.com. Singh, Ireland, and Harper (2012). Laney

7991_Ch09_135-148 13/08/19 3:39 PM Page 142
(2013) utilized King’s Interacting System Multicultural Applications

Framework to examine registered nurses’ per- Multicultural applications of KCS and related
ceptions of patient advocacy in the clinical set- theories have been reported. Such applications
ting.7 The use of standardized client outcomes are particularly critical because many theoret-
as study variables increases the ease with which ical formulations are limited by their culture-
research findings can be compared across set- bound nature; however, King’s theory is relevant
tings and contributes to knowledge develop- across cultures. Cho (2013) drew heavily from
ment. Therefore, King’s concept of mutually King’s framework to conduct a randomized
set goals may be studied as “expected out- controlled trial to examine the effect of a
comes.” Also, by using SNLs, King’s (1981) health contract intervention on renal dialysis
middle-range Theory of Goal Attainment can patients in Korea. S. B. Hampton (2017) uti-
be conceptualized as the “attainment of ex- lized KCS to examine whether the race and
pected outcomes” and/or as the evaluation step gender of patients and providers influence
in the application of the nursing process. In postoperative pain management decisions made
summary, although these terminologies, in- by nurses. Tuason (2016) explored the indica-
cluding SNLs, were developed after many tors for nonrisky and risky sexual behaviors of
original nursing theorists had completed their Filipino youths in the United States and the
works, nursing frameworks such as the KCS Philippines.
(1981) still find application and use within the Undoubtedly, the strongest evidence for the
new terminologies. cultural utility of King’s conceptual framework
Multidisciplinary Applications and middle-range Theory of Goal Attainment
(1981) is the extent of work that has been done
Because of King’s emphasis on the attainment in other cultures. Applications of the frame-
of goals and the relevancy of goal attainment work and related theories have been docu-
to many disciplines, both within and external mented in the following countries beyond the
to health care, it is reasonable to expect that United States: Brazil (Borges, Moreira, &
King’s work can find application beyond nurs- Andrade, 2018; Carneiro, Lopes, Lopes,
ing-specific situations. Examples of this in- Santos, Bachion, & Barros, 2018; Primo &
clude the application of King’s work to case Brandão, 2017; Vieira, Morais, Lima, de
management (Sowell & Lowenstein, 1994) Pontes, Brandão, & Primo, 2017); Canada
and to managed care (Hampton, 1994). Both (Draaistra, Singh, Ireland, & Harper, 2012);
case management and managed care involve China (Huan & Cao, 2012); France (Senn,
multiple disciplines working to improve the Needham, & Antille, 2012); Korea (Cho,
overall quality and cost-effectiveness of the 2013; Park & Oh, 2012); India (D’Souza,
health care provided. These applications also
Somayaji, & Subrahmanya, 2011; George,

address the continuum of care, a priority in Roach, & Andrade, 2011); Japan (Kameoka,
today’s health-care environment. Specific re- Funashima, & Sugimori, 2007); Portugal
searchers (Carmouche, 2017; Fewster-Thuente (Chaves & Araujo, 2006; Goyatá, Rossi,
& Velsor-Friedrich, 2008; Khowaja, 2006) re- & Dalri, 2006; Pelloso & Tavares, 2006);
ported their work related to multidisciplinary Slovenia (Harih & Pajnkihar, 2009); Sweden
activities and interdisciplinary collaborations, (Rooke, 1995a, 1995b); Turkey (Gok, Ugur,
respectively (Carmouche, 2017; Fewster- Orak, Ağaçdiken, Alkan, & Yüksel, 2017); and
Thuente & Velsor-Friedrich, 2008; Khowaja, West Africa (Nwinee, 2011).9
2006).8 Cultural communication norms can be re-
spected when using King’s theory. In Korea,
Cho (2013) used the classification system of
7See Table 9-4 in the bonus chapter content available at
http://davisplus.fadavis.com.

7991_Ch09_135-148 13/08/19 3:39 PM Page 143
nurse–patient interactions identified within From hospitals (Anyaoha, 2013; Jackson, 2018;
the Theory of Goal Attainment (King, 1981) Laney, 2013) to nursing homes (Kangkolo,
to analyze the effects of nurse–patient partner- 2012), King’s framework and related theories
ships. In addition to research and publications provide a foundation on which nurses can build
regarding the application of King’s work to their practice interventions. In addition, the use
nursing practice internationally, publications of the KCS and related theories is evident
by and about King have been translated into within quality improvement projects (Dickman,
other languages, including Japanese (King, 2014; Frazier-Warmack, 2017; Sullivan, 2013).10
1976, 1985; Kobayashi, 1970). Therefore, per- Nurses also use the Theory of Goal Attainment
ception and the influence of culture on percep- (King, 1981) to examine concepts related to the
tion were identified as strengths of King’s theory (Batson & Yoder, 2012; Caceras, 2015;
theory. da Silva & Ferreira, 2016; Shanta & Connolly,
2013).
Research Applications in Varied Settings
and Populations Research Applications with Clients
The KCS has been used to guide nursing prac- Across the Life Span
tice and research in multiple settings and with Additional evidence of the scope and useful-
multiple populations. For example, Friend ness of King’s framework and theory is its use
(2015) examined group empowerment in nurs- with clients across the life span. For example,
ing faculty and administrators in baccalaureate several applications have targeted high-risk in-
and higher nursing programs. Perkins (2016) fants (Frey & Norris, 1997; Syzmanski, 1991).
studied nonmonetary factors related to associ- Smith (2017) used an advance directive docu-
ate degree admission status. Grandinetti (2013) ment as a guide to initiate communication
explored self-directed learning with prelicen- about advanced care planning (ACP) for
sure nursing students. KCS was also applied young adults with high-risk cancer. Swain
to home health settings (Gok Ugur, Orak, (2012) examined interpersonal relationships
Agaçdiken Alkan, & Yuksel, 2017) and rural and perception with nurse practitioners among
emergency nursing care (Williams, 2017). adults 62 years of age and older. Communica-
Warren (2014) examined nursing care and pation effectiveness during surgical time out was
tient’s unrealistic expectations related to plastic the focus of a study by Anyaoha (2013). Inter-
surgery in cosmetic surgery centers using both estingly, studies also considered personal sys-
Goal Attainment Theory and Knowles Adult tems (young adults), interpersonal systems
Learning Theory. In summary, King’s frame- (patients, nurse practitioners), and social sys-
work and related theories are relevant to a va- tems (the nursing staff and hospital environ-
riety of health-care settings. ment) (Frey, 1993, 1995, 1996; Lehna, 2009).
An additional potential source of division Clearly, a strength of King’s framework and

within the nursing profession is the worksites theory is its utility in encompassing complex
where nursing is practiced and care is deliv- settings and situations.11
ered. As the delivery of health care moves
from the acute-care hospital to community- Research Applications to Client Systems
based agencies and clients’ homes, it is impor- In addition to discussing client populations
tant to highlight commonalities across these across the life span, client populations can be
settings. It is also important to recognize that identified by focus of care (client system)
King’s framework and middle-range Theory and/or focus of health problem (phenomenon
of Goal Attainment continue to be applicable of concern). The focus of care, or interest, can
to these various settings. Although many ap-
plications tend to be with nurses and clients 10See Table 9-11 in the bonus chapter content available at
in traditional settings, successful applications http://davisplus.fadavis.com.
have been shown across other settings, includ- 11See Table 9-7 in the bonus chapter content available at
ing newer and nontraditional environments. http://davisplus.fadavis.com.

7991_Ch09_135-148 13/08/19 3:39 PM Page 144
be an individual (personal system) or group use of King’s framework in a variety of clin-

(interpersonal or social system). Thus, applica- ical settings.
tion of King’s work across client systems can Applicable to administration and manage-
be divided into the three systems identified ment in a variety of settings, a middle-range
within the KCS (1981): personal (the individ- Theory of Group Power within Organizations
ual), interpersonal (small groups), and social has been developed and revised to the Theory
(large groups/society). of Group Empowerment within Organiza-
Use with personal systems has included tions (Sieloff, 1995, 2003, 2007; Sieloff
patients, students, and nurses. Fuson’s (2012) & Bularzik, 2011; Sieloff & Dunn, 2008).
research focused on nursing students as per- Educational settings, also considered as social
sonal systems. When the focus of interest systems, have been the focus of numerous
moves from an individual to include interac- applications of King’s work (Friend, 2015;
tion between two people, the interpersonal Fuson, 2012; George, Roach, & Andrade,
system is involved. Interpersonal systems 2011; Jennings, 2017; Payne-Payne, 2017;
often include clients and nurses. An applica- Perkins, 2016). In addition, Echevairra (2015)
tion of a nurse–client dyad was studied by utilized KCS to evaluate whether education,
Frazier-Warmack (2017) in relation to the emotional intelligence, and leadership experi-
effects of follow-up phone calls on adult on- ence predicted nurses’ transformational lead-
cology patients. Wetter (2014) developed a ership style.12
module to decrease nurse-on-nurse hostility
focusing on the interprofessional system. Research Applications Focusing on
Many publications focus on the family as the Phenomena of Concern to Clients
interpersonal system; one such example is a Within King’s work, it is critically important
qualitative study describing the relationship for the nurse to focus on and address the phe-
between the elderly and the family done by nomenon of concern to the client. Without
Vieira, Freitas, Brito, Teófilo, and da Silva this emphasis on the client’s perspective, mu-
(2013). tual goal setting cannot occur. Hence, a
KCS and middle-range Theory of Goal client’s phenomenon of concern was selected
Attainment have a long history of application as neutral terminology that clearly demon-
with large groups or social systems (organi- strated the broad application of King’s work
zations, communities). The earliest applica- to a wide variety of practice situations. A
tions involved the use of the framework topic that frequently divides nurses is their
and theory to guide continuing education area of specialty. However, by using a consis-
(Brown & Lee, 1980) and nursing curricula tent framework across specialties, nurses may
(Daubenmire, 1989; Gulitz & King, 1988). be able to focus more clearly on their com-
More contemporary applications address a monalities rather than their differences. A re-
variety of organizational settings. For exam- view of the literature clearly demonstrates
ple, the Theory of Goal Attainment was the that King’s framework and related theories
foundation for a quality improvement project have application within a variety of nursing
to reduce rehospitalization rates for home specialties.13 For example, the Theory of
health patients (Panozzo, 2018), and to ex- Goal Attainment provided the framework for
plore unnecessary hospitalizations among a qualitative study examining the perceptions
nursing home residents (Peterson-DeVries, of goal setting among persons with spinal
2017). Carmouche (2017) used the Theory
of Goal Attainment to examine team com- 12See Table 9-8 in the bonus chapter content available at
petency and synergy within a culture of safety. http://davisplus.fadavis.com.
These latter applications are especially im- 13See Table 9-10 in the bonus chapter content available at
portant because they represent the continued http://davisplus.fadavis.com.

7991_Ch09_135-148 13/08/19 3:39 PM Page 145
cord injuries (Draaistra, Singh, Ireland, & theoretical base is well-positioned for appli-
Harper, 2012). It was also used to structure a cation by nurse caregivers (Stalians, 2018)
study to evaluate the effects of shared ap- and nurse administrators (Dickman, 2014;
pointments on outcomes related to persons Echevairra, 2015; Herm-Barabasz, 2015)
with diabetes (Krewsky, 2016). as part of evolving evidence-based nursing
Patient safety and satisfaction are impor- practice.15
tant patient outcomes and have been the
subject of several studies utilizing King’s Recommendations for Future
Theory of Goal Attainment (Anyaoha, 2013; Applications Related to King’s
Carmouche, 2017; Frazier-Warmack, 2017; Framework and Theory
Ketcham, 2013; Senn et al., 2012). In com- Obviously, new nursing knowledge has re-
bination with King’s Theory of Goal Attain- sulted from applications of King’s conceptual
ment, Latham and Locke’s Expectancy system and theory. However, nursing is
Theory and Bass’s Transactional Transfor- evolving as a science. Additional work con-
mational Leadership Model were used to tinues to be needed. On the basis of a review
examine levels of patient satisfaction and or- of the applications previously discussed, rec-
ganization performance using HCAHPS ommendations for future applications con-
scores in acute-care hospitals in northern tinue to focus on the following areas: (1) the
California (Patton, 2017). Nursing diagnoses need for evidence-based nursing practice that
related to the safety/protection domain were is theoretically derived; (2) the integration of
the focus of a study done by Lima-Aguiar King’s work in evidence-based nursing prac-
and Cavalcante-Guedes (2017). The Theory tice; (3) the integration of King’s concepts
of Goal Attainment was utilized in a ran- within SNLs; (4) analysis of the future ef-
domized controlled trial to examine the re- fects of managed care, continuous quality
sponses of health contracts by patients improvement, and technology on King’s con-
receiving dialysis in Korea (Cho, 2013). The cepts; (5) identification, development, and
theory also provided the foundation to de- implementation of additional instruments to
velop and implement a tool to assist clini- measure relevant constructs; and (6) identi-
cians in goal setting to improve medication fication of effective nursing interventions
adherence and reduce rehospitalization based on King’s theoretical work for catego-
rates in a home health-care setting (Panozzo, rization in the Nursing Interventions Classi-
2018).14 fications framework.
As part of its mission, the King Interna-
Relationship to Evidence-Based Practice tional Nursing Group (KING) continuously
Currently, safety and quality initiatives in or- monitors the latest publications and research
ganizations, with evidence-based practice as based on King’s work and related theories,
the innovation, use many concepts initially providing updates to members. To further
defined by King and found in middle-range assist in the dissemination of such research,
theories (Sieloff & Frey, 2007). King’s KING also conducts a biannual research
(1981) work on the concepts of client and conference. The following exemplar illus-
nurse perceptions, and the achievement of trates the application of the Theory of Goal
mutual goals, has been assimilated and been Attainment to an interdisciplinary team,
distilled into core beliefs of the discipline of quality improvement, and evidence-based
nursing. Research conducted with a King practice.

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Practice Exemplar
Written by Mary B. Killeen, PhD, RN, NEA-BC The following are the questions and the
Claire Smith, RN, BSN, recent graduate, is conclusions that Claire and her colleagues
employed in her first position on a medical discuss:
intensive care unit in a suburban community 1. How does King’s Theory of Goal Attainment
hospital. Claire’s manager suggests that she help the unit’s quality improvement (QI)
should join the unit’s interdisciplinary quality committee?
improvement committee to develop her lead- Goal Attainment Theory is derived from
ership skills. The goal of the committee is to KCS, which includes personal, interper-
improve patient care by using the best avail- sonal, and social systems. The QI commit-
able evidence to develop and implement tee is a type of interpersonal system. An
practice protocols. interpersonal system encompasses individ-
At the first meeting, Claire is asked if uals in groups interacting to achieve goals.
she had any burning clinical questions as a The QI committee is engaged in the com-
new graduate. She states that she was mittee’s goal attainment for the benefit of
taught to avoid use of normal saline for tra- patients: “Role expectations and role per-
cheal suctioning. However, she notices formance of nurses and clients influence
many respiratory therapists and some nurses transactions” (King, 1981, p. 147). When
routinely using normal saline with suction- used in interdisciplinary teams, the transac-
ing. When she asks about this practice, tion process in King’s theory facilitates mu-
Claire is told that normal saline is useful to tual goal setting with nurses, and ultimately
break up secretions and aid in their removal. patients, based on each member of the
The committee affirms Claire’s observation team’s specific knowledge and functions.
of a contradiction between what is taught Multidisciplinary care conferences, an
and what is done in practice. After discus- example of a situation where goal setting
sion, the group formulates the following among professionals occurs, is a label for an
clinical question: Does instilling normal indirect nursing intervention within the
saline decrease favorable patient outcomes Nursing Interventions Classification (NIC)
among patients with endotracheal tubes or (Bulechek, Butcher, Dochterman, & Wagner,
tracheostomies? 2013). Some of the activities listed under this
Claire suggests to the committee that NIC reflect King’s (1981) concepts: “estab-
King’s Theory of Goal Attainment might lish mutually agreeable goals; solicit input for
be useful as a theoretical guide for this proj- patient care planning; revise patient care
ect because the question is focused on pa- plan, as necessary; discuss progress toward
tient outcomes or, according to King’s goals; and provide data to facilitate evalua-
theory, goals. The nursing members are fa- tion of patient care plan” (p. 501).
miliar with King’s theory, and all members 2. How does King define goals and goal attain-
value using theory to guide practice. Claire’s ment and how are these related to quality
proposal is accepted. Claire experienced patient outcomes?
working on evidence-based practice (EBP) According to King’s Theory of Goal At-
group projects as a student, so she feels tainment (1981), goals are mutually agreed
comfortable volunteering to develop a draft upon, and through a transaction process, are
of the theoretical foundation for the project. attained. Goals are similar to outcomes that
Two other committee members agree to are achieved after agreement on the defini-
work on the plan and present it at the next tions and measurement of the outcomes.
meeting. Quality improvement has shown agreement

7991_Ch09_135-148 13/08/19 3:39 PM Page 147

that evaluation of care must include process lead to favorable patient outcomes (goals)
and outcomes. Outcomes are the results of among patients similar to the population on
interventions or processes. The term “out- the unit. Claire’s subgroup enlists the help of
come” assumes that a process is central to the hospital librarian in searching the litera-
effective care. An outcome is defined as a ture using the elements of the clinical ques-
change in a patient’s health status. Effec- tion and the theoretical concepts as key words.
tiveness of care can be measured by whether Second, the theoretical formulation of the
the patient goals (i.e., outcomes) have been study helps organize the implementation and
attained. The QI Committee engages in evaluation plans, so they are attainable.
goal attainment through communication by 4. What key words would you use for the search
setting goals, exploring means, and agreeing considering the clinical question and King’s
on means to achieve goals. In this example, theory?
members will gather information, examine Key words used are endotracheal tubes,
data and evidence, interpret the informa- tracheostomies, normal saline, suctioning,
tion, and participate in developing a proto- outcomes, King’s Theory of Goal Attain-
col for patients to achieve quality patient ment, and goal attainment.
outcomes (i.e., goals). 5. How does a theoretical foundation, such as
3. How does King’s Theory of Goal Attainment King’s Theory of Goal Attainment, apply to a
provide a theoretical foundation for the clin- quality improvement or EBP project?
ical problem of using normal saline with Claire uses these criteria from her nurs-
suctioning? ing program to develop a theoretical founda-
First, the use of King’s theory will help tion for the project. The theoretical foundation
guide the literature search to include studies for the project is presented to the committee
that address interventions or processes that and accepted (Fig. 9-3).
Clinical Problem King’s Application to

Elements Concepts the Project
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.
FIG 9-3 ■ Theoretical foundation for a quality improvement project using

Imogene King’s theory of goal attainment derived from King’s conceptual
system (1981).
(continued)

7991_Ch09_135-148 13/08/19 3:39 PM Page 148

6. What were the results of the committee’s work? the specific outcomes to track for the project:
The search strategy includes using sputum recovery, oxygenation, and subjective
MEDLINE, CINAHL, Cochrane Library, symptoms of pain, anxiety, and dyspnea.
Joanna Briggs Institute, and TRIP data- Owing to anticipated small samples, hemo-
bases. All types of evidence (nonexperi- dynamic alterations and infections are not se-
mental, experimental, qualitative studies, lected as outcomes. The committee devises a
systematic reviews) are included. The evi- theory-based implementation plan to discon-
dence is evaluated by the QI committee and tinue normal saline for suctioning using the
includes physiological and psychological five W’s (who, what, where, when, why) and
effects of instillation of normal saline. The how as the outline for the plan. Change
collective evidence, relevant to their unit’s processes are employed in the plan. Evalua-
practice problem, does not support the rou- tion of the attainment of outcomes will ad-
tine use of normal saline with suctioning dress the effectiveness of the plan using the
(similar to Halm & Kriski-Hagel, 2008). measurable outcomes and the degree to
From the evidence, the committee selects which they are attained.
Summary
An essential component in the analysis of con- scope because interaction is a part of every
ceptual frameworks and theories is the consid- nursing encounter. Although previous evalua-
eration of their adequacy (Ellis, 1968). Adequacy tions of the scope of King’s framework and
depends on the three interrelated characteristics middle-range theory have resulted in mixed
of scope, usefulness, and complexity. Conceptual reviews (Austin & Champion, 1983; Carter
frameworks are broad in scope and sufficiently & Dufour, 1994; Frey, 1996; Jonas, 1987;
complex to be useful for many situations. Theo- Meleis, 2012), the nursing profession has
ries, on the other hand, are narrower in scope, clearly recognized their scope and usefulness.
usually addressing less abstract concepts, and are In addition, the variety of practice applications
more specific in terms of the nature and direc- evident in the literature clearly attests to the
tion of relationships and focus. value of King’s work. As researchers continue
King fully intended her conceptual system to integrate King’s theory and framework
for nursing to be useful in all nursing situa- within the dynamic health-care environment,
tions. Likewise, the middle-range Theory of future applications will evolve and advance the
Goal Attainment (King, 1981) has broad conceptual system and theory.
Questions for Reflection chapter tables and describe how the re-
searchers used King’s conceptual system or
and Discussion Theory of Goal Attainment to guide the
■ Describe the usefulness of King’s Theory study.
of Goal Attainment with nurse–patient ■ What are the concepts in the personal,
situations in primary care, acute care, and interpersonal, and social systems within
long-term care settings. King’s Conceptual System? Do you think
■ Identify one research study of interest these concepts could be interchangeable
within the chapter or using the bonus across systems? Why or why not?

7991_Ch10_149-164 12/08/19 5:12 PM Page 149
Callista Roy’s Adaptation

CHAPTER
10
Model
Pamela Senesac and
Callista Roy

Overview of the Model Introducing the Theorist
Applications of the Model Sister Callista Roy is a highly respected nurse
Practice Exemplar theorist, writer, lecturer, researcher, and teacher.
Summary She is currently an Adjunct Professor at Mount
Questions for Reflection and Discussion St. Mary’s University Los Angeles and Profes-
sor Emeritus at the Connell School of Nursing
at Boston College. Roy has been a member of
the Sisters of St. Joseph of Carondolet for nearly
60 years.
Nurses worldwide recognize Roy’s work;
some experts say she is one of the top 10 thinkers
in the field. As a theorist, Roy often emphasizes
her primary commitment to define and develop
nursing knowledge and regards her work with
the Roy Adaptation Model as a rich source of
knowledge for improving nursing practice for in-
dividuals and for groups. In the first two decades
of the 21st century, Roy provided an expanded,
values-based concept of adaptation based on in-
sights related to the place of the person in the
universe and in society. In addition, she added to
practice applications of her work in conceptual-
izing and measuring coping and adaptation pro-
cessing. She has welcomed the contributions of
others in the development of the work; she often
notes that her best work is yet to come and likely

will be done by one of her students.
Roy credits the major influences of her fam-
ily, her religious commitment, and her teachers
and mentors in her personal and professional
growth. Born in Los Angeles, California, Roy
is the oldest daughter of a family of seven boys
and seven girls. A deep spirit of faith, hope,
love, commitment to God, and service to oth-
ers was central in the family. Her mother, a li-
censed vocational nurse, instilled the values of
always seeking to know more about people and
their care, and of selfless giving as a nurse.
Roy earned a bachelor of arts degree with a
major in nursing from Mount St. Mary’s College,
149
7991_Ch10_149-164 12/08/19 5:12 PM Page 150
Los Angeles; a master’s degree in pediatric nurs- education, and research. Extensive implementa-
ing; and a master’s degree and a PhD in sociology tion efforts around the world and continuing
from the University of California, Los Angeles. philosophical and scientific developments by the
Roy completed a 2-year postdoctoral program as theorist have contributed to model-based knowl-
a clinical nurse scholar in neuroscience nursing edge for nursing practice. This chapter introduces
at the University of California, San Francisco. the reader to the knowledge that the Roy Adap-
She was a Senior Fulbright Scholar in Australia. tation Model provides as the basis for planning
Important mentors in her life have included nursing care in the 21st century, a practice exem-
Dorothy E. Johnson, Ruth Wu, Connie plar, and questions for reflection and discussion.
Robinson, and Barbara Smith Moran.
Roy’s best-known work is developing and Historical Development
continually updating the Roy Adaptation Model Under the mentorship of Dorothy E. Johnson,
as a framework for theory, practice, and research Roy first developed a description of the adap-
in nursing. Books on the model have been trans- tation model while a master’s student at the
lated into many languages, including French, University of California at Los Angeles. The
Italian, Spanish, Finnish, Chinese, Korean, and first publication on the model appeared in 1970
Japanese. Two publications that Roy considers (Roy, 1970) while Roy was on the faculty of the
significant are The Roy Adaptation Model (Roy, baccalaureate nursing program of a small col-
2009a) and Generating Middle Range Theory: lege where she had the opportunity to lead im-
From Evidence to Practice (Roy, 2014). The latter plementation of the model as the basis of the
creates new knowledge from an outgoing project nursing curriculum. During the next decade,
to analyze and critique research based on the more than 1,500 faculty and students at Mount
Roy Adaptation Model. About 500 English- St. Mary’s College helped to clarify, refine, and
language publications are in the database. develop this approach. The constant influence
Roy was honored as a Living Legend by of practice was important during this develop-
the American Academy of Nursing and the ment. Data from practice were used to derive
Massachusetts Association of Registered four adaptive modes from 500 samples of pa-
Nurses. She has received many other awards, tient behaviors described by nursing students.
including the National League for Nursing The mid-1970s to the mid-1980s saw the
Martha Rogers Award for advancing nursing expansion of the use of the model in nursing
science; the Sigma Theta Tau International education. Roy and the faculty at her home
Founders Award for contributions to profes- institution consulted on curriculum in more
sional practice; and six honorary doctorates. than 30 schools across the United States and
Sigma Theta Tau International, Honor Society Canada. By 1987, estimates showed that more
of Nursing, included Roy as an inaugural in-
than 10,000 students had graduated from cur-

ductee to the Nurse Researcher Hall of Fame.1 ricula based on the Roy model. Theory devel-
opment was a focus during this time; Roy
identified 91 model-based propositions that
Overview of the Model described relationships between and among
The Roy Adaptation Model (McCurry, Hunter concepts of the regulator, the cognator, and the
Revell, & Roy, 2009; Roy, 1970, 1984, 2009a, four adaptive modes (Roy & Roberts, 1981).
2011a, 2011b, 2014; Roy & Andrews, 1991, In the 1980s, postdoctoral work in neuro-
1999; Roy, Bakan, Li, & Nguyen, 2016; Roy & science nursing, an increasing number of inter-
Roberts, 1981; Roy, Whetzell, & Fredrickson, national commitments, and interdisciplinary
2009) has been in use for more than 50 years, work influenced Roy as well. Roy focused on
providing direction for nursing practice, contemporary movements in nursing knowl-
edge and the continued integration of spiritu-
1For additional information about Sister Roy, see online ality with an understanding of nursing’s role
resources; also see the bonus chapter content available in promoting adaptation. The first decade of
at http://davisplus.fadavis.com. the 21st century included a greater focus on

7991_Ch10_149-164 12/08/19 5:12 PM Page 151
C H APTER 10 ■ Callista Roy’s Adaptation Model 151
philosophy, knowledge for practice, and global BOX 10-1 Assumptions of the Roy Adaptation
concerns. The second decade included work Model for the 21st Century
with colleagues to define a broad unifying focus
of the discipline that nurses could articulate Philosophical Assumptions
(Grace, Willis, Roy, & Jones, 2015; Mason, ■ Persons have mutual relationships with the
Jones, Roy, Sullivan, & Wood, 2015; Roy, world and the God-figure.
2018; Willis, Grace, & Roy, 2008). ■ Human meaning is rooted in an omega point
convergence of the universe.
Philosophical, Scientific, and Cultural ■ God is intimately revealed in the diversity
Assumptions of creation and is the common destiny of
creation.
Assumptions provide the beliefs, values, and ■ Persons use human creative abilities of
accepted knowledge that form the basis for the awareness, enlightenment, and faith.
work. For the Roy Adaptation Model, the con- ■ Persons are accountable for entering the
cept of adaptation rests on scientific and philo- process of deriving, sustaining, and
sophical assumptions that Roy has developed transforming the universe.
over time. The scientific assumptions reflected Scientific Assumptions
von Bertalanffy’s (1968) General Systems
Theory and Helson’s (1964) Adaptation-level ■ Systems of matter and energy progress to
Theory. Later beliefs about the unity and higher levels of complex self-organization.
meaningfulness of the created universe were in-
■ Consciousness and meaning are consistent
of person and environment integration.
cluded (Young, 1986). Early identification of ■ Awareness of self and environment is rooted
the philosophical assumptions for the model in thinking and feeling.
named humanism and veritivity. Roy (1988) ■ Human decisions are accountable for the
introduced the concept of veritivity as an option integration of creative processes.
to total relativity. Veritivity was a term coined ■ Thinking and feeling mediate human
by Roy, which offered the notion of the root- action.
edness of all knowledge being one. The term ■ System relationships include acceptance,
refers to the principle within the model that protection, and fostering interdependence.
affirms a common purposefulness of human ■ Persons and the Earth have common
existence. Veritivity is the affirmation that human patterns and integral relations.
beings reflect the context of the purposefulness
■ Person and environment transformations
created human consciousness.
of their existence, unity of purpose of hu- ■ Integration of human and environment
mankind, activity and creativity for the com- meanings result in adaptation.
mon good, and the value and meaning of life.
Roy views the 21st century as a time of Cultural Assumptions

transition, transformation, and need for spiritual ■ Experiences within a specific culture will
vision. The further development of the philo- influence how each element of the Roy
sophical assumptions focuses on people’s mutu- Adaptation Model is expressed.
ality with others, the world, and a God-figure. ■ Within a culture, there may be a concept
The development and expansion of the major that is central to the culture and will
concepts of the model show the influence of influence some or all of the elements of the
Roy Adaptation Model to a greater or lesser
the theorist’s scientific and philosophical back- extent.
ground and global experiences. For nursing in ■ Cultural expressions of the elements of the
the 21st century, Roy (1997) provided a redefi- Roy Adaptation Model may lead to changes
nition of adaptation and a restatement of the as- in practice activities such as nursing
sumptions that are foundational to the model, assessment.
which led to expanded philosophical and scien- ■ As Roy Adaptation Model elements evolve
tific assumptions in contemporary society and to within a cultural perspective, implications for
education and research may differ from
adding cultural assumptions. These assumptions experience in the original culture.
are listed in Box 10-1 and further described in

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the basic work on the model (Roy, 2009a). Roy their responsibilities to maintain the family.
uses the idea of cosmic unity that stresses her vi- Groups have processes to respond to the envi-
sion for the future and emphasizes the principle ronment with innovation and change by way
that people and the Earth have common pat- of the innovator subsystem. Organizations use
terns and integral relationships. Rather than the strategic planning activities and team-building
system acting to maintain itself, the emphasis sessions. When the innovator is functioning
shifts to the purposefulness of human existence well, the group creates new goals and growth,
in a creative universe. achieving new mastery and transformation.
Nurses can use innovator subsystems to create
Model Concepts organizational change in practice.
The underlying assumptions of the Roy Adap- Both the cognator–regulator and stabilizer–
tation Model are the basis for, and are evident innovator coping processes are manifested in
in, the specific description of the major con- four particular ways of adapting in each indi-
cepts of the model. The major concepts include vidual and in groups of people. These four ways
people as adaptive systems (both individuals of categorizing the effects of coping activity are
and groups), the environment, health, and the called adaptive modes. These are termed the
goal of nursing. physiological–physical, self-concept–group iden-
tity, role function, and interdependence modes.
People as Adaptive Systems These four categories describe responses to,
People, both individually and in groups, are ho- and interaction with, the environment and are
listic adaptive systems, complete with coping how adaptation can be observed.
processes acting to maintain adaptation and to For individuals, the physiological mode is as-
promote person and environment transforma- sociated with the way individuals interact as
tions. People have internal processes that act to physical beings with the environment. Behavior
maintain the integrity of the individual or in this mode is the manifestation of the physi-
group. These processes have been broadly cate- ological activities of the cells, tissues, organs,
gorized as a regulator subsystem and a cognator and systems comprising the human body. The
subsystem for the person, and a stabilizer sub- physiological mode has nine components: the five
system and an innovator subsystem for the basic needs of oxygenation; nutrition; elimina-
group. The regulator uses physiological processes tion; activity and rest; and protection; and four
such as chemical, neurological, and endocrine complex processes that are involved in physio-
responses to cope with the changing environ- logical adaptation, including the senses; fluid,
ment. When an individual sees a sudden threat electrolyte, and acid–base balance; neurological
such as an oncoming car, an increase of adrenal function; and endocrine function. The under-
hormones provides immediate energy enabling lying need for the physiological mode is physio-
them to escape harm. The cognator subsystem logical integrity.

involves the cognitive and emotional processes The category of behavior related to the
that interact with the environment. The cognator personal aspects of individuals is the self-
acts to process the emotion of fear. The person concept mode. The underlying need in the self-
processes perceptions of the situation and comes concept mode is psychic and spiritual integrity;
to a new decision about how to cross the street one needs to know who one is to be or exist
safely. with a sense of unity. Self-concept is defined
The coping processes for the group relate to as the composite of beliefs and feelings that a
stability and change. The stabilizer subsystem person holds about himself or herself at a
has structures, values, and daily activities to ac- given time. Formed from internal perceptions
complish the primary purpose of the group. A and perceptions of others, self-concept directs
family group is structured to earn a living and one’s behavior. Components of the self-
to provide for the nurturance and education of concept mode are the physical self, including
children. Family values influence how the body sensation and body image; and the per-
members respond to the environment to fulfill sonal self, including self-consistency, self-ideal,

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and moral–ethical–spiritual self. Processes in In addition, the nurse feels comfortable meeting
the mode are the developing self, perceiving self-expectations of being a caring professional.
self, and focusing self. In a social system, such as a nursing care unit,
Behavior relating to positions in society is an associated culture can be described. A social
the role function mode for both the individual environment is experienced by the nurses, ad-
and groups. From the perspective of the indi- ministrators, and other staff that is reflected by
vidual, the role function mode focuses on the those who are part of the nursing care group.
roles that the individual occupies in society. A The group feels shared values and counts on
role is defined as a set of expectations about each other. As such, the self-concept–group iden-
how a person occupying one position behaves tity mode can reflect adaptive or ineffective be-
toward a person occupying another position. haviors associated with an individual nurse or
The underlying need for the role function mode the nursing care unit as an adaptive system.
for the individual is social integrity, the need Family coherence is an adaptive goal in the
to know who one is in relation to others to act. group mode.
The underlying processes include developing Roles within a group are the vehicles
roles and role taking. through which the goals of the social system
Behavior related to interdependent rela- are accomplished. They are the action compo-
tionships of individuals and groups is the in- nents associated with group infrastructure.
terdependence mode. For the individual, the Roles are designed to contribute to the accom-
mode focuses on interactions related to the plishment of the group’s mission, or the tasks
giving and receiving of love, respect, and or functions associated with the group. The role
value. The underlying need of this mode is re- function mode includes the functions of admin-
lational integrity, the feeling of security in nur- istrators and staff, the management of infor-
turing relationships. Two relationships are the mation, and systems for decision making and
focus within the interdependence mode for the maintaining order. The underlying need asso-
individual: significant others—persons who ciated with the group role function mode is role
are the most important to the individual; and clarity, the need to understand a commitment
support systems—others who contribute to to fulfilling expected tasks and to achieve com-
meeting interdependence needs. Interdepend- mon goals. Processes involve socializing for
ence processes include affectional adequacy role expectations, reciprocating roles, and in-
and developmental adequacy. tegrating roles.
For people in groups it is more appropriate For groups, the interdependence mode per-
to use the term physical in referring to the first tains to the social context in which the group
adaptive mode. At the group level, this mode operates. It involves private and public con-
relates to how the adaptive system of the tacts within the group and with those outside
group relates to basic operating resources— the group. The components of group interde-
participants, physical facilities, and fiscal re- pendence include context, infrastructure, and
sources. The underlying need of the physical resources. The processes for group interde-
mode for the group is resource adequacy, or pendence include relational integrity, devel-
wholeness achieved by adapting to change in opmental adequacy, and resource adequacy.
physical resource needs. Processes in this The four adaptive modes are interrelated,
mode for groups include resource manage- which can be illustrated by drawing the modes
ment and strategic planning. Group identity is as overlapping circles. The physiological–physical
the second mode related to groups. Identity mode is intersected by each of the other three
integrity is the underlying need in the group modes. Behavior in the physiological–physical
adaptive mode. The mode comprises interper- mode can influence or act as a stimulus for one
sonal relationships, group self-image, social or all the other modes. In addition, a given
milieu, and culture. stimulus can affect more than one mode, or a
A nurse may have a self-concept of seeing behavior can be indicative of adaptation in more
self as physically capable of the work involved. than one mode. Such complex relationships

7991_Ch10_149-164 12/08/19 5:13 PM Page 154
among modes further demonstrate the holis- environmental interactions that are adaptive.
tic nature of humans as adaptive systems. The Health is defined as (1) a process, (2) a state of
adaptive modes and coping processes for indi- being, and (3) becoming whole and integrated
viduals and groups of individuals are described in a way that reflects individual and environ-
by the Roy Adaptation Model (Roy, 2009a). ment mutuality.
Environment Goal of Nursing

The Roy Adaptation Model defines envi- When Roy began her theoretical work, the
ronment as the conditions, circumstances, and goal of nursing was the first major concept to
influences surrounding and affecting the de- be described. She began by attempting to iden-
velopment and behavior of individuals and tify the unique function of nursing in promot-
groups. For persons in the evolving universe, ing health and to identify a unique goal for
the environment is a biophysical community nursing. While working as a staff nurse in pe-
of beings with complex patterns of interaction, diatric settings, Roy noted the great resiliency
feedback, growth, and decline, constituting pe- of children in responding to major changes.
riodic and long-term rhythms. Individual and Nursing intervention was needed to support
environmental interactions are input for the and promote this positive coping. From this
individual or group as adaptive systems. This initial notion, Roy developed a description of
input involves both internal and external fac- the goal of nursing: the promotion of adaptation
tors. Roy used the work of Helson (1964), a for individuals and groups in each of the four
physiological psychologist, to categorize these adaptive modes, thus contributing to health,
factors as focal, contextual, and residual stimuli. quality of life, and dying with dignity.
The focal stimulus most immediately con-
fronts the individual and holds the focus of at-
tention; contextual stimuli are those factors also Applications of the Model
acting in the situation; and residual stimuli are Basis for Practice—Theory
possible factors that as yet have an unknown af-
and Process
fect. A specific internal input stimulus is the
adaptation level that represents the current The assumptions and concepts of the model
coping capacities of the individual or group. provide the basis for theory building for nurs-
This changing level of ability has an internal ef- ing practice, as well as a specific approach to
fect on adaptive behaviors. Roy defined three the nursing process. As early as the 1970s,
levels of adaptation: integrated, compensatory, human life processes and patterns were iden-
and compromised. Integrated adaptation occurs tified as the common focus of nursing knowl-
when the structures and functions of the adap- edge (Donaldson & Crowley, 1978). In a more
tive modes are successfully working as a whole recent article, a central unifying focus of nurs-
to meet human needs. The compensatory adap- ing has extended this view to include nursing
tation level occurs when the cognator and regu- concepts categorized as facilitating humaniza-
lator or stabilizer and innovator are activated by tion, meaning, choice, quality of life, healing,
a challenge. Compromised adaptation occurs living, and dying (Willis, Grace, & Roy,
when integrated and compensatory processes 2008). Adaptation is a significant life process
are inadequate, creating an adaptation problem. that leads to these ideals.
Health Theory Development for Practice

Health is related to the concept of adaptation To lead to middle-range theories within the
and the idea that adaptive responses promote model, Roy identified the major life processes
integrity. Individuals and groups are viewed as within each adaptive mode. In the physiological
adaptive systems that interact with the envi- mode, for example, there are processes and pat-
ronment and grow, change, develop, and flour- terns for the need for oxygenation that include
ish. Health is the reflection of personal and ventilation, patterns of gas exchange, transport

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of gases, and compensation for inadequate oxy- Also, in collaboration with the person or
genation. The self-concept mode includes three group, the nurse sets goals, establishing clear
processes necessary to meet the person’s need statements of the behavioral outcomes for
for psychic and spiritual integrity: the develop- nursing care. Interventions involve the deter-
ing self, the perceiving self, and the focusing mination of how to assist the person in attain-
self. On the group level, two processes identi- ing the established goals, by changing stimuli
fied to meet the need for a shared self-image or strengthening coping ability, to promote an
are group shared identity and family coherence. integrated adaptation level. Evaluation in-
The group identity mode reflects how people in volves judging the effectiveness of the nursing
groups perceive themselves based on environ- intervention in relation to the resulting behav-
mental feedback about the group. Persons in a ior in comparison with the established goal.
group have perceptions about their shared re- The steps of the nursing process have been
lations, goals, and values. The social milieu and given in sequential order; however, the process
the culture provide feedback for the group. The is ongoing and the steps can be simultaneous.
social milieu refers to the human-made environ- For example, the nurse may be intervening in
ment in which the group is embedded, includ- one adaptive mode and assessing in another at
ing economic, political, religious, and family the same time.
structures. Ethnicity and socioeconomic status The most recent development of the Roy
make up the social culture, a specific part of the Adaptation Model is the theorizing and meas-
milieu or environment of the group. The belief urement of coping. Coping is a crucial concept
systems of the milieu and social culture act as in understanding adaptation to changing situ-
stimuli for the group and affect other groups ations of health and illness. Roy developed a
with which the group interacts. The family is 47-item Coping and Adaptation Processing
most often the first group with which a person Scale (CAPS) to further the understanding
identifies. The group self-image and shared re- and measurement of this complex construct
sponsibility for goal achievement is central to (Roy, 2011b). The instrument was based on a
group identity. Identity integrity is the underly- middle-range theory of Coping and Adapta-
ing need in the group identity mode. Nursing tion. Coping and adaptation processing was de-
care uses the understanding of these processes fined as the patterning of innate and acquired
to evaluate the adaptation level and to provide ways of taking in, handling, and responding to
care to promote integrated processes at the a changing environment in daily situations and
highest level of adaptation possible. in critical periods that direct an individual’s be-
havior toward survival, growth, reproduction,
Nursing Process for Care mastery, and transcendence. Researchers in
The first-level assessment of behavior involves many countries have used the scale in several
gathering data about the behavior of the per- languages.

son or group as an adaptive system in each Roy and colleagues (Roy, Bakan, Li, &
of the adaptive modes. The second-level as- Nguyen, 2016) used Item Response Theory to
sessment is the assessment of stimuli, that is, clarify the concept of coping as unidimensional,
the identification of internal and external to shorten the scale, assess its metric equiva-
stimuli that influence the adaptive behaviors. lence, and test the preliminary validity of the re-
The nurse uses the first- and second-level sulting shortened scale. The revised 15-item
assessment to make a nursing judgment Coping and Adaptation Processing Scale
called a nursing diagnosis. In collaboration (CAPS)–Short-Form can be useful in both
with the person or group, the data are used practice and research for nurses who deal with
to describe the current adaptation status of people adapting to chronic and acute health con-
the person, including behavior and most rel- ditions. The tool lists common coping strategies
evant stimuli. The overall adaptation level is that nurses can teach to patients either to en-
then classified as integrated, compensatory, hance their selected coping abilities or to learn
or compromised. new coping strategies. As an outcome measure

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for nursing interventions, the shortened tool is varied opinions about the usefulness of theory.
welcomed in research. Contrary to what is often reported, the find-
ings from one study indicate that nursing
Applications of the Theory in Nursing theory is still being taught within nursing pro-
Organizations grams throughout the United States. Hurton
Senesac (2003) reviewed published projects that and Roy (2009) sent an electronic survey to all
have implemented the Roy Adaptation Model accredited nursing programs, with a 44% re-
in institutional practice settings and identified sponse rate. Respondents from associate and
seven distinct projects ranging from an ideology baccalaureate programs reported that the ma-
basis for a single unit to hospital-wide projects. jority of nursing schools teach nursing theory
In some cases, the published project developed using an eclectic, integrated approach, dis-
from a unit implementation to a full agency im- cussing the work of many theorists in many dif-
plementation, as in one of the early projects re- ferent courses. When a single theory was the
ported by Mastal, Hammond, and Roberts basis of the curriculum, Roy was the most fre-
(1982). quently used, followed by Orem and Watson.
Gray (1991) discussed her involvement in Over 80 percent of master’s programs had a
five projects. She reported that not all imple- single course where theory is taught. In PhD
mentation projects were completed due to and DNP programs theory was used as a “strat-
changes in hospital management, philosophy, egy for knowledge development.” Close to half
or direction. Gray’s initial work was at a of the PhD program respondents indicated that
132-bed acute-care, not-for-profit children’s use of theories depended on the faculty. More
hospital. Other projects varied from a 100-bed than half reported using theories as frameworks
proprietary hospital to a 248-bed nonprofit, for research or to synthesize variables from
community-owned hospital. The focus of the middle-range theories.
implementation projects was to improve patient Hospitals on the magnet journey are re-
care using quality nursing care plans, and in quired to select a nursing framework for prac-
some cases to develop performance stan- tice, reinforcing the ongoing advancement of
dards. Two implementation projects in Colom- nursing as a discipline and the preservation of
bia were reported on by Moreno-Ferguson and nursing theories in nursing practice and re-
Alvarado-Garcia (2009). One project was in search. More nursing groups are requesting
an ambulatory rehabilitation service (Moreno- information about application of the Roy
Ferguson, 2001) and the other a pediatric inten- Adaptation Model in institutional health-care
sive care unit of a cardiology institute (Monroy, settings. One example is Morristown Hospital
2003). in New Jersey, now renewed four times as a
Magnet Hospital using the Roy Adaptation
Applications for the 21st Century Model (Silverstein & Kowalski, 2017). The
Theories are invented by humans to explain new millennium provides opportunities to en-
experience, interpret observation, describe re- hance the usefulness of nursing theories. The
lationships, and project outcomes. Nursing Roy Adaptation Model is being used to guide
theory is always in the process of developing, change in nursing practice globally, develop
and is simultaneously in use for the purposes middle-range theories, and support evidence-
and work of the professional discipline (Smith based practice.
& Parker, 2015). Nursing is a performing art,
based on a knowledge of nursing and the ability Roy Adaptation Model: Guide Change
to execute skills in the moment. The knowledge in Nursing Practice Globally
of nursing includes philosophies, theories, re- Significant global changes in the beginning of
search findings, methods of inquiry and prac- the 21st century call for worldwide conscious-
tice, and nursing wisdom. ness, inclusive of health status of individuals
Although theory has a time-honored place and the larger society. A profession survives
in knowledge development, nurses today have only if it continues to meet the changing needs

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of the population served. Social issues in the and nomenclature facilitates the sharing of
new century include the following (Roy, data. Both nurses and their patients benefit
2009b): the increasing racial and ethnic diver- from utilization of a theoretical framework
sity within countries; a greater number of ei- that is relevant to caregivers and clients alike.
ther older or younger people within countries;
interdependence of world economies; global Roy Adaptation Model–Based Research
warming; rapid evolution, change, and dis- Used to Develop Middle-Range Theory
parate use of technology and information sys- The Roy Adaptation Model is a rich and com-
tems; shifts to population-based complex care; plex framework. The breadth of knowledge
and the need for ongoing care of persons with generation associated with the model is directly
chronic needs, increasingly related to lifestyle related to Roy’s ongoing generosity of spirit in
behaviors. her work with students and colleagues, and her
Major nursing theories can provide guid- ongoing willingness to support others in pur-
ance in these changing times as a way to suing topics of interest to their practice and
achieve nursing’s social mandate, including improvement of health-care outcomes around
promoting positive adaptation in individuals the world. The process is cyclic and expansive.
and groups; contributing to health, quality of Documentation and publication allows the
life, and dying with dignity; and transforming community to test and validate new assump-
societies to those that promote dignity and tions, which is followed by modifications—
sustain the universe. Roy calls upon the additions, changes, and deletions—the ongoing
adaptation of the model. Samples of research
global brain of nursing, the quasi-neural energy- based on the Roy Adaptation Model include
information-processing network created by the the development of a middle-range theory of
more than 11 million nurses around the globe in- Psychological Adaptation in Death and Dying
teracting publicly and privately, envisioning a (Dobratz, 2011); an international study by
global society where health needs are primary 13 international investigators about women’s
and resources are channeled to meet needs perceptions of cesarean birth (Fawcett, et al.,
worldwide for the individual and common good 2011); a study of the coping and health prob-
(Roy, 2011a, p. 349). lems of caregivers of survivors with traumatic
International chapters of the Roy Adapta- brain injury using the Thai version of the
tion Association have demonstrated the inter- CAPS (Chayaput, Utriyaprasit, Bootcheewan,
est of nurses around the world to address & Thosingha, 2014); and the development
similar clinical problems in different cultures and use of a Roy Adaptation Model–based
and with the advancement and development EHR in a 21-bed Japanese rehabilitation hos-
of structures to facilitate the impact of nursing pital (Hidaka, Miyabayashi, Tsuhako, Ide, &
care. In reviewing Roy Adaptation Model– Kanayama, 2007).

based research over time, these areas of ongo- The structure of knowledge comprises grand
ing interest around the world in clinical areas theories, middle-range theories, research, and
include cancer, cardiovascular health, neurol- practice traditions (Smith & Parker, 2015). In
ogy, end-stage renal disease, and diabetes, in the new millennium, interest in middle-range
populations including women, the elderly, theories has accelerated beyond the develop-
children/adolescents, and caregivers; in the ment of new grand theories. Grand theories
location of care; and in the discipline of nurs- contain concepts and relational statements and
ing itself. Work is ongoing in development of assumptions. Middle-range theories are appli-
the CAPS research tool, now available in Eng- cable in complex situations and appropriate
lish, Spanish, Thai, Korean, Japanese, Polish, for empirical testing. Theory at this level in-
and Persian, facilitating the use and testing of cludes instrument development, testing of theory
various strategies for similar problems. The use and related propositions, and development of
of electronic health records (EHRs) based on strategies for nursing practice. Nursing values
Roy Adaptation Model theoretical frameworks must include ongoing understanding, respect,

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and commitment to health beliefs around the BOX 10-2 How Middle-Range Theories are
world and from setting to setting as care is in- Generated from Related Research
creasingly provided in less structured environ- Studies
ments, practice interventions are developed
within less regimented structures, and care is 1. Studies are selected that cluster together by
similarities.
monitored and improved in quality improve-
2. The studies are used as observations,
ment projects rather than hospital peer review classified, and major concepts identified.
committees. 3. The concepts are discrete and observable,
Several authors have reported that the Roy but at a level of abstraction that can be
Adaptation Model is the most widely used generalized across clinical situations.
theory in nursing research (Im & Chang, 4. The concepts are used to draw a pictorial
2012; Roy, 2018). The Executive Board of the schema of the interrelated concepts.
Roy Adaptation Association has conducted 5. The identified concepts are interrelated in
three reviews of research (1993 through 2015) theoretical statements or propositions.
based on the model with a current database of 6. The findings from the research are used
to provide evidence to support the new
nearly 500 studies in English. In two major middle-range theory and to make recom-
publications (BBARNS, 1999; Roy, 2014), the mendations for practice and policy.
authors present an analysis of the studies and
From Roy, S. C. (2014). Overview of processes for creating
ways this research has contributed to the cre- knowledge for practice. In Sister Callista Roy (Ed.), Generating
ation of new nursing knowledge. Reviewing a middle range theory: From evidence to practice (pp. 3–26).
New York, NY: Springer (p. 22).
large number of research projects based on the
Roy Adaptation Model provides data on com-
mon concepts close to practice. These concepts of social support, social networking, spiritual
cross clinical areas, are based on adapting peo- beliefs, and demographics, which were linked
ple and groups, and can be generalized. The to an adaptive outcome of coping processes
scholars whose work was reviewed used mul- and grief responses. The next steps of the
tiple research designs and methods represent- process of middle-range theory development
ing multiple ways of knowing. are shown in Figure 10-1.
We will focus on the second review that Three of the six propositions stated were
covered the years 1995 to 2010. The team as follows: (1) Adapting to loss is a profound
used this review of 172 studies to create mid- experience, and this focal stimulus affects
dle-range theories and evidence-based rec- coping processes, the cognator, and the reg-
ommendations for practice and policy. Roy ulator. (2) Adapting to loss is purposeful and
(2014) developed a six-step process for deriv- the responses of bereaved individuals cross all
ing middle-range theory from Roy Adapta- four adaptive modes. (3) Adapting to loss is
tion Model–based research. The steps are influenced by the contextual stimuli of social
described in Box 10-2. support and spirituality. The author made
The five clusters of studies chosen focused recommendations for practice that are evi-
on coping, adapting to life events, adapting dence based by the research used to derive the
to loss, adapting to chronic health conditions, middle-range theory of loss. Practice recom-
and the adapting family. An example of one mendations included consistent awareness
derived middle-range theory is Adapting to and sensitive response in all areas of nursing
Loss. The studies in this cluster had samples practice to needs of those suffering losses.
that varied from persons who were coping One policy recommendation was that a nurs-
with the death of a spouse to studies of ing diagnosis of grief or any form of coping
women who suffered the death and loss of a with loss should be given a reimbursement
stillborn infant. Designs varied from descrip- code that does not place a predetermined
tive correlational to phenomenological. In limit on the length of a given visit or time
addition to the type of loss, the scholars ana- frame for visits addressing the needs of those
lyzing the studies explored contextual stimuli suffering loss.

7991_Ch10_149-164 12/08/19 5:13 PM Page 159
Stimuli Coping Strategies Outcomes
Focal Regulator–Subsystem Physical-Physiologic

Loss as a profound Declining health
emotional experience Cognator–Subsystem
Self-reintegrating to loss Self-Concept
Contextual • Resolving/resigning to loss, Finding/constructing
Social support • Overcoming loneliness meaning
Spirituality Oscillating, complex processing Going forward
from grieving to resolving Being strong
Residual Finding strength
Time of enduring Forcing self to go on
Role
Relinquishing previous roles
Assuming previous roles
lnterdependence
Creating memories
Remaining connected
Connecting to others/
higher power
Forming new relationships
FIG 10-1 ■ Depicting steps 2, 3, and 4 of the process for deriving middle-range theory. (Adapted from
Dobratz, M. C. [2014]. Synthesis of middle range theory of adapting to loss. In Sister Callista Roy [Ed.], Generating middle
range theory: From evidence to practice [pp. 253–275]. New York, NY: Springer [p. 266].)
Evidence-Based Practice The Roy Adaptation Model offers an oppor-

The end of the 20th century brought an in- tunity to create standardized criteria for
terest in evidence-based practice (EBP) in providing evidence of safe, practicable inter-
nursing, nursing practice based on interven- ventions, as well as those untested with po-
tions derived from the results of research tential for success. It also offers methods for
studies that support their efficacy, effective- increasing numbers of opportunities to test
ness, and appropriateness. While there was propositions and to recalibrate portions of
general agreement related to the value of em- propositions, moving toward stronger sup-
pirical evidence rather than practice based port. Use of tools such as the Health-Related
solely on tradition, many recognized the need Quality of Life (HRQOL) indicators can fol-
for practice based on diverse ways of know- low scores to identify the specific factors or
stimuli that are likely to improve outcomes.
ing: theory-guided, evidence-based holistic

practice, and knowledge based on the integra- Both EBP and middle-range theory offer op-
tion of theory, inquiry, and evidence. Bring- portunities to make improvements that are
ing EBP full circle requires the ability to based on ways of knowing that correspond
articulate and measure the desired outcomes with nursing’s theoretical heritage, and ad-
of care, a challenge in a constantly moving dress the personal, ethical, social, and empir-
environment for data collection and analysis. ical methods of improving practice.

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Practice Exemplar
Family coherence is an indicator of positive started at the local community college. As a
adaptation and refers to a state of unity or a sophomore, Mark was accepted to his first-
consistent sequence of thought that connects choice college in a city in Pennsylvania.
family members who share group identity, The family’s well-being was shattered one
goals, and values (Roy, 2009a). Roy’s group night when the city hospital called to tell his
identity mode provides a useful conceptual parents that Mark was in the emergency
framework guiding health-care providers room being treated for a drug overdose. As
working with families who are facing threat- the parents drove to the city, they searched
ening changes and striving for family coher- their memories for what they knew about
ence. Many events threaten family coherence, drug use and anything specific to Mark. Both
for example, a newborn with a birth defect or parents believed the opioid epidemic was an
external factors such as economic downturns. urban problem. As they approached the hos-
In the contemporary United States, opioid pital, they were hoping and praying that if
abuse is a “common issue that has been rav- Mark survived this episode, it was only a one-
aging American families for decades” (Hayes time event resulting in a difficult but com-
& Manos, 2018). In this exemplar the family plete recovery.
includes a male and female set of married
parents and two children, a young adult male Nursing Approach to Family
in college and a teenage girl. This family In the case of the Smith family, the focus of
is facing the struggle of the young adult nursing practice is on the family adaptive sys-
son being addicted to opioids and suffering tem to help them develop family cohesion as
depression. A community health nurse is they witness and engage in Mark’s struggle to
working with this family using the Roy come to terms with his chronic debilitating
Adaptation Model. and life-threatening illness. Nursing practice
focuses on supplementing other treatment ap-
Background of Family and Change proaches for Mark so that he will have the
in Health Status necessary coping skills to adapt to the changes
The Smith family includes the father, Tom; he will face as he comes to terms with his new
his wife, Josephine; a 20-year-old son, Mark; life situation, which include the unconditional
and an 18-year-old daughter, Julie. The fam- love and support of his family.
ily lives in a town in rural Pennsylvania. Tom The nurse, Ms. Tyler, met with the Smith
is a welder and Josephine works as a dietary family shortly after Mark was discharged from
aide. The parents have enjoyed raising their the hospital. Upon discharge Mark chose to
children and feel the life they have provided go home with his family. In preparing for the
for their children is like the one they experi- visit, the nurse was focused on family cohe-
enced growing up. Tom and Josephine par- sion. Family members were observed behaving
ticipated in their children’s school and social as a tight-knit group who communicated well
activities, and gradually provided greater in- with one another and appeared supportive in
dependence as the children grew older. this time of difficulty. Nurse Tyler was also
Julie was diagnosed with type 1 diabetes aware that the family was facing a difficult
at age 7, which has been well controlled and time for which they were ill prepared. Mark’s
maintained with minimal episodes requiring dual medical diagnoses of opioid addiction
emergent care. Mark was active in sports. An and depression combined with Josephine and
injury kept him out for a time and he never Tom’s lack of knowledge on many levels pre-
seemed to get back to the level needed for sented the most immediate challenge.
major teams. He had some academic diffi- Following a discussion with Mark, Nurse
culty toward the end of high school and Tyler and Mark agreed that sharing Mark’s

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personal story would help his family to under- member’s reactions and concerns. Josephine
stand more about the nature of addiction and was crying and a blamed herself for not rec-
depression. As the family gathered, Nurse ognizing Mark’s drug problem, feeling as if
Tyler noted the serious but composed de- she had failed to protect her child. Tom tried
meanor of each family member. Mark was to comfort Josephine and felt the world Mark
fidgeting as he began to talk about how his was living in was something he and Josephine
addiction started. Following his sports injury, couldn’t relate to. Tom was worried about
he had been prescribed large quantities of oxy- what “other people” (family, friends, local
codone. He liked the way the pills made him community) would think, expressing shame
feel so he started seeking ways to get more and embarrassment common among families
pills without a prescription. He searched and in this situation. Julie initially felt anger be-
found expired pain medications in his parent’s cause she was the one who “really” had a
medicine cabinet. Later he found prescription health problem, and why would Mark want to
drugs plentiful on the street. Feeling a con- create one? She then quickly started sobbing
nection with individuals who used drugs, and hugging Mark. Julie knew a girl at her
Mark’s drug use increased and he started school who had died of a drug overdose while
drinking alcohol. Mark was aware of feeling in a rehabilitation facility, and she recognized
depressed but does not remember when he the seriousness of Mark’s addiction. Nurse
started feeling this way. He felt the alcohol Tyler listened as Julie, Josephine and Tom
and pills helped with his feelings of depres- discussed more, while Mark just hung his
sion. Mark was aware that he should “cut head. The family were most concerned with
back,” knowing this would be what his family how to support Mark and work toward recov-
expected. Despite his increasing drug and al- ery; the family almost in unison asked, “What
cohol use, however, he was accepted to the can we do to help?” Nurse Tyler suggested an-
college of his choice, so in his mind he was other family meeting in a week with everyone
encouraged that perhaps his usage was not af- including Mark agreeing. She shared a variety
fecting his life significantly. Mark left home of resources related to depression and drug
to attend college and time passed. and alcohol addiction with the family, to
While in college, Mark soon discovered which they were very receptive.
that it was easier and cheaper to find synthetic
opioids such as fentanyl and methadone and Analysis of the Practice Exemplar
eventually illegal heroin over prescription Assessment
drugs. A national and statewide public health Nurse Tyler grouped her observations under
effort to decrease narcotic pain usage made the four adaptive modes:
prescription drugs difficult and expensive to
1. Physical Resources: Family resources were
obtain. Mark recognized that he needed to
currently adequate—a cohesive family
seek professional help when his girlfriend
unit, a stable home life, and available
broke up with him because of his drug use and
financial resources. Possible new stimuli.
the fact that Mark himself recognized a con-
New financial demands if required to pay
tinued increase in his alcohol and drug con-
for repeated rehabilitation programs.
sumption. Despite this, Mark still felt helpless
2. Group Identity: Everyone in their small
to break his habit. Nurse Tyler suggested
rural town in Pennsylvania knew the fam-
Mark might want to begin using the word ad-
ily as one that met with expected commu-
diction when describing his drug and alcohol
nity norms. Stimuli. This image was
“habit.”
based on the job interactions of the par-
Following Mark’s story, Nurse Tyler ini-
ents, child attending college, and social
tiated the family discussion, listening to each
(continued)

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situations over many years. New focal would be alert for any knowledge from the
stimuli. Son diagnosed with a substance role and interdependence modes that could be
abuse disorder and depression. Contextual of help in dealing with group identity.
stimuli. Drug abuse and mental health is-
Nursing Diagnosis
sues affect all members of society, includ-
Family coherence threatened by a need to in-
ing rural and urban populations, all
clude a new reality in their shared identity.
socioeconomic groups, and all age levels.
The family is at the level of compensatory adap-
Families are deeply affected, suffering as
tation as their coping processes are challenged.
they watch a loved one’s struggle with re-
It will take effort and the help of the nurse to
covery while many lose loved ones in the
reach integrated adaptation.
process. Residual stimulus. Unfamiliarity
with addiction, the process of recovery, Goals
the diagnosis of depression, and the sud- 1. To reshape their identity as a family who
den challenge to the family unit brought shared with others the problems of drug
about by all this change. addiction and mental health issues; to
3. Shared Values: Valued recovery for their become a family that acknowledges
son/brother. Focal stimulus. The whole the problems and is ready to help
family all truly cared about Mark and 2. To maintain their value of recovery and to
wanted him to survive and be well. He have realistic understanding of what this
was in some ways a bulwark of the fam- might involve
ily, the first to go to college. Contextual 3. To maintain their unconditional love and
stimuli. Characteristics of the disorders: support as they obtain more knowledge
commitment to recovery takes time and and experience the realities of Mark’s
often much therapy; the route to recovery recovery trajectory
is not a straight line; there are many fail-
ures in rehabilitation programs, even in a Nursing Interventions
successful recovery. In addition, there is Nurse Tyler will suggest weekly meetings with
the diagnosis of depression and the im- the family, with or without Mark, and pri-
plications this will have on the recovery vate meetings as necessary. She will facilitate
and rehabilitation process. Mark’s contact with his therapist. She will
4. Shared Goals: Family members all ex- share the proposed goals and discuss these
pressed a desire to help. Focal stimuli. with the family. The focus of the family meet-
Parents’ lack of knowledge about opioid ings will be to provide education and to build
and alcohol addiction. Mark has not yet up the coping strategies needed to be the fam-
declared his commitment to recovery, po- ily of support for Mark. She will follow the
tentially limiting the effectiveness of any lead of each person’s awareness and support
offered assistance. Positive contextual the positive coping strategies of the family
stimulus. Mark chose to return home after helping each other both in learning the facts
his hospitalization. Residual stimuli. Each and in how they respond to new learning and
family member’s ability to tolerate help- experiences. When possible, the nurse will
lessness and to remain supportive over a suggest new coping strategies and will provide
possible number of recovery failures. contact with other families with adult children
suffering addiction and mental health issues.
As the nurse looked at behaviors in the
role function and interdependence adaptive Evaluation
modes of the group, she noted that these The nurse will track progress on each goal
modes intertwined with behaviors noted in and identify the need to modify a goal or an
the group identity adaptive mode. The nurse approach.

7991_Ch10_149-164 12/08/19 5:13 PM Page 163
Summary
This chapter focused on the Roy Adaptation The exemplar illustrated the use of the self-
Model as a foundation for knowledge-based identity adaptive mode as an example of using
practice. The background of the theorist and the theory-based knowledge to provide care for a
historical development of the model were pre- family dealing with an adult child diagnosed
sented. The description of the model assump- with opioid addiction and depression. The Roy
tions and major concepts included Roy’s most Adaptation Model response to 21st-century
recent theoretical developments. The effects of needs is described as global, accumulated re-
the Roy Adaptation Model on practice were ar- search, and the process for developing middle-
ticulated from a general summary of major prac- range theory that is tested in research and leads
tice projects and through a practice exemplar. to evidence-based recommendations.
Questions for Reflection assessment questions or observations

might elicit information related to these
and Discussion stimuli?
■ What are the differences in the adaptive ■ What are some examples of integrated,
modes for individuals and groups (families, compensatory, and compromised levels of
communities)? adaptation?
■ What are some examples of focal, resid-
ual, and contextual stimuli and what

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7991_Ch11_165-182 12/08/19 5:25 PM Page 165
Betty Neuman’s Systems

CHAPTER
11
Model
Sarah Beckman and
Jacqueline Fawcett

Overview of the Model Introducing the Theorist
Applications of the Model Betty Neuman developed the Neuman Sys-
Practice Exemplar tems Model (NSM) in 1970 to “provide
Summary unity, or a focal point, for student learning”
Questions for Reflection and Discussion (Neuman, 2002, p. 327) at the School of Nurs-
ing, University of California at Los Angeles
(UCLA). Betty recognized the need for edu-
cators and practitioners to have a framework
to view nursing comprehensively within vari-
ous contexts. Although she developed the
model strictly as a teaching aid, it is now
used globally as a nursing conceptual model to
guide curriculum development, research, clin-
ical practice, and administration of health-care
services in the full array of health-care disci-
plines. (We use Betty Neuman’s first name in
this section of the chapter as a mark of our
affection for this remarkable nurse theorist.)
Betty’s autobiography, summarized here, is
presented more fully in the fifth edition of The
Neuman Systems Model (Neuman & Fawcett,
2011). Betty 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.

Betty idealized nursing because her father
had praised nurses during his 6 years of inter-
mittent hospitalizations. In gratitude, she de-
veloped a strong commitment to become an
excellent bedside nurse. She also attributed her
decisions about her life’s work to the important
influence of her mother’s charity experiences
as a self-taught rural midwife.
Betty graduated from high school soon
after the onset of World War II. Although she
had dreamed of attending nearby Marietta
College, she lacked the financial means and
instead became an aircraft instrument repair
technician. After the Cadet Nurse Corps
165
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Program became available, she entered the Valley State University in Allendale, Michigan.
3-year diploma nurse program at People Hos- She is an honorary fellow in the American
pital, Akron, Ohio (currently General Hospi- Academy of Nursing. On October 17, 2014,
tal Medical Center). Walsh University in North Canton, Ohio, an-
Betty completed her baccalaureate degree nounced establishment of the Betty Neuman
in nursing and earned a master’s degree with a Award for Nursing Leadership; Betty was the
major in public health nursing from UCLA. first recipient of this award. Subsequent recip-
During her master’s program, she worked ients are nurse leaders who have contributed to
on special projects, as a relief psychiatric head advancement of the NSM.
nurse, and as a volunteer crisis counselor.
These experiences led her to become one of the
first California Nurse Licensed Clinical Fel- Overview of the Model
lows of the American Association of Marriage The philosophic base of the Neuman Systems
and Family Therapy. Model encompasses wholism, a wellness orienta-
In 1967, Betty became a faculty member at tion, client perception and motivation, and a dy-
UCLA and assumed the role of chair of the namic systems perspective of energy and variable
program from which she had graduated. She interaction with the environment to mitigate
expanded the master’s program, focusing on possible harm from internal and external stres-
multidisciplinary practice in community men- sors, while caregivers and clients form a partner-
tal health. ship relationship to negotiate desired outcome
In 1970, Betty developed the Neuman’s goals for optimal health retention, restoration,
System Model (NSM) as a guide for graduate and maintenance. This philosophic base pervades
nursing students. The model was first pub- all aspects of the model.
lished in 1972 in Nursing Research (Neuman —BETTY NEUMAN (2002, p. 12)
& Young, 1972). Since 1980, several impor-
tant changes have enhanced the model. A
nursing process format was designed, and in Concepts of the Neuman Systems
1989, Betty introduced the concepts of the Model
created environment and the spiritual variable. The concepts of the NSM are client/client sys-
In collaboration with Dr. Audrey Koertve- tem, interacting variables, basic structure (also
lyessy, Neuman developed a theory of client called the central core), flexible line of defense,
system stability. Along with the members of normal line of defense, lines of resistance, inter-
the Neuman Systems Trustees Group and nal environment, external environment, created
other colleagues, she continues to revise the environment, stressors, health/wellness/optimal
concepts and propositions of the model. The client system stability, variances from wellness,
NSM content and applications have been illness, reconstitution, and prevention as inter-
published in five editions of The Neuman Sys- vention. These concepts, their dimensions, and
tems Model (Neuman, 1982, 1989, 1995; Neu- the definitions are listed in Table 11-1.
man & Fawcett, 2002, 2011), as well as in A diagram of the NSM is shown in
the chapters of many nursing theory books Figure 11-1. As can be seen in Figure 11-1,
and journal articles. A complete bibliography the basic structure (central core) of the client
of NSM publications is available online in system is surrounded by metaphorical rings
the NSM Resources Folder at https://www. (the lines of defense and resistance) that act
neumansystemsmodel.org. as barriers to invasion of noxious stressors
Betty completed a doctoral degree in clinical and facilitate the entry of beneficial stressors
psychology in 1985 from Pacific Western Uni- into the basic structure.
versity. She has received honorary doctorates Over the years, some of the concepts of
from Neumann College (now Neumann Uni- the NSM, including the client system as a
versity) in Aston, Pennsylvania, and Grand social issue, the spiritual variable, the created

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C H APTER 11 ■ Betty Neuman’s Systems Model 167
Table 11-1 Neuman Systems Model Concepts and Definitions
Neuman Systems Model

Concept Definition of the Concept
Client/Client System An open system that interacts with the internal and external environments.
The four dimensions of Individual is an individual person.
client/client system are
Family is a type of group.
■ Individual
■ Family Community is a type of group.
■ Community Social issue a policy or major concern of society.
■ Social issue
Interacting Variables The five components of the client system, which function more or less
The five dimensions of harmoniously in interactions with internal and external environmental
interacting variables are stressors. The extent of the interactions between and among the five
■ Physiological variables variables determines how much resistance a client system has to
■ Psychological variables environmental stressors.
■ Sociocultural variables Physiological variable is “bodily structure and internal function” (Neuman,
■ Developmental variables 2011, p. 16).
■ Spiritual variables Psychological variable is “mental processes and interactive environmental
effects, both internally and externally” (Neuman, 2011, p. 16).
Sociocultural variable is “combined effects of social cultural conditions and
influences” (Neuman, 2011, p. 16).
Developmental variable is “age-related development processes and
activities” (Neuman, 2011, p. 16).
Spiritual variable is “spiritual beliefs and influences … on a continuum of
dormant, unacceptable, or undeveloped to recognition, development, and
positive system influence” (Neuman, 2011, pp. 16–17).
Basic Structure (Central Core) The basic structure (central core) of the client system, which is made up of
basic survival factors that are common to all human beings and provide the
energy for system function.
Flexible Line of Defense The outer boundary of the client system, which is a buffer that protects the
client system’s normal line of defense from stressor invasion; the flexible
line of defense is highly dynamic in that it can rapidly expand away from
the normal line of defense, offering greater protection, or rapidly draw
closer to the normal line of defense, offering less protection.
Normal Line of Defense The client system’s normal or usual wellness level, which reflects a typical
yet evolving range of responses to environmental stressors; expansion of

the normal line of defense reflects an enhanced wellness state whereas
contraction reflects a diminished state of wellness.
Lines of Resistance Internal factors that protect basic structure and support return of the client
system to wellness at the same or a higher state of wellness.
Internal Environment All forces or interacting factors that are internal to the client system,
including intrapersonal stressors.
External Environment All forces or interacting factors that are external to the client system,
including interpersonal and extrapersonal stressors.
Created Environment “The client’s unconscious mobilization of all system variables (particularly
the psycho-sociocultural), including the basic structure energy factors,
toward system integration, stability and integrity. … Though unconsciously
developed, its function is to offer a protective coping shield … or safe
arena for system function … It supersedes or goes beyond the internal
and external environments, encompassing both … [and] is intrapersonal,
interpersonal, and extrapersonal in nature” (Neuman, 2011, pp. 20–21).
Continued

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Table 11-1 Neuman Systems Model Concepts and Definitions—cont’d
Neuman Systems Model

Concept Definition of the Concept
Stressors “Tension producing stimuli or forces occurring within the internal and
The three dimensions of external environmental boundaries of the client system” (Neuman, 2011,
Stressors are p. 22).
■ Intrapersonal stressors Intrapersonal stressors are “internal environmental forces that occur within
■ Interpersonal stressors the boundary of the client system” (Neuman, 2011, p. 22).
■ Extrapersonal stressors Interpersonal stressors are “external environmental forces that occur outside
the boundaries of the client system at proximal range” (Neuman, 2011,
p. 22).
Extrapersonal stressors are “external environmental interaction forces that
occur outside the boundaries of the client system at distal range” (Neuman,
2011, p. 22).
Health/Wellness/Optimal “The best possible wellness state at any given time” (Neuman, 2011,
Client System Stability p. 23).
Variances from Wellness “Varying degrees of system instability [that] are caused by stressor invasion
of the normal line of defense” (Neuman, 2011, p. 24).
Illness “A state of insufficiency with disrupting needs unsatisfied” (Neuman,
2011, p. 24).
Reconstitution “The successful mobilization of client resources to prevent further stressor
reaction or regression; it represents a dynamic state of adjustment to stres-
sors and integration of all necessary factors towards optimal use of existing
resources for client system stability or wellness maintenance. … Complete
reconstitution may progress well beyond the previously determined normal
line of defense or usual wellness state, it may stabilize the system at a
lower level, or it may return to the level prior to illness. … If reconstitution
does not occur, death occurs as a result of failure of the basic structure”
(Neuman, 2011, pp. 28–29).
Prevention as Intervention The goals and outcomes components of the Neuman Systems Model
The three dimensions of nursing process format.
the concept of prevention Primary prevention as intervention is “wellness retention [used] to protect
as intervention are the client system normal line of defense or usual wellness state by strength-
■ Primary prevention as ening the flexible line of defense … [by means of] stress prevention and
intervention reduction of risk factors” (Neuman, 2011, p. 26).
■ Secondary prevention as Secondary prevention as intervention is “wellness attainment [used]

intervention to protect the basic structure by strengthening the internal lines of
■ Tertiary prevention as resistance … [by means of] appropriate treatment of symptoms (Neuman,
intervention 2011, pp. 27–28).
Tertiary prevention as intervention is “wellness maintenance [used] to
protect client system reconstitution or return to wellness following …
[secondary prevention as intervention] by means of supporting existing
strengths and conserving client system energy” (Neuman, 2011, pp. 28–29).
environment, and reconstitution, have been definitions of the words social and issue led to
explored in depth. the NSM dimensional definition of social issue:
a matter that has to be or has been decided
Client System as a Social Issue by means of interactions between people.
Aronowitz and Fawcett (2016) explored the Aronowitz and Fawcett also identified several
meaning of the client as a social issue. The in- examples of social issues from a search of
tegration and identification of the dictionary the literature, a survey of NSM Trustees, and

7991_Ch11_165-182 12/08/19 5:25 PM Page 169
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
Known commonalities
ible Line of Defe

Flex nse
mal Line of Defe

Nor n
s of Resista se
Primary prevention L ne
i 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
FIG 11-1 ■ The Neuman Systems Model. (Original diagram copyright 1970 by Betty Neuman. A holistic
view of a dynamic open client–client system interacting with environmental stressors, along with client
and caregiver collaborative participation in promoting an optimum state of wellness.) (From Neuman &
Fawcett, 2011, p. 13, with permission.)

7991_Ch11_165-182 12/08/19 5:25 PM Page 170
responses from the audience at the 2015 15th Sweden, and Denmark. Survey findings indi-
Biennial NSM Symposium (Box 11-1). cated that a personal interest in spirituality, a
broad view of spirituality, curriculum content,
The Spiritual Variable and caring for clients are factors that con-
Fulton and Carson (1995) and van Leeuwen tribute to spiritual care knowledge, skills, and
(2008, 2013, 2017) have contributed to ad- attitude competencies of nurses (van Leeuwen,
vancement and understanding of the spiritual 2013).
variable. Based on a review of existing re-
search, Fulton and Carson (1995) extended Created Environment
understanding of spiritual well-being, spiri- Verberk and Fawcett (2017) enhanced under-
tual needs, spiritual distress, and spiritual standing of the created environment. Drawing
care. They pointed out that spiritual needs in- on previous work by du Kuiper (2011), they
clude (1) the need for meaning and purpose offered a comprehensive format for assessment
in life, (2) the need to receive love and give of the individual client system’s created envi-
love, (3) the need for hope and creativity, and ronment within the context of the five NSM
(4) the need for forgiving, trusting relation- interacting variables.
ships with self, others, and God, a deity or a Created environment–physiological variable
guiding philosophy. refers to “the meaning a person ascribes to the
van Leeuwen (2008) studied relations be- physical shape of his or her body as well as its
tween health, spirituality, and the role of the functioning … and to his or her home or neigh-
nurse in meeting spiritual needs. He identified borhood” (p. 180) Assessment questions are:
competencies needed by nurses for provision ■ What do you think about your body?
of appropriate, client system-centered spiritual ■ What do you think about your home?
care, and developed the Spiritual Care Com- ■ What do you think about the area
petence Scale (van Leeuwen, 2008). Later, van
(or neighborhood) where you live?
Leeuwen reported the results of a multina-
tional survey with nursing participants from Created environment–psychological variable
the United Kingdom (England, Wales, and refers to “the meaning the person ascribes to
Scotland), Malta, the Netherlands, Norway, his or her personality and the way in which
emotions are expressed” (p. 180). Assessment
questions are:
BOX 11-1 Examples of the Client System ■ What do you think about your mind?
as a Social Issue ■ What do you think about your emotional
Health policies, including practice guidelines state?
and health insurance Created environment–sociocultural variable

Family issues, such as caregiver burden, refers to “the meaning the person ascribes to
financial situation, cultural beliefs, and extent
of acculturation the extent of his or her interactions with others
Social problems, such as poverty, extent of access and awareness and meaning of cultural her-
to health care, human trafficking, migration itage” (p. 180). Assessment questions are:
and asylum seeking, interpersonal violence,
hunger, overpopulation
■ What do you think about your social
Lifestyle behaviors, such as eating behaviors, network (family, friends, acquaintances,
timing of sexual initiation, and living coworkers)?
arrangements ■ What do you think about your place in
Terrorism and war society (or country)?
Environmental problems, such as toxic waste ■ What do you think about your cultural
disposal, nuclear proliferation, and pollution heritage?
Adapted from Aronowitz & Fawcett (2016). Thoughts about
social issues: A Neuman Systems Model perspective. Nursing
Created environment–developmental variable
Science Quarterly, 29(2), 173–176. refers to “the meaning the person ascribes to

7991_Ch11_165-182 12/08/19 5:25 PM Page 171
life changes over time and innovations in ■ What have been the most and least help-
lifestyle.” An assessment question is: ful interventions by health-care providers
in the past?
■ What do you think about growing up ■ What are the greatest challenges that you
(or getting older)?
(the client system) are encountering?
Created environment–spiritual variable refers ■ What do you (the client system) need to
to “the meaning the person ascribes to his or prepare for life following this event?
her beliefs, hopes, and dreams, as well as the
Prevention as intervention modalities tar-
meaning of any religious or other spiritual
geted to reconstitution include:
practices” (p. 180). An assessment question is:
■ Administration of medications, treatments,
■ What do you think about religion or
and various other physical interventions
spirituality? ■ Providing support
Reconstitution ■ Doing more than is professionally
required, and thinking about and doing
Gehrling (2011, pp. 91, 95) extended the un-
things that are “outside the box”
derstanding of reconstitution. She identified ■ Providing community activities
three attributes of reconstitution, which are an ■ Help with finding meaningful work
integration of attributes evident in diverse defi- ■ Help with finding a safe place to live
nitions of reconstitution, as well as attributes
identified by Neuman (2011): Areas of evaluation, paraphrased and re-
stated here as questions, are:
■ Reconstitution is a regenerative or recon-
structive process whereby a client system ■ In what way has your (the client system’s)
undergoes a rearrangement of existing perception of the situation changed?
variables (physiological, psychological, ■ What interventions have been the most
sociocultural, developmental, spiritual) at helpful and least helpful?
the site of stressor impact. ■ What challenges do you (the client
■ Reconstitution occurs after the client system) continue to confront?
system has experienced a negative reaction ■ Where do you think you (the client system)
to a stressor, which required the client are in the life process following the event?
system to alter itself to preserve the system
and protect the basic structure. Reconsti- Relational Propositions of the
tution is client (system) initiated, not Neuman Systems Model
externally provided.
Several statements that link the NSM concepts
■ Reconstitution occurs with or without the
(relational propositions) were identified by

implementation of a prevention interven-
Beckman and Fawcett (2017). These proposi-
tion, although a more favorable outcome,
tions are listed here and are displayed as a
that is, a higher level of return to wellness,
diagram in Figure 11-2.
may be realized if a prevention interven-
tion is provided. 1. The physiological, psychological, sociocul-
tural, developmental, and spiritual variables
As she continued to enhance understanding
are interrelated.
of reconstitution, Gehrling (2011, pp. 96–97)
2. The relation between stressors and the nor-
offered areas for assessment, modalities for pre-
mal line of defense is moderated by the flex-
vention as intervention, and areas of evaluation
ible line of defense.
that operationalize the abstract concept of re-
3. The relation between stressors and the lines
constitution for practice. The assessment areas,
of resistance is mediated by the normal line
paraphrased and restated here as questions, are:
of defense.
■ What is your (the client system’s) percep- 4. The lines of resistance are positively related
tion of what is needed to function? to the basic structure (central core).

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Physiological
variable
Prevention interventions Optimal client

Psychological system stability
variable
Normal Basic
Sociocultural Lines of
Stressors line of structure
variable resistance
defense (central core)
Developmental
variable Flexible line of defense
Spiritual
variable
FIG 11-2 ■ Diagram of the propositions of the Neuman Systems Model.
5. Prevention as intervention (primary, second- stressors). A unique feature of the NSM is the
ary, tertiary prevention) has a positive effect created environment, which directs attention
on the flexible line of defense, the normal to client systems’ perceptions of their lives and
line of defense, and the lines of resistance. surroundings. Another unique feature of the
6. Prevention as intervention (primary, sec- NSM is the emphasis on wellness, as captured
ondary, tertiary prevention) has a positive in the concept of variances from wellness, that
effect on optimal client system stability. is, the extent to which the client is well, rather
than the extent to which the client is ill, as is
Mataoui (2018) proposed another proposi-
more common in many perspectives of health
tion: The effect of stressors on the basic struc-
care. A related unique feature is the focus on
ture (central core) is influenced by the normal
optimal client system stability, which directs
line of defense. This proposition is not shown
attention to the stability of the system that is
in Figure 11-2.
the best for a client system, rather than an ab-
solute level of stability that is considered best.
Unique Perspective of the Neuman
All of these features of the NSM, along with
Systems Model
the inclusion of five interacting variables—

The NSM is a unique systems-oriented per- physiological, psychological, sociocultural,
spective of health care that directs attention to developmental, and spiritual—provide a com-
the impact of both beneficial and noxious stres- prehensive, wholistic perspective of health
sors that may be intrapersonal, interpersonal, or care. Noteworthy is that Neuman chose the
extrapersonal. The inclusion of beneficial stres- term client to show respect for collaborative
sors allows researchers and clinicians to consider relationships that exist between client systems
how stressors can have a positive impact on the and caregivers, as well as the wellness perspec-
client system. The NSM also directs attention tive of the model.
to prevention as intervention, allowing re-
searchers and clinicians to consider not only pri-
mary prevention (before the impact of noxious Applications of the Model
stressors and during or after the occurrence of Inasmuch as the NSM is flexible and appli-
beneficial stressors) but also secondary and ter- cable to numerous client systems experiencing
tiary prevention (after the impact of noxious diverse health conditions in various settings,

7991_Ch11_165-182 12/08/19 5:25 PM Page 173
it has been used globally for more than four the NSM practice methodology and
decades. Neuman’s first book was published diagnostic taxonomy
in 1982 as a response to requests for data and
An example of a NSM practice methodol-
support in applying the NSM in practice set-
ogy tool is displayed in Box 11-2. As can be
tings and as a guide for entire nursing curric-
seen, the NSM practice methodology encom-
ula. The second and third editions (1989,
passes the NSM nursing process of nursing
1995) present examples of the use of the
diagnosis, nursing goals, and nursing out-
model primarily for practice and education.
comes. The practice methodology tool shown
The fourth edition (2002) includes integra-
in Box 11-2 is based on the NSM Assessment
tive reviews of practice, education, and re-
and Intervention Tool and the Neuman Sys-
search literature and discussions of practice
tem Model Nursing Process Format (Neuman
and educational tools. The fifth edition (2011)
& Fawcett, 2011). Many other practice tools,
continued the tradition of including contri-
which are listed and briefly described in Fawcett
butions that reflect the broad applicability of
and DeSanto-Madeya (2013), have been de-
the NSM.
veloped to guide assessment and/or interven-
A comprehensive NSM bibliography, avail-
tion and evaluation of individuals as client
able in the NSM Resources folder at https://
systems, families as client systems, and com-
www.neumansystemsmodel.org, includes nu-
munities as client systems. References for these
merous references to applications of the model
practice tools are available in the NSM bibli-
to practice, research, education, and adminis-
ography (see the NSM Resource folder at
tration of health-care services.
https://www.neumansystemsmodel.org).
Application to Nursing Practice The NSM diagnostic taxonomy, which was
developed by Ziegler (1982), encompasses
The NSM is one of the most frequently used
(1) client system (individual, family, group,
conceptual models to guide nursing practice
community, social issue), (2) level of response
and has been used by other members of the
(primary, secondary, tertiary), (3) client vari-
health-care team. “The function of a concep-
able responding to the stressor (physiological,
tual model in nursing practice is to provide a
psychological, sociocultural, developmental,
distinctive frame of reference that guides
spiritual), (4) source of the stressor (intrap-
approaches to patient care” (Amaya, 2002,
ersonal, interpersonal, extrapersonal), and
p. 43).
(5) type of stressor (physiological, psychologi-
Guidelines for NSM-guided practice,
cal, sociocultural, developmental, spiritual).
proposed by Freese, Russell, Neuman, and
The NSM Practice Center was founded by
Fawcett (2011), are summarized and updated
NSM Trustee Diane Breckinridge. The pur-
here and stipulate that:
pose of the Center is to facilitate and acknowl-

■ The purpose of practice is to use primary, edge individuals’ endeavors to translate research
secondary, and/or tertiary prevention as into practice and to implement the NSM in
interventions to assist client systems in health-care practice settings. The Center offers
retaining, attaining, or maintaining the two awards—the Diane Breckenridge Practice
optimal system stability achievable at a Center Fellow Award and the Betty Neuman
given point in time Translation into Practice Grant. Information
■ The emphasis in practice is attending to about the Practice Center and award and
actual or potential problems in the client grant applications are available at https://www.
system’s reactions to actual or potential neumansystemsmodel.org/nsm-practice-center/.
beneficial and noxious stressors in any The NSM model was recently extended
actual or virtual setting through academic-practice partnerships within
■ The client system–health-care team the context of the six Quality and Safety Edu-
relationship is a partnership involving cation for Nurses (QSEN) competencies—
negotiations for care goals by use of client system–centered care, teamwork and

7991_Ch11_165-182 12/08/19 5:25 PM Page 174
BOX 11-2 An Example of a Neuman Systems Model Practice Methodology Tool
Nursing Diagnosis
Physiological Variable
■ How do you usually feel physically? [Normal line of defense]
■ How do you feel physically today? [Flexible line of defense]
■ What happened to make you feel this way? [Stressors]
Psychological Variable
■ How do you usually feel emotionally? [Normal line of defense]
■ How do you feel emotionally today? [Flexible line of defense]
■ What happened to make you feel this way? [Stressors]
Sociocultural Variable
■ Please tell me about your lifestyle and culture. [Normal line of defense]
■ What changes have you experienced in your lifestyle and culture recently? [Flexible line of defense]
■ What has happened to result in these changes? [Stressors]
Developmental Variable
■ What are your current goals for yourself? [Normal line of defense]
■ In what ways have your personal goals changed recently? [Flexible line of defense]
■ What has happened to result in these changes? [Stressors]
Spiritual Variable
■ What are your spiritual beliefs? What gives your life meaning? What gives you hope? [Normal line
of defense]
■ Have your spiritual beliefs, ideas about meaning in life, and/or sources of hope changed recently?
[Flexible line of defense]
■ What has happened to result in this change? [Stressors]
Nursing Goals
■ The nurse and the client system identify goals for primary, secondary, and/or tertiary prevention as
intervention.
Nursing Outcomes
■ The nurse and the client system implement primary, secondary, and/or tertiary prevention as
interventions and evaluate outcomes.
collaboration, quality improvement, infor- goals to achieve Baby Friendly certification.

matics, evidence-based practice, and client Critical thinking and reflection throughout the
system safety (Beckman & Fawcett, 2017). project contributed to an expanded awareness
Each competency is exemplified here by proj- of the student’s own potential biases about and
ects conducted as part of academic–practice perceptions of the topic. Norton (2017) con-
partnerships. cluded that “outcomes included increased buy-
An example of client system–centered care was in and support from the staff nurses on the
presented by Norton (2017). She applied the practice of rooming-in as well as increased
NSM in partnership with the manager and staff awareness of the variations of maternal/infant
of an obstetrics setting in an acute care hospital. bonding in multiple cultures” (p. 58), and the
Norton’s project, “Patient-Centered Care: Best target audience agreed that “thorough assess-
Practices with Rooming-In,” advanced unit ment of the family often reveals that the system

7991_Ch11_165-182 12/08/19 5:25 PM Page 175
stability of the mother/infant dyad is best man- nurses, and teachers in all of this?” (p. 137).
aged through addressing the needs and goals of Fawcett wondered whether the bus driver’s
the larger community and tailoring education concern was an indication of fear of doing
to meet the cultural preferences of the group” something wrong, fear of something bad hap-
(p. 59). pening as an outcome, or fear of administering
An example of teamwork and collaboration the injection incorrectly. Fawcett (2017) and
was reported by Pluck (2017) as instrumental her advisors decided to put a face to the dis-
in improving care while reducing costs of ease. She created a 1-minute video clip
care for older adults in the Netherlands with of an 11-year-old with T1DM, concluding
mental health problems living in nursing with the child saying, “Thank you for keeping
homes who exhibited challenging behaviors. me safe.”
An interdisciplinary resource team, including Carpenter (2017) provided an example of
a mental health care nurse, a nurse practi- use of the model in health-care informatics.
tioner, a psychologist, and a psychiatrist, Some adult learners are digital neophytes,
used the NSM to guide development of challenged to learn basic computer and infor-
wholistic plans of care responsive to stressors mation literacy skills, whereas others embrace
that affect optimal client system stability. new technology as a positive stressor. Carpen-
The resource team provided education for ter was eager to learn and adopt technologies
the nursing home staff and supervised imple- to create evidence-based, interactive, engaging
mentation of recommended care strategies to educational materials. She wrote, produced,
deal with the nursing home residents’ chal- and edited a health education video about
lenging behaviors. Pluck (2017) concluded menstruation targeted to client systems of
that “the collaborative experiences between 9- to 10-year-old girls at an elementary school.
the expertise center [resource] team and the Major stressors identified were the girls’
care professionals and families in the nursing knowledge deficit and anticipatory fear or anx-
homes are positive. Sharing experiences from iety about changes in their bodies during pu-
different occupational perspectives helps all berty. The video was an innovative example of
stakeholders to optimize care for people with primary prevention as intervention; it provided
challenging behavior” (p. 98). information in an acceptable format designed
An example of quality improvement was of- to alleviate, or minimize, anxiety about the
fered by Fawcett (2017) in her project “Pri- normal bodily function of menstruation. Car-
mary Prevention Targeting Safety of Children penter realized that “engaging the people you
with Type 1 Diabetes Mellitus (T1DM) in a are attempting to educate is as important to
Public School System.” Fawcett and her col- the learning process as the information itself,
leagues focused on an identified gap: the lack and the technology helped to make that pos-
of training on emergency response for bus sible” (p. 187). Carpenter’s work demonstrates
drivers transporting children with type 1 dia- that the use of the NSM and Quality and Safety
betes mellitus (T1DM) to and from school. Education for Nurses (QSEN) grounded infor-
Stakeholders included school nurses, leaders matics in nursing practice.
from other school corporations, the trans- An example of client system safety was
portation director, bus drivers, the student presented by Merks and Verberk (2017). They
services director, the human resource director, developed a comprehensive NSM-based defi-
and the children with T1DM and their fami- nition of client system safety: “Client system
lies. Educational materials for the teaching safety is the application of each step of the
project were current, creative, and evidence Neuman Systems Model Nursing Process For-
based. As presentations progressed, Fawcett mat—nursing assessment and diagnosis, nurs-
(2017) reported that the feedback loop re- ing goals, and nursing outcomes—to ensure a
vealed an unanticipated finding—one of the safe environment for client systems, practicing
bus drivers asked, “Why should bus drivers be nurses, and nursing students” (p. 225). The au-
responsible? Where are the parents, school thors provided an example of the nurse–client

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partnership found at Emergis, a Dutch mental levels of nursing education in the United
health institute, where nurses were viewed as States, Canada, and several other countries.
excellent problem solvers in exploring spiritu- Guidelines for education based on the
ality with clients. Merks and Verberk (2017) NSM were proposed by Newman et al. (2011)
explained that and are summarized and updated here. The
guidelines are as follows:
most of the nurses indicated they felt insecure
starting a conversation about spirituality with ■ The focus of an NSM-based curriculum is
clients using formal questions, and nurses indi- to learn how to manage the client system’s
cated that spirituality remains a very delicate sub- reaction to beneficial and noxious intrap-
ject to talk about, as they would be entering the ersonal, interpersonal, and extrapersonal
client’s deeper world of underlying feelings and environmental stressors by means of pri-
experiences. (p. 246) mary, secondary, and/or tertiary preven-
tion as intervention.
With respect and enhanced sensitivity, ■ The content of the curriculum encom-
nurses chose to use “talk walks” with clients,
passes all NSM concepts and proposi-
side by side, so there was no face-to-face con-
tions, which may be taught in any formal
tact. Merks and Verberk (2017) determined
or informal in-person or online educa-
that this approach was a safe way of sharing
tional program.
and being equal, stating, “Clients reported ■ The emphasis in a NSM-based curricu-
great appreciation for the conversations they
lum is fostering critical thinking using
had with the nurses,” and one client com-
individual and team teaching-learning
mented “[How] beautiful that nurses were so
strategies.
open to our communication” and “I feel appre- ■ Evaluation of curriculum outcomes is
ciated as a person” (p. 247). They went on to
done using one or more NSM-based
conclude that the efficacy of the NSM had
educational tools.
been supported:
The Lowry-Jopp Neuman Model Evalua-
Using the Neuman Systems Model to guide the tion Instrument (Lowry, 1998; Lowry & Jopp,
project operationalized the spiritual variable to 1989) is an especially comprehensive tool for
structure communication between nurses and evaluating NSM-based single courses, an entire
clients, which contributed to a different culture or curriculum, end-of-program outcomes, and
climate, where clients and nurses are equal, have employer satisfaction. Other tools for use in
a better understanding of each other, and build education are listed and briefly described in
strong relationships, resulting in greater client Fawcett and DeSanto-Madeya (2013). Most of
and nurse safety. (p. 247) these tools are used to evaluate student class-
A special feature of this example is the focus room, clinical learning, or progression through
on client system safety for both the client and the curriculum. References for these tools
the nurse. are available in the NSM bibliography (see
the NSM Resources folder at https://www.
Application of the Neuman Systems neumansystemsmodel.org).
Model to Education The NSM Education Academy was founded
Neuman explained that she originally de- by NSM Trustee Betsy McDowell. The pur-
signed the NSM “as a focal point for student pose of the Academy is to recognize educators
learning” (Neuman & Fawcett, 2011, p. 332) for their contributions to NSM-based educa-
because it considered four variables of human tion. Projects that warrant recognition are
experience: physiological, psychological, soci- NSM-guided courses and/or curricula, teaching
ocultural, and developmental, with the spiri- strategies, educational tools, and/or publica-
tual variable added soon thereafter. Before tions. Education applications may be at the as-
long, the potential of using the model for cur- sociate, baccalaureate, master’s, or doctoral level
riculum development was recognized at all of education. Activities of this Academy include

7991_Ch11_165-182 12/08/19 5:25 PM Page 177
the funding of two awards—the Rosalie Sanders, 1995) is used “to assess, resolve, pre-
Mirenda Education Fellow Award and the Lois vent, and evaluate stressors in any type of admin-
Lowry Education Grant. Information about istrative setting; [and] measures the total system
the Education Academy and awards can be response to an environmental stressor” (Fawcett
found at https://www.neumansystemsmodel. & DeSanto-Madeya, 2013, p. 152). The Systems-
org/nsm-education-academy/. Based Assessment Tool for Child Day Care
Centers (Bowman, 1982) “guides assessment of
Application of the Neuman Systems stressors in child day-care centers” (Fawcett &
Model to Nursing Administration DeSanto-Madeya, 2013, p. 152).
and Management
Although there is relatively little literature ad- Application of the Neuman Systems
dressing use of the NSM in administration Model to Nursing Research
compared with the literature addressing practice
Each edition of The Neuman Systems Model
and education, the available literature empha-
from the second to the fifth (1989–2011) pro-
sizes how complex systems greatly benefit by
vides a chapter that summarizes the research
using a systems approach as a guide to manage-
based on the model completed in the years be-
ment. For example, the purpose of the Magnet
tween the editions. Through the years, the
recognition program is to promote high-quality
growth of NSM-based research is evident. In
care within a culture that supports excellent
the early years, most of the research was de-
nursing practice (McClure, 2005). One of the
scriptive, focusing on one concept from the
attributes of Magnet status is practicing from a
model, such as stressor reactions or primary
professional model of care, such as the NSM.
prevention interventions. Many of the early
Guidelines for administration of health-care
studies were completed by master’s and doc-
services, which were developed by Shambaugh,
toral students as fulfillment of requirements for
Neuman, and Fawcett (2011), are summarized
advanced degrees (Neuman & Fawcett, 2011).
and updated here. The guidelines are as follows:
Guidelines for NSM-based research, which
■ The client system (individuals, families were proposed by Louis, Gigliotti, Neuman,
and other groups, communities, and social and Fawcett (2011), are summarized and up-
issues) is the focus of NSM-based health- dated here. The guidelines are as follows:
care services. In addition, the entire staff ■ The purpose of NSM-guided research is
and/or each department of a health-care
to understand the effects, cost, benefits,
organization can be considered the client
and utility of primary, secondary, and
system.
tertiary prevention as intervention on
■ The purpose of health-care services
retention, attainment, and maintenance
administration is to foster delivery of

of optimal client system stability.
primary, secondary, and tertiary preven- ■ All concepts and propositions of the NSM
tion as intervention, the goal of which is
are to be studied with an emphasis on prob-
retention, attainment, and maintenance
lems that address the impact of stressors on
of optimal client system stability.
optimal client systems stability, taking into
■ Administrators and staff understand
account all interacting variables (physiologi-
systems thinking, as well as how to apply
cal, psychological, sociocultural, develop-
the NSM, and are willing to do so using
mental, spiritual) and the lines of defense
strategies and policies that emphasize the
and resistance from both the client system’s
effect of beneficial and noxious stressors
and the researcher’s perspectives.
on optimal client systems stability. ■ Research designs may be qualitative, quan-
Two tools have been developed for use titative, or mixed-methods approaches,
with health-care organizations as client systems. with appropriate techniques used for data
The Neuman Systems Management Tool for analysis. Mediator and moderator analyses
Nursing and Organizational Systems (Kelley & should be used to account for the effects of

7991_Ch11_165-182 12/08/19 5:25 PM Page 178
the normal line of defence and the flexible A particularly important opportunity for net-
line of defense, respectively. Existing data working is connections with global colleagues
sets may be used to reinterpret findings who are implementing country- and culture-
within the context of the NSM. appropriate uses of the NSM. More than 12 coun-
tries have been introduced to the NSM over the
The numerous research instruments that have
years. Especially noteworthy is the work by
been used to measure NSM concepts are listed
NSM colleagues in Holland, who have adopted
and briefly described in Fawcett and DeSanto-
the model widely primarily due to its translation
Madeya (2013). These instruments include
into Dutch (Merks, Verberk, de Kuiper, &
measures of stressors, coping strategies, lines of
Lowry, 2012). The International Resources sec-
defense and resistance, needs assessment, client
tion in the NSM Resources folder at https://
system perceptions, client system variables, and
www.neumansystemsmodel.org includes refer-
prevention interventions. References for these
ences for several editions of a Dutch version of
instruments are available in the NSM bibliogra-
the NSM by Verberk and colleagues. Also in-
phy (see the NSM Resources folder at http://
cluded in this section of the website are Power-
www.neumansystemsmodel.org).
Point files that are translations of overviews of
The Neuman Systems Model Research Institute
the NSM from English into various languages,
was founded by NSM Trustee Eileen Gigliotti.
such as Dutch and Spanish.
The purpose of the Research Institute is to en-
Networking also can occur through use of the
courage generation and testing of middle-range
Neuman Archives, which were established to
and situation-specific theories that are derived
preserve and protect the work of Betty Neuman
from the NSM (Gigliotti & Fawcett, 2011).
and others working with the NSM. The archives,
The Institute sponsors two types of awards—the
previously located at Neumann University in
John Crawford Award and the Patricia Chad-
Aston, PA, are now housed in the Barbara Bates
wick Research Grant. Information about the
Center for the Study of the History of Nursing
Research Institute and awards and grants can
at the University of Pennsylvania. For more in-
be found at https://www.neumansystemsmodel.
formation about the Bates Center, see http://
org/nsm-research-institute/.
www.nursing.upenn.edu/history/about-us/. Visi-
tors must make an appointment ahead of a visit
Networking to Enhance Applications to access the Archives by emailing the University
of the Model of Pennsylvania.
Opportunities exist to network with others
using the NSM in a variety of applications and Value of the Neuman Systems Model
settings. One way is to attend the Biennial for the Future
Neuman Systems Model International Sym- Theory development is the hallmark of any
posium. Each biennium, the Neuman Systems profession. The NSM continues to guide devel-
Model Trustees Group sponsors an interna- opment of many theories, and its utility is con-
tional symposium where nurses and other tinually supported through research findings;
health-care team members, as well as the Prac- thus, it becomes increasingly more valuable as
tice Center, Education Academy, and Re- the basis for high-quality evidence-based client
search Institute awardees, present their system care and for the advancement of the dis-
NSM-guided work and share new insights cipline of nursing.
that advance understanding of the NSM con- The continuing derivation of middle-range
cepts and propositions, as well as how the and situation-specific theories from the NSM is
NSM is used as a guide for innovative research imperative. The concepts of wholism, wellness,
and practice projects, educational programs, and prevention as intervention used to attain, re-
and administration of health-care services. In- tain, and maintain optimal client system stability
formation about past and future symposia is are as viable and valuable today in our complex
available in the Conferences folder at https:// health-care system as they were in 1970 when
www.neumansystemsmodel.org. the NSM was first proposed.

7991_Ch11_165-182 12/08/19 5:25 PM Page 179
Practice Exemplar
This practice exemplar is fictional and pres- both perceptions of the stressors and found no
ents an example of how the NSM can be discrepancies. The nurse identified the intrap-
applied to a practice situation where the ersonal, interpersonal, and extrapersonal stres-
client systems are individuals and a family. sors that made up Gloria’s environment. To
The individual client systems are Gloria and ensure the assessment was wholistic and com-
her mother, Susan. Together, Gloria and prehensive, she identified the physiological,
her mother comprise a family as the client psychological, sociocultural, developmental,
system. and spiritual variables that are part of each of
A nurse whose practice is guided by the the identified stressors. Gloria indicated that
NSM met Gloria while providing care for caring for her mother was her major stressor.
her mother, Susan, in Gloria’s home. Susan Gloria expressed that while providing her
is a 74-year-old woman diagnosed with mother’s care was a challenge it also brought
Alzheimer’s disease. Gloria has been her her a sense of purpose and meaning.
mother’s caregiver for 4 years. The nurse uses
Assessment of Intrapersonal Stressors
best practices to guide her work. She recently ■ Physiological: Gloria experiences occa-
read Jones-Cannon and Davis’s (2005) re-
sional signs and symptoms of increased
search about coping strategies of African
anxiety such as rapid heart rate and
American caregiving daughters. The authors
increased blood pressure.
found that African American caregivers of a ■ Psychological: Gloria occasionally worries
family member with dementia or a stroke
about the future, but she tries to focus on
perceived that attending support groups and
the present and prides herself on her
knowing their parent needed them positively
sense of humor. Gloria expresses confi-
influenced their caregiving experience. Most
dence in providing safe care. Gloria tries
caregivers indicated that religion provided
to maintain emotional control; however,
them with a strong tolerance for the caregiv-
she admits to crying episodes when alone.
ing situation and served to mediate strain. ■ Sociocultural: Gloria values her belief that
Caregivers who voiced a lack of support from
African American families take care of
family, especially siblings, felt more anger
their older adult family members.
and resentment. ■ Developmental: Gloria is in Erikson’s
The nurse used this new knowledge to en-
(1959) developmental stage of middle
hance the nursing process with Gloria. By
adulthood with its challenge of generativ-
using the Neuman Systems Model Assess-
ity versus stagnation. She strives to look
ment and Intervention Tool, she learned that

outside of herself to care for others.
Gloria is a 52-year-old divorced African ■ Spiritual: Gloria reports that religion,
American woman who is employed full-time
faith, and prayer help her to cope with
by a company for which she enjoys working.
caregiving demands. She finds meaning
Gloria has a teenage daughter who lives with
and purpose in this current calling.
her and a grown son who lives away from
home. Gloria attends the Baptist church in Assessment of Interpersonal Stressors
her neighborhood two or three times a week, ■ Physiological: Gloria occasionally has in-
enjoying connections with people from her terrupted sleep when her mother awakens
congregation; she attributes this experience and wanders during the night.
to strengthening her ability to care for her ■ Psychological: Gloria reminds herself when
mother. physically caring for her mother that this

The nurse assessed stressors as they were is an expected part of her mother’s aging.
perceived from her nursing perspective and ■ Sociocultural: Gloria is the full-time care-
by Gloria herself. The nurse then compared giver of her mother. She works full-time
(continued)

7991_Ch11_165-182 12/08/19 5:25 PM Page 180

with supportive people but does not The nurse and Gloria identified Gloria’s
attend an Alzheimer’s support group full-time role as a caregiver for her mother
because she did not know anything with Alzheimer’s disease as a significant stres-
about them. Gloria invites her daughter sor. The nurse considered the findings of
to assist her with some areas of care, as Jones-Cannon and Davis’ (2005) study, which
she believes her daughter’s time with her revealed that caregivers of a family member
grandmother is important. Her daughter with dementia believed attendance at a sup-
willingly helps with care when called port group influenced their caregiving in a
upon, though Gloria does not want to positive way. One of the nursing diagnoses
spoil the relationship between her they determined was “risk for caregiver role
mother and her daughter. strain.” Although this was identified as a risk,
■ Developmental: Gloria has significant they both agreed there were no relevant signs
positive relationships with her coworkers. or symptoms to support the existence of care-
■ Spiritual: Gloria is supported by her giver role strain at this time.
pastor and friends at church. Gloria The nurse recognized that Gloria’s and her
identifies a special connectedness own perceptions provided a glimpse of Gloria’s
with her daughter and mother during normal line of defense; they then mutually
caregiving activities. identified an immediate goal to strengthen
Gloria’s flexible line of defense. Specifically,
Assessment of Extrapersonal Stressors
■ Physiological: From a coworker, Gloria
the goal is that Gloria will report that she has
participated in a monthly Alzheimer support
received the gift of a comfortable bed
group session. Together, Gloria and the nurse
mattress that promotes her sleep.
■ Psychological: Gloria shared that reading
planned nursing actions for primary prevention
as intervention. An example of primary pre-
her Bible helps her think positive
vention as intervention is involving Gloria’s
thoughts.
■ Sociocultural: Gloria earns $35,000
daughter in future meetings with the nurse,
and to explore opportunities for her to be more
per year.
■ Developmental: Gloria can feel “in
involved in direct caregiving activities. Gloria’s
son will be invited to attend a future meeting
charge of the situation” with a comfort-
with Gloria and the nurse when possible. The
able house for her mother, as well as for
desired outcome for Gloria was retention of
her daughter, and for her son when he is
optimal client system stability.
able to visit.
■ Spiritual: Gloria attends church services
Although the risk for caregiver role strain
was a potential nursing diagnosis, the nurse

in her neighborhood two or three times
understood that she should have a potential
a week.
plan for secondary and tertiary prevention as
The nurse applied the NSM Nursing interventions. Examples of these interventions
Process Format (Neuman & Fawcett, 2011) include the following:
and constructed a plan of care encompassing ■ Secondary prevention as intervention: As-
(1) nursing diagnosis; (2) nursing goals ne-
sist Gloria to schedule respite care for a
gotiated with Gloria, including appropriate
determined period of time.
levels of prevention as interventions; and ■ Tertiary prevention as intervention: Pro-
(3) nursing outcomes. The nurse prepared a
vide ongoing education about practical
comprehensive list of nursing diagnoses
resources available for caregiver support at
based on a wholistic and comprehensive as-
each visit.
sessment and then prioritized the list. She
validated her findings with Gloria to ensure In an ongoing process, the nurse evaluated
that their perceptions were consistent. the outcomes of the secondary and tertiary

7991_Ch11_165-182 12/08/19 5:25 PM Page 181

prevention interventions to determine if the plan and provide wholistic and comprehen-
goal of reduction or elimination of caregiver sive care for Gloria’s mother, Susan, and by
role strain was achieved, optimal client sys- strengthening Gloria’s lines of defense, the
tem stability was maintained, and reconsti- nurse strengthened Gloria’s mother’s lines of
tution occurred. defense.
The nurse also used the Neuman Sys-
tems Model Nursing Process Format to
Summary
The NSM has been used for more than four The model is well accepted by nurses and
decades, first as a teaching tool and later as a other health-care team members and is
conceptual model to observe and interpret the guided by the Neuman Systems Model
phenomena of nursing and health care globally. Trustees, who are committed to improving
The NSM is well positioned as a contemporary client system health worldwide through ap-
and future guide for health-care practice, replication of the NSM for practice, education,
search, education, and administration far into research, and administration. See https://
the 21st century. The concepts and processes www.neumansystemsmodel.org/trustees/
of the model are so universal and timeless and https://www.neumansystemsmodel.org/
that they are easily understood by all members officers-20172019/. The NSM website (https://
of health-care teams worldwide (Neuman & neumansystemsmodel.org) includes a great
Fawcett, 2011, p. 317). deal of information and many resources.
Questions for Reflection ■ What tools and additional resources are

available to guide nurses wishing to use
and Discussion the NSM in practice?
■ How can the NSM be used to guide care ■ What are the major concepts of the
in a nursing practice situation? Provide a NSM? Provide specific examples of these
detailed example. for a current nursing practice area.

7991_Ch11_165-182 12/08/19 5:25 PM Page 182

7991_Ch12_183-210 13/08/19 3:31 PM Page 183
Helen Erickson, Evelyn

CHAPTER
12
Tomlin, and Mary Ann
Swain’s Theory of Modeling
and Role-Modeling
Helen L. Erickson and
Margaret E. Erickson Introducing the Theorist
My life journey, filled with challenges and
opportunities, helped me discover the essence
of my Self, understand my Reason for Being,
and uncover my Life Purpose (H. Erickson,
Applications of the Theory
2006a). My Self is reflected in my values and
Practice Exemplar
beliefs; my Reason for Being is to learn that
Summary
unconditional love is the key to human rela-
tionships; and my Life Purpose is to facilitate
growth in others. The following snippets of my
journey offer an occasional glimpse into my
Self and the underlying philosophy of model-
ing and role-modeling (MRM).
Born and raised in north-central Michigan
with one older brother and two younger sisters,
I learned that our early experiences affect who
we become. My father worked for the high-
way department; our mother cared for the
family and worked part-time as a retail clerk.
I learned that family connections, caring about
others, positive attitudes, respect for the envi-
ronment, and hard work are essential.
I was 5 years old when World War II was
declared. Although too young to understand
the implications of the war, I learned that it
was important to stand up for our beliefs and

life principles.
I learned that anything is possible if we are
persistent, our goals have integrity, and we are
honest with others and ourselves. I started
working when I was about 10 years old. My
jobs included babysitting, keeping house for a
family in need, waitressing, and clerking. Each
was an opportunity to learn about myself, and
each was a step toward nursing school.
I enrolled in a diploma program for nurses,
and in my junior year, I met my future husband
and his family. His father, Milton Erickson,
well known for his work with mind–body
healing, taught me that people know more
183
7991_Ch12_183-210 13/08/19 3:31 PM Page 184
about themselves than health-care providers affairs, and then moved to the University of
do, that their inner-knowing is essential to Texas, where I assumed the role of professor
healing, and that we can help them by attend- and chair of adult health nursing. When I re-
ing to their worldview. I committed to married tired in 1997, the Helen L. Erickson Endowed
life, moved to Texas, and accepted the position Lectureship on Holistic Nursing was estab-
of head nurse in the emergency room of the lished at the University of Texas in Austin.
Midland Memorial Hospital. I have authored or coauthored chapters
Between 1959 and 1967, I worked in a va- on MRM and/or holistic nursing (Clayton,
riety of settings in Texas, Michigan, and Puerto Erickson, & Rogers, 2006; H. Erickson,
Rico and welcomed four children into our fam- 1990a, 1990b, 1996, 2002, 2006b, 2006c,
ily. I learned valuable lessons about blind prej- 2006d, 2006e, 2007, 2008, 2010; M. Erickson,
udice, discrimination, and staying true to self; H. Erickson, & Jensen, 2006; Walker &
about how personal stories provide insight into Erickson, 2006). Advancing the holistic
client needs; and about the uniqueness of peo- healing–caring process is my mission, my life
ple and how limiting labels did not capture work; MRM is a vehicle for that purpose.1
their wholeness. I had opportunities to develop
a professional practice model.
In 1974, I completed my RN-BSN pro- Overview of the Theory
gram at the University of Michigan and was MRM is based in several nursing principles
recruited as a faculty member and consultant that guide the assessment, intervention, and
at the University Hospital. evaluation aspects of practice. These principles,
I enrolled in the master’s program in medical– reflected in the data collection categories
surgical and psychiatric nursing and graduated (H. Erickson et al., 2009, pp. 148–168),
in 1976. During this time, Evelyn Tomlin and are linked to intervention aims and goals
I talked freely about the nursing model I had (H. Erickson et al., 1983/2009, pp. 168–201).
derived from practice. I labeled and developed Although both intervention aims and goals in-
the Adaptive Potential Assessment Model and volve nursing actions, they differ in their pur-
worked with Mary Ann Swain to test some of my pose. Nursing interventions should have intent;
hypotheses (H. Erickson, 1976; H. Erickson, nurses should aim to make something happen
1984; H. Erickson & Swain, 1982). I contin- that facilitates health and healing when they in-
ued in my faculty position and advanced to teract with clients. There should also be markers
chairman of the undergraduate program and that help us evaluate the efficacy of our
assistant dean. activities—intervention goals. Table 12-1
Over the next 10 years, my model of nursing shows the relations among MRM principles of
acquired a life of its own. By the early 1980s, nursing, data needed to practice this model,
I had speaking invitations, but little had been the aims of nursing actions, and specific goals.
written (H. Erickson, 1976; H. Erickson &
Swain, 1982). Together Evelyn, Mary Ann, and Modeling
I further elaborated the concepts. The term The modeling process involves assessing the
modeling and role-modeling (MRM), first coined client’s situation. It starts when we initiate an
by Milton Erickson, was selected as the best interaction with an individual and concludes
descriptor of the work. The original edition, with an understanding of that person’s perspec-
printed in November 1982 (H. Erickson, tive of his or her circumstances. We aim to learn
Tomlin, & Swain, 1983/2009), has had eight how that individual describes the situation,
reprints, and is now considered a classic by the what he or she expects will happen, and his or
Society for the Advancement of Modeling and her perceived resources and life goals. As we lis-
Role-Modeling (SAMRM). I completed my ten and observe, we interpret the information
PhD in 1984, left Michigan in 1986, spent
2 years at the University of South Carolina 1For additional information, see the bonus chapter content
School of Nursing as associate dean of academic available at http://davisplus.fadavis.com.

7991_Ch12_183-210 13/08/19 3:31 PM Page 185
CHAPT ER 1 2 ■ Helen Erickson, Evelyn Tomlin, and Mary Ann Swain’s Theory of Modeling and Role-Modeling 185
Table 12-1 Relations Among Principles, Data Categories, Intervention Goals, and Aims
Principles Categories of Data Goals Aims

The nursing process requires Description of the Develop a trusting and Build trust.
that a trusting and functional situation functional relationship
relationship exist between between self and your
nurse and client. client.
Affiliated-individuation is Expectation Facilitate a self- Promote
contingent on the individual’s projection that is client’s positive
perceiving that he or she is an futuristic and positive. orientation.
acceptable, respectable, and
worthwhile human being.
Human development is dependent Resource potential— Promote affiliated- Promote
on the individual’s perceiving that external individuation with the client’s control.
he or she has some control over minimum degree of
life while concurrently sensing a ambivalence possible.
state of affiliation.
There is an innate drive toward Resource potential— Promote a dynamic, Affirm and
holistic health that is facilitated internal adaptive, and holistic promote
by consistent and systematic state of health. client’s
nurturance. strengths.
Human growth is dependent on Resource potential— Promote (and nurture) Set mutual
satisfaction of basic needs and internal coping mechanisms that goals that
facilitated by growth-need satisfy basic needs are health
satisfaction. and permit growth-need directed.
satisfaction.
Goal and life tasks Facilitate congruent
actual and chronological
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: Unicorn Unlimited Books.
using the constructs embedded in the theory. model (Table 12-4; H. Erickson et al.,
Stated simplistically, modeling is the process we 1983/2009, pp. 148–167). We interpret the
use to build a mirror image of an individual’s meaning of information acquired and search for
worldview. This worldview helps us understand linkages and patterns among the data that will
what that person perceives to be important, what help us understand the client’s worldview. As
has caused his or her problems, what will help, and we analyze the data, implications for nursing
how he or she wants to relate to others. actions emerge (H. Erickson et al., 2009,
Table 12-2 shows the categories of data and pp. 168–220). Nursing actions are then artistically
the type of information needed in the model- designed with intent (i.e., the aims of interven-
ing process. Table 12-3 shows the priority tions) and specific outcomes (i.e., intervention
given to the information we collect. Primary goals). Our overall objectives are to help people
and secondary data are essential for profes- grow, heal, and find meaning in their experi-
sional practice, whereas tertiary data are added ences (Erickson, 2006e). The following sections
as needed. elaborate each of these objectives. The first sec-
tion addresses the philosophical assumptions
Role-Modeling that underlie this model; theoretical underpin-
The role-modeling process requires both objec- nings follow with implications for practice.
tive and artistic actions. First, we analyze the Finally, the global applications of MRM are
data using theoretical propositions in the MRM presented.

7991_Ch12_183-210 13/08/19 3:31 PM Page 186
Table 12-2 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 client’s perception of the problem
2. Etiology of the problem
3. Client’s 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: Unicorns Unlimited Books.
Table 12-3 Sources of Information

Primary Source Client’s self-care knowledge
Secondary Source Information from family and nurses’ observations
Tertiary Source Medical records and other information related to client’s case
Table 12-4 Selected Theoretical Propositions in Modeling and Role-Modeling 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 deficits.
5. Affiliated-individuation is dependent on one’s 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.
personal philosophy affects how we identify

Philosophical Assumptions important ways of knowing (H. Erickson &
Nursing has a metaparadigm that includes M. Erickson, 2010a), how we define and op-
four extant constructs: person, environment, erationalize the constructs of nursing, and
health, and nursing; sometimes social justice therefore how we articulate our models. For
is added as a fifth construct (Schim, Benkert, this reason, it is important to be clear about
Bell, Walker, & Danford, 2007). The oper- our own philosophical beliefs and how they
ational definitions of these constructs pro- affect our conceptual definitions and our the-
vide the context necessary to clarify how an oretical models. Nurses can use clear philo-
individual’s actions are unique to nursing as sophical statements to determine whether
opposed to the actions of another profession. the underpinnings of a theoretical model are
Although all nursing theories are developed consistent with their own belief systems
and articulated within this context, our (H. Erickson, 2010b). When they are not,

7991_Ch12_183-210 13/08/19 3:31 PM Page 187
discrepancies among nursing’s philosophical

beliefs, the nurse’s personal belief system,
and the theoretical propositions can create Biophysical
dissonance that impedes the nurses’ ability
to use the model (H. Erickson et al., 2009).
The philosophical assumptions underlying
and spiritual D.G.P.I.

the MRM theory and paradigm are described
Genetic base
in the text that follows. The first section pres-
ents MRM’s orientation toward two of nurs- Cognitive Psychological
ing’s metaparadigm constructs: person and
environment. Health, nursing, and social jus-
tice are described in the following sections.
Person and Environment

Humans are inherently holistic (H. Erickson, Social
2007; H. Erickson et al., 1983/2009). This
means that all aspects of the human are inter-
connected and dynamically interactive; what
affects one part affects another. This is differ- A The Holistic model
ent from the wholistic person, wherein the
parts are associated but not necessarily inter-
connected or interactive (Fig. 12-1).
When we approach people from a wholis-
tic perspective, we can break them down into
systems, organs, and other parts. When we
view them as holistic, we understand that all Biophysical Social
the dimensions of the human being are inter-
connected; what affects one part has the po-
tential to affect other parts. Our holistic
nature is manifested through our innate in-
stincts and drives necessary for humans to ma- Psychological Cognitive
neuver through the pathways of their life
journey. Table 12-5 provides examples of
each of these. Although some might argue
that all animals have an innate instinct to cope
and ability to receive and interpret stimuli,

most would agree that not all animals have an
innate drive to receive stimuli in a cognitive B The Wholistic model
form, to acquire skills necessary to perceive FIG 12-1 ■ Holism versus wholism.
and understand stimuli, to give and receive
feedback, the freedom to speak, or the free-
dom to choose. These latter characteristics As holistic beings, our mind, body, brain,
are unique to the human species and motivate and spirit are inextricably interrelated with con-
our behaviors (Maslow, 1968, 1982). I have tinuous feedback loops. Cells in each dimen-
added one instinct and two human drives. sion can produce stimuli affecting responses in
They are, respectively, an inherent need cells of other dimensions. Cellular responses
for holistic well-being, a drive for healthy af- have the potential to become new stimuli, cre-
filiated-individuation, and a drive for self- ating a cascade of reactions around and among
actualization. These instincts affect how we the dimensions of the human being. These in-
function as holistic beings. teractions are dynamic and ongoing.

7991_Ch12_183-210 13/08/19 3:31 PM Page 188
Table 12-5 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 mind–body–spirit interconnectedness 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 affiliated-individuation
To be self-actualized
To agree that we are holistic is to believe ourselves as individuated from these same
that we are human beings, living in a context people. We call this affiliated-individuation
that includes all that is within us and within (Acton, 1992; H. Erickson et al., 1983/2009,
our external environment—holistic beings, p. 47; M. Erickson et al., 2006, pp. 182–207).
constantly in process both internally and ex- Our drive to be both affiliated and individu-
ternally with the environment and universe. ated at the same time mandates a balance
These dynamically interactive dimensions can- between being connected while perceiving a
not be separated without a loss of information sense of one’s self as an independent human
about the person, a loss that diminishes our being. A balanced affiliated-individuation is
ability to fully understand the person’s situa- achieved through our interactions with others.
tion, who we are in relation to that person, and This balance, at any point in our life, deter-
how we affect one another. mines how we relate to others in the following
Humans are inherently intuitive. We know years (M. Erickson, 2006a).
(at some level) what we need. We know what Although we are social beings with a drive
has made us sick and what will help us get for affiliated-individuation with others, we are
well, grow, develop, and heal. We have instinc- also spiritual beings with an inherent drive to
tual information about our own personhood be connected with our soul. More specifically,
and our mind–body–spirit linkages. This infor- our drive for individuation is to fulfill our
mation is called self-care knowledge. Our per- psychosocial needs while doing soul-work
ceptions of what we have available to help us unique to our life journey (H. Erickson, 2006a;
are called self-care resources. Self-care resources M. Erickson et al., 2006).
are both internal and external. We have re-
sources within ourselves as well as resources Health
within our external environment. Our actions, Health is a matter of perception. It is a state
thoughts, biophysical responses, and behavior of well-being in the whole person, not just a
that help us get our needs met are our self-care part of the person. It is not the presence, ab-
actions. We are inherently social beings with a sence, or control of disease; one’s ability to
drive to grow and develop, to become the most adapt; or one’s ability to perform social roles.
that we can be, find meaning in our lives, fulfill Instead, it is a eudemonistic health that incor-
our potential, and self-actualize. However, we porates these and more. It is a sense of well-
are vulnerable. Our ability to grow and develop being in the holistic, social being. It includes
is dependent on repeated satisfaction of our one’s perceptions of his or her quality of life,
needs. We want and need to be affiliated with ability to find meaning in one’s existence,
others. Simultaneously, we need to perceive and a capacity to enjoy a positive orientation

7991_Ch12_183-210 13/08/19 3:31 PM Page 189
toward the future. It is possible for persons Theoretical Constructs

with no obvious physical problem to perceive People have an innate instinct to cope and
a low level of health, while at the same time adapt to stressors and related stress responses
others, taking their last mortal breath, may that confront us constantly. We adapt as
perceive themselves as very healthy. The per- much as we can, given our life situation. We
ception of health status is always related to need oxygen, glucose, and protein to maintain
perceived balance of affiliated-individuation. our physical systems; we also need to feel safe
Nursing and to be loved. When these needs are per-
ceived to be unmet, they create stressors;
Nursing is the unconditional acceptance of the stressors produce the stress response. Stress
inherent worth of another human being. When responses can become new stressors mandat-
we have unconditional acceptance for another ing still more responses, and so on (Benson,
person, we recognize that all humans have an 2006, pp. 240–266; H. Erickson, 1976;
innate need to be loved, to belong, to be re- H. Erickson et al., 2009). Many of our stress
spected, and to feel worthy. Unconditional ac- responses are instinctual, a part of our human
ceptance of a person as a worthwhile being is makeup; however, some have to be learned and
not the same as accepting all behaviors without developed. As our needs are met, the stressors
conditions. It does mean, however, that we rec- decrease and we are able to work through the
ognize that behaviors are motivated by unmet stress response.
needs. Our work, then, is to help people find
ways to get their needs (H. Erickson, 2006d) Adaptive Potential
met without harming themselves or others. Our ability to mobilize resources at any mo-
We do this through nurturance and facili- ment in time can be identified as our adaptive
tation of the holistic person. Our goal is to help potential. The adaptive potential assessment
people grow, develop, and heal. We use all of model (APAM; Fig. 12-2), first labeled in
our skills acquired through formal education as 1976 (H. Erickson, 1976; H. Erickson &
well as our own innate ability to connect with Swain, 1982; H. Erickson et al., 2009), was
others to help them to live meaningful lives. derived by synthesizing Selye’s (1974, 1976,
We do this from the beginning of physical life 1980, 1985) work with that of George Engel
to the end, even as people are taking their last (1964; 1968). Our adaptive potential has three
breath. Within this context, our intent to facil- states: equilibrium, arousal, and impoverish-
itate when we interact with another human ment. Equilibrium, a state of nonstress or eu-
being is important. stress, represents maximum ability to mobilize
Social Justice resources. The individual in equilibrium is in a
healthy balance between need demands and

As professional nurses, we are committed to need resources.
live by the ethics of our profession, serve as
advocates for our clients, and serve the public
as defined by our professional standards. For
nurses who use the MRM theory, this means Equilibrium
that we are committed to recognize the indi-
vidual’s worldview as valid information, to act
Co
r
on that information with the intent of nurtur-

so
pin
Str
es
ing and facilitating growth (H. Erickson,

g
es
Str
pin
so
2006c) and well-being in our clients, and to

Co
practice within the context of the Standards of

Holistic Nursing as defined by the American Stressor
Holistic Nurses Association (AHNA, 2018) Stress
Arousal Impoverishment
and recognized by the American Nurses As- FIG 12-2 ■ The adaptive potential assessment
sociation (ANA, 2015). model.

7991_Ch12_183-210 13/08/19 3:31 PM Page 190
Arousal and impoverishment are both stress Deprivation Deficit Unmet Met Satisfied Assets
states; needs are unmet, creating stressors and 0 1 2 3 4 5
the related stress responses. However, people in FIG 12-3 ■ The needs status scale, 0 to 5.
arousal are temporarily able to mobilize their re-
sources, whereas those in impoverishment are
not. Persons in the first group (arousal) need growth needs emerge when basic needs are
help solving their problem, finding alternatives. met (to some degree). Unmet growth needs
They tend to be tense and anxious but do not do not create tension unless they are related
demonstrate depleted resources through the ex- to a basic need. Instead, satisfaction of growth
pression of fatigue and sadness. On the other needs creates tension. The need increases in
hand, impoverished people show the wear and intensity. Until one feels satiated, the need to
tear of prolonged stress. They have diminished continue to behave in ways that will meet
physical resources and are fatigued and sad. Peo- growth needs continues.
ple in arousal are at risk for becoming impover-
ished, and impoverished people are at risk for Need Satisfaction and the Object
depleting their resources, getting sick, develop- Attachment Process
ing complications, and even dying (Barnfather, Objects that repeatedly meet human needs
1987; Barnfather & Ronis, 2000; Benson, 2006, become attachment objects. These objects take
pp. 242–254; H. Erickson, 1976; H. Erickson on significance unique to the individual, are
et al., 2009, pp. 75–83; H. Erickson & Swain, both human and nonhuman, have a physical
1982). A person’s ability to cope is related to form (so they stimulate one of the five senses)
how well his or her needs are met at any given or are abstract (such as an idea), and are nec-
point in time. essary throughout life. When a person per-
ceives that the object is or will be lost, a
Human Needs grieving response occurs. Loss is a subjective
Human needs, classified as basic, social, and experience known by the individual; it can be
growth needs, drive our behavior. They pro- real, threatened, or perceived. Any loss pro-
vide motivation for our self-care actions and duces a grieving process. One’s difficulty in re-
emerge in a quasi-hierarchical order. Physio- solving the loss depends on the significance of
logical needs must be met to some degree the lost object. The grieving response is nor-
before social needs emerge. Growth or mal, occurs in a predetermined sequence, and
higher-level needs emerge after the basic and is self-limited. Normal grieving processes take
social needs have been met to some degree about 1 year (Fig. 12-4).
(for a more detailed taxonomy of human Grief resolution occurs as the individual
needs, see H. Erickson, 2006a, pp. 484–485). finds new ways to view the lost object or finds
Basic needs are related to survival of the alternative objects that meet their needs. Com-
species. When they are unmet, tension rises, monly accepted processes of grief include
motivating behavioral response(s) necessary sequential phases of shock/disbelief, anger,
to decrease the tension. When self-care ac- bargaining, sadness, and acceptance (Kübler-
tions decrease the tension, the need dissi- Ross, 1969). Other models (Engel, 1964;
pates. When the need is completely satisfied, Bowlby, 1973) indicate slightly different phases
the tension disappears. When needs are met (M. Erickson, 2006, p. 229). Table 12-6 com-
repeatedly, need assets are built. Conversely, pares three of these models. Their differences
when the need is not met, the tension rises, are due to the nature of the lost object, its mean-
and need deficits emerge. When the tension ing to the individual, and the resources accrued
continues, need deprivation exists. Need sta- before the experienced loss. Resources are based
tus can be classified on a 0 to 5 scale ranging on an ability to work through the normal devel-
from deprivation to asset status (Fig. 12-3). opmental tasks encountered during the human
Growth needs are different. Because people journey (H. Erickson, 2006c). This issue is dis-
have an innate drive for self-actualization, cussed further in the text that follows.

7991_Ch12_183-210 13/08/19 3:31 PM Page 191
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 or
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
FIG 12-4 ■ The needs–attachment–development–loss–reattachment model.
Table 12-6 Stages of Grief According to Contributing Authors
Engel Kübler-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 client’s world (p. 229). Cedar Park, TX: Unicorns Unlimited Books.
Attachment to new objects is necessary for children as preschoolers often experience a

continued growth and grief resolution. The loss when their children start school and be-
new object can be the same object, perceived come increasingly independent. It is common
in a new way, or a completely new object. to see these mothers attach to their child’s
Sometimes transitional objects are used to fa- baby shoes, pictures, or some other symbol of
cilitate this process. Transitional objects are who they were in their previous life stage.
those that symbolize the lost object and are Morbid grief emerges when the individual
never human but are almost always concrete. is unable to find alternative objects that repeat-
For example, mothers attached to their edly meet their needs. Because we are holistic

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beings, morbid grief has the potential to result other. They are not interested in the well-being
in physical symptoms, illness, and over the of the other, might be threatened by growth in
long period, disease. What happens in one part significant others, and are intolerant of the
of the holistic person has the potential of cre- uniqueness of others. More interested in what
ating disease in another part, disease that be- they can get from someone than what they can
comes distressful, mandates mobilization of give, these people often view others as a source
resources often not available, and therefore of getting their basic needs met. As a result,
producing alternative biophysical responses, often unable to meet the needs of significant
depleting psychoneuroimmunological resources others, they are perceived as “needy people.”
(Walker & Erickson, 2006). Their life orientation is called a deficit orienta-
Behaviors that indicate emergence of mor- tion. Being and deficit orientations exist on a
bid grief include an inability to move on and let scale; most people have some of both. The bal-
go of the lost object, combined with vacillation ance between the two is what determines one’s
between anger and sadness (M. Erickson, 2006, overriding traits or personal attributes, one’s
pp. 209–239; Lindeman, 1944, pp. 141–148). values and virtues, and one’s ways of interact-
Initially individuals are able to focus their anger ing with others.
and sadness, but with time, anger grows into
hostility and sadness into depression. When Developmental Processes
this happens, people are less able to articulate People have an inherent drive for self-
the focus of their feelings or recognize the loss actualization. This requires that they pass
that produced the grieving response in the be- through predetermined chronological devel-
ginning. They often use language that describes opmental stages—stages with tasks that man-
giving up rather than letting go, and sometimes date attention as they emerge. Our ability to
express nostalgia for the lost object. In contrast, work on these developmental tasks depends on
those who have let go of the lost object, worked our ability to mobilize resources. Resources
through the normal grief response, and reat- are derived by getting our needs met at any
tached to a new object can usually describe the given time as well as our past experiences. Be-
importance of moving on. cause our experiences are always contextual,
how we resolve our developmental tasks will
Need Satisfaction and Life Orientation determine the resources we have to work on
The degree to which a person’s needs are met current tasks. As we work through a stage-
repeatedly determines how he or she relates to related task, a developmental residual is produced.
others; it affects his or her life orientation. This residual includes positive and negative
When needs are met repeatedly, people can attributes, strengths, and virtues. In our orig-
grow and develop, to integrate mind–body– inal work, we followed Erik Erikson’s (1994)
spirit, to perceive themselves as worthy human work to define eight stages, their tasks, and
beings, and to experience a healthy balance of the associated residual. Our more recent
affiliated-individuation. When this happens, work has expanded the stages to include one
they are interested in others as individuals who before birth and another at the time of death
are unique and worthwhile. They enjoy both a because the work of the soul affects the devel-
sense of connectedness and a sense of individ- opmental processes during one’s physical life
uation. Their life orientation is called a being (M. Erickson, 2006, pp. 121–181; Table 12-7).
orientation because they are interested in be-
coming all they can be and in relating with Sequential Development
others so that they too can self-actualize. Development occurs as a series of predeter-
On the contrary, when needs are repeatedly mined stages with specific tasks in each stage.
unmet, growth is limited, and people have dif- It is also chronological: unique, sequential
ficulty with their developmental processes. stage and their related tasks emerge during a
Their relationships with others exist within a specific time frame in our lives. During that
context of what can be obtained from the time, the task becomes predominant in our life

7991_Ch12_183-210 13/08/19 3:31 PM Page 193
Table 12-7 Developmental Stages, Residual, Virtues, and Strengths
Stages/Age Residual Virtue Strength(s)

Integration of Spirit Unity vs. duality Groundedness Awareness
(pre–post birth)
Building Trust Trust vs. mistrust Hope Drive toward future
(birth–15 months)
Acquiring Autonomy Autonomy vs. introspection Willpower Self-control
(12–36 months)
Taking Initiative Initiative vs. responsibility Purpose Drive
(2–7 years)
Developing Industry Competency vs. inferiority Competence Methodological
(5–13 years) problem solving
Developing Identity Self-identity vs. role confusion Fidelity Devotion
(11–30 years)
Building Intimacy Intimacy vs. isolation Love Affiliation with
(20–50 years) individuation
Developing Generativity Generativity vs. stagnation Caring Production
(midlife to 60s)
Ego Integrity Ego integrity vs. despair Wisdom Renunciation
(60s to transformation)
Transformation Reconnecting vs. disconnecting Oneness Peace, cosmic
(end of physical life) understanding,
compassion
Adapted with permission from Erickson, H. (Ed.). (2006). Modeling and role-modeling: A view from the client’s world
(Table 5.1, pp. 128–129). Cedar Park TX: Unicorns Unlimited Books.
journey, drawing resources, focusing attention, (2) need status, object attachment, loss, and
and motivating behaviors. new attachment status; and (3) developmen-
tal task resolution and need satisfaction. Se-
Epigenesis lected theoretical propositions, derived from
Development is also epigenetic. Although we these linkages, are shown in Table 12-4.
have specific tasks that focus our attention at Others exist, limited only by an understand-
specific times in life, we also rework earlier life ing of MRM.
tasks and set the framework for later tasks at

the same time. This later work is done within
the context of the appointed life task. Simply Applications of the Theory
stated, we repeatedly work on all the develop- MRM Practice Strategies
mental tasks at every stage of life, although we MRM practice strategies include processes of
have a key task that dominates at any given initiating the relationship and understanding
time. Our ability to manage multiple tasks is the data.
dependent on the residual we have produced
throughout the process and our current ability Initiating the Relationship
to have our needs met. Three sequential strategies are important for ini-
tiating the relationship in the MRM model:
Linkages (1) establishing a mindset, (2) creating a nurturing
Three key theoretical linkages exist in the space, and (3) facilitating the story (H. Erickson,
MRM model. Relations exist between or 2006b, pp. 309–317; Table 12-8). Each can be
among (1) adaptive potential and need status; done in seconds once the essence of the strategy

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Table 12-8 Three Strategies That Facilitate a Trusting–Functional Relationship

Establish a Mindset 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 client’s space. Recognize and respect client’s physical/
energetic space.
Connect spirit to spirit. Use eye contact, soft tones, and gentle touch
to connect with client.
Facilitate the Client’s Story Tap self-care knowledge. Address stimuli, encourage focus on
nurse–client linkage.
Relate to beliefs about client’s self-care
knowledge as primary.
Encourage client’s perceptions of the situation.
Adapted with permission from Erickson, H. (Ed.). (2006). Modeling and role-modeling: A view from the client’s world
(pp. 307–317). Cedar Park, TX: Unicorns Unlimited Books.
is understood. However, before starting, it is nec- Creating a Nurturing Space

essary to reflect on personal beliefs about human Creating a nurturing space follows naturally
nature and nursing and to consider how these af- when we have established a mindset. Our
fect one’s practice. This helps to clarify how to get goal is to create a caring–healing environment
personal needs met—a prerequisite to meeting the that fosters energetic connections with an-
needs of others. Unless we know how to initiate other person. Although one cannot force
our own self-care, we have difficulty mobilizing growth in others, we can create environments
the energy necessary to focus on the needs of our that nurture growth. We do this by decreas-
clients. Finally, we must open ourselves to the ing adverse stimuli while increasing positive
worth of each individual, to unconditionally ac- ones. It is important to remember that you
cept that each human has an inherent need to be are entering the client’s space and to respect
valued, to be treated with respect, and to live with it. Even though you may think it is important
dignity (H. Erickson & M. Erickson, 2018). to close the door, turn on the radio, or fluff
pillows, you will want to assess whether your

Establishing a Mindset actions serve to comfort the client. Each of
Establishing a mindset involves three strate- these processes helps you connect with your
gies: centering, focusing, and opening. Cen- client in such a way that you will initiate a
tering helps to organize our resources so that trusting relationship and create a caring–heal-
we can connect energetically with our client. ing environment. Any stimulus that affects
It requires that we temporarily put aside the five senses has the possibility of being
other thoughts, worries, or concerns and be- comforting, uncomfortable, or discomforting.
lieve that at some level we can discover what We can influence these by our actions in the
we need to know to help our clients; it re- milieu and by our interactions with our client.
quires us to focus on the other with the intent For example, a noisy hallway or bright lights
of nurturing their growth and facilitating shining in our eyes are stimuli that seem to
their healing (H. Erickson, 2006e). When drain energy from us, and no doubt our
we focus on our client’s needs, we open an en- clients experience the same thing. Or con-
ergetic connection, necessary for a caring– sider a beautiful picture, the glimpse of a fully
healing environment. leafed tree swaying in a gentle breeze, soft

7991_Ch12_183-210 13/08/19 3:31 PM Page 195
music of our choice, clean sheets against our Understanding the Data
skin, or the gentle touch of a loving person. There are three phases in understanding the
In thinking about how you respond to these information gained in MRM practice model:
stimuli, you will understand that these have data interpretation, data aggregation and data
the possibility of comforting another human analysis.
being. You will also understand that how you
touch, look, or speak to someone conveys a Data Interpretation
message about your intent to comfort or not The phase of data interpretation involves using
to comfort. Of course, it is extremely impor- the philosophical and theoretical underpin-
tant that we consider the individual’s cultural nings discussed earlier as we attend to
perspectives and values as we consider how to words, affect, and nonverbal cues, searching
create a nurturing space; what works for one for evidence of coping potential (i.e., adaptive
person does not for another. The only way we potential), needs status, and developmental
can know is to ask our clients or, when they residual. Sometimes it is necessary to clarify
are unable to speak for themselves, to ask what we observe to avoid superimposing our
their significant others. own interpretations on these data. For exam-
ple, clients might have a spouse or significant
Facilitating the Story other but not perceive this individual as
Facilitating the story is the third strategy that supportive. When this happens, they often
MRM nurses use. Disclosure of our clients’ describe them as “draining” rather than invig-
self-care knowledge provides basic information orating. We cannot always make these distinc-
needed before we can decide what nursing actions without asking the client how they
tions are required—information that provides perceive their relationship with their significant
insight into their worldview. We learn about other (H. Erickson et al., 2009, pp. 160–163). A
their perceptions and beliefs, what they believe person’s story usually includes information
about their current situation, what they expect about interactions among the dimensions of
will happen, what resources they believe they the holistic person, but nurses often have trou-
have, and what they would like to do to ble understanding the significance of what
alter the situation. It also allows them to they have heard. For example, when people say
“contextualize life experiences and present they are sick because they are too stressed, our
them in a way that softens associated feelings” first response might be to think about the
(H. Erickson, 2006b, p. 315). cause and effect of disease—for example, bac-
Our clients’ self-care knowledge is best teria (not stress) cause infections. However,
obtained by allowing them to tell their story the MRM model supports a holistic perspec-
in their own way. We use active listening to tive; we know that mind and body are inextri-
facilitate our clients to tell their stories. This cably interactive. Therefore, we recognize that
can be done very quickly by initiating the dis- psychosocial stress stimulates the hypothala-
cussion with statements such as, “Tell me mic–pituitary–adrenal axis interactions, com-
about your situation” followed by “Why do promising the immune system. When this
you think this has happened?” or “What do happens, we have more difficulty fighting bac-
you think has caused it?” and “How do you terial invasions. As a result, we know that psy-
feel about that?” and so forth (H. Erickson chosocial stress has the potential of causing
et al., 2009, pp. 153–167). The data are then signs and symptoms of physical illness and/or
organized into four distinct but interrelated disease.
categories: description of the situation, ex-
pectations, resource potential, and goals Data Aggregation
(see Table 12-2). Information provided by The second phase of data aggregation is the
our clients has to be interpreted, aggregated, process of understanding the data; this some-
and analyzed before we can use it to plan times occurs as we interpret data derived from
interventions (H. Erickson et al., 2009, the primary source (i.e., the client), but not al-
pp. 153–168). ways. To aggregate data accurately, we need to

7991_Ch12_183-210 13/08/19 3:31 PM Page 196
consider data derived from the secondary and and heal. We project these messages through
tertiary sources as well as the data derived from our actions when we unconditionally accept
the client. Although data can be aggregated the worth of another human being and set in-
with only the client’s story and the nurse’s clin- tent to facilitate health and healing. Watzlawick
ical knowledge, it is also helpful to hear the (1967) stated that “we cannot not communi-
family’s perspective. Sometimes it is important cate.” Our attitudes, nonverbal behaviors, and
to include the information collected from ter- touch are often more important than what we
tiary sources as well. say when we convey our intent to help others
When aggregating data, we consider all the heal and grow; words are not always necessary.
information and look for consistencies as well Our demeanor, the way we look at the person,
as inconsistencies across the sources of infor- what we focus on first, and how we touch our
mation. Additional information may be nec- clients relays our intent. When we enter a
essary to clarify perspectives. Usually, this relationship with the intent to comfort and
phase helps determine what needs to be done nurture the other person, our energy field
when moving into the intervention phase of connects with the other; we convey presence
the nursing process. and initiate a caring–healing environment
(H. Erickson, 2006b, pp. 300–324; H. Erickson
Data Analysis
& M. Erickson).
During the final phase of data analysis, theo-
retical linkages and patterns among the data
are identified to inform diagnoses. All three
phases of understanding the data—interpreting, Applications of the Theory
aggregating, and analyzing—may occur simul- MRM, recognized by the American Holistic
taneously or iteratively. Nurses Association as one of the extant holistic
nursing theories, is used in a variety of settings
Proactive Nursing Care including educational institutions as a frame-
Often the process of assessing our clients’ work for entire programs or specific courses, in
worldview serves as a therapeutic intervention. hospitals to guide practice, and within inde-
People in arousal commonly state that they feel pendent nursing practice (Table 12-9).
much better after talking. Some will ask for The Society for the Advancement of Model-
minimal help, but some require more sophis- ing and Role-Modeling (SAMRM; www.mrm-
ticated help. In any case, based on our diag- nursingtheory.org), established in 1985, meets
noses, nursing care is planned within the biennially with retreats in alternate years. Se-
context of the MRM principles of care, aimed lected publications (Table 12-10) demonstrate
at facilitating well-being in our clients, and de- how MRM has been applied across populations
signed specifically to meet intervention goals. and settings from pediatrics to the elderly,
We do this as we manage technical care such chronically ill to the well, and intensive care to
as wound management, intravenous insertion, home care. Other authors (Baas, Barnfather,
and so forth. We use nonjudgmental language, Duke, Frisch, Hertz, Kelly, and Perese; see
caring tones, and direct statements that relay Table 12-10) describe the application of MRM
information needed to feel safe and cared with those who have heart failure, underedu-
about. We also use Ericksonian hypnother- cated adult learners, and/or employed mothers
apeutic techniques to promote growth and with preschool children.
facilitate healing (H. Erickson & M. Erickson, For example, Linda S. Baas (2004) has tested
2018; H. Erickson et al., 2009, pp. 84–85, relations between self-care resources and activi-
145–147; H. Erickson, 2006b, pp. 315–317, ties and quality of life and developed a protocol
372–374; Zeig, 1982). for nursing practice. Baas, past President of
We can also do this without ever touching the American Association of Heart Failure
the person because we use ourselves as con- (AAFH) Nurses and Director of Nursing Re-
duits of healing energy. Sometimes knowing search at the University of Cincinnati Medical
that someone cares about us will help us grow Center (2009–2012), continues to be actively
(Text continued on page 205)

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Table 12-9 Agencies Using or Teaching Modeling and Role-Modeling

Harding University, Carr College of Nursing, Theoretical foundation for pediatric theory and clinical
Searcy, Arkansas course
Metro State University, School of Nursing, Theoretical foundation, and student advising
St. Paul, Minnesota
The College of St. Catherine’s, School Theoretical foundation, associate degree nursing (ADN)
of Nursing, St. Paul, Minnesota program
The University of Texas at Austin, Theoretical foundation, the Alternate Entry Program
School of Nursing
Contemporary Health Care, Austin, Texas Independent Nurse Practice Agency
University Health System, University of Patient care based on MRM throughout the system
Texas, San Antonio
Capitol Metropolitan University, Columbus, Ohio Framework for curriculum in selected courses
Memorial Health System, McPherson, Kansas Philosophy and aims provide framework for practice
Table 12-10 Practice/Intervention Studies Related to Modeling and Role-Modeling (MRM) Theory
and Paradigm
Author Tested Source

Erickson, H. (1976) States of coping, utilization of Unpublished master’s thesis, University
physiological and psychological of Michigan, Ann Arbor, MI
data
Kleinbeck, S. (1977) Coping states of stress Unpublished master’s thesis, University
of Michigan, Ann Arbor, MI
Clementino, D., & Effects on different preparatory Unpublished master’s thesis, University
Lipinski, M. (1980) messages of Michigan, Ann Arbor, MI
Smith, K. (1980) Social support and goal Unpublished master’s thesis, University
attainment of Michigan, Ann Arbor, MI
Erickson, H. C., & A Model for Assessing Potential Research in Nursing and Health, 5,
Swain, M. A. (1982) Adaptation to Stress 93–101
Doombus, M. (1983) Relationship between social Unpublished master’s thesis, University
network and emotional health of Michigan, Ann Arbor, MI
Erickson, H. (1985) Self-care knowledge, support, In Sigma Theta Tau International

hope, control, satisfaction with Proceedings: Social support and health:
life and physical health New directions for theory development
and research, University of Rochester,
Rochester NY
Boodley, C. A. (1986) Experience of having a healthy Unpublished doctoral dissertation,
examination University of Michigan, Ann Arbor, MI
Cain, E., & Utilization of Self-care Model Unpublished master’s thesis, University
Perzzynskis, K. (1986) of Michigan, Ann Arbor, MI
Campbell, J., Finch, D., Theoretical approach to nursing Journal of Advanced Nursing, 10,
Allport, C., & assessment 111–115
Erickson, H. (1986)
Miller, S. H. (1986) Psychosocial development and Dissertation Abstracts International, 47,
coping ability 4113B
Continued

7991_Ch12_183-210 13/08/19 3:31 PM Page 198
and Paradigm—cont’d

Barnfather, J. S. Mobilizing coping resources and Dissertation Abstracts International,
(1987) basic needs status 49(02-B), 0360
Darling-Fisher, C. S. Ericksonian psychosocial Unpublished doctoral dissertation,
(1987) attributes, perceptions of University of Michigan, Ann Arbor, MI
family support, adaptation to
parenthood
Finch, D. (1987) Testing theoretical-based nursing Unpublished doctoral dissertation,
assessment University of Michigan, Ann Arbor, MI
MacLean, T. T. (1987) Health behaviors, developmental In H. Erickson and C. Kinney (Eds.),
residue, and stressors Modeling and role-modeling: Theory,
practice, and research (Vol. 1), Austin,
TX, Society for Advancement of
Modeling and Role-Modeling
Darling-Fisher, C. S., Modified Erikson psychosocial Psychological Reports, 62, 747–754
& Leidy, N. (1988) stage inventory
Kline, N. W. (1988) Psychophysiological processes Dissertation Abstracts International, 49,
of stress 2129B
Barnfather, J., Construct validity of Adaptive Issues in Mental Health Nursing, 10(1),
Swain, M. A. P., & Potential Assessment Model 23–40
Erickson, H. (1989) (APAM)
Keck, V. E. (1989) Perceived social support, basic Dissertation Abstracts International, 50,
needs satisfaction, and coping 3921B
strategies
Barnfather, J. S. (1990) Mobilizing coping resources In H. Erickson and C. Kinney (Eds.),
and basic needs Modeling and role-modeling: Theory,
Barnfather, J. S. Mobilizing coping resources In H. Erickson and C. Kinney (Eds.),
(1990b) and basic needs Modeling and role-modeling: Theory,

Boodley, C. (1990) Experience of a healthy In H. Erickson and C. Kinney (Eds.),
examination Modeling and role-modeling: Theory,
practice, and research (Vol. 1),
Austin, TX, Society for Advancement
of Modeling and Role-Modeling
Erickson, H. (1990) MRM with mind–body problems In J. K. Zeig & S. Gilligan. (Eds.),
Brief therapy: Myths, methods, and
metaphors. New York: Brunner/Mazel,
473–491
Erickson, H. (1990) MRM and psychophysiological In J. K. Zeig & S. Gilligan (Eds.), Brief
problems therapy: Myths, methods, and
metaphors. New York: Brunner/Mazel
Erickson, H. (1990) Theory-based nursing In H. Erickson and C. Kinney (Eds.),
Modeling and role-modeling: Theory,

7991_Ch12_183-210 13/08/19 3:31 PM Page 199

Erickson, H. C., Self-care activities, knowledge, Unpublished manuscript, University
Kinney, C., Stone, D., and resources related to physical of Texas, Austin, TX
& Acton, G. (1990) health
Erickson, H., & MRM and hypertension reduction Issues in Mental Health Nursing, 11(3),
Swain, M. (1990) 217–235
Finch, D. (1990) MRM nursing assessment model Modeling and Role-Modeling: Theory,
Practice and Research, 1(1), 203–213
Kinney, C. (1990) Facilitating growth and Issues in Mental Health, 11, 375–395
development: A case
Kinney, C., & Modeling client’s world Mental Health Nursing, 11, 93–108
Erickson, H. C. (1990)
Kline-Leidy, N. (1990) Relations among stress, Nursing Research, 39, 230–236
resources, and symptoms
of chronic illness
Leidy, N. K. (1990) Model of stress, psychosocial Nursing Research, 39(4), 230–236
resources, and symptomatic
experience
MacLean, T. T. (1990) Erikson’s development and Dissertation Abstracts International, 48,
stressor as factors 1710A
Acton, G., Irvin, B., Theory testing research: Building Advances in Nursing Science, 14(1),
& Hopkins, B. (1991) the science 52–61
Hertz, J. E. G. (1991) Perceived enactment of Dissertation Abstracts International, 52,
autonomy scale 1953B
Kennedy, G. T. (1991) Comfort and comforting care in Dissertation Abstracts International, 52,
the acutely ill 6318B
Landis, B. J. (1991) Uncertainty, spiritual well-being, Dissertation Abstracts International, 52,
and psychosocial adjustment 4124B
Raudonis, B. (1991) A study of empathy from hospice Unpublished doctoral dissertation,
patients’ perspective University of Texas, Austin, TX
Rosenow, D. J. (1991) Multidimensional scaling Dissertation Abstracts International, 53,
analysis of self-care actions 1789B
Scheela, R. (1991) Remodeling process: adult male Unpublished doctoral dissertation,

incest offenders’ perceptions University of Texas, Austin, TX
Baas, L. S. (1992) Self-care knowledge, self-care Dissertation Abstracts International, 53,
resources, and activity and life s1780B
satisfaction after myocardial
infarction
Curl, E. (1992) Psychosocial developmental Dissertation Abstracts International, 47,
residual and hope 992B
Dildy, S. M. P. (1992) Meaning and Impact of Suffering Unpublished doctoral dissertation,
University of Texas, Austin, TX
Holl, R. (1992) Effect of role-modeled visiting to Dissertation Abstracts International, 53,
restricted visiting on well-being 4030B
Kinney, C. (1992) Psychosocial developmental Unpublished manuscript, University of
correlates Texas, Austin, TX
Continued

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MacLean, T. T. (1992) Influence of psychosocial Issues in Mental Health Nursing, 13,
development and life events 403–414
on health practices
Robinson, K. (1992) Scale to measure responses of Dissertation Abstracts International, 53,
clients with actual or potential 6226B
myocardial infarctions
Acton, G. (1993) Theory testing research: building Unpublished doctoral dissertation,
the science University of Texas, Austin, TX
Barnfather, J. (1993) Testing a theoretical proposition Issues in Mental Health Nursing, 14,
of MRM 1–18.
Holl, R. (1993) MRM vs. restricted visiting Critical Care Nursing Quarterly, 16(2),
70–82
Irvin, B. A. (1993) Social support, self-worth, and Dissertation Abstracts International,
hope as self-care resources for 54(06), B2995
coping
Baas, L., Deges-Curl, E., Innovative approaches to Advances in Nursing Science Series:
Hertz, J., & Robinson, K. theory-based measurement: Advances in Methods of Inquiry, 5,
(1994) MRM research 147–159
Erickson, H. C., Modeling and Role-Modeling with National Institutes of Health (funded
Kinney, C., Becker, H., Alzheimer’s patients grant), unpublished manuscript,
Acton, G., Irvin, B., University of Texas, Austin, TX
Hopkins, R., et al.
(1994)
Miller, E. W. (1994) Meaning of encouragement and Unpublished doctoral dissertation,
its connection to inner-spirit as University of Texas, Austin, TX
perceived
Hopkins, B. A. (1995) Adaptive potential of caregivers Paper presented at Sigma Theta
of adults with dementia International Conference, Detroit, MI
Jensen, B. (1995) Caregiver responses to a Unpublished doctoral dissertation,
theoretically based intervention University of Texas, Austin, TX
program
Kline-Leidy, N., & Relations between psychophysio- Research in Nursing and Health, 18,
Travis, G. (1995) logical factors and physical 535–546

functioning
Webster, D., Vaughn, K., MRM and brief solution-focused Issues in Mental Health Nursing, 16(6),
Webb, M., & Player, A. therapy 505–518
(1995)
Weber, G. J. (1999) Lived experience and nature of Dissertation Abstracts International,
well-being 56-06(B), 3131
Acton, G., & Miller, E. Affiliated-individuation, Issues in Mental Health Nursing, 17,
(1996) caregivers of adults with 245–260
dementia
Baldwin, C. (1996) Perceptions of hope Journal of Multicultural Nursing and
Health, 2(3), 41–45
Chen, Y. (1996) Health control orientation, Unpublished doctoral dissertation,
self-efficacy, self-care, and University of Texas, Austin, TX
subjective well-being

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Erickson, M. (1996) A theoretical model derived by Issues in Mental Health Nursing, 17,
synthesizing research findings 185–200
relevant to maternal perceived
support, maternal attachment,
infant wellbeing, and infant
attachment
Erickson, M. (1996) Relationships among support, Unpublished doctoral dissertation,
need satisfaction, and maternal University of Texas, Austin, TX
attachment
Hertz, J. (1996) Perceived enactment of Issues in Mental Health Nursing, 17,
autonomy (PEA) 261–273
Irvin, B. A., & Acton, G. Stress mediation in caregivers Nursing Research, 45(3), 160–166
(1996)
Rogers, S. (1996) Facilitative-affiliation Issues in Mental Health Nursing, 17,
171–184
Sappington, J., & A case study Journal of Holistic Nursing, 14(2),
Kelly, J. (1996) 130–141
Softhauser, C. (1996) Psychosocial antecedents of Dissertation Abstracts International,
hostility 5B/01-B
Acton, G., Irving, B., Explicating middle-range theory Advances in Nursing Science, 19(3),
Jensen, B., Hopkins, B., through methodological diversity 78–85
& Miller, E. (1997)
Baas, L., Fontana, J., Self-care resources and the Progress in Cardiovascular Nursing,
& Bhat, G. (1997) quality of life 12(1), 25–38
Raudonis, B., & Theory-based nursing practice Journal of Advanced Nursing, 26(1),
Acton, G. (1997) 138–145
Irvin, B. A., & Stress, hope, and well-being Holistic Nursing Practices, 11(2),69–79
Acton, G. (1997)
Acton, G., Mayhew, P., Communicating with persons Journal of Gerontological Nursing,
Hopkins, B., & Yauk, S. with dementia 25(2), 6–13
(1999)
Acton, G. (1997) The mediating effect of Journal of Holistic Nursing, 15(4),

affiliated-individuation 336–357
Baas, L. S., Self-care resources and quality Progress in Cardiovascular Nursing,
Fontana, J. A., & of life with heart failure 12(1), 25–38
Bhat, G. (1997)
Irvin, B., & Acton, G. Stress, hope, and well-being Holistic Nursing Practice, 11(2), 69–79
(1997)
Jensen, B. (1997) Caring for the caregiver Home Care Provider, 2(6), 34–36
Raudonis, B., & Theory-based nursing practice Journal of Advanced Nursing,
Acton, G. (1997) 26(1),138–145
Bowman, S. (1998) Human-environment relationship Unpublished doctoral dissertation,
in self-care University of Texas, Austin, TX
Schultz, E. (1998) Academic advising from a theory Nurse Educator, 23(1), 22–25
perspective
Continued

7991_Ch12_183-210 13/08/19 3:31 PM Page 202

Baas, L., Berry, T., Developmental growth in adults Journal of Holistic Nursing, 17(2),
Fontana, J., & with heart failure 117–138
Wagoner, L. (1999)
Beltz, S. (1999) Perception of self among Unpublished doctoral dissertation,
85-year-olds and older University of Texas, Austin, TX
Hertz, J. (1999) Testing two self-care measures In S. H. Guelder & L. W. Poon (Eds.),
in elderly Gerontological nursing issues for the
21st century (pp. 195–205).
Indianapolis, IN: Center Nursing Press
Jensen, B. (1999) Caregiver responses to MRM Dissertation Abstracts International,
B 56/06, 3127
Scheela, R. (1999) Remodeling sex offenders Journal of Psychosocial Nursing and
Mental Health Services, 37(9), 25–31
Weber, G. (1999) The meaning of well-being Western Journal of Nursing Research,
(self-care knowledge) 21(6), 785–795
Acton, G., & Basic need satisfaction, Western Journal of Nursing Research,
Malathum, P. (2000) health-promoting self-care 22(7), 796–811
behaviors
Anschutz, C. (2000) Perceived enactment of Unpublished master’s thesis, Fort Hays
autonomy State University, Hays, KS
Barnfather, J., & Psychosocial resources, stress, Research in Nursing and Health, 23,
Ronis, D. (2000) and health 55–66
Clayton, D. (2001) Experiences of prolonged Unpublished doctoral dissertation,
suffering and evolving spiritual University of Texas, Austin, TX
identity
Mayhew, P., Acton, G., Communication, dementia, and Gerontological Nursing, 22, 106–110
Yauk, S., & Hopkins, B. well-being
(2001)
Timmerman, G., & Relations between needs and Issues in Mental Health Nursing, 22(7),
Acton, G. (2001) emotional eating 691–701
Berry, T., Baas, L., Spirituality in persons with heart Journal of Holistic Nursing, 20(1),
Fowler, C., & Allen, G. failure pp. 5–30

(2002)
Hertz, J. E., & Relationships among PEA, Journal of Holistic Nursing, 20,
Anschutz, C. (2002) self-care, and holistic health 166–186
Perese, E. (2002) Integrating psychiatric nursing Journal of American Association of
into educational models Psychiatric Nurses, 8(5), 152–158
Benson, D. (2003) Adaptive Potential Assessment Unpublished doctoral dissertation,
Model applied to small groups University of La Verne, La Verne, CA
Kinney, C., Mind–body–spirit self- Journal of Holistic Nursing, 21,
Rodgers, D. R., Nash, K., empowerment program 260–279
& Bray, C. (2003)
Softhauser, C. (2003) Psychosocial antecedents of hos- Journal of Holistic Nursing, 21(3),
tility in persons with coronary 280–300
heart disease
Baas, L. (2004) Self-care resources, activities as Dimensions of Critical Care Nursing,
predictors of quality of life 23(3), 131–138

7991_Ch12_183-210 13/08/19 3:31 PM Page 203

Baas, L. G. A. (2004) Psychosocial aspects of heart In S. Stewart, D. D. Moser, &
failure management D. Thompson (Eds.), Caring for heart
failure patients: A textbook for the
healthcare professional (pp. 197–209).
London: Martin Bunitz
Baas, L., Berry, T., Awareness in persons with heart Journal of Cardiovascular Nursing,
Allen, G., Wizer, M., failure or transplant 19(1), 32–40
& Wagoner, L. (2004)
Hwang, H., & Lin, H. Perceived enactment of The Kaoshiung of Medical Sciences,
(2004) autonomy and related 20(4), 166–173
sociodemographic factors
Beery, T. A., Development of Implanted Dimensions of Critical Care Nursing,
Baas, L. S., Mathews, H., Devices Adjustment Scale 24(5), 242–248
Burroughs, J., &
Henthorn, R. (2005)
Bray, C. O. (2005) Psychosocial attributes, self-care University of Texas Graduate School of
resources, basic need satisfac- Biomedical Sciences at Galveston
tion, and measure of cognitive
and psychological health of
adolescents
Lamb, P. B. (2005) Mentoring nurses Unpublished master’s thesis, Montana
State University–Bozeman, Bozeman, MT
Lombardo, S. L., Application of MRM to person Home Healthcare Nurse, 23(7),
& Roof, M. (2005) with morbid obesity 425–428
Benson, D. (2006) Coping with stress In H. Erickson (Ed.), Modeling and
role-modeling: A view from the client’s
world (pp. 240–274). Cedar Park, TX:
Unicorns Unlimited Books, 2009.
Erickson, H. (2006) Modeling and role-modeling: Cedar Park, TX: Unicorns Unlimited
A view from the client’s world Books
Hertz, J. E., Rossetti, J., Self-care activities reported by Unpublished manuscript, Northern
& Nelson, C. M. (2006) older adults Illinois University, DeKalb, IL
Sung, P. H., & Yu, Nursing experience applying Hu Li Za Zhi, 53(4), 89–95
S. K. (2006) MRM model to personality
disorder
Berry, T., Baas, L., & Self-reported adjustment to Journal of Cardiovascular Nursing,
Henthorn, C. (2007) implanted cardiac devices 22(6), 516–524
Cleary, J., & Crafti, N. Basic need satisfaction, E-Journal of Applied Psychology,
(2007) emotional eating, and dietary Clinical, and Social Issues, 3(2)
restraint
Folse, V. (2007) Family experience with eating Archives of Psychiatric Nursing, 21(4),
disorder 210–221
Nash, K. (2007) Implementation and evaluation Journal of Holistic Nursing, 25(1),
of the Empower Youth program 26–36
Nash, K. (2007) Evaluation of the Empower Youth Journal of Holistic Nursing, 25(1),
Program 26–36
Continued

7991_Ch12_183-210 13/08/19 3:31 PM Page 204

Haylock, P. J. (2008) Advocacy and oncology nursing Electronic Theses and Dissertations,
URN: etd-12022008, University of
Texas, Medical Branch at Galveston, TX
Liang, C. V. (2008) Urinary incontinence among rural Doctoral Dissertation, State University
elders of New York at Binghamton, 3344237
Matsui, M., & Perceived autonomy and Geriatric Nursing, 29(2),141–147
Capezuti, E. (2008). self-care resources
Erickson, H., Tomlin, E., Modeling and role-modeling: A Cedar Park, TX: Unicorns Unlimited
& Swain, M. (2009) theory and paradigm for nursing Books
Hagglund, L. A. (2009) Challenges in treatment of Archives of Psychiatric Nursing, 23(1),
factitious disorder 58–64
Pokorny, M., Scott, E., Caring for morbidly obese Home Healthcare Nurse, 27(1), 43–52
Rose, M. A., Baker, G.,
Swanson, M.,
Waters, W., Watkins, F.,
& Drake, D. (2009)
Ackerman-Barger, P. Embracing multicultural nursing Journal of Nursing Education, 49(12),
(2010) learning environments 677–682
Arruda, E. (2010) Nursing retention using MRM Journal for Staff Development, 26(1),
17–22
Erickson, H. (2010) Interface between the philosophy Cedar Park, TX: Unicorns Unlimited
and discipline of holistic nursing Books
Haylock, P. J. (2010) Mind–body–spirit approach in life Seminars in Oncology Nursing, 26(3),
183–194
Perese, E. F., & Shortfalls of treatment for International Journal of Psychosocial
Wu, Y. B. (2010) patients with schizophrenia Rehabilitation, 14(2), 43–56
Veo, P. (2010) Concept mapping and nursing Journal for Nurses in Professional
practice Development, 26(1), 17–22
Alligood, M. (2011) Utilization of MRM in major Journal of Nursing Management, 19,
medical center 981–988
Faye, F. (2011) Integrating nursing science into Creative Nursing, 17(3), 113–117
education
Jonker, L. (2012) Experiences and perceptions Thesis retrieved February 14, 2013,
of mothers Stellenbosch University, http://scholar.
sun.ac.za
Falk, K. (2013) Appreciative inquiry to transform Dissertation, City University of
nursing practice New York, 2013, 173 pages, 3561585
Goldstein, L. (2013) Quality of life, self-care, Electronic Theses and Dissertations,
affiliated-individuation URN: etd-http://hdl/handle.net/2152/
21865, University of Texas, Austin, TX
Kapp, S. (2013) Effects of Violence Assessment http://scholar.valpo.edu/ebpr/23
Checklist
Koren, M. E., & Spirituality of staff nurses Holistic Nursing Practice, 27(1), 37–44
Papmiditriou, C. (2013)
Falk, K. (2014) Appreciative inquiry with Nursing Science Quarterly, 27(4),
children of incarcerated parents 315–323

7991_Ch12_183-210 13/08/19 3:31 PM Page 205

Hodge, D., Bonifas, R., Model to address African Clinical Gerontologist, 37(4), 386–405
Sun, F., & Wollsin, R. Americans’ spiritual needs
(2014)
Knox-Woodward, J. Mentoring/coaching to improve https://pdfs.semanticscholar.org/f66f/
(2014) quality 5c83c52ad173cc145d0466a25fcf
999e2df2.pdf
Shams, M., Favara, I., Nursing and psychological issues DOI: 10.1007/978-88-470-5382-3_3
Meneghello, E., & in obese people https://www.researchgate.net/publication/
Barzon, F. (2014) 278661570_The_Globesity_Challenge_
to_General_Surgery
Softhauser, C. (2015) Hostility patterns: implications Nursing Science Quarterly, 28(3),
for practice 202–208
involved in setting practice protocols for nurses spirit, and as a result, they become more fully
working with people experiencing congestive actualized. A caring–healing environment, cre-
heart failure. Gloria Duke, Professor of Nursing ated by the nurses’ intent, fosters growth and
and Associate Dean for Research, University well-being in their clients. Because people
of Texas at Tyler, previously interested in the have inherent instincts and drives to grow, de-
experiences of single mothers (published in velop, and heal, all nursing actions focus on
Weber, 1999), is currently studying attitudes facilitation and nurturance of these innate abil-
about and preferences for end-of-life care in ities. We use ourselves to connect with our
persons of Jewish, Hindu, Muslim, Buddhist, clients in such a way that we can create trusting
and Bahá’í faiths living in Texas. Both Frisch functional relationships with them, relation-
and Frisch (2010) and Perese (2012) have pub- ships that have a purpose or are aimed at some
lished textbooks for mental health practition- outcome. In the MRM model, these relation-
ers. Frisch and Frisch’s book is used as a ships aim to affirm clients’ worth; to help them
foundational book, whereas Perese’s was writ- mobilize and build resources needed to cope
ten specifically for advanced practice nurses. with their stressors/stress; foster hope for
Hertz has developed and tested a middle- the future; and promote a sense of affiliated-
range theory derived from MRM that meas- individuation. When people have these expe-
ures perceived enactment of autonomy in the riences, a sense of well-being follows. Al-
elderly. Hertz, Professor and Director of Grad- though we use every professional skill we have
uate Studies, Northern Illinois University, is acquired, these are secondary to using our-
currently involved with mentoring graduate selves as healing agents. As nurses, we nurture
students interested in advancing holistic care and facilitate people to become the most that
for the elderly. Case studies are reported they can be. We help them actualize their life
by practitioners in each of the SAMRM roles and find meaning in their existence. It af-
newsletters; these and additional publications fects not only our clients but also those who
can be found on the SAMRM website (www. are significant in their lives.
mrmnursingtheory.org). As nurses, every interaction with our
We cannot cure people, but we can help clients and their loved ones provides us with
them heal and grow, even as they are taking opportunities to affect the future. Erickson
their first or last breath. When people heal, called this the “long-arm affect” (H. Erickson,
they become more fully connected with the 2006b, p. 390). This perspective is symbolized
multiple dimensions of their mind, body, and in the MRM logo. How we perceive our roles

7991_Ch12_183-210 13/08/19 3:31 PM Page 206
as nurses will determine our intent. This in they loved him. He agreed, and for the next
turn affects what we do, how we interact, the few days his family members took turns just
focus of our work, and the outcomes of our re- being with him. On the third day when he
lationships. We cannot always change what quietly passed, he and his family were able to
will happen in our lives or those of others, but grieve with dignity and peace. Eight years
we can set the intent to help people grow, heal, later, I received a letter from his son (only 16
and move on. at the time of his father’s death), notifying me
One example of this occurred when I that his mother had died. He knew I would
helped a family during a life tragedy, discover- want to know that because of what they had
ing ways to find meaning in the experience and learned from me, she was able to pass at home
grow, heal, and move on. This man who once with her family at her side, singing her favorite
saw himself as the strong, dominant member songs and strumming on the guitar. He went
of his family was lying in bed, incontinent, rid- on to state:
dled with cancer, and feeling hopeless. When
I learned that he no longer allowed his family In the year my Dad was with you people in Ann
to visit, I gently took his hand and told him Arbor, you were of incalculable aid and comfort
I was happy to be his nurse that evening. He to both my parents—you gave them confidence
“looked at me with very sad eyes … [and said] in you and your staff, and the dignity and respect
that he didn’t want his family to see him in this which makes life worth living; no one else could,
condition … [H]e had always taken care of his or did, more genuinely have their gratitude and
family, and now … he couldn’t take care of respect. When I would come down and all
himself” (H. Erickson, 2006a, p. 325). I re- seemed to be lost, the one bright spot was that
phrased his words and then told him that al- Mrs. Erickson would be coming on, and we could
though he had been the breadwinner in the breathe a little more easily as Dad’s anxiety visibly
past and his family members had enjoyed and receded. Your kindness and humanity made the
appreciated that, all they wanted now was to world a better place at that time and without you
be with him, to share his life, to show him that the experience would have been more difficult
he was important because he loved them and than you probably believe. Thank you, J. M.
Practice Exemplar
Most data are easy to understand, although Mr. S. looked surprised and said he didn’t
there are some that are symbolic of earlier know what had made him think of that event
losses. A middle-aged man I worked with and that he hadn’t thought about it for years.
number of years ago had just been admitted When I asked him what he expected to hap-
to the hospital for a “workup.” Mr. S. had pen to him, he said he guessed that he was
complained of chronic fatigue for the past going to die. He went on to say that he
6 months. An hour or so before I saw him, thought he had developed leukemia because
he had learned that he had acute leukemia. he hadn’t been responsible, and when he
When I asked him to tell me about his situ- wasn’t responsible people died. As we ex-
ation, he told me about his leukemia and plored his resources, he explained that he had
then launched into a story about his child- been promoted about 9 months earlier and
hood. He described a time when he was that his new job required skills he didn’t think
about 16 years old, had been told to watch he had. His conclusions were that he was sick
his younger sister, and had let her ride a because he had “worried himself to death.” He
horse without supervision. She fell off and also stated that he didn’t want his wife to
was killed. He remembered his father telling come see him, that he needed to decide what
him that he had not been responsible and he wanted to do first and how he could take
that he needed to grow up and be a man. care of her now that he was sick. When I

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asked if she or someone else could help him a conduit of healing energy from the
consider options, he said no, that it was his Universe. Setting an intent is a prerequi-
responsibility to take care of himself. To site to facilitating a client’s storytelling. It
understand these data, I needed to recognize is also an important strategy for helping
the following: people mobilize resources needed to help
themselves heal. Centering, setting intent
■ People who link new stressful experi-
to connect, and to serve as an energetic
ences to past experiences are usually
conduit were purposefully initiated with
dealing with a loss related to the experi-
each visit.
ence. In his case, it was not only the loss ■ When I asked Mr. S to describe his situa-
of his sister but also the meaning of the
tion, I also stated he could talk about any-
loss. As a 16-year-old boy, he was learn-
thing that popped into his mind, even if
ing about his ability to make sound deci-
it didn’t seem to be related to his current
sions, to be independent, to determine
situation. This strategy is used because
who he was as a unique human being in
people have state-dependent memory;
society. He had learned that “when he
their current experiences are often related
wasn’t responsible, people died.”
to losses incurred in the past. Although
■ Although he identified his wife as
they are unaware of these relations, it may
his significant other, he was over-
be important to help them “uncover”
individuated. Rather than seeking his
these experiences in their own time and
wife as a source of support during this
their own way—a prerequisite for mobi-
stressful time, he needed to decide how
lizing resources needed to contend with
to “tell” his wife about his problem—his
the current situation.
problem of not being responsible, not ■ I used active listening skills as he told his
being a “man.” He did not perceive that
story, using nonverbal communications to
it was appropriate to seek comfort from
encourage him to open, staying energeti-
her or others.
cally connected, and remaining quiet
■ Mr. S. is in arousal with unmet safety
when he paused, allowing him an oppor-
and belonging needs, unresolved loss
tunity to express his self-care knowledge.
with morbid grief, and both positive ■ My question: What do you expect will hap-
and negative residual from adolescence
pen? was used to assess self-care resources
on. Strong positive residual from early
and to allow him to identify associated
childhood provides some resources that
factors and express his worse fears. His
could be mobilized with assistance.
response indicated that he was depleted

■ Although Mr. S. is chronologically in
of resources (i.e., impoverished). His defi-
the stage of Intimacy versus Isolation,
nition of being responsible no longer
his stressors are related to residuals
worked for him; he needed help refram-
from the stage of Competency versus
ing his behaviors and identifying new re-
Limitations.
sources. I further explored his resources
■ Mr. S’s healthy affiliated-individuation
with the follow-up questions.
has been threatened due to over- ■ Considering that the loss had occurred
individuation.
during adolescence and the task of devel-
■ Mr. S. wished to be “responsible” to
oping identity is important for the devel-
“take care of his wife.”
opment of healthy intimacy in the next
Specific interventions used in this case are stage of life, follow-up interventions in-
as follows: cluded exploring alternative ways to think
about “being responsible”—the role he
■ I centered myself and set intent to be
had chosen for himself. Using open-ended
energetically connected, using myself as
(continued)

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questions, I helped him consider his rela- help himself. Aiming to reframe his per-
tionship with his family by thinking ception, I suggested that chemotherapy
about how he was like the 16-year-old was designed to fight with the bad
boy and how he was different; how he cells, but he didn’t need to have the
wanted to be like that boy and how he chemotherapy fight with his good cells,
wanted to be different; and how he that he could protect them if he wanted.
wanted to relate to his wife in the future When he expressed curiosity about pro-
and how he might start. Rhetorical ques- tecting his good cells, I helped him learn
tions, stated as curiosities rather than a how to use guided imagery to envision
demand for a response, were used to the chemotherapy seeking out bad cells
stimulate growth. For example: It might and attacking them while leaving the oth-
be interesting to think about how you want ers alone. We then talked about ensuring
to be like that boy—or different. that the chemotherapy had a good chance
■ Biophysical care was offered and pro- of doing its work by getting sufficient
vided with consideration for his devel- sleep, drinking fluids, seeking nurturing
opmental resources. Adolescents with relations, participating in activities that
healthy developmental resources often helped him laugh, and other activities
vacillate in their need to be independent that made him feel loved, happy, and
in their activities of daily life and their at peace.
needs to have care consistent with earlier ■ Upon discharge, I offered him a business
stages provided. The only way to know is card as a transitional object. I explained
to offer care and follow the client’s re- that it contained my name and contact
sponses. Thus, when asked to help with information if he wanted to talk with me
foot care, it was provided; when told at any time. I also stated that many
that he could manage making his own people find they can remember our time
outpatient appointments, he was given together—what they felt, heard, smelled,
the information needed to make his and saw—by holding the card and/
appointments and asked if he needed or thinking about it.
any other information after the
I followed him for several weeks, visiting
appointments were confirmed.
■ As he prepared for discharge to the out-
him occasionally in the outpatient clinic. He
always had my business card with him and
patient clinic, I explored his perceptions
often commented that it was magic and that
of the effects of chemotherapy. He
it helped him get through the bad days. Two
stated that chemotherapy was a poison

years later I received a letter thanking me for
and would make him sick, and he didn’t
helping him and stating that he was in remis-
look forward to that. I agreed that
sion. He and his wife were planning a trip to
chemotherapy was a poison, but that
celebrate their anniversary.
there were several things he could do to

7991_Ch12_183-210 13/08/19 3:31 PM Page 209
Summary
Nurses who use modeling and role-modeling may impede health and wellness and what is
believe the human is holistic with ongoing, meaningful and has potential to facilitate heal-
dynamic mind–body–spirit interactions; clients ing and growth.
are the primary source of information; and Role-modeling is helping clients find alter-
nurses are instruments of healing. Modeling is native ways to fulfill their desired roles in life.
the process used to gain an understanding of This requires interventions, including biophys-
their clients’ perceptions and understandings ical care, as well as psychosocial strategies
of their conditions, health needs, and possible designed to help people articulate their self-
therapeutic interventions. During the model- care knowledge, mobilize resources, and par-
ing process, nurses gain an understanding of ticipate in healthy self-care actions. Strategies
their clients’ perceptions of what has caused are designed within the context of develop-
their health problem, what impedes their mental residual and with consideration for
healing, and what will facilitate healing and losses and related attachment objects. Verbal
growth. Modeling the clients’ worldviews also and nonverbal communication and basic bio-
helps nurses to understand their clients’ rela- physical nursing skills are considered essential
tionships and related roles and identify what prerequisites in the use of MRM.
Questions for Reflection Role-Modeling and what are examples of

each of these strategies?
and Discussion ■ How is nursing defined in the Theory of
■ What is modeling, and what are examples Modeling and Role-Modeling? How is
of data needed by the nurse in the model- that definition evident in the Practice
ing process? Exemplar?
■ What are the practice strategies associ-
ated with the Theory of Modeling and

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7991_Ch13_211-234 12/08/19 5:23 PM Page 211
Barbara Dossey’s Theory

CHAPTER
13
of Integral Nursing
Barbara Montgomery Dossey

Practice Exemplar, Written by Sarah Oerther Barbara Montgomery Dossey, PhD, RN,
Questions for Reflection and Discussion AHN-BC, FAAN, HWNC-BC, is interna-
Summary tionally recognized as a pioneer in the holis-
tic nursing movement and the integrative
nurse coach movement, and is a Florence
Nightingale scholar. She is Co-Director,
International Nurse Coach Association
(INCA), and Core Faculty, Integrative
Nurse Coach Certificate Program (INCCP);
International Co-Director, Nightingale Ini-
tiative for Global Health (NIGH); and Di-
rector, Holistic Nursing Consultants. She is
a Fellow of the American Academy of Nurs-
ing, an advanced holistic nurse (AHN-BC),
and a health and wellness nurse coach
(HWNC-BC). She is an 11-time recipient
of the prestigious American Journal of Nursing
Book of the Year Award. She is the author
or coauthor of 25 books. Her most recent
books include Holistic Nursing: A Handbook
for Practice (7th ed., 2016), Nurse Coaching:
Integrative Approaches for Health and Wellbe-
ing (2015), The Art and Science of Nurse
Coaching: The Provider’s Guide to Coaching
Scope and Competencies (2013), Florence

Nightingale: Mystic, Visionary, Healer (Com-
memorative Edition, 2010), and Florence
Nightingale Today: Healing, Leadership, Global
Action (2005).

The nursing profession calls nurses to wrap
themselves around “all of life” on so many
levels, within self and between self and oth-
ers. This begs the question, “How do we
1With written contributions from Carey S. Clark, Sarah connect the complexity of so much informa-
Oerther, and William Rosa. tion that arises in clinical practice as well as
211
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in our personal life?” This is a process and integrality, chaos, spiral dynamics, complex-
we can “start right now” by asking “Who am ity, and systems.1
I?” “What is my “state of being” in this mo-
ment? The intent of this chapter is to guide Personal Journey Developing the
nurses to answer these questions using an in- Theory of Integral Nursing
tegral process and the Theory of Integral As a young nurse attending my first nursing
Nursing. theory conference in the mid-1960s, I was cap-
As you begin to explore the Theory of In- tivated by nursing theory and the eloquent vi-
tegral Nursing, reflect on the following ques- sionary words of nurse theorists as they spoke
tions: Why am I here? Are my personal and about the art and science of nursing. I realized
professional values and actions sourced from that nursing was not either “science” or “art,”
my soul’s purpose and wisdom? What is my but both. From the beginning of my critical
mission and vision for my work in the world? care and cardiovascular nursing focus, I learned
How can I strengthen my passion for nurs- how to seamlessly integrate science and tech-
ing? What am I currently doing to become nology with the art of nursing through holistic
more aware of my personal health and the healing integrative interventions including re-
health of my home and workplace? What is flective practices, touch therapies, biofeedback,
my role in advancing healthy people living on relaxation, imagery, music, and meditation.
a healthy planet—local to global? What is my In the late 1960s, I began to study and attend
calling? workshops on holistic and mind–body-related
The Theory of Integral Nursing is a grand concepts, branching outside the discipline. These
theory in the integrative-interactive para- included Systems Theory, quantum physics, In-
digm that presents the science and art of tegral Theory, Eastern and Western philosophy,
nursing. It incorporates physical, mental, and mysticism. My husband, a physician of in-
emotional, social, spiritual, cultural, and en- ternal medicine who was caring for critically ill
vironmental dimensions and is an expansive patients and their families, began this journey of
worldview. The theory provides a framework discovery with me. We both began to take
for the unfolding, emergent, upward spiral courses related to body–mind–spirit interven-
second-tier process of human consciousness tions and started incorporating these practices
to a higher order and level. It invites nurses into our daily lives. These interventions played a
to think widely and deeply about the integral significant role in guiding both of us through our
philosophy of One Mind–One Health–One individual health challenges—mine with post–
Planet (L. Dossey, 2013; Rosa, 2017c). As corneal transplant rejection and my husband’s
the name suggests, this theory integrates blinding migraine headaches.
the philosophical foundation and legacy of As my husband and I started to strengthen
Florence Nightingale (1820–1910) (Dossey, our own self-care and self-regulation capacities,
2010), healing and healing research, the our personal and professional philosophies
metaparadigm of nursing (nurse, person[s], changed along with our clinical practices. We
health, and environment [society]), six pat- introduced what today is called integrative and
terns of knowing (personal, empirics, aes- integral health care into our clinical practices,
thetics, ethics, not knowing, sociopolitical), demonstrating our changed way of approaching
Integral Theory, and theories outside of the the traditional health-care setting. The integra-
discipline of nursing. It builds on the existing tion of these caring–healing modalities com-
integral, integrative, and holistic theoretical bined with traditional surgery, treatments,
nursing foundations and has been informed protocols, and technology soon became evident
by the work of other nurse theorists; thereby, in the remarkable “outcomes” we were observing
it is not a freestanding theory. Instead, the in our patients and their families—some of our
Theory of Integral Nursing incorporates
concepts from various philosophies and 1For additional information, see the bonus chapter content
fields including holism, multidimensionality, available at http://davisplus.fadavis.com.

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C H APTER 13 ■ Barbara Dossey’s Theory of Integral Nursing 213
greatest teachers—including decreased pain and humankind. Her social action was also sacred
fear, increased resiliency, and faster healing. activism (Harvey, 2009), the fusion of the
In 1981, I became a founding member of deepest spiritual knowledge with radical action
the American Holistic Nurses Association in the world. Nightingale was ahead of her
(AHNA, n.d.) and continue to remain an ac- time; her dedicated and focused 50 years of
tive member. Through the collective work of work and service still inform and positively af-
members of the AHNA, the specialty of ho- fect the modern nursing profession and the
listic nursing was recognized by the American global nursing mission of health and healing.
Nurses Association (ANA) in November 2006 In the 1880s, Nightingale began to write
(AHNA & ANA, n.d.). Using an integral lens in letters indicating it would take 100 to
can now expand all nursing endeavors—local 150 years before sufficiently educated and ex-
to global. An integral perspective can also fur- perienced nurses would change the health of
ther our endeavors in the American Nurses the world. In 2020, the world will celebrate the
Association Healthy Nurse Healthy NationTM bicentennial—the 200th year of Nightingale’s
(ANA, 2016), Healthy People and the 2030 birth. Today’s nurses are the generation of
Agenda (Healthy People 2030, 2018), and the 21st-century Nightingales who can trans-
United Nations 17 Sustainable Development form health care and carry forth her vision to
Goals and the 2030 Agenda (UN, 2018). The create a healthy world into the 22nd century
emerging professional nurse coaching move- (Beck, Dossey, & Rosa, 2018; Dossey, Beck,
ment with strategies to increase patient engage- Oerther, & Manjrekar, 2017; McDonald,
ment can also be strengthened when applying an 2001–2012). My sustained nursing career
integral perspective (Dossey, Luck, & Schaub, focus with nursing colleagues on wholeness,
2015; Hess et al., 2013). unity, and healing along with my scholar-
ship on Florence Nightingale and holistic ap-
Philosophical Foundation: Florence proaches to growth in leadership (integral
Nightingale’s Legacy focus) led to my development of the Theory of
In 1992 in London I began primary historical Integral Nursing. The Nightingale Initiative
research of Florence Nightingale, studying and for Global Health (NIGH), the Nightingale
synthesizing her original letters, manuscripts, Declaration for a Healthy World (Nightingale
books, and her coauthored army and public Declaration, n.d.), and my work with col-
health documents. This deepened my under- leagues to expand nursing consciousness as a
standing of her relevance for nursing. Florence way of understanding how all our endeavors
Nightingale (1820–1910), the philosophical are related to global nursing outcomes as we
founder of modern secular nursing and the first translate the United Nations (UN) 17 Sustain-
recognized nurse theorist, was an integralist. able Development Goals by 2030 (NIGH,
Her worldview focused on the individual and n.d.). My integral and holistic focus has re-
the collective, the inner and outer dimensions/ sulted in numerous books, protocols, articles,
experiences, and human and nonhuman con- and various scope and standards for practice,
cerns. She identified environmental determi- education, research, and health-care policy
nants (clean air, water, food, houses, etc.) and initiatives.
social determinants (poverty, education, family
relationships, employment)—local to global. Integral Foundation and the Integral
She also experienced and recorded her per- Model
sonal understanding of the connection with Since the 1970s I have been reading and study-
the Divine—that is, the awareness that some- ing the work of Ken Wilber, one of the most sig-
thing greater than she was present in all as- nificant American new-paradigm philosophers
pects of her life (Dossey, 2010). of our time. His elegant Four-Quadrant Theory
Nightingale’s work was social action that and Integral Spirituality (Wilber, 2006) was de-
clearly articulated the science and art of an in- veloped over 35 years and is published in his
tegral worldview for nursing, health care, and many works, including The Collected Works of Ken

7991_Ch13_211-234 12/08/19 5:23 PM Page 214
Wilber (Wilber, 1999, 2000a). As I continued to in the next section on theory developmental
explore Integral Theory using my integral lens, I process.
began to see how the individual and collective
interior perspectives were left out of nursing and Theory of Integral Nursing
health care as the focus was more situated within Developmental Process
a medical model characterized by technology,
It can assist nurses in mapping human capac-
protocols, procedures, and quantitative research.
ities, beginning with healing and evolving to
I could see then how an integral perspective
transpersonal self-connecting with the Divine,
(could be/was) a way to strengthen healing, car-
however defined, in an endeavor to create a
ing, and compassion, as well as personal and
healthy world—local to global. Dossey (2008)
professional self-development. An integral per-
outlines the intentions of the Theory of Integral
spective was also more likely to expand interpro-
Nursing as follows:
fessional dialogues and explore commonalities
and differences across disciplines. Thus, I began ■ To embrace the unitary whole person and
to think, live, dream, and write from an integral, the complexity of the nursing profession
holistic, and integrative perspective and my mis- and health care
sion focused on developing and translating the ■ To explore the direct application
Theory of Integral Nursing. The reader is re- of an integral process and integral
ferred to the Theory of Integral Nursing defini- worldview that includes four perspectives
tions (Table 13-1), and most frequently used of realities—the individual interior
nursing interventions (Table 13-2) (Dossey, and exterior, and the collective interior
2008, 2018). and exterior
The Theory of Integral Nursing intentions ■ To expand nurses’ capacities as
and the philosophical assumptions are described 21st-century Nightingales, health
Table 13-1 Integral Nursing Definitions
Terms Definitions
Integral Comprehensive way to organize multiple phenomena of human experience
related to four perspectives of reality: (1) individual interior (personal/
intentional), (2) individual exterior (physiology/behavioral), (3) collective
interior (shared/cultural), (4) collective exterior (systems/structures).
Integral dialogue Transformative and visionary exploration of ideas and possibilities across
disciplines where the four integral perspectives of reality are considered as
equally important to exchange and outcomes.
Integral healing process The unitary whole person(s) interacting in mutual process with the environment
that includes a four quadrants perspective.
Integral health Process through which we reshape basic assumptions and worldviews about
well-being and see death as a natural process of living.
Integral health care A patient-centered and relationship-centered caring process that includes the
patient, family, and community and conventional, integrative, and integral
health-care practitioners and services and interventions.
Integral nurse A 21st-century Nightingale who is engaged as a “health diplomat” and an
integral health coach who is coaching for integral health.
Integral nursing A comprehensive integral worldview and process that enlarges our holistic un-
derstanding of body–mind–spirit–cultural–environmental connections and our
knowing, doing, and being to more comprehensive and deeper levels.
Integral worldview Process where values, beliefs, assumptions, meaning, purpose, and judgments
are identified and related to how individuals perceive four perspectives of reality.
Source: © 2008 Barbara M. Dossey.

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diplomats, and integral nurse coaches— ■ Integral nursing is applicable in practice,

local to global education, research, and health-care
policy—local to global.
The Theory of Integral Nursing advances
the evolutionary growth processes, stages, and The Theory of Integral Nursing was first
levels of human development and conscious- published as an article (Dossey, 2008), and
ness toward a comprehensive integral philos- then in three editions of Holistic Nursing: A
ophy and understanding. The philosophical Handbook for Practice (Dossey et al., 2009;
assumptions of the Theory of Integral Nursing Dossey et al., 2013; Dossey et al., 2016).
(Dossey, 2018) include the following: Over the past 10 years these three textbook
publications have reached a large number of
■ An integral understanding of recognizing
nurses and student nurses. The textbooks
the individual as an energy field connected
have been endorsed by the American Holis-
to the energy fields of others and the
tic Nurses Association (AHNA, n.d.), which
wholeness of humanity; the world is open,
supports certification in the holistic nursing
dynamic, interdependent, fluid, and
specialty through the American Holistic
continuously interacting with changing
Nurses Credentialing Corporation (AHNCC,
variables that can lead to greater complex-
n.d.). The textbooks clearly develop the in-
ity and order.
tegral, integrative, and holistic processes of
■ An integral worldview is a comprehensive
the theory. Clinical applications of the theory
way to organize multiple phenomena of
in traditional and nontraditional settings
human experience from four perspectives
with integrative interventions are outlined in
of reality: (a) individual interior (subjec-
Table 13-2.
tive, personal); (b) individual exterior
(objective, behavioral); (c) collective
Content, Context, and Process
interior (interobjective, cultural); and
(d) collective exterior (interobjective, The Theory of Integral Nursing, when
systems/structures). presented within Barbara Barnum’s (2005)
■ Healing is a process inherent in all living critique framework of a nursing theory—
things; it may occur with curing of symp- content, context, and process—provides an
toms, but it is not synonymous with curing. organizing structure that is most useful. The
■ Integral health is experienced by a person Theory of Integral Nursing includes an inte-
as wholeness with development toward gral process, integral worldview, and integral
personal growth and expanding states of dialogues that compose praxis—theory in ac-
consciousness to deeper levels of personal tion (B. M. Dossey, 2008, 2016a; Dossey,
and collective understanding of one’s 2016b). An integral process is defined as a
physical, mental, emotional, social, comprehensive way to organize multiple

spiritual, cultural, and environmental phenomena of human experience and reality
dimensions. from four perspectives: (1) the individual in-
■ Integral nursing is founded on an integral terior (personal/intentional); (2) individual
worldview using integral language and exterior (physiology/behavioral); (3) collec-
knowledge that integrates integral life tive interior (shared/cultural); and (4) collec-
practices and skills each day. tive exterior (systems/structures).
■ Integral nursing is broadly defined to
include knowledge development and all Content
ways of knowing that also recognizes the Content of a nursing theory includes the sub-
emergent patterns of not knowing. ject matter and building blocks that give a the-
■ An integral nurse is an instrument in the ory its form. It comprises the stable elements
healing process and facilitates healing that are acted on or that do the acting. In the
through her or his knowing, doing, Theory of Integral Nursing, the subject matter
and being. and building blocks are as follows.

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Table 13-2 Interventions Most Frequently Used with the Theory of Integral Nursing
Affirmations Humor and laugher Presence
Appreciative inquiry Intention Probing questions
Aromatherapy Journaling Reflection
Art and drawing Meditation Relaxation modalities
Celebration Mindfulness practice Ritual
Client assessments Motivational interviewing Rulers
Cognitive reframing Movement Self-assessments
Contracts Music and sound Self-care interventions
Deep listening Nature walks Self-reflection
Energy practices Observation Silence
Exercise Play Somatic awareness
Goal setting Open-ended questions Stories
Guided imagery Prayer Visioning
Source: © 2018 Barbara M. Dossey.
Content Component 1: Healing ■ Involves recovery, repair, renewal, and

Healing is at core and includes knowing, transformation that increase wholeness
doing, and being (Fig. 13-1a). Healing is a and often (though not invariably) order
lifelong journey of seeking harmony and bal- and coherence.
ance in one’s own life and in family, commu- ■ Leads to more complex levels of personal
nity, and global relations. It is an emergent understanding and meaning, and may be
process of the whole system bringing together synchronous but not synonymous with
aspects of one’s self and the body–mind–spirit– curing.
culture–environment at deeper levels of inner ■ Healing with self or another can happen
knowing, leading toward integration and bal- until the moment of death.
ance, with each aspect having equal impor-
tance and value. Healing (Dossey, 2008) is Content Component 2: Metaparadigm
defined within the Theory of Integral Nursing of Nursing
as follows: The metaparadigm of nursing includes nurse,
person(s) (patient/client, family members, sig-
■ Includes evolving one’s state of conscious- nificant others), health, and environment (inter-
ness to higher levels of personal and col- nal and external) (society) (Fawcett, Watson,
lective understanding that acknowledges Neuman, Walker, & Fitzpatrick, 2001). Starting
the individual’s interior and exterior expe- with healing at the center, a Venn diagram
riences and the shared collective interior surrounds healing to illustrate the interrelation,
and exterior experiences with others where interdependence, and effect of these domains
authentic power is recognized within each as each informs and influences the others. A
person. change in one will create a change in the
■ Disease and illness at the physical level other(s), thus affecting healing at many levels
may manifest for many reasons and vari- (Fig. 13-1b). Table 13-3 provides more details.
ables. It is important not to equate physi-
cal health, mental health, and spiritual Content Component 3: Patterns of Knowing
health, as they are not the same thing. in Nursing
They are facets of the whole jewel of The third content component in a Theory of
health. Integral Nursing is the recognition of the

7991_Ch13_211-234 12/08/19 5:23 PM Page 217
Nurse Health
Healing
Person(s) Environment
Healing (society)
A B
Personal Empirics
Not knowing Healing Sociopolitical
Aesthetics Ethics
I It
Me
ve
subjective objective
reti
asu
personal biological
Interp
rable
intentional behavioral
Healing
We Its
Q u ali
tiv e
tit a
intersubjective interobjective
tat
cultural systems
an
iv e
shared values structures

Qu
D
FIG 13-1 ■ (A) Healing. (Source: Copyright © Barbara Dossey, 2007.), (B) Healing and meta paradigm of
nursing. (Source: Copyright © Barbara Dossey, 2007.), (C) Healing and patterns of knowing in nursing. (Source:
Adapted from B. Carper [1978]. Copyright © Barbara Dossey, 2007.), (D) Healing and the four quadrants (I, We, It,
Its). (Source: Adapted with permission from Ken Wilber. http://www.kenwilber.com. Copyright © Barbara Dossey, 2007.),
(E) Theory of Integral Nursing (healing, metaparadigm, patterns of knowing in nursing, four quadrants,
and AQAL). (Source: Adapted with permission from Ken Wilber. http://www.kenwilber.com. Copyright © Barbara
Dossey, 2007.), (F) Healing and AQAL (all quadrants, all levels). (Source: Adapted with permission from Ken
Wilber. http://www.kenwilber.com. Copyright © Barbara Dossey, 2007.)
Created from humber on 2023-05-08 02:32:28. Continued
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Spirit Causal
Mind Subtle
Body Gross
Healing
Me Group
Us Nation
E All of us Global
Spirit Causal
Mind Subtle
Body Gross
Personal Empirics
I It
subjective objective
personal Nurse Health biological
intentional behavioral Meas
ive
Interpret
urable
Not knowing Sociopolitical

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
F All of us Global
FIG 13-1—cont’d
7991_Ch13_211-234 12/08/19 5:23 PM Page 219
Table 13-3 Content Component 2: Metaparadigm in a Nursing Theory
Domain Definition
Nurse A registered nurse that is a 21st-century Nightingale engaged in social action and sacred
activism. The nurse is an instrument in the healing process where she or he brings one’s
whole self into relationship to the whole self of another or a group of significant others
that reinforces the meaning and experience of oneness and unity.
Person An individual (patient/client, family members, significant others) who engages with a
nurse in a manner that is respectful of a person’s subjective experiences about health,
health beliefs, values, sexual orientation, and personal preferences. It also includes an
individual nurse who interacts with nursing colleagues, other health-care team members
or a group of community members, and concerned citizens around health issues.
Health A state or process defined by an individual in which one experiences a sense of growth,
well-being, harmony, and unity. Each individual reshapes basic assumptions and
worldviews about well-being and sees death as a natural process of living. Health places
the client/patient at the center of care and addresses the bio–psycho–social–spiritual–
cultural–environmental aspects that influence health.
Environment An expanded consciousness to usher in the 21st century for healthy people living on a
(society) healthy planet—local to global. Includes both interior and exterior aspects. The interior
environment includes the individual’s feelings, meaning, mental, emotional, and spiritual
dimensions. It also includes a person’s physiology, an internal (inside) aspect of the
exterior self. The exterior environment includes objects that can be seen and measured
that are related to the physical and social in some form in any of the gross, subtle, and
causal/infinite levels.
Source: Copyright ©2018 Barbara M. Dossey.
patterns of knowing in nursing. These six pat- are adapted from Wilber’s (2000a) Integral
terns of knowing are personal, empirics, aes- Theory:
thetics, ethics, not knowing, and sociopolitical ■ Upper-left quadrant (UL): individual in-
(Fig. 13-1c). As a way to organize nursing
terior “I” (subjective, personal/intentional)
knowledge, Carper (1978) in her now-classic ■ Upper-right quadrant (UR): individual
1978 article identified the four fundamental
exterior “IT” (objective, behavioral)
patterns of knowing (personal, empirics, ethics, ■ Lower-left quadrant (LL): collective
aesthetics) followed by the introduction of the
interior “WE” (intersubjective, cultural)
pattern of not knowing by Munhall (1993) and ■ Lower-right quadrant (LR): collective
the pattern of sociopolitical knowing by White

exterior “ITS” (interobjective, systems/
(1995). All of these patterns continue to be re-
structures)
fined and reframed with new applications and
interpretations. These patterns of knowing as- Healing, the core concept in the Theory of
sist nurses in bringing themselves into a full Integral Nursing, with the metaparadigm of
presence in the moment, integrating aesthetics nursing, and the patterns of knowing are trans-
with science, and developing the flow of ethical formed by adapting Ken Wilber’s (2000b) in-
experience with our knowing, doing, and being. tegral model. Starting with healing at the
The patterns of knowing in nursing are de- center to represent our integral nursing philos-
scribed further in Table 13-4. ophy, human capacities, and global mission,
dotted horizontal and vertical lines illustrate
Content Component 4: Quadrants that each quadrant can be understood as
The fourth content component in the Theory permeable and porous, with each quadrant’s
of Integral Nursing examines the following experience(s) integrally informing and empow-
four perspectives of reality (Fig. 13-1d) that ering all other quadrant experiences. Within

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Table 13-4 Content Component 3: Patterns of Knowing in Nursing
Concept Definition
Personal Knowing The nurse’s dynamic process and awareness of wholeness that focuses on the
synthesis of perceptions and being with self. It may be developed through art,
meditation, dance, music, stories, and other expressions of the authentic and
genuine self in daily life and nursing practice. This may be related to living and
nonliving people and things, such as a deceased relative, animal, or a lost
precious object through flashes of memories stimulated by a current situation
(a touch may bring forth past memories of abuse or suffering). Insights gained
through dreams and other reflective practices that reveal symbols, images, and
other connections also influence one’s interior environment.
Empirical Knowing The science of nursing that focuses on formal expression, replication, and
validation of scientific competence in nursing education and practice. It is
expressed in models and theories and can be integrated into evidence-based
practice. Empirical indicators are accessed through the known senses that are
subject to direct observation, measurement, and verification.
Aesthetic Knowing The art of nursing that focuses on how to explore experiences and meaning in life
with self or another that includes authentic presence, the nurse as a facilitator
of healing, and the artfulness of a healing environment. It is the combination of
knowledge, experience, instinct, and intuition that connects the nurse with a
patient/client in order to explore the meaning of a situation about the human
experiences of life, health, illness, and death. It calls forth resources and inner
strengths from the nurse to be a facilitator in the healing process. It is the
integration and expression of all the other patterns of knowing in nursing praxis.
Ethical Knowing The moral knowledge in nursing that focuses on behaviors, expressions, and
dimensions of both morality and ethics. It includes valuing and clarifying
situations to create formal moral and ethical behaviors intersecting with legally
prescribed duties. It emphasizes respect for the person, the family, and the
community that encourages connectedness and relationships that enhance
attentiveness, responsiveness, communication, and moral action.
Not Knowing The capacity to use healing presence, to be open spontaneously to the moment
with no preconceived answers or goals to be obtained. It engages authenticity,
mindfulness, openness, receptivity, surprise, mystery, and discovery with self and
others in the subjective space and the intersubjective space that allows for new
solutions, possibilities, and insights to emerge. It acknowledges the patterns
that may not be understood that may manifest related to various situations or
relationships.
Sociopolitical Knowing Addresses the important contextual variables of social, economic, geographic,
cultural, political, historical, and other key factors in theoretical, evidence-based
practice and research. This pattern includes informed critique and social justice
for the voices of the underserved in all areas of society along with protocols to
reduce health disparities.
Source: Adapted from Carper, 1978; Dossey, 2008; Munhall, 1993; White, 1995. Copyright © 2018 by Barbara M. Dossey.
each quadrant, we see “I,” “We,” “It,” and “Its” who is speaking,” which includes pronouns such
to represent four perspectives of realities that as I, me, mine in the singular, and we, us, ours in
are already part of our everyday language and the plural (Wilber, 2000b, 2005a). Second-person
awareness. means “the person who is spoken to,” which in-
Virtually all human languages use first- cludes pronouns such as you and yours. Third-
person, second-person, and third-person pro- person is “the person or thing being spoken
nouns to indicate three basic dimensions of re- about,” such as she, her, he, him, or they, it, and
ality (Wilber, 2000b). First-person is “the person its. For example, if I am speaking about my new

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car, “I” am first-person, and “you” are second- as the upper-left quadrant (UL), upper-right
person, and the new car is third-person. If you quadrant (UR), lower-left quadrant (LL), and
and I are communicating, the word “we” is used lower-right quadrant (LR). It is simply the in-
to indicate that we understand each other. “We” side and the outside of an individual and the in-
is technically first-person plural, but if you and I side and outside of the collective. It includes
are communicating, then you are second person expanded states of consciousness where one
and my first person is part of this second person feels a connection with something greater than
and my first person is part of this extraordinary the ego; it may be expressed as the Divine and
“we.” So, we represent first-, second-, and third- the vastness of the universe, the infinite that is
person as “I,” “We,” “It,” and “Its.” beyond words. Integral nursing considers all of
The four quadrants describe the territory of these areas in our personal development and any
our own awareness that is already present within area of practice, education, research, and health-
us and an awareness of things outside of us. care policy—local to global. Each quadrant,
These quadrants help us connect the dots of the which is intricately linked and bound to each
actual process to more deeply understand who other, carries its own truths and language
we are and how we are related to others and all (Wilber, 2000b).
things. The specifics of the quadrants are pro- We see that the left-hand quadrants (UL,
vided in Table 13-5. (Note: When working with LL) describe aspects of reality as interpretive and
various cultures, it is important to remember that qualitative (see Fig. 13-1d). In contrast, the
within many cultures, the “I” comes last or is right-hand quadrants (UR, LR) describe aspects
never verbalized or recognized, as the focus is on of reality as measurable and quantitative. When
the “We” and relationships. However, this de- we fail to consider these subjective, intersubjec-
velopment of the “I” and an awareness of one’s tive, objective, and interobjective aspects of re-
personal value, beliefs, and ethics is critical.) ality, our endeavors and initiatives become
These four quadrants show the four primary fragmented and narrow, inhibiting our ability
dimensions or perspectives of how we experi- to reach meaningful outcomes and goals. See
ence the world; these are represented graphically Table 13-5 for the integral model and quadrants.
Table 13-5 Integral Model and Quadrants
Upper Left Upper Right

Individual interior (intentional/personal) Individual exterior(behavioral/biological)
“I” space includes self and consciousness “It” space that includes brain and organisms (physiology,
(self-care, fears, feelings, beliefs, values, pathophysiology [cells, molecules, limbic system,
esteem, cognitive capacity, emotional neurotransmitters, physical sensations], biochemistry,
maturity, moral development, spiritual matu- chemistry, physics, behaviors [skill development in health,
rity, personal communication skills, etc.) nutrition, exercise, etc.])
■ Subjective I It ■ Objective
■ Interpretive ■ Observable
We Its
■ Qualitative ■ Quantitative
Collective interior (cultural/shared) Collective exterior (systems/structures)
“We” space includes the relationship to each “Its” space includes the relation to social systems and
other and the culture and worldview (shared environment, organizational structures and systems (in
understanding, shared vision, shared health-care—financial and billing systems), educational
meaning, shared leadership and other values, systems, information technology, mechanical structures
integral dialogues and and transportation, regulatory structures (environmental
communication/morale, etc.) and governmental policies, etc.)
Lower Left Lower Right
Source: Ken Wilber, Integral Psychology: Consciousness, Spirit, Psychology, Therapy (Boston: Shambhala, 2000).
Table adapted with permission from Ken Wilber. http://www.kenwilber.com. Copyright © 2007 by Barbara M. Dossey.

7991_Ch13_211-234 12/08/19 5:24 PM Page 222
Content Component 5: AQAL (All Quadrants, child or infant) to ethnocentric (centers on

Levels, Lines, States, Types) group, community, tribe, nation) to world-
The fifth content component in the Theory of centric (care and concern for all peoples re-
Integral Nursing is the exploration of Wilber’s gardless of race or national origin, color, sex,
“all quadrants, all levels, all lines, all states, all gender, sexual orientation, creed, and to the
types” or A-Q-A-L (pronounced ah-qwul), as global level).
seen in Figure 13-1e. These levels, lines, In the UL, the “I” space, the emphasis is on
states, and types are important elements of the unfolding “awareness” from body to mind
any comprehensive map of reality. The inte- to spirit. Each increasing circle includes the
gral model simply assists us in further articu- lower as it moves to the higher level.
lating and connecting all areas, awareness, and In the UR, the “It” space, is the external of
depth in these four quadrants. Briefly stated, the individual. Every state of consciousness has
these levels, lines, states, and types are shown a felt energetic component that is expressed
in Table 13-6. from the wisdom traditions as three recog-
This part of the Theory of Integral Nursing nized bodies: gross, subtle, and causal (Wilber,
(see Fig. 13-1e) starts with healing at the cen- 2000b, 2005). We can think of these three
ter surrounded by three increasing concentric bodies as the increasing capacities of a person
circles with dotted lines of the four quadrants. toward higher levels of consciousness. Each
This part of the Integral Theory moves to level is a specific vehicle that provides the ac-
higher orders of complexity through personal tual support for any state of awareness. The
growth, development, expanded stages of con- gross body is the individual physical, material,
sciousness (permanent and actual milestones sensorimotor body that we experience in our
of growth and development), and evolution. daily activities. The subtle body occurs when
These levels or stages of development can also we are not aware of the gross body of dense
be expressed as being self-absorbed (such as a matter, but of a shifting in energy, emotional
Table 13-6 Content Component 5: AQAL (All Quadrants, Levels, Lines, States, Types)
Levels: Levels (also referred to as stages or waves) Lines: Developmental areas that are known as mul-
of development that become permanent with growth tiple intelligences (e.g., cognitive line [awareness
and maturity (e.g., cognitive, relational, psychosocial, of what is]; interpersonal line [how I relate socially
physical, mental, emotional, spiritual) that represent to others]; emotional/affective line [the full spec-
a level of increased organization or level of trum of emotions]; moral line [awareness of what
complexity. Each individual possesses both the should be]; needs line [Maslow’s hierarchy of
masculine and the feminine voice or energy. One is needs]; aesthetics line [self-expression of art,
not superior to the other; they are two equivalent beauty, and full meaning]; self-identity line [who
types at each level of consciousness and am I?]; spiritual line [where “spirit” is viewed as
development. its own line of unfolding, and not just as ground
and highest state], and values line [what a person
considers most important]).
States: Temporary changing forms of awareness Types: Differences in personality and masculine
(e.g., waking, dreaming, deep sleep, altered and feminine expressions and development
meditative states [such as occurs in meditation, yoga, (e.g., cultural creative types, personality types,
contemplative prayer, etc.]; altered states [due to Enneagram).
mood swings, physiology and pathophysiology shifts
with disease/illness, seizures, cardiac arrest, low or
high oxygen saturation, drug induced]; peak
experiences [triggered by intense listening to music,
walks in nature, lovemaking, mystical experiences
such as hearing the voice of God or of a deceased
person, etc.]).
Source: Copyright © 2018 by Barbara M. Dossey. Adapted from B. M. Dossey (2015) and K. Wilber (2007) with permission.

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feelings, and fluid and flowing images. Exam- group of health-care professionals or the
ples might be in our shift during a dream, dur- physical and technical structural of a hospital
ing different types of bodywork, walks in or a clinic versus the relational aspect that is
nature, or other experiences that move us to a an LL aspect.
profound state of bliss. The causal body is the Integral nurses strive to integrate concepts
body of the infinite that is beyond space and and practices related to body, mind, and spirit
time. Causal also includes nonlocality in which (the all-levels) in self, culture, and nature (“all
minds of individuals are not separate in space quadrants” part). The individual interior and
and time (L. Dossey, 2013). When this is ap- exterior—”I” and “It”—as well as the collec-
plied to consciousness, separate minds behave tive interior and exterior—”We” and “Its”—
as if they are linked, regardless of how far apart must be developed, valued, and integrated
in space and time they may be. Nonlocal con- into all aspects of culture and society. The
sciousness may underlie phenomena such as AQAL integral approach suggests that we
remote healing, intercessory prayer, telepathy, consciously touch all of these areas and do so
and premonitions, as well as so-called miracles. in relation to self, to others, and the natural
Nonlocality also implies that the soul does not world. Yet to be integrally informed does not
die with the death of the physical body— mean that we have to master all of these
hence, immortality forms some dimension of areas; we just need to be aware of them and
consciousness. Nonlocality can be both upper choose to integrate integral awareness and in-
and lower quadrant phenomena. tegral practices. Because these areas are al-
The LL, the “We” space, is the interior ready part of our being-in-the-world and
collective dimension of individuals that come cannot be imposed from the outside (they are
together. The concentric circles from the cen- part of our makeup from the inside), our
ter outward represent increasing levels of challenge is to identify specific areas for de-
complexity of our relational aspect of shared velopment and find new ways to deepen our
cultural values, as this is where teamwork and daily integral life practices.
the interdisciplinary and transpersonal disci-
plinary development occur. The inner circle Structure
represents the individual labeled as me; the The structure of the Theory of Integral Nurs-
second circle represents a larger group labeled ing is shown in Figure 13-1f. All content
us; the third circle is labeled as all of us to rep- components are represented together as an
resent the largest group consciousness that overlay that creates a mandala to symbolize
expands to all people. These last two circles wholeness. Healing is placed at the center,
may include people but also animals, nature, then the metaparadigm of nursing, the pat-
and nonliving things that are important to terns of knowing, the four quadrants, and all
individuals. quadrants and all levels of growth, develop-

The LR, the “Its” space, the exterior social ment, and evolution. (Note: Although the pat-
system and structures of the collective, is rep- terns of knowing are superimposed as they are
resented with concentric circles. An example in the various quadrants, they can also fit into
within the inner circle might be a group of other quadrants.)
health-care professionals in a hospital clinic Using the language of Ken Wilber (2000b)
or department or the complex hospital sys- and Don Beck (2007, 2018) and his spiral dy-
tem and structure. The middle circle expands namics, integral individuals move through
in increased complexity to include a nation; primitive, infantile consciousness to an inte-
the third concentric circle represents even grated language that is considered first-tier
greater increased complexity to the global thinking. As they move up the spiral of
level where the health of all humanity in the growth, development, and evolution and ex-
world is considered. It is also helpful to em- pand their integral worldview and integral
phasize that these groupings are the physical consciousness, they move into what is second-
dynamics such as the working structure of a tier thinking and participation. This is a radical

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leap into holistic, systemic, and integral modes Applications of the Theory
of consciousness. Wilber also expands to a
The Theory of Integral Nursing can strengthen
third-tier level of stages of consciousness that
21st-century nursing endeavors, guide integral
addresses an even deeper level of transpersonal
nurse self-development, and expand our con-
understanding.
sciousness to recognize that all of us are en-
Context gaged in global nursing. When we focus on
improving our own health and that of our fam-
Context in a nursing theory is the environ-
ily and community at the local level, each small
ment in which nursing acts occur and the na-
change connects “me” to “us” to “all of us”—
ture of the world of nursing (Dossey, 2016a).
creating the ripple effect of healthy people
In an integral nursing environment, the
living on a healthy planet—local to global.
nurse strives to be an integralist, which
Equally important in our endeavors is to doc-
means that she or he strives to be integrally
ument our process and progress with quanti-
informed, challenged to further develop an
tative and qualitative data, meanings, and
integral worldview, integral life practices,
experiences from the individual interior/
and integral capacities, behaviors, and skills.
individual exterior and the collective interior/
The term nurse healer is used to describe the
collective exterior.
nurse as an instrument in the healing process
and a major part of the external healing en- Integral Nurse Self-Development
vironment of a patient or family. An integral
nurse values, articulates, and models the in- Integral Nursing Principle 1 (UL):
tegral process, integral worldview, and inte- “I” Capacity of Self
gral life practices with self-care. Nurses assist Integral Nursing Principle 1 recognizes the in-
and facilitate the individual person(s) (client/ terior individual “I” (subjective) space. We ask,
patient, family, and coworkers) to access “Who am I?” and “What is my capacity of Self?”
their own healing process and potentials; To deepen our state of beingness, our mindful-
they do not do the actual healing. An integral ness about intentions, attitudes, and values helps
nurse recognizes herself or himself as a heal- us develop a conscious awareness about per-
ing environment interacting with a person, sonal health and our role in creating a healthy
family, or colleague, being with rather than world—local to global. We become aware of
always doing to or doing for another person. our personal challenges and parts of self that are
The integral nurse enters into a shared expe- in need of healing. It also includes addressing
rience (or field of consciousness) that pro- one’s own shadow as described by Jung (1981).
motes healing potentials and an experience This is a composite of personal characteristics
of well-being. Relationship-centered care is and potentials that have been denied expression
valued and integrated as a model of caregiv- in life and of which one is unaware; the ego de-
ing that is based in a vision of community nies the characteristics because they are in con-
and partnerships. flict and incompatible with a person’s chosen
conscious attitude. We also recognize conscious
Process dying and find time to contemplate one’s own
Process in a nursing theory is the method by death and to increase awareness that there is no
which the theory works. An integral healing separation between our practice and actions in
process contains both nurse processes and everyday life. This is a mature practice that is
patient/family and health-care worker processes wise and empty of a separate self.
(individual interior and individual exterior),
and collective healing processes of groups/ Integral Nursing Principle 2 (LR): “We”
individuals and of systems/structures (interior Capacity for Collective Intelligence
and exterior). This is the understanding of the Integral Nursing Principle 2 recognizes the
unitary whole person interacting in mutual importance of the “We” (intersubjective)
process with the environment. space. We explore “Who are we together?” and

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“What is our capacity for collective intelli- Integral Nursing Principle 4 (LR): “Its”
gences?” We use deep listening, being present, Capacity for Alignment in Systems/
and focused with intention to understand what Structures
another person is expressing or not expressing. Integral Nursing Principle 4 recognizes the
Through authentic sharing of worldviews, be- importance of the exterior collective “Its” (in-
liefs, priorities, values, and concerns, we ex- terobjective) space. Nurses and the health-care
plore multiple perspectives. This space also team come together and ask, “How can we
applies to the “we” with our family, friends, strengthen our capacity for alignment and col-
and communities. We engage in transpersonal laboration in our work?” and “What are the
dimensions moving from superficial conversa- priorities?” They create exterior healing envi-
tions to a deeper dialogue that goes beyond the ronments that incorporate nature and the nat-
individual ego. This is the exploration of the ural world when possible. This principle also
sacred or holy that involves feelings, thoughts, applies to the family system and structures and
experiences, rituals, meaning, value, direction, to seek ways to enhance all endeavors and gain
and purpose as valid aspects of the universe. It a deeper understanding for what is working
is a unifying force of a person with all that is— and what is not working, thus connecting all
the essence of beingness and relatedness that the other quadrant principles from an integral
permeates all of life and interconnectedness perspective.
with self, others, nature, and God/Life Force/
Absolute/Transcendent. Six Lines of Development
The Theory of Integral Nursing can assist us to
Integral Nursing Principle 3 (UR): strengthen our self-development and human
“It” Capacity for Actions and Skill flourishing in all four quadrants by reflection
Development on the six lines of development (cognitive,
Integral Nursing Principle 3 recognizes the emotional, somatic, interpersonal, spiritual,
importance of the individual exterior “It” (ob- and moral) in each quadrant (Wilber, 2000a,
jective) space. We ask, “What skills, behaviors, 2005b). As we already focus on wholeness—
and action steps can assist me to achieve per- body, mind, spirit–culture–environment—we
sonal health?” “What personal actions can ex- can consciously touch these six lines and do so
pand my awareness of my place with the health in relation to self, to others, and the natural
of my family, workplace, and community?” world. This is part of being-in-the-world and
“How do my behaviors and actions lead to a is not imposed from the outside. It is already a
healthy planet?” and “What are the effects of part of our inherent makeup. Our challenge is
my behaviors and actions?” All behaviors and to expand our consciousness and find new
actions can be measurable and observable. ways to deepen our integral understanding so
In this space nurses and the health-care that our personal and professional lives and en-
team members compile the data around phys- deavors come from a depth that encourages ex-
iological and pathophysiological assessment, ploration of new insights and possibilities for
nursing diagnosis, outcomes, plans of care (in- greater health and well-being.
cluding medications, technical procedures, Table 13-7a explores the six lines of devel-
monitoring, treatments, and traditional and opment with reflective questions in each quad-
integrative practice protocols), implementa- rant to more deeply connect the dots of our
tion, and evaluation. Nurses co-create plans of beingness, thoughts, and actions. Each quad-
care with patients, families, and community rant contains the same six lines of development
and integrate a caring–healing philosophy and questions. However, a shift in one’s conscious-
interventions/modalities with traditional med- ness occurs by using a different word/words in
ical and surgical technology and treatment. each quadrant that is bolded. The upper left
Specific education is offered based on out- (UL) quadrant has the bolded words inner self;
comes and evaluation, which also guides re- the upper right (UR) quadrant has the bolded
search questions and data collection. word body; the lower left (LL) has the bolded

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Table 13-7a Six Lines of Development: Reflective Questions

Individual
UL Inner Self (Subjective) Outer Self (Objective) UR
Reflective Questions Reflective Questions
Cognitive: “What is My Awareness of What is?” Cognitive: “What is My Awareness of What is?”
■ What leads to my new inner self understand- ■ What body behaviors do I embody that
ings about possibilities insights, action leads to my new understandings about

steps, breakdowns, and resistance to possibilities, insights, action, steps,
change? breakdowns, or resistance to change?
Emotional: “Awareness to Spectrum of Emotions” Emotional: “Awareness to Spectrum of Emotions”
■ How do I skillfully recognize my inner ■ What does my body feel or recognize about
self-emotional state about life conditions life conditions (present, past, future) as
(present, past, future) and how they are related to the present moment?
related to the present moment? ■ How does my body react in situations
■ What situations evoke various inner self that evoke various emotions (challenges,
emotions (challenges, joy, fears, anger, joys, fears, anger, difficulties, disappoint-
difficulties, disappointments, etc.)? ments, etc.)?
■ What is my inner self capacity to enter into the ■ How does my body enter into the energy
energy field with another and listen deeply. field with another to listen deeply?
Somatic: “Awareness of Body/Mind” Somatic: “Awareness of Body/Mind”
■ What is my inner self awareness as I feel and ■ What does my body notice about sensations
notice my body sensations (tired, tight, (tired, tight, open, energized) and how do I
I open, energized in the present moment and respond in the present moment? E
N how do I respond? ■ How can I connect my body sensations
X
T ■ How do I access my inner self wisdom and and wisdom and make subtle shifts as T
E make subtle shifts as needed? needed? E
R Interpersonal: “Awareness of How I Relate Interpersonal: “Awareness of How I Relate R
I to Others” to Others” I
O ■ How does my inner self engage socially with ■ How does my body engage socially with O
R others from the I/We/It/Its perspectives? others from the I/We/It/Its perspectives? R
■ How does my inner self listen deeply to ■ How does my body reflect deep listening to
others’ intentions, goals, and desires, and others’ intentions, goals, and desires, and
offer appropriate support? offer appropriate support?
Interpersonal: “Awareness of Ultimate Issues” Spiritual: “Awareness of Ultimate Issues”
■ How does my inner self explore feelings, ■ How do I make body connections to the
thoughts, experiences, and behaviors that feelings, thoughts, experiences, and behav-
arise from a search for meaning around iors that arise in exploring a search for
ultimate issues, questions, and concerns? meaning around ultimate issues, questions,
■ How does my inner self respond when concerns?
I connect to who I am and to my soul’s ■ How does my body respond to who I am
purpose? when I connect with my soul’s purpose?

■ How does my inner self feel the intercon- ■ How does my body feel interconnected to the
nected web of life (“me” “us” “all of us”)? web of life (“me” “us” “all of us”)?
Moral: “Awareness of What to Do” Moral: “Awareness of What to Do”
■ What is my inner self experience as I reach a ■ How does my body feel as I reach a decision
decision about a choice/right thing to do? about a choice/right thing to do?

■ How does my inner self enact chosen behav- ■ How does my body enact chosen behaviors
iors and actions (“me” us” “all of us”)? and actions (“me” “us” “all of us”)?
Collective

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Table 13-7a Six Lines of Development: Reflective Questions—cont’d

Individual
LL Relational/Collective (Intersubjective) Worldly / Collective (Interobjective) LR
Reflective Questions Reflective Questions
Cognitive: “What is My Awareness of What is?” Cognitive: “What is My Awareness of What is?”
■ What is my relational self in understandings ■ What leads to worldly self understandings
about possibilities, insights, action steps, about possibilities, insights, action steps,
breakdowns, and resistance to change? breakdowns, and resistance to change?
Emotional: “Awareness to Spectrum of Emotions” Emotional: “Awareness to Spectrum of Emotions”
■ How does my relational self recognize my life ■ What is my worldly self emotional state
conditions (present, past, future) and how about the life conditions (present, past,
they are related in the present moment? future) and how they are related in the
■ How does my relational self respond when present moment?
different situations evoke various emotions ■ What situations evoke various worldly self
(challenges, joy, fears, anger, difficulties, emotions (challenges, joy, fears, anger,
disappointments, etc.)? difficulties, disappointments, etc.)?
■ How does my relational self enter into the ■ How does my worldly self enter into the
energy field of another to listen deeply? energy field of another to listen deeply?
Somatic: “Awareness of Body/Mind” Somatic: “Awareness of Body/Mind”
■ What is my relational self awareness as I feel ■ What is my worldly self awareness as I feel
and notice my body sensations (tired, tight, and notice my body sensations (tired, tight,
open, energized) and how do I respond in open, energized) and how do I respond in
I the present moment? the present moment? E
N ■ How do I access my relational self wisdom ■ How do I access my worldly self wisdom and
X
T and make subtle shifts as needed? make subtle shifts as needed? T
E Interpersonal: “Awareness of Ultimate Interpersonal: “Awareness of How I Relate E
R Issues” to Others” R
I ■ How does my relational self engage socially ■ How does my worldly self engage socially I
O with others from the I/We/It/Its perspectives? with others from the I/We/It/Its perspectives? O
R ■ How does my relational self listen deeply to ■ How does my worldly self listen deeply to R
others’ intentions, goals, and desires, and others’ intentions, goals, and desires, and
offer appropriate support? offer appropriate support?
Spiritual: “Awareness of Ultimate Issues” Spiritual: “Awareness of Ultimate Issues”
■ How does my relational self explore feelings, ■ How does my worldly self explore feelings,
thoughts, experiences, and behaviors that thoughts, experiences, and behaviors that
arise from a search for meaning around arise from a search for meaning around
ultimate issues, questions, and concerns? ultimate issues, questions, and concerns?
■ How does my relational self respond when ■ What does my worldly self experience as
I connect to who I am and to my soul’s I reflect on who I am and on my soul’s

purpose? purpose?
■ How does my relational self feel the ■ How does my worldly self feel the
interconnected web of life (“me” “us” interconnected web of life (“me” “us”
“all of us”)? “all of us”)?
Moral: “Awareness of What to Do” Moral: “Awareness of What to Do”
■ What is my relational self experience when ■ What is my worldly self experience when
I and others reach a decision about a choice I reach a decision about a choice about the
about the right thing to do? right thing to do?
■ How does my relational self and the group ■ How does my worldly self enact chosen
enact chosen behaviors and actions (“me” behaviors and actions (“me” “us” “all
“us” “all of us)? of us”)?
©Barbara Dossey, 2015
Collective

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Table 13-7b Reflective Practices: Body-Mind-Spirit-Cultural-Environment Dimensions

Individual
UL Reflective Practices: Inner Self Reflective Practices: Outer Self UR
Affirmations and positive thinking Aerobic exercise and strength training
Art and drawing Aromatherapy
Cognitive reframing Assessments
Deep listening Contracts and goal setting
Emotional, mental, spiritual training practices Health and wellness tools
Guided imagery Massage and other body therapies
Forgiveness, loving, kindness, and compassion Nutrition
Humor, laughter, play Movement/dance
Journaling and stories Music/sound/singing
Meditation Nature
Prayer, silence, stillness Pets and other animals
I Presence, intention, intuition Sleep (6-8 hours each day) E
N Relaxation modalities Sports X
T Self-reflection (beliefs, values, purpose, Trauma and grief work T
E reading) Weight management E
R Rituals of healing and celebrations Yoga, Tai Chi/Qigong (other subtle energy R
I Shadow work practices) I
O LL Reflective Practices: Reflective Practices: LR O
R Relational/Collective Worldly/Collective R
Appreciative Inquiry Centering practices
Community and volunteer work Compassion and random kindness to
Conferences, retreats, workshops others
Coaching sessions Community and volunteer work (local to
Healthy relationships building global)
Interpersonal communication and skills Healthy work environments
development Healing rooms and sacred spaces
Motivational Interviewing Organization initiatives and protocols
Personality and typology tools Polarity recognition in staff and workplace
Self-reflection, reading, and studying with Self-care in the workplace (meals)
groups Safety precautions at work
Spiritual and/or religious group gatherings Visionary projects and endeavors
© Barbara Dossey, 2015*
Collective
*These four quadrants create wholeness. Practices listed in one quadrant can also be listed in other quadrants. A practice
done in one quadrant will impact all other quadrants. © Barbara Dossey, 2015.
words relational self; and the lower right (LR) each quadrant, they become an integral part of
quadrant has the bolded words worldly self. Re- one’s being and flow into the co-creative dance
member this is a dynamic developmental with others and more of our personal and pro-
process where one line of development may be fessional endeavors.
stronger than other lines depending on life’s
circumstances that are always changing and Integral Nursing, Global Health,
evolving. We can integrate various reflective and Planetary Sustainability2
practices as seen in Table 13-7b to help us make The Theory of Integral Nursing is pivotal in as-
shifts and to explore life challenges and to raise sisting nurses to understand their essential
our consciousness to a higher level of aware- roles in the global and planetary agendas of our
ness. This discovery process often leads to find- time. As theory and knowledge development
ing more life balance and satisfaction. As we
explore these lines of development with self in 2Written by William E. Rosa

7991_Ch13_211-234 12/08/19 5:24 PM Page 229
adapt to the emerging needs that arise in and the shadow of all circumstances affecting
the face of human inequities, substantial bio- health and well-being in order to effect tangi-
diversity loss, and environmental degradation ble advancement from a health infrastructure
(Rosa, 2017a), the Theory of Integral Nursing rooted in “sick care” to the fullness of Nightin-
inspires a holistic lens that promotes our inter- gale’s vision for a socially just and human-
connected and interdependent well-being. centered, accessible system. In role-modeling
Across all quadrants and all levels, from the in- both art and science, nurses can guide leader-
terpretive to the measurable, and through the ship initiatives using the Theory of Integral
myriad dynamics of all ways of knowing, the Nursing as both an ethical foundation and a
very foundations of this work are rooted in the moral compass.
core tenets of the profession identified by
Nightingale: healing, leadership, and global Global Action
action (B. M. Dossey, Selanders, Beck, & The pivotal role of nurses in the health-care
Attewell, 2005). arena, local to global, is growing each day.
Currently there are an estimated 20.7 million
Healing nurses and midwives worldwide, accounting
The Theory of Integral Nursing propels the for up to 70% of all human resources for
disciplinary commitment to healing into the health, and delivering up to 90% of all pri-
space of Beck’s (2007, 2018) Spiral Dynamics mary health-care services (Klopper, Darling,
Second Tier Turquoise stage of development Vlasich, Catrambone, & Hill, 2017; World
with a focus on experiencing the wholeness of Health Organization, 2016). One of the most
existence through the body, mind, and spirit. formidable transnational contracts of our time,
This notion has long been evidenced by scien- encompassing everything from personal to
tists who recognize the One Mind connections planetary health, is the 2030 United Nations
that link the nontemporal consciousness of all Agenda for Sustainable Development (United
living beings (L. Dossey, 2013). The theory in- Nations, n.d.). Composed of 17 Sustainable
vokes an understanding that the health and Development Goals (SDGs) and 169 targets,
healing of one directly affects the health and nurses are a vital component to achieving the
healing of all. Rosa (2017c) adapts B. M. components of the Agenda worldwide (Rosa,
Dossey’s (2016b) definition of healing in light 2017b). The SDGs, as listed in Table 13-8, are
of these universal considerations to be a blueprint for living, breathing, and realizing
the Theory of Integral Nursing and a Nightin-
a lifelong journey into understanding the whole- gale vision for healing through leadership and
ness of [planetary] existence. Healing occurs global action.
when we help [the planet] embrace what is The concept of Rosa’s (2017c) planetary cit-
feared most. … Healing is learning how to open izenship ushers the Theory of Integral Nursing
what has been closed so that we can expand toward the 22nd century alongside expanded
[new planetary] potentials. … It is accessing what personal–professional duties to self, other,
we have forgotten about connections, unity, and community, and planet. The idea of planetary
interdependence. (p. 23) citizenship
Leadership moves beyond man-made borders and limita-

To actualize the moral gravitas of the Theory tions to the universal principles of a shared and
of Integral Nursing, nurses must recognize reciprocal humanity and all-life relationship. It
their potentials as leaders, foster their own eth- moves us from the notions of one woman, one
ical self-awareness, develop habits of demon- man, one child, one country, or one continent,
strable compassion and caring, and respect the toward One Mind–One Health–One Planet.
life force of all beings across cultures and con- (Rosa, 2017c, p. 519)
texts (B. M. Dossey, 2016a). Integral nurse In striving to promote a universal experi-
leaders must be willing to embrace the light ence of dignity; loving but direct action
Smith, Marlaine C.. Nursing Theories and Nursing Practice, F. A. Davis Company, 2019. ProQuest Ebook Central,
http://ebookcentral.proquest.com/lib/humber/detail.action?docID=5985004.
7991_Ch13_211-234 12/08/19 5:24 PM Page 230
Table 13-8 The United Nations 17 Sustainable Development Goals

1. No Poverty
2. Zero Hunger
3. Good Health and Well-being
4. Quality Education
5. Gender Equality
6. Clean Water and Sanitation
7. Affordable and Clean Energy
8. Decent Work and Economic Growth
9. Industry, Innovation, and Infrastructure
10. Reduced Inequalities
11. Sustainable Cities and Communities
12. Responsible Consumption and Production
13. Climate Action
14. Life Below Water
15. Life on Land
16. Peace, Justice, and Strong Institutions
17. Partnerships for the Goals
Source: United Nations, 2016. https://sustainabledevelopment.un.org/content/documents/21252030%20Agenda%20for
%20Sustainable%20Development%20web.pdf
regarding threats to well-being; a global vil- and healing of many, as does one’s illness
lage of transformation and unity; a commit- or unconsciousness. The awareness of One
ment to create healing environments at all Mind recognizes that interior/subjective work
levels and in all spaces; and an honoring of is essential to witnessing exterior/objective
the light in all of life, the components of progress.
planetary citizenship walk hand in hand with One Health “recognizes that the health of
the Theory of Integral Nursing into the fu- humans, animals, and ecosystems [is] inter-
ture of nursing, health, healing, and whole- connected. It involves applying a coordinated,
ness. As nurses emerge as fully embodied collaborative, multidisciplinary and cross-sec-
advocates of healing, leadership, and global toral approach to address potential or existing
action, the Theory of Integral Nursing will risks that originate at the animal–human–
continue to develop in keeping with the aris- ecosystems interface” (One Health Global
ing holistic needs of all persons, peoples, Network, 2012–2015). Embedding humani-
species, ecosystems, and planetary elements tarian agendas throughout current health ini-
of the future. tiatives, recognizing and addressing power

and resource imbalances worldwide, and mov-
Toward the Space of Integrality ing from a “sick-care” culture toward a “health
In his book One Mind, integrative physician and well-being culture” are all key actions to
and leader Dr. Larry Dossey (2013) provides shifting the health-care mindset toward One
ample evidence that all human beings—and, Health (Leudekke, 2016). One Health creates
in fact, all sentient beings on the planet—are an inclusive future for all beings and recog-
interconnected through a universal sphere of nizes them as worthy of care, attention, and
consciousness. The implications are stirring. respect.
Ultimately, L. Dossey (2013) is positing that Building on the One Mind and One
each being, by Its very existence on the Health philosophies, the idea of One Planet
planet, contributes Its individual interior seeks to invite healing to the fractures in the
vastness to the infinite collective energy. personal/planetary and individual/collective
Through his scholarship, it becomes clear experience through awakening consciousness
how the level of consciousness and corollary and inviting nurses to become planetary lead-
healing of one influences the consciousness ers, planetary advocates, and planetary change
7991_Ch13_211-234 12/08/19 5:24 PM Page 231
agents (Rosa, 2017a). As the Pledge to Plane- Education3

tary Citizenship reads, The development of an integral curriculum ex-
perience has at its heart the goal of supporting
I pledge partnership with all beings in an effort to
students’ evolution as movement out of the lim-
realize Planetary Citizenship and a Planetary
iting space of being self-focused (ego-centric)
World,
and toward the expanded space of being more
To remain open, available, and flexible,
capable of working effectively in the world at
To teach what I know and learn what I don’t know,
the local and global level. An integral educa-
To honor the light in all of life,
tional experience can support students toward
And to leave the Planet better than I found it.
better understanding their holistic nursing role
This is my solemn pledge and commitment.
and the necessity for enacting a caring–healing–
(Rosa, 2017a, p. 520)
sustainable practice. This integral educational
The Theory of Integral Nursing is a philos- experience can also enhance, through deeper
ophy of One Mind–One Health–One Planet, self-awareness, the student’s and nurse’s ability
ushering in a new consciousness that will pro- to respond to the unique needs and circum-
mote healing at all levels—healing at depths stances of those in their care. A beginning level
and heights we may not even be aware are nec- of understanding of the theory of integral nurs-
essary for a sustainable and thriving world. ing and integral concepts can support curricu-
Nurses, as the bearers of Nightingale’s candle- lum development and evaluation, and provide a
light, are on the frontlines of this healing and structure used to guide an inquiry process, based
awakening; more important, they are the con- on AQAL, which is transferable beyond the
sciousness that will promote it. And nursing— classroom to myriad clinical nursing practice
integral nursing—is what will move the contexts (Carey, 2006, 2011, 2012, 2013).
discipline toward the fragile space of integrality The AQAL approach helps educators to
so long awaited. design and revise the curriculum to ensure that
there is not an overemphasis or overreliance on
Practice the right-hand path, and brings us back into a
Using the Theory of Integral Nursing assists more balanced approach of supporting stu-
nurses in assessment and care management in dents’ evolution on their own healing path via
all clinical practice situations. By using an UL quadrant emphasis to best support others
AQAL framework, the nurse can see from on their healing paths in the LL quadrant in
multiple perspectives at once and better con- the following areas:
nect the dots to the complexity within a pa-
■ How to structure the overall curriculum
tient’s care. For example, managing a person’s
■ How to structure individual assignments
pain is a useful example because of its acute

■ Texts that support UL quadrant growth,
and chronic multifactorial nature that may
student success, and tools
evoke physical, emotional, mental, social,
■ Educating faculty and getting buy-in
spiritual, or existential aspects (Shea &
■ Evaluating student success
Frisch, 2014). Remember that whole person
care is allowing for a person’s stories and ex- An AQAL approach provides educators
periences to be heard and to connect these and nursing students with a structure to guide
with the family’s stories and experiences. It an inquiry process that invites exploration and
means bearing witness and being present for application of nursing knowledge to practice
things as they are, which involve integrating situations from four quadrant perspectives.
qualities of deep listening to understand what Additionally, the four quadrants may also be
another person is expressing or not express- used as a framework to guide self-inquiry in
ing. By using an integral nurse coaching situations where students recognize an inter-
process, we honor the capacity to be with not nal dissonance in nursing situations. Through
knowing, that is, a willingness to be free of
fixed ideas. 3Written by Carey S. Clark
7991_Ch13_211-234 12/08/19 5:24 PM Page 232
caring–healing sustainable practices and a Research

willingness to examine one’s taken-for-granted The Theory of Integral Nursing assists nurses to
assumptions, beliefs, and values, students can consider the importance of all methods of in-
be supported in learning to navigate challeng- quiry (B. M. Dossey, 2016; Delaney, Zahourek,
ing situations, while also potentially develop- & Barrere, 2016; Shea & Frisch, 2014). We are
ing a broader, more inclusive worldview and challenged to consider the findings from both
link to levels (stages) and the six lines of de- qualitative and quantitative data and always
velopment. There is also an ethical obligation consider triangulation of data when appropriate.
(autonomy, justice) to offer students the op- Nurses as researchers must always value intro-
portunities and tools to enhance evolution, spective, cultural, and interpretive experiences
which can enable their abilities toward creat- and expand our personal and collective capaci-
ing truly sustainable caring–healing practices. ties of consciousness as evolutionary progression
This can indeed address nurse retention and toward achieving our goals. Since knowledge
nursing shortages now and in the future. emerges from all four quadrants, the Theory of
An example of use of the Theory of Integral Integral Nursing assists in connecting all parts
Nursing for an entire curriculum is by Darlene of ourselves at a deeper level.
Hess, PhD, NP, AHN-BC, HWNC-BC
(Hess, 2016), who designed an RN-to-BSN Health-Care Policy
program at Northern New Mexico State in Compelling evidence in nursing and all of the
Espanola, New Mexico. This RN-to-BSN health-care professions shows that the origins
program prepares registered nurses to assume of health and illness cannot be understood by
leadership roles as holistic and integral nurses focusing only on the physical body. Percep-
at the bedside, within organizations, in the tions of health and illness within the Theory of
community, and in other areas of professional Integral Nursing and an AQAL approach are
practice. Another example of the Theory of In- expanded and provide limitless possibilities.
tegral Nursing in curriculum development is When we do this, we can account for One
seen in the Integrative Nurse Coach Certifi- Mind–One Health–One Planet. This must in-
cate Program (INCCP, n.d.), the development clude the social and environmental determi-
of the middle-range Theory of Integrative nants of health and our (human beings) entire
Nurse Coaching, and the component of inte- physical, mental, emotional, social, spiritual,
gral perspectives and change (Dossey, Luck, & cultural, and environmental dimensions and
Schaub, 2015). interrelationships.
Practice Exemplar
Written by Sara Oerther, MSN, MEd, RN, FRSPH international students living in rental apart-
Nurses are committed to dramatic social and ments without access to land and low-income
economic advancement by empowering un- community members suffering from food in-
derserved communities through the creation security. Community gardens include sub-
of networks to access resources and educa- plots of arable land where members grow
tion. Nurses are shifting their consciousness fresh produce. With a lot of work, nurses
and realizing that all nursing endeavors done converted unused land donated by the town
in their local communities are contributions into green vegetable plots for 20 families.
to global health. The garden improved access to fresh vegeta-
bles for international families and low-income
Community Garden and Integral community members.
Modeling UL—Among Individuals
Nurses helped establish the first commu- We challenged ourselves to deeply listen to
nity garden in a small college town in rural the stories of these 20 families and others
Missouri. The target audience included about what a community garden meant to
7991_Ch13_211-234 12/08/19 5:24 PM Page 233

them, as well as the foods of their culture and nature of healing from many viewpoints sur-
what foods they wanted to grow in the gar- rounding nutrition and provided an affordable
den plots. As we listened, we realized that means of keeping people healthy.
these stories were about more than their fa- This community garden project, based on
vorite foods; they were about how their the Theory of Integral Nursing, was substan-
mothers, grandmothers, aunts, and commu- tially unique in design (linked the relevance
nities prepared foods. These stories provoked of gardens with evidence-based research on
images and feelings that revealed deeper feel- nutrition) and implementation (authentic
ings about being away from their native community engagement for minorities and
countries, school and work stressors, acute low-income residents). Unique aspects of this
and chronic health problems, and family dy- project included assessment of community
namics and relationships. We provided indi- needs, stakeholder and nurses’ input, and lit-
vidual and group coaching sessions as erature review of best practices. Training in
needed. gardening and nutritional educational material
preparation based on a nursing perspective
LL—Within Groups
was provided to help tackle health disparities
To promote social responsibility and em-
related to nutrition.
power community members to address social
In this practice exemplar the Theory of
determinants of health, such as nutrition, in-
Integral Nursing is used as the framework
terprofessional teams are necessary. Nurses
for partnering with local groups to develop a
started this project by working with the local
community garden project (Oerther, 2018).
university extension specialist and then
Dossey’s collaborative Nightingale Initiative for
formed a team of community members to
Global Health (NIGH) (NIGH, n.d.) applies
take charge of the project. The team reached
the Theory of Integral Nursing and modeling to
out to the local city council and together they
present the whole picture, as well as the pieces
enacted a long-lasting, sustainable improve-
of the whole and—perhaps most important—
ment measure in the local community, a
the relationships among these pieces (Dossey,
community garden. During the garden grow-
Beck, Oerther, & Manjrekar, 2017). Using the
ing season, the nurse team gave a report at
NIGH’s team jigsaw puzzle metaphor, the UL
the monthly community meeting.
“I” quadrant is named “Among Individuals”; the
UR—Grassroots Levels LL “We” quadrant is named “Within Groups”;
The initial team was made up of nurses. The the UR “It” quadrant is named “At Grassroots
goal of the team was to develop a stronger Levels”; and the LR “Its” quadrant is named “At
partnership with the local residents and to Global Levels.”

exchange ideas. A big challenge was the deer! First, nurses identified four interrelated
Overcoming this obstacle created an oppor- challenges. They believed that an integral ap-
tunity for an Eagle Scout volunteer project proach, to mobilize community awareness for
for members of the local Boy Scout troop, addressing these challenges at the local level,
who built a fence to keep animals away from could have an impact on global endeavors.
the vegetables. ■ Challenge 1: The U.S. health-care system
LR—Global Level faces the challenge of improving health
This project displayed nurse-healer compe- outcomes through nutrition as an afford-
tence because the team involved scholarly- able means of providing preventive care
based expertise and global endeavors, which (LL—Within Groups; UR—At Groups
initially leveraged SDG #2, SDG #3, SDG Levels).
#10, and SDG #17. This community project ■ Challenge 2: Achieving the UN 17 Sus-
explored new possibilities into the complex tainable Development Goals (SDGs) (see
(continued)
7991_Ch13_211-234 12/08/19 5:24 PM Page 234

Table 13-8) at the local level is an excit- pivots to an evidence-seeking approach to
ing challenge. For this community gar- develop communities (UL—Among In-
den project, the focus was on SDG #2, dividuals; UR—At Grassroots Levels).
Zero Hunger; SDG #3, Health and ■ Challenge 4: Partnerships are one of the
Well-Being; SDG #10, Reduced In- most important skills to use when nurses
equalities; and SDG #17, Partnerships engage in community development projects.
for the Goals at the local level (UL— Thus, determining the best partnerships was
Among Individuals; UR—At Grassroots key to the success of the community garden
Level), knowing that it would also have (LL—Among Groups).
a global impact (LR—At Global Levels)
By using the Theory of Integral Nursing
as these international students and
and its four-quadrant integral approach, nurses
families shared the project with their
developed a deeper understanding of commu-
relatives in many countries.
■ Challenge 3: Many public health efforts
nity health as they partnered with community
members to solve health challenges relating to
fall short because they are driven by an
people, prosperity, and planet. They used a
overemphasis on technology. Thus, the
nurse coaching approach to build on individual
true intellectual contribution of this
and community strengths rather than attempt-
practice exemplar rests in the rejection
ing to “fix” weaknesses.
of the technology-first approach and
Summary
The Theory of Integral Nursing addresses how With an integral approach and worldview,
we can increase our integral awareness, enhance we are in a better position to share with others
our wholeness and healing, and strengthen our the depth of nurses’ knowledge, expertise, and
personal and professional capacities to more critical-thinking capacities and skills for assist-
fully open to the mysteries of life’s journey and ing others in creating health and healing. Only
the wondrous stages of self-discovery with self with an attention to the heart of nursing, for
and others. Contemporary nursing demands a “sacred” and “heart” reflect a common mean-
new paradigm with a new language that allows ing, can we generate the vision, courage, and
nurses to take the best of what is known from hope required to unite nursing in healing. This
both the science and art of nursing, including assists us as we engage in health-care reform to
integral, holistic, integrative, and human caring address the challenges in these troubled
theories and modalities, to create real-world times—local to global. It is not an abstract mat-
solutions to current local and global issues. ter of philosophy, but of survival.
Questions for Reflection behavior using an integral perspective and

the four quadrants?
and Discussion ■ What do I discover when I explore the six
■ What ways do I integrate the integral lines of development in each quadrant?
principles in my personal life and profes-
sional endeavors?
■ What new understanding and insights do
I have about my own capacity to change a
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SE C T I O N
IV
Conceptual Models/
Grand Theories in the
Unitary–Transformative
Paradigm
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SECTION
IV Conceptual Models/Grand Theories in the

Unitary–Transformative Paradigm
There are three grand theories clustered in the Unitary–Transformative Paradigm. In
this paradigm 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.
In Chapter 14, Rogers’ Science of Unitary Human Beings is explicated by Howard
Butcher and Violet Malinski. The Science of Unitary Human Beings is based on
the premise that humans and environments are patterned, pandimensional energy
fields in continuous mutual process. Persons participate in their wellbecoming, which
is relative and personally defined. Several theories, research traditions, and practice
traditions have evolved from this conceptual system.
Parse’s Humanbecoming Paradigm is featured in Chapter 15, written by the the-
orist herself. Humanbecoming is defined as a basic human science that has co-
created human experiences as its central focus. The Humanbecoming Paradigm 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 tran-
scending with the possibles. The Humanbecoming Paradigm has well-developed re-
search and practice methods that guide the inquiry and practice of nurses embracing
humanbecoming.
Newman’s Theory of Health as Expanding Consciousness (HEC) is explicated in
Chapter 16 by Margaret Dexheimer Pharris. According to HEC, health is an evolving
unitary pattern of the whole, including patterns of disease. Consciousness, or the
informational capacity of the whole, is revealed in the evolving pattern. Pattern iden-
tifies the human–environmental 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 nurse–patient relationship. These concepts are reflected in the praxis method
developed to guide practice-research.
236
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Martha E. Rogers’ Science

CHAPTER
14
of Unitary Human Beings
Howard Karl Butcher and
Violet M. Malinski

Overview of Rogers’ Science of Unity Human Introducing the Theorist
Beings Martha E. Rogers, one of nursing’s foremost
Applications of the Conceptual System scientists, was a staunch advocate for nursing
Practice Exemplar as a basic science from which the art of practice
Summary would emerge. A common refrain throughout
Questions for Reflection and Discussion her career was the need to differentiate skills,
techniques, and ways of using knowledge from
the actual body of knowledge needed to guide
practice to promote well-being for humankind.
Rogers identified the human–environmental
mutual process as nursing’s central focus, not
health and illness. She repeatedly emphasized
the need for nursing science to encompass
human beings in space and 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 re-
turned 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. She then at-
tended George Peabody College in Nashville,
Tennessee, where she earned her bachelor of sci-

ence degree in public health nursing, choosing
that field as her professional focus. Rogers spent
the next 13 years in rural public health nursing
in Michigan, Connecticut, and Arizona, where
she established the first visiting nurse service in
Phoenix, serving as its executive director (Hektor,
1989/1994). In 1945, recognizing the need for
advanced education, she earned a master’s de-
gree in nursing from Teachers College, Colum-
bia University, in the program developed by
another nurse theorist, Hildegard Peplau. In
1951, she left public health nursing in Phoenix
to return to academia, this time earning both a
masters of public health and a doctor of science
237
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238 S E C T IO N IV ■ Conceptual Models/Grand Theories in the Unitary–Transformative Paradigm
degree from Johns Hopkins University in Balti- to homeodynamics, waking as a basic state to
more, Maryland. waking as an evolutionary emergent, and closed
In 1954, after her graduation from Johns to open systems. She pointed out that in a uni-
Hopkins, Rogers was appointed head of the verse of open systems, energy fields are contin-
Division of Nursing at New York University uously open, infinite, and integral with one
(NYU), beginning the second phase of her another. A view of change as predictable, or even
career overseeing baccalaureate, master’s, and probabilistic, yields to change as diverse, creative,
doctoral programs in nursing and developing innovative, and unpredictable.
the nursing science she knew was integral to Rogers (1994a) identified the unique focus
the knowledge base nurses needed. During the of nursing as “the irreducible human being and
1960s, she successfully shifted the focus of its environment, both defined as energy fields”
doctoral research from nurses and their func- (p. 33). “Human” encompasses both Homo
tions to humans in mutual process with the sapiens and Homo spatialis, the evolutionary
environment. She wrote three books that ex- transcendence of humankind as we voyage into
plicated her ideas: Educational Revolution in space; environment encompasses outer space,
Nursing (1961), Reveille in Nursing (1964), and the cosmos itself.
the landmark An Introduction to the Theoretical Rogers was aware that the world looks very
Basis of Nursing (1970). From 1963 to 1965, different from the vantage point of this newer
she edited Nursing Science, a journal that was view as contrasted with the older, traditional
far ahead of its time; it offered content on the- worldview. She pointed out that we are already
ory development and the emerging science of living in a new reality, one that is “a synthesis of
nursing, as well as research and issues in edu- rapidly evolving, accelerating ways of using
cation and practice. Rogers died in 1994, leav- knowledge” (Rogers, 1994a, p. 33), even if people
ing a rich legacy in her writings on nursing are not always fully aware that these shifts have
science, the space age, research, education, and occurred or are in process. She urged nurses to
professional and political issues in nursing. be visionary, looking forward and not backward
and not allowing themselves to become “stuck”
in the present, in the details of how things are
Overview of Rogers’ Science now, but envision how they might be in a uni-
of Unitary Human Beings verse where continuous change is the only given.
The historical evolution of the Science of Rogers (1994b) cautioned that although tradi-
Unitary Human Beings has been described by tional modalities of practice and methods of re-
Phillips (2016) and Malinski and Barrett search serve a purpose, these modalities are
(1994). This chapter presents the science in its inadequate for a newer worldview. Rogers urged
current form and identifies work in progress to nurses to use the knowledge base of Rogerian
expand it further. nursing science creatively to develop innovative

new modalities and research approaches that
Rogers’ Worldview would promote the betterment of humankind.
Rogers (1992) articulated a new worldview in
nursing, one that was commensurate with new Postulates of Rogerian Nursing
knowledge emerging across disciplines, which Science
rooted nursing science in “a pandimensional Rogers (1992) identified four fundamental pos-
view of people and their world” (p. 28). Rogers tulates that form the basis of the new reality:
(1992) described the evolution from older to ■ Energy fields
newer worldviews in such shifting perspectives ■ Openness
as cell theory to field theory, entropic to negen- ■ Pattern
tropic universe, three-dimensional to pandimen- ■ Pandimensionality (formerly called both
sional, person–environment as dichotomous to
four-dimensionality and multidimensionality)
person–environment as integral, causation and
adaptation to mutual process, dynamic equilib- Rogers (1990) defined the energy field as
rium to innovative growing diversity, homeostasis “the fundamental unit of the living and the
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C H A P T E R 14 ■ Martha E. Rogers’ Science of Unitary Human Beings 239
non-living,” noting that it is dynamic, infinite, example, auras are energy fields that alterna-
and continuously moving (p. 7). Although tively surround a person rather than the person
Rogers did not define energy per se, Todaro- being the energy field. In an open universe,
Franceschi’s (1999) wide-ranging philosophi- there are multiple potentials and possibilities.
cal study of the enigma of energy sheds light People experience their world in multiple
on a Rogerian conceptualization of energy. ways, evidenced by the diverse manifestations
She highlighted the communal, transformative of field patterning that continuously emerge.
nature of energy, noting that energy is every- Rogers (1992, 1994a) described pattern as
where and is always changing and actualizing changing continuously while giving identity to
potentials. Energy transformation is the basis each unique human–environmental field
of all that is, both in living and dying. process. Although pattern is an abstraction, not
Rogers identified two energy fields of con- something that can be observed directly, “it re-
cern to nurses, which are distinct but not sep- veals itself through its manifestations” (Rogers,
arate: the human field and the environmental 1992, p. 29). Individual characteristics of a par-
field. The human field can be conceptualized ticular person are not characteristics of field
as person, group, family, or community. The patterning. Pattern manifestations reflect the
human and environmental fields are irre- human–environmental field mutual process
ducible; they cannot be broken down into as a unitary, irreducible whole. They reveal
component parts or subsystems. For example, innovative diversity flowing in lower and
the unitary human is neither understood nor higher frequency rhythms within the human–
described as a bio–psycho–sociocultural or environmental mutual field process. Rogers
body–mind–spirit entity. Instead, she main- identified some of these manifestations as lesser
tained that each field, human and environ- and greater diversity; longer, shorter, and seem-
mental, is identified by pattern, defined as “the ingly continuous rhythms; slower, faster, and
distinguishing characteristic of an energy seemingly continuous motion; time experienced
field perceived as a single wave” (Rogers, 1990, as slower, faster, and timeless; pragmatic, imag-
p. 7). Pattern manifestations and characteristics inative, and visionary; and longer sleeping,
are specific to the whole, the unitary human– longer waking, and beyond waking. Beyond
environment in mutual process. Change occurs waking refers to emergent experiences and per-
simultaneously for human and environment. ceptions such as hyperawareness, unitive expe-
The fields are pandimensional, defined as “a riences attained in meditation, precognition,
non-linear domain without spatial or temporal déjà vu, intuition, tacit knowing, mystical expe-
attributes” (Rogers, 1992, p. 29). Pandimen- riences, clairvoyance, and telepathy. She ex-
sional reality transcends traditional notions of plained “seems continuous” as “a wave frequency
space and time, which can be understood as so rapid that the observer perceives it as a single,
perceived boundaries only. Examples of pandi- unbroken event” (Rogers, 1990, p. 10). This view
mensionality include phenomena commonly of the ongoing process of change is captured in
labeled “paranormal” that are, in Rogerian Rogers’ principles of homeodynamics.
nursing science, manifestations of the chang-
ing diversity of field patterning and examples Principles of Homeodynamics
of pandimensional awareness. Homeodynamics conveys the dynamic, ever-
The postulate of openness resonates changing nature of life and the world. Her three
throughout the preceding discussion. In an principles of homeodynamics—resonancy,
open universe, there are no boundaries other helicy, and integrality—describe the nature and
than perceptual ones. Therefore, human and process of change in the human–environmental
environment are not separated by boundaries. field process.
The energy of each flows continuously through Resonancy is “the continuous change from
the other in an unbroken wave. Rogers repeat- lower to higher frequency wave patterns in
edly emphasized that person and environment human and environmental fields” (Rogers,
are themselves energy fields, rather than per- 1992, p. 31). Although she verbalized the need
sons or environments having energy fields. For to delete the “from–to” language, which seems
7991_Ch14_235-258 12/08/19 5:23 PM Page 240
to imply linearity and directionality, Rogers identified by transmission of nursing’s theoret-

never actually removed this in print. However, ical knowledge, and nursing practice is the cre-
it is important to remember that this process ative use of nursing knowledge. “Research is
is nonlinear and nondirectional because in a done in relation to the theories” (Rogers,
pandimensional universe there is no space and 1994a, p. 34) to illuminate the nature of the
no time (Phillips, 2010a). Resonancy specifies human–environmental field change process
the nonlinear, continuous flow of lower and and its many unpredictable potentials.
higher frequency wave patterning in the human–
environmental field process, the way change Theory of Accelerating Change
occurs. Rogers derived the Theory of Accelerating
Both lower and higher frequency aware- Change, formerly known as the Theory of Ac-
ness and experiencing are essential to the celerating Evolution, to illustrate that the only
wholeness of rhythmical patterning. As “norm” is accelerating change. Higher frequency
Phillips (1994, p. 15) described it, “we may field patterns that manifest growing diversity
find that growing diversity of pattern is related open the door to wider ranges of experiences and
to a dialectic of low frequency–high frequency, behaviors, calling into question the very idea of
similar to that of order–disorder in chaos the- “norms” as guidelines. Human and environmen-
ory. When the rhythmicities of lower-higher tal field rhythms are accelerating. We experience
frequencies work together, they yield innova- faster environmental motion now than ever be-
tive, diverse patterns.” fore. It is common for people to experience time
Helicy is “the continuous, innovative, un- as rapidly speeding by. People are living longer.
predictable, increasing diversity of human and Rather than viewing aging as a process of decline
environmental field patterns” (Rogers, 1992, or as “running down,” as in an entropic world-
p. 31). It describes the creative and diverse na- view, Roger’s Theory of Accelerating Change
ture of ongoing change in field patterning, a views aging as a creative process in which field
“diversity of pattern that is innovative, creative, patterns show increasing diversity in such man-
and unpredictable” (Phillips, 2010a, p. 57). ifestations as sleeping, waking, and dreaming;
Integrality is “continuous mutual human “in fact, as evolutionary diversity continues to ac-
field and environmental field process” (Rogers, celerate, the range and variety of differences be-
1992, p. 31). It specifies the process of change tween individuals also increase; the more diverse
within the integral human–environmental field field patterns evolve more rapidly than the less
process where person and environment are diverse ones” (Rogers, 1992, p. 30).
unitary, thus inseparable. The Theory of Accelerating Change provides
Together the principles of homeodynamics— the basis for reconceptualizing the aging
resonancy, helicy, and integrality—suggest that process. Rogers (1970, 1980) used the principle
the mutual patterning process of human and of helicy and the Theory of Accelerating
environmental fields changes continuously, in- Change to put forward the notion that aging is
novatively, and unpredictably, flowing in lower a continuously creative process of growing di-
and higher frequencies. Rogers (1990, p. 9) be- versity of field patterning. Therefore, aging is
lieved that these principles serve as guides both not a process of decline or running down.
to the practice of nursing and to research in the Rather, field patterns become increasingly di-
science of nursing. verse with age, as older adults need less sleep;
are more satisfied with personal relationships;
Theories Derived from the Science are better able to handle their emotions; are bet-
of Unitary Human Beings ter able to cope with stress; and have increasing
Rogers clearly stated her belief that multiple crystallized intelligence, wisdom, and im-
theories can be derived from the Science of proved problem-solving abilities (Whitbourne
Unitary Human Beings. Nursing theories are & Whitbourne, 2011). Butcher (2003) ex-
specific to nursing and reflect not what nurses panded on Rogers’ “negentropic” view of aging
do but an understanding of people and our in outlining key elements for a “unitary model
world (Rogers, 1992). Nursing education is of aging as emerging brilliance” that includes
7991_Ch14_235-258 12/08/19 5:23 PM Page 241
replacing ageist stereotypes with new positive work of L. Dossey (1993, 1999), Nadeau and
images of aging and developing policies, Kafatos (1999), Sheldrake (1988), and Talbot
lifestyles, and technologies that enhance suc- (1991) explicate the role of nonlocality in evo-
cessful aging and longevity. Within a unitary lution, physics, cosmology, consciousness,
view of aging, later life becomes a potential for paranormal phenomena, healing, and prayer.
“a life imbued with splendor, meaning, accom- Tart (2009), in his excellent text The End of
plishment, active involvement, growth, adven- Materialism: How Evidence of the Paranormal Is
ture, wisdom, experience, compassion, glory, Bringing Science and Spirit Together, reviews the
and brilliance” (Butcher, 2003, p. 64). research supporting common paranormal ex-
periences with separate chapters on telepathy,
Theory of Emergence of Paranormal clairvoyance/remote viewing, precognition,
Phenomena psychokinesis, psychic healing, out-of-body ex-
Another theory derived by Rogers is the Emer- periences, near-death experiences, postmortem
gence of Paranormal Phenomena, in which she survival, and mystical experiences. Murphy
suggests that experiences commonly labeled (1992), in his highly referenced and researched
“paranormal” are manifestations of changing text, presents the evidence supporting what
diversity and innovation of field patterning. he refers to as emergent extraordinary human
These “paranormal” experiences are pandimen- abilities such as placebo effects; paranormal ex-
sional forms of awareness, examples of pandi- periences; spiritual healing; and meditative,
mensional reality that manifest visionary, mystical, and contemplative practices on health
beyond waking potentials. Meditation, for ex- and healing. The relevance of these experiences
ample, transcends traditionally perceived limi- and practices to nursing is in the number that
tations of time and space, opening the door to occur in health-related contexts, and Rogers’
new and creative potentials. Therapeutic Touch nursing science provides a theoretical and sci-
provides another example of such pandimen- entific understanding that accounts for the
sional awareness. Both participants often share occurrence of paranormal experiences.
similar experiences during Therapeutic Touch, Within a nonlinear–nonlocal context, para-
such as a visualization of common features that normal events are an experience of the deep
evolves spontaneously for both, a shared expe- nonlocal interconnections that bind the uni-
rience arising within the mutual process both verse together. Existence and knowing are lo-
are experiencing, with neither able to lay claim cally and nonlocally linked through deep
to it as a personal, private experience. connections of awareness, intentionality, and
The idea of a pandimensional or nonlinear interpretation. Pandimensionality embraces
domain provides a framework for understand- the infinite nature of the universe in all its di-
ing paranormal phenomena. A nonlinear do- mensions and includes processes of being more
main unconstrained by space and time provides aware of naturally occurring changing energy
an explanation of seemingly inexplicable events patterns. Pandimensionality also includes in-
and processes. Rogers (1992) asserted that tentionally participating in mutual process
within the Science of Unitary Human Beings, with a nonlinear–nonlocal potential of creating
psychic phenomena become “normal” rather new energy patterns. Distance healing, the
than “paranormal.” Dean Radin, director of the healing power of prayer, Therapeutic Touch,
Conscious Research Laboratory at the Univer- out-of-body experiences, phantom pain, pre-
sity of Nevada in Las Vegas, suggests that an cognition, déjà vu, intuition, tacit knowing,
understanding of nonlocal connections along mystical experiences, clairvoyance, and tele-
with the relationship between awareness and pathic experiences are a few of the energy field
quantum effects provides a framework for un- manifestations patients and nurses experience
derstanding paranormal phenomena (Radin, that can be better understood as natural events
1997). “Deep interconnectedness” demon- in a pandimensional universe characterized by
strated by Bell’s Theorem (Shimony, 2017) em- nonlinear–nonlocal human–environmental field
braces the interconnectedness of everything integrality propagated by increased awareness
unbounded by space and time. In addition, the and intentionality.
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Manifestations of Field Patterning synthesized a situation-specific theory of men’s

Rogers’ third theory, Rhythmical Correlates of healing from childhood maltreatment from a
Change, was changed to Manifestations of federally funded hermeneutic-phenomenolog-
Field Patterning in Unitary Human Beings, ical study of community dwelling adults and
discussed earlier. Here, Rogers suggests that discussed implications for practice using pat-
evolution is an irreducible, nonlinear process tern manifestation knowing and appreciation
characterized by increasing diversity of field and voluntary mutual patterning.
patterning. She posits some manifestations of
Applications of the Conceptual System
this relative diversity, including the rhythms of
motion, time experience, and sleeping–waking, New worldviews require new ways of thinking,
encouraging others to suggest further examples. sciencing, languaging, and practicing. Rogers’
In addition to the theories that Rogers derived, Science of Unitary Human Beings postu-
a number of others have been developed by lates a pandimensional universe of human–
Rogerian scholars that are useful in informing environmental energy fields manifesting as
Rogerian pattern–based practice and research. continuously innovative, increasingly diverse,
The first such theory to be developed was Bar- creative, and unpredictable unitary field pat-
rett’s (1989, 2010) Theory of Power as Know- terns. The principles of homeodynamics provide
ing Participation in Change® (see Chapter 29). a way to understand the process of human–
Butcher’s (1993) Theory of Kaleidoscoping environmental change, paving the way for
in Life’s Turbulence is an example of a theory Rogerian theory–based practice. Rogers often
derived from Rogers’ Science of Unitary Human reminded us that unitary means whole. There-
Beings, Chaos Theory (Briggs & Peat, 1989; fore, people are always whole, regardless of
Peat, 1991), and Csikszentmihalyi’s (1990) The- what they are experiencing in the moment,
ory of Flow. Butcher’s theory (1993) focuses on and therefore do not need nurses to facilitate
facilitating well-being and harmony amid tur- their wholeness. Rogers identified noninvasive
bulent life events. Turbulence is a dissonant modalities as the basis for nursing practice now
commotion in the human–environmental field and in the future. She stated that nurses must
characterized by chaotic and unpredictable use “nursing knowledge in non-invasive ways
change. Any crisis may be viewed as a turbulent in a direct effort to promote well-being”
event in the life process. Nurses often work (Rogers, 1994a, p. 34). This focus gives nurses
closely with clients who are in a “crisis.” Turbu- a central role in health care rather than medical
lent life events are often chaotic in nature, un- care. She also noted that health services should
predictable, and always transformative.1 be community based, not hospital based. Hos-
Other theories derived from Rogers’ nurs- pitals are properly used to provide satellite serv-
ices in specific instances of illness and trauma;
ing science include Reed’s (1991, 2003; see

Chapter 23) Theory of Self-Transcendence, they do not provide health services. Rogers urged
the Theory of Enfolding Health-as-Wholeness- nurses to develop autonomous, community-
and-Harmony (Carboni, 1995a), Bultemeier’s based nursing centers. See Box 14.1.
(1997) Theory of Perceived Dissonance, the Rogers (1986) also identified the living–
Theory of Enlightenment (Hills & Hanchett, dying process as one characterized by rhythmical
2001), Alligood and McGuire’s Theory of patterning, thereby opening the door to new
Aging (2000), Butcher’s Theory of Aging ways of studying and working with the dying
as Emerging Brilliance (2003), Zahourek’s process. For example, Todaro-Franceschi (2006)
(2004, 2005) Theory of Intentionality in Healing, identified the existence of synchronicity experi-
and Phillips’ (2016) Theory of Pandimen- ences and meaningful coincidences in many who
sional Awareness–Integral Presence. Willis, were grieving the loss of a spouse, reflecting a
DeSanto-Madeya, and Fawcett (2015) pioneering effort in delineating a unitary view of
death and dying. From the results of Todaro-
1For additional information, see the bonus chapter content Franceschi’s (2006) qualitative study, she de-
available at http://davisplus.fadavis.com. scribed how such experiences help the bereaved
7991_Ch14_235-258 12/08/19 5:23 PM Page 243
BOX 14-1 Rogerian Nursing Science web book human–environmental energy field is con-
stantly changing, even a term such as well
In 2008, Howard Butcher launched a wiki site being is inconsistent with this science, so he
on Rogerian Science with the purpose of pro- reintroduced a term he had coined earlier,
viding a website to gather Rogerian Nursing wellbecoming, defined as “participating in one’s
Scholars so they can mutually create a com-
prehensive and easily accessible and in-depth
changing pattern and its manifestations for
explication of the science of unitary human be- the betterment of rhythms of living and for
ings. The wiki can be viewed by anyone and is transcending as energy–spirit” (2015, p. 45).
organized like a textbook with chapters on Returning to another term he had coined pre-
Martha Rogers’ life, the aim of nursing science, viously, Phillips reintroduced human field image,
Rogerian cosmology, Rogers’ postulates, princi-
ples, theories, practice methods, research meth-
highlighting its importance in wellbecoming
ods, and Rogerian research instruments. There via “ongoing changes that create potentials in
are rare photos of Martha Rogers on the site as one’s rhythms of living” (2015, p. 45). Finally,
well as other valuable resources. The wiki book he offered “integral presence, a perceiving-
is not complete, but ever evolving and is a valu- experiencing of the integrality of human and
able resource for all interested in learning more
about the science of unitary human being. The
the environment, an integral presence that is
link was moved from wikispaces.com to Press- relative and infinite” (2015, p. 46).
books in May 2018 (https://pressbooks.uiowa. Continuing in his creative scholarly en-
edu/rogeriannursingscience/front-matter/cover/). deavor to expand Rogerian nursing science,
Phillips (2016) synthesized a new middle-
range theory of Pandimensional Awareness–
to relate to their deceased loved ones in a new, Integral Presence. Combining Rogers’ theories
meaningful way, one that is potentially healing, of Accelerating Change and Paranormal, this
rather than that found in a more traditional view theory “opens perception-experience of visible-
of grieving as learning to let go and move on. invisible phenomena of the universe ener-
Malinski (2012) conceptualized the unitary gyspirit for living and transcending” (Phillips,
rhythm of dying–grieving, highlighting the 2016, p. 44). He suggested creating an aware-
shared nature of this process, for the one grieving ness-presence instrument using patterning
is also dying a little just as the one dying is si- processes such as imagery, meditation, color,
multaneously grieving. She synthesized this uni- storytelling, and play, just to name a few, to help
tary rhythm as “a process of kaleidoscopic better understand pandimensional awareness–
patterning flowing now swiftly now gently, spi- integral presence. Phillips (2017) further
raling creatively through shifting rhythms of expanded on the ideas he introduced and
now-elsewhen-elsewhere, becoming in solitude identified the challenge for Rogerian scholars
and silence alone-all one, timeless-boundaryless” as one of designing research and patterning
(p. 242). Pandimensional awareness and experi- processes that focus on knowingly participat-
ence of this rhythm means recognition that there ing with people in their wellbecoming.
is no space or time, no boundary or separation.
The reality is one of unity amid changing con- Evolution of Rogerian Practice
figurations of patterning, with endless potentials. Methods
Caratao-Mojica (2015) offered a Rogerian prac- A hallmark of a maturing scientific profes-
tice perspective for persons with terminal ill- sional discipline is the development of specific
nesses that integrated art forms such as symbols practice and research methods evolving from
and metaphors to provide comforting messages the discipline’s extant conceptual systems.
for patients and their families. Rogers (1992) asserted that practice and re-
In 2015 Phillips introduced new languag- search methods must be consistent with the
ing into the lexicon of Rogerian nursing sci- Science of Unitary Human Beings to study ir-
ence: “unitariology is the study of unitary reducible human beings in mutual process with
phenomena revealing truth of the universe a pandimensional universe. Therefore, Rogerian
and humankind” (2015, p. 45). Because the practice and research methods must be
7991_Ch14_235-258 12/08/19 5:23 PM Page 244
congruent with Rogers’ postulates and princi- provides an explanation of the scientific and
ples if they are to be consistent with Rogerian theoretical basis for Imbalanced Energy Field
science. and explains how Rogers’ Science of Unitary
The goal of nursing practice is the promo- Human Beings provides the theoretical foun-
tion of wellbecoming (Phillips, 2015) and dation for the newly revised and reconceptu-
human betterment. Nursing is a service to alized experience. The final submission of
people wherever they may reside. Nursing proposed Imbalanced Energy Field diagnosis
practice—the art of nursing—is the creative submitted by Noreen Frisch, Howard Butcher,
application of substantive scientific knowledge and Deborah Shields was approved by the
developed through logical analysis, synthesis, NANDA-I membership and is included in the
and research. Since the 1960s, the nursing 2018–2020 edition of NANDA-I (Herdman
process has been the dominant nursing prac- & Kamitsuru, 2018). Imbalanced Energy Field
tice method. The nursing process is an appro- is defined as “a disruption in the vital flow of
priate practice methodology for many nursing human energy that is normally a continuous
theories. However, there has been some con- whole and is unique, creative and nonlinear”
fusion in the nursing literature concerning the (Herdman & Kamitsuru, 2018, p. 225).
use of the traditional nursing process within In addition to the term diagnosis, other as-
Rogers’ nursing science. pects of the current nursing process remain
In early writings, Rogers (1970) did refer to inconsistent with the Science of Unitary
nursing process and nursing diagnoses. But in Human Beings. The nursing process is a
later years she asserted that nursing diagnoses stepwise sequential process inconsistent with
were not consistent with her scientific system. a nonlinear or pandimensional view of reality.
Rogers (quoted in Smith, 1988) stated: In addition, the term intervention is not con-
sistent with Rogerian science. Intervention
Nursing diagnosis is a static term that is quite in- means to “come, appear, or lie between two
appropriate for a dynamic system. … It [nursing things” (American Heritage Dictionary,
diagnosis] is an outdated part of an old worldview, 2000, p. 916). The principle of integrality de-
and I think by the turn of the century, there are scribes the human and environmental field as
going to be new ways of organizing knowledge. integral and in mutual process. Energy fields
(p. 83) are open, infinite, dynamic, and constantly
Furthermore, nursing diagnoses are partic- changing. The human and environmental
ularistic and reductionist labels describing fields are inseparable, so one cannot “come
cause-and-effect “human responses” and are between.” The nurse and the client are al-
expressed with “related to” factors that are in- ready inseparable and interconnected. Out-
consistent with a “nonlinear domain without comes are also inconsistent with Rogers’
spatial or temporal attributes” (Rogers, 1992, principle of helicy: expected outcomes infer
p. 29). However, instead of using the term causality and predictability. The principle of
nursing diagnosis or human response, some helicy describes the nature of change as being
nursing diagnoses may be reconceptualized unpredictable. Within an energy-field per-
within a Rogerian Science perspective as “en- spective, nurses in mutual process assist clients
ergetic unitary experiences” expressed as man- in actualizing their field potentials by enhanc-
ifestations of patterning emerging acausally ing their ability to participate knowingly in
from the human–environmental mutual field change. Given the inconsistency of the tradi-
process. tional nursing process with Rogers’ postulates
The new NANDA-I nursing diagnosis Im- and principles, the Science of Unitary Human
balanced Energy Field is one example of a nurs- Beings requires the development of new and
ing diagnosis that was reconceptualized within innovative practice methods derived from and
Rogers’ Science of Unitary Human Beings consistent with the Roger’s conceptual system.
(Shields, Fuller, Resnicoff, Butcher, & Frisch, Many practice methods have been derived
2017). In another publication, Butcher (2018) from Rogers’ postulates and principles.
7991_Ch14_235-258 12/08/19 5:23 PM Page 245
Barrett’s Rogerian Practice Method or emotionally” (Cowling, 1997, p. 130). Pat-

Barrett’s Rogerian practice methodology for tern appreciation has a potential for deeper
health patterning was the first accepted alter- understanding.2
native to the nursing process for Rogerian
Unitary Pattern-Based Praxis Method
practice (see Chapter 29). It was followed by
Cowling’s conceptualization. Butcher (1997a, 1999a, 2001) synthesized
Cowling’s Rogerian practice constituents
Cowling’s Rogerian Practice with Barrett’s practice method to develop a
Cowling (1990) proposed a template compris- more inclusive and comprehensive practice
ing 10 constituents for the development of model. In 2006, Butcher expanded the
Rogerian practice models. Cowling (1993b, “praxis” model by illustrating how the Rogerian
1997) refined the template and proposed that cosmology, ontology, epistemology, esthet-
“pattern appreciation” was a method for uni- ics, ethics, postulates, principles, and theo-
tary knowing in both Rogerian nursing re- ries all form an “interconnected nexus”
search and practice. Cowling preferred the informing both Rogerian-based practice and
term appreciation rather than assessment or ap- research models (Butcher, 2006a, p. 9). The
praisal because appraisal is associated with unitary pattern–based practice (Fig. 14-1)
evaluation. Appreciation has broader mean- consists of two nonlinear and simultaneous
ing, which includes “being fully aware or sen-
sitive to or realizing; being thankful or grateful 2For additional information, see the bonus chapter content
for; and enjoying or understanding critically available at http://davisplus.fadavis.com.
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 wellbecoming
FIG 14-1 ■ The unitary pattern–based praxis model. (Model modified 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], 8–33.)
7991_Ch14_235-258 12/08/19 5:23 PM Page 246
processes: pattern manifestation appreciation being able to fully understand and know the
and knowing, and voluntary mutual pattern- suffering of another, (2) creating actions de-
ing. The focus of nursing care guided by signed to transform injustices, and (3) not only
Rogers’ nursing science is on pattern trans- grieving in another’s sorrow and pain but also
formation by facilitating pattern recognition rejoicing in another’s joy (Butcher, 2002).
during pattern manifestation knowing and Pattern manifestation knowing and appre-
appreciation and by facilitating the client’s ciation involves focusing on the experiences,
ability to participate knowingly in change, perceptions, and expressions of a health situa-
harmonizing person–environment integrality, tion, revealed through a rhythmic flow of com-
and promoting healing potentialities and munion and dialogue. In most situations, the
wellbecoming through voluntary mutual nurse can initially ask the client to describe his
patterning. or her health situation and concern. The dia-
logue is guided toward focusing on uncovering
Pattern Manifestation Knowing the client’s experiences, perceptions, and ex-
and Appreciation pressions related to the health situation as a
Pattern manifestation knowing and apprecia- means to reaching a deeper understanding of
tion is the process of identifying manifestations unitary field pattern. Humans are constantly
of patterning emerging from the human– all-at-once experiencing, perceiving, and ex-
environmental field mutual process and in- pressing (Cowling, 1993a). Experience in-
volves focusing on the client’s experiences, per- volves the rawness of living through sensing
ceptions, and expressions. “Knowing” refers to and being aware as a source of knowledge and
apprehending pattern manifestations (Barrett, includes any item or ingredient the client
1988), whereas “appreciation” seeks a percep- senses (Cowling, 1997). The client’s own ob-
tion of the “full force of pattern” (Cowling, servations and description of his or her health
1997). Pattern is the distinguishing feature of situation includes his or her experiences. “Per-
the human–environmental field. Everything ceiving is the apprehending of experience or
experienced, perceived, and expressed is a man- the ability to reflect while experiencing”
ifestation of patterning. During the process (Cowling, 1993a, p. 202). Perception is mak-
of pattern manifestation knowing and appre- ing sense of the experience through awareness,
ciation, the nurse and client are coequal par- apprehension, observation, and interpreting.
ticipants. In Rogerian practice, nursing situations Asking clients about their concerns, fears, and
are approached and guided by a set of Rogerian- observations is a way of apprehending their
ethical values, a scientific base for practice, and perceptions. Expressions are manifestations of
a commitment to enhance the client’s desired experiences and perceptions that reflect human
potentialities for wellbecoming. field patterning. In addition, expressions are
Unitary pattern–based practice begins by any form of information that comes forward in
creating an atmosphere of openness and free- the encounter with the client. All expressions
dom so that clients can freely participate in the are energetic manifestations of field patterns.
process of knowing participation in change. Body language, communication patterns, gait,
Approaching the nursing situation with an ap- behaviors, laboratory values, and vital signs are
preciation of the uniqueness of each person examples of energetic manifestations of human–
and with unconditional love, compassion, and environmental field patterning.
empathy can help create an atmosphere of Because all information about the client–
openness and healing patterning (Butcher, environment–health situation is relevant, var-
2002; Malinski, 2004). Rogers (1966/1994) ious health assessment tools, such as the
defined nursing as a humanistic science dedi- comprehensive holistic assessment tool devel-
cated to compassionate concern for humans. oped by B. M. Dossey, Keegan, and Guzzetta
Compassion includes energetic acts of uncon- (2004), may also be useful in pattern knowing
ditional love and means (1) recognizing the in- and appreciation. However, all information
terconnectedness of the nurse and client by must be interpreted within a unitary context.
7991_Ch14_235-258 12/08/19 5:23 PM Page 247
A unitary context refers to conceptualizing all clients’ energy field patterns in relation to their
information as energetic/dynamic manifesta- capacity to knowingly participate in the con-
tions of pattern emerging from a pandimen- tinuous patterning of human–environmental
sional human–environmental mutual process. fields as manifest in frequencies of awareness,
All information is interconnected, is insepa- choice making ability, sense of freedom to act
rable from environmental context, unfolds intentionally, and degree of involvement in
rhythmically and acausally, and reflects the creating change. Juanita Watson’s (1993) As-
whole. Data are not divided or understood by sessment of Dream Experience Scale can be
dividing information into physical, psycholog- used to know and appreciate clients’ dream ex-
ical, social, spiritual, or cultural categories. periences, and Ference’s (1979, 1986) Human
Rather, a focus on experiences, perceptions, Field Motion Tool is an indicator of the wave
and expressions is a synthesis more than and frequency pattern of the energy field.
different from the sum of parts. From a unitary Hastings-Tolsma’s (1992) Diversity of
perspective, what may be labeled as abnormal Human Field Pattern Scale may be used as a
processes, nursing diagnoses, or illnesses or means for knowing and appreciating clients’
diseases are conceptualized as episodes of dis- perception of the diversity of their energy field
cordant rhythms or nonharmonic resonancy pattern, Johnston’s (1994) Human Image
(Bultemeier, 2002). Metaphor Scale can be used as a way of know-
A unitary perspective in nursing practice ing and appreciating the clients’ perception of
leads to an appreciation of new kinds of infor- the wholeness of their energy field, and the
mation that may not be considered within Well-being Picture Scale for adults (Gueldner
other conceptual approaches to nursing prac- et al., 2005; Johnson, Guadron, Verchot, &
tice. The nurse is open to using multiple forms Gueldner, 2011) and the Well-being Picture
of knowing, including pandimensional modes Scale for children (Terwillinger, Gueldner, &
of awareness (intuition, meditative insights, Bronstein, 2012) afford a way to measure a
tacit knowing) throughout the pattern mani- sense of unitary well-being. Paletta (1990) de-
festation knowing and appreciation process. veloped a tool consistent with Rogerian science
Intuition and tacit knowing are artful ways to that measures the subjective awareness of tem-
enable seeing the whole, revealing subtle pat- poral experience.
terns, and deepening understanding. Pattern The pattern manifestation knowing and
information concerning time perception, sense appreciation is enhanced through the nurse’s
of rhythm or movement, sense of connected- ability to grasp meaning, create a meaningful
ness with the environment, ideas of one’s own connection, and participate knowingly in
personal myth, and sense of integrity are rele- the client’s change process (Butcher, 1999a).
vant indicators of human–environment–health Through integrality, nurse and client are al-
potentialities (Madrid & Winstead-Fry, 1986). ways connected in mutual process; “grasping
A person’s hopes and dreams, communica- meaning entails using sensitivity, active lis-
tion patterns, sleep–rest rhythms, comfort– tening, conveying unconditional acceptance,
discomfort, waking–beyond waking experiences, while remaining fully open to the rhythm,
and degree of knowing participation in change movement, intensity, and configuration of
provide important information regarding each pattern manifestations” (Butcher, 1999a, p. 51).
client’s thoughts and feelings concerning a A meaningful connection with the client is
health situation. facilitated by creating a rhythm and flow
The nurse can also use several pattern ap- through the intentional expression of uncondi-
praisal scales derived from Rogers’ postulates tional love, compassion, and empathy. Together,
and principles to enhance the collecting and in mutual process, the nurse and client explore
understanding of relevant information specific the meanings, images, symbols, metaphors,
to Rogerian science. For example, nurses can thoughts, insights, intuitions, memories, hopes,
use Barrett’s (1989) Power as Knowing Partic- apprehensions, feelings, and dreams associated
ipation in Change Tool as a way of knowing with the health situation.
7991_Ch14_235-258 12/08/19 5:23 PM Page 248
Rogerian ethics are integral to all unitary coevolving together. “Voluntary” signifies free-
pattern–based practice situations. Rogerian dom of choice or action without external
ethics are pattern manifestations emerging compulsion (Barrett, 1998). The nurse has no
from the human–environmental field mutual investment in changing the client in a partic-
process that reflect those ideals concordant ular 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 pattern–based practice includes mak- pattern profile with the client is a means of val-
ing the Rogerian values of reverence, human idating the interpretation of pattern informa-
betterment, generosity, commitment, diversity, tion and may spark further dialogue, revealing
responsibility, compassion, wisdom, justice- new and more in-depth information. Sharing
creating, openness, courage, optimism, humor, the pattern profile with the client facilitates
unity, transformation, and celebration in- pattern recognition and also may enhance the
tentional in the human–environmental field client’s knowing participation in his or her own
mutual process (Butcher, 1999b, 2000). change process. An increased awareness of
When initial pattern manifestation know- one’s own pattern may offer new insight and
ing and appreciation is complete, the nurse increase one’s desire to participate in the
synthesizes all the pattern information into a change process. In addition, the nurse and
meaningful pattern profile. The pattern profile client can continue to explore goals, options,
is an expression of the person–environment– choices, and voluntary mutual patterning strate-
health situation’s essence. The nurse weaves gies as a means to facilitate the client’s actual-
together the expressions, perceptions, and ex- ization of his or her human–environmental field
periences in a way that tells the client’s story. potentials.
The pattern profile reveals the hidden meaning A wide variety of mutual patterning strate-
embedded in the client’s human–environmental gies may be used in Rogerian practice, includ-
mutual field process. Usually the pattern pro- ing many “interventions” identified in the
file is in a narrative form that describes the Nursing Intervention Classification (Butcher,
essence of the properties, features, and qualities Bulechek, Dochterman, & Wagner 2018).
of the human–environment–health situation. In However, “interventions,” within a unitary
addition to a narrative form, the pattern profile context, are not linked to nursing diagnoses
may also include diagrams, poems, listings, and are reconceptualized as voluntary mutual
phrases, metaphors, or a combination of these. patterning strategies, and the activities are
Interpretations of any measurement tools reconceptualized as patterning activities. Rather
may also be incorporated into the pattern than linking voluntary mutual patterning
profile. strategies to nursing diagnoses, the strategies

emerge in dialogue whenever possible out of
Voluntary Mutual Patterning the patterns and themes described in the pat-
Voluntary mutual patterning is a process of tern profile. Furthermore, Rogers (1988, 1992,
transforming human–environmental field pat- 1994a) placed great emphasis on modalities
terning. The goal of voluntary mutual pat- that are traditionally viewed as holistic and
terning is to facilitate each client’s ability to noninvasive. In particular, the use of sound, di-
participate knowingly in change, harmonize alogue, affirmations, humor, massage, journal-
person–environment integrality, and promote ing, exercise, nutrition, reminiscence, aroma,
healing potentialities, lifestyle changes, and light, color, artwork, meditation, storytelling,
wellbecoming in the client’s desired direction of literature, poetry, movement, and dance are
change without attachment to predetermined just a few of the voluntary mutually patterning
outcomes. The process is mutual in that both strategies consistent with a unitary perspective.
the nurse and the client are changed with each In addition, patterning modalities have been
encounter, each patterning one another and developed that are conceptualized within the
7991_Ch14_235-258 12/08/19 5:23 PM Page 249
Science of Unitary Human Beings such as irreducible, and unitary context. Unitary pattern–
metaphoric unitary landscape narratives and based practice provides a new way of thinking
written emotional expression (Butcher, 2004a, and being in nursing that distinguishes nurses
2006b), Therapeutic Touch (Malinski, 1993), from other health-care professionals and offers
guided imagery (Butcher & Parker, 1988; new and innovative ways for clients to reach
Levin, 2006), magnet therapy (Kim, 2001), their desired health potentials.
and music (Horvath, 1994; Johnston, 2001).
Sharing of knowledge through health educa-
tion and providing health education literature Applications of the Theory
and teaching also have the potential to en- Research provides a foundation for nursing
hance knowing participation in change. These practice. The Science of Unitary Human Be-
and other noninvasive modalities are well de- ings has a long history of theory-testing re-
scribed and documented in both the Rogerian search. As new practice theories and health
(Barrett, 1990; Madrid, 1997; Madrid & patterning modalities evolve from the science
Barrett, 1994) and the holistic (B. M. Dossey, of unitary human beings, there remains a need
1997; B. M. Dossey, Keegan, & Guzzetta, to test the viability and usefulness of Rogerian
2004) nursing practice literature. theories and voluntary health patterning strate-
The nurse continuously apprehends changes gies. The mass of Rogerian research has been
in patterning emerging from the human– reviewed in a number of publications (Butcher,
environmental field mutual process throughout 2008; Caroselli & Barrett, 1998; Dykeman
the simultaneous pattern manifestation know- & Loukissa, 1993; Fawcett, 2013; Fawcett &
ing and appreciation and voluntary mutual Alligood, 2003; Kim, 2008; Malinski, 1986a;
patterning processes. Although the concept Phillips, 1989; Watson, Barrett, Hastings-
of “outcomes” is incompatible with Rogers’ Tolsma, Johnston, & Gueldner, 1997). Rather
notions of unpredictability, outcomes in the than repeat the reviews of Rogerian research,
Nursing Outcomes Classification (Moorhead, the following section describes current method-
Swanson, Johnson, & Maas, 2018) can be ological trends within the science of unitary
reconceptualized as potentialities of change or human beings to assist researchers interested in
“client potentials” (Butcher, 1997a, p. 29), and Rogerian science in making methodological
the indicators can be used to evaluate the decisions.
client’s desired direction of pattern change. At Rogers (1994b) maintained that both quan-
various points in the client’s care, the nurse can titative and qualitative methods may be useful
also use the scales derived from Rogers’ science for advancing Rogerian science. Similarly,
(previously discussed) to coexamine changes in Barrett (1996), Barrett and Caroselli (1998),
pattern. Regardless of which combination of Barrett, Cowling, Carboni, and Butcher
voluntary patterning strategies and evaluation (1997), Cowling (1986), Rawnsley (1994), and
methods is used, the intention is for clients to Smith and Reeder (1996) have all advocated
actualize their potentials related to their desire for the appropriateness of multiple methods in
for wellbecoming and betterment. Rogerian research. Conversely, Butcher (cited
The unitary pattern–based practice method in Barrett et al., 1997), Butcher (1994), and
identifies the aspect that is unique to nursing and Carboni (1995b) have argued that the onto-
expands nursing practice beyond the traditional logical and epistemological assumptions of
biomedical model dominating much of nursing. causality, reductionism, particularism, control,
Rogerian nursing practice does not necessarily prediction, and linearity of quantitative method-
need to replace hospital-based and medically ologies are inconsistent with Rogers’ unitary
driven nursing interventions and actions for ontology and participatory epistemology. Later,
which nurses hold responsibility. Rather, unitary Fawcett (1996) also questioned the congruency
pattern–based practice complements medical between the ontology and epistemology of
practices and places treatments and procedures Rogerian science and the assumptions em-
within an acausal, pandimensional, rhythmical, bedded in quantitative research designs. Like
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Carboni (1995b) and Butcher (1994), she change. Another potentially promising area yet
concluded that interpretive/qualitative meth- to be explored is participatory action and coop-
ods may be more congruent with Rogers’ on- erative inquiry (Reason, 1994), because of their
tology and epistemology. This chapter presents congruence with Rogers’ notions of knowing
an inclusive view of methodologies. participation in change, continuous mutual
process, and integrality. Cowling (1998) pro-
Approaches to Rogerian Research posed that a case-oriented approach is useful in
Cowling (1986) was among the first to sug- Rogerian research because case inquiry allows
gest a number of research designs that may be the researcher to attend to the whole and strives
appropriate for Rogerian research, including to comprehend his or her essence.
philosophical, historical, and phenomenolog-
ical ones. There is strong support for the ap- Selecting a Focus of Rogerian Inquiry
propriateness of phenomenological methods In selecting a focus of inquiry, concepts that are
in Rogerian science. Reeder (1986) provided congruent with the Science of Unitary Human
a convincing argument demonstrating the Beings are most relevant. The focus of inquiry
congruence between Husserlian phenome- flows from the postulates, principles, and con-
nology and the Rogerian Science of Unitary cepts relevant to the conceptual system. Non-
Human Beings. Experimental and quasi-ex- invasive voluntary patterning modalities, such
perimental designs are problematic because of as guided imagery, Therapeutic Touch, humor,
assumptions concerning causality; however, sound, dialogue, affirmations, music, massage,
these designs may be appropriate for testing journaling, written emotional expression, exer-
propositions concerning differences in the cise, nutrition, reminiscence, aroma, light, color,
change process in relation to “introduced en- artwork, meditation, storytelling, literature, po-
vironmental change” (Cowling, 1986, p. 73). etry, movement, and dance, provide a rich
The researcher must be careful to interpret source for Rogerian science-based research.
the findings in a way that is consistent with Creativity, mystical experiences, transcendence,
Rogers’ notions of unpredictability, integral- sleeping-beyond-waking experiences, time ex-
ity, and nonlinearity. Emerging interpre- perience, and paranormal experiences as they
tive evaluation methods, such as Guba and relate to human health and wellbecoming are
Lincoln’s (1989) Fourth Generation Evalua- also of interest in this science. Feelings and
tion, offer an alternative means for testing for experiences are a manifestation of human–
differences in the change process within or environmental field patterning and are a mani-
between groups (or both) more consistent festation of the whole (Rogers, 1970); thus,
with the Science of Unitary Human Beings. feelings and experiences relevant to health and
Cowling (1986) contended that in the early wellbecoming are an unlimited source for po-
stages of theory development, designs that gen- tential Rogerian research. Discrete particularis-
erate descriptive and explanatory knowledge are tic biophysical phenomena are usually not an
relevant to the science of unitary human beings. appropriate focus for inquiry because Rogerian
For example, correlational designs may provide science focuses on irreducible wholes. An ex-
evidence of patterned changes among indices ception could be the use of blood pressure as
of the human field. Advanced and complex depart of diverse data collected to obtain different
signs with multiple indicators of change that views of pattern manifestations and pattern
may be tested using linear structural relations change. For example, see Madrid, Barrett, and
(LISREL) statistical analysis may also be a Winstead-Fry’s (2010) study of Therapeutic
means to uncover knowledge about the pattern Touch and blood pressure, pulse, and respira-
of change (Phillips, 1990). Barrett (1996) sug- tions in the operative setting with patients
gested that canonical correlation may be useful undergoing cerebral angiography, and Malinski
in examining relationships and patterns across and Todaro-Franceschi’s (2011) study of
domains and may also be useful for testing the- comeditation and anxiety and relaxation in a
ories pertaining to the nature and direction of nursing school setting.
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Rogers clearly identified that everything is characterized by the creation of more diverse
a manifestation of the whole, of field pattern- patterns reflecting the nature of change. The Di-
ing. However, one cannot use just the numer- versity of Human Field Pattern Scale measures
ical data, mere “facts,” so interpretation would the process of diversifying human field pattern
differ accordingly (Rogers, 1989). Researchers and may also be a useful tool to test theoretical
need to ensure that concepts and measurement propositions derived from the postulates and
tools used in the inquiry are defined and con- principles of Rogerian science to examine the ex-
ceptualized within a unitary perspective and tent of selected patterning modalities designed
congruent with Rogers’ principles and postu- to foster harmony and well-being (Hastings-
lates. Diseases or medical diagnoses are not the Tolsma, 1992; Watson et al., 1997). Other
focus of Rogerian inquiry. Disease conditions measurement tools developed within a unitary
are conceptualized as labels and as manifesta- science perspective may be used in a wide variety
tions of patterning emerging acausally from of research studies and in combination with
the human–environmental mutual process. other Rogerian measurements. For example,
there are the Assessment of Dream Experience
Measurement of Rogerian Concepts Scale, which measures the diversity of dream
The Human Field Motion Test (HFMT) is an experience as a beyond-waking manifestation
indicator of the continuously moving position using a 20-item Likert scale (Watson, 1993;
and flow of the human energy field. Two Watson et al., 1997); Temporal Experience
major concepts—”my motor is running” and Scale, which measures the subjective experience
“my field expansion”—are rated using a se- of temporal awareness (Paletta, 1990); and
mantic differential technique (Ference, 1979, Mutual Exploration of the Healing Human
1986). Examples of indicators of higher Field–Environmental Field Relationship Cre-
human field motion include feeling imagina- ative Measurement Instrument developed by
tive, visionary, transcendent, strong, sharp, Carboni (1992), which is a creative qualitative
bright, and active. Indicators of relative low measure designed to capture the changing con-
human field motion include feeling dull, weak, figurations of energy field pattern of the healing
dragging, dark, pragmatic, and passive. The tool human–environmental field relationship.
has been widely used in numerous Rogerian Several tools have been developed that are
studies. rich sources of measures of concepts congruent
The Power as Knowing Participation in with unitary science. The Human Field Image
Change Tool (PKPCT) has been used in more Metaphor Scale used 25 metaphors that cap-
than 26 major research studies (Caroselli & Bar- ture feelings of potentiality and integrality
rett, 1998) and is a measure of one’s capacity to rated on a Likert-type scale. For example, the
participate knowingly in change as manifested metaphor “I feel at one with the universe” re-
by awareness, choices, freedom to act intention- flects a high degree of awareness of integrality;
ally, and involvement in creating changes using “I feel like a worn-out shoe” reflects a more
semantic differential scales. Statistically signifi- restricted perception of one’s potential (Johnston,
cant correlations have been found between 1994; Watson et al., 1997). Future research may
power as measured by the PKPCT and the focus on developing an understanding of how
following: human field motion, life satisfaction, human field image changes in a variety of
spirituality, purpose in life, empathy, transfor- health-related situations or how human field
mational leadership style, feminism, imagina- image changes in mutual process with selected
tion, and socioeconomic status. Inverse relations patterning strategies.
with power have been found with anxiety,
chronic pain, personal distress, and hopelessness Research Methods Specific to the
(Caroselli & Barrett, 1998). Science of Unitary Human Beings
Diversity is inherent in the evolution of The criteria for developing Rogerian research
the human–environmental mutual field process. methods are presented in the supplementary
The evolution of the human energy field is material (see the bonus chapter content available
7991_Ch14_235-258 12/08/19 5:23 PM Page 252
at http://davisplus.fadavis.com). They are a the researcher and the participants develop a

synthesis and modification of the Criteria of shared understanding and awareness of the
Rogerian Inquiry developed by Butcher (1994) human–environmental field patterns mani-
and the Characteristics of Operational Rogerian fested in diverse multiple configurations of
Inquiry developed by Carboni (1995b). The cri- patterning. All the data are synthesized using
teria are a useful guide in designing research inductive and deductive data synthesis. Through
methods that are consistent with Rogers’ prin- the mutual sharing and synthesis of data, uni-
ciples and postulates. Two Rogerian research tary constructs are identified.
methods were developed using the criteria: the The constructs are interpreted within the
Unitary Field Pattern Portrait research method perspective of unitary science, and a new uni-
and the Rogerian Process Inquiry. A third tary theory may emerge from the synthesis of
method, Unitary Appreciative Inquiry, was de- unitary constructs. Carboni (1995b) also de-
veloped by Cowling (2001).3 veloped special criteria of trustworthiness to
ensure the scientific rigor of the findings con-
Rogerian Process of Inquiry veyed in the form of a Pandimensional Unitary
Carboni (1995b) developed the Rogerian Process Report. Carboni’s research method
process of inquiry from her characteristics of affords a way of creatively measuring manifes-
Rogerian inquiry. The method’s purpose is to tations of field patterning emerging during co-
investigate the dynamic enfolding-unfolding participation of the researcher and participant’s
of the human field–environmental field energy process of change.
patterns and the evolutionary change of con-
figurations in field patterning of the nurse and The Unitary Field Pattern Portrait
participant. Rogerian process of inquiry tran- Research Method
scends both matter-centered methodologies The unitary field pattern portrait (UFPP) re-
espoused by empiricists and thought-bound search method (Butcher, 1994, 1996, 1998,
methodologies espoused by phenomenologists 2005) was developed at the same time Carboni
and critical theorists (Carboni, 1995b). Rather, was developing the unitary process of inquiry
this process of inquiry is evolution centered and was derived directly from the criteria of
and focuses on changing configurations of Rogerian inquiry. The term well-being used
human and environmental field patterning. originally in this methodology is updated in
The flow of the inquiry starts with a sum- this chapter to the term wellbecoming. The
mation of the researcher’s purpose, aims, and purpose of the UFPP research method is to
visionary insights. Visionary insights emerge create a unitary understanding of the dynamic
from the study’s purpose and researcher’s un- kaleidoscopic and symphonic pattern manifes-
derstanding of Rogerian science. Next, the re- tations emerging from the pandimensional
searcher focuses on becoming familiar with the human–environmental field mutual process as
participants and the setting of the inquiry. a means to enhance the understanding of a sig-
Shared descriptions of energy field perspectives nificant phenomenon associated with human
are identified through observations and discus- betterment and wellbecoming. The UFPP re-
sions with participants and processed through search method is part of the unitary pattern–
mutual exploration and discovery. The re- based praxis model (see Fig. 14-1) illustrating
searcher uses the Mutual Exploration of the the inherent unity of Rogerian philosophy, sci-
Healing Human Field–Environmental Field ence, theory, practice, and research (Butcher,
Relationship Creative Measurement Instru- 2006a). There are eight essential aspects and
ment (Carboni, 1992) as a way to identify, un- three essential processes in the method. The as-
derstand, and creatively measure human and pects include initial engagement, a priori nurs-
environmental energy field patterns. Together, ing science, immersion, manifestation knowing
and appreciation, the unitary field pattern pro-
3For additional information, see the bonus chapter content file, the mutually constructed unitary field pat-
available at http://davisplus.fadavis.com. tern profile, the unitary field pattern portrait,
7991_Ch14_235-258 12/08/19 5:23 PM Page 253
and the theoretical unitary field pattern por- question of central interest to understand-
trait. The UFPP (Fig. 14-2) and the three es- ing unitary phenomena associated with
sential processes are creative pattern synthesis, human betterment and wellbecoming. For
immersion and crystallization, and evolutionary example, experiences, perceptions, and ex-
interpretation. pressions related to noninvasive voluntary
patterning modalities such as guided im-
1. Initial engagement: Inquiry within the
agery, Therapeutic Touch, humor, sound,
UFPP begins with initial engagement,
dialogue, affirmations, music, massage,
which is a passionate search for a research
Unitary Field Pattern Portrait Research Method
Initial engagement A priori nursing science Immersion
Pattern manifestation knowing and appreciation
Creative Pattern
Synthesis
Unitary field pattern profile
Emerging unitary themes

Mutual processing of human-environmental
pattern manifestations
Mutually shaped unitary field pattern profile
Resonating unitary themes of

human/environmental pattern manifestations
Immersion and
Crystallization
Unitary field pattern portrait
Evolutionary
Interpretation
Theoretical unitary field pattern portrait
FIG 14-2 ■ The unitary field pattern portrait research method. (Model from
Butcher, H. K. (2005). The unitary field pattern portrait research method: Facets, processes
and findings. Nursing Science Quarterly, 18, 293–297.)
7991_Ch14_235-258 12/08/19 5:23 PM Page 254
journaling, written emotional expression, associated with the phenomenon of con-

exercise, nutrition, reminiscence, aroma, cern. The researcher also maintains an in-
light, color, artwork, meditation, story- formal conversational style while focusing
telling, literature, poetry, movement, and on revealing the rhythm, flow, and config-
dance provide a rich source for UFPP re- urations of the pattern manifestations
search. Creativity, mystical experiences, emerging from the human–environmental
transcendence, sleeping-beyond-waking mutual field process associated with the
experiences, time experience, and paranor- research topic. The dialogue is taped and
mal experiences as they relate to human transcribed. The researcher maintains ob-
health and wellbecoming are also experi- servational, methodological, and theoreti-
ences that can be researched using the cal field notes, and a reflexive journal. Any
UFPP. The UFPP research method can artifacts the participant wishes to share
also be used to create a unitary conceptual- that illuminate the meaning of the phe-
ization and understanding of an unlimited nomenon may also be included. Artifacts
number of human experiences relevant to may include pictures, drawings, poetry,
understanding health and wellbecoming music, logs, diaries, letters, notes, and
within a unitary perspective. New concepts journals.
that describe unitary phenomena may also 5. Unitary field pattern profile is a rich de-
be developed through research using this scription of each participant’s experiences,
method. perception, and expressions created
2. A priori nursing science identifies the through a process of creative pattern syn-
Science of Unitary Human Beings as the thesis. All the information collected for
researcher’s perspective. As in all research, each participant is synthesized into a narra-
the perspective of the researcher guides all tive statement (profile) revealing the
aspects and processes of the research essence of the participant’s description of
method, including the interpretation the phenomenon of concern. The field pat-
of findings. tern profile is in the language of the partic-
3. Immersion involves becoming steeped in ipant and is then shared with the
the research topic. The researcher may im- participant for revision and validation.
merse in poetry, art, literature, music, dia- 6. Mutual processing involves constructing
logue with self and/or others, research the mutual unitary field pattern profile by
literature, or any activity that enhances mutually sharing an emerging joint or
the integrality of the researcher and the shared profile with each successive partici-
research topic. pant at the end of each participant’s
4. Pattern manifestation knowing and appre- pattern manifestation knowing and appre-
ciation includes participant selection, in- ciation process. For example, at the end of
depth dialoguing, and recording pattern the interview of the fourth participant, a
manifestations. Participant selection is joint construction of the phenomenon is
made using intensive purposive sampling. shared with the participant for comment.
Patterning manifestation knowing and ap- The joint construction (mutual unitary field
preciation occurs in a natural setting and pattern profile) at this phase would consist
involves using pandimensional modes of of a synthesis of the profiles of the first
awareness during in-depth dialoguing. The three participants. After verification of the
activities described earlier in the pattern fourth participant’s pattern profile, the
manifestation knowing and appreciation profile is folded into the emerging mutual
process in the practice method are used in unitary field pattern profile. Pattern
this research method. However, in the manifestation knowing and appreciation
UFPP research method the focus of pat- continues until there are no new pattern
tern appreciation and knowing is on expe- manifestations to add to the mutual unitary
riences, perceptions, and expressions field pattern profile. If it is not possible to
7991_Ch14_235-258 12/08/19 5:23 PM Page 255
either share the pattern profile with each of the phenomenon. The purpose of theo-
participant or create a mutually constructed retical UFPP is to explicate the theoretical
unitary field pattern profile, the researcher structure of the phenomenon from the per-
may choose to bypass the mutual process- spective of nursing science using Rogers’
ing phase. postulates and principles. The theoretical
7. The UFPP is created by identifying emerg- UFPP is expressed in the language of
ing unitary themes from each participant’s Rogerian science, thereby lifting the UFPP
field pattern profile, sorting the unitary from the level of description to the level of
themes into common categories, creating unitary science. Scientific rigor is main-
the resonating unitary themes of human– tained throughout processes by using the
environmental pattern manifestations criteria of trustworthiness and authenticity
through immersion and crystallization, (Butcher, 1998, 2005).
which involves synthesizing the resonating
Butcher’s (1997b) study of the experience of
themes into a descriptive portrait of the
dispiritedness in later life was the first published
phenomenon. The UFPP is expressed in
study using the UFPP. Ring (2009) used the
the form of a vivid, rich, thick, and accu-
method to investigate and describe changes in
rate aesthetic rendition of the universal
pattern manifestations in individuals receiv-
patterns, qualities, features, and themes
ing Reiki, and Fuller (2011) used the UFPP
exemplifying the essence of the dynamic
method to create a vivid portrait of adult sub-
kaleidoscopic and symphonic nature of the
stance users and family pattern in rehabilitation.
phenomenon of concern.
Charbonneau-Dahlen (2016) explored the
8. The UFPP is interpreted from the perspec-
American Indian tradition of quilting as a heal-
tive of the Science of Unitary Human
ing modality for an American Indian woman
Beings using the process of evolutionary
and her depressed daughter using the UFPP.
interpretation to create a theoretical UFPP
Practice Exemplar
Rogerian nurses participate knowingly with Rogers’ (1992) manifestations of patterning,
people as they explore, choose, and live po- patterning beyond death of the body is charac-
tentials for wellbecoming. The focus is on pat- terized by rhythms so rapid they seem contin-
tern transformation by facilitating pattern uous, visionary, timeless, increasingly diverse,
recognition using the practice methodology and beyond waking. The following example
developed and refined by Barrett (see previous illustrates these theoretical ideas.
discussion in this chapter and Chapter 29). When Tessa’s husband Frank was dying,
This consists of processes known as pat- she chose to have him home with hospice care
tern manifestation knowing and apprecia- rather than in the hospital. She wanted to par-
tion and voluntary mutual patterning. ticipate as actively as possible in the dying
The nurse is guided by the three principles process, which she was sharing with him. Rosa,
of homeodynamics—resonancy, helicy, and the hospice nurse grounded in the Science of
integrality—which describe the ongoing process Unitary Human Beings, assured her that dying
of change. Energy patterning is continuously was, indeed, a communal process: “Inherent in
flowing, and with this comes both change and the principle of integrality, the mutuality of
transformation. As energy fields have no begin- human–environment field process, is the idea
ning and no ending, Rogers (1970) speculated that dying is not an isolated act involving a soli-
that energy patterning persists beyond the tary person” (Malinski, 2012, p. 240). All are
death of the physical body, with physical death in mutual process and experience both dying
representing another transformative shift. Using and grieving simultaneously: “Although only
(continued)
7991_Ch14_235-258 12/08/19 5:23 PM Page 256

one is physically dying, both are changing and Once she was able to articulate her expe-
forever changed” (Malinski, 2012, p. 243). riences to the group, she found that she was
Tessa expressed uncertainty about how not alone. Others, although not everyone,
much Frank understood what was happen- shared similar experiences, saying they still
ing, as his ability to communicate was se- felt very connected with loved ones who
verely compromised. Rosa introduced the were gone. Richard described a qualitative
idea of pandimensionality, beyond perceived study with bereaved women done from a
constraints of space and time, where every- Rogerian perspective by Todaro-Franceschi
thing is present all-at-once. She discussed (2006), in which she described synchronicity
various health patterning modalities and en- related to dead loved one as a healing modal-
couraged Tessa to talk with Frank, play his ity. Synchronicity, meaningful coincidence,
favorite music, and record and play messages is a nonlinear, nonlocal experience which
from family and friends. Finding that touch Todaro-Franceschi (1999, 2006) described
was important to Tessa, Rosa encouraged as an energy manifestation arising within a
Tessa to use touch, to hold Frank’s hand and universal communal process, such as dying
massage him. Along with the care necessary and bereavement. Richard shared one of the
for the physical body, she taught Tessa Ther- synchronicity experiences described by a
apeutic Touch (TT), and together they did widow in that group. She was struggling to
TT with Frank as Tessa continued it on her put on bracelets without her husband’s help.
own. Rosa also did TT with Tessa to help As she fastened the bracelets, the music
her relax and maintain a calm, centered pres- from her jewelry box suddenly starting play-
ence with Frank. She offered guided medi- ing, which she took as a sign that her hus-
tations and imagery exercises that Tessa band was still with her. “I wasn’t even near
could choose to do on her own or with the jewelry box! … When it started to play,
Frank, and encouraged her to journal her ex- I knew he was saying, you see, you can do it
periences, reflections, and dreams daily. without me …” (2006, p. 157).
After Frank passed on, Tessa chose to Tessa verbalized a great sense of relief. Her
participate in a grief and bereavement group experiences were meaningful, not crazy. The
facilitated by Richard, a Rogerian nurse col- group discussed ways to move beyond with
league of Rosa’s. She was having experiences dead loved ones in transformative ways rather
that both baffled and excited her. Talking than leaving them behind, separating from
about them with friends, she found, was un- them. Those who did not share such experi-
comfortable, as her well-meaning friends had ences, while appreciating being able to listen
started suggesting that she needed to see a them, questioned why they did not have such
physician and get medication, that she experiences themselves. Richard hastened to
should be moving beyond Frank’s death and explain that everyone grieves in their own way,
investing her time and energy into forging that there is no right or wrong in the process,
new relationships; in short, to get on with and that the focus of the bereavement group
her life, a life without Frank. Tessa, however, was listening to everyone’s unique as well as
felt strongly that Frank was still with her. shared experiences and encouraging explo-
There were times when she clearly heard his ration of the personal meanings found in
voice, often assuring her that she could do them. He explained that the principle of he-
something she was unsure about or letting licy tells us that change is unpredictable and
her know that he was okay. She occasionally increasingly diverse, while the principle of res-
smelled his favorite cologne, as though he onancy posits that continuous change is char-
had just walked through the room. She was acterized by higher wave frequencies, such as
conflicted, unsure whether to treasure these those experienced in dreams and meditation.
experiences or seek help because of them. At each session, Richard offered suggestions
7991_Ch14_235-258 12/08/19 5:23 PM Page 257

of health patterning modalities members existence, where one lives with freedom in a
could use if they wished. If asked, he shared pandimensional universe energyspirit with
articles that presented the Rogerian view of a more diverse pandimensional awareness-
living and dying, including Phillips’ (2017) integral presence” (p. 225). Tessa was eager to
view of transcendence, wellbecoming, and explore these ideas and, when the time came,
pandimensional awareness–integral pres- left the group energized, feeling ready to par-
ence, describing “a becoming even after ticipate knowingly in the creative journey
death of the physical body, where living ahead, which still included Frank, just in a
continues without the confines of physical very different way.
Summary
If nursing’s content and contribution to the Rogerian science to practice and research.
human betterment and wellbecoming of a so- Rogers’ Science of Unitary Human Beings is
ciety is not distinguishable from other disci- applicable in all nursing situations. Rather than
plines and has nothing unique or valuable to focusing on disease and cellular biological
offer, nursing’s continued existence may be processes, the Science of Unitary Human Be-
questioned. Thus, nursing’s survival rests on ings focuses on human beings as irreducible
its ability to make a difference in promoting wholes inseparable from their environment.
the human betterment and wellbecoming of For 30 years, Rogers advocated that nurses
people. The Science of Unitary Human Beings should become the experts and providers of
offers nursing a new way of conceptualizing noninvasive modalities that promote health.
health as human wellbecoming that is congru- Now, the growth of “complementary/integrative,”
ent with the most contemporary scientific the- noninvasive practices is outpacing the growth
ories. As with all major theories embedded in of allopathic medicine. If nursing continues to
a new worldview, new terminology is needed be dominated by biomedical frameworks that
to create clarity and precision of understanding are indistinguishable from medical care, nurs-
and meaning. There is an ever-growing body ing will lose an opportunity to become expert
of literature demonstrating the application of in unitary health-care modalities.
Questions for Reflection ■ What are the different principles of home-

odynamics? Provide examples of how these
and Discussion
principles of homeodynamics are integral

■ How does Rogerian nursing science de- to understanding nursing practice from a
fine energy spirit? What rationale and Rogerian nursing science perspective.
meaning can you provide for replacing ■ Describe your understanding of pandi-
the term body–mind–spirit with energy– mensionality. How does this concept help
spirit as it relates to Rogerian nursing nurses with an expanding view of human
science? experiences and potentials?
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Rosemarie Rizzo Parse’s

CHAPTER
15
Humanbecoming Paradigm
Rosemarie Rizzo Parse

Summary Rosemarie Rizzo Parse is a Distinguished Pro-
Questions for Reflection and Discussion fessor Emerita at Loyola University Chicago
and a Fellow in the American Academy of
Nursing, where she initiated and is past chair
of the Nursing Theory–Guided Practice Ex-
pert Panel. She is founder and editor of Nurs-
ing Science Quarterly; president of Discovery
International, which sponsors international
nursing theory conferences; and founder of the
Institute of Humanbecoming, where each
summer in Pittsburgh she teaches new mate-
rial on the ontological, epistemological, and
methodological aspects of the Humanbecom-
ing Paradigm. There are also sessions on the
Humanbecoming Community Change Model
(Parse, 2003a, 2012a, 2013a, 2014), the Hu-
manbecoming Teaching–Learning Model
(Parse, 2004, 2014), the Humanbecoming
Mentoring Model (Parse, 2008c, 2014), the
Humanbecoming Leading–Following Model
(Parse, 2008b, 2011a, 2014), the Humanbe-
coming Family Model (Parse, 2008a, 2009a,
2014), and the Humanbecoming Concept In-
venting Model (Parse, 2018). The goal of all
sessions is the understanding of the meaning

of humanuniverse from a humanbecoming
perspective.
Dr. Parse has published more than 300 ar-
ticles and 10 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 Science: Major
Paradigms, Theories, and Critiques (Parse, 1987);
Illuminations: The Human Becoming Theory
in Practice and Research (Parse, 1995); The
Human Becoming School of Thought (Parse,
1998a); Hope: An International Human Becom-
ing Perspective (Parse, 1999a); Qualitative
259
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Inquiry: The Path of Sciencing (Parse, 2001); frameworks and theories. Nursing is both a dis-
Community: A Human Becoming Perspective cipline and a profession (Parse, 1999b). The
(Parse, 2003a); and The Humanbecoming Para- goal of the discipline is to expand knowledge
digm: A Transformational Worldview (Parse, about human experiences through creative
2014). Her books and other publications have conceptualization and research (Parse, 2005,
been translated into many languages, demon- 2009c). The knowledge base of the discipline is
strating the use of her theory as a guide for the scientific guide to living the art of nursing.
practice in various health-care settings. Her The discipline-specific knowledge is born and
modes of inquiry are used by nurse scholars fostered in academic settings where research
in Australia, Canada, Denmark, Finland, and education advance knowledge to new
Greece, Italy, Japan, South Korea, Sweden, realms of understanding (Parse, 2008d, 2009b).
Switzerland, Taiwan, the United Kingdom, The goal of the profession is to provide service to
the United States, and many other countries humankind through living the art of the science.
on five continents. Members of the nursing profession are respon-
Dr. Parse has received two lifetime achieve- sible for regulating the standards of practice
ment awards, one from the Midwest Nursing and education based on disciplinary knowledge
Research Society and one from the Asian that reflects safe health service to society in all
Nurses’ Association. The Rosemarie Rizzo settings (Parse, 1999b, 2012b, 2013b).
Parse Scholarship was endowed in her name
at the Henderson State University School of The Profession of Nursing
Nursing. She is a sought-after speaker and The profession of nursing consists of people
consultant for local, national, and international educated according to nationally regulated, de-
venues. She also received the Medal of Honor fined, and monitored standards that are in-
from the University of Lisbon. tended to preserve the integrity of health care
Dr. Parse is a graduate of Duquesne Uni- for members of society. The standards are
versity in Pittsburgh and received her master’s specified predominantly in medical terms, ac-
and doctorate from the University of Pitts- cording to a tradition largely related to nurs-
burgh. She was a member of the faculty of the ing’s early subservience to medicine. Nurse
University of Pittsburgh, dean of the School of leaders in health-care systems and in regulat-
Nursing at Duquesne University, professor and ing organizations have developed standards
coordinator of the Center for Nursing Re- of practice (Mitchell, 1998) and regulations
search at Hunter College of the City Univer- (Damgaard, 2012; Damgaard & Bunkers,
sity of New York (1983–1993), and professor 1998, 2012) consistent with discipline-specific
and Endowed Niehoff Chair in Nursing Re- knowledge as articulated in the theories and
search at Loyola University Chicago (1993– frameworks of nursing. This is a significant de-
2006). From January 2007 to 2014, she was velopment that has fortified the identity of
consultant, visiting scholar, and adjunct pro- nursing as a discipline with its own body of
fessor at the New York University College of knowledge—one that specifies the service that
Nursing, and (since 2015) is a visiting nurse society can expect from members of the pro-
scholar and faculty research consultant at the fession (Parse, 2011c). With rapidly changing
State University of New York at Binghamton. health policies and the general dissatisfaction
of consumers with health-care delivery, clearly
stated expectations for services from each of
Overview of the Theory nursing’s paradigms are welcome changes
Prologue: Reflections on the Discipline (Parse, 1999b, 2013a).
and Profession of Nursing
At present, nurse leaders in research, adminis- The Discipline of Nursing
tration, education, and practice are focusing at- The discipline of nursing encompasses at least
tention on expanding the knowledge base of three paradigmatic perspectives about human-
nursing through enhancement of the discipline’s universe (Parse, 2012a, 2013a). The totality
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C H A P T E R 15 ■ Rosemarie Rizzo Parse’s Humanbecoming Paradigm 261
paradigm posits the human as body–mind– (Barrett, 2010; Phillips, 2017, 2018; Rogers,
spirit whose health is considered a state of 1992).
biological, psychological, social, and spiritual
well-being. The body–mind–spirit perspective The Humanbecoming Paradigm
is particulate—focusing on the bio–psycho– In 2012, Parse identified a third paradigm, the
social–spiritual parts of the whole human as Humanbecoming Paradigm (Parse, 2012a,
the human interacts with and adapts to the en- 2013a, 2014) (Table 15-1). This paradigm was
vironment. The ontology leads to research and created inasmuch as the ontology (now the
practice on phenomena related to preventing nature of existence), epistemology (now the in-
disease and maintaining and promoting health vestigative tradition), and methodologies (now
according to societal norms. The totality par- modes of inquiry) of the Humanbecoming
adigm frameworks and theories are more school of thought have moved on from the tra-
closely aligned with the medical model. Nurses ditional metaparadigm conceptualization and
practicing according to this paradigm are con- beyond the totality and simultaneity paradigms
cerned with participation of persons in health- (Parse, 2013a, 2014). With the Humanbecom-
care decisions but have specific regimens and ing Paradigm, humanuniverse is an indivisible,
goals to bring about change for the people they unpredictable, everchanging cocreation, and
serve (Parse, 1999b). living quality is the becoming visible-invisible
In contrast, the simultaneity paradigm becoming of the emerging now. The ethos of
views the human as unitary—indivisible, un- humanbecoming is also described, and this is
predictable, and everchanging (Parse, 1987, unlike any other paradigm.
1998a, 2007b), wherein health is considered With the investigative tradition, the focus of
a value and a process. The ontology leads re- study is on universal humanuniverse living ex-
search and practice scholars to focus on, for periences. There are two modes of inquiry: Parse-
example, energy and environmental field sciencing and humanbecoming hermeneutic
patterns (Rogers, 1992). Nurses focus on sciencing. Sciencing is qualitative (Parsescienc-
power as knowing participation in change ing and the humanbecoming hermeneutic
Table 15-1 Paradigms of the Discipline of Nursing
Totality Paradigm Simultaneity Paradigm Humanbecoming Paradigm

Ontology Ontology Nature of Existence
Human Human Humanuniverse
Bio–psycho–social–spiritual being Unitary pattern Indivisible, unpredictable, everchanging

Universe Universe cocreation
Internal and external environment Unitary pattern in mutual Ethos of Humanbecoming-Dignity
Health process with the human Presence, existence, trust, worth
A state and process of well-being Health Living Quality
A value and a process Becoming visible-invisible becoming of
the emerging now
Epistemology Epistemology Investigative Traditions
Human attributes Human patterns Universal living experiences
Methodologies (Research and Methodologies (Research Sciencing (Parsesciencing and
Practice) and Practice) Humanbecoming Hermeneutic
Quantitative, qualitative, mixed Quantitative, qualitative, Sciencing)
Steps of the nursing process praxis Living the Art
Pattern recognition True presence illuminating meaning,
shifting rhythms, inspiring anticipation
Copyright Rosemarie Rizzo Parse, 2014.
7991_Ch15_259-270 12/08/19 5:23 PM Page 262
sciencing are described in detail in Parse, 2016), to describe people, such as noncompliant, dys-
and living the art of humanbecoming is in true functional, and manipulative.
presence with illuminating meaning, shifting In 2007, Parse set forth a clarification of the
rhythms, and inspiring anticipation (Parse, 1981, ontology, which is the description of the nature
1992, 1997a, 1998a, 2010, 2014). Nurses living of existence of the school of thought. She spec-
the Humanbecoming Paradigm beliefs hold ified humanbecoming as one word and huma-
that their primary concern is people’s perspec- nuniverse as one word (Parse, 2007b). Joining
tives of living quality with human dignity the words creates one concept and further con-
(Parse, 1981, 1992, 1997a, 1998a; 2010, 2012a, firms the idea of indivisibility. She also de-
2013a, 2014). The new conceptualization living scribed postulates to clarify the ontology further
quality is described in detail in Parse (2013a). (Parse, 2007b). The assumptions, postulates,
(See Parse, 2012a, 2013a, 2014 for details about and principles set forth beliefs that are clearly
the Humanbecoming Paradigm.) different from other nursing frameworks and
Because the ontologies of the three paradig- theories. Discipline-specific knowledge is ar-
matic perspectives are different, they lead to ticulated in unique language specifying a posi-
different research and practice modalities, dif- tion on the phenomenon of concern for each
ferent ethical considerations, and different pro- discipline. The humanbecoming language is
fessional services to humankind. (See Parse, unique to nursing. For example, the three hu-
2010 and 2016 for the humanbecoming ethical manbecoming principles contain nine concepts
tenets of human dignity, which are reverence, written in verbal form with -ing endings to
awe, betrayal, and shame.) Humanbecoming is make clear the importance of the ongoing
rooted in the human sciences and knowledge process of change as basic to humanuniverse
development is focused on gaining insight into emergence. In addition, each concept is expli-
cocreated universal humanuniverse living expe- cated with paradoxes, not opposites, but
riences. It is called a paradigm and a school of rhythms, further specifying the uniqueness of
thought because it encompasses a unique de- the humanbecoming language.
scription of the nature of existence, the inves- Humanbecoming encompasses the beliefs
tigative tradition, and sciencing and living the of the worldview, sciencing, and living the art.
art (Parse, 1997b, 2010, 2012a, 2013a, 2014). In 2012, the school of thought was expanded
Parse’s (1981) original work was titled Man- and new conceptualizations created the Hu-
Living-Health: A Theory of Nursing. When the manbecoming Paradigm (Parse 2012a, 2013a,
term mankind was replaced with male gender in 2014).
the dictionary definition of man, the name of
the theory was changed to Human Becoming The Ontology (the Nature
(Parse, 1992). No aspect of the principles of Existence)
changed at that time. With the publication of The assumptions, postulates, and principles of
The Human Becoming School of Thought (1998a), the Humanbecoming Paradigm make up the
Parse expanded the original work to include ontology (Parse, 2007b, 2012a, 2013a, 2014)
descriptions of three research methodologies (Table 15-2).
and additional specifics related to the practice
methodology (Parse, 1987), thus classifying Philosophical Assumptions
the Science of Humanbecoming as a school The assumptions of the Humanbecoming Par-
of thought (Parse, 1997b). The fundamental adigm are written at the philosophical level of
idea of humanbecoming—that humanuniverse discourse (Parse, 1998a, 2010, 2012a, 2013a,
is indivisible, unpredictable, everchanging— 2014). There are nine fundamental assumptions
precludes any use of terms such as physiological, about humanuniverse, ethos of humanbecom-
biological, psychological, or spiritual to describe ing, and living quality (Parse, 2013a, 2014). The
humanuniverse. These terms are particulate, assumptions arose beginning with the first book
thus inconsistent. Other terms inconsistent in 1981, from a synthesis of ideas from the
with humanbecoming include words often used Science of Unitary Human Beings (Rogers,
7991_Ch15_259-270 12/08/19 5:23 PM Page 263
Table 15-2 The Humanbecoming Paradigm: The Nature of Existence
Assumptions Postulates Principles Concepts and Paradoxes

Humanuniverse is indivisible, Illimitability is Structuring Imaging: explicit-tacit;
unpredictable, everchanging. the indivisible un- meaning is the reflective-prereflective
Humanuniverse is cocreating reality bounded knowing imaging and Valuing: confirming–not
as a seamless symphony of becoming. extended to infinity, valuing of confirming
the all-at-once languaging.
Humanuniverse is an illimitable remembering- Languaging: speaking–
mystery with contextually construed Configuring being silent; moving–
prospecting with rhythmical
pattern preferences. the emerging now. being still
patterns is the
Ethos of humanbecoming is dignity. Paradox is an revealing- Revealing-concealing:
Ethos of humanbecoming is august intricate rhythm concealing disclosing–not disclosing
presence, a noble bearing of expressed as a and enabling- Enabling-limiting:
immanent distinctness. pattern preference. limiting of potentiating-restricting
Freedom is contex- connecting-
Ethos of humanbecoming is abiding separating. Connecting-separating:
truths of presence, existence, trust, tually construed attending-distancing
and worth. liberation. Cotranscending
with possibles Powering: pushing-
Living quality is the becoming Mystery is the resisting; affirming–not
unexplainable, that is the powering
visible-invisible becoming of the and originating affirming; being-nonbeing
emerging now. which cannot be
completely known of transforming. Originating: certainty-
Living quality is the everchanging unequivocally. uncertainty; conforming–
whatness of becoming. not conforming
Living quality is the personal Transforming: familiar-
expression of uniqueness. unfamiliar
1992) and from existential phenomenologi- idea of cocreating reality as a seamless sym-
cal thought, particularly Heidegger, Merleau- phony of becoming (Parse, 1996), a central
Ponty, and Sartre; see Parse (1981, 1992, thought foundational to the ontology, as
1994a, 1995, 1997a, 1998a, 2013a, 2014). In foregrounded with four postulates of illim-
the assumptions, Parse posits humanuniverse as itability, paradox, freedom, and mystery (see
indivisible, unpredictable, everchanging, cocre- Parse, 2007b, for detailed descriptions of the
ating unique becoming. She also posits addi- postulates). The meanings of the postulates
tional descriptions of humanuniverse, ethos of permeate all three of the principles; the words
humanbecoming, and living quality. Living of the postulates are not used in the statements
quality is the chosen way of being in the becom- of the principles. Thus, the wording has been
ing visible-invisible becoming of the emerging clarified to provide semantic consistency with-
now (2012a, 2013a, 2014). Humans live an all- out changing the original meaning of the prin-
at-onceness, which is the becoming visible- ciples. The principles of humanbecoming, often
invisible becoming of the emerging now, in freely referred to as the theory, describe the central
choosing meanings that arise with the illimitable phenomenon of nursing (humanuniverse), and
(2007b, 2012a, 2013a, 2014). The chosen mean- arise from the three major themes of the as-
ings are the value priorities cocreated in tran- sumptions: meaning, rhythmicity, and tran-
scending with the possibles (Parse, 1998a). scendence. Each principle describes a theme
with three concepts. Each of the concepts ex-
Postulates and Principles plicates fundamental paradoxes of humanbe-
In 2007, Parse elaborated certain truths em- coming (Parse, 1998a, 2007b). The paradoxes
bedded in the conceptualizations of the ontol- are rhythms lived all-at-once as pattern pref-
ogy (2007b). In so doing, she expanded the erences (Parse, 2007b). Paradoxes are not
7991_Ch15_259-270 12/08/19 5:23 PM Page 264
opposites or problems to be solved but rather the idea that humanuniverse is everchanging,
are ways humans live their chosen meanings. that is, moving on with the possibilities of
This way of viewing paradox is unique to intended hopes and dreams. A changing diver-
the Humanbecoming school of thought sity unfolds as humanuniverse affirms and does
(Mitchell, 1993a; Parse, 1981, 1994b, 2007b, not affirm in the pushing–resisting of powering,
2014). as creating new ways of living the conformity–
nonconformity and certainty–uncertainty of
Statements of Principles originating sheds new light on the familiar–
The statements of principles are presented in unfamiliar of transforming. Powering is the
detail in Parse (2007b, 2010, 2012a, 2013a, pushing–resisting of affirming–not affirming
2014). With the first principle (see Parse, 1981, being in light of nonbeing (Parse, 1998a,
1998a, 2007b, 2013a, 2014), Parse explicates 2007b, 2012a, 2013a, 2014). The being–
the idea that individuals construct personal nonbeing rhythm is all-at-once living the ever-
realities with unique choosings arising with changing becoming visible-invisible becoming
illimitable humanuniverse options. Reality, the of the emerging now. Humanuniverse, in orig-
meaning given to a situation, is the individual’s inating, seeks to conform–not conform, that
everchanging seamless symphony of becoming is, to be like others and unique all-at-once,
(Parse, 1996). The seamless symphony is the while living the ambiguity of the certainty–
unique story of humanuniverse as mystery uncertainty embedded in all change. The
emerging with the explicit-tacit knowings of changing diversity arises with transforming the
imaging. Individuals live the confirming–not familiar–unfamiliar, as illimitable possibles are
confirming of valuing as cherished beliefs, viewed in a different light.
while languaging with speaking–being silent The three principles, together with the pos-
and moving–being still in the becoming tulates and assumptions, comprise a description
visible-invisible becoming of the emerging now of the nature of existence in the Humanbecom-
(for details, see Parse, 2007b, 2012a, 2013a, ing school of thought. The principles are re-
2014). ferred to as the Humanbecoming Theory. The
The second principle (Parse, 1981, 1998a, concepts, with the paradoxes, describe human-
2007b, 2010) describes rhythmical humanuniverse. The beliefs described therein give
universe patterns. The paradoxical rhythm rise to sciencing and living the art of human-
“revealing–concealing is disclosing–not dis- becoming. Sciencing is inquiring with the in-
closing all-at-once” (Parse, 1998a, p. 43). tent to enhance understanding. Consistent
Not all is explicitly known or can be told in with the Humanbecoming paradigm, the
the unfolding mystery of humanbecoming. focus of inquiry is universal humanuniverse
“Enabling–limiting is living the opportunities– living experiences (Parse, 2005, 2012a, 2013a,
restrictions present in all choosings all- 2014).

at-once” (Parse, 1998a, p. 44). There are
opportunities and restrictions whatever the
choice; all choosings are potentiating–
restricting (see Parse, 2007b and 2014, for Humanbecoming Sciencing
details). “Connecting–separating is being with Sciencing humanbecoming is coming to know;
and apart from others, ideas, objects and sit- it is an ongoing inquiry to discover and under-
uations all-at-once” (Parse, 1998a, p. 45). It stand the meaning of living experiences. The hu-
is a coming together and moving apart; there manbecoming investigative tradition has two
is closeness in the separation and distance basic modes (Parse, 1998a, 2005, 2011b, 2016a,
in the closeness—a rhythmical attending– 2016b) that flow from the paradigm. The basic
distancing (for details, see Parse, 2007b, modes were initially the Parse Method (Parse,
2012a, 2013a). 1987, 1990, 1992, 1995, 1997a, 1998a, 2001,
With the third principle, Parse (1981, 2005, 2011b, 2012a, 2013a, 2014) and the
1998a, 2007b, 2010, 2012a, 2013a) explicated Humanbecoming Hermeneutic Method (Cody,
7991_Ch15_259-270 12/08/19 5:23 PM Page 265
1995; Parse, 1995, 1998a, 2001, 2005, 2011b, some with Parsesciencing, many of which have
2012a, 2013a, 2014). The Humanbecoming been published (e.g., Baumann, 2000, 2003,
Hermeneutic Method was created in congru- 2009, 2013; Bunkers, 2010, 2012, 2016;
ence with the assumptions and principles of Condon, 2010; Doucet, 2012a, 2012b; Doucet
Parse’s theory, drawing from works by Bernstein & Bournes, 2007; MacDonald & Jonas-
(1983), Gadamer (1976, 1960/1998), Heidegger Simpson, 2009; Maillard-Struby, 2012;
(1962), Langer (1976), and Ricoeur (1976, Morrow, 2010; Naef & Bournes, 2009;
1981). Now the modes of inquiry with human- Peterson Lund, & Bunkers, 2018; S. M. Smith,
becoming are Parsesciencing and humanbecom- 2012; and many others). Parse (1999a) was the
ing hermeneutic sciencing. For details on these principal investigator for a nine-country re-
modes, see Parse (2016a, 2016b). search study on the living experience of hope
The purpose of these modes of inquiry is using the Parse Method, with participants
to advance the science of humanbecoming by from Australia, Canada, Finland, Italy, Japan,
studying universal humanuniverse living ex- Sweden, Taiwan, the United Kingdom, and
periences from historians’ descriptions (Parse- the United States. The findings from these
sciencing) and from written texts and studies and the stories of the participants are
artforms (humanbecoming hermeneutic sci- published in Hope: An International Human
encing). The phenomena for inquiry with Becoming Perspective (Parse, 1999a). Collabo-
Parsesciencing are universal humanuniverse rative research projects using the Parse Re-
living experiences such as joy, sorrow, hope, search Method have also been published on
grieving, shame, feeling overwhelmed, hav- feeling very tired (Baumann, 2003; Huch &
ing faith, feeling at home, and suffering, Bournes, 2003; Parse, 2003b). Nine studies
among others. Written texts from any liter- have been published in which authors used
ary source or artforms may be the focus of the humanbecoming hermeneutic method
humanbecoming hermeneutic sciencing. The (Baumann, 2008; Baumann, 2014; Baumann,
phases of sciencing in both modes call for a Carroll, Damgaard, Millar, & Welch, 2001;
unique dialogue; scholar with historian or Baumann, Murphy, & Ganzer, 2015; Baumann
scholar with text or artform. The scholar in & Ganzer, 2016); Cody, 1995, 2001; Ortiz,
Parsesciencing is in true presence as the his- 2003; Parse, 2007a). Additionally, one inquiry
torian moves with an unstructured dialogue published by Parse (2016a) on reverence, awe,
about the living experience under investigation. betrayal, and shame in The Lives of Others used
The scholar in humanbecoming hermeneutic humanbecoming hermeneutic sciencing.
sciencing is in true presence with the emerg- Living-the-art projects are initiated when a
ing possibilities in the horizon of meaning scholar wishes to describe the changes, satis-
arising in dialogue with texts or artforms. factions, and effectiveness when humanbe-
True presence is an intense attentiveness to coming guides health care (Parse, 1998a, 2001,
unfolding essences and emergent meanings. 2006, 2014). The major purpose of the projects
The scholar’s intent in sciencing is to discover is to understand what happens when human-
discerning extant moments (Parsesciencing) becoming is living as health professional with
and emergent meanings (humanbecoming person, family, and community. A number of
hermeneutic sciencing) (see Parse, 2001, scholars have conducted such living-the-art
2005, 2011b, 2012a, 2013a, 2014, 2016a, projects, all of which demonstrated enhanced
2016b). The contributions of the new satisfaction among persons, families, and com-
knowings arising from investigations with munities (Bournes & Ferguson-Paré, 2007,
sciencing include “new knowledge and un- 2008; Bournes et al., 2007; Jonas, 1995a;
derstanding of” humanuniverse living expe- Legault & Ferguson-Paré, 1999; Maillard-
riences (Parse, 1998a [p. 62], 2016a, 2016b, Strüby, 2007, 2008, 2009, 2010, 2012b;
2017). Mitchell, 1995; Northrup & Cody, 1998;
Many nurse scholars worldwide have con- Santopinto & Smith, 1995), and a synthesis of
ducted studies using the Parse Method, and the findings of these and other such studies has
7991_Ch15_259-270 12/08/19 5:23 PM Page 266
been written and published (Bournes, 2002; persons, families, and communities in discus-
Doucet & Bournes, 2007). sions, imaginings, or remembrances through
stories, films, drawings, photographs, movies,
Humanbecoming: Living the Art metaphors, poetry, rhythmical movements,
The goal of the nurse living the humanbecom- and other expressions (Parse, 1998a).
ing beliefs is true presence in bearing witness Many publications explicate the art of true
and being with others in their changing pat- presence with a variety of persons and groups.
terns of living quality. True presence is lived See, for example, Arndt, 1995; Banonis, 1995;
nurse with person, family, and community Bournes, 2000, 2003, 2006; Bournes, Bunkers,
in illuminating meaning, shifting rhythms, & Welch, 2004; Bournes & Flint, 2003;
and inspiring anticipation (Parse, 1987, 1992, Bournes & Naef, 2006; Butler, 1988; Butler
1994a, 1995, 1997a, 1998a, 2010, 2012a, & Snodgrass, 1991; Chapman, Mitchell, &
2013a, 2014). The nurse with individuals or Forchuk, 1994; Cody, Mitchell, Jonas-Simpson,
groups is in true presence with the unfolding & Maillard-Strüby, 2004; Hansen-Ketchum,
meanings as persons explicate, dwell with, and 2004; Hutchings, 2002; Jonas, 1994, 1995b;
move on with changing patterns of diversity. Jonas-Simpson & McMahon, 2005; Karnick,
Living true presence is unique to the art of 2005, 2007; Lee & Pilkington, 1999; Mattice
humanbecoming. True presence is not to be & Mitchell, 1990; Mitchell, 1988, 1990;
confused with terms now prevalent in the lit- Mitchell & Bournes, 2000; Mitchell, Bournes,
erature such as authentic presence, transforming & Hollett, 2006; Mitchell & Bunkers,
presence, presencing, and others. It is sometimes 2003; Mitchell & Cody, 1999; Mitchell &
misinterpreted as simply asking persons what Copplestone, 1990; Mitchell & Pilkington,
they want. Often nurses say it is what they al- 1990; Naef, 2006; Norris, 2002; Paille &
ways do (Mitchell, 1993b); this is not true Pilkington, 2002; Quiquero, Knights, & Meo,
presence. “True presence is an intentional re- 1991; Rasmusson, 1995; Rasmusson, Jonas,
flective love, an interpersonal art grounded in & Mitchell, 1991; M. K. Smith, 2002; Stanley
a strong knowledge base” (Parse, 1998a, p. 71). & Meghani, 2001; and others.
The knowledge base underpinning true pres-
ence is specified in the assumptions, postulates, Living the Art of Humanbecoming
and principles of humanbecoming (Parse, with Persons and Groups
1981, 1992, 1995, 1997a, 1998a, 2007b, 2010, It is important here to clarify some terminol-
2012a, 2013a, 2014). True presence is a free- ogy. Nursing practice is a generic term that
flowing attentiveness in the emerging now that refers to the genre of activities of the pro-
arises from the belief that the humanuniverse fession in general. The term practice is not
is indivisible, unpredictable, everchanging. appropriate to use when referring to human-
Humans freely choose with situations, struc- becoming, since according to various diction-
ture personal meaning, live paradoxical rhythms, ary definitions it means a habit, or to drill,
and move on with changing diversity (Parse, exercise, try repeatedly, or do over and over
1998a, 2007b, 2012a, 2013a, 2014). Parse again. The word practice is antithetical to the
(1987, 1998b) stated that to know, understand, worldview of humanbecoming, since major
and live the beliefs of humanbecoming requires foci of humanbecoming are reverence, awe,
concentrated study of the beliefs, sciencing, and human freedom, and dignity (Parse, 2010).
living the art, and a commitment to a different Humanbecoming professionals live the art of
way of being with people. The different way that the science of humanbecoming. The art of
arises from the humanbecoming beliefs is true humanbecoming refers to living true pres-
presence. ence, which arises directly from a sound un-
True presence is a powerful humanuniverse derstanding of the paradigm. True presence
connection. It is lived in face-to-face discus- flows only from humanbecoming profession-
sions, silent immersions, and lingering pres- als, who have studied, understand, believe in,
ence (Parse, 1987, 1998a). Nurses may be with and live the humanbecoming assumptions,
7991_Ch15_259-270 12/08/19 5:23 PM Page 267
postulates, and principles. Living is the the new diagnosis of lung cancer was the most
proper term to describe what humanbe- important issue for a person, she began to de-
coming professionals experience when with sign a teaching plan to inform the person about
recipients of health care. Humanbecoming the disease; however, when a humanbecoming
professionals who live humanbecoming be- professional asked the person, “What is the
lieve that persons, families, and communities most important issue for you right now?” the
are the experts on their own health situations, gentleman answered, “Telling my family and
and all are treated with dignity (Parse, 2010). continuing to work to care for them.” The hu-
In health-care situations, humanbecoming manbecoming professional continued to dis-
professionals in true presence come to persons cuss these concerns with the gentleman with
with an availability to be with and bear witness, no agenda except the one set by the gentleman.
as persons illuminate the meaning of the situ- Humanbecoming professionals are with per-
ations, shift rhythms, and inspiring anticipation sons in ways that honor their wishes and
in focusing on the becoming visible-invisible desires. Persons are seamless symphonies of be-
becoming of the emerging now (Parse, 1981, coming, and humanbecoming professionals are
1987, 1998a, 2007b, 2010, 2012a, 2013a, only one note in the symphony (Parse, 1996).
2014). Illuminating meaning, shifting rhythms,
and inspiring anticipation occur in the true Living the Art of Humanbecoming
presence of the humanbecoming professional, with Community
as persons explicate their situations, dwell with The Humanbecoming paradigm is a guide
the becoming visible-invisible becoming of the for sciencing, living the art, education, and
emerging now. In explicating, dwelling with, administration in settings throughout the
and moving on, persons experience new in- world. Scholars from five continents have
sights and even surprises, as situations are seen embraced the belief system and live human-
in the new light that arises with the true pres- becoming in a variety of venues, including
ence of humanbecoming professionals who health-care centers and university nursing
bear witness and do not label. Labeling or di- programs. The Humanbecoming Community
agnosing is objectifying, ignoring the impor- Model (Parse, 2003a, 2014), the Humanbe-
tance of persons’ dignity and freedom (Parse, coming Teaching–Learning Model (Parse,
2010). Humanbecoming professionals believe 2004, 2014), the Humanbecoming Mentoring
that persons know their way and live quality ac- Model (Parse, 2008c, 2014), the Humanbe-
cording to their unique value priorities (Parse, coming Leading–Following Model (Parse,
2012a, 2013a, 2014). Humanbecoming profes- 2008b, 2011a, 2014), the Humanbecoming
sionals do not have a preset agenda or teaching Family Model (Parse 2008a, 2009a, 2014) and
plan about what persons should or ought do, now the Humanbecoming Concept Inventing
but rather listen carefully to the intents and de- Model (Parse, 2018) are disseminated and
sires stated by persons, because these intents are used in academic and health-care settings
value priorities that are the living choices of worldwide. Many health centers throughout
persons. With recipients of health care, hu- the world use humanbecoming as a guide to
manbecoming professionals ask what is most health care (Bournes et al., 2004; Cody et al.,
important for the moment and explore mean- 2014; Ortiz, 2018). In several university-
ings, wishes, intents, and desires related to affiliated health-care settings in Canada, pro-
what is emerging now from the perspective of vision of health care based on humanbecoming
the recipients and these guide humanbecoming has been evaluated, and the theory has pro-
professionals’ participation (Parse, 2008e, vided underpinnings for standards of care
2012a, 2013a, 2014). What may seem impor- (Bournes, 2002; Legault & Ferguson-Paré,
tant to the humanbecoming professional may 1999; Mitchell, 1998; Mitchell, Closson,
not be what is important to the person. For ex- Coulis, Flint, & Gray, 2000; Northrup &
ample, when a health-care professional (not liv- Cody, 1998) and nursing best practice guide-
ing humanbecoming) thought that fear about lines (Nelligan et al., 2002). For example, in
7991_Ch15_259-270 12/08/19 5:23 PM Page 268
Toronto, Sunnybrook Health Science Centre was implemented in collaboration with Regina
and University Health Network created mul- Qu’Appelle Health Region and the Saskatchewan
tidisciplinary standards of care that arose from Union of Nurses.
the beliefs and values of the Humanbecoming Findings from the research (Bournes &
paradigm. Ferguson-Paré, 2007, 2008; Bournes et al.,
In settings worldwide where humanbecom- 2007) to evaluate implementation of the hu-
ing has guided nursing care on a large scale, manbecoming 80/20 model have been ex-
scholars examined the effects on the nurses tremely positive. For example, interviews with
and persons who were involved (Bournes & nurses, patients, families, and other health pro-
Ferguson-Paré, 2007, 2008; Bournes et al., fessionals in the Bournes and Ferguson-Paré
2007; Jonas, 1995a; Legault & Ferguson-Paré, (2007) study “supported the Humanbecoming
1999; Maillard-Strüby, 2007, 2008, 2009, Theory as an effective basis for learning and im-
2010, 2012a; Mitchell, 1995; Northrup & plementing patient-centered care that benefits
Cody, 1998; Santopinto & Smith, 1995). The both nurses and patients” (p. 251). Patients and
findings of the studies describe what happened families in that study “reported that they appre-
when humanbecoming was the guide for nurs- ciated the reverent consideration given to them by
ing care on an orthopedic surgery and rheuma- nurses who had learned about humanbecoming-
tology unit (Bournes & Ferguson-Paré, 2007); guided patient-centered care” (p. 251). They
a cardiac surgery unit (Bournes et al., 2007); a also described “being confident engaging in
medical oncology unit and a general surgery discussions with nurses who understood and
unit (Bournes & Ferguson-Paré, 2008); a fam- attentive experts interested in who they were
ily unit affiliated with a large teaching hospital and what was important to them” (p. 251).
(Jonas, 1995a); a 41-bed vascular and general Similarly, the nurse participants in Bournes and
surgery unit (Legault & Ferguson-Paré, 1999); Ferguson-Paré’s (2007) and Bournes and col-
an acute-care medical unit (Mitchell, 1995); leagues’ (2008) studies reported that after learn-
three acute-care psychiatry units (Northrup & ing about humanbecoming-guided nursing
Cody, 1998); three units in a 400-bed commu- practice, they were more concerned with listen-
nity teaching hospital (Santopinto & Smith, ing to patients and families, being with them,
1995); and a medical oncology unit (Maillard- getting to know what is important to them, and
Strüby, 2007). The findings from five of the respecting them as the experts about their living
studies are summarized in Bournes (2002) and quality. They also reported being more satisfied
are consistent with other evaluations (Bournes with their work—a theme noted by nurse lead-
& Ferguson-Paré, 2007, 2008; Bournes et al., ers and allied health participants who shared
2007; Maillard-Strüby, 2007, 2008, 2009, that nurses listened more and focused on pa-
2010, 2012a). tients’ perspectives (Bournes & Ferguson-Paré,
Bournes and Ferguson-Paré (2007, 2008) and 2007, p. 251).

Bournes, Plummer, Hollett, and Ferguson- Participants in both studies described the
Paré (2008) examined the impact of an in- benefits of the program, not only in relation to
novative academic employment model (the how it changed their relationships with pa-
humanbecoming 80/20 model—in which tients but also in relation to how it changed
nurses spent 80% of their paid work time in their view of how to be with their colleagues
direct patient care guided by humanbecoming in more meaningful ways (see Bournes &
and 20% of their paid work time learning Ferguson-Paré, 2007; Bournes et al., 2007). In
about humanbecoming and engaging in re- addition, study findings show that the cost of
lated professional development activities). providing education about humanbecoming-
The humanbecoming 80/20 model has been guided practice and staffing the 80/20 aspect
implemented on four units—three in Toronto, of the model is offset by higher nurse and pa-
Ontario (Bournes & Ferguson-Paré, 2007, tient satisfaction scores and a reduction in sick
2008), and one in Regina, Saskatchewan time and overtime (Bournes & Ferguson-Paré,
(Bournes et al., 2007). The Regina project 2007; Bournes et al., 2007). At a large academic
7991_Ch15_259-270 12/08/19 5:23 PM Page 269
teaching hospital, the humanbecoming 80/20 for nurses to offer health-care delivery to
model has been tested as the basis for a men- homeless women and children with diverse
toring program among experienced critical backgrounds. The PRISM Model, based on
care nurses and new nurses who want to work humanbecoming, was the guide to living the
in critical care (Bournes et al., 2008). The men- art (Cody, 2003). This model has been further
toring program is based on the Humanbecom- elaborated by Ortiz (2018) for use in an up-
ing Mentoring Model (Parse, 2008c). state New York setting and in north central
In South Dakota, a parish nursing model Indiana. At the Espace Mediane community
was built on the Eight Beatitudes and the nursing center in Geneva, Switzerland (for
principles of humanbecoming to guide nursing persons who have concerns about cancer and
practice in the health model at the First Pres- palliative care), living the art and teaching–
byterian Church in Sioux Falls (Bunkers, learning are guided by humanbecoming,
1998a, 1998b; Bunkers, Michaels, & Ethridge, meaning that nurses in the center live true
1997; Bunkers & Putnam, 1995). Bunkers and presence with visitors. Many of these are
Putnam (1995) stated, “The nurse, in practic- linked with academic partners to provide an
ing from the human becoming perspective and academic service for postgraduate nursing stu-
emphasizing the teachings of the Beatitudes, dents specializing in oncology and palliative
believes in the endless possibilities present care (Cody et al., 2004). The purpose of an-
for persons when there is openness, caring, other project was to evaluate what happens
and honoring of justice and human freedom” when the art of humanbecoming was initiated
(p. 210). Also, the Board of Nursing of South in a palliative care inpatient setting in Fribourg,
Dakota adopted a decisioning model based on Switzerland (F. Maillard-Strüby, personal com-
the Humanbecoming school of thought munication, August 7, 2008).
(Damgaard & Bunkers, 1998, 2012). Augustana Shifting from the traditional medical model
College (in Sioux Falls) had humanbecoming to living the art of humanbecoming is a chal-
as one of the theoretical focuses of the curricula lenge for health-care institutions and requires
for the baccalaureate and master’s programs. high-level administrative commitment for re-
The Humanbecoming Theory was the basis sources, including educational opportunities
of Augustana’s Health Action Model for for nurses. The commitment to humanbecom-
Partnership in Community (Bunkers, Nelson, ing requires a systemwide change in value pri-
Leuning, Crane, & Josephson, 1999). “The orities (Bournes, 2002; Bournes & DasGupta,
purpose of the model is to respond in a new 1997; Linscott, Spee, Flint, & Fisher, 1999;
way to nursing’s social mandate to care for the Mitchell et al., 2000).
health of society by gaining an understanding Participants worldwide who are interested
of what is wanted from those living these in living the art of humanbecoming can refer
health experiences” (Bunkers et al., 1999, to the International Consortium of Parse

p. 94). The creation of the model was “for persons Scholars home page on the Internet that is up-
homeless and low income who are challenged dated regularly (see www.humanbecoming.
with the lack of economic, social and interper- org). Every other year, most of the 100 or more
sonal resources” (Bunkers et al., 1999, p. 92). members of the International Consortium of
The Humanbecoming paradigm is the the- Parse Scholars meet in Canada or the United
oretical foundation of the baccalaureate, mas- States for a weekend immersion in Humanbe-
ters, and doctor of nursing practice (DNP) coming Theory sciencing, and living the art.
curricula at the California Baptist University The DVD The Human Becoming School of
College of Nursing in Riverside, California. Thought: Living the Art of Human Becoming
Faculty and students learn and live the art of (International Consortium of Parse Scholars,
humanbecoming in various venues. The Nurs- 2007; available from the Consortium at www.
ing Center for Health Promotion with the humanbecoming.org) shows Parse nurses in
Charlotte Rainbow PRISM Model was estab- true presence with persons in different settings
lished in Charlotte, North Carolina, as a venue and features Rosemarie Rizzo Parse talking
7991_Ch15_259-270 12/08/19 5:23 PM Page 270
about humanbecoming. Parse is also featured also a video called I’m Still Here, which is a
on the video in the Portraits of Excellence humanbecoming research-based drama on
Series called Rosemarie Rizzo Parse: Human living with dementia (Ivonoffski, Mitchell,
Becoming (Fitne, 1997), available from Fitne Krakauer, & Jonas-Simpson, 2006). It is
(www.fitne.net). Another video showing a available from the Murray Alzheimer Re-
nurse with persons is The Grief of Miscarriage search and Education Program at the Uni-
(Gerretsen & Pilkington, 1990). There is versity of Waterloo.
Summary
Through the efforts of Parse scholars, the living-the-art projects related to fostering
Humanbecoming Paradigm continues to understanding of humanbecoming with per-
emerge as a major force in the 21st-century sons, families, and communities also con-
evolution of nursing knowledge. Knowledge tinue to be synthesized. These syntheses
gained from sciencing humanbecoming guide decisions for continually creating the
continues to be synthesized to explicate fur- vision for sciencing and living the art of the
ther the meaning of universal humanuniverse Humanbecoming Paradigm for the better-
living experiences. The discoveries from ment of humankind.
Questions for Reflection ■ How does Parse describe true presence?

Based on this understanding, describe sit-
and Discussion uations when you feel you have lived true
■ How does the Humanbecoming Paradigm presence with persons, families, and/or
differ from the totality and simultaneity communities.
paradigms?
■ How does Parse’s Humanbecoming
Theory differ from other grand theories
of nursing?
7991_Ch16_271-290 12/08/19 5:22 PM Page 271
Margaret Newman’s Theory

CHAPTER
16
of Health as Expanding
Consciousness
Margaret Dexheimer Pharris

Overview of the Theory Margaret Newman’s Theory of Health as Ex-
Applications of the Theory panding Consciousness (HEC) invites nurses
Practice Exemplar to focus on being fully present to the meaning
Summary and patterns in patients’ lives. Newman (2005)
Questions for Reflection and Discussion stated that “one does not practice nursing using
the theory, but rather the theory becomes a
I don’t like controlling, way of being with the client—a way of offering
manipulating other people. clients an opportunity to know and be known
I don’t like deceiving, withholding, and to find their way” (p. xiv). A nurse who
or treating people as subjects or objects. practices within the theory of HEC engages
I don’t like acting as an objective non-person. patients in recognizing the evolving pattern of
I do like interacting authentically, listening, what is meaningful in their lives, and through
understanding, communicating freely. this relational process, patients are able to re-
I do like knowing and expressing myself in alize previously undiscovered paths for moving
mutual relationships. forward and previously unseen potential within
—MARGARET NEWMAN (1990) themselves. They come to see health not as the
absence of disease, but as a process of becom-
ing more of themselves, of finding greater
meaning in their lives, and “of reaching new
heights of connectedness with other people
and the world” (Newman, 2008a, p. 6). Just as
patients’ health predicaments are situated
within the evolving pattern of complex rela-
tionships and events in their lives, so too,
Newman’s theory has evolved within the con-

text of the meaningful relationships and events
of her life.
After graduating from Baylor University,
Newman returned to Memphis to work and to
care for her mother, who had been diagnosed
a few years earlier with amyotrophic lateral
sclerosis (ALS), a degenerative neurological
disease that progressively diminishes the
movement of all muscles except those of the
eyes. The process of caring for her mother over
a 5-year period was transformative. Not know-
ing the trajectory of the disease, Newman
learned to live day by day, fully immersed in
the present (Newman, 2008a), and learned
271
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that “each day is precious and that the time of Health as Expanding Consciousness, at the time
one’s life is contained in the present” (Newman, Newman felt the method precluded direct ap-
2008b, p. 225). plication to shape nursing practice, which was
Caring for her mother provided Newman what most interested her (Newman, 1997a).
with two additional significant realizations. After receiving her PhD in 1971, Newman
The first was that simply having a disease does joined the NYU faculty. While there, New-
not make a person unhealthy. Although New- man published a seminal article in Nursing
man’s mother’s life was confined by the disease, Outlook on nursing’s theoretical evolution
her life was not defined by it. In other words, (Newman, 1972) and with colleague Florence
she could experience health and wholeness in Downs coauthored two editions of a book on
the midst of having a chronic and progressive research in nursing (Downs & Newman,
disease. The second important realization was 1977). Newman’s early career in academia was
that time, movement, and space are in some centered on articulating the knowledge of the
way interrelated with health, which can be discipline and how it was developed.
manifested by increased connectedness and In 1977, Newman joined the faculty at
quality of relationships. Penn State University as the professor-in-
These early seeds of the HEC theory found charge of graduate studies. At that time, she
fertile ground in 1959 when Newman entered was invited to speak at a theory conference to
nursing school at the University of Tennessee be held in New York in 1978. It was in that
(UT) in Memphis. Her mother died 2 weeks address that she first clearly articulated her
before the beginning of the fall semester. theory of health. The transcript of her talk
Newman knew she could not go back to her was published as a chapter in a book she
previous life; the experience with her mother wrote about theory development in nursing
had deeply changed her. (Newman, 1979), which was one of the first
After graduating from UT’s baccalaureate books published on the subject. Newman also
nursing program, Newman stayed on at UT as organized a Nursing Theory Think Tank and
a clinical instructor. The next year she went to was a member of a group of nurse theorists fa-
the University of California, San Francisco cilitated by Sister Callista Roy to discern how
(UCSF), and obtained her master’s degree in to organize nursing diagnoses so that they
medical–surgical nursing. When she graduated would be rooted in the knowledge of the dis-
from UCSF in 1964, Newman was recruited cipline of nursing. This group presented papers
back to Memphis to become the director of the in 1978 and 1980 to the North American
Clinical Research Center. After directing the Nursing Diagnosis Association. In 1982, they
Clinical Research Center for 21/2 years, New- presented an organizing framework they had
man decided to pursue doctoral studies in developed for nursing diagnoses called patterns
nursing at New York University (NYU), where of unitary man (humans).

she would be able to study with Dr. Martha In 1984, Newman took an endowed posi-
Rogers. In her doctoral work at NYU, New- tion at the University of Minnesota. As part of
man began studying movement, time, and her theory development work, she conducted
space as parameters of health; however, she did a pilot study of pattern identification. She in-
so out of a logical positivist scientific paradigm. vited Richard Cowling from Case Western
She designed an experimental study that ma- and Jim Vail from the Army Nurse Corps to
nipulated participants’ movements and then collaborate with her. Newman was at that time
measured their perception of time (Newman, also a consultant to the Army Nurse Corps.
1971, 1982). Her results showed a changing While at the University of Minnesota,
perception of time across the life span, with Newman published two editions of her book,
people’s subjective sense of time increasing Health as Expanding Consciousness (Newman,
with age in such a way that time expanded for 1986, 1994a), which attracted international at-
them (Newman, 1987). Although her work tention. She conducted a series of lectures and
seemed to support what she later would term dialogues in New Zealand in 1985 and in
7991_Ch16_271-290 12/08/19 5:22 PM Page 273
CHAPTER 16 ■ Margaret Newman’s Theory of Health as Expanding Consciousness 273
Finland in 1987 on health as expanding con- the discipline of nursing. Reading and reflect-
sciousness and nursing knowledge development. ing on the philosophical work of scholars from
Shortly after retiring from her position at various disciplines—mainly Bentov (1978),
the University of Minnesota, Margaret New- Bohm (1980), Johnson (1961), Prigogene
man returned to Memphis, Tennessee, where (1976), Rogers (1970), and Young (1976)—
she continued to work on nursing knowledge stretched Newman’s view of the possibilities
development and dialogues with HEC schol- of nursing and enriched the theory of HEC.
ars from around the world. An endowed Work and dialogue with colleagues and students
“Dr. Margaret Newman professorship in further explicated the theory.
Nursing Theory” is being established at UT,
and under the leadership of Dr. Emiko Endo, Academic and Philosophical Influences
a “Newman Theory/Research/Practice Study on the Theory
Society” has been established in Japan, where During her time at the University of California,
HEC is widely established in nursing practice, San Francisco, Newman explored how nurses
education, and research. could respond to patients in a meaningful way
Honors awarded to Dr. Newman include during short time spans. Newman’s interest in
being named a Fellow of the American Acad- attending to what is meaningful to the patient
emy of Nursing; a New York University Dis- was influenced by Ida Jean Orlando’s delibera-
tinguished Scholar in Nursing; an outstanding tive nursing approach. Inspired by Orlando’s
alumna by both the University of Tennessee theoretical work, Newman began making de-
and NYU; a Living Legend by the American liberative observations about patients and re-
Academy of Nursing; and a recipient of the flecting what she observed back to the patient.
Sigma Theta Tau International’s Founders The specific attention stimulated patients to re-
Award for Excellence in Nursing Research spond by talking about what was meaningful in
and the University of Minnesota E. Louise their unique circumstances.
Grant Award for Nursing Excellence. Toward In a publication of the results of her explo-
the end of her life, Dr. Newman wrote a re- ration of this approach to nursing during short
flection about gerotranscendence and how it time spans, Newman (1966) recounted walking
aligns with the theory of Health as Expanding into the room of a patient who had been in the
Consciousness.1 hospital for some time. Newman noticed that
The following overview of the Theory of the woman was reading the want ads and sim-
Health as Expanding Consciousness was in- ply stated, “Reading the want ads, huh?” She
formed by a pattern recognition process with waited for a response. The woman, who had
Margaret Newman that focused on the evolving been diagnosed with a chronic lung problem,
pattern of meaningful people and events in her worked in a factory that exuded toxic fumes
life. The overview was also informed by an analy- and would no longer be able to work there. She
sis of Newman’s many written works and mate- was deeply concerned about her future. What
rials in the Margaret A. Newman archives at the ensued through their dialogue was a break-
UT Memphis library. through for the patient, whose health care
predicament was couched in the larger context
of her potential loss of income. Newman asked
Overview of the Theory the woman if she had discussed this with her
As previously described, the seeds for HEC physician, and the woman responded that she
theory were planted in Margaret Newman’s had not discussed it with anyone. When New-
personal experiences, practice, research, and man asked why not, the woman replied that no
academic studies, which launched her quest for one had asked her about it. Once the meaning
exploring and articulating the knowledge of of her illness was understood within the context
of her entire life, not just her physical state, a
1For additional information, see the bonus chapter content path toward health became apparent for the pa-
available at http://davisplus.fadavis.com. tient. This process of focusing on meaning in
7991_Ch16_271-290 12/08/19 5:22 PM Page 274
patients’ lives to understand where the current her address (Newman, 1978) and in a written
health predicament fits in the whole of people’s overview of the address (Newman, 1979), New-
lives has endured as central to HEC. man outlined the basic assumptions that were
Newman’s theoretical insights evolved as she integral to her theory at that time. Drawing on
delved into the works of Martha Rogers and the work of Martha Rogers and Itzhak Bentov
Itzhak Bentov, while at the same time reflecting and on her own experience and insight, New-
back on her own experience (Newman, 1997b). man (1979) proposed that:
Several of Martha Rogers’s assumptions became ■ Health encompasses conditions known as
central in enriching Margaret Newman’s theo-
disease or pathology, as well as states
retical perspective (Newman, 1997b). First and
where disease is not present.
foremost, Rogers saw health and illness not as ■ Disease/pathology can be considered a
two separate realities, but rather as a unitary
manifestation of the underlying pattern
process. This was congruent with Newman’s
of the person.
earlier experience with her mother and with her ■ The pattern of the person manifesting it-
patients. On a very deep level, Newman knew
self as disease was present before the struc-
that people can experience health even when
tural and functional changes of disease.
they are physically or mentally ill. Health is not ■ Removal of the disease/pathology will
the opposite of illness, but rather health and ill-
not change the pattern of the individual.
ness are both manifestations of the underlying ■ If becoming “ill” is the only way a person’s
pattern of a greater whole. One can be very
pattern can be manifested, then that is
healthy in the midst of a terminal illness.
health for the person.
Second, Rogers argued that all of reality is
■ Health is the expansion of consciousness.
a unitary whole and that each human being ex-
hibits a unique pattern. Rogers (1970) saw en- Newman’s presentation drew thunderous
ergy fields to be the fundamental unit of all applause as she ended with the statement, “The
that is living and nonliving, and she posited responsibility of the nurse is not to make peo-
that there is interpenetration between the ple well, or to prevent their getting sick, but to
fields of person, family, and environment. Per- assist people to recognize the power that is
son, family, and environment are not separate within them to move to higher levels of con-
entities but rather are an interconnected, uni- sciousness” (Newman, 1978).
tary whole (Rogers, 1990). Finally, Rogers saw Although Margaret Newman never set
the life process as showing increasing complex- out to become a nursing theorist, in that
ity. These assumptions from Rogers’s theory, 1978 presentation in New York City, she
along with the work of Itzhak Bentov (1978), articulated a theory that resonated with what
helped to enrich Margaret Newman’s (1997b) was meaningful in the practice of nurses
conceptualization of health and eventually the in many countries throughout the world.
articulation of her theory. Bentov viewed life Nurses wanted to go beyond the medical par-
as a process of expanding consciousness, which adigm of combating diseases; they wanted to
he defined as the informational capacity of the accompany their patients in the process of
system and the quality and quantity of inter- discovering meaning and wholeness in their
actions with the environment. lives. Margaret Newman’s proposed theory
served as a guide for them to do so; it offered
Basic Assumptions of the Theory of a new way of looking at the essence of nurs-
Health as Expanding Consciousness ing practice.
Reflecting on these theoretical works helped
Newman prepare for her Toward a Theory of Developing the Theory of Health
Health presentation at the 1978 nursing theory as Expanding Consciousness
conference in New York City. It was at that con- After identifying the basic assumptions of the
ference that the Theory of Health as Expanding theory of HEC, the next step was to focus on
Consciousness was first formally explicated. In how to test the theory with nursing research
7991_Ch16_271-290 12/08/19 5:22 PM Page 275
and how the theory could inform nursing prac- divide people’s lives into fragmented variables
tice. Newman (1997a) began to concentrate on but rather attends to the nature and meaning of
the following: the whole, which becomes apparent in the
nurse–patient dialogue. Newman described the
■ The mutuality of the nurse–client interac-
HEC research process as involving being fully
tion in the process of pattern recognition
present with clients, exploring what is meaning-
■ The uniqueness and wholeness of the
ful in their lives, conceptualizing the evolving se-
pattern in each client situation
quential configuration of meaningful people and
■ The sequential configurations of pattern
events at key points in the person’s life, and re-
evolving over time
flecting the pattern to the person, knowing that
■ Insights occurring as choice points of
insights will occur as action potential in the
action potential
nurse–client dialogue (1994a, 1997a, 1997b).
■ The movement of the life process toward
This process—in research as in practice—starts
expanded consciousness
with the nurse saying something like, “Tell me
To test the theory of HEC, which em- about the most meaningful people and events
braces reality as an undivided whole, Newman in your life.” Active listening, attuning, and
found that Western scientific research dialogue reveal insight into pattern and its
methodologies, which isolate particulate vari- meaning.
ables and analyze the relationships between A nurse practicing within the HEC theo-
them, were insufficient. retical perspective possesses multifaceted levels
Newman saw a need to articulate that her of awareness and is able to sense how physical
work fell within a new paradigm of nursing. signs, emotional conveyances, spiritual in-
Like Martha Rogers (1970, 1990), Newman sights, physical appearances, and mental in-
saw human beings as unitary and inseparable sights are all meaningful manifestations of a
from the larger unitary field that combines person’s underlying pattern. These manifesta-
person, family, and community all at once. tions also provide insight into the nature of the
Seeing change as unpredictable and transfor- person’s interactions with his or her environ-
mative, she named the paradigm within ment. It takes disciplined study and reflection
which her work and the work of Martha on practical experience applying the theory for
Rogers are situated the unitary–transformative nurses to be able to see pattern as insight into
paradigm (Newman, Sime, & Corcoran- the whole. Newman (2008a) stated that prac-
Perry, 1991). A nurse practicing within the ticing within a unitary paradigm requires a
unitary–transformative paradigm does not completely new way of seeing reality—it is like
think of mind, body, spirit, and emotion as moving from seeing the Sun as revolving
separate entities but rather sees them as man- around Earth to realizing that it is actually
ifestations of an undivided whole. Earth that revolves around the Sun. Newman
Newman’s theory (1979, 1990, 1994a, 1997a, (1997a) stated:
1997b, 2008a) proposes that we cannot isolate,
manipulate, and control variables to understand The paradigm of the discipline is becoming clear.
the whole of a phenomenon. The nurse and We are moving from attention on the other as
client form a mutual partnership to attend to the object to attention to the we in relationship, from
evolving pattern of the client’s meaningful rela- fixing things to attending to the meaning of the
tionships and life experiences. In this way, a pa- whole, from hierarchical one-way intervention to
tient who has had a heart attack can understand mutual process partnering. It is time to break with
the experience of the heart attack in the context a paradigm of health that focuses on power,
of all that is meaningful in his or her life and, manipulation, and control and move to one of re-
through the insight gained with pattern recog- flective, compassionate consciousness. The par-
nition, experience expanding consciousness and adigm of nursing embraces wholeness and
discern how to move on with life. Newman’s pattern. It reveals a world that is moving, evolving,
(1994a, 1997a, 1997b) methodology does not transforming—a process. (p. 37)
7991_Ch16_271-290 12/08/19 5:22 PM Page 276
Newman’s theory points the way for Applications of the Theory

nurses to practice and conduct research
within a unitary–transformative paradigm. In
Essential Aspects of Nursing Practice
the unitary–transformative paradigm, the within the Health as Expanding
process of the nurse–patient partnership is Consciousness Perspective
integral to the evolving definition of health Newman (2008a) synthesized the basic as-
for the patient (Litchfield, 1993, 1999; sumptions of HEC in the following way:
Newman, 1997a) and is synchronous ■ Health is an evolving unitary pattern of
with participatory philosophical thought
the whole, including patterns of disease.
(Skolimowski, 1994) and research method- ■ Consciousness is the informational capacity
ology (Heron & Reason, 1997).
of the whole and is revealed in the evolv-
When nurses view the world from a uni-
ing pattern.
tary perspective, they begin to see the nature ■ Pattern identifies the human–environ-
of relationships and their meaning in an
mental process and is characterized by
entirely new light. Frank Lamendola and
meaning. (p. 6)
Margaret Newman (1994) illustrated this in
their study with people with HIV/AIDS. Concepts important to nursing practice
They found that the experience of HIV/AIDS grounded in the theory of HEC include ex-
opened participants to suffering and physical panding consciousness, time, presence, reso-
deterioration and at the same time intro- nance with the whole, pattern, meaning,
duced greater sensitivity and openness to insights as choice points, and the mutuality of
themselves and others. Lamendola and New- the nurse–patient relationship.
man drew on the work of cultural historian
William Irwin Thompson, systems theorist Expanding Consciousness
Will McWhinney, and musician David Ultimate consciousness has been equated with
Dunn, who saw “the loss of membranal in- love, which embraces all experience equally and
tegrity as a signal of the loss of autopoetic unconditionally: pain as well as pleasure, failure
unity analogous to the breaking down of as well as success, ugliness as well as beauty, dis-
boundaries at a global level between coun- ease as well as nondisease.
tries, ideologies, and disparate groups” (p. 14). —M. A. NEWMAN (2003, p. 241)
Thompson viewed HIV/AIDS not just as a
pathogen, but rather as part of a larger cul- Consciousness within the theory of HEC
tural phenomenon heralding the need for is not limited to cognitive thought. Newman
“living together in symbiotic relationship” (1994a) defined consciousness as the infor-
and stated that we need to “learn to tolerate mation of the system: the capacity of the sys-
aliens by seeing the self as a cloud in a tem to interact with the environment. In the
clouded sky and not as a lord in a walled-in human system, the informational capacity in-
fortress” (as cited in Lamendola & Newman, cludes not only all the things conventionally
1994, p. 14). This change in perspective associated with consciousness, such as think-
helps nurses and patients move away from ing and feeling, but also all the information
military metaphors in relationship to pa- embedded in the nervous system, the im-
tients’ bodies (i.e., combating disease, waging mune system, the genetic code, and so on.
battles against invading cells, etc.) to focus The information of these and other systems
instead on harmony and balance. Nursing reveals the complexity of the human system
care within a unitary perspective unveils and how the information of the system
meaning and opens the possibility for a within each utterly unique human being in-
new way of living for people with chronic teracts with the information of the environ-
conditions. mental system (p. 33).
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To illustrate consciousness as the interac- Time and Presence

tional capacity of the person–environment, The time experienced
Newman (1994a) drew on the work of In a moment
Bentov (1978), who presented consciousness Expands or diminishes
on a continuum ranging from rocks on one With consciousness.
end of the spectrum (which have little If I am fully present
known interaction with their environment), There is
to plants (which provide nutrients, give off No time.
oxygen, and draw carbon dioxide from the Only consciousness.
atmosphere) to animals (which can move —M. A. NEWMAN (2008a, p. 225)
about and interact freely), to humans (who
can reflect and make in-depth plans regard-
ing how they want to interact with their en- Newman’s earliest published work pointed
vironment), and ultimately to spiritual beings to the ability of nurses to quickly and effec-
on the spectrum’s other end. Newman de- tively attend to what is most important to pa-
scribed death as a transformation point, with tients and, by engaging patients in a dialogue
a person’s consciousness continuing to de- about what is of utmost importance to them,
velop beyond the physical life, becoming a to discern the patient’s unique path toward
part of a universal consciousness (Newman, health (Newman, 1966). Newman asserted
1994a). that it is only when nurses move away from a
Nurses and their clients know that there sense of linear time to a more universal syn-
has been an expansion of consciousness when chronization with the here and now that they
there is a richer, more meaningful quality to can be truly present to patients in a meaning-
their relationships. Relationships that are ful and whole manner (Newman, 2008a).
more open, loving, caring, connected, and Newman stated:
peaceful are a manifestation of expanding
consciousness. These deeper, more meaning- There is a need to get back to the natural cycles
ful relationships may be interpersonal, or of the universe. The time of civilization (clock
they may be relationships with the wider time and the Gregorian calendar) is not the same
community or biosphere. Expanding con- as the time of the rest of the biosphere, our living
sciousness is evident when people transcend planet earth. Natural time is radial in nature, pro-
their own egos, dedicate their energy to jecting from the center, and continuously moving
something greater than the individual self, in the direction of greater consciousness. (2008a,
and learn to build order against the trend of p. 227)
disorder. The process of expanding con- Newman asserted that the artificial time
sciousness may look different with changes frame of clinic schedules and hospital shift
in cognitive function; nurses must carefully work places nurses at odds with the natural
discern patterns of meaning when this is the rhythm of nurse–patient relationships, serves
case. For example, when being present to the needs of health systems administrations
people with dementia or to very young chil- more than those of patients, and disrupts a
dren, nurses realize that there is no past or meaningful nursing practice. She pointed out
future—there is only the present, and they that the discipline of nursing has followed a
must be fully present in the present on a trajectory from adherence to artificial linear
deeper level than cognitive and verbal time to the synchronization of time in inter-
processes can take them (Newman, 2008a). personal relationships, and now must move to
People are best able to experience expanding the “instantaneous flow of information in each
consciousness when they are not chained to center of consciousness” and that “it is time to
linear time. opt for practice that reflects this dimension”
7991_Ch16_271-290 12/08/19 5:22 PM Page 278
(Newman, 2008b, p. 227). When nurses must and preclude receptivity to other data that
move out of a linear sense of time, they can be would present a more complete picture. It as-
more fully present to patients. sumes we are all the same” (p. 45). Resonance
Newman (2008a) stressed that it is only in enables nurses to sense the unique situation
relationship that people can fully come to and concerns of patients.
know themselves. She drew on the work of To resonate with patients and form open
T. D. Smith (2001), to conclude that “when relationships, nurses must let go of personal
the nurse considers the patient a mystery to be judgments about patients and transcend cul-
engaged in rather than a problem to be solved, the tural beliefs and values. In other words, the
relationship is characterized by presence” nurse needs to free himself or herself of all
(Newman, 2008a, p. 53). Newman further “should” and “ought to” attitudes and all per-
stated that “presence is enhanced by the nurse’s sonal preoccupations that might prevent total
openness and sensitivity to the other” and in- presence. Newman (2008a) explained there is
volves the nurse letting go of judgments of no prescriptive way to sense the whole through
“good” or “bad” in relationship to patients’ resonance. She recommended that nurses pay
health behaviors. attention to the client at the simplest level,
When nurses are truly present to patients begin with whatever presents itself, and as-
they concentrate more on intuitive knowing sume that it is purposeful (Newman, 2008a).
than on the gathering of facts and health- Learning to resonate with patients involves re-
related data. They enter into a relaxed alertness lational engagement and reflection.
and realize that transforming presence involves Most conventional education programs
a keen awareness of their oneness with the teach analytic processes attending to what is
patient (Newman, 2008a; Newman, Smith, “logical.” This leads students away from under-
Pharris, & Jones, 2008). Understanding the standing the whole. Methods that involve em-
concept of resonance enables a transforming pirical investigation assume that the whole
presence. comes after the parts; these methods tend to
blind investigators to their relationship with
Resonating With the Whole the whole. Newman (2008a) drew on the work
Newman (2008a) described resonance as the of Bohm (1980) to stress that “wholeness is
mechanism for acquiring essential information what is real, with fragmentation as our re-
to guide nursing actions and to understand sponse to fragmentary thought. The whole is
meaning in patients’ lives. She stated, “This is irreducible and omnipresent” (p. 40). Newman
an important distinction in the explication of (2008a) differentiated between the general and
nursing knowledge. Knowledge at the unitary, the universal. “Seeing comprehensively is con-
transformative level includes and transcends crete and holistic, whereas generalization is ab-
energy transfer at the sensorial level. It is stract and analytical; these ways of seeing go in
nonenergetic, nonlocal, and present everywhere” opposite directions” (p. 47). Resonance is a
(p. 35). She differentiated this information way to sense into the whole through attention
transfer from the transfer of sensory informa- to one aspect or part of it, always with an
tion (such as heat and touch, which involve eye on comprehending the whole. Resonance
physical energy transfer) and suggested nurses enables nurses to tap into the pattern of the
continually rely on this information transfer whole.
when intuitive insights arise during the care of
patients. Newman cautioned that “intellectu- Attention to Pattern and Meaning
alization breaks the field of resonance. If we Essential to Margaret Newman’s theory is the
analyze or evaluate an experience before we belief that each person exhibits a distinct pat-
have resonated with it, the field is broken—the tern, which is constantly unfolding and evolving
resonance is damped” (p. 37). “For instance, as the person interacts with the environment.
sometimes when we see familiar symptoms of Pattern is information that depicts the whole of
a disease, we jump into a diagnostic conclusion a person’s relationship with the environment
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and gives an understanding of the meaning of talked as usual in a very detached manner, but
relationships all at once (Endo, 1998; Newman, his words came out in bursts. The nurse chose
1994a). Pattern is characterized by meaning to give him feedback about what she was see-
(Newman, 2008a) and is a manifestation of ing and sensing from his body. She reflected
consciousness. that he seemed to be exerting a great deal of
To describe the nature of pattern, Newman energy holding back something that was
drew on the work of David Bohm (1980), who erupting within him. With this insight, he was
said that anything explicate (that which we can quiet for a few minutes, and tears began rolling
hear, see, taste, smell, touch) is a manifestation down his cheeks. Suddenly he began talking
of the implicate (the unseen underlying pattern; about a very painful family history of sexual
Newman, 1997b). In other words, there is in- abuse that had been kept secret for many years.
formation about the underlying pattern of each It became obvious that the experience of cover-
person in all that we sense about them, such as ing up the abuse had been so all-encompassing
their movements, tone of voice, interactions that his pattern had been suppressed.
with others, activity level, genetic pattern, and This young man had reached a point at
vital signs. People can be identified from a dis- which he realized his old ways of interacting
tance by someone who knows them, just from with others were no longer serving him, and
the way in which they move. There is also in- he chose to interact with his environment in
formation about their underlying pattern in all a different way. By the next meeting, his
that they tell us about their experiences and movements had become smooth and sure, his
perceptions, including stories about their life, complexion had cleared up, he was able to re-
recounted dreams, and portrayed meanings. flect on his insights, and he disengaged from
The HEC perspective sees disease, disorder, the chaos and fighting in his cellblock. He
disconnection, and violence as an explication could connect with the emotions of his child-
of the underlying implicate pattern of the per- hood experiences and to cry for the first time
son, family, and community. Reflecting on the in years.
meaning of these conditions can be part of the In their subsequent work together, this
process of expanding consciousness (Newman, young man and the nurse were able to distin-
1994a, 1997a, 1997b). guish between his implicate pattern, which had
Pharris (1999) offered the example of a now come into fuller focus through their dia-
16-year-old young man placed in an adult cor- logue, and the impact that keeping the abusive
rectional facility after a murder conviction. experience a secret had had on him and on
This young man was constantly getting into other members of his family. He was able to
fights and generally feeling lost. As he and the free himself of the shame he was carrying and
nurse researcher met over several weeks to gain got involved in several efforts to help others,
insight into patterns of meaningful people and both in and out of the prison environment. He
events in his life, the process seemed to be reported warmer and more loving relationships
blocked, with no pattern emerging and little with family members and friends and aca-
insight gained. He spoke of how he felt he had demic success—all evidence of expanding con-
lost himself several years back when he went sciousness for this young man. He reflected
from being a straight-A student from a stable that he wished he had had a nurse to talk with
family to stealing cars, drinking, getting into before “catching his case” (being arrested for
fights, and eventually murdering someone. murder). He had been seen by a nurse in the
One week he walked into the room where the juvenile detention center, who performed a
nurse was waiting, and his movements seemed physical examination and gave him aspirin for
more controlled and labored; he sat with his a headache. A few days before the murder, he
arms tightly cradling his bloated abdomen; his saw a nurse practitioner in a clinic who wrote
chest was expanded as though he were about a prescription for antibiotics and talked with
to explode. His palms were glistening with him about safe sex. These interactions were ex-
sweat. His face was erupting with acne. He plications of the pattern of the U.S. health care
7991_Ch16_271-290 12/08/19 5:22 PM Page 280
system and the increasingly task-oriented role theory of HEC have clearly demonstrated how
that nursing has been pressured to take on as nurses can create a mutual partnership with
juxtaposed with the transforming presence of their patients to reflect on their evolving pattern
a nurse whose practice is rooted in partnership and the points of transformation. Through this
focused on what is of utmost importance to the process, expanding consciousness is realized
person (Jonsdottir, Litchfield, & Pharris, (Barron, 2005; Berry, 2004; Endo, 1998; Endo,
2003, 2004). Minegishi, & Kubo, 2005; Endo et al., 2000;
The focus of nursing is on pattern and Endo, Takai, & Miyahara, 2014; Endo,
meaning. The underlying pattern of the patient Takaki, Nitta, Abbe, & Terashima, 2009;
makes itself known in the physical realm. Flanagan, 2005, 2009; Fujiwara & Endo, 2017;
Endo (2017) referred to the patient–nurse re- Hayes, 2015; Hayes & Jones, 2007; Jonsdottir,
lationship focused on pattern recognition as 1998; Kiser-Larson, 2002; Lamendola, 1998;
“caring partnership” (p. 51). Nurses grounded Lamendola & Newman, 1994; Litchfield,
in the theory of HEC are able to be in rela- 1993, 1999, 2005; Macharia, Jeagat, & Juma,
tionships with patients, families, and commu- 2015; MacLeod, 2011; MacNeil, 2012; Moch,
nities in such a way that insights arising in 1990; Musker, 2008; Neill, 2002a, 2002b;
their pattern recognition dialogue shed light Newman, 1995; Newman & Moch, 1991;
on an expanded horizon of potential actions Noveletsky-Rosenthal, 1996; Pharris, 2002,
(Litchfield, 1999; Newman, 1997a). 2005, 2011; Picard, 2000, 2005; Pierre-Louis,
Akoh, White & Pharris, 2011; Rosa, 2006,
Insights Occurring as Choice Points 2011, 2016; Ruka, 2005; Stec, 2016; Tommet,
of Action Potential 2003; Yang, Xiong, Vang, & Pharris, 2009;
The disruption of disease and other traumatic Younas, 2017).
life events may be critical points in the expan- Newman (1999) pointed out that nurse–
sion of consciousness. To explain this phenom- client relationships often begin during periods
enon, Newman (1994a, 1997b) drew on the of disruption, uncertainty, and unpredictability
work of Ilya Prigogine (1976), whose theory in patients’ lives. When patients are in a state
of dissipative structures asserts that a system of chaos because of disease, trauma, loss, or
fluctuates in an orderly manner until some dis- other causes, it is difficult to see their past or
ruption occurs, and the system moves in a seem- future clearly. In the context of a nurse–patient
ingly random, chaotic, disorderly way until at partnership centered on the meaning the pa-
some point it chooses to move into a higher tient gives to the health predicament, insight
level of organization (Newman, 1997b). Nurses for action arises and how to get on with life be-
see this all the time—the patient who is lost to comes clear (Jonsdottir et al., 2003, 2004;
his work and has no time for his family or him- Litchfield, 1999; Newman, 1999). Litchfield
self, and then suddenly has a heart attack, which (1993, 1999) explained this as experiencing an
leaves him open to reflecting on how he has expanding present that connects to the past
been using his energy. Insights gained through and creates an extended horizon of action po-
this reflection give rise to transformation and tential for the future.
decisions about where energy will be spent; and Endo (1998), in her work with Japanese
his life then becomes more creative, relational, women with cancer; Noveletsky-Rosenthal
and meaningful. Nurses also see this in people (1996), in her work in the United States with
diagnosed with a terminal illness that causes people with chronic obstructive pulmonary
them to reevaluate and reflect on what is really disease; and Pharris (2002), in her work with
important and then to state that for the first U.S. adolescents convicted of murder, found
time they feel as though they are really living. that it is when patients’ lives are in the greatest
The expansion of consciousness is an innate ten- states of chaos, disorganization, and uncer-
dency of humans; however, some experiences tainty that the HEC nursing partnership and
and processes precipitate more rapid transfor- pattern recognition process is perceived as
mations. Nurse researchers working within the most beneficial (Fig. 16-1).
7991_Ch16_271-290 12/08/19 5:22 PM Page 281
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
FIG 16-1 ■ Prigogine’s theory of dissipative structures applied to health as expanding consciousness
(HEC) nursing.
Many nurses who encounter patients in a choice point for the person to either continue
times of chaos strive for stability; they feel going on as before, even though the old rules
they have to fix the situation, not realizing are not working, or to shift into a new way of
that this disorganized time in the patient’s life being. To explain the concept of a choice
presents an opportunity for significant growth. point more clearly, Newman drew on Arthur
Newman (1999) stated: Young’s (1976) theory of the evolution of
consciousness.
The “brokenness” of the situation is only a point Young suggested that there are seven stages
in the process leading to a higher order. We need of binding and unbinding, which begin with
to join in partnership with clients and dance their total freedom and unrestricted choice, followed
dance, even though it appears arrhythmic, until by a series of losses of freedom. After these losses
order begins to emerge out of chaos. We know, come a choice point and a reversal of the losses
and we can help clients know, that there is a of freedom, ending with total freedom and un-
basic, underlying pattern evolving even though it restricted choice. These stages can be conceptu-
might not be apparent at the time. The pattern alized as seven equidistant points on a V shape
will be revealed at a higher level of organization. (Fig. 16-2). Beginning at the uppermost point
(p. 228) on the left is the first stage, potential freedom. The
The disruption brought about by the pres- next stage is binding. In this stage, the individual
ence of disease, illness, and traumatic or stress- is sacrificed for the sake of the collective, with
ful events represents a time when patients most no need for initiative because everything is being
need an HEC nursing partnership. Newman regulated for the individual. The third stage, cen-
(1999, p. 228) stated, “Nurses have a respon- tering, involves the development of an individual
sibility to stay in partnership with clients as identity, self-consciousness, and self-determina-
their patterns are disturbed by illness or other tion. “Individualism emerges in the self’s break
disruptive events.” This disrupted state presents with authority” (Newman, 1994b). The fourth
7991_Ch16_271-290 12/08/19 5:22 PM Page 282
Potential freedom Real freedom Nursing within the HEC perspective in-
volves being fully present to the patient without
judgments, goals, or intervention strategies. It
involves being with rather than doing for. It is
Binding Unbinding
caring in its deepest, most respectful sense with
a focus on what is important to the patient
(Newman 1994a, 2008). The nurse–patient in-
Centering De-centering
teraction becomes like a pure reflection pool
through which both the nurse and the patient
achieve a clear image of their pattern and come
away transformed by the insights gained.
Choice To illustrate the mutually transforming ef-
FIG 16-2 ■ Young’s spectrum of the evolution of fect of the nurse–patient interaction, Newman
consciousness. (1994a) offers the image of a smooth lake into
which two stones are thrown. As the stones hit
stage, choice, is situated at the base of the V. In the water, concentric waves circle out until the
this stage, the individual learns that the old ways two patterns reach one another and interpen-
of being are no longer working. It is a stage of etrate. The new pattern of their interaction rip-
self-awareness, inner growth, and transforma- ples back and transforms the two original
tion. A new way of being becomes necessary. circling patterns. Nurses are changed by their
Newman (1994b) described the fifth stage, de- interactions with their patients, just as patients
centering, as being characterized by a shift from are changed by their interactions with nurses.
the development of self (individuation) to dedi- This mutual transformation extends to the sur-
cation to something greater than the individual rounding environment and relationships of the
self. The person experiences outstanding com- nurse and patient.
petence; his or her works have a life of their own In the process of doing this work, it is im-
beyond the creator. The task is transcendence of portant that the nurse sense his or her own
the ego. Form is transcended, and the energy pattern. Newman (1994b) stated:
becomes the dominant feature—in terms of
animation, vitality, a quality that is somehow in- We have come to see nursing as a process of
finite. In this stage, the person experiences the relationship that coevolves as a function of the in-
power of unlimited growth and has learned how terpenetration of the evolving fields of the nurse,
to build order against the trend of disorder client, and the environment in a self-organizing,
(pp. 45–46). unpredictable way. We recognize the need for
Newman (1994b) stated that few experi- process wisdom, the ability to come from the cen-
ence the sixth stage, unbinding, or the seventh ter of our truth and act in the immediate moment.
stage, real freedom, unless they have had these (p. 155)
experiences of transcendence characterized by Sensing one’s own pattern is an essential
the fifth stage. It is in the moving through the starting point for the nurse. In her book Health
choice point and the stages of decentering and as Expanding Consciousness, Newman (1994a,
unbinding that a person moves on to higher pp. 107–109) outlined a process of focusing to
levels of consciousness (Newman, 1999). assist nurses as they begin working in the
HEC perspective. Once the process is mas-
The Mutuality of the Nurse–Client tered, nurses can quickly gain intuitive insight
Interaction in the Process of Pattern into the world of the patient. To do this they
Recognition must be able to practice from the center of
We come to the meaning of the whole not by their own truth—being fully present to the pa-
viewing the pattern from the outside, but by en- tient, while sensing into their own feelings and
tering into the evolving pattern as it unfolds. perceptions, knowing that they contain poten-
—M. A. NEWMAN tially valuable insights. Newman gave the
7991_Ch16_271-290 12/08/19 5:22 PM Page 283
example of a woman newly diagnosed with system, which is dependent on diagnosing and
cancer, who described fear and pain as she an- treating diseases (Jonsdottir et al., 2003, 2004).
ticipated sharing her diagnosis with her family. Practicing from an HEC perspective involves
Newman took in all that the woman was a holistic approach, which places what is
telling her and had a vision of the woman as a meaningful to patients back into the center of
“sink” into which the enormous fear of her the focus of nurses and what is meaningful to
family was flowing. Newman sensed that this students back into the center of the focus of
was the pattern in this family over time. The nurse educators.
woman felt whole and strong in facing the
cancer treatment, but unable to deal with her Health as Expanding Consciousness
family’s fears. Newman chose to share her Research as Praxis
“observation” with the woman, who resonated Margaret Newman’s early research (1966,
with it right away. Her pain left her and she 1971, 1972, 1976, 1982, 1986, 1987) added to
could let go of feeling obligated to absorb the an understanding of the interrelatedness of
family’s fears. To be of maximal help to pa- time, movement, space, and consciousness as
tients, it is important that nurses center them- manifestations of health. Newman’s further
selves to deeply and clearly sense into the reflection on these studies in light of work
patient’s pattern (1994a, pp. 108–109). she did at Walter Reed Hospital with Richard
The nurse’s consciousness, or pattern, be- Cowling and John Vail related to pattern
comes like the vibrations of a tuning fork that recognition, revealed the need to look at health
resonate at a centering frequency, and the as expanding consciousness using a research
client has the opportunity to resonate and tune methodology that acknowledges, understands,
to that clear frequency during their interactions and honors the undivided wholeness of the
(Newman, 1994a; Quinn, 1992). The nurse– human health experience. Newman, Cowling,
patient relationship ideally continues until the and Vail’s study participants were nurses at
patient finds his or her own rhythmic vibra- Walter Reed Hospital. Newman described
tions without the need of the stabilizing force one of the interviews she conducted as Vail
of the nurse–patient dialogue. Newman (1999) and Cowling watched from another room.
instructed that the partnership demands that Newman asked the nurse to describe meaning-
nurses develop tolerance for uncertainty, dis- ful events in her life and Newman diagrammed
organization, and dissonance, even though it the unfolding trajectory of the nurse’s life.
may be uncomfortable. It is in the state of dis- When they met the next day to reflect the se-
equilibrium that the potential for growth ex- quential patterns Newman had identified, the
ists. She states, “The rhythmic relating of nurse nurse was able to see that experiences she had
with client at this critical boundary is a window previously viewed as being extremely negative
of opportunity for transformation in the health (e.g., a divorce), actually were stepping stones
experience” (Newman, 1999, p. 229). to expanded possibilities; she was suddenly
able to view her life in a new way. The nurse
Relevance of Health as Expanding researchers and participants were excited about
Consciousness Across Cultures the insights they gained. The pattern recogni-
Margaret Newman’s Theory of Health as Ex- tion research method was a powerful nursing
panding Consciousness is being used through- practice process that shed light on theory—
out the world, but it has been more quickly research, theory, and practice each illuminated
embraced and understood by nurses from in- and developed the other two. Newman went
digenous and Eastern cultures (Endo, 2017). on to develop her pattern recognition nursing
Increasingly, however, HEC is being enthusi- research method in which theory, practice, and
astically embraced by nurses in industrialized research are one undivided process, each aspect
and Western cultures who are finding it diffi- shedding greater light on the other two.
cult to nurse in the modern technologically Newman realized a need to step inside to
driven and intervention-oriented health care view the whole from within—which is simply
7991_Ch16_271-290 12/08/19 5:22 PM Page 284
a metaphorical process since the researcher on the pattern of their interactions with each
has been integrally within the whole all other and the environment, insight into action
along. Newman’s Pattern Recognition Method may involve a transformative process, with the
cleared away the murky waters surrounding re- same events being seen in a new light. Family
search, theory, and practice and what previously health is a function of the nurse–family rela-
appeared to be three separate islands, became tionship. Many of the families in partnership
clearly visible as mountaintops on one undi- with Litchfield (1999, 2005) gained insight
vided piece of land, newly emerged but always into their own predicaments in such a way that
existing as an undivided whole. HEC research they required less interaction and service from
as praxis unfolded uniquely in various countries traditional health-care services, and thus a cost
and settings as nurse researcher-practitioner- saving in such services was realized.
theorists engaged in partnerships with individ-
uals, families, and communities to understand Exploring Pattern Recognition as a
patterns of meaning. Nursing Intervention
Emiko Endo (1998) explored HEC pattern
Focusing on the Process of Health recognition as a nursing intervention in Japan
Patterning and the Nurse–Patient with women living with ovarian cancer. She
Partnership asked, “When a person with cancer has an op-
Merian Litchfield (1993) from New Zealand portunity to share meaning in the life process
was the first researcher to apply the Theory of within the nurse–client relationship, what
Health as Expanding Consciousness to a nurs- changes may occur in the evolving pattern?”
ing partnership with families. Litchfield (1993, Attending to the flow of meaningful thoughts
1999, 2005) led the way in focusing on the for each participant and building on the previ-
process of the nursing partnership with patients ous work of Litchfield (1993), Endo found four
and families. In her first study, Litchfield common phases of the process of expanding
(1993) described health patterning as “a process consciousness for all participants: client–nurse
of nursing practice whereby, through dialogue, mutual concern, pattern recognition, vision and
families with researcher as practitioner, recog- action potential, and transformation. Partici-
nize pattern in the life process providing op- pants differed in the pace of evolving move-
portunity for insight as the potential for action; ment toward a turning point and in the
a process by which there may be increased self- characteristics of personal growth at the turning
determination as a feature of health” (p. 10). point. The characteristics of growth ranged
Litchfield (1993) described her research as a from assertion of self, to emancipation of self,
“shared process of inquiry through which par- to transcendence of self. Reflecting on her ex-
ticipants are empowered to act to change their perience, Endo (1998) put forth that pattern
circumstances” (p. 20). Through her research recognition is “not intended to fix clients’ prob-
over several years with families with complex lems from a medical diagnostic standpoint, but
health predicaments requiring repeated hospi- to provide individuals with an opportunity to
talizations, Litchfield (1993, 1999, 2005) found know themselves, to find meaning in their cur-
that she could not stand outside of the process rent situation and life, and to gain insight for
of recognizing pattern to observe a fixed health the future” (p. 60).
pattern of the family. She saw the pattern as Endo et al. (2000) conducted a similar
continuously evolving dialectically in the dia- study with Japanese families in which the wife-
logue within the nursing partnership. The find- mother was hospitalized because of a cancer
ings are literally created in the participatory diagnosis. Families found meaning in their
process of the partnership (Litchfield, 1999). patterns and reported increased understanding
For this reason, Litchfield did not use diagrams of their present situation. In the pattern recog-
to reflect pattern because she thought they nition process, most families reconfigured
would imply that the pattern is static rather from being a collection of separated individuals
than continually evolving. As the family reflects to trustful, caring relationships as a family unit,
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showing more openness and connectedness. the families themselves, health care costs can
The researchers concluded that pattern be reduced while family health is enhanced.
recognition as a nursing intervention was a Endo and colleagues (Endo, Minegishi, &
“meaning-making transforming process in the Kubo, 2005; Endo, Miyahara, Suzuki, &
family–nurse partnership” (p. 604). Ohmasa, 2005) in Japan expanded their work to
incorporate the pattern recognition process at
Health as Expanding Consciousness– the hospital nursing unit level. Endo, Miyahara,
Inspired Practice Suzuki, and Ohmasa (2005) concluded:
Patricia Tommet (2003) used the HEC
hermeneutic dialectic methodology to explore Retrospectively it was found through dialogue in
the pattern of nurse–parent interaction in fam- the research/project meetings that in the usual
ilies faced with choosing an elementary school nurse–client relationships, nurses were bound by
for their medically fragile children. She found their responsibilities within the medical model to
a pattern of living in uncertainty in the families help clients get well, but in letting go of the old
during the intense period of disruption and rules, they encountered an amazing experience
disorganization after the birth of their med- with clients’ transformations. The nurses’ trans-
ically fragile child through the first few years. formation occurred concomitantly, and they were
After 2 to 3 years, the families exhibited a pat- free to follow the clients’ paths and incorporate
tern of order in chaos where they learned how all realms of nursing interventions in everyday
to live in the present, letting go of the way they practice into the unitary perspective. (p. 145)
lived in the past. Tommet found that “families Jane Flanagan (2005, 2009) transformed
changed from being passive recipients to active the practice of presurgical nursing by develop-
participants in the care of their children” ing the preadmission nursing practice model,
(p. 90) and that the “experience of their chil- which is based on HEC. The nursing practice
dren’s birth and life transformed these families model shifted from a disease focus to a process
and through them, transformed systems of focus, with attention being given to the nurses
care” (p. 86). Tommet demonstrated insights knowing their patients and what is meaningful
gained in family pattern recognition and con- to them so that the surgery experience could
cluded that a nurse–parent partnership could be put in proper context and appropriate care
have a more profound impact on these fami- provided. Nursing presurgical visits were em-
lies, and hence the services they use, during the phasized. Flanagan reported that the nurses
first 3 years of their children’s lives. were exuberant to be free to be nurses once
Working with colleagues in New Zealand, again and that patients frequently stopped by
Litchfield undertook a pilot project that in- to comment on their preoperative experience
cluded 19 families in a predicament of strife and evolving life changes.
(Litchfield & Laws, 1999). The goal of the Similarly, Susan Ruka (2005) made HEC
pilot project, which built on Litchfield’s previ- pattern recognition the foundation of care at a
ous work (1993, 1999), was to explore a model long-term-care nursing facility, transforming
of nurse case management incorporating the the nursing practice and the sense of connect-
use of a family nurse who understands the the- edness among staff, families, and residents—
ory of health as expanding consciousness. In each became more peaceful, relaxed, and
analyzing costs of medical care for one partici- loving. The work of Flanagan (2009) and Ruka
pating family, it was estimated that a 3% to (2005) resulted in changes to the nurse–patient
13% savings could be seen by employing the care environments.
model of family nursing, with greater savings
being possible when family nurses are available Application of Health as Expanding
immediately after a family disruption takes Consciousness at the Community Level
place (Litchfield & Laws, 1999). This study Pharris (2002, 2005) attempted to understand
demonstrated that when nurses are free to focus a community pattern of rising youth homicide
on family health as defined and experienced by rates by conducting a study with incarcerated
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teens convicted of murder. The youth in the in myriad interactions with family and friends
study reported the pattern recognition process in the community. Then they described their
to be transformative, and expanding conscious- life in the United States where they sit alone
ness was visible in changed behaviors, increased at home all day watching television in a lan-
connectedness, and more loving attention to guage they do not understand and where they
meaningful relationships. The experience of the are fearful to walk outside and are driven by
young men demonstrated that alterations in their sons and daughters to the grocery store,
movement, time, and space inherent in the where they buy food wrapped in plastic. Dia-
prison system can intensify the process of ex- logue on these findings, which were presented
panding consciousness. When the experiences by two Hmong students as a play at a commu-
of meaningful events and relationships were nity dinner for Hmong women living with
compared across participants, the pattern of diabetes, shed light on needed individual, fam-
disconnection with the community became ev- ily, and community actions that would help
ident. People from various aspects of the com- Hmong women living with diabetes lead
munity (youth workers, juvenile detention staff, happy and healthy lives.
emergency hospital staff, pediatric nurses and Similarly, Pierre-Louis et al. (2011) con-
physicians, social workers, chaplains, educators) ducted an HEC study with African American
were engaged in dialogues reflecting on the sto- women with diabetes. Pattern recognition re-
ries and the community pattern. Insights trans- vealed that blood sugars rose and fell with
formed community responses to young people stress, depression, and trauma and that spiri-
at risk for violent perpetration. System changes tual strength, mentors, and sister friends help
ensued. to balance energy demands. Findings were
Pharris (2005) and colleagues extended woven into a spoken-word performance by the
the community pattern recognition process Black Story Tellers Alliance to engage African
through partnerships within a multiethnic American women who have diabetes in action
community interested in understanding and planning to help health can flourish in their
transforming patterns of racial inequities. They lives.
engaged women and girls from all walks of Pavlish and Pharris (2012) put forth a
community life in dialogue about their experi- community-based collaborative action research
ences of health, well-being, and race. Findings process rooted in Newman’s theory to provide a
were woven into a spoken word narrative that framework for nurses to engage communities—
was presented in various forms (performances whether hospital units, refugee camps, small
at meetings and gatherings, through commu- towns, or groups of people—in a process of
nity television and radio, and showing of DVD pattern recognition and action research to pro-
recordings) to members of the community so mote human flourishing.
that meaningful dialogue could ensue. The Sharon Falkenstern (Falkenstern, Gueldner,
process of reflecting on the community pattern & Newman, 2009) found the community pat-
generated insight into the nature of commu- tern to emerge as significant when she studied
nity patterns and what actions could be taken the process of HEC nursing with families with
to enhance health and well-being. a child with special health-care needs. She em-
In a related study comparing the evolving phasized the importance of nursing partner-
patterns of Hmong women with diabetes liv- ship with families as they struggle to make
ing in the United States, Yang et al. (2009) sense of their experiences and try to discern
found that the women’s blood sugars rose and how to get on with their lives. The evolving
fell with their experiences of trauma, loss, sep- pattern of the families in Falkenstern’s study
aration, and isolation. Women in the study de- illuminated the social and political forces
scribed their lives in Laos where they walked on families from the educational, disabilities
up and down hills carrying large bags of rice support, and health-care systems, as well as
on their backs, picked fresh fruits and vegeta- community patterns of caring, prejudice, and
bles that grew near their homes, and engaged racism.
7991_Ch16_271-290 12/08/19 5:22 PM Page 287
The pattern of the community is visible in more equitable, and deeper sense of health, in-
the stories of individuals and families. Nurses terconnectedness, and meaning.
can play an important role in engaging commu- Readers who are interested in learning
nities in dialogue as these stories are shared and more about Margaret Newman’s theory in
their meaning reflected on. Methods that en- practice are referred to two distinct integrative
gage communities in dialogue about the mean- reviews done by Marlaine Smith (2011) and
ing of patterns of health hold great potential. Katherine Rosa (2016), and an interview with
For example, if an HEC nurse were to take on Dorothy Jones on Expanding Consciousness
the task of engaging nurses at the national level in nursing education and practice (Clarke &
in a dialogue about what is meaningful in their Jones, 2011). Health system transformation
practice, expanding consciousness would be inspired by HEC can be found in Arcari and
manifest as the profession reorganizes at a Flanagan (2015), Jones (2013), and Somerville
higher level of functioning, with resultant (2009). The nature of HEC in nursing educa-
health-care systems change. In the process, the tion is explicated by Lindsay (2011) and Stec
population would no doubt experience a fuller, (2016).
Practice Exemplar
Sandra is an adult–gerontology nurse practi- situation. She knew that the focus of her care
tioner working in a community clinic in an for Gloria would arise out of their dialogue;
urban area of the United States; she is about she could not prescribe or predetermine the
to enter the room of Gloria, a new patient best care for Gloria, based on clinical guide-
with diabetes and hypertension. Gloria was lines alone.
referred by Anna, a physician colleague who Before entering the room where Gloria is
felt that Gloria was “noncompliant,” as evi- waiting, Sandra consciously attends to freeing
denced by her uncontrolled hypertension and herself of any personal preoccupations or ex-
hemoglobin A1c levels that consistently hov- pectations of what might happen. She wants
ered around 10. Anna felt that Gloria needed to fully attend to Gloria and sense what is of
more care than she could provide for her. greatest importance to her right now, knowing
Sandra studied Margaret Newman’s The- that this will guide Sandra’s nursing actions so
ory of Health as Expanding Consciousness that they can be of most benefit to Gloria.
in her graduate program, where the faculty Sandra is confident that she will get a sense of
paid attention to knowing Sandra and what this not only by asking questions and listening
was meaningful to her in her educational and deeply but also through intuitive hunches that
professional journey. She experienced a rela- will arise through her resonant presence with
tionship-based education process where the Gloria.
teacher is seen as “a catalyst to help students On entering the room, Sandra warmly
become who they will become rather than be greets Gloria and concentrates on what she is
‘trained’” and the learning process is a “dance sensing from Gloria’s presence. She sits down
between content and resonance” (Newman, next to Gloria in a relaxing and open manner.
2008a, p. 75). Sandra felt known and loved What most strongly calls Sandra’s attention is
by her professors. She had ample experience that Gloria is wringing her hands, which are
performing problem-solving approaches con- sweaty, and her muscles seem very tense.
sistent with the medical paradigm that After pausing for a moment, Sandra
leads to diagnoses, yet she realized that her chooses to reflect back to Gloria what she sees.
nursing actions were best guided by a dia- “Your muscles seem tense, like you might be
logue focused on understanding Gloria’s anxious about something. How has life been
physical health within the context of her life going for you?” Gloria looks at Sandra, curious
(continued)
7991_Ch16_271-290 12/08/19 5:22 PM Page 288

that Sandra is interested in her life. She re- a neighborhood women’s walking group,
sponds, “Well, things have been hard.” which might be a source of support. They also
Sandra responds, “Hmm, tell me about talk about a women’s group at the local library,
that.” Gloria explains that it has been dif- but Gloria seems hesitant.
ficult to take care of the two children for During the course of their conversation,
whom she provides day care. She says she Sandra has tried to clear herself of her own
doesn’t have the energy yet needs the concerns, yet, as they talk, she keeps thinking
money to pay her rent, which leaves her about an experience of racism she witnessed
very little money to buy food, and she can- at that library. She decides that it is important
not afford her medications. information and shares the story with Gloria.
Sandra assures Gloria that the clinic has This provokes an outpouring of emotion from
a plan that will provide her with her medica- Gloria as she recounts her experiences of
tions and that she will see that this is taken racism. They discuss how distorting these ex-
care of today—that she will go home with periences are and how to move through them.
adequate medications. She tells Gloria that They talk about how blood sugar and pressure
she would like to learn a little more about respond to these situations and ways in which
what has been meaningful in her life and asks Gloria can best cope.
her to describe meaningful events. Sandra Sandra does all of the things for Gloria that
uses the examination table paper to draw a her medical colleagues would do. She also dis-
diagram of what Gloria tells her. In very little cusses the services of the social worker, dietitian,
time, Sandra has sketched a diagram of the and psychologist at the clinic so that Gloria can
flow of important events in Gloria’s life. She choose what might be most helpful to her at this
learns that when immigrating to the United time. Gloria hugs Sandra as she leaves, saying
States from Liberia, Gloria suffered intense that she feels so much better, and adding, “You
abuse and was separated from her family and are a very good nurse!” Gloria leaves with a
friends. She has children in the United States greater understanding of herself, of what is
who constantly call her to babysit their chil- meaningful to her, and what actions she might
dren and to help them out. Gloria has also take. Sandra is also left with an enhanced un-
experienced intimate partner violence, and derstanding of herself and her practice.
her current economic stress and depression Sandra tucks the diagram they have drawn
have flowed from this experience. Gloria into a folder so that it can be elaborated on at
lives in a small apartment in a neighborhood subsequent visits. Sandra knows that Gloria’s
where she would need to walk 2 miles to get experience of health and well-being will evolve
to a store that sells fresh fruits and vegeta- and that she can serve as a catalyst, witnessing
bles. She tells Sandra she is hesitant to leave and engaging in dialogue about the meaning
her apartment. of the pattern of Gloria’s evolving health.
Sandra reflects back to Gloria that she Sandra will continue to focus on what she
sees all of Gloria’s energy going out to others senses as meaningful to Gloria and engage in
and none coming back to her. She has gone a relationship centered on Gloria’s unfolding
from being very active to only moving pattern of health. Hemoglobin A1c levels and
around within her apartment. Tears run blood pressure readings are only one aspect of
down Gloria’s cheeks as she listens to San- that pattern.
dra’s reflection. “That is so true!” They talk As Sandra engages with more and more pa-
about sources of support, nurturance, and tients with similar predicaments, she gets a
energy. Gloria identifies a woman in her sense of the community pattern of health. She
building whose company she enjoys. They brings her insight to the clinic staff meetings
talk about the possibility of the two women where a rich dialogue about community health
walking to the supermarket together and ensues. Sandra joins the CEO for a dialogue
simply getting together to talk. They identify with the clinic’s community board of directors
7991_Ch16_271-290 12/08/19 5:22 PM Page 289

to offer their insights. Through the subsequent provide an affordable source of nutritious food
dialogue, the board of directors and CEO in the immediate neighborhood, and lobbying
commit themselves to ensuring that health- for health care financing reform.
care providers have sufficient time to attend The circle of dialogue continues for Sandra.
to patients in a holistic manner, sponsoring Her attention is on pattern and meaning in
community forums on racism and how to deal the evolving health of her patients and the
with it, embedding a mental health practi- community. She trusts that health is inher-
tioner in the medical clinic, partnering with a ently present in her patients and the commu-
community recreational facility so that pa- nity and that reflection on what is meaningful
tients have a safe place to exercise, encourag- is a catalyst for its evolving pattern. With this
ing community microeconomic enterprises for realization, Sandra can return home where she
women, working with a community co-op to can be fully present to her family.
Summary
Margaret Newman’s Theory of Health as Ex- on predetermined outcomes mandated by the
panding Consciousness calls nurses to focus on health system or on fixing the patient, but
that which is meaningful in their practice and more important, on partnering with the pa-
in the lives of their patients. It attends to the tient to focus on what is meaningful in his or
evolving pattern of interactions with the envi- her experience of health. Rather than simply
ronment for individuals, families, and commu- using technological tools and following pre-
nities. It is a theory that is relevant across scribed clinical pathways, nurses offer their
practice settings and cultures. It informs and own transforming presence, knowing that
guides nursing practice, health-care adminis- the direction of their interaction with pa-
tration, and education. The theory of HEC tients will arise out of the relationship’s
presents a philosophy of being with rather than focus on the patient’s evolving experience of
simply doing for. It involves a different way of health. Nurses realize that the process of ex-
knowing—of resonating with patients, stu- panding consciousness involves transcen-
dents, and health care colleagues. dence and new possibilities as people age or
Nurses grounded in the Theory of Health encounter a challenging life event. As nurses
as Expanding Consciousness bring to the pa- come to understand the meaning of patterns
tient encounter all that they have learned in in the lives of individuals, families, and com-
school and in practice, yet they begin with a munities, they gain insights that inform pop-
sense of nonknowing to take in what is most ulation level dialogue for health policy
meaningful to the patient. The focus is not transformation.
Questions for Reflection ■ Why has Newman’s theory been more

readily adopted in Indigenous and Eastern
and Discussion cultures? Why are nurses in Western
■ How is resonance defined by Newman cultures, particularly those without
and how does this influence a nurse prac- national health systems, increasingly
ticing within Newman’s theory of HEC? drawn to the power of Health as
■ What is the process of pattern recognition Expanding Consciousness?
and in what ways can it be used as a nurs-
ing intervention in practice?
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SE C T I O N
V
Grand Theories About Care

or Caring
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SECTION
V Grand Theories About Care or Caring

Three of the grand theories in this book focus on the phenomenon of care or caring
in nursing. These theorists describe care or caring as the central domain of the
discipline of nursing. Rather than place these in the sections on the integrative–
interactive or unitary–transformative paradigm they are situated in a category of
their own.
Madeleine Leininger’s Theory of Culture Care Diversity and Universality is covered
in Chapter 17, authored by an expert in the theory and transcultural nursing, Hiba
Wehbe-Alamah. The theory is described, and practice applications of the theory are
provided. Leininger defined care as the essence of nursing; she asserted that care or
nurturance can be understood only within cultural contexts.
Jean Watson’s theory in Chapter 18, authored by Watson, can be conceptualized
as a philosophy, grand theory, or middle-range theory, depending on the lens of the
nurse working with the theory. Watson’s theory is composed of the 10 caritas
processes, the transpersonal caring relationship, the caring occasion, and caring–
healing modalities. Watson’s 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. Her latest work has evolved as unitary caring science.
Anne Boykin and Savina Schoenhofer contributed Chapter 19, on their theory of
Nursing as Caring. They identify the focus of nursing as nurturing the person living
and growing in caring. The theory encompasses coming to know the other as caring,
hearing and answering calls for caring, and nurturing the growth of the other as caring
person. This theory has transformed, and is currently transforming, care in a variety
of settings.
292
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Madeleine Leininger’s
CHAPTER
17
Theory of Culture Care
Diversity and Universality
Hiba B. Wehbe-Alamah

Overview of the Theory Madeleine M. Leininger (1925–2012) is an
Applications of the Theory internationally renowned nurse theorist, re-
Practice Exemplar searcher, author, consultant, public speaker,
Summary educator, administrator, scholar, human rights
advocate, and presenter. She is the founder of
transcultural nursing, the International Tran-
scultural Nursing Society, and the Journal of
Transcultural Nursing (Wehbe-Alamah, 2017).
Dr. Leininger obtained her initial nursing ed-
ucation at St. Anthony School of Nursing in
Denver, Colorado. She earned her undergrad-
uate degree from Mt. St. Scholastic College in
Atchison, Kansas; her master’s degree in psy-
chiatric and mental health nursing from the
Catholic University of America; and her PhD
in social and cultural anthropology at the Uni-
versity of Washington (Boyle & Glittenberg
Hinrichs, 2013). Dr. Leininger served as
dean at the Universities of Washington and
Utah, where she helped initiate and direct
the first doctoral programs in nursing and fa-
cilitated the development of master’s degree
programs in nursing at institutions in the
United States and other countries. Recog-
nized as a Living Legend by the American

Academy of Nursing and a distinguished fel-
low by the Australian Royal College of Nurs-
ing, she served as professor emerita in the
College of Nursing at Wayne State Univer-
sity and adjunct professor at the University
of Nebraska College of Nursing. Dr. Leininger
passed away in Omaha, Nebraska, at the age
of 87 on August 10, 2012.
In the span of her prolific career, Madeleine
Leininger published 35 books, wrote approxi-
mately 3,000 articles (some of which were never
published), and gave more than 5,000 presen-
tations or public lectures throughout the world,
in addition to contributing to numerous books
293
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294 S E C T IO N V ■ Grand Theories About Care or Caring
and videos (Boyle & Glittenberg Hinrichs, Transcultural Nursing: Concepts, Theories, and
2013). Some of her well-known books include Practices (McFarland & Wehbe-Alamah, 2018)
Basic Psychiatric Concepts in Nursing (Leininger includes a depiction of the revisions to and evo-
& Hofling, 1960); Caring: An Essential Human lution of the Culture Care Theory, Sunrise and
Need (1981); Care: The Essence of Nursing and other Enablers, and the Ethnonursing Research
Health (1984); Care: Discovery and Uses in Clin- Method (ERM).
ical and Community Nursing (1988); Ethical and
Moral Dimensions of Care (1990d); and Culture
Care Diversity and Universality: A Worldwide Overview of the Theory
Nursing Theory (1991a, 2006a). Leininger’s first One of Dr. Leininger’s most significant and
book to bring together nursing and anthropol- unique contributions was the development of
ogy was Nursing and Anthropology: Two Worlds her Culture Care Diversity and Universality
to Blend (1970) while her first work on transcul- Theory, also known as the Culture Care The-
tural nursing was Transcultural Nursing: Con- ory (CCT), and the Ethnonursing Research
cepts, Theories, and Practices (1978, 1995, 2002). Method (ERM), which she introduced in the
Her book Qualitative Research Methods in early 1960s after conducting the first field
Nursing (1985, 1998) was the first published study of the Gadsup Akuna of the Eastern
qualitative research methods book in nursing. Highlands of New Guinea (Leininger, 1991b,
In 1974, Dr. Leininger, then Professor and 1995, 2006a; McFarland, 2010; McFarland &
Dean of the College of Nursing at the Univer- Wehbe-Alamah, 2015b). She believed that
sity of Utah, founded the Transcultural Nurs- transcultural nursing care could provide mean-
ing Society (TCNS). Former students of ingful, therapeutic health and healing out-
Dr. Leininger from the University of Colorado comes. As she developed the theory, she
and the University of Washington, as well as identified transcultural nursing concepts, prin-
current students and faculty from the Univer- ciples, theories, and research-based knowledge
sity of Utah, were the first charter members of to guide, challenge, explain nursing practices,
the society (Wehbe-Alamah, 2017). In 1987, and provide culturally congruent and compe-
Leininger initiated the idea of worldwide nurs- tent care. This was a significant innovation in
ing certification for nurses prepared in transcul- nursing and has helped open the door to new
tural nursing. Today, basic (undergraduate) and scientific and humanistic dimensions of caring
advanced (graduate) certifications are available for people of diverse and similar cultures.
through the Transcultural Nursing Society. In The theory of Culture Care Diversity and
1989, Dr. Leininger founded the Journal of Universality was developed to establish a
Transcultural Nursing, the first transcultural substantive knowledge base to guide nurses in
nursing journal in the world, and served as discovery and use of transcultural nursing prac-
editor through 1995. tices. During the post–World War II period,

Shortly before her passing, Dr. Leininger Dr. Leininger realized that nurses would need
charged Drs. Marilyn McFarland and Hiba transcultural knowledge and practices to func-
Wehbe-Alamah with the continuation of the tion with people of diverse cultures worldwide
development of her theory, research method, (Leininger, 1970, 1978). Many new immi-
and future editions of her Culture Care Diver- grants and refugees were coming to the United
sity and Universality: A Worldwide Nursing States, and the world was becoming more
Theory and Transcultural Nursing: Concepts, multicultural.
Theories, and Practices books. The third edition Leininger held that caring for people of
of the Culture Care Diversity and Universality: many cultures was a critical and essential need,
A Worldwide Nursing Theory book (McFarland yet nurses and other health professionals were
& Wehbe-Alamah, 2015a) features the last not prepared to meet this global challenge. In-
two book chapters/publications authored by stead, nursing and medicine were focused on
Dr. Leininger (Leininger, 2015; Leininger & using new medical technologies and treatment
Wehbe-Alamah, 2015). The fourth edition of regimens concentrating on biomedical study of
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CHAPTER 17 ■ Madeleine Leininger’s Theory of Culture Care Diversity and Universality 295
diseases and symptoms. Shifting to a transcul- would be helpful from a nursing perspective.
tural perspective was a major but critically To care for children of diverse cultures and
needed change. link such knowledge into nursing knowledge
This part of the chapter presents an and practice was a major challenge. It was es-
overview of the Culture Care Theory (CCT), sential to incorporate new cultural knowledge
along with its purpose, goals, assumptions, that went beyond the traditional physical and
theoretical tenets, predicted hunches, related emotional needs of individuals. Leininger was
general features, and newest features. The next concerned about whether such learning would
part of the chapter discusses applications of be possible, given nursing’s traditional norms
the knowledge in clinical and community and orientation.
settings. For a more in-depth discussion of At that time, she questioned what made
the theorist’s perspectives, consult the pri- nursing a distinct and legitimate profession. She
mary literature on the theory (Leininger, 1970, declared in the mid-1950s that care is (or should
1981, 1989a, 1989b, 1990a, 1990b, 1991a, be) the essence and central domain of nursing.
1995, 1997a, 1998, 2002, 2006a; McFarland, However, according to Leininger, many nurses
2010; McFarland & Wehbe-Alamah, 2015b, resisted this idea because they thought care was
2018). unimportant, too feminine, too soft, and too
vague to explain nursing and be accepted by
Factors Leading to the Theory medicine (Leininger, 1970, 1977, 1981, 1984).
Dr. Leininger’s major motivation for the de- Nonetheless, Leininger firmly held to her claim
velopment of the CCT was the desire to dis- and began to teach, study, and write about care
cover unknown or little-known knowledge as the essence of nursing, emphasizing care
about cultures and their core values, beliefs, as nursing’s unique and dominant attribute
and needs. The idea for the CCT came to her (Leininger, 1970, 1981, 1988, 1991a, 2006a).
while she was a working as a child nurse clin- From both anthropological and nursing per-
ical specialist in a guidance home for children spectives, she held that care and caring were
in a large Midwestern city (Leininger, 1970, basic and essential human needs for human
1991a, 1995, 2006a; McFarland & Wehbe- growth, development, and survival (Leininger,
Alamah, 2018). From her focused observations 1977, 1981, 2006a; McFarland & Wehbe-
and daily nursing experiences, she became Alamah, 2015a, 2018). She argued that what
aware of how many of the children were from humans need is caring to survive from birth to
a variety of other cultures. The children dif- old age, whether ill or well, and care needed to
fered in their behaviors, needs, responses, and be specific and appropriate to cultures.
care expectations. Their parents responded to Her next step in the theory was to concep-
them differently, and their expectations of care tualize selected cultural perspectives and
and treatment modes were different. This re- transcultural nursing concepts derived from
alization was a shock to Leininger because she anthropology. She developed assumptions of
was not prepared to care for children of diverse culture care to establish a knowledge base for
cultures. Likewise, nurses, physicians, social the new field of transcultural nursing. Synthe-
workers, and other health professionals in the sizing or interfacing culture care into nursing
guidance home were also not prepared to re- was a real challenge (Leininger, 1976, 1978,
spond to such cultural differences. 1990a, 1990b, 1991a, 2006a). Findings from
It soon became evident that she needed cul- the theory could provide the knowledge
tural knowledge to be helpful to the children needed by nurses to care for people of different
and their families. Her psychiatric and general cultures. The idea of providing care was largely
nursing care knowledge and experiences were taken for granted or assumed to be under-
inadequate, which prompted her to pursue stood by nurses, individuals, and the public
doctoral study in anthropology. While in the (Leininger, 1981, 1984). Yet the meaning of
anthropology doctoral program, she discovered “care” from the perspective of different cultures
a wealth of potentially valuable knowledge that did not appear in the literature before the
7991_Ch17_291-310 12/08/19 5:21 PM Page 296
establishment of Leininger’s theory in the early 4. There were signs that some clients
1960s. Care knowledge had to be discovered from different cultures were angry,
with cultures. frustrated, and misunderstood by health
Leininger (1981, 1988, 1990a, 1991a, personnel owing to ignorance of the
1995) maintained that before her work, there clients’ cultural beliefs, values, and
were no theories explicitly focused on care expectations.
and culture in nursing environments, let alone 5. There were signs of misdiagnosis
research studies to explicate care meanings and mistreatment of clients from
and phenomena in nursing. Theoretical and diverse cultures because health
practical meanings of care in relation to spe- personnel did not understand the
cific cultures had not been studied, especially culture of the client.
from a comparative cultural perspective. 6. There were signs that nurses, physicians,
Leininger saw the urgent need to develop a and other professional health personnel
whole new body of culturally based care were becoming quite frustrated in caring
knowledge to support transcultural nursing for clients from unfamiliar cultures. Cul-
care. Shifting nurses’ thinking and attitudes ture care factors were largely misunder-
from medical symptoms, diseases, and treat- stood or neglected.
ments to that of knowing cultures and caring 7. There were signs that consumers of differ-
values and patterns was a major task. But ent cultures, whether in the home, hospi-
nursing needed an appropriate theory to distal, or clinic, were being treated in ways
cover care, and Leininger held that her theory that did not satisfy them and this influ-
was “the only theory focused on developing enced their recovery.
new knowledge for the discipline of transcul- 8. There were many signs of intercultural
tural nursing” (Leininger, 2006a, p. 7). Essen- conflicts and cultural pain among clinical
tial features of the CCT and the ethnonursing staff that led to tensions.
research method were developed and/or re- 9. There were very few health personnel of
vised throughout Leininger’s life (Leininger, diverse cultures caring for clients.
2006a, 2011). 10. Nurses were beginning to work globally
in the military or as missionaries, and
Rationale for Transcultural Nursing: they were having great difficulty under-
Signs and Need standing and providing appropriate
The rationale for change in nursing in America caring for clients of diverse cultures.
and elsewhere (Leininger, 1970, 1978, 1984, They complained that they did not
1989a, 1990a, 1995) was based on the follow- understand the people’s needs, values,
ing observations: and lifeways.
1. There were global migrations and interac- Although anthropologists were clearly ex-
tions of people from virtually every place perts about cultures, many did not know what
in the world due to modern electronics, to do with patients, nor were they interested
transportation, and communication. All in nurses’ work, in nursing as a profession, or
people needed culturally sensitive and in the study of human care phenomena in the
appropriate care. early 1950s. Most anthropologists in that era
2. There were signs of cultural stresses were far more interested in medical diseases,
and cultural conflicts as nurses tried archaeological findings, and physical and psy-
to care for clients from diverse chological problems of culture. For these rea-
cultures. sons and many others, it was evident in the
3. There were cultural indications of con- 1960s that people of different cultures were
sumer fears and resistance to health not receiving care congruent with their cul-
personnel as they used new technologies tural beliefs and values (Leininger, 1978,
and treatment modes that did not fit 1995). Nurses and other health professionals
their clients’ values and lifeways. urgently needed transcultural knowledge and
7991_Ch17_291-310 12/08/19 5:21 PM Page 297
skills to work efficiently with people of di- practices (Leininger, 1978, 1990a, 1990b, 1991a,
verse cultures. 2006a).
Leininger therefore took a leadership role
in the new field she called transcultural nurs- Worldview and Social Structure Factors
ing. She defined transcultural nursing as an
Another major tenet of the theory was that
area of study and practice focused on cultural
worldview and social structure factors—such
care (caring) values, beliefs, and practices of
as technology, religion (including spirituality
particular cultures. The goal was to provide
and philosophy), kinship (family ties), cultural
culture-specific and congruent care to people
values, beliefs and lifeways, political and legal
of diverse cultures (Leininger, 1978, 1984,
factors, and economic and educational factors,
1995, 2006a). The central purpose of tran-
as well as ethnohistory, language expressions,
scultural nursing was to use research-based
environmental context, and generic and pro-
knowledge to help nurses discover care values
fessional care—influence ways individuals,
and practices and use this knowledge in safe,
families, groups, and/or communities consider
responsible, and meaningful ways to care for
and deal with health, well-being, illness, heal-
people of different cultures. Today the CCT
ing, disabilities, and death (Leininger, 1995,
has led to a wealth of research-based knowl-
2006a). This broad and multifaceted view pro-
edge used to guide nurses and other health
vides a holistic perspective for understanding
professionals in the care of individuals, fami-
people and grasping their world and environ-
lies, and communities of different cultures or
ment within a historical context. Data from
subcultures.
this holistic research–based knowledge guide
nurses in caring for the health and well-being
Major Theoretical Tenets of the individual or to help disabled or dying
In developing the Theory of Culture Care Di- individuals from different cultures. Social
versity and Universality, Leininger identified structural factors influencing care of people
several predictive tenets or premises as essen- from different cultures provide new insights
tial for nurses and others to use. for culturally congruent care. Systematic study
by nurse researchers rather than superficial
Diversities and Similarities knowledge of culture is required to provide
A principal tenet was that diversities and sim- culturally congruent care. These factors, to-
ilarities (or commonalities) in culture care ex- gether with the history of cultures and knowl-
pressions, meanings, patterns, and practices edge of their environmental factors, were
would be found within cultures. This tenet discovered to create the theory and to bring
challenges nurses to discover this knowledge forth new insights and new knowledge. These
so nurses could use cultural data to provide data disclose ways that individuals can stay
therapeutic outcomes. It was predicted there well and prevent illnesses. Leininger (1991a,
would be a gold mine of knowledge if nurses 2006a) maintained that holistic cultural knowl-
were patient and persistent enough to dis- edge must be discovered to meet the theory’s
cover care values and patterns within cultures, goal of making decisions capable in providing
a dimension that had been missing from tra- culturally congruent care.
ditional nursing practice. Leininger main- Discovering cultural care knowledge re-
tained that human beings are born, live, and quires entering the cultural world to observe,
die with their specific cultural values and be- listen, and validate ideas. Transcultural nursing
liefs, as well as with their historical and envi- is an immersion experience, not a “dip in and
ronmental context, and that care is important dip out” experience. No longer can nurses rely
for their survival and well-being. Leininger only on fragments of medical and psychologi-
predicted that discovering which elements of cal knowledge. Nurses must become aware of
care were culturally universal and which were the social structure, cultural history, language
different would revolutionize nursing and ul- use, and the environment in which people live
timately transform health-care systems and to understand cultural care expressions. Thus,
7991_Ch17_291-310 12/08/19 5:21 PM Page 298
nurses need to understand the philosophy of and could lead to cultural imposition, tensions,
transcultural nursing, the Culture Care The- and conflicts. Nurses need to shift from relying
ory, and ways to discover culture knowledge. on routine interventions and from focusing on
Transcultural nursing courses and programs symptoms to employing care practices derived
are essential to provide the necessary instruc- from the individuals’ culture and from the the-
tion and mentoring. ory. They need to use holistic care knowledge
based on theory as opposed to relying solely on
Professional and Generic Care medical data. Most important of all, nurses
Another major and predicted tenet of the theory need to use both generic and professional care
is that differences and similarities exist between findings. This presented a new challenge, yet a
the practices of two kinds of care: professional rewarding one, for the nurse and the client if
(etic) and generic (emic, traditional, indigenous, thoughtfully done, as it fosters nurse–client col-
or “folk”) (Leininger, 1991a, 2006a; McFarland, laboration. Examples of the use of the three care
2010). These differences influence the health, ill- modes can be found in several published sources
ness, and well-being of individuals. Elucidating (Eipperle, 2015; Leininger, 1995, 1999, 2002;
these differences helps identify gaps in care, in- McFarland, Wehbe-Alamah, Wilson, & Vossos,
appropriate care, and beneficial care. Such find- 2011; Wehbe-Alamah, 2008a, 2011) and are
ings influence the recovery (healing), health, and presented in the next part of this chapter.
well-being of individuals of different cultures. Use of Leininger’s Culture Care Theory has
Marked differences between generic and profes- led to the discovery of new kinds of transcultural
sional care ideas and actions lead to serious nursing knowledge. Culturally based care can
client–nurse conflicts, potential illnesses, and prevent illness and maintain wellness. Methods
even death (Leininger, 1978, 1995). Such dif- for helping people throughout the life cycle,
ferences must be identified and resolved. Tran- from birth to death, have been discovered. Cul-
scultural nurses collaborate with individuals, tural patterns of caring and health maintenance
families, and communities to co-develop and along with environmental and historical factors
provide integrative care that combines generic are important. Most important, the use of
and professional care practices. Leininger’s theory has helped uncover signifi-
cant cultural differences and similarities.
Three Modes of Culture Decisions
or Actions (Culture Care Modes) Theoretical Assumptions: Purpose,
Leininger identified three ways to attain and Goal, and Definitions of the Theory
maintain culturally congruent care (Leininger, This section discusses some of the major as-
1991a, 2006a; McFarland, 2010). The three cul- sumptions, definitions, and purposes of the
ture care modes are (1) culture care preservation theory. The theory’s overriding purpose is to
and/or maintenance, (2) culture care accommo- discover, document, know, and explain the
dation and/or negotiation, and (3) culture care interdependence of care and culture phenom-
restructuring and/or repatterning (Leininger, ena with differences and similarities between
1991a, 1995, 2006a). These three care modes and among cultures (McFarland & Wehbe-
were very different from traditional nursing Alamah, 2015b, 2018).
practices, routines, or interventions. They are fo- The theory paves the way to discovering
cused on ways to use theoretical data creatively generic (folk) and professional care beliefs, ex-
to facilitate congruent care to fit individuals’ par- pressions, and practices that could be incorpo-
ticular cultural needs. To arrive at culturally ap- rated into collaborative plans of care designed to
propriate care, the nurse has to draw on fresh provide culturally appropriate, safe, beneficial,
culture care research and knowledge discovered and satisfying care to people of diverse or similar
from the people within the culture, along with cultures, to promote their health and well-being,
theoretical data findings. The care is tailored to and to assist them in facing death or disabilities.
individual needs. Leininger believed that routine Thus, the goal of the theory is to provide tailor-
interventions would not always be appropriate made culturally congruent care that contributes
7991_Ch17_291-310 12/08/19 5:21 PM Page 299
to the health and well-being of people, and helps 8. Culturally congruent and therapeutic care
them face disabilities, dying, or death using the occurs when culture care values, beliefs,
three modes of culture care decisions and actions. expressions, and patterns are explicitly
The ultimate goal of the theory is to establish known and used appropriately, sensitively,
a body of transcultural nursing knowledge for and meaningfully with people of diverse
current and future nursing best-care prac- or similar cultures.
tices worldwide (Leininger, 1991a, 1995, 2006a; 9. The three theoretical modes of care offer
McFarland, Mixer, Wehbe-Alamah, & Burke, new, creative, and different therapeutic
2012; McFarland & Wehbe-Alamah, 2018). ways to help people of diverse cultures.
10. The Ethnonursing Research Method and
Theory Assumptions other qualitative research methods offer
Leininger postulated several theoretical as- important means to discover largely em-
sumptions, or basic beliefs, designed to assist bedded, covert, epistemic, and ontological
researchers exploring diverse cultures (Leininger, culture care knowledge and practices.
1970, 1977, 1981, 1984, 1991a, 1997b, 2006a; 11. Transcultural nursing is a discipline with a
McFarland & Wehbe-Alamah, 2018): body of knowledge and practices to attain
and maintain the goal of culturally con-
1. Care is the essence and the central gruent care for health and well-being
dominant, distinct, and unifying focus (McFarland & Wehbe-Alamah, 2015b,
of nursing. pp. 8–9).
2. Humanistic and scientific care is essential
for human growth, well-being, health, Orientational Theory Definitions
and survival, and to face death and
To encourage discovery of qualitative knowl-
disabilities.
edge, Leininger used orientational (not oper-
3. Care (caring) is essential to curing or heal-
ational) definitions for her theory, to allow the
ing, for there can be no curing without
researcher to discern previously unknown phe-
caring. (This assumption was held to have
nomena or ideas. Orientational terms allow
profound relevance worldwide.)
discovery and are usually congruent with the
4. Culture care is the synthesis of two major
client’s lifeways. They are important in using
constructs (culture and care) that guide the
the qualitative ethnonursing discovery method,
researcher to discover, explain, and account
which is focused on how people understand
for health, well-being, care expressions,
and experience their world using cultural knowl-
and other human conditions.
edge and lifeways (Leininger, 1985, 1991a,
5. Culture care expressions, meanings, pat-
1997b, 1997c, 2002, 2006a). The following
terns, processes, and structural forms
are select examples:

are diverse, but some commonalities
(universalities) exist among and between 1. Culture: The learned, shared, and transmitted
cultures. values, beliefs, norms, and lifeways of a par-
6. Culture care values, beliefs, and practices ticular group that guides their thinking, deci-
are influenced by and embedded in the sions, and actions in patterned ways and often
worldview, social structure factors (e.g., intergenerationally (Leininger, 2006a, p. 13).
spirituality, religion, philosophy of life, 2. Care: Those assistive, supportive, and en-
kinship, politics, economics, education, abling experiences or ideas toward others
technology, biological factors, and cultural with evident or anticipated needs to ame-
values), and ethnohistorical and environ- liorate or improve a human condition or
mental contexts. lifeway. Caring refers to actions, attitudes,
7. Every culture has generic (lay, folk, natura- and practices to assist or help others to-
listic, mainly emic) and usually some pro- ward healing and well-being (Leininger,
fessional (etic) care to be discovered and 2006a, p. 12). Care is both an abstract and
used for culturally congruent care practices. a concrete phenomenon.
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3. Culture care: Subjectively and objectively 9. Culture care accommodation and/or negotia-
learned and transmitted values, beliefs, tion: Those assistive, accommodating,
and patterned lifeways that assist, facilitative, or enabling creative provider
support, facilitate, or enable another care actions or decisions that facilitate
individual or group to maintain well- adaptation to or negotiation with others
being and health, to improve their human for culturally congruent, safe, and
condition and lifeway, or to deal with effective care for their health and well-
illness, disabilities, or death (Leininger, being or to deal with illness or dying
1991a, p. 47). (Leininger, 2006a, p. 8).
4. Culture care diversity: The differences or 10. Culture care repatterning and/or restruc-
variabilities among human beings with turing: Those assistive, supportive, facili-
respect to culture care meanings, patterns, tative, or enabling professional actions
values, lifeways, symbols, or other features and mutual decisions that help people to
related to providing beneficial care to reorder, change, modify, or restructure
clients of a designated culture (Leininger, their lifeways and institutions for better
2006a, p. 16). (or beneficial) health-care patterns, prac-
5. Culture care universality: The commonly tices, or outcomes (Leininger, 2006a,
shared or similar culture care phenomena p. 8). These patterns are mutually
features of human beings with recurrent established between caregivers and
meanings, patterns, values, lifeways, or care receivers.
symbols that serve as a guide for caregivers 11. Ethnohistory: The past facts, events,
to provide assistive, supportive, facilitative, instances, and experiences of human
or enabling people care for healthy out- beings, groups, cultures, and institutions
comes (Leininger, 2006a, p. 16). that occur over time in particular
6. Professional (etic) care: Formal and explicit contexts that help explain past and
cognitively learned professional care current lifeways about culture care
knowledge and practices obtained generally influencers of health and well-being
through educational institutions. They are or the death of people (Leininger,
taught to nurses and others to provide as- 2006a, p. 15).
sistive, supportive, enabling, or facilitative 12. Environmental context: The totality of an
acts for or to another individual or group to event, situation, or particular experience
improve their health, to prevent illnesses, that gives meaning to people’s expressions,
or to help with dying or other human con- interpretations, and social interactions
ditions (Leininger, 2006a, p. 14). within particular geophysical, ecological,
7. Generic (emic) care: The learned and trans- spiritual, sociopolitical, and technological
mitted lay, indigenous, traditional, or local factors in specific cultural settings

folk knowledge and practices to provide as- (Leininger, 2006a, p. 15).
sistive, supportive, enabling, and facilitative 13. Worldview: The way people tend to look
acts for or toward others with evident out on their world or their universe to
or anticipated health needs to improve form a picture or value stance about life
well-being or to help with dying or other or the world around them (Leininger,
human conditions (Leininger, 2006a, 2006a, p. 15).
p. 14). 14. Cultural and social structure factors:
8. Culture care preservation and/or mainte- religion (spirituality); kinship (social
nance: Those assistive, supportive, facilita- ties); politics; legal issues; education;
tive, or enabling professional acts or economics; technology; biological factors;
decisions that help cultures to retain, pre- political factors; philosophy of life; and
serve, or maintain beneficial care beliefs cultural beliefs and values. The theorist
and values or to face disabilities and death has predicted that these diverse factors
(Leininger, 2006a, p. 8). must be understood as they directly
7991_Ch17_291-310 12/08/19 5:21 PM Page 301
or indirectly influence health and well- important to keep in mind. Nursing decisions
being (Leininger, 2006a; McFarland and actions are studied until one realizes the
& Wehbe-Alamah, 2018). care needed. The nurse discovers with the
15. Culturally congruent care: Culturally based informant the appropriate decisions, actions,
care knowledge, actions, and decisions or plans for care. Throughout this discovery
used in sensitive and knowledgeable ways process, the nurse holds his or her own etic bi-
to appropriately and meaningfully fit the ases in check so that the informants’ ideas will
cultural values, beliefs, and lifeways of come forth, rather than the researcher’s. Tran-
clients for their health and well-being, scultural nurses are mentored in ways to with-
or to prevent illness, disabilities, or death hold their biases or wishes and to enter the
(Leininger, 2006a, p. 15). client’s worldview.
The nurse begins the study by making
The Sunrise Enabler: A Conceptual explicit a specific domain of inquiry. For ex-
Guide to Knowledge Discovery ample, the researcher may focus on a domain
Leininger developed the Sunrise Enabler of inquiry such as “culture care of Mexican
(Fig. 17-1) to provide a holistic and compre- American mothers caring for their children in
hensive conceptual picture of the major fac- their home.” Every word in the domain state-
tors influencing the Culture Care Diversity ment is important and studied with the Sun-
and Universality Theory (Leininger, 1995, rise Enabler and the theory tenets. The nurse
1997b; Leininger & McFarland, 2002, 2006; or researcher may have hunches about the do-
McFarland & Wehbe-Alamah, 2018). The main and care, but until all data have been
enabler can be a valuable visual guide to studied with the theory tenets, she or he can-
elucidating multiple factors that influence not prove them. Informants’ viewpoints, expe-
human care and lifeways of different cul- riences, and actions are fully documented.
tures. It serves as a cognitive guide for the re- Generally, informants select what they like to
searcher to reflect on different predicted talk about first, and the nurse/researcher ac-
influences on culturally based care. commodates their interest or stories about
The Sunrise Enabler can also be used as a care. During in-depth study of the domain of
valuable aid in cultural and health care as- inquiry, all areas of the Sunrise Enabler are
sessment of clients. As the researcher uses identified and confirmed with the informants.
the enabler, the different factors alert him or The informants become active participants
her to find culture care phenomena. Care throughout the discovery process in such a way
values and beliefs are usually lodged into en- as to feel comfortable and willing to share their
vironment, religion, kinship, and daily life ideas.
patterns. The real challenge is to focus care meanings,
The nurse can begin the discovery at any beliefs, values, and practices related to inform-
place in the enabler and follow the informants’ cultures so that subtle and obvious differ-
ant’s ideas and experiences about care. If one ences and similarities about care are identified
starts in the upper part of the enabler, one among key and general informants. The differ-
needs to reflect on all aspects depicted to ob- ences and similarities are important to docu-
tain holistic or total care data. Some nurses ment with the theory. If informants ask about
start with generic and professional care then the researcher’s views, the latter must be care-
look at how religion, economics, and other fully and sparsely shared. The researcher keeps
factors affect these care modes. One always in mind that some informants may want to
moves with the informant’s, rather than the please the researcher by talking about profes-
researcher’s, interest and story. Flexibility in sional medicines and treatments. Professional
using the enabler promotes a total or holistic ideas, however, often cloud or mask the client’s
view of care. real interests and views. If this occurs, the re-
The three transcultural care decisions and searcher must be alert to such tendencies and
actions (in the lower part of the figure) are very keep the focus on the informant’s ideas and on
7991_Ch17_291-310 12/08/19 5:21 PM Page 302
Culture Care
Worldview
Cultural and social structure

dimensions
Cultural values,
Biological
beliefs, and
factors
lifeways
Kinship Environmental context, Political
and social language, and ethnohistory and legal
factors factors
Influences
Religious, Economic
spiritual, and factors
philosophical Care expressions,
factors patterns, and practices
Technological Educational
Holistic health, wellbeing, disability,
factors factors
illness, dying, and death
Focus: Individuals, families, groups, communities, or institutions

in diverse health contexts of
Code: (Influencers)
Generic (folk) Integrative care Professional

care practices care–cure practices
Three modes of care decisions and actions
Culture care preservation and/or maintenance

Culture care accommodation and/or negotiation
Culture care repatterning and/or restructuring
Culturally congruent care for holistic health, wellbeing,

disability, illness, dying, and death
FIG 17-1 ■ Leininger’s Sunrise Enabler to Discover Culture Care. (Used by permission. © McFarland
& Wehbe-Alamah, 2018.)
the domain of inquiry studied. The informant’s studying the theory (Leininger, 1985, 1991a,
knowledge is always kept central to the discov- 1995, 1997b; Leininger & McFarland, 2002,
ery process about culture care, health, and 2006; McFarland & Wehbe-Alamah, 2015a,
well-being. If the researcher finds some factors 2018).
unfamiliar, such as kinship, economics, and Throughout the study and use of the theory,
political and other considerations depicted in the meanings, expressions, and patterns of cul-
the model, the researcher should listen atten- turally based care are important. The nurse/
tively to the informant’s ideas. Obtaining in- researcher listens attentively to informants’ ac-
sight into the informant’s emic (insider’s) counts about care and then documents the
views, beliefs, and practices is central to ideas. What informants know and practice
7991_Ch17_291-310 12/08/19 5:21 PM Page 303
about care or caring in their culture is signifi- and actions by informants that reveal a desire
cant. Documenting ideas from the informants’ and a plan to work with others to identify, at-
emic viewpoint is essential to arrive at accurate tain, and maintain health and well-being and
culturally based care. Unknown care meanings, to resolve conflicts. This care construct was
such as the concepts of protection, respect, published in 2015, three years after Leininger’s
love, and many other care concepts, need to be passing (McFarland & Wehbe-Alamah, 2015a).
teased out and explored in depth, as they are
the key words and ideas in understanding care. Newest Addition to the Theory
Such care meanings and expressions are not al-
In 2015, Wehbe-Alamah and McFarland an-
ways readily known; informants ponder care
nounced upcoming changes to the Culture
meanings and are often surprised that nurses
Care Theory and Ethnonursing Research
are focused on care instead of medical symp-
Method at the 41st annual Transcultural So-
toms. Sometimes informants may be reluctant
ciety Conference in Portland, Oregon. These
to share ideas about social structure, religion,
changes were released in the fourth edition of
and economics or politics, as they fear these
Transcultural Nursing: Concepts, Theories, Re-
ideas may not be accepted or understood by
search & Practice (McFarland & Wehbe-
health personnel. Generic folk or indigenous
Alamah, 2018). The ongoing and continued
knowledge often has rich care data and needs
evolution of the theory and method to address
to be explored. Generic care ideas need to be
local, regional, and global care and health
appropriately integrated into the three modes
needs necessitated these revisions, which con-
of decisions and actions for culturally congru-
sisted of the following:
ent care outcomes. Generic and professional
care are integrated so the clients benefit from 1. Adding Biological Factors as a new con-
both types of care. struct to the CCT and a new Cultural and
The Sunrise Enabler was developed with the Social Structure dimension to the Sunrise
idea to let the sun enter the researcher’s mind and Enabler to emphasize the importance of
discover largely unknown care factors of cul- assessing hereditary and genetic illnesses
tures. Letting the sun rise and shine is important and culture-bound syndromes that influ-
and offers fresh insights about care practices. A ence and are influenced by generic and
metasynthesis of 24 doctoral dissertations using professional care expressions, patterns, and
Leininger’s CCT and the ERM led to the dis- practices (McFarland & Wehbe-Alamah,
covery of interpretive and explanatory culture 2018; Wehbe-Alamah & McFarland,
care findings, new theoretical formulations, and 2015).
evidence-based recommendations to guide 2. Revising Leininger’s Semi-Structured
nursing practice (McFarland, Wehbe-Alamah, Inquiry Guide Enabler to Assess Culture
Wilson, & Vossos, 2011; McFarland, Wehbe- Care and Health by editing/updating
Alamah, Vossos, & Wilson, 2015). previous questions embedded under
In the summer of 2011, Dr. Leininger in- each inquiry mode, adding the Biological
troduced collaborative care as a new care con- Factors section with new open-ended
struct, which she offered as the next phase in questions, and separating the previous
the evolutionary development of CCT. She Professional and Generic Care Beliefs
maintained that diverse cultural values, beliefs, and Practices inquiry mode into two
expressions, actions, and practices within a distinct headings: Professional Care Beliefs
family, a group, an institution, or other unit and Practices and Generic (folk or lay)
may present with situations in which conflicts Care Beliefs and Practices (McFarland
may arise. She proposed collaborative care as a & Wehbe-Alamah, 2018).
means or a strategy to resolve differences and 3. Reversing order and editing language con-
provide culturally congruent care. tent of the Leininger’s Phases of Ethnonurs-
Leininger defined the collaborative care ap- ing Data Analysis Enabler for Qualitative
proach as those values, meanings, expressions, Data (McFarland & Wehbe-Alamah,
7991_Ch17_291-310 12/08/19 5:21 PM Page 304
2018). These can be found in the ERM nurses might use the research findings related
electronic bonus chapter associated with to a theory. However, with the CCT, along
this book. with the ethnonursing research method, there
4. Contributing minor edits to language used is a built-in means for discovering and con-
in all other enablers. firming data with informants to make practical
nursing decisions and actions that are mean-
Current Status of the Theory ingful and culturally congruent (Leininger,
Currently, the Theory of Culture Care Diversity 2002).1
and Universality continues to be studied and Leininger purposefully avoided using the
used in many schools of nursing within the phrase nursing intervention because this term
United States and in other countries, such as often implies to clients from different cultures
Lebanon, Jordan, Saudi Arabia, Taiwan, China, that the nurse is imposing his or her (etic)
Japan, and Finland (Leininger & McFarland, views, which may not be helpful. Instead, the
2002, 2006; Wehbe-Alamah & McFarland, term nursing decisions and actions was used, but
2012). Interdisciplinary health professionals always with the clients helping to arrive at
are becoming increasingly aware of transcul- whatever decisions or actions were planned
tural nursing concepts that help them in their and implemented. The care modes fit with the
work. Several disciplines, including dentistry, clients’ or peoples’ lifeways and are both ther-
medicine, social work, physical therapy, and apeutic and satisfying for them. The nurse can
pharmacy, have reported using the Culture draw on scientific and evidence-based nursing,
Care Theory or teaching it in their programs medical, and other knowledge with each care
(McFarland, 2011; Wehbe-Alamah & Fry, mode.
2014). Data collected from the upper and lower
The Theory of Culture Care will remain of parts of the Sunrise Enabler provide culture
global interest and significance as nurses and care knowledge for the nurse and other re-
other health-care professionals continue to searchers to discover and establish useful ways
explore cultures and their care needs and prac- to provide quality care practices. Active partic-
tices worldwide. Transcultural nursing con- ipatory involvement with clients is essential to
cepts, principles, theory, and findings must arrive at culturally congruent care with one or
become fully incorporated into professional all three care modes in order to meet clients’
areas of teaching, practice, consultation, and care needs in their particular environmental
research. When this occurs, one can anticipate contexts. The use of these modes in nursing
true transcultural health practices and con- care is one of the most creative and rewarding
comitant benefits. Unquestionably, the theory features of transcultural and general nursing
will continue to grow in relevance and use as practice with clients of diverse cultures. Using
our world becomes more intensely multicul- Leininger’s care modes in clinical practice
tural. Nurses and other health professionals shows respect to clients’ beliefs, values, and
are expected to provide culturally congruent expressions and establishes a partnership be-
care to people of diverse cultures. The theory, tween health-care providers and clients to en-
along with many transcultural nursing con- sure safe, beneficent, and culturally congruent
cepts, principles, and research findings, will care (McFarland & Eipperle, 2008; Eipperle,
continue to prove indispensable. 2015).
It is most important (and a shift in nursing)
to carefully focus on the holistic dimensions, as
Applications of the Theory depicted in the Sunrise Enabler, to arrive at
The purpose of this part of the chapter is to therapeutic culture care practices. All the factors
present the implications for nursing practice of
the CCT and related ethnonursing research 1For additional information about the Ethnonursing
findings. Many nursing theories are rather ab- Research Method, see the bonus chapter content available
stract and do not focus on how practicing at http://davisplus.fadavis.com.
7991_Ch17_291-310 12/08/19 5:21 PM Page 305
in the Sunrise Enabler must be considered to protection (gender related); touching; and com-
arrive at culturally congruent care. These include fort measures (Leininger, 2006b; McFarland,
worldview; technological, religious, kinship, 2002). These care constructs are the most criti-
political–legal, economic, biological factors and cal and important universal or common findings
educational factors; cultural values and lifeways; to consider in nursing practice, but care diver-
environmental context, language, and ethnohis- sities will also be found and must be considered.
tory; and generic (folk) and professional care The ways in which culture care is applied and
practices (Leininger, 2002, 2006a; McFarland used in specific cultures will reflect both simi-
& Wehbe-Alamah, 2018). Care generated larities and differences among and within differ-
from the CCT will become safe, congruent, ent cultures.
meaningful, and beneficial to clients only when Next, an ethnonursing study is reviewed
the nurse in clinical practice becomes fully aware with focus on the findings and the implications
of and explicitly uses knowledge generated from for nursing practice.
the theory and ethnonursing method, whether
in a community, home, or institutional context. Culture Care of Traditional Syrian
The CCT, used with the ethnonursing method, Muslims in the Midwestern
is a powerful means for exploring new directions United States
and practices in nursing. Incorporating culture- The Theory of Culture Care Diversity and
specific care into client care is essential to Universality and the Ethnonursing Research
the practice of transcultural professional care. Method were used to guide a study of the cul-
Culture-specific care is the safe means to ensure ture care of traditional Syrian Muslims in the
culturally based holistic care that fits the client’s Midwestern United States (Wehbe-Alamah,
culture—a major challenge for nurses and other 2008b, 2011, 2015). The domain of inquiry
health-care professionals who practice and pro- for this ethnonursing study was the generic
vide services in all health-care settings. and the professional care meanings, beliefs, and
practices related to health and illness of tradi-
The Use of Culture Care Research tional Syrian Muslims living in several urban
Findings communities in the Midwestern United States.
Over the past six decades, Dr. Leininger and The purpose of this study was to discover, de-
other research colleagues have used the CCT scribe, and analyze the effect of worldview, cul-
and the ethnonursing method to focus on tural context, and technological, religious,
the care meanings and experiences of 100 political, educational, and economic factors on
cultures (Leininger, 2002). They discovered the traditional Syrian Muslims’ generic and
185 care constructs in diverse cultures be- professional care meanings, beliefs, and prac-
tween 1960 and 2016 (Leininger, 1998a, tices. The goal was to provide practicing nurses
1998b; McFarland & Wehbe-Alamah, 2018). and other health-care providers with knowledge
Newest care constructs include collaborative that can be turned into care actions and deci-
care, collective care, father protective care, sions that facilitate the provision of culturally
mentoring and co-mentoring, herbs as care, congruent care to traditional Syrian Muslims
community as care, and praying to/for as care living in similar contexts (Wehbe-Alamah,
(Leininger, 2015a; McFarland & Wehbe- 2011, 2015).
Alamah, 2018). Leininger listed the 11 most Findings revealed that the worldview of
dominant constructs of care in priority rank- the traditional Syrian Muslims in this study
ing, with the most universal or frequently were deeply embedded in the Islamic religion
discovered first: respect for/about, concern and the Syrian culture. Life was viewed as a
for/about; attention to (details)/in anticipa- test from God and a journey in which one
tion of; helping–assisting or facilitative acts; must attempt to do as many good deeds as
active helping; presence (being physically possible and to behave in a righteous way
there); understanding (beliefs, values, life- whether conducting business, taking care of
ways, and environmental); connectedness; housework, or engaging in any other regular
7991_Ch17_291-310 12/08/19 5:21 PM Page 306
daily activity. Kinship and familial relation- Caring can additionally be exemplified by
ships were treasured. Socializing with family withholding a diagnosis and/or prognosis
members and friends was considered an im- from a patient, especially if an impending
portant aspect of the Syrian lifeway. Visita- death was expected, and by burying the dead
tions and telephone conversations and Friday within 24 hours of their passing. Caring at-
prayer congregations were major social activ- tributes of nurses were identified as smiling,
ities. In traditional Syrian Muslim society, responding quickly to the needs of sick pa-
the man typically assumed the role of the tients, loving the nursing profession and role,
breadwinner, whereas the woman took on and respecting the patient’s culture (Wehbe-
other responsibilities, such as managing the Alamah, 2008b, 2015).
household and raising the children (Wehbe- A plethora of generic or folk practices were
Alamah, 2008b); however, for many immi- discovered and included some that are bene-
grants, gender-specific roles were often ficial to health and others with potentially
ignored out of need or desire for change. harmful ramifications. One such example is
Some of the discovered traditional cul- the consumption of raw liver, which is rich in
tural beliefs and practices included modesty, iron and is used to treat iron deficiency ane-
generous hospitality, segregation of men and mia. Another example is treating head lice by
women during social events such as wedding pouring gasoline over the scalp and massag-
parties and dinner invitations, wearing of a ing it into the hair. Folk practices that are
coat or jilbab over clothes for women when beneficial to health included eating in mod-
in public, caring for older family members eration, exercising, and taking vitamin C
within the home setting, and visiting, pray- when treating a cold (Wehbe-Alamah, 2008b,
ing for, and cooking for the sick. Normal 2015).
everyday actions were considered by many Such information can be turned into cultur-
informants as acts of worship. Engaging in ally congruent decisions and actions that can af-
religious practices such as prayer and Qur’an fect clinical practice through the application of
recitation or memorization was reported as a Leininger’s culture care modes. Accordingly,
source of physical, spiritual, emotional, and nurses and other health-care providers can pre-
mental support by numerous informants. Re- serve and/or maintain the cultural beliefs, ex-
ligious beliefs were determined to play an pressions, and practices of the traditional Syrian
important role in a person’s decision making Muslims in the community studied by respect-
involving abortion, sterilization, autopsy, ing the need for modesty and assigning same-
organ donation, birth control, and other sex health-care providers whenever possible. The
significant health issues (Wehbe-Alamah, cultural belief and practice of visiting the sick can
2008a, 2015). be accommodated by encouraging a large num-
Caring was described as being considerate of ber of visitors within the hospital setting with
other people’s feelings and respecting their be- the negotiation of having only a few visitors in
liefs. Empathy, sympathy, sensitivity, unselfish- the patient’s room at a time. The harmful folk
ness, and understanding were other qualities practices of using gasoline to treat head lice and
used to describe caring. Caring can be expressed consuming raw liver to treat anemia can be
by checking on others, being available to them, repatterned and/or restructured through educa-
offering them help, cooking healthy food, and tion of ramifications and discussion/provision of
keeping a clean body and a hygienic environment. healthier alternatives.
7991_Ch17_291-310 12/08/19 5:21 PM Page 307
Practice Exemplar
A Middle Eastern patient in labor identified and gelatin-encapsulated medications
as Mrs. Sarah Islam has just been admitted contain gelatin and should be avoided.
to the maternity floor. She is accompanied ■ The Athan or call to prayer is an important
by her husband and is dressed in loose cloth- birth ritual and needs to be whispered by the
ing that covers all of her body except for her father or other male figure in the newborn’s
face and hands. She identifies with the Mus- ear after birth. The couple requests that the
lim faith and wears a head cover, also known newborn be handed to the father as soon as
as hijab. Her husband requests that only fe- possible after birth to facilitate this practice.
male health-care providers be assigned to his ■ Visitation by family members and friends
wife. The nurse provides culturally congruent is to be expected following birth. The
care to this family using Leininger’s Culture couple informs the nurse that they expect
Care Theory. at least 30 visitors.
According to this theory, the worldview ■ Smoking the water pipe is a common cul-
of every human being is affected by cultural tural practice and is often carried out in
and social structural dimensions, including the presence of children. Mr. Islam
but not limited to cultural values, beliefs, smokes the water pipe twice a day.
and lifeways, and kinship, social, and reli-
Having identified important cultural and
gious factors. Therefore, professional nurs-
religious values, practices, needs, and prohibi-
ing care must incorporate an understanding
tions, the nurse proceeds to develop a cultur-
of these beliefs and practices. As a result, the
ally congruent plan of care using Leininger’s
nurse proceeds by conducting a cultural as-
culture care modes:
sessment to identify important needs and
prohibitions that need to be addressed in the Culture care preservation and/or maintenance:
plan of care. The nurse begins by explaining ■ The nurse includes a note in the elec-
that she would like to ask questions to learn tronic health record about identified
about how to best care for the client and her cultural and religious values, prac-
family. The cultural assessment reveals the tices, needs, and prohibitions. This
following: will assist with continuity of culturally
congruent care.
■ Modesty and privacy are important ■ The nurse is female; therefore, she can
values to Mrs. and Mr. Islam and
care for Mrs. Islam.
should be preserved whenever possible, ■ The nurse places a sign at Mrs. Islam’s
according to cultural and religious
door that reads: “No males allowed

teachings. The couple explains that
without permission.”
this can be achieved by assigning ■ The obstetrician and all nursing staff
same-sex health-care professionals and
attending the birth are informed about
by preventing male individuals from
the important practice of handing the
entering the patient’s room without
newborn to the father within minutes
first obtaining permission to do so or
of birth. The father recites the Athan
giving Mrs. Islam time to cover herself
in the baby’s ears.
in accordance with the teachings of
Culture care accommodation and/or
her religion.
negotiation:
■ Pork-derived products, including gelatin, ■ The nurse arranges for kitchen staff
are prohibited in Islam and therefore
to provide vegetarian Jell-O versus
should be excluded from diet and med-
animal-derived Jell-O.
ications. The couple explains that Jell-O
(continued)
7991_Ch17_291-310 12/08/19 5:21 PM Page 308

■ The nurse arranges for medications to inhalation implications to the new-
be ordered or dispensed in tablet born. She advises the discontinuation
rather than gelatin-encapsulated form. of this practice. (Alternatively, the
■ The nurse negotiates with the family nurse negotiates with Mr. Islam to
to have visitors come at different only smoke outdoors and cut down to
times, wait in the waiting room, once a day.)
and visit in numbers of two or
Upon discharge, Mr. and Mrs. Islam thank
three at a time.
their nurse for providing them with the best
Culture care restructuring and/or repatterning:
■ The nurse educates the client and her
care they have ever received in a Western
health-care setting.
husband about dangers associated
with smoking and secondhand smoke
Summary
The purpose of the CCT and the ethnonursing cultures (Leininger & McFarland, 2002;
method is to discover culture care knowledge McFarland et al., 2011; McFarland & Wehbe-
and to combine generic and professional care. Alamah, 2018).
The goal is to provide culturally congruent The Theory of Culture Care Diversity and
nursing care using the three modes of nursing Universality is one of the most comprehensive
decisions and actions that are meaningful, safe, yet practical theories to advance transcultural
and beneficial to people of similar and diverse and general nursing knowledge with concomi-
cultures worldwide (Leininger, 1991b, 1995, tant ways for practicing nurses to establish or
2006a; McFarland & Wehbe-Alamah, 2015b, improve care to people. Nursing students and
2018). The clinical use of the three care modes practicing nurses have remained the strongest
(culture care preservation and/or maintenance; advocates of the CCT (Leininger, 2002).
culture care accommodation and/or negotia- The theory focuses on a long-neglected area in
tion; and culture care repatterning and/or nursing practice—culture care—that is most
restructuring) by nurses to guide nursing judg- relevant to our multicultural world.
ments, decisions, and actions is essential to The Theory of Culture Care Diversity and
providing culturally congruent care that is ben- Universality is depicted in the Sunrise Enabler
eficial, satisfying, and meaningful to the people as a rising sun. This visual metaphor is partic-
nurses serve. The study presented here sub- ularly apt. The future of the CCT shines
stantiated that the three modes are care cen- brightly indeed because it is holistic and com-
tered and are based on the use of generic care prehensive, and it facilitates discovering care
(emic) knowledge along with professional care related to diverse and similar cultures, contexts,
(etic) knowledge obtained from research using and ages of people in familiar and naturalistic
the CCT along with the ethnonursing ways. The theory is useful to nurses and nurs-
method. More in-depth culture care findings, ing, as well as to professionals in other disci-
along with the use of the three modes, can be plines such as physical, occupational, and
found in the Journal of Transcultural Nursing speech therapy; medicine; social work; and
(1989–present), and in the numerous books pharmacy. Health-care practitioners in other
and articles written by Leininger and re- disciplines are beginning to use this theory be-
searchers using her theory and method. Nurses cause they also need to become knowledgeable
in clinical practice can refer to research studies about and sensitive and responsible to people
and doctoral dissertations conceptualized of diverse cultures who need care (Leininger,
within the CCT for additional detailed nursing 2002; McFarland, 2011; Wehbe-Alamah &
implications for individuals from diverse Fry, 2014).
7991_Ch17_291-310 12/08/19 5:21 PM Page 309
Questions for Reflection ■ Why did Leininger use the terms nursing
decisions and nursing actions instead of
and Discussion nursing interventions?
■ Provide examples of how a nurse might
choose to apply each of the cultural care
modes.
■ How can the Sunrise Enabler model
assist nurses to provide culturally
congruent care?
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7991_Ch18_311-332 12/08/19 5:20 PM Page 311
Jean Watson’s Theory

CHAPTER
18
of Unitary Caring Science
and Theory of Human
Caring
Jean Watson
Dr. Jean Watson is distinguished professor
emerita and dean of nursing emerita at the
University of Colorado, Denver, where she
served for more than 30 years and held an en-
Practice Exemplar written by Chris Griffin
dowed Chair in Caring Science for more than
Summary
16 years. She is founder of the original Cen-
ter for Human Caring at the University of
Colorado Health Sciences, is a Living Legend
in the American Academy of Nursing, and
served as president of the National League for
Nursing. Dr. Watson founded and directs the
nonprofit Watson Caring Science Institute,
dedicated to furthering the work of caring,
science, and heart-centered Caritas Nursing,
restoring caring and love for nurses’ and
health-care clinicians’ healing practices for self
and others.
Watson earned undergraduate and graduate
degrees in nursing and psychiatric–mental
health nursing and holds a doctorate in edu-
cational psychology and counseling from the
University of Colorado at Boulder. She is a
widely published author and is the recipient of
numerous awards and honors, including an in-
ternational Kellogg Fellowship in Australia; a

Fulbright Research Award in Sweden; and
14 honorary doctoral degrees, including 11
from international universities in Sweden, the
United Kingdom, Spain, Japan, Canada, Peru,
Colombia, and Turkey.
Dr. Watson’s original book on caring was
published in 1979. Her second book, Nursing:
Human Science and Human Care (1985), was
written while on sabbatical in Australia and re-
flects the metaphysical and spiritual evolution
of her thinking. A third book, Postmodern
Nursing and Beyond (1999), moves beyond
theory to reflect the ontological foundation
of nursing as an overarching framework for
311
7991_Ch18_311-332 12/08/19 5:20 PM Page 312
transforming caring and healing practices in Advances in Caritas Literacy (Lee, Palmeiri, &
education and clinical care (Watson, 1999). Watson, 2017); and Watson’s Caring in the
Additional empirical and clinical caring re- Digital World: A Guide for Caring when Inter-
search foci developments include the first and acting, Teaching, and Learning in Cyberspace
second editions of the book on caring instru- (Sitzman & Watson, 2016).
ments (an American Nurses Association [ANA] As Founder/Director of the Watson Caring
book of the year), Assessing and Measuring Science Institute (WCSI), Watson guides
Caring in Nursing and Health Sciences (2002, and creates/develops educational, clinical, and
2008b; now in production for the third edition administrative–leadership and research models
with Dr. Kathleen Sitzman as first editor and that seek to sustain and deepen authentic
Watson as second editor). This work offers a caring–healing practices for self and other,
critique and collation of more than 20 instru- transforming practitioners and patients alike.
ments for assessing and measuring caring. The Caring Science model, integrating Caritas
Watson’s (2005) Caring Science as Sacred Sci- with the science of the heart in collaboration
ence makes a case for a deep moral, ethical, and with the Institute of HeartMath (www.heart-
spirit-filled foundation for caring science and Math.com, HeartMath.org), deepens intelli-
healing based on infinite love and an expand- gent heart-centered caring and new self-caring
ing cosmology. This work draws on E. Levinas’ practices that translate into CaritasHeart(tm)
philosophy posting “Ethic of Belonging” as the practice methodologies. Most of Watson’s
first principle of science, uncovering an evolved current and future activities are devoted to in-
worldview of science, beyond Western reduc- ternational global programs, developing new
tionist science. Watson’s (2008a) theoretical projects and associates of Caring Science and
work, Nursing: The Philosophy and Science of WCSI worldwide, including Japan, South
Caring, Revised Edition, revisits and reworks Africa, China, Italy, Switzerland, Peru, Chile,
her first book, Nursing: The Philosophy and Sci- and Jordan.
ence of Caring (1979, reprinted 1985), bringing All of Watson’s latest publications, such as
the original publication up to date to include innovative educational partnerships, global ac-
all the changes made during the past 30 years. tivities, new programs, global and domestic
This latest update introduces Caritas nursing speaking calendar, and directions and develop-
as the culmination of a caring science founda- ments, continue to evolve, including a Summer
tion for professional nursing. Institute Postdoctoral/Postgraduate Watson
A coauthored educational book, Creating Caring Science Scholar program and the na-
a Caring Science Curriculum: Emancipatory tionally certified WCSI Caritas Coach Edu-
Pedagogies by Marcia Hills and Watson, was cational Program (CCEP). The CCEP provides
published in 2011 (extending the original caring science scholars and experts in human
Bevis and Watson: Toward a Caring Curricu- caring for self, for others, and for clinical set-
lum [1989]). This was followed by two addi- tings with the purpose of transforming self and
tional coauthored research and measurement system through deep engagement in translat-
books, Measuring Caritas: International Re- ing Caritas into personal and professional
search on Caritas as Healing (Nelson & Watson, life. All of these activities, including teaching
2011) and Caring Science, Mindful Practice: and meditation videos, can be found at www.
Implementing Watson’s Human Caring Theory watsoncaringscience.org.
(Sitzman & Watson, 2014). Other works
more recently completed with Watson include
Caring Science, Mindful Practice: Implementing Overview of the Theory
Watson’s Human Caring Theory (Sitzman & The Theory of Human Caring was developed
Watson, 2018); Unitary Caring Science: The between 1975 and 1979 while I was teaching
Philosophy and Praxis of Nursing (Watson, at the University of Colorado. It was motivated
2018); Handbook of Caring Science (Rosa, by the consciousness of the system at that time,
Horton-Deutsch, & Watson, 2018); Global which was adhering more and more to medical
7991_Ch18_311-332 12/08/19 5:20 PM Page 313
CHAPTER 18 ■ Jean Watson’s Theory of Unitary Caring Science and Theory of Human Caring 313
science as framework for its science scholar- explicit ontology of unity and relationships,
ship, without a meaningful philosophical foun- which underlie nursing as a distinct disci-
dation consistent with the discipline of nursing. pline and profession; this ontology is in sharp
I was asking myself, Why is nursing located contrast to the dominant Western scientific
within a major research university, within an ontology of separation, void of a meaningful
academic health science center, and not ques- philosophical foundation for its science.
tioning or pursuing its distinct scholarship of My most current work makes more explicit
nursing as a distinct discipline and profession how the Theory of Human Caring is located
in its own right, separate from, but comple- within a unitary caring science worldview,
mentary to, medical science? At that time, and uniting quantum thinking of Rogerian science
perhaps still today, we continue to witness with caring science. This latest turn in my the-
nursing advancing nursing qua medicine, detour- ory goes beyond the dominant physical world-
ing the scholarship of the discipline, that is, view and opens to subjective, intersubjective,
nursing qua nursing—human caring, healing, nonphysical, metaphysical, even mystical, mys-
and health. terious, and miracles; nonphysical spirit-filled
The first book emerged from my own views phenomena, which cannot be explained in the
of nursing, my background in psychiatric– conventional medical science mindset. It in-
mental health nursing, combined with and invites inner meanings, underlying inner healing
formed by my doctoral studies in educational, processes and the lifeworld of the person’s ex-
clinical, and social psychology. It was my initial perience. For a more in-depth overview of this
attempt to provide a philosophical–ethical thinking, see Watson and Smith (2002).
foundation to nursing’s science, distinct from, The original language in the Theory of Car-
but complementary to, medical science. A fur- ing (Watson, 1979) integrated both arts and
ther attempt was to bring meaning and focus humanities as foundational to caring–healing
to nursing as an emerging discipline and dis- arts and caring processes; all further develop-
tinct health profession with its own unique val- ment of the theory has focused on healing arts
ues, knowledge, and worldview, practices; to and caring healing modalities as being as in-
advance nursing’s moral covenant with hu- trinsic to nursing as caring science practice.
manity and mission to society; and to sustain The human caring processes were originally
global human caring, healing, and health for named the “10 carative factors,” which com-
all. The work was further influenced by my in- plemented conventional medicine but stood in
volvement with an integrated academic nurs- stark contrast to “curative factors.” At the same
ing curriculum and efforts to identify common time, this emerging philosophy and Theory of
core meanings and values and bring focus to Human Caring sought to balance the cure ori-
the discipline of nursing that transcended set- entation of medicine with human caring as
tings, populations, specialty areas, and subspe- essential to health and healing—thus giving
cialty areas. In other words, to shift focus from nursing its unique disciplinary, scientific,
medical–clinical technological–biological phe- philosophical/ethical, and professional stand-
nomena to humanity and inner experiences of ing with itself and its public.
health/illness/healing and the subjective needs Nursing as a discipline has historically been
of other, while staying within the subjective ontologically insecure in not making explicit
lifeworld of patients/families/society. its relational ontology, seemingly having to
From my continuously emerging perspec- justify its worldview within the separatist on-
tive, I make explicit that nursing’s values, ethic, tology of medicine, leading to further despair.
philosophy, knowledge, worldview, and prac- Or, on the other hand, engaged in existential
tices of the discipline of nursing with regard to struggles and attempts to mature within the
human caring require a language order, struc- dominant medical science paradigm, ignoring
ture, and clarity of its ethos, ethic, and orien- its major contribution and raison d’être for so-
tation to humankind. The philosophical and ciety. Watson’s early work has continued to
scientific foundation of nursing requires an evolve dynamically from the original writings
7991_Ch18_311-332 12/08/19 5:20 PM Page 314
of 1979, 1981, 1985, and the 1990s, the 2000s, ■ Advanced caring–healing modalities/
and into 2018 and beyond, to a more updated nursing healing arts as a future model for
view of 10 Caritas Processes®, to caring sci- advanced practice/praxis of mature nursing
ence as sacred science, and to a unitary caring qua nursing (consciously guided by disci-
science global consciousness for leadership. plinary knowledge and nursing ethical–
Watson’s work now makes connections be- ontological theoretical–philosophical
tween human caring, healing, and even peace orientation)
in our world, with nurses as caritas–communitas
peacemakers when they are practicing human Caring Science as Sacred Science
caring for self and others. This shift moves to The emergence of the work makes more ex-
more explicit metaphysical/spiritual focus on plicit the development of unitary caring science
the “transpersonal caring moment,” expanding as a deep moral–ethical context of infinite, cos-
postmodern critiques, to metaphysical to mic love, to which we all “belong”—as sacred
openness to infinity—from theory to a unitary circle of life/death. As soon as one is more
ontological paradigm for unitary caring sci- explicit about placing humanity and caring
ence; to Ethic of Belonging as first principle of within a unitary science model, it automatically
unitary caring science. The Ethic of Belonging forces a relational unitary quantum worldview
informs the theory and new concepts of phi- and makes explicit caring as a moral ideal to
losophy and praxis. A broad, evolving unitary sustain humanity across time and space. This
caring science worldview underlies the fluid worldview is one of the gifts and the raison
evolution of the theory and the philosophical– d’être of nursing in the world; however, the
ethical scientific foundation for this work. irony is that this unitary ontological discipli-
nary worldview has yet to be fully recognized
Major Conceptual Elements and made explicit within nursing itself. Nev-
ertheless, a unitary caring-science orientation
The major conceptual elements of the original
is necessary for the survival of nursing, as well
(and emergent) theory are as follows:
as humanity and Mother Earth at this cross-
■ Ten carative factors (transposed to roads in human evolution.
10 Caritas Processes®) This unitary worldview takes nursing and
■ Transpersonal caring moment (which healing work beyond conventional thinking.
resides within a unitary field) The latest orientation of unitary caring science
■ Unitary Caring consciousness/intentionality and the evolving theory is located within and
and energetic heart-center presence as an realigns nursing with ageless wisdom traditions
ontology of Being/Becoming and perennial philosophy to underpin the dis-
■ Caring–healing energetic modalities cipline of nursing, while transcending nursing.
■ CaritasHeart modalities—influenced by Unitary caring science allows nursing’s caring–

Heart science (HeartMath.org) healing core to become both discipline specific
and transdisciplinary. Thus, nursing’s timeless,
Other dynamic aspects of the theory that
ancient, enduring, and most noble contributions
have emerged or are emerging as more explicit
come of age through a unitary caring-science
components include the following:
orientation—scientifically, philosophically, aes-
■ Expanded views of self and person (uni- thetically, ethically, and practically.
tary oneness; embodied spirit)
■ Caring–healing evolving human con- Ten Carative Factors
sciousness and energetic heart-to-heart The original work (Watson, 1979) was organ-
connection ized around 10 carative factors as a framework
■ Human–environmental–infinite field of a for providing a format and focus for nursing
transpersonal caring moment phenomena. Although carative factors is still
■ Unitary oneness worldview: unbroken the current terminology for the “core” of nurs-
wholeness and connectedness of all ing, providing a structure for the initial work,
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the term factor is too stagnant for my sensibil- Such thinking calls for a sense of reverence
ities today. In the 1990s I extended and trans- and sacredness with regard to sacred circle of
posed the concept of carative to caritas and all of life and all living things. It incorporates
Caritas Processes® as consistent with a more art, humanities, spirituality, and science, as
fluid and contemporary movement of these they are also being redefined, acknowledging
ideas and with my own evolving consciousness. a convergence of ancient wisdom traditions
Caritas comes from the Latin word mean- and latest quantum science thinking—uniting
ing “to cherish and appreciate, giving special East and West, North and South—one world,
attention to, or loving.” It connotes something one heart, one humanity. As we enter into the
that is very fine; indeed, it is precious. The Transpersonal Caring Theory and philosophy,
word caritas is also closely related to the origi- we simultaneously are challenged to relocate
nal word carative from my 1979 book. Now ourselves in these emerging ideas and to ques-
caritas evokes and makes connections, without tion for ourselves how the theory speaks to us.
hesitation, between and among Caritas, Love– This invites us into a new relationship with
Healing–acknowledging the Energy of Love, ourselves and our ideas about humanity, life,
as perhaps the greatest source of all healing. nursing, and theory.
This usage allows love and caring to come to-
gether for a new form of deep, transpersonal Original Carative Factors
caring. This relationship between love and car-
The original carative factors served as a guide
ing connotes inner healing for self and others,
to what was referred to as the “core of nursing”
extending to nature and the larger universe, un-
in contrast to nursing’s “trim.” Core pointed to
folding and evolving within a cosmology that is
those aspects of nursing that potentiate thera-
both metaphysical and transcendent with the
peutic healing processes and relationships—
coevolving human in the universe. This emerg-
they affect the one caring and the one being
ing model of transpersonal caring moves from
cared for. Further, the basic core was grounded
carative to caritas. This integrative expanded
in what I referred to as the philosophy, science,
perspective is postmodern in that it critiques
and art of caring. Carative is that deeper and
and transcends conventional industrial, static
larger dimension of nursing that goes be-
models of nursing and an outdated worldview,
yond the “trim” of changing times, setting,
while simultaneously evoking both the past and
procedures, functional tasks, specialized focus
the future. For example, the future of nursing is
around disease, and treatment and technology.
tied to Nightingale’s sense of “calling,” guided
Although the “trim” is important and not ex-
by a deep sense of commitment to humanity, a
pendable, the point is that nursing cannot be
spiritual practice within a covenantal ethic of
defined around its trim and what it does in a
human service, cherishing our phenomena, our
given setting and at a given point in time. Nor

subject matter, and those we serve.
can nursing’s trim define and clarify its larger
It is when we include caring and love in our
professional ethic and mission to society—its
work and in our life that we discover and af-
raison d’être for the public. That is where nurs-
firm that nursing, like teaching, is more than
ing theory comes into play, and Transpersonal
just a job; it is also a life-giving and life-receiving
Caring Theory offers another way that both
career for a lifetime of growth and learning.
differs from and complements that which has
Such maturity and integration of past with
come to be known as “modern” nursing and
present and future now require transforming
conventional medical–nursing frameworks.
self and those we serve, including our institu-
The 10 carative factors included in the orig-
tions and our profession. As we more publicly
inal work are the following (Watson, 1979,
and professionally assert this distinct discipli-
1985):
nary position for our theories, our ethics, and
our practices—even for our science—we locate 1. Formation of a humanistic–altruistic
ourselves and our profession and discipline system of values
within a new, emerging cosmology. 2. Instillation of faith–hope
7991_Ch18_311-332 12/08/19 5:20 PM Page 316
3. Cultivation of sensitivity to one’s self and 3. Cultivation of sensitivity to one’s self and
to others to others becomes cultivation of one’s own
4. Development of a helping–trusting, spiritual practices and transpersonal self,
human caring relationship going beyond ego self, opening to others
5. Promotion and acceptance of the expres- with sensitivity and compassion.
sion of positive and negative feelings 4. Development of a helping–trusting, human
6. Systematic use of a scientific problem- caring relationship becomes developing and
solving caring process sustaining a helping–trusting, authentic
7. Promotion of interpersonal teaching– caring relationship.
learning 5. Promotion and acceptance of the expres-
8. Provision for a supportive, protective, sion of positive and negative feelings be-
and/or corrective mental, physical, comes being present to, and supportive of,
societal, and spiritual environment the expression of positive and negative
9. Assistance with gratification of human needs feelings as a connection with deeper spirit
10. Allowance for existential–phenomenological of self and the one being cared for (authen-
forces tically listening to another’s story).
6. Systematic use of a scientific problem-solving
Although some of the basic tenets of the
caring process becomes creative use of self
original carative factors still hold and indeed are
and all ways of knowing as part of the caring
used as the basis for some theory-guided practice
process, to engage in the artistry of caring-
models and research, what I am proposing here,
healing practices (creative solution-seeking
as part of my evolution and the evolution of
becomes caritas coach role). This process
these ideas and the theory itself, is to transpose
invites an expanded epistemology, whereby
the carative factors into “Caritas Processes®.”
we honor all ways of knowing, beyond
From Carative to Caritas Processes®— empirical-technical-objective mindsets.
Universals of Human Caring 7. Promotion of interpersonal teaching-
learning becomes transpersonal genuine
It is important to acknowledge that in this post-
teaching-learning experience that attends
modern era of science and society, it has been
to unity of being and meaning, attempting
acknowledged that “if you do not have your own
to stay within others’ frames of reference.
language, you do not exist.” Language brings a
8. Provision for a supportive, protective,
phenomenon into being. The language of the
and/or corrective mental, physical, societal,
10 Caritas Processes® has been validated world-
and spiritual environment becomes creating
wide as universals of human caring. For exam-
a healing environment at all levels (a physi-
ple, I was in 18 different countries in 2016
cal and nonphysical, subtle environment of
giving voice and language to nursing’s caring

energy and consciousness, whereby whole-
phenomenon, which otherwise remains invisi-
ness, beauty, comfort, dignity, and peace
ble to nurses, systems, and society.
are potentiated). This view honors the Car-
I now offer the following translation and
itas Consciousness person as the environ-
language of the original carative factors into
ment, whereby the person’s energetic
universals of human caring, via the 10 Caritas
higher vibration consciousness affects the
Processes®:
whole field.
1. Formation of a humanistic–altruistic sys- 9. Assistance with gratification of human
tem of values becomes the practice of loving needs becomes assisting with basic needs as
kindness and equanimity within the con- a sacred act; with an intentional caring
text of caring consciousness. consciousness, administering “human care
2. Instillation of faith–hope becomes being au- essentials,” which potentiate wholeness
thentically present and enabling and sus- and unity of being in all aspects of care;
taining the deep belief system and subjective sacred acts of basic care; touching embod-
lifeworld of self and one being cared for. ied spirit.
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10. Allowance for existential–phenomenolog- ethic are embodied in unitary caring science
ical forces becomes opening and attending as the disciplinary ground for nursing, now
to spiritual-mysterious and existential di- and in the future. The advancement of nurs-
mensions of one’s own life-death; soul ing theory, which includes both ideals and
care for self and the one being cared for. practical guidance, is increasingly evident as
“Allowing for miracles.” nursing makes its major contribution to
health care and matures as a distinct caring–
What differs in the caritas process frame- healing profession—one that balances and com-
work is that a decidedly spiritual- metaphysical plements conventional, medical–institutional
dimension and an overt evocation of the en- practices and processes. Nevertheless, much
ergy of love and caring merged for a new uni- work remains to be done.
tary cosmology for this millennium. Such a Thus, I consider my work increasingly a
perspective ironically places nursing within its philosophical, ethical, intellectual, and theoret-
most mature framework and is consistent with ical blueprint for nursing’s evolving disciplinary/
the Nightingale model of nursing—yet to be professional matrix, rather than a specific the-
actualized but awaiting its evolution. This ory per se. Nevertheless, others interact with
direction, while embedded in unitary caring the original work at levels of concreteness or
science and caritas transpersonal theoretical abstractness. If the theory is “read” at the Car-
perspective, goes beyond theory per se, and itas Processes® structural level, it can be inter-
becomes a converging paradigm for nursing’s preted as a middle-range theory. If the theory
future. is “read” at the transpersonal unitary caring
Consistent with the wisdom and vision of science/transpersonal caring consciousness
Florence Nightingale, nursing is a lifetime jour- level, the theory can be interpreted as a grand
ney of caring and healing, seeking to understand theory located within the unitary–transforma-
and preserve the wholeness of human existence tive context—an evolving quantum-universe
across time and space and national/geographical, worldview.
cultural, economic, and religious boundaries The Transpersonal Human Caring Theory
and borders—offering heart-centered, com- has been and increasingly is being used nation-
passionate, informed knowledgeable human ally and internationally. It serves as a guide and
caring to society and humankind. This timeless blueprint for educational curricula, clinical prac-
view of nursing transcends conventional tice models, scholarship within disciplinary–
minds and mindsets of illness, pathology, and philosophical inquiry, methods for research/
disease that are located in the physical body creative scholarship, and administrative caring
with curing as end goal, often at all costs. In science leadership, inviting new patterns of de-
nursing’s timeless model, caring, kindness, livery of caritas healing/health care.
love, and heart-centered compassionate serv-

ice to humankind are restored. The unifying Reading the Theory
focus and process is on connectedness with The “theory” can be “read” as a philosophy, an
self, other, nature, and God/the Life Force/ ethic, a paradigm, an expanded science model,
Source/the Absolute. This vision and wisdom or a theory. As noted, if read as a philosophy/
is being reignited today through a blend of old theory, it can be “read”/interpreted as a grand
and new values, ethics, and theories and uni- theory within the unitary–transformative/Ethic
tary, global scientific, ethical, and philosophi- of Belonging paradigm. This includes the
cal practices of human caring and healing. transpersonal, energetic-field level of caritas–
These caritas consciousness practices preserve universal love and evolving consciousness.
humanity, human dignity, and wholeness and It can be “read” as middle-range theory
are the very foundation of transformed think- when read at the caritas process level, which
ing and actions. provides the structure and language of the the-
Such a values-guided relational unitary ory, as both middle range and specific and
ontology and expanded epistemology and grand. Thus, the work moves between and
7991_Ch18_311-332 12/08/19 5:20 PM Page 318
among paradigms, depending on the reader However, the caring moment is most evi-
and focus of the scholarship. When used in dent within the transpersonal caritas energetic
clinical settings, the theory helps nurses to field model, in that one’s consciousness, inten-
frame their experiences around the Caritas tionality, energetic heart-centered presence
Processes® to sustain the caring-science focus, is radiating a field beyond the two people or
as well as developing language systems, includ- the situation, affecting the larger field. Thus,
ing computerized documentation systems, to nurses can become more aware, more awake,
document and study caring within a designated more conscious of manifesting/radiating a car-
language system (Rosenberg, 2006, p. 55). The itas field of love and healing for self and others,
middle-range focus is also congruent with clin- helping to transform self and system. For a
ical caring research projects, using the caring more comprehensive understanding of this
language of caritas and “caring moment,” work, see Nursing: The Philosophy and Science of
“transpersonal caring.” Indeed, many of the Caring (Watson, 2008a). Indeed, the latest re-
more formalized caring assessment tools are search based on the science of the heart has
based on the language of this structure. Several demonstrated that the heart-centered person
multisite research projects are now underway radiates love at a higher vibration of conscious-
using consistent caring assessment tools, such ness and is consistent with Rogers’ (1990) Sci-
as Duffy’s Caring Assessment Tool© (CAT; ence of Unitary Human Beings. This energetic
Duffy, Hoskins, & Seifert, 2007) and the vibration of Love, Compassion, Caring, For-
Nelson, Watson, and Inova Health Instrument giveness, and so on can be measured several
Caring Factor Survey (Persky, Nelson, Watson, feet beyond themselves, affecting the subtle
& Bent, 2008). The latest Watson Caritas Pa- environment of all. Moreover, this heart-
tient Score (Watson, 2008b contains different science research affirms that the heart is send-
versions for assessing caring for self, other, ing more messages to the brain, rather than the
leaders, and so on and is being used for edu- other way around. For more information, visit
cational and scholarly projects and multisite www.heartMath.com and www.heartMath.org.
clinical studies as an international research This work posits a unitary oneness world-
project. (For more information, go to www. view of connectedness of all; it embraces a
watsoncaringscience.org.) In addition, most of value’s explicit moral foundation and takes a
the current caring-science assessment tools may specific position with respect to the centrality
be found in Assessing and Measuring Caring in of human caring, “caritas,” and infinite univer-
Nursing and Health Sciences (Watson, 2008b), sal love as an ethic and ontological starting
and a new edition is in production with Sitzman point. It is also a critical starting point for
and Watson (2018) as the new authors. nursing’s existence, broad societal mission, and
the basis for further advancement, needed to
Heart-Centered Transpersonal sustain human caring–healing for humanity.

Caring Moment: Caritas Field Nevertheless, its use and evolution are depend-
Whether the “theory” is read at different lev- ent on “critical, creative, reflective practices
els, used as a language system for documen- that must be continuously questioned and cri-
tation, as a guide for professional nursing tiqued in order to remain dynamic, flexible,
practice models, as the focus of multisite or and endlessly self-revising and emergent”
individual clinical caring research, or as the- (Watson, 1996, p. 143).
oretical disciplinary scholarship, the essence
of the “Living Caritas Theory” is in the Transpersonal Caring Relationship
transpersonal caring moment. The caring The terms transpersonal and transpersonal caring
moment can be located within any caring oc- relationship are foundational to the work.
casion, as a concept within middle-range, Transpersonal conveys a concern for the inner
grand, or specific focus, including a moral/ lifeworld and subjective meaning of another
ethical philosophical focus for all areas of who is fully embodied. But the transpersonal
exploration. also energetically goes beyond the ego self and
7991_Ch18_311-332 12/08/19 5:20 PM Page 319
beyond the given moment, reaching to the Transpersonal caring competencies and
deeper connections to spirit and with the modalities are related to ontological develop-
broader universe. Thus, a transpersonal caring ment of the nurse’s human caring literacy and
relationship moves beyond ego self and radiates ways of being and becoming. Thus, “ontologi-
to spiritual, even cosmic, concerns and connec- cal caritas consciousness literacy,” beyond com-
tions that tap into healing possibilities and po- petencies, becomes critical for health/healing;
tentials. Transpersonal caring is immanent: fully “technological curing competencies” of the
physical and embodied physically, while also conventional Western science nursing–medicine
paradoxically transcendent, beyond physical self. model is now coming to an end.
Transpersonal caring seeks to connect with Within the model of transpersonal caring,
and embrace the spirit or soul of the other caritas consciousness becomes a foundational
through the processes of caring and healing ethical level for entry into this framework. The
and being in authentic relation in the mo- nurse attempts to enter into and stay within
ment. Transpersonal also opens to Source and the other’s frame of reference for connecting
seeks to align in right relation with Higher with the inner lifeworld of meaning and spirit
Source/Spirit for Healing. Such a transper- of the other. Together, they join in a mutual
sonal relationship is influenced by the caring search for meaning and wholeness of being
consciousness and intentionality and energetic and becoming, to potentiate comfort, pain con-
heart-centered presence of the nurse as she or trol, a sense of well-being, wholeness, healing,
he enters into the life space or phenomenal and even a spiritual transcendence of suffering.
field of another person and is able to detect The person is viewed as whole and complete,
the other person’s condition of being (at the regardless of illness or disease (Watson, 1996,
soul or spirit level). It implies a focus on the p. 153).
uniqueness of self and other and the unique-
ness of the moment, wherein the coming to- Assumptions of the Transpersonal
gether is mutual and reciprocal, each fully Caring Relationship
embodied in the moment, while paradoxically The nurse’s moral commitment, intentional-
capable of transcending the moment, open to ity, and caritas consciousness exist to protect,
Source and infinite new possibilities. This is enhance, promote, and potentiate human dig-
one reason, for example, why prayer is consid- nity, humanity, wholeness, health, and heal-
ered a caring–healing modality. ing, wherein a person creates or cocreates his
The transpersonal caritas consciousness or her own meaning for existence, healing,
nurse seeks to “see” the spirit-filled person be- wholeness, and living and dying. The general
hind the patient, behind the colleague, behind nursing goals are related to self-caring, self-
the disease or the diagnosis or the behavior or knowing, self-control, self-growth, and even
personality one may not even like, and connect self-healing.

with that spirit-filled individual who exists be- The nurse’s will and consciousness affirm
hind the illusion. This is heart-centered caritas the subjective–spiritual significance of the per-
practice guided by the very first caritas process: son within the sacred circle of life, while seek-
cultivation of loving kindness and equanimity ing to sustain caring in the midst of threat and
with self and other, allowing for development despair—biological, institutional, societal, or
of more caring, love, compassion, and authen- otherwise. This theory adheres to and honors
tic caring moments. an I–Thou relationship versus an I–It relation-
Transpersonal caring calls for an authentic- ship (Buber, 1923/1996).
ity of being and becoming, an ability to be The nurse seeks to recognize, accurately de-
present to self and others in a reflective frame. tect, and connect with the inner condition of
The transpersonal nurse has the ability to cen- spirit of another through authentic caritas (lov-
ter consciousness and intentionality on caring, ing) presencing and being centered in the
healing, and wholeness, beyond the physical, transpersonal caring moment. Actions, words,
rather than on disease, illness, and pathology. behaviors, cognition, body language, feelings,
7991_Ch18_311-332 12/08/19 5:20 PM Page 320
intuition, thought, senses, the energy field, To some degree, the necessary knowledge and
and so on—all contribute to the transpersonal consciousness can be gained through work
caring connection. The nurse’s ability to con- with other cultures and the study of the hu-
nect with another at this transpersonal spirit- manities (art, drama, literature, personal story,
to-spirit level is translated via presence, narratives of illness journeys) along with an ex-
silence, movements, gestures, facial expres- ploration of one’s own values, deep beliefs, re-
sions, procedures, information, intentional lationship with self and others, one’s spiritual
touch, sound, verbal expressions, and other growth, and evolving global consciousness of
scientific, technical, aesthetic, and human oneness of all of humanity/Planet/Mother
means of communication into nursing human Earth. Other facilitators include personal-
art/acts or intentional caring–healing modal- growth experiences such as psychotherapy,
ities. For example, nurses may be administer- transpersonal psychology, meditation, bioen-
ing very technical–medical procedures, but the ergetics, work, yoga, prayer, meditation, move-
nurse administers such with a caring–healing ment, dance, singing, storytelling, nature, and
consciousness, done with loving kindness and so one, along with multiple other models for
compassion. spiritual awakening. Continuous growth is on-
The caring–healing modalities within the going for developing and maturing within a
context of transpersonal caring/caritas con- transpersonal caritas model. The notion of
sciousness potentiate harmony, wholeness, and health professionals as wounded healers is
unity of being by releasing some of the dishar- acknowledged as part of the necessary growth
mony, the blocked energy that interferes with for awakening to heart-centered compassion
the natural healing processes and prevents per- called forth within this theory/philosophy.
son from being in right relation with Source/
Inner soul self. Transpersonal Caring Moment/Caring
As a result, the nurse helps another through Occasion
this process to access the healer within, in the A caring occasion occurs whenever the nurse
fullest sense of Nightingale’s view of nursing. and another come together with their unique
Healing is an inner process, not outer treat- life histories and phenomenal fields in a
ment process. Healing requires Yin energy of human-to-human moment/interaction. The
love and caring; medical–technology interven- coming together in a given moment becomes
tion is Yang energy. No human being can heal a focal point in space and time. It becomes
with Yang energy, making Caritas practices transcendent and transpersonal when a shared
more important than ever. Indeed, human car- spirit-to-spirit connection is experienced.
ing is critical to sustaining our humanity, per- The caritas nurse is awake to the fact that the
sonally and globally. actual caring occasion has a greater field of its
Ongoing personal–professional develop- own, in a given moment; the nurse’s energetic

ment and spiritual growth and personal spiri- presence and consciousness are affecting the
tual practice assist the nurse in entering into whole field. The process goes beyond itself
this deeper level of professional healing yet arises from aspects of itself that become
practice, allowing the nurse to awaken to part of the life history of each person, as well
the transpersonal, unitary oneness of the as part of a larger, more complex pattern of
world and to actualize more fully “ontological- life (Watson, 1985, p. 59; 1996, p. 157).
consciousness competencies” necessary for this A transpersonal caring moment involves an
level of advanced practice/praxis of nursing. action and a choice by both the nurse and the
Valuable teachers for this work include the other. The moment of coming together pres-
nurse’s own life history and previous experi- ents the two with the opportunity to decide
ences, which provide opportunities for focused how to be in the moment in the relationship—
studies, as the nurse has lived through or expe- what to do with, and in, the moment. If the
rienced various human conditions and has imag- caring moment is transpersonal, each feels a
ined others’ feelings in various circumstances. connection with the other at the spirit level;
7991_Ch18_311-332 12/08/19 5:20 PM Page 321
thus, the moment transcends time and space process is intersubjective with transcendent
and physicality, opening up new possibilities possibilities that go beyond the given caring
for healing and human connection at a deeper moment.
level than that of physical interaction. For ex-
ample: Because one person’s level of humanity Implications of the Unitary Caring
reflects on the other, Watson (1985) states: Model
The unitary caring science theory of Caritas
We learn from one another how to be human by can be considered a philosophical and moral/
identifying ourselves with others, finding their ethical foundation for professional nursing and
dilemmas in ourselves. What we all learn from it is part of the central focus for nursing at the
is self-knowledge. The self we learn about … is disciplinary level. Unitary caring science in-
every self. IT is universal—the human self. We cludes a call for integration and oneness of art,
learn to recognize ourselves in others … [it] humanities, spirituality, and sacred science.
keeps alive our common humanity and avoids re- It offers a framework that embraces whole
ducing self or other to the moral status of object. person/whole spirit/whole system/whole society
(pp. 59–60) for embracing old/new dimensions of healing/
health and wholeness.
Unitary Caring (Healing) I want to emphasize that it is possible to
Consciousness read, study, learn about, and even teach and re-
The dynamic of transpersonal caring (heal- search the caring theory. However, to truly
ing) within a transpersonal caring moment is “get it,” one has to experience it personally.
manifest in an energetic field of evolving con- The model is both an invitation and an oppor-
sciousness. The transpersonal dimensions of tunity to interact with the ideas, to experiment
a caring moment are affected by the nurse’s with and grow within the ethic, the conscious-
consciousness, presence, and intentionality, ness, the language, the philosophy, the science,
in the caring moment, which in turn affects and to live it out in one’s personal and profes-
the field of the whole. The role of conscious- sional lives.
ness with respect to a holographic view of sci- A new book, Unitary Caring Science: The
ence has been discussed in earlier writings Philosophy and Praxis of Nursing (Watson,
(Watson, 1992, p. 148) and includes the fol- 2018) focuses on elevating the paradigm of
lowing points: unitary caring science to the most mature
level of nursing’s disciplinary evolution. A
■ The whole caring–healing–loving con-
second focus is locating caritas processes
sciousness is contained within a single
within a theory and philosophy of praxis for
caring moment.
Unitary Caring Science. By extending caritas
■ The one caring and the one being cared

into a model of praxis–beyond conventional
for are interconnected; the caring-healing
practice, I draw upon the Greek (Aristotelian)
process is connected with the other
origin and meaning of praxis, which is tied
human(s) and with the higher energy of
to values and morality. Praxis, in this con-
the universe.
text, is “informed moral practice”—practice,
■ The caring–healing–loving consciousness
informed by timeless values, disciplinary
and presence of the nurse are communi-
knowledge, philosophical ethical worldview
cated to the one being cared for.
Caritas Consciousness, and nursing theory.
■ Caring–healing–loving consciousness
When one is guided by Unitary Caring Sci-
exists through and transcends time and
ence philosophy and praxis, one is practicing
space and can be dominant over physical
the most mature level of the discipline. In
dimensions.
this latest book, I integrate the Latin word
Within this context, it is acknowledged veritas, conveying universal human truths
that the process is relational and connected. It and values, with caritas, love and caring—
transcends time, space, and physicality. The expanding the connection with evocative
7991_Ch18_311-332 12/08/19 5:20 PM Page 322
language that captures the essence of each Indeed, Caring Science is a path for nurses
caritas/veritas praxis process. to attain planetary sustainability for future gen-
erations and to extend acts of human caring
The Paradigmatic Expanse: A across cultures and nations toward the attain-
Summation of Universal Human ment of a peaceful and just interconnected civ-
ilization (Watson, 2014, 2017b). Watson’s
Caring Upon the Horizon
Caring Science ethics move nursing beyond a
Written by William Rosa concern for human welfare toward a movement
In 2019, Human Caring Science celebrates its of planetary caring to nurture all life forms
40th anniversary since the release of Nursing: The inhabiting our Earth home (Rosa, 2018). It is
Philosophy and Science of Caring (Watson, 1979, embedded into the hearty fabric of emerging
2008a). As the decades pass, interprofessional nursing theories and converges with like-
scholars embrace Caring Science for its inherent hearted philosophies to shed light for new and
heart-centered wisdom, which resonates eternal heightened ways of being, knowing, seeing,
and yet beckons evolutionary approaches to and doing.
tending the world’s well-being with compas- It illuminates the Theory of Integrative
sionate spirits and renewed commitments to Nursing (described in Chapter 13), which
healing self and system. Watson’s theory returns calls for holistically minded nurses caring for
us, as individuals and nurses, to the bedrock of whole-people and whole-systems, for the bet-
existence—a transpersonal space where we cel- terment of humankind (Koithan, Kreitzer, &
ebrate our belonging to each other and our Watson, 2017; Kreitzer & Koithan, 2014).
shared humanity before we claim and root to Caring Science lays the fabric for Conscious
separate, boundaried identities. It is in this ac- Dying, a transformational practice-based the-
knowledgment of mutual human engagement ory for ushering in presence, kindness, grace,
that we resonate with the humblest of Caring and healing in the final moments of life and
Science truths, as if it were a sacred code embed- living, reminding nurses of their moral obli-
ded upon the genetic sequencing of our global gation to human realization and becoming
village. This truth is what we have always known even in the most transformative of moments
but continue to misplace. It is the message of (Rosa, 2014b; Rosa & Estes, 2016; Rosa,
Caritas Nursing the world over and the ethos of Estes, & Watson, 2017; Rosa & Hope,
enlightenment that our egos consistently strug- 2017). It vibrates with the resonant pulse of
gle to assimilate and metabolize: We are One. Ubuntu from African ontology, meaning, “I
This Oneness is a universal truth that re- am because you are”; a cry to the depths of
minds us of our shared, Cosmic consciousness – humanity to remember that we only exist in
and that we are One Mind–One Health–One the mirror image of our fellow humans
Planet (Dossey, 2013; Rosa, 2017). Caring (Downing, 2017; Nolte & Downing, 2018).
Science moves us toward an embodied accept- The song of Caring Science invokes the sa-
ance that, indeed, we are also One Heart–One cred consciousness of Native American cul-
Spirit–One Soul–One Life Force. The para- ture and epistemology to invite intersections
digm emerges from the annals of nursing theory between all planes of existential understand-
as a deeply grounded disciplinary guide, but also ing (McDermott, 2018. It is the undercurrent
as a compass for personal and spiritual growth, of Reflective Practice (Horton-Deutsch &
and a calling for the advancement of societal Rosa, 2018; creates a space to embody Mind-
structures that resist unity. The next era of Car- fulness and Mindful Practice (Sitzman &
ing Science scholarship and innovation carries Watson, 2014); drives the conscious devel-
with it the encouraging whispers of historical opment of online learning and teaching
leadership, the visions of present-day luminar- (Sitzman & Watson, 2016); serves as a syn-
ies, and the unrealized future possibilities of ergistic underpinning of Heart Science in the
health, healing, and wholeness for all peoples outward demonstration of love as authentic
and life everywhere. human caring (Watson & Browning, 2012);
7991_Ch18_311-332 12/08/19 5:20 PM Page 323
and offers a starting point for self-care and future of our personal–professional being and
self-compassion in the striving toward be- becoming.
coming a holier representation of godlike love
and a limitless capacity for healing (Rosa, Applications of the Theory
2014a; Watson, 2012).
The ideas as originally developed, as well as in
We stand at a precipice in time that over-
the current evolving phase (Watson, 1979,
looks valleys of Caritas Literacy (cultivating
1985, 1999, 2003, 2005, 2008b, 2011, 2018),
personal caring consciousness and intentional-
provide us with a chance to assess, critique,
ity as starting point) just out of reach, endan-
and see where or how, or even if, we may
gered by the shadows of Caritas Illiteracy
locate ourselves within a framework of unitary
(inhumanity; divisive and dehumanizing ob-
caring science/transpersonal moments of cari-
jectification; insensitivity and lower vibration
tas, as a basis for the emerging ideas in relation
identification) (Watson, 2008a, 2017a). It is in
to our own theories and philosophies of pro-
recognizing the care of humanity as an analogy
fessional nursing and/or caring practice. If one
for universal well-being that we learn to come
chooses to use the unitary caring-science per-
home again. As Dr. Watson says, maybe the
spective as theory, model, philosophy, ethic, or
whole reason you are on the Earth at this
ethos for transforming self and practice, or self
very moment in time is to be here right now
and system, the following questions may help
for another in need—to love, honor, and serve
(Watson, 1996, p. 161):
through the expression of caring that being
human affords us. This requires an under- ■ Is there congruence between the values
standing that this caring occasion is and major concepts and beliefs in the
transpersonal but also ever-evolving. Evolving model and the given nurse, group, system,
human-centered care is defined as organization, curriculum, population
needs, clinical administrative setting, or
compassionate and empathic care that responds, other entity that is considering interacting
attends, and conforms to the human as a living, with the caring model to transform and/
breathing, evolving experience; human as a or improve practice?
fluctuating phenomenological being of engage- ■ What is one’s view of “human”? And what
ment; human as history, as story, and as narrative; does it mean to be human? To be caring?
human as presence, emergence, and possibility; What is healing? What does it mean, to be
human as fellow sojourner; human as caring- Becoming? Growing? Transforming?
healing; and human as LOVE. (Rosa & Estes, And so on? For example, in the words of
2016, p. 336) Teilhard de Chardin (1959): “Are we hu-
Evolving human-centered care reflects the mans having a spiritual experience, or are we
need of humanity to open our arms to the spiritual beings having a human experience?”
paradigmatic expanse of human caring on the Such thinking in regard to this philosophical
horizon. As we live, breathe, and evolve to- question can guide one’s worldview and help
gether, we rediscover the shared miracle of to clarify where one may locate self within
love—and in that love, the possibility of the caring framework.
healing. Human Caring Science is the uni- ■ Are those interacting and engaging in the
versal language of the future; a future of light model interested in their own personal
in the institutional darkness, rehumanization evolution? Are they practicing lovingkind-
in a system of fragmentation and othering, ness and compassion with self? Are they
and reintegration for the marginalized and committed to seeking authentic connec-
vulnerable. Caring Science is a movement of tions and caring–healing relationships
social justice and advocacy beginning its with self and others?
steady rise from the constitutional nurtu- ■ Are those involved “conscious” of their
rance of infancy; learning to stand and walk caring caritas or noncaring consciousness
amid a wave of love and healing to usher the and intentionally in a given moment at an
7991_Ch18_311-332 12/08/19 5:20 PM Page 324
individual and a systemic level? Are they practice settings by supporting and learn-
interested and committed to expanding ing from each other
their caring consciousness and actions ■ To share knowledge and experiences so
to self, other, environment, nature, and that we might help guide self and others
wider universe? in the journey to live the caring philoso-
■ Are those working within the model phy and theory in our personal and
interested in shifting their focus from professional lives.
a Westernize modern medical science–
The consortium gatherings, sponsored by
technocure, clinical orientation to
systems implementing caring theory in practice:
self/other and human health and
healing, to a true heart-centered ■ Provide an intimate forum to renew,
authentic caring–healing–loving restore, and deepen each person’s and
model of well-being? each system’s commitment and authentic
practices of human caring in their
Watson Caring Science Institute personal/professional life and work.
(WCSI) ■ Learn from each other through shared
The WCSI was established in 2007 as a non- work of original scholarship, diverse
profit foundation. The following statements forms of caring inquiry, and modeling
define and describe the goals, missions, and of caring–healing practices.
purposes of the International Caritas Consor- ■ Mentor self and others in using and
tium (ICC) and the WCSI as two interrelated extending the theory of human caring to
entities. The general goals and objectives of the transform education and clinical practices.
WCSI are to steward and serve the ICC in its ■ Develop and disseminate caring science
activities and more specifically to: models of clinical scholarship and profes-
sional excellence in the various settings in
■ Transform the dominant model of med-
the world.
ical science to a model of caring science by
reintroducing the ethic of caring and love, Activities for Caritas Consortium
necessary for healing. Gatherings
■ Deepen the authentic caring–healing rela- ■ Provide a safe forum to explore, create,
tionships between practitioner and patient
and renew self and system through
to restore love and heart-centered human
reflective time out.
compassion as the ethical foundation of ■ Share ideas, inspire each other, and learn
health care.
together.
■ Translate the model of caring–healing/ ■ Participate in use of appreciative inquiry
caritas into more systematic programs and

in which each member is facilitative
services to help transform health care one
of each other’s work, each participant
nurse, one practitioner, one educator, and
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
based clinical and educational practices.
to the system. ■ Generate and share multisite projects in
International Caritas Consortium caring theory/caring science scholarship.

■ Network for educational and professional
Charter
models of advancing caring–healing
The main purposes of the unfolding and
practices and transformative models
emerging ICC (Watson, 2008a, pp. 278–280)
of nursing.
are as follows: ■ Share unique experiences for authentic
■ To explore diverse ways to bring the car- self-growth within the caring science
ing theory to life in academic and clinical context.
7991_Ch18_311-332 12/08/19 5:20 PM Page 325
■ Educate, implement, and disseminate ■ Intentional use of caring–healing modali-

exemplary experiences and findings to ties for self and patients (e.g., massage,
broader professional audiences through therapeutic touch, reflexology, aromather-
scholarly publications, research, and apy, calmative essential oils, sound,
formal presentations. music, arts, a variety of energetic
■ Envision new possibilities for transforming modalities, etc.).
nursing and health care. ■ Dim the unit lights and have designated
“quiet time” for patients, families, and
Because of the many national and interna-
staff alike to soften, slow down, and calm
tional developments and sincere desire for
the environment.
authentic change, new projects using caring ■ Create healing spaces for nurses—
science, caritas theory, and the philosophy of
sanctuaries for their own time out; this
human caring are now underway in many sys-
may include meditation or relaxation
tems. The WCSI and the ICC are examples of
rooms for quiet time. Some systems have
individuals and representatives of systems
named these spaces “Watson Rooms”
convening (in these cases, once a year) to
(e.g., Virginia Commonwealth University,
deepen and sustain what is referred to as caritas
Richmond, VA, Dr. Crystal Crewe;
nursing—that is, bringing caring and love and
St. Joseph’s Hospital, Patterson, NJ).
heart-centered human-to-human practices ■ Cultivate one’s own spiritual heart-
back into our personal life and work world
centered practices of loving kindness
(Watson, 2008a).
and equanimity to self and others.
Caring/Caritas Practice Indicators ■ Intentionally, pause and breathe, prepar-
and Programs ing the self to be present before entering
patient’s room; before starting a meeting,
Examples of how Caring Science systems are
have quiet silence—seconds/moments to
translating the theory are captured through
ground self.
identified acts and processes. Caring/Caritas ■ Use centering exercises and mindfulness
theory-in-action reflects transformative processes
practices, individually and collectively.
that are representative of actions taking place ■ Place magnets on patient’s door with
in many of the systems in the ICC and other
positive affirmations and reminders of
systems guided by caring science and caring
caring practices.
theory. The following are examples of such ■ Explore documentation of caring
caring-in-action indicators:
language and integration in computerized
■ Make human caring integral to the orga- documentation systems.
nizational vision and culture through new ■ Participate in multisite research assessing
language and documentation of caring, caring among staff and patients’ experi-
such as posters. ence of caring beyond objective “problem-
■ Introduce and name new professional focused” research.
caring practice models, leading to new ■ Create healing environments, attending to
patterns of delivery of caring/care the subtle, nonphysical environment of
(e.g., Attending Caring Nursing Project, caritas field.
Patient Care Facilitator Role, the 12-Bed ■ Display and use healing objects, stones, or
Hospital). a blessing basket.
■ Create conscious intentional meaningful ■ Create Caritas Circles to share caring
rituals—for example, hand washing is for moments.
infection control but may also be a mean- ■ Perform Caring Rounds at bedside with
ingful ritual of self-caring—energetically patients.
cleansing, blessing, and releasing the last ■ Interview, hire, and select staff on the basis
situation or encounter, and being open to of a “caring” orientation. Ask candidates to
the next situation. describe a “caring moment.”
7991_Ch18_311-332 12/08/19 5:20 PM Page 326
■ Develop “caring competencies” using cari- today as the system shifts toward an evolved
tas literacy as guide to assess and promote consciousness for system transformation from
staff development and ensure caring. within. These criteria rely on moral, ethical,
philosophical, and theoretical foundations to
These and other practices are occurring in
restore human caring and healing and health
a variety of hospitals across the United States,
in a system that has gone astray—educationally,
often in Magnet hospitals or those seeking
economically, clinically, and socially. This
Magnet recognition, where caring theory and
shift is in a hopeful direction and is based on
models of human caring are used to transform
a grassroots transformation of nursing, one
nursing and health care for staff and patients
that is emerging from the inside out. The
alike. These identified indicators are exem-
dedicated leaders who are ushering in these
plars of new forms of evidence, establishing
changes serve as an inspiration for sustaining
new criteria to be recognized as a National
nursing and human caring for practitioners
Caring Science System or organization. This
and patients alike.
shift emphasizes the changing momentum
Practice Exemplar1
Written by Christine Griffin, MS, RN, CPN, Caritas Coach, and language that enabled me to care deeply
Master HeartMath trainer for others while flourishing in my own self-
The philosophy, science, and practice of car- awareness and self-care. Thanks to the Caring
ing not only helps me sustain my nursing Science, I am back to being the nurse I always
practice, it enables me to flourish within the dreamed of being. I have reconnected with my
complexities of caring for others. Like many passion for caring and have found an endless
nurses, I entered a health-care profession be- source of energy to sustain it.
cause I wanted to make a difference and help Throughout this journey, I have experi-
others heal. Right from the start, I cared pro- enced so many meaningful interactions and
foundly for my patients. I felt there should lessons. In my journey of being and becoming
not be a limit to what I could do to help a caritas nurse there are countless examples
someone else and my care was the most im- of how my thinking and practice have shifted.
portant and fulfilling part of my job. But I I have shared some here to illustrate how Car-
began to feel worn down and my body and ing Science has shaped me into the nurse and
eventually my soul were in pain. For a while, person I am today.
making a difference was enough to sustain
me. Then a three-year-old patient that In the Moment We Are Equal
I cared for deeply literally died in my arms. Transpersonal caring is the gold standard for
In that moment, I broke and began to build care between two people. Caring only happens
walls to protect what little bit of myself was within relationships. A healing relationship
left. As I did, I became very aware that I was transcends space and time and is felt by both
no longer the inspired or caring nurse the nurse and the patient. In this moment, it
I wanted to be. I had lost my capacity for basic is clear that both people matter and compas-
acts of kindness like tolerance or empathy. sion can emerge as one sees the other in their
The walls only caused more suffering as I wholeness. Pema Chödrön (2008) writes,
grieved for the nurse I once was. Then, by “Compassion is not a relationship between the
some small miracle, I met Dr. Jean Watson healer and the wounded. It’s a relationship be-
and she helped put me on a path that focused tween equals. Compassion becomes real when
on peace. It was a path of reflection, not we recognize our shared humanity” (p. 74).
shame; of hope, not despair. I began to re- I used to think caring moments just hap-
member my purpose and learned a structure pened naturally. When this did not happen,
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I believed it was because I failed. I now un- but the only choice is to fight and live and teach.
derstand that these moments come from When I met you, I was scared. I didn’t want to
being in right relation with myself first so I go in the room. I didn’t want to touch you. I
can then be in right relation with others. As didn’t want to be your nurse because I may
Watson (2005) writes, “Caring is such a vul- have to see your pain. I may have to come to
nerable place; first because we come face-to- terms with not being able to help you. I may
face with our own humanity and ourselves. cry. I may suffer.
We are remembering we are touching the life You are my…
force, the very soul of another person, hence I meet you. We connect. I push my fear away
ourselves” (p. 61). and lead with my heart. She is just a child …
Indeed, Watson reminds us over and over get her to laugh. Help her play. Help her forget.
that when we understand the connectedness If she forgets then so can I. Forget the
and oneness of all humanity, cruelty to an- limitations. Forget the prognosis. Just forget.
other becomes intolerable (Watson, 2005, You needed to change your dressings … No,
2008a). We see another’s body and soul as not that! I have heard the screams. You need to
our own body and soul and we treat both take the bath with the bleach. Please God don’t
with a new kind of reverence and care. Being make me be there. The fear resurfaces. NO—
in this space with another human is the lead with your heart, be present, and bring love
biggest gift we offer to humanity. I cannot with you. Let’s play. I will wrap myself in
think of a better way to describe this than to saran wrap … Head to toe. I promise this will
share a story about a little girl who brought be the best bath you have ever had.
out the best and worst in me both as a person Why did I promise? Covered head to toe—if
and as a nurse. Her diagnosis brought me you just get in—oh the pain the bleach causes on
fear but her heart taught me about humility the open sores must be unbearable—I will give
and grace. Abbi had epidermolysis bullosa you these syringes to shoot water at me. Yes, the
(EB), a rare and complex disease that leaves water with the bleach, with the skin, with the
the skin extremely fragile so that it blisters blood. I don’t care. This will be the best bath you
and tears from minor friction. Patients with ever had … I promised. In the bath—the fastest
EB endure a life of infection and pain and she has ever gotten in the water. Is that a smile?
often lose their battle with the disease at a The pain must be terrible. Squirt … was that a
very young age. One of the worst treatments laugh?. Do you need morphine? Squirt … Are
they endure is a bath filled with bleach to you giggling? No, that was me. I am breathing
clean their open sores. What follows are my now. I am being squirted everywhere (except
reflections about my journey with Abbi from my face). The water is gross. I don’t care. My
the moment I met her to the time I had to scrubs are wet. I don’t feel it. My eyes are
say goodbye. watering. I won’t hide it. Abbi and I are alone
in our world. We splash and squirt and spill
Your disease is pure evil. I don’t like that word
water everywhere. People come and check on
but it is the only way I can describe how awful
us—Are we okay? Yes, we are okay. Abbi is
it is. Your fragile body comes apart at the skin.
done but she doesn’t want to get out—wait—
Where is the glue that others have? Why does
what? The pain has to be there. A water fight
my skin stay on while yours falls off? What
can’t remove the effects of bleach on open
was God thinking?
wounds. She doesn’t care. The pain is normal for
You are my …
her—expected—prepared for. Playing during
You smile. You laugh. You take challenges
the dressing change, it is a new experience.
with a stride that can only come from an old
Please don’t let it end … for both of us.
soul. One who understands that this isn’t fair
(continued)
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You are my … nurse. Nurses can’t do this part alone. You are
We fight to spend time together. Other there in body but where is your mind? Where
nurses. Other patients. No matter. Abbi and is your soul? I pray they are in a safe place.
I need each other. She gets to laugh at me. I get Away from here. Away from the waiting …
to feel human. I make a difference when I am the people all staring at you. The people who
her nurse. She calls for me on the call light. don’t know what to do with their sadness. The
“Abbi, I have other patients. Do you need people who are scared and feeling fragile.
me?” No, I just want you to come. When can Emotions surfacing that won’t help anyone …
you come? “Now” is always the answer. I can’t People like me.
take away her disease. I usually can’t even I talk to you. I thank you. I lie and say it is
take away the pain. I can give her the only okay. I lie and say that your mom will be okay.
thing I have to give … my heart, my presence, She will be … but not for a long time. I tell you
and my care. Care—that’s what I give her. how you have changed me … to my core …
I care for her. I care about her. I care. changed me. I remind you that I hate it when
You are my … you sleep with your eyes open. You always
It’s been several years now. I get to see you freaked me out with that trick. Now … lying
several times a year. More when you are sick. here in your pain medicated–slumber … your
You tell me stories of your life. Horses, family, eyes are open. Until I spoke those last words
combined with this disease and medications. I was not sure you could still hear me. I wasn’t
Fun combined with pain. Always the pain. sure I wanted you to hear me. My words were
You teach me something new each time more for me, weren’t they? My closure, my
I see you. You are vulnerable with me. You know needs, my suffering. Did I even say them out
you can cry. You know you can be grumpy. loud? When I said those words, you gave me
I shoulder your anger when it spills over. the most precious gift. Without saying a word,
I don’t mind. I am grateful you trust me for you told me that you cared about me. That our
every emotion. You cannot scare me anymore. journey was together and even now, at the
I am your nurse and I was meant to be that. end, we changed each other. You made all my
We were placed in each other’s path and you fears go away and all my feelings of failure
have become part of my story. Am I part of fade. I could not always take away your pain
yours? Do you talk about me like I talk about or make you laugh. I could not always make
you? Do your friends know my name? You are you forget your prognosis or give you hope for
imprinted on my heart. Is there a spot in yours tomorrow. But, I did connect with you. I did
for me? Is that important? Is my worth as a find a way into your heart. We did touch each
nurse dependent on my patients’ feelings other in some way, as a nurse with her special
about me? Isn’t doing the right thing and patient. When I was holding your hand and
caring enough reward? I reminded you that I hated when you slept
I get my answer the last time we see each with your eyes open, you, despite not moving
other. The last time we touched hands. The once for the entire time I was there, simply
last time you told me everything I needed to closed your eyes for me.
know without saying a word. Your death You are my biggest fear, my hero, my friend,
bed. A terrible thing for a child. It’s not fair my patient, my heart.
to live your whole life in pain only to be
I am still processing this loss, looking at it
placed on your death bed at age nine. Still
from new ways of knowing and becoming.
fighting. “I don’t want to go to heaven
Watson reminds us that we cannot skip the
without you, mommy.” She is not ready. I am
painful parts of life. We must walk through
not ready. Damn it … can’t she at least choose
joy and suffering to find meaning and purpose.
when she is ready? Unfair, unjust, evil
Watson teaches us that we can move toward
disease. I go to you. Not alone. With a fellow
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joy while pain is present. Doing this for our- make her stronger. More important, we talked
selves is one thing. Being able to help others to her, sang to her, and held her. We bathed her
in this process is a true gift. and dressed her and did her hair, as though each
day was the day she would go home to play with
Pulling Others Up her brothers and sisters. Slowly she calmed more
Caritas calls on us to pull from our deepest easily and cried less. She began to heal in all the
humanity to hold others up until they can do ways her broken body could. As for her family,
it for themselves. I was proud to be among a we took care of them too. Still consumed by
group of nurses who did this for one family anger and guilt and grief, they rarely visited
in distress. Jenny and when they did, they often told us how
poorly we were caring for their daughter.
This family belonged to a little girl named
But we kept caring. When they gave us
Jenny. Jenny had a near-death experience that
anger, we gave them compassion. When they
left her neurologically devastated. Jenny’s
gave us frustration, we showed them empathy.
family was grief-stricken, angry, and consumed
Ever so slowly, as Jenny began to look
with guilt. They simply could not let go of her
better, her mother started to visit more often.
and fought anyone who suggested it. When she
She started to bring in more outfits for Jenny
arrived on my unit, she was in poor condition
and to pick out what she wanted Jenny to
and what we call “riding the ventilator,”
wear the next day. She gave suggestions on
meaning she did not take any spontaneous
hairstyles. She told us Jenny’s favorite songs
breaths on her own. She had bed sores and she
and TV programs, so we could play them for
was so fragile that even a simple touch tore at
Jenny when she wasn’t here. She brought
her skin. She rarely opened her eyes. When she
more family members to visit Jenny,
did she would cry.
including Jenny’s siblings. She started to hold
This was the patient we started with but
Jenny to talk to her like she saw us do. More
it was not the end of the story. You see, I work
significantly, Jenny’s mother started to come
on a unit filled with caritas nurses, who look
to terms with the limitations of her daughter’s
for and therefore find humanity in every
diagnosis. She began to let go of a future with
situation, who look for connections and
her daughter and to take things moment to
therefore make them, who look for the person
moment. Eventually, she began to ask us
behind the diagnosis. They don’t ask if they can
what we thought about end of life for Jenny.
care. They ask what is the best way to care
What would it look like? Would Jenny suffer?
for this patient in this moment.
Was there any chance for a recovery? Would
We knew Jenny would not recover from her
Jenny think we gave up on her? These were

brain injury. We could not hope for the miracle
hard questions. There were no simple
of a full recovery. So, we asked ourselves what
answers. But there were caring answers, and
we could hope for. The answers were clear. We
those were the answers we gave.
wanted to support the family, manage her
Answers like, “We are here for you.” “We are
pain, and make her feel loved. Surprisingly,
with you.” We also asked Jenny’s mother one
we realized we could do this by making Jenny
question of our own: What do you want for
feel she would get better. we could do this by
your daughter? At first, the answer was, “I
treating Jenny like we would if we knew she
want her back.” Then it changed to, “I want her
would get better. That meant believing in
to not suffer anymore.” And finally, it became,
possibilities, ignoring limitations, expecting
“I want her to be at peace.” It was then that
the miracle, and never looking back. We took
Jenny’s mother had the strength to make the
care of her skin and her bedsores healed. We
decision to remove her from the ventilator.
administered medicine and treatments to
(continued)
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Jenny did not receive the miracle of everything. Watson (2008a) describes this as an
recovery. But she did receive the miracle expanded, deeper moral–ethical foundation. In
of care. And her family received the miracle of this awakening we “open to a sense of humanity-
seeing their daughter whole again before she in-relation-to-the-larger-universe, inspiring
passed on. They did not have to let go of her a sense of wonder, wisdom, awe and humility”
while she was broken. She was their little girl (p. 10). We become someone whose own self-
with possibilities and potential and they will journey and self-discovery lead to being a light
always see her that way. Ram Dass has said, in the world to contributing to a shared con-
“We’re all just walking each other home.” As sciousness and vision of love for those in our
nurses, while holding the hands of her family, lives and for our greater humanity and world.
we walked Jenny home. Now more than ever, we need to care for each
other. We need to be the hope for others. In
Final Reflections Watson’s words, “Because we are here, we are
There are so many other stories I can tell. How the hope … we may be the only one who makes
I learned to let go of my ego to care. How to a difference” (Watson, 2008a, p. 62).
shoulder angry parents without owning the
emotions. How to forgive myself when I don’t Living Caritas
have the capacity to show up and fail to create By sharing stories about caring for children,
a healing environment. Caring Science has Chris demonstrates how Caring Science guides
given me the tools I need to manage all these her to discover the uniqueness of each child and
complexities and I get to be the nurse I want family. As she reflects on each story, Chris
to be. Caritas consciousness helps answer the shares her own inner journey toward deeper
really big questions, including why I am called knowing and ultimate wisdom. Importantly,
to be a nurse, and reminds me to see the value Chris openly explores where she falls short and
in simple acts of kindness, finding compassion how she reflects on these experiences through
for my own struggles and the struggles of those the lens of Caring Science so that she can grow
around me, and sense the connectedness of as a Caritas Coach and humanitarian.
Summary
Nursing’s future and nursing in the future will and will need to embrace healing arts and car-
depend on nursing maturing as the distinct ing practices and processes and the spiritual
health, healing, and unitary caring profession dimensions of care much more completely.
that it has always represented across time but Indeed, in light of all the noncaring and vio-
has yet to fully actualize. Nursing ironically is lence in our world today, the future of human
now challenged to stand and mature within health will perhaps have to involve soul-
its own unitary caring science paradigm, retrieval for soul-care. In this ancient and
while simultaneously having to transcend it more contemporary view of health and heal-
and share with others. The future already ing, for every physical condition there is a
reveals that all health-care practitioners will nonphysical, metaphysical aspect or overlay
need to work within a shared framework of that influences healing outcomes.
caring–healing relationships and human– Thus, nursing is at its own crossroad of pos-
environmental–universal energetic field modal- sibilities, between worldviews and paradigms.
ities. Practitioners of the future will need to Nursing has entered a new era; it is invited and
pay attention to consciousness, intentionality, required to build on its heritage and latest evo-
energetic human heart-centered presence, lution in science and technology; but it must
and transformed mind–body–spirit medicine, also transcend itself for a new future, yet to be
7991_Ch18_311-332 12/08/19 5:20 PM Page 331
known. However, nursing’s future holds Professional and personal models are re-
promise of caring and healing mysteries and quired that open the hearts of nurses and
models yet to unfold, as opportunities for of- other practitioners. New horizons of possi-
fering compassionate caritas/veritas services bilities have to be explored to create space
at individual, system, societal, national, and whereby compassionate, intentional, heart-
global levels for self, for profession, and for centered human caring can be practiced.
the broader world community. Nursing and Such authentic personal/professional practice
evolved humans have a critical role to play in models of caring science are capable of lead-
sustaining humanity and Mother Earth, making us, locally and globally, toward a moral
ing new connections between caring, love, community of caring. This community will
healing, and peace in the world. restore healing and health at a level that
New transformative, creative, human- honors and sustains the dignity and human-
spirit–inspired approaches are required to ity of practitioners and patients alike; in-
reverse institutional and system cultural deed, self-caring and self-healing possibilities
lethargy and darkness. To create the neces- are on the horizon for self-control and self-
sary cultural change, the human spirit has to knowledge changing the direction toward
be invited back into our health-care systems. health for all.
Questions for Reflection ■ What are the consequences of developing

“nursing qua medicine” versus “nursing
and Discussion qua nursing,” as it continues to mature as
■ Why did Watson choose to change her a distinct discipline?
original 10 Carative Factors to Caritas
Processes®?
■ How does Watson describe the ontologi-
cal difference between medical science and
unitary caring science?
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Theory of Nursing As Caring

CHAPTER
19
Anne Boykin and
Savina O. Schoenhofer

Applications of the Theory Introducing the Theorists
Practice Exemplar by Emily Hunter Werthman
Summary Anne Boykin
Questions for Reflection and Discussion Anne Boykin is Professor Emerita and past
Dean of the Christine E. Lynn College of
Nursing at Florida Atlantic University. She is
Director of the College’s Anne Boykin Insti-
tute for the Advancement of Caring in Nurs-
ing. This Institute provides global leadership
for nursing education, practice, and research
grounded in caring; promotes the valuing
of caring across disciplines; and supports
the caring mission of the College. She has
demonstrated a long-standing commitment
to the advancement of knowledge in the dis-
cipline, especially regarding the phenomenon
of caring.
She has been an international force in call-
ing for the importance of caring in the disci-
pline of nursing. Positions she has held within
the International Association for Human
Caring include president-elect (1990–1993),
president (1993–1996), and member of the
nominating committee (1997–1999). As im-
mediate past president, she served as coeditor
of the International Journal of Human Caring

from 1996 to 1999.
Her scholarly work is centered in caring as the
grounding for nursing. This is evidenced in her
coauthored book Nursing As Caring: A Model for
Transforming Practice (Boykin & Schoenhofer,
1993, rev. ed. 2001a), the edited book Liv-
ing a Caring-based Program (Boykin, 1994), and
the coedited book Health Care System Transfor-
mation for Nursing and Health Care Leaders:
Implementing a Culture of Caring (Boykin,
Schoenhofer, & Valentine, 2014). Living a
Caring-based Program illustrates how caring
grounds all aspects of a nursing education pro-
gram. Dr. Boykin has also authored numerous
book chapters and articles. She is currently
333
7991_Ch19_333-348 12/08/19 5:20 PM Page 334
retired and serves as a consultant locally, region- an abstract, integrated, comprehensive picture
ally, nationally, and internationally on the topic of nursing as a practiced discipline. The The-
of caring-based health-care transformations. ory of Nursing As Caring offers a view that
Dr. Boykin is a graduate of Alverno College permits a broad, encompassing understanding
in Milwaukee, Wisconsin; she received her of any and all situations of nursing practice
master’s degree from Emory University in At- (Boykin & Schoenhofer, 1993, 2001a). This
lanta, Georgia, and her doctorate from Van- theory serves as an organizing framework for
derbilt University in Nashville, Tennessee. nursing scholars in the various roles of practi-
tioner, researcher, administrator, teacher, and
Savina O. Schoenhofer developer.
Savina O’Bryan Schoenhofer began her initial Initially, we present the theory in its most
nursing study at Wichita State University, abstract form, addressing assumptions and key
where she earned undergraduate degrees in themes. We then illustrate the meaning of the
nursing and psychology and graduate degrees Theory of Nursing As Caring through exem-
in nursing and counseling. She completed a plars in the role dimensions of nursing care,
PhD in educational foundations/administration nursing education, nursing administration, and
at Kansas State University in 1983. In 1990, nursing research.
Schoenhofer cofounded Nightingale Songs, an
early venue for communicating the beauty of Nursing As Caring: A Historical
nursing in poetry and prose. In addition to her Perspective
work on caring, she has written on nursing The Theory of Nursing As Caring is an out-
values, primary care, nursing education, sup- growth of the curriculum development work
port, touch, personnel management in nursing in the Christine E. Lynn College of Nursing
homes, and mentoring. Her career in nursing at Florida Atlantic University, where the
has been significantly influenced by three col- authors led the faculty group revising the
leagues: Lt. Col. Ann Ashjian (Ret.), whose caring-based curriculum for initial program ac-
community nursing practice in Brazil presented creditation. When the revised curriculum was
an inspiring model of nursing; Marilyn E. Parker, in place, each of us recognized the potential
PhD, a faculty colleague who mentored her in and even the necessity of continuing to develop
the idea of nursing as a discipline, the academic and structure ideas and themes toward a com-
role in higher education, and the world of nurs- prehensive expression of the meaning and pur-
ing theories and theorists; and Anne Boykin, pose of nursing as a discipline and a profession.
PhD, who introduced her to caring as a sub- The point of departure from the curriculum
stantive field of nursing study. work was the acceptance that caring is the end,
Schoenhofer coauthored the book Nursing
rather than the means, of nursing, and that caring

As Caring: A Model for Transforming Practice is the intention of nursing, rather than merely its
(1993, 2001a) with Boykin. Boykin and instrument. This work led to the statement of
Schoenhofer, together with Kathleen Valen- focus of nursing as “nurturing persons living
tine, coauthored the book Health Care System caring and growing in caring.”
Transformation for Nursing and Health Care Further work to identify foundational as-
Leaders: Implementing a Culture of Caring sumptions about nursing clarified the idea of
(2014). See http://www.nursingascaring.com the nursing situation, a shared lived experience
for additional information. in which the caring between nurse and nursed
enhances personhood, with personhood un-
derstood as living grounded in caring. The
Overview of the Theory clarified focus and the idea of the nursing sit-
This chapter is intended as an overview of the uation are the key themes that draw forth the
Theory of Nursing As Caring, a general theory, meaning of the assumptions underlying the
framework, or disciplinary view of nursing. A theory and permit the practical understanding
general theory or framework of nursing presents of nursing as both a discipline and a profession.
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C H APTER 19 ■ Theory of Nursing As Caring 335
As critique of the theory and study of nursing reflect a set of values that provide a basis for
situations progressed, the notion of nursing understanding and explicating the meaning of
being primarily concerned with health was nursing and are key to understanding the
limiting, and we now understand nursing to be practical meaning of the theory of Nursing As
concerned with human living. Caring.
Three bodies of work significantly influ- ■ Persons are caring by virtue of their
enced the initial development of the Theory of
humanness.
Nursing As Caring. Roach’s (2002) basic the- ■ Persons are whole and complete in the
sis that caring is the human mode of being was
moment.
incorporated into the most fundamental as- ■ Persons are caring, moment to moment.
sumption of the theory. We view Paterson and ■ Personhood is a way of living grounded
Zderad’s (1988) existential phenomenological
in caring.
theory of humanistic nursing as the historical ■ Personhood is enhanced through partici-
antecedent of the Theory of Nursing As Caring.
pation in nurturing relationships with
Seminal ideas from humanistic nursing such
caring others.
as “the between,” “call for nursing,” “nursing ■ Nursing is both a discipline and a
response,” and “personhood” serve as substantive
profession.
and structural bases for our conceptualization
of Nursing As Caring. Mayeroff’s (1971) work. Key Themes
On Caring, and particularly the ingredients
of caring, provided a language that facilitated Caring
the recognition and description of the prac- Caring is an altruistic, active expression of love
tical meaning of caring in nursing situations. and is the intentional and embodied recogni-
Roach’s (2002) originally five, now six, Cs of tion of value and connectedness. Caring is not
caring expand on that basic language. In ad- the unique province of nursing. However, as a
dition to the work of these thinkers, both discipline and a profession, nursing uniquely
authors are long-standing members of the In- focuses on caring as its central value, its pri-
ternational Association for Human Caring, a mary interest, its focus for scholarship, and the
community of scholars who study caring; we direct intention of its practice. “As an expres-
are supported and undoubtedly influenced in sion of nursing, caring is the intentional and au-
many subtle ways by the members of this com- thentic presence of the nurse with another who is
munity and their work. recognized as person living caring and growing in
Fledgling forms of the theory of Nursing As caring” (Boykin & Schoenhofer, 2001a, p. 13).
Caring were first published in 1990 and 1991, The full meaning of caring cannot be restricted
with the first complete exposition of the theory to a definition but is illuminated in the expe-
presented at a conference in 1992 (Boykin & rience of caring and in dynamic and informed
Schoenhofer, 1990, 1991; Schoenhofer & reflection on that experience.
Boykin, 1993), followed by the publication of Focus and Intention of Nursing
Nursing As Caring: A Model for Transforming Disciplines as identifiable entities or “branches
Practice in 1993 (Boykin & Schoenhofer, of knowledge” grow from the holistic “tree of
1993), which was revised with the addition of knowledge” as need and purpose develop. A
an epilogue in 2001 (Boykin & Schoenhofer, discipline is a community of scholars with a
2001a). particular perspective on the world and on
what it means to be in the world. The discipli-
Assumptions and Key Themes
nary community represents a value system that
of Nursing As Caring
is expressed in its unique focus on knowledge
Assumptions and practice. The focus of nursing, from the per-
Certain fundamental beliefs about what it spective of the theory of Nursing As Caring, is
means to be human underlie the Theory of person living caring and growing in caring. The
Nursing As Caring. The following assumptions general intention of nursing as a practiced
7991_Ch19_333-348 12/08/19 5:20 PM Page 336
discipline is nurturing persons living caring and through this invitation that the call for nurs-
growing in caring. ing is heard and nursing responses are created.
Direct invitation establishes an openness be-
Nursing Situation tween the nurse and one nursed and strength-
The practice of nursing, and thus the practi- ens the caring between.
cal knowledge of nursing, lives in the context
of person-with-person caring. The nursing Call for Nursing
situation involves values, intentions, and ac- “A call for nursing is a call for acknowledg-
tions of two or more persons choosing to live ment and affirmation of the person living
a nursing relationship. The nursing situation caring in specific ways in the immediate situ-
is understood to mean “the shared lived ex- ation” (Boykin & Schoenhofer, 2001a, p. 13).
perience in which caring between nurse and Calls for nursing are calls for nurturance
nursed enhances personhood” (Boykin & through personal expressions of caring. Calls
Schoenhofer, 2001a, p. 13). Nursing is cre- for nursing originate within persons as they
ated in the “caring between.” All knowledge live caring uniquely, expressing personally
of nursing is created and understood within meaningful dreams and aspirations for grow-
the nursing situation. Any single nursing sit- ing in caring. Calls for nursing are individually
uation has the potential to illuminate the relevant ways of saying, “Know me as caring
depth and complexity of nursing knowledge. person in the moment and be with me as I try
Nursing situations are best communicated to live fully who I truly am.” Intentionality
aesthetically to preserve the lived meaning of and authentic presence open the nurse to
the situation and the openness of the situa- hearing calls for nursing. Because calls for
tion as text. Storytelling, poetry, graphic arts, nursing are unique situated personal expres-
dance, and other expressive modes effectively sions of that which matters to the person
represent the lived experience of nursing and nursed, they cannot be predicted, as in a “di-
allow for reflection and creativity in advanc- agnosis.” Nurses develop sensitivity and ex-
ing understanding. pertise in hearing calls through intention,
experience, study, and reflection in a broad
Personhood range of human situations.
Personhood is understood to mean living
grounded in caring. From the perspective of Nursing Response
the Theory of Nursing As Caring, person- As an expression of nursing, “caring is the in-
hood is the universal human call. A profound tentional and authentic presence of the nurse
understanding of personhood communicates with another who is recognized as living
the paradox of person-as-person and person- caring and growing in caring” (Boykin &
Schoenhofer, 2001a, p. 13). The nurse enters
in-communion all at once.

the nursing situation with the intentional
Direct Invitation commitment of knowing the other as caring
The concept of direct invitation was briefly in- person, and in that knowing, acknowledging,
troduced in the epilogue of the 2001 revised affirming, and celebrating the person as car-
edition of Nursing As Caring (Boykin & ing. The nursing response is a specific expres-
Schoenhofer, 2001a). It evolved from a con- sion of caring nurturance to sustain and
vergence of ontology and aesthetics as a way enhance the one nursed in ways that matter
to more effectively communicate Nursing As as he or she lives caring and grows in caring
Caring in practice. in the situation at hand. Nursing responses to
The context for understanding direct in- calls for caring evolve as nurses clarify their
vitation is the nursing situation. Direct invi- understandings of calls through presence and
tation communicates clearly that the core dialogue. Nursing responses are uniquely cre-
service of nursing is to offer caring and to in- ated for the moment and cannot be predicted
vite the one nursed to share that which mat- or automatically applied as preplanned pro-
ters most to her or him in that moment. It is tocols. Sensitivity and skill in creating unique
7991_Ch19_333-348 12/08/19 5:20 PM Page 337
and effective ways of communicating caring each other in the growth of caring” (Pross,
are developed through intention, experience, Hilton, Boykin, & Thomas, 2011, p. 28).
study, and reflection in a broad range of
human situations. Lived Meaning of Nursing As Caring
The “Caring Between” Abstract presentations of assumptions and
The caring between is the source and ground of themes lay the groundwork and provide an ori-
nursing. It is the loving relation into which enting point. However, the lived meaning of
nurse and nursed enter and cocreate by living Nursing As Caring can best be understood by
the intention to care. Without the loving re- the study of a nursing situation. The following
lation of the caring between, unidirectional ac- poem is one nurse’s expression of the meaning
tivity or reciprocal exchange can occur, but of nursing, situated in one particular experi-
nursing in its fullest sense does not occur. It ence of nursing and linked to a general con-
is in the context of the caring between that perception of nursing.
sonhood is enhanced, each expressing self as I CARE FOR HIM
caring and recognizing the other as caring My hands are moist,
person. My heart is quick,
Dance of Caring Persons My nerves are taut,
The relational model for organizational design He’s in the next room,
involving nursing is analogous to the dancing I care for him.
circle, the dance of caring persons. What this cir- The room is tense,
cle represents is the commitment of each It’s anger-filled,
dancer to honor all involved as caring persons The air seems thick,
of value, each making an important contribu- I’m with him now,
tion to the caring enterprise. Core dimensions I care for him.
of caring illustrated in the dance of caring per- Time goes slowly by,
sons model include the following: As our fears subside,
I can sense his calm,
■ Acknowledgment that all persons have
He softens now,
the capacity to care by virtue of their
I care for him.
humanness.
His eyes meet mine,
■ Commitment to respect for person in all
Unable to speak,
organizational structures and processes.
I feel his trust,
■ Recognition that each participant in the
I open my heart,
enterprise has a unique valuable contribu-
I care for him.
tion to make to the whole and is present

It’s time to leave.
in the whole.
Our bond is made,
■ Appreciation for the dynamic though
Unspoken thoughts,
rhythmic nature of the dance of caring
But understood,
persons, enabling opportunities for
I care for him!
human creativity.
—J. M. COLLINS (1993)
Persons making up the dance of caring per-
sons in any given situation involving nursing Each encounter—each nursing experience—
are the one nursed, the family, nurses and brings with it the unknown. In reflection, Jim
other health-care workers, administrative and Collins shares a story of practice that illumi-
support staff, and relevant corporate, govern- nates the opportunity to live and grow in car-
mental, and social communities. Regardless of ing. In the nursing situation that inspired
the role, the “responsibility of all is to recog- this poem, the nurse and nursed live caring
nize, value, and celebrate the unique ways car- uniquely. Initially, the nurse experiences the
ing is lived by colleagues, as well as to support familiar human dilemma, aware of separateness
7991_Ch19_333-348 12/08/19 5:20 PM Page 338
while choosing connectedness as he responds dreams and aspirations for growing in caring
to a yet unknown call for nursing: “My hands are realized: “His eyes meet mine … I open my
are moist, my heart is quick, my nerves are heart.” In the last stanza, the nursing situation
taut … I care for him.” As he enters the situ- is completed in linear time. But each one,
ation and encounters the patient as person, he nurse and nursed, goes forward newly affirmed
is able to “let go” of his presumptive knowing and celebrated as caring person, and the nurs-
of the patient as “angry.” The nurse enters ing situation continues to be a source of living
with the guiding perspective that all persons caring and growing in caring.
are caring. This allows the nurse to see past the
“anger-filled” room and to be “with him” Assumptions Underlying Nursing As
(Stanza 2). As they connect through their hu- Caring in the Context of the Nursing
manness, the beauty and wholeness of the one Situation
nursed is uncovered and nurtured. By living In Collins’s (1993) poem, the power of the
caring moment to moment, hope emerges, basic assumption that all persons are caring
and fear subsides. The nurse issues a direct in- by virtue of their humanness enabled the
vitation as “I open my heart” (Stanza 4) to nurse to find the courage to live his inten-
hear that which matters most in the moment. tions. The idea that persons are whole and
Through this experience, both nurse and complete in the moment permits the nurse to
nursed live and grow in their understanding accept conflicting feelings and to be open to
and expressions of caring. the nursed as a person, not merely as an entity
Clarity of the call for nursing emerges as the with a diagnosis and superficially understood
nurse begins to understand that this particular behavior. The nurse demonstrated an under-
man in this moment is calling to be known as standing of the assumption that persons live
a uniquely caring person, a person of value, caring from moment to moment, striving to
worthy of respect and regard. The nurse listens know self and other as caring in the moment
intently and recognizes the unadorned honesty with a growing repertoire of ways of ex-
that sounds angry and demanding and is a per- pressing caring. Personhood, a way of living
sonal expression of a heartfelt desire to be truly grounded in caring that can be enhanced in
known and worthy of care. The nurse responds relationship with a caring other, comes through
with steadfast presence and caring, communi- in that the nurse is successfully living his
cated in his way of being and of doing. The commitment to caring in the face of difficulty,
caring ingredient of hope is drawn forth as the and in the mutuality and connectedness that
man softens and the nurse takes notice. emerged in the situation. The assumption that
In the second stanza, the nurse enters the nursing is both a discipline and a profession is
room, experiences the challenge that his inten- affirmed as the nurse draws on a set of values
tion to nurse has presented, and responds to and a developed knowledge of Nursing As
the call for authentic presence and caring: “I’m Caring to actively offer his presence in service
with him now, I care for him.” Patterns of to the nursed.
knowing are called into play as the nurse brings Nursing practice guided by the theory of
together intuitive, personal knowing, empirical Nursing As Caring entails living the commit-
knowing, and the ethical knowing that it is ment to know self and other as living caring
right to offer care, creating the integrated in the moment and growing in caring. Living
understanding of aesthetic knowing that en- this commitment requires intention, formal
ables him to act on his nursing intention study, and reflection on experience. Mayeroff’s
(Boykin, Parker, & Schoenhofer, 1994; Carper, (1971) caring ingredients offer a useful
1978). Mayeroff’s (1971) caring ingredients starting point for the nurse committed to
of courage, trust, and alternating rhythm are knowing self and other as caring persons.
clearly evident. These ingredients include knowing, alter-
In the fourth stanza, the “caring between” nating rhythm, honesty, courage, trust, pa-
develops and personhood is enhanced as tience, humility, and hope. Roach’s (1992)
7991_Ch19_333-348 12/08/19 5:20 PM Page 339
six Cs—commitment, confidence, conscience, nurse is presented with someone for whom it
competence, compassion, and comportment— is difficult to care. “Difficult-to-care” situa-
provide another conceptual framework that is tions are those that demonstrate the extent of
helpful in providing a language of caring. knowledge and commitment needed to nurse
Coming to know self as caring is facilitated by effectively. In these extreme (although not
the following (Schoenhofer & Boykin, 1993, unusual) situations, a task-oriented, non–
pp. 85–86): discipline-based concept of nursing may be
adequate to ensure the completion of certain
■ Trusting in self; freeing self up to
treatment and surveillance techniques. Still,
become what one can truly become,
in our eyes, that is an insufficient response; it
and valuing self
certainly is not the nursing we advocate. The
■ Learning to let go, to transcend—to let go
Theory of Nursing As Caring calls on the
of problems, difficulties, in order to
nurse to reach deep within a well-developed
remember the interconnectedness that
knowledge base that has been structured
enables us to know self and other as living
using all available patterns of knowing,
caring, even in suffering and in seeking
grounded in the obligations inherent in the
relief from suffering
commitment to know persons as caring.
■ Being open and humble enough to experi-
These patterns of knowing may honor intu-
ence and know self to be at home with
ition and knowledge of self gained through
one’s feelings
reflection; empirical data emerging from ob-
■ Continuously calling to consciousness that
servation and nursing research; ethics; expres-
each person is living caring in the moment
sions of art; and the socio-political context.
and we are each developing uniquely in
All knowledge held by the nurse that may be
our growing in caring
relevant to understanding the situation at
■ Taking time to fully experience our
hand is drawn forward and integrated into
humanness, for one can only truly
situations of nursing practice. Although the
understand in another what one can
degree of challenge presented from situation
understand in self
to situation varies, the commitment to know
■ Finding hope in the moment
self and other as caring persons is steadfast.
All persons are caring, even when not all
chosen actions of the person live up to the
Applications of the Theory ideal to which we are all called by our hu-
Nursing Practice manness. In discussions of hypothetical sit-
The Nursing As Caring Theory, grounded in uations involving child molesters, serial
the assumption that all persons are caring, has killers, and even political figures who have
as its focus a general call to nurture persons attempted mass destruction and racial anni-
as they live caring uniquely and grow as car- hilation, certain ethical systems permit and
ing persons. The challenge for nursing, then, even call for making judgments. However,
is not to discover what is missing, weakened, when such a person presents to the nurse for
or needed in another but to come to know the care, the nursing ethic of caring supersedes
other as caring person and to nurture that all other values. The Theory of Nursing As
person in situation-specific, creative ways. Caring asserts that it is only through recog-
We no longer understand nursing as a nizing and responding to the other as a car-
“process” in the sense of a complex sequence ing person that nursing is created, and
of predictable acts resulting in some prede- personhood enhanced in that nursing situa-
termined desirable end product. Nursing, we tion. Caring effectively in “difficult-to-care”
believe is always unfolding, guided by inten- situations is the most challenging prospect a
tion and open to innovation. nurse can face. It is only with sustained in-
An everyday understanding of the mean- tention, commitment, study, and reflection
ing of caring is obviously challenged when the that the nurse is able to offer nursing in
7991_Ch19_333-348 12/08/19 5:20 PM Page 340
these situations. Falling short in one’s com- rule-driven conception of caring. Practice
mitment does not necessitate self-deprecation guided by the theory of Nursing As Caring
nor warrant condemnation by others; rather, reflects the assumption that caring is created
it presents an opportunity to care for self from moment to moment and does not de-
and other and to grow in personhood. Mak- mand idealized patterns of caring. Caring in
ing real the potential of such an opportunity the moment (and from moment to moment)
calls for seeing with clarity, reaffirming occurs when the nurse is living a committed
commitment, and engaging in study and re- intention to know and nurture the other as
flection, individually and in concert with caring person (Boykin & Schoenhofer,
caring others. 2000). No predetermined ideal amount of
To know the other as caring, the nurse time or form of dialogue is prescribed. Sim-
must find some basis for respectful human ple examples of living this intention to care
connection with the person. Does this mean follow.
that the nurse must like everything about the When the nurse goes first to the person,
person, including personal life choices? Per- rather than going directly to the IV or the
haps not; however, the nurse as nurse is not monitor, it becomes clear that the use of
called on to judge the other, only to care for technology is one way the nurse expresses
the other. A concern with judging or censuring caring for the person (Schoenhofer, 2001). In
another’s actions is a distraction from the real proposing his model of machine technologies
purpose for nursing—that is, coming to know and caring in nursing, Locsin (1995, 2001)
the other as caring person, as someone with distinguishes between mere technological
dreams and aspirations of growing in caring, competence and technological competence as
and responding to calls for caring in ways that an intentional expression of caring in nurs-
nurture personhood, that matter to the one ing. Simply avowing an intention to care is
nursed. not sufficient; the committed intention to
Nurses are frequently heard to say they have care is supported by serious study of caring
no time for caring, given the demands of the and ongoing reflection if nurses are to com-
role (Boykin & Schoenhofer, 2000). All nurs- municate caring effectively from moment to
ing roles are lived out in the context of a con- moment. As Locsin (1995, p. 203) so aptly
temporary environment, and the environment stated:
for practice, administration, education, and re-
search is fraught with many challenges. Here As people seriously involved in giving care know,
is a short but illustrative list of these challenges there are various ways of expressing caring. Pro-
(Boykin, Schoenhofer, & Valentine, 2014): fessional nurses will continue to find meaning in
their 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 technol-
giver, as well as the one seeking care ogy the practice of nursing is transformed into an
■ Demands for immediate and measurable experience of caring.
outcomes that favor a focus on the sim-
Another example of living the commit-
plistic and the superficial
ment to care is witnessed in caring for the
■ Organizational and occupational configu-
unconscious person. How is this commit-
rations that tend to promote fragmenta-
ment lived? It requires that all ways of know-
tion and alienation
ing be brought into action. The nurse must
■ Economic focus and profit motive (“time
make self as caring person available to the
is money”) as the apparent prime institu-
one nursed. The fullness of the nurse as car-
tional value
ing person is called forth. This requires use
Nurses express frustration when evaluat- of Mayeroff’s caring ingredients: the alter-
ing their own caring efforts against an idealized, nating rhythm of knowing about the other
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and knowing the other directly through au- that is part of that person’s life, and recognize
thentic presence and attunement; the hope postmortem care as truly nursing. One nurse
and courage to risk opening self to one was moved by the beauty of postmortem nurs-
who cannot communicate verbally, patiently ing care offered by her colleagues in the oper-
trusting in self to understand the other’s ating room and shared this poetic expression
mode of living caring in the moment; honest of connectedness.
humility as one brings all that one knows and
remains open to learning from the other. The JOURNEY’S END
nurse attuned to the other as person might, The chaos has stopped,
for example, experience the vulnerability of The journey from birth to death has ceased,
the person who lies unconscious from surgi- Your body lies on the OR table, alone,
cal anesthetic or traumatic injury. In that vul- We cluster at the end of the room,
nerability, the nurse recognizes that the one Making the necessary phone calls,
nursed is living caring in humility, hope, and Starting the paperwork,
trust. Instead of responding to the vulnera- Telling the young resident:
bility, merely “taking care of” the other, the “Yes, you must complete the paperwork.” And
nurse practicing Nursing As Caring might “Go talk to the family now,”
respond by honoring the other’s humility, by Then we turn back to you
participating in the other’s hopefulness, by And begin our reverent and loving care:
steadfast trustworthiness. Creating caring in Covering your wound, removing the lines,
the moment in this situation might come cleansing your body,
from the nurse resonating with past and One of us says, “We are being good nurses,”
present experiences of vulnerability. Con- And another quips back, “It’s because we are old
nected to this form of personal knowing nurses,”
might be an ethical knowing that power as a And we laugh
reciprocal of vulnerability can develop unde- (But we know we will teach the young ones how
sirable status differential in the nurse–patient to do this too),
role relationship. As the nurse sifts through We place you on a stretcher (not the gruesome
myriad empirical data, the most significant morgue gurney)
information emerges—this is a person with And take you to the viewing room,
whom I am called to care. Ethical knowing One of us goes and brings your family to you,
again merges with other pathways as the Murmuring comfort, “We are so sorry for your
nurse forms the decision to go beyond vul- loss.”
nerability and engage the other as caring per- After a few minutes, we leave
son, rather than as helpless object of And return to the OR
another’s concern. Aesthetic knowing comes To take care of another patient.

in the praxis of caring, in living chosen —FLORENCE N. COOPER, RN
ways of honoring humility, joining in hope,
and demonstrating trustworthiness in the The nurse practicing within the caring con-
moment (Schoenhofer & Boykin, 1993, text described here will most often be interfac-
pp. 86–87). ing with the health-care system in two ways:
A third example of living the intention to first, communicating nursing so that it can be
care is evidenced in postmortem care: “Nurses understood; second, articulating nursing serv-
speak of caring for their deceased patients as ice as a unique contribution within the system
nursing those who have gone and who are still in such a way that the system itself grows to
in some way present” (Boykin & Schoenhofer, support nursing. Recognizing these system re-
2001a, p. 19). Nurses who practice in end-of- lationships as aspects of the dance of caring
life situations offer genuine presence, continue persons involving the nursed and family and
to feel the human connection to the person encompassing all who are part of the system is
who has recently died and to the family circle crucial for creating the kind of environment in
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which caring is expressed effectively and per- Schoenhofer, 2001b). The nurse administrator,
ceived as growth-promoting. whether at the executive or managerial level of
the organization chart, is held accountable for
Nursing Administration “customer satisfaction” as well as for the “bottom
From the viewpoint of the theory of Nursing line.” Nurses who move up the executive ladder
As Caring, the nurse administrator makes deci- may be suspected of disassociating from their
sions through a lens in which the focus of nurs- nursing colleagues on the one hand and of not
ing is on nurturing persons living caring and being sufficiently cognizant of the harsh realities
growing in caring. All activities in the practice of fiscal constraint on the other hand. Adminis-
of nursing administration are grounded in a trative practice guided by the assumptions and
concern for creating, maintaining, and support- themes of Nursing As Caring can enhance elo-
ing an environment in which calls for nursing quence in articulating the connection between
are heard and nurturing responses are offered. caregiver and institutional mission: the person
From this point of view, the expectation arises seeking care. Nursing practice leaders who rec-
that nursing administrators participate in shap- ognize their care role, indirect as it may be, are
ing a culture that evolves from the values artic- in an excellent position to act on their commit-
ulated within the theory of Nursing As Caring ted intention to promote caring environments.
and recognized as the dance of caring persons. Participating in rigorous negotiations for fiscal,
Although often perceived to be “removed” material, and human resources and for improve-
from the direct care of the nursed, the nursing ments in nursing practice calls for special skill on
administrator is intimately involved in multiple the part of the nurse administrator, skill in rec-
nursing situations simultaneously, hearing calls ognizing, acknowledging, and celebrating the
for nursing and participating in responses to other (e.g., CEO, CFO, nurse manager, or staff
these calls. As calls for nursing are known, one nurse) as a caring person. The nurse administra-
of the unique responses of the nursing adminis- tor who understands the caring ingredients
trator is to enter the world of the nursed either (Mayeroff, 1971) recognizes that knowing self
directly or indirectly, to understand special calls as caring person is essential to a practice of nurs-
when they occur, and to assist in securing the re- ing administration grounded in caring. This
sources needed by each nurse to nurture persons knowledge of self helps one to understand what
living and growing in caring (Boykin & Schoen- it means to live and grow in caring and to ap-
hofer, 1993). All administrative activities should preciate that caring is neither soft nor fixed in its
be approached with this goal in mind. Here, the expression. A developed understanding of the
nurse administrator reflects on the obligations caring ingredients helps the nurse administrator
inherent in the role in relation to the nursed. The mobilize the courage to be honest with self and
presiding moral basis for determining right ac- “other,” to trust patience, and to value alternat-
tion is the belief that all persons are caring. Fre- ing rhythm with true humility while living a
quently, the nurse administrator may enter the hope-filled commitment to knowing self and
world of the nursed through the stories of col- “other” as caring persons.
leagues who are assuming another role, such as The publication Health Care System Transfor-
that of nurse manager. Policy formulation and mation for Nursing and Health Care Leaders:
implementation allow for the consideration of Implementing a Culture of Caring (Boykin,
unique situations. The nursing administrator as- Schoenhofer, & Valentine, 2014) proposes prac-
sists others within the organization to under- tical strategies for total, integrated system trans-
stand the caring focus of nursing and to secure formation based on the tenets of the dance of
the resources necessary to achieve the goals of caring persons and grounded in the assumptions
Nursing As Caring. of Nursing As Caring. Many of the challenges of
The nurse administrator is subject to chal- nurse managers and nurse administrators, as well
lenges similar to those of the practitioner and as those experienced by other health-care system
often walks a precarious tightrope between direct leaders, are currently being addressed by the In-
caregivers and corporate executives (Boykin & stitute of Medicine, The Joint Commission, and
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other health policy groups. Solutions implied in In this nursing situation, the dance of car-
the Hospital Consumer Assessment of Health- ing persons helped these nurse practitioners
care Providers and Systems are congruent with to widen their focus so that the family and
the values of the Theory of Nursing As Caring community joined the dance. Initially, these
and are amplified and given substance by specific nurse practitioners engaged with a woman
assumptions and themes of Nursing As Caring. living with diabetes; over time, the “caring
When the practice of administration of between” expanded to the nephew and the
nursing services is guided by the Theory of larger community.
Nursing As Caring, the dance of caring persons
(Boykin & Schoenhofer, 2001b; Hilton & Nursing Education
Sherman, 2015; Linette & Sherman, 2014; Pross From the perspective of Theory of Nursing As
et al., 2011) is the organizing model. This Caring, all nursing structures and activities
relational model is a framework for transform- should reflect the fundamental assumption
ing not only nursing but entire health-care that persons are caring by virtue of their hu-
systems. manness. This view applies in nursing educa-
tion as in practice and administrative role
Nursing Practice engagement. Other assumptions and values
Two nurse practitioners, Kathi Voege Harvey, reflected in the education program include
FNP, and Elizabeth Tsarnas, FNP, whose knowing the person as whole and complete in
practice setting is a primary care clinic, shared the moment and living caring uniquely; under-
their way of creating Nursing As Caring in a standing that personhood is a way of living
community-based program of nursing for per- grounded in caring and is enhanced through
sons living with diabetes. participation in nurturing relationships with
caring others; and, finally, affirming nursing as
One evening after a support group, which BP and a discipline and profession.
her mother-in-law attended, we walked them to The curriculum, the foundation of the edu-
the front of the building where they met BP’s hus- cation program, asserts the focus and domain
band, who had been exercising in the gym as part of nursing as nurturing persons living caring
of the comprehensive diabetes care clinic, and his and growing in caring; thus, all activities of the
nephew, who was only 12 years old and had been program of study are directed toward develop-
abandoned by his natural parents. As we intro- ing, organizing, and communicating nursing
duced ourselves to this shy, very thin, 12-year-old knowledge, that is, knowledge of nurturing
young man, we engaged him in conversation so persons living caring and growing in caring
that we could come to know him. We learned that (Touhy & Boykin, 2008).
he had been made to come but was angry be- The dance of caring persons relational
cause he was too young to be in the gym. His model is relevant for organizational design of
grandmother had previously confided in us that nursing education, as well as for nursing prac-
he did not have any friends, did not participate in tice (Welch, 2015). Participants in the dance
anything, and that he was beginning to have anger of caring persons include administrators, fac-
outbursts. We identified yet another call for nurs- ulty, colleagues, students, staff, community,
ing and decided to explore possible sports or ac- and the nursed and their families. What the
tivities in which this young man would like to dance of caring persons represents in nursing
participate. After some investigation, we were able education settings is the commitment of each
to include him in an adolescent “boot camp” that dancer to understand and support the study of
met at the same time as his family’s exercise the discipline of nursing. The role of educa-
classes and also a soccer team right on the prem- tional administrator in the circle is more clearly
ises. As he experiences caring through nurturing understood through reflection on the origin of
with his family and us, it is our hope that his fears the word. The term administrator derives from
will subside and allow him to realize the beauty of the Latin ad ministrare, to serve (according to
his uniqueness and his boundless potential. Webster’s New World Dictionary of the American
7991_Ch19_333-348 12/08/19 5:20 PM Page 344
Language; Guralnik, 1976). This definition Valentine, 2014; Schoenhofer, 1995; Schoenhofer
connotes the idea of rendering service. Admin- & Boykin, 1998a).
istrators within the circle are by the nature of The practicality of the Theory of Nursing
their role obligated to ministering, to securing, As Caring has been tested in various nursing
and to providing resources needed by faculty, practice settings. Nursing practice models have
students, and staff to meet program objectives. been developed in acute and long-term care
Faculty, students, and administrators dance to- settings. Research studies focused on design-
gether in the study of nursing. Faculty support ing, implementing, and evaluating a theory-
an environment that values the uniqueness of based practice model using Nursing As Caring
each person and sustains each person’s unique on a telemetry unit of a for-profit hospital
way of living caring and growing in caring. (Boykin, Schoenhofer, Smith, St. Jean, &
This process requires trust, hope, courage, and Aleman, 2003); the emergency department of
patience. Because the purpose of nursing edu- a community hospital (Boykin, Bulfin, Baldwin,
cation is to study the discipline and practice of & Southern, 2004; Boykin, Schoenhofer,
nursing, the nursed must be in the circle. The Bulfin, Baldwin, & McCarthy, 2005); and the
community created is that of persons living intensive care unit of a for-profit hospital
caring in the moment and growing in person- (Dyess, Boykin, & Bulfin, 2013) have demon-
hood, each person valued as special and unique strated that when nursing practice is intention-
(Boykin & Schoenhofer, 1993, pp. 73–74). ally focused on coming to know a person as
In teaching Nursing As Caring, faculty as- caring and on nurturing and supporting those
sist students to come to know, appreciate, and nursed as they live their caring, transformation
celebrate self and the ones nursed as caring of care occurs. Within these practice models
persons. Students, as well as faculty, are in a based on Nursing As Caring, those nursed
continual search to discover greater meaning could articulate the “experience of being cared
of caring as uniquely expressed in nursing. Ex- for”; patient and nurse satisfaction increased
amples of a nursing education program based dramatically; nurse retention increased; and
on values similar to those of Nursing As Car- the environment for care became grounded in
ing are illustrated in the book Living a Caring- the values of and respect for person.
based Program (Boykin, 1994). Touhy, Strews, and Brown (2005) described
a project to transform an entire for-profit
Nursing Research and Development health-care organization by intentionally
The roles of researcher and developer in nurs- grounding it in Nursing As Caring. Caring from
ing take on a focus when guided by the Theory the heart—the model for interdisciplinary prac-
of Nursing As Caring. The assumptions and tice in a long-term care facility and based on
focus of nursing explicated in the theory pro- the theory of Nursing As Caring—was designed
vide an organizing value system that suggests through collaboration between project person-
certain key questions and methods. Research nel and all stakeholders. Foundational values of
questions lead to exploration and illumina- respect and coming to know ground the model,
tion of patterns of living caring personally which revolves around the major themes of re-
(Schoenhofer, Bingham, & Hutchins, 1998) sponding to that which matters, caring as a way
and in nursing practice (Schoenhofer & Boykin, of expressing spiritual commitment, devotion
1998b). Dialogue, description, and innova- inspired by love for others, commitment to cre-
tions in interpretative approaches characterize ating a home environment, and coming to
research methods. Development of systems know and respect person as person. The major
and structures (e.g., policy formulation, infor- building blocks of the nursing model for an
mation management, nursing delivery, and acute-care hospital and for a long-term care
reimbursement) to support nursing necessi- facility each reflect central themes of Nursing
tates sustained efforts in reframing and refo- As Caring, but those themes are drawn out in
cusing familiar systems, as well as creating ways unique to the setting and to the persons
novel configurations (Boykin, Schoenhofer, & involved in each setting. The differences and
7991_Ch19_333-348 12/08/19 5:20 PM Page 345
similarities in these two practice models machines including robots in the practice of
demonstrate the power of the Theory of Nurs- nursing.
ing As Caring to transform practice in a way Nursing administration, nursing practice,
that reflects unity without conformity, unique- nursing education, and nursing research re-
ness within oneness. quire a full understanding of nursing as nur-
The Theory of Nursing As Caring is the turing persons living caring and growing in
underpinning for research and development caring. The online supplemental resource for
by nursing education scholars. Welch (2015) this chapter contains four practice exemplars,
related themes uncovered in a phenomeno- illustrating the use of the Nursing As Caring
logical study of student caring for faculty to Theory to guide practice in nursing admin-
the major themes of Nursing As Caring. The istration, clinical simulation laboratory in
model for primary care developed by Dunphy, nursing education, and nursing research. The
Winland-Brown, and Porter (2011) draws on exemplars were drawn from the practice expe-
themes of the theory as well. rience of the nurses who wrote them, and most
The Theory of Nursing As Caring is the illustrate stories of actual nursing situations. A
foundational nursing theoretical framework for nursing administration exemplar addresses
middle-range theories addressing technology health-care system leadership and caring. The
and technological advances in nursing and nursing education exemplar illustrates the use
health care (Locsin, 1995; Tanioka, 2017). In of the simulation laboratory in teaching nurs-
1995, Locsin launched his vision of the right ing from the perspective of Nursing As Car-
relationships between technology and caring in ing. Two research exemplars are also provided
nursing. That early publication led to research online, one focusing on the development of a
and development of the middle-range theory research approach compatible with Nursing As
of Technological Competency as Caring in Caring, and a second addressing the use of
Nursing in the universal technological do- Nursing As Caring as the nursing theoretical
main (Locsin, 2001; Locsin & Purnell, 2015). perspective underpinning a doctoral disserta-
Tanioka’s middle-range theory of Transactive tion study.1
Relationship Theory of Nursing (TRETON),
grounded in the theory of Nursing As Caring
and Locsin’s middle-range theory, is a caring- 1For additional information, see the bonus chapter content
based framework for positioning intelligent available at http://davisplus.fadavis.com.
Practice Exemplar
“The Mirror,” written by Emily every step, trying to regain a physical closeness
Hunter Werthman, RN that had been so difficult to maintain in the
We walked down the hallway towards the months in the intensive care unit.
mirror. The fluorescent lights drew her newly The mirror was a full length one designed
formed scars in sharp relief, highlighting the for staff to use after changing into scrubs. It
new topography of her skin. Her 17-year-old was the only mirror large enough for her to see
eyes peered out at me with worry. Her par- the full devastation of her injuries. As we had
ents, boyfriend, and psychologist walked be- walked around the unit in the days leading up
yond us like a funeral procession. Their eyes to this day, she had peeked furtively at her ap-
downcast on the floor, their hands trembling, pearance in the security mirrors in the corners
their breaths coming in short, audible gasps of the hallways. She had an inkling that her
behind my back. I could feel her mother’s face and chest had been burned, but she had
breath on my neck as we reached the mirror. not seen herself since the day of the bonfire.
She was inching her way closer to us with It was well after my shift should have been
(continued)
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over by the time we worked up the courage got her Passey-Muir valve and spoke, the day
to do it. The fellow on call refused at first, she told me what music she wanted to listen
saying the surgeon should be there. But she to during wound care.
insisted. She wanted me to be there. “My It shouldn’t have surprised me that I would
nurse,” she said. “My nurse can do it.” feel the mirror too. She stood in front of it
I had admitted her the day she came to with her eyes closed. When she opened them,
us. Her skin was still hot to the touch and she didn’t look for herself in the mirror. She
she smelled like a happy, autumn day: smoke, found my eyes there. We looked at each other
wood, fire, and leaves. The trauma bay smelled there in the mirror, nurse and patient. We
so lovely, I was almost surprised to see the each took some deep breaths as she finally
blisters and the blood. Her face was begin- looked. I could feel the tears in her hand be-
ning to swell and would, over the course of fore I saw them. Her grasp tightened on my
24 hours, swell to almost three times its size. hand. Her finger amputations had not yet
Her eyes were swollen shut. Her ears were no healed so I felt the strings from her sutures
more. Her breasts were so swollen from the scratching my palm. I desperately wanted to
burns that I knew we would most likely have itch them. Her eyes were searching for some-
to perform a bilateral mastectomy on this thing familiar in her own reflection and failing
child. to find it.
Her parents arrived then. Her mother be- Her face had the tight appearance of a
came feral. Her screams were audible in the mask. The color was off—a bright red that
elevator bay as I made my way up to the unit somehow managed to still look pale, like lip-
to prepare for her daughter’s admission. Her stick rubbed off. Her mouth pulled tight at the
father, a stoic man, stood silent and pale, corners where the scars were forming, causing
quietly asking for a chair. I told them I would a near constant stream of saliva. Her eye-
take care of her like she was my own, newly brows, hair, and lashes were gone. Her facial
pregnant with my first child at the time. For features were nearly entirely gone. In truth, I
months after that, I did just that: caring, en- knew she looked like a monster. Those were
couraging, chastising, confiding. the words she used, “I’m a monster.” She
We spent hours alone each week as I looked at me as if it were a question. Before I
changed her dressings. She knew my daughter could answer, the well-meaning lies of her
was a girl before I did, the morning sickness parents began. You are beautiful, you will al-
she said. I was diagnosed with hyperemesis ways be beautiful, and the people who love
gravidarum and would often have to leave her you know that. “But what about the people
room to vomit. Eventually she told me to that don’t?” She looked at me again. I took a
stop, as it drew out the process of the dressing breath and found her eyes in the mirror. “Your
change longer. “Just do it in here. You clean outside doesn’t match your inside, but whose
my poop, I don’t think I can complain about does,” I asked. I laughed a little. “Will anyone
your puke.” ever love me again?” More lies from her par-
And so, it went for months. I felt each of ents followed. She looked at me again. “I don’t
her setbacks as personal failures: pneumonia, know,” I said, “but how about we work on you
sepsis, wound infections, amputations. I loving you first?”
should have suctioned her more, I should I still don’t know if it was the right thing
have noticed that temperature variation, that to say. I still don’t know if I could have saved
wound bed should have been cleaned better, her fingers had I titrated quicker. I still don’t
those black fingers were from the pressors I know if any of it would have made a differ-
should have titrated quicker. I felt her suc- ence. What I do know is that she was right;
cesses too: the day she walked, the day she her nurse could do it.
7991_Ch19_333-348 12/08/19 5:20 PM Page 347
Summary
The Theory of Nursing As Caring is grounded situation. In nursing situations, shared lived
in the assumptions that persons are caring by experiences of caring, the nurse hears calls for
virtue of their humanness, that caring unfolds caring and creates effective caring responses.
moment to moment, that personhood is living In the caring between nurse and nursed, per-
grounded in caring, and that personhood is en- sonhood is enhanced.
hanced in relationships with caring persons. The Theory of Nursing As Caring is used
From that basic philosophical perspective, the by practitioners and administrators of nurs-
focus of nursing as a discipline and a profes- ing services in a range of institutional and
sional practice is nurturing persons living car- community-based nursing practice settings.
ing and growing in caring. The nurse enters The theory is also used to guide nursing edu-
into the world of the other with the intention cation, nursing education administration, and
of knowing the other as person living caring nursing research. More detailed information
and growing in caring. In authentic presence, about the theory, an extensive bibliography,
the nurse offers a direct invitation to the one and examples of use of the theory are available
nursed to express what matters most in the at http://nursingascaring.com.
Questions for Reflection ■ How would you “re-language” a research

question consistent with the Theory of
and Discussion Nursing As Caring that would address the
■ In the practice exemplar in this chapter, “outcomes” of nursing practice guided by
how do the nurse and family express living this theory?
and growing in caring?
■ How does the theory of Nursing As
Caring call for a “re-languaging” of
outcomes of care in nursing?
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SE C T I O N
VI
Middle-Range Theories
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SECTION
VI Middle-Range Theories
Fourteen middle-range nursing theories are presented in this final section. Other than
Chapter 33, each chapter is written by the scholars who developed the theory.
Although all can be classified to be at the middle range because of their more cir-
cumscribed focus on a phenomenon and more immediate relationship to practice
and research, they still vary in level of abstraction.
Transitions are part of the human experience, and how we negotiate these
transitions affects health and well-being. Afaf Meleis’ Transitions Theory appears in
Chapter 20. The theory includes the elaboration of transition triggers, properties of
transitions, the conditions of change, and patterns of responses to transitions. Nursing
interventions to promote a smooth passage during transitions are described.
Comfort is an important concept to nursing practice. Katherine Kolcaba’s middle-
range Theory of Comfort is presented in Chapter 21. 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.
Joanne Duffy’s Quality-Caring Model, described in Chapter 22, is being used in
many healthcare settings to address the issues of patient satisfaction 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.”
Pamela Reed’s Theory of Self-Transcendence is presented in Chapter 23. 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), in-
terpersonally (to connect with others, nature, and surrounding environment), transper-
sonally (to relate in some way to dimensions 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).
Mary Jane Smith and Patricia Liehr present Story Theory in Chapter 24. They posit
that story is a narrative happening wherein a person connects with self-in-relation
through nurse–person intentional dialogue to create ease. This theory has already
been applied in a number of practice and research initiatives.

Marilyn Parker and Charlotte Barry’s Community Nursing Practice Model
(Chapter 25) has guided nursing practice in community settings in several countries.
The model is represented by concentric circles with the nursing situation as core and
connected with the outer spheres of influence in the community and environment.
Chapter 26 contains Rozzano Locsin’s Theory of Technological Competency as
Caring in Nursing. With this theory Locsin 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.
Marilyn Ray and Marian Turkel coauthored Chapter 27 on Ray’s Theory of Bureau-
cratic Caring (BCT), as well as their Theory of Relational Complexity. BCT uses a mul-
tidimensional, holographic model to facilitate the understanding of caring within the
complex environment of health-care systems. The theory is being used to guide the
U.S. Air Force nursing services.
350
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In Chapter 28 Meredith Troutman-Jordan describes her Theory of Successful

Aging. The theory was informed by Roy’s adaptation model and Tornstam’s Theory of
Gerotranscendence. Successful aging is characterized by living with meaning and
purpose. Intrapsychic factors, functional performance, and spirituality contribute to
gerotranscendence and successful aging.
Elizabeth Barrett details her Theory of Power as Knowing Participation in Change
in Chapter 29. This middle-range theory is derived from Rogers’ Science of Unitary
Human Beings. Barrett identifies the dimensions of power as awareness, choices,
freedom to act intentionally, and involvement in creating change. The theory has been
used extensively in research, often tested using Barrett’s instrument.
In Chapter 30 Marlaine Smith presents her Theory of Unitary Caring. The theory
evolved from viewing caring through the lens of unitary science. The concepts of
the theory are manifesting intentions, appreciating pattern, attuning to dynamic
flow, experiencing the Infinite, and inviting creative emergence.
Kristen Swanson completely rewrote Chapter 31 for this edition to expand on her
caring theory (Swanson Caring Theory [SCT]) by including the healing outcomes of
caring elaborating on recent research and practice applications of the theory. SCT
includes the processes of knowing, being with, doing for, enabling, and maintaining
belief.
Two new chapters were added to this edition; both feature theories originating
from scholars outside the United States. Adeline Falk-Rafael’s Critical Caring Theory
(Chapter 32) was developed through a synthesis of Watson theory, Nightingale’s ideas
about nursing, and feminist critical-social theories. She elaborates the praxis dimen-
sion of critical caring theory and the applications of the theory, especially useful for
guiding public health nursing practice. In Chapter 33, Diane Gullett and Camilla
Koskinen elaborate Katie Eriksson’s Theory of Caritative Caring. Koskinen has worked
with Eriksson, and both authors have conducted research based on the theory. The
theory has foundations in human science and includes concepts of caritas, whole-
ness of human beings, suffering and health, caring, and the value of human dignity.
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Afaf Meleis’ Transitions

CHAPTER
20
Theory
Afaf I. Meleis

Practice Exemplar by Diane Gullett Dr. Afaf I. Meleis is a Professor of Nursing
Summary and Sociology and the former Margaret Bond
Questions for Reflection and Discussion Simon Dean of Nursing at the University of
Pennsylvania School of Nursing, as well as the
former Director of the School’s World Health
Organization Collaborating Center (WHOCC)
for Nursing and Midwifery Leadership. Before
coming to Penn, she was a Professor on the fac-
ulty of nursing at the University of California
Los Angeles and the University of California
San Francisco for 34 years, where she is currently
a Professor Emeritus. She is a member of the
National Academy of Medicine and the Amer-
ican Academy of Nursing, as well as a Fellow of
the Royal College of Nursing in the United
Kingdom and the College of Physicians of
Philadelphia. She is a former member of the
George W. Bush Presidential Center Women’s
Initiative Policy Advisory Council and the Na-
tional Institutes of Health Advisory Committee
on Research on Women’s Health, as well as a
former Board Member of the Consortium of
Universities for Global Health and CARE
USA. She cochaired the IOM Global Forum on
Innovation for Health Professional Education

and the Harvard-Penn-Lancet Commission on
Women and Health. Dr. Meleis is also Presi-
dent Emerita and Counsel General Emerita of
the International Council on Women’s Health
Issues and a former Global Ambassador for
the Girl Child Initiative of the International
Council of Nurses.
Dr. Meleis’ research and scholarship focus
on the theoretical structure and organization
of nursing knowledge and global women’s
health. She is the originator of transition as a
central nursing phenomenon and the middle-
range Theory of Transitions, which she devel-
oped with her doctoral and postdoctoral
353
7991_Ch20_349-370 12/08/19 5:20 PM Page 354
354 S E C T IO N V I ■ Middle-Range Theories
students. This theory continues to be translated Origins of the Theory

into policy, research, and evidence-based prac- Three paradigms guided the development of
tice for higher-quality care in the 21st century. Transitions Theory in more than 40 years of
She has mentored hundreds of students, clinical research and theoretical work. The first
clinicians, and researchers from around the is Role Theory, a dynamic and interactionist par-
world, who, under her guidance, achieved adigm developed by Dr. Ralph Turner, the
prominent leadership positions. She is the father of Interactive Role Theory. Role Theory
author of more than 200 articles in social framed the type and nature of questions about
sciences, nursing, and medical journals; more how to help patients, clients, and families in
than 40 chapters; seven books; and numerous their transition from one role to another, how
monographs and proceedings. Her award- to take on a new role, or how to change behav-
winning book, Theoretical Nursing: Develop- iors in a role. I wondered about the mecha-
ment and Progress, is now in its sixth edition nisms and the processes that new mothers and
(Meleis, 1985, 1991, 1997, 2007, 2012, 2018) fathers learned and negotiated as they became
and is used widely throughout the world. adept at performing the behaviors of parenting,
at picking up the cues that differentiate the
meaning of the different crying episodes or dif-
Overview of the Theory ferent patterns of sleep. From that theoretical
A person is admitted to the hospital; another heritage, I developed a framework for interven-
is being discharged to a home, to a rehabilitation that I called role supplementation (Meleis,
tion center, or to an assisted-living facility; a 1975). This framework requires the nurse to
third is diagnosed with a life-threatening dis- accurately analyze the goals, sentiments, and
ease; a fourth is preparing for an intrusive sur- behaviors necessary for the role he or she wishes
gery; a fifth just got the news that her spouse to help the client develop. Such roles might in-
has a long-term illness; and a sixth is a new clude parenting roles, patient roles, or wellness
graduate from a nursing school beginning his roles. The desired outcome of applying role
first position as a nurse. What do they all have theory is the client’s mastery of the role. Nurses
in common? Each of these scenarios is about help people acquire or change roles by model-
the experience and responses of people to ing behaviors, allowing their clients to rehearse
health and illness situations; the experience of roles, and providing them with support while
coping with changes from one phase, site, they are developing these roles.
identity, position, role, or situation to another. A second paradigm that influenced the devel-
The change event itself—whether it is birthing opment of Transitions Theory is the lived expe-
a baby, starting a new position, receiving a life- rience, which contrasts the perceived views with
changing diagnosis, or facing impending the received views. As we, in nursing, began
death, hospitalization, or surgery—is a turning questioning what we know and how we know it,
point, but the experience is more fluid and it became apparent that other ways of knowing
longitudinal. The transition experience starts (Carper, 1978) complement and, perhaps, tran-
before the event and has an ending point that scend empirical knowing. This personal, experi-
is fluid, that varies based on many variables. ential knowing is by its nature subjective. It is
Understanding the nature of and responses to more holistic and encompassing, embedded in
change, facilitating and supporting the expe- practice, and framed by history. Based on the
rience and responding to it at different phases, writing of many illuminating nonnurse authors
and remaining or becoming healthy before, (Polanyi, 1962) and nurse authors (among them
during, or at the end of the event, wherever Benner, Tanner, & Chesla, 1996; Munhall,
that elusive ending point is, is what Transi- 1993; Sarvimaki, 1994), I described the perceived
tions Theory is about. This theory provides a view (Meleis, 2012) and used it as a driving par-
framework to generate research questions and adigm for the development of the concept of
to serve as a guide to effective nursing care be- transitions (Chick & Meleis, 1986). This para-
fore, during, and after the transition. digm helped us focus on questions related to the
7991_Ch20_349-370 12/08/19 5:20 PM Page 355
C H APTER 20 ■ Afaf Meleis’ Transitions Theory 355
nature and lived experience of the response to ■ Individuals have the capacity to learn and
change and the experience of being in transition. enact new roles.
The third paradigm that informs Transi- ■ By producing critical and well-supported
tions Theory is that of feminist postcolonial- evidence of inequities in health-care sys-
ism. The tenets of this paradigm encompass an tems, strategies could be developed and
epistemic system that questions power rela- implemented to enhance equities.
tionships in societies and institutions and that ■ Gender, race, culture, heritage, and sexual
links societal and political oppressions that orientation are contexts that shape people’s
shape the responses to change events. This par- experiences and outcomes of health–illness
adigm gave us a framework for understanding events, as well as the health care provided.
the experience of transition through the mul- ■ Nursing perspective is defined by human-
tiple lenses of race, ethnicity, nationality, and ism, holism, context, health, well-being,
gender. Each of these qualities creates power ability to manage daily activities, compas-
differentials that must be considered if we truly sion, and caring.
want to understand how people experience and ■ Environment is defined as physical, social,
cope with transition and to provide preventive cultural, organizational, and societal and it
and therapeutic interventions to help them influences experiences, responses, inter-
achieve health and wellness outcomes. Using ventions, and outcomes.
a feminist postcolonialist framework helps us ■ Individuals, families, and communities are
consider the conditions shaped by power in- partners in the care processes.
equities in a society or in institutions of healing
(e.g., hospitals, nursing homes, community Concepts and Propositions
agencies) and how these power inequities can of Transitions Theory
shape the allocation of resources, as well as the The Transitions Theory provides a framework
provision of nursing care through transitions. to describe the experience of individuals who
The delineation of conditions surrounding the are confronting, living with, and coping with
transition experience was illuminated by em- an event, a situation, or a stage in growth and
ploying a feminist postcolonialist framework. development that requires new skills, senti-
These three paradigms—Role Theory, per- ments, goals, behaviors, or functions. Transi-
ceived views on lived experiences, and feminist tion is defined as “a passage from one life
postcolonialism—shaped the evolution of Tran- phase, condition, or status to another” (Chick
sitions Theory through some 40 years of its & Meleis, 1986). It is a complex and multifac-
development. eted concept embracing several components,
including process, time span, and perception.1
Assumptions of the Theory
■ A human being’s responses are shaped by

1This section of the chapter borrows heavily from the many
interactions with significant others and
publications about this theory, which evolved and was
reference groups. transformed by many mentees and collaborators over the
■ Change, through health and illness events years (Chick & Meleis, 1986; Meleis, 2010; Meleis,
and situations, triggers a process that be- Sawyer, Im, Schumacher, & Messias, 2000; Schumacher
gins at or before and extends beyond the & Meleis, 1994). Without the partnerships, the coauthor-
ship, and collaboration of many mentees, I would not have
event time.
been able to develop Transitions Theory. It is an integration
■ Whether aware or not aware, individuals of all the previous writings about Transitions Theory. Their
and/or families experience a process, influence is manifested in the many co-authored publica-
shaped by changes resulting in varied tions. Among my mentee collaborators are Drs. DeAnne
responses and outcomes. Messias, Eun-Ok Im, Kathy Dracup, Linda Sawyer,
Karen, Schumacher, Pat Jones, Norma Chick, Leslie
■ Responses and outcomes to changes are
Swendsen, and Patrician Tragenstein. While I acknowl-
shaped by the nature of the experience. edge and respect the co-opted contributions of all my col-
■ Preventive and therapeutic actions can in- laborators, the liberty I have taken in integrating the theory
fluence the responses and final outcomes. from all previous work is entirely my responsibility.
7991_Ch20_349-370 12/08/19 5:20 PM Page 356
Transition Triggers menopause) or by roles (e.g., mothering, father-

Four types of situations trigger a transition ing, marrying, divorcing).
experience (Fig. 20-1). All are characterized Developmental transitions influence the
by some type of change. Change is related health and well-being of people and may or
to an external event, whereas transition is an may not require interfacing with health-care
internal process (Chick & Meleis, 1986). professionals and the health-care system.
The first trigger is a change in health or an Developmental phases and roles influence
illness situation that could initiate a diagnosis health and illness behaviors, as well as inform
or an intervention process, particularly the the responses of individuals to such events as
kinds that require prolonged diagnostic pro- birthing or breastfeeding, among many oth-
cedures or treatment protocols, for example, ers. These examples of developmental tran-
cancer, schizophrenia, autism, diabetes, or sitions are of interest to nursing because of
Alzheimer’s disease, among others. Each of the evidence in the literature that demon-
these diagnoses is preceded by many un- strates how nurses deal with, what they write
knowns, uncertainties about the processes about and research, and how they care for in-
that follow, and fears about consequences. dividual health-care needs during many
They all also require new behaviors, re- phases of development.
sources, and coping strategies, and they in- Similarly, the third change trigger for a
volve sets of relationships that are newly transition is what we call situational transi-
established, changed, or severed. tions, all of which have health-care implica-
A second trigger is developmental transitions. These are exemplified by experiences
tions, which are exemplified by life phases as and responses to situational changes such as
manifested by age (e.g., adolescence, aging, the admission to or discharge from a hospital
Change Triggers Properties Conditions Patterns of Response
Developmental Time span Process Outcome

Personal
Engaging Mastery
Process
Situational Fluid and
Community Locating and
integrative identity
being situated
Disconnectedness
Resourcefulness
Health-illness Seeking and
Society receiving support
Awareness Healthy interaction
Acquiring Perceived
Organizational Critical points Global confidence well-being
Intervention
Preventative • Enhance awareness Therapeutic
• Clarify roles,
competencies and
meanings
• Idenitify milestones
• Mobilize support
Modified from Transitions: A Middle-Range Theory, • Debrief

Meleis, Sawyer, Im, Messias, Schumacher, 2000)
FIG 20-1 ■ Modified from Meleis, A. I., Sawyer, L., Im, E., Schumacher, K., & Messias, D. (2000).
Experiencing transitions: An emerging middle range theory. Advances in Nursing Science, 23(1), 12.
7991_Ch20_349-370 12/08/19 5:20 PM Page 357
or rehabilitation institution, the changes that or a neutral period followed by a period he calls
a new graduate nurse experiences becoming a the new beginning. That is when the process
manager or an expert, or the process by which is completed. When facing a breast cancer
a nursing student is learning the ropes during diagnosis, patients go through a transition
his or her first clinical rotation experiences in process toward living with it. In a study of the
a new hospital. health status perception of women diagnosed
The fourth type of change trigger that starts with breast cancer, the investigators concluded
a process of transition is linked to organiza- that participants went through four steps of re-
tional rules and functioning (Schumacher & acting emotionally, facing the situation, con-
Meleis, 1994). There are many examples of structing a new identity, and reacting to what
organizational transitions: the arrival of a new represents cancer (Hébert, Gallagher, &
chief executive officer, chief nursing officer, or Tribble, 2016). Knowing these steps uncovers
any other new leader; the implementation of the internal changes women experience and
electronic health records; the adjustment to a fosters providers’ understanding of care and
different system of care; the attainment of providing interventions that are congruent
magnet designation; the use of new technology with each phase/step.
throughout an organization; or the transfer of Disconnectedness is an additional character-
nursing practice to the community. The expe- istic of transition. Whether the triggering
rience of transition here is for the collective change is health related, developmental, situ-
experience of a whole organization as opposed ational, or organizational, one of the properties
to individuals or families. of the transition experience is a sense of im-
pending or actual disconnectedness. A clear
Properties of Transition example is the implementation of electronic
Besides a triggering change event, transitions health records in a school or hospital. Those
are characterized by properties that we de- who will experience the change will manifest
scribed in 1986 (Chick & Meleis, 1986). The responses that could reflect a level of discon-
first is a time span, which could begin from nect from their current mode of recording pa-
the moment an event or a situation comes to the tients’ health data and maintaining continuity
awareness of an individual. It could be a symp- in patients’ files. The transition experience
tom, a diagnosis, an emergency room visit, a reflects a disruption in a person’s feeling of
flood, an earthquake, an accident, or a decision security associated with what is known and
to undergo surgery. Unlike its beginning, the familiar. There is a sense of loss—of familiar
end of a transition is more fluid. The end may signposts, reference points, or state of health—
be determined when a final goal is achieved, and a feeling of incongruity between past,
be it mastery of new roles, developing certain present, and future expectations. Those who
competencies, feeling a sense of well-being, or are responding to the change experience a dis-
acquiring a desired quality of life. It is de- continuity of regular patterns disrupted by the
scribed as being settled with a sense of relief, unfamiliar.
of knowing what to expect, and being able to Another important property of transitions is
manage new and old demands. awareness, awareness of the change event, of the
Another property that defines transition is situation, of triggers, and of the internal expe-
that it is a process. The change event itself is rience of transition. The difference between
static, but the experience that ensues is a dy- change and transition is the difference between
namic and fluid process. The distance between external and internal experience. Perception,
the beginning of this process and when it ex- awareness, and the defining and redefining of
actly ends may correspond with other similar the meaning of the change for the self and oth-
processes or may be unique. Bridges (1980, ers are properties of a transition experience.
1991) characterized the process following They make transition dynamic, incorporating
change events as requiring at first an ending meaning and changing interpretation over a
period followed by an experience of confusion span of time. Awareness influences engagement
7991_Ch20_349-370 12/08/19 5:20 PM Page 358
in the different aspects of the change, in & Meleis, 1994). In addition, the responses are
managing responses to that change, and in mediated by the level of vulnerability and sense of
learning the necessary new knowledge and skills marginalization experienced by those in transi-
related to coping with the change (Kindarara, tion (Hall, Stevens, & Meleis, 1994; Stevens,
McEwen, Crist, & Loescher, 2017). Awareness Hall, & Meleis, 1992). Availability of resources
is also a strategy for intervention to enhance the is also a condition. Galeano and Carvajal (2016)
support needed during all stages in the transi- found that variables such as income and avail-
tion process. Male spouse caregivers of women ability of information at admission and in
with breast cancer were able to provide support preparation for motherhood are among the con-
during the process of diagnosis and treatment ditions that influence coping abilities of mothers
by becoming proactively aware and involved at discharge. A study in Spain related to the
in their spouse’s experiences and responses, as transition process for family caregivers demon-
well as through fostering a positive approach strated that hospitals are not equipped to ac-
(Montford et al., 2016). commodate caregivers, which influences their
The presence of critical points, milestones abilities to become effective caregivers (Mora-
that may be turning points, is yet another prop- López, Ferré-Grau, & Montesó-Curto, 2016).
erty of transitions. Identifying milestones is Preparing caregivers to be supportive during
essential to understanding the phases in the family members’ health and illness transitions
transition experience, as well as to identifying are among the useful interventions that promote
the appropriate assessment points and inter- healthy transitions. When patients described
vention points. The goals of Transitions Theory their health care as integrated, they tended to
are to describe triggers, to anticipate experi- have better transition outcomes as compared
ence, to identify milestones and turning points, with those who described it as fragmented
to predict outcomes, and to provide guidelines (King et al., 2017). Other community conditions,
for interventions that are congruent with the in addition to integrated services and family
different stages in the transition process. member support, that may promote or inhibit
effective and healthy transitions are the avail-
Conditions of Change and Transitions ability of role models and opportunities to practice
Change triggers initiate a process with patterns or rehearse new roles. Community norms about
of responses that are both observable and dealing with sexism, homophobia, poverty,
nonobservable behaviors and either functional ageism, and nationalism also could promote or
or dysfunctional. These responses start from the inhibit healthy experiences and outcomes of
moment a change trigger is anticipated and are transitions. Global conditions that could influ-
influenced by the context of personal, commu- ence the experience of transitions, including
nity, societal, or global conditions. That context policies and mandates developed by interna-
influences the entire transition process, re- tional organizations, define how certain triggers
sponses, and/or outcomes. Among the personal are viewed and appear at the global conscious-
conditions are the meaning and the values at- ness. Undoubtedly, the transitions of the
tributed to the change and the context of it. A HIV/AIDS patient through the diagnosis and
person’s experience and responses are also in- treatment processes were profoundly mediated
fluenced by the expectations of how self or oth- by the global attention and resources that were
ers will react, the level of knowledge and skills given to researchers, clinicians, and patients
related to the change, and the belief about what who have or are associated with the disease.
is expected of those undergoing the change. There are vast differences between how infected
Other personal conditions that influence the individuals experienced the diagnosis and treat-
experience and responses are the level of planning ment of HIV/AIDS before the global attention
and the level of existing health and well-being of and post–President’s Emergency Plan for AIDS
the person, the family, the organization, the Relief (PEPFAR) aid was offered by the
community, or the country at large (Schumacher Western world (Office of the US Global AIDS
7991_Ch20_349-370 12/08/19 5:20 PM Page 359
Coordinator, 2009). For major concepts of Sawyer, Im, Schumacher, & Messias, 2000).
theory, see Table 20-1. Recognizing one’s position in a complex
system of relationships and being connected
Patterns of Responses and able to interact with a web of different
How do individuals, families, and organiza- interactions is a pattern of response that
tions respond to a change event? What should be examined to uncover the nature of
questions should be asked to define and un- responses to a transition trigger. How a per-
derstand their responses? This is an area of son sees, initiates, and relates to teams of
knowledge that is ripe for systematic investi- health professionals following a diagnosis of
gation. Many theories can describe responses. cancer or how a recent immigrant sees, initi-
Among them are grief theories (Kübler-Ross, ates, and relates to a new environment deter-
1969) and crisis theories (Lindemann, 1979). mines a pattern of response. How and when
We have proposed two sets of responses from a person, a family, or a community con-
a nursing perspective: process patterns and fronted by a change trigger seeks support
outcome patterns. from health-care providers are indicators of
Process Patterns the extent that they understand the needs
and timeliness in seeking the support. It is
Process patterns are observed and/or experi- also an indication of realizing their position
enced throughout the transition process. They within the health-care system.
are measured by the degree of engagement in the A third process pattern is manifested in the
particular change event, as well as in the action timely follow-up to recommendations related
and intervention plans (Schumacher, Jones, & to the triggers, the process, and the interven-
Meleis, 1999). Engagement is recognized as a tions that are designed to achieve certain out-
vital component of management of care (Van comes. These may be compliance to health
Cleave, Smith-Howell, & Naylor, 2016). Lev- regimen, lifestyle changes, coordination of
els of engagement could be assessed through care, or establishing relations to support and
patterns of questions, types of responses, and enhance a healthy transition.
the congruency between actions, sentiments, Another process pattern is the level of con-
and goals of those who are experiencing the fidence in handling the new, multiple, and
transition and those who are guiding and ad- sometimes conflicting demands on a person,
vising about these actions. Following direc- family, or organization in the midst of at-
tions, accuracy of perceived information, the tempting to deal with a triggering event.
consistency of meanings of the event, and the Similarly, the level of confidence may be
degree of involvement in all aspects of tran- determined by the individual’s ability to
sition experience and actions related to the identify priorities of needs and to outline dif-
change event are indicators of engagement lev- ferent levels of actions or interventions. The
els, and engagement levels may be related to actions could be as simple as describing from
final outcomes of the transition process. whom they should seek help to more com-
A second process pattern of response is plex self-care interventions. The level of con-
called location and being situated (Meleis, fidence is also experienced by novice nurses
as they strive for a new professional identity,
as described in a thematic review of 26 stud-
Table 20-1 Concepts ies that focused on nurses’ perceptions and
experiences of work role transitions (Arrow-
■ Time smith, Lau-Walker, Norman, & Maben, 2016).
■ Process Another example of process indicators is new
■ Experiences
mothers of babies born with special needs
■ Milestones
■ Conditions and their level of comfort and perceived
success in breastfeeding and in touching
7991_Ch20_349-370 12/08/19 5:20 PM Page 360
their babies (Korukcu, Deliktaş, & Kukulu, function in their other roles, despite the un-
2017). certainties and ambiguities of living with a
chronic illness, a nagging pain, or a set of es-
Outcome Patterns sential treatments. This pattern of outcome
Although patterns in process responses are as- response is characterized by the ability to carry
sessed at different points in dealing with a the sentiments, the goals, the actions, and
change trigger, outcome responses are assessed the baggage of their different ways of being
at a point determined to be at the end of the (Messias, 1997). It is the ability to “navigate
transition process. Five patterns of responses unknown waters” (Duggleby et al., 2010). One
are defined as outcomes: mastery, fluid inte- indicator for this outcome pattern of response
grative identities, resourcefulness, healthy in- is living a fully modified quality of life without
teractions, and perceived well-being (Meleis constantly striving to replicate a previously
et al., 2000). Mastery includes role mastery, experienced quality of life.
which is manifested by integrating the senti- Another outcome pattern of response is
ment, goals, and behaviors in one’s identity, healthy interactions, connections, and becoming
and behaving with confidence, knowledge, ex- resourceful, as manifested in maintaining rela-
pertise, and ability to function up to one’s full tionships and/or developing new connections
capacity. A consequence of a successful tran- or relationships, as well as demonstrating an
sition includes an increased knowledge of one’s ability to use appropriate resources and/or find
experience, the development of new skills, the new resources that affirm the completion of a
attainment of a particular identity, and the transition. In a meta-analysis and synthesis of
transformation and reorganization of daily 72 studies about family caregivers and their
activities (Hart & Swenty, 2016; Lundmark, transition experiences, the investigators con-
Erlandsson, Lennerling, Almgren, & Forsberg, cluded that caregivers experience “life transi-
2016). Examples are becoming a mother tions” that permanently alter their lives, and in
(Hattar-Pollara, 2010; Mercer, 2004; Shin & the process toward redefining what is normal,
Whitetraut, 2007), accepting hospice or end- they came to terms with their situation and
of-life care (Larkin, Dierckx de Casterlé, & connected with others (Duggleby et al., 2017).
Schotsmans, 2007), or becoming adept at The outcomes of the transition processes were
being at risk while continuing to function in maintaining a sense of personhood, reframing
other roles. Mastery goes beyond roles, how- hope, maintaining self-efficacy, finding mean-
ever, and includes mastery of one’s environ- ing, and preparing for the death of their care
ment as manifested in seeking and utilizing recipient. Questions to be investigated about
appropriate resources and co-opting supportive interactions and connections include the extent
environmental conditions. Learning to cope to which family caregivers burdened by exten-
with technology at home, living with it, and sive health-care needs of heart failure patients
reformulating one’s identity to incorporate it are able to develop relationships with health-
in one’s daily repetitions is an example of this care providers while maintaining meaningful
mastery (Fex, Gullvi, Ik, & Soderhamn, 2010). supportive relationships in their lives. This
Fluid and integrative identity is another out- is where telehealth can play a significant
come response pattern (Meleis et al., 2000). role. It facilitates caregivers’ abilities to meet
This pattern is characterized by the ability to the needs of heart failure patients by maintain-
swing back and forth between the multiple ing continuous communication with family
identities experienced by a person in transition. and caregivers. Telenurses can then deliver
Let us consider a person who must undergo evidence-based professional consulting and sup-
kidney dialysis and who emerges from her portive care based on technology that improves
dialysis session to assume other identities, patients’ self-care behaviors. Knowing that their
without any one of the identities dominating questions and concerns can be answered
her time and energy. A person with an inte- through telehealth alleviates caregivers’ burdens
grative identity is able to live and continue to and improves their own health outcomes by
7991_Ch20_349-370 12/08/19 5:20 PM Page 361
allowing them time to meet their own health providing expertise, engaging patients, setting
or social needs (Chiang, Chen, Dai, & Ho, goals, modeling the role of others, providing
2012). information, activating resources, identifying
These types of questions are important to opportunities, initiating and monitoring re-
answer because some research has demon- hearsal of new behaviors, facilitating connec-
strated that the health of partners or caregivers tions to supportive reference groups and role
is intertwined with that of seriously ill patients; models, and ensuring time and resources for
that is, the more an illness affects the patient’s debriefing.
physical and mental ability, the greater the im-
pact this will have on the health of the patient’s Enhancing Awareness
partner or caregiver due to insurmountable To engage those who are facing changes in the
stress, disruption in relationships, and neglect care process, it may affect the process of heal-
of the partner’s/caregiver’s own health. These ing, recovery, and coping by enhancing aware-
unintended health consequences may be fur- ness of the change, its potential implications,
ther exacerbated by the lack of social, emotional, and what might be expected in the transition
or practical support the partner or caregiver process. Discussing the change as a transition
experiences (Christakis & Allison, 2006). process, experience, and with varied responses
For this reason, having strong social net- at different stages and phases, may enhance
works in place during these periods of transi- awareness, which in turn may lead to desired
tion could play a significant role in promoting outcomes. This is another productive program
positive health outcomes for the caregiver, of investigation that includes self-awareness of
which would in turn positively affect the health the client and the caregiver (Sturesson & Ziegert,
of the patient. 2014).
The ultimate outcome driven by a nursing
perspective is perceived well-being as described Clarifying Roles, Meanings,
by the person experiencing the transition or the Competencies, Expertise, Goals,
caregivers providing the care. Perceived well- and Role Taking
being as a subjective measure may be compli- Through interaction, dialogue, and interviews,
mented by objective measures of health. For the nurse probes for the values and beliefs of
major areas of investigation, see Table 20-2. the person experiencing the transition process,
as well as those of their significant others, and
Intervention Framework determines the meanings they attribute to
The goal of intervention within Transitions the change event, their own experience, and
Theory is to initiate, facilitate, support, and in- perceptions of the transition. Competencies
spire healthy process and outcome responses. needed to deal with the change and the extent
Nursing interventions that initiate, facilitate, to which the person is able to master each of
support, or inspire healthy transition process the competencies should be identified. The
behaviors as well as healthy outcome behaviors ease in performing the competency and the
include the following: clarifying meanings, level of engagement in learning or modifying
Table 20-2 Major Areas of Investigation

■ Describe and interpret the different transition experiences and responses.
■ Identify transition properties.
■ Develop and test preventive and therapeutic interventions.
■ Identify milestones and turning points associated with different change triggers.
■ Describe and test determinants of process and outcome responses.
■ Develop instruments and investigative tools for properties, conditions, processes, and outcome responses.
■ Explore strategies to modify policies essential to mitigate, facilitate, or inhibit healthy processes and out-
come responses.
7991_Ch20_349-370 12/08/19 5:20 PM Page 362
the competency—be it testing blood sugar normal size. However, it is imperative to iden-
levels, bathing a baby, changing a nursing unit, tify milestones from a nursing perspective
or reaching out for new connections in a nurs- when our goals are self-care, quality of life, role
ing home—should be carefully accessed. Iden- mastery, and managed care. Identifying mile-
tifying facilitators and barriers in the context stones or turning points is essential in the
and the conditions in the world that families trajectory of managing and facilitating transi-
live, inclusive of their personal, community, tions. This area of the theory invites research
and family resources, and giving families op- to provide evidence to identify and support
portunities to express their needs are strategies those points where there is a need for inter-
to support them in their transition from vention to enhance both a healthy transition
hospital to home (Gaskin, 2018), particularly process and outcomes. Biomedical-driven
following a life-threatening situation that ren- goals are not inclusive of those driven by a
ders families more vulnerable for additional nursing perspective, a holistic approach, and
health risks. one that focuses on health, well-being, and
Similarly, observing, questioning, or inter- abilities to manage quality daily life.
viewing significant others—whether they are
partners or friends—to determine levels of en- Mobilizing Support: Providing
gagement and the extent of mastery is another Supportive Resources
significant component of a program for inter- A Transitions Theory–based discharge plan-
vention during the transition process, espe- ning program can be effective in improving the
cially at critical milestones. Significant others care and the outcomes of asthma management
or reference groups to be included in the as- at home for children, as reported by Ekim and
sessment or the intervention are those whose Ocakci (2016). Similarly, to promote a suc-
viewpoints are used as a frame of reference. cessful transition for immigrants, integrating
Roles, whether they are new ones, at-risk ones, them in a new country must include providing
or those that may be lost, are formed and im- a predeparture preparatory program to set
puted through a process of definition and re- goals, define realistic expectations, and iden-
definition. Similarly, new competencies are tify supportive resources (Toosi, Richter, &
acquired through a process of teaching, learn- Woytowich, 2017). Mobilizing partnerships,
ing, rehearsing, modeling, and reinforcement resources, and supportive groups is therefore
by those who are in the support or network another component in intervention strategies.
systems (Petch, 2009; Swendsen, Meleis, & Clarifying roles, competencies, values, and
Jones, 1978; van Staa, 2010). abilities to understand what others are experi-
encing are important processes for facilitating
Identifying Milestones and Using a healthy transition and in achieving healthy
Critical Points outcomes at the termination of a transition.

A critical point is the time when questions tend These may be accomplished by identifying a
to arise about a care trajectory or when signs nurse as a go-to person for questions, observ-
and symptoms tend to manifest themselves. It ing patients who may have gone through a
is a point when healing progresses or there is a similar event, and being afforded opportunities
relapse, a point when infection, inflammation, to imagine, mentally enact, or actually practice
distress, anxiety, noncompliance, or other con- what the person may encounter, do, or feel
ditions may begin appearing and when an ap- during the different phases of transition. Hav-
propriate intervention may advance the ing a support group, rehearsing competencies,
treatment and healing course. Care is maxi- becoming in touch with feelings about events
mized at such a point. A six-week checkup for or competencies, visualizing different scenar-
a postpartum mother has always been desig- ios, and describing the different if–then situa-
nated a critical point or a milestone, but this tions may enhance healthy transitions and
milestone is driven by the biomedical model outcomes. We have called these processes role
as it relates to when the uterus reverts to its modeling and role rehearsal, as well as defining
7991_Ch20_349-370 12/08/19 5:20 PM Page 363
and identifying reference groups (Meleis, 1975; receive information and reasons for care they
Meleis & Swendsen, 1978). An example of have been provided or need (Steele & Beadle,
this type of intervention is an interdiscipli- 2003).
nary mentoring program that the Hospital of In addition to patients, nurses themselves
the University of Pennsylvania implemented, and other health-care providers benefit from
which pairs nurses with medical students start- debriefing. Hospitals have implemented de-
ing their first clinical rotations to facilitate the briefing, or critical incident stress manage-
transitional adjustment of the medical students ment, programs to help their staff cope with
to their new environment. This program also stress and sorrow at work and to mitigate the
highlights the important role nurses play in pa- impact of traumatic events. For example,
tient care, which fosters a sense of teamwork Children’s Memorial Hospital in Chicago
and collegiality between medical students and launched a mentor program that matched
nurses from the beginning (Sapega, 2012). new nursing graduates with seasoned nurses
to help them cope with the stress and
Debriefing heartache of caring for sick children and in-
Debriefing is a well-researched, core nursing teracting with distressed parents and family
intervention used at critical points during tran- members. This program significantly reduced
sition experiences; “debriefing is defined as a the high turnover rate among new nursing
process of communicating to others the expe- graduates that the hospital had been experi-
riences that a person or group encountered encing (Huff, 2006).
around a critical event” (Meleis, 2010, p. 457).
It is a tool used in nursing to help a person
come to terms with the transition experience Applications of the Theory
and attain psychological well-being (Steele & Applications to Research
Beadle, 2003). Nurses ask their patients ques-
Transitions Theory has been used extensively
tions after birthing, traumatic events, disasters,
as a theoretical framework in research all
surgical procedures, and so on during a new
around the world to examine a broad spectrum
admissions process and at discharge. The pa-
of transition experiences resulting from health–
tient may recount his or her story emotionally,
illness, developmental, situational, and organi-
relate to it cognitively, describe it, interpret its
zational transitions and the effect of these
meaning, reflect on it, or share feelings. The
transitions on the health of individuals, fami-
story usually includes the context, the before,
lies, and communities. It has been used to de-
the during, and the subsequent responses re-
velop strategies and interventions to facilitate
lated to the experience. Nurses engage in dia-
healthy transitions and has served as a concep-
logues with their patients about the events, ask
tual basis and guide to:

questions, and provide patients and families
with the opportunity to process the events and ■ Understand and examine teenagers’
the aftermath. For example, a number of ma- concerns as they transition through high
ternity units provide postnatal debriefing serv- school in the United States (Rew, Tyler,
ices for new mothers. Postnatal debriefing is a & Hannah, 2012).
psychological intervention that enables women ■ Demonstrate in Taiwan that nurse-led
to come to terms with their experience and transitional care combining telehealth care
promotes psychological well-being. Through and discharge planning significantly alle-
postnatal debriefing, health-care professionals viates family caregiver burden and stress
can identify the emotional and psychological and improves family function (Chiang
needs of the patient and refer them to appro- et al., 2012).
priate resources or other mental health spe- ■ Study the impact on self-care of people
cialists. This service gives new mothers the with heart failure and develop strategies
opportunity to ask questions, debrief about to implement a therapeutic regimen in
their experiences, describe their feelings, and Portugal (Mendes, Bastos, & Paiva, 2010).
7991_Ch20_349-370 12/08/19 5:20 PM Page 364
■ Explore in greater depth chronic obstruc- transitions should include longitudinal

tive pulmonary disease (COPD) patients’ comparative and longitudinal cross-
experiences during and after pulmonary sectional designs.
rehabilitation in Norway (Halding & ■ In a review of Transitions Theory contri-
Heggdal, 2011). butions, the author concluded that while
■ Analyze Finnish women’s hysterectomy the concept of transition is central to the
experiences as a process of transition in profession, Swiss nursing experts did not
their lives and describe representations consider its connection to research and
of hysterectomy in Finnish women’s and practice well documented and recom-
health magazines (Nykanen, Suominen, mended integrating all transition studies
& Nikkonen, 2011). in a database and developing an interna-
■ Assess the cultural factors that may tional board to develop needed programs
contribute to the low diagnosis rate of of research (Bohner, 2017).
postpartum depression in Asian American ■ In 2007, at the University of Pennsylva-
(i.e., Asian Indian, Chinese, Filipina) nia, we established the New Courtland
mothers (Goyal, Wang, Shen, Wong, Center on Transitions and Health.
& Palaniappan, 2012). Transitions Theory provided the founda-
■ Develop a measurement tool for transition for its theoretical basis. Driven by
tions in cancer scale (Schulman-Green Dr. Mary Naylor’s scholarship, a current
& Jeon, 2017). focus of the center is on the transitional
■ Understand patient and caregiver hospital- care model for the elderly population.
to-home transition experiences (Ang, Although independently developed on
Lang, Ang, & Lopez, 2016; Gaskin, the East Coast of the United States as
2017). an intervention using advanced practice
■ Study family caregivers’ transition experi- nurses, the transitional care model
ences caring for persons with advanced reflects the components of Transitions
cancer at the end of life (Duggleby et al., Theory (Naylor, 2002).
2017).
■ Investigate how family caregivers’ involve- Applications in Practice
ment in the care of patients with dementia Transitions Theory has been applied in prac-
can be guided by health-care professionals tice by nurses to aid clients, families, and
(Lethin, Hallberg, Karlsson, & Janlöv, communities in preparing for, navigating
2016). through, and adapting to transition experi-
ences to enhance health outcomes. The oper-
These research studies demonstrate how
ationalization of Transitions Theory enhances
Transitions Theory has supported and aided

nurses’ understanding of patient and caregiver
nurse researchers and scholars to describe the
transitions and leads to the development of
transition experiences and responses, confirm
nursing therapeutics, interventions, and re-
the components of the transition experience,
sources that are tailored to the unique expe-
and identify the essential properties of transi-
riences of clients and their families to promote
tion, including the critical points and events,
successful, healthy responses to transition. As
to ultimately reach the goal of promoting
mentioned earlier in this chapter, the illness
healthy outcomes and easing transitions for
of patients can take a heavy toll on the health
their clients, families, and communities. Oth-
of their caregivers due to the stress, role tran-
ers reflect futuristic recommendations and
sitions, disruption in relationships, and be-
utilization.
reavement they may experience. Transitions
■ As indicated by Kralik, Visentin, and van Theory has been used as a conceptual frame-
Loon (2006) in their comprehensive liter- work in practice to help health-care providers
ature review of Transitions Theory, future gain a holistic understanding of the care-
research to advance knowledge about giver’s beliefs, views, unique experiences, and
7991_Ch20_349-370 12/08/19 5:20 PM Page 365
desired outcomes, which in turn enables systems that provide strategies for transitioning
nurses and health-care providers to allocate from pediatric to adult care (Lestishock, Daley,
resources and implement interventions tar- & White, 2018in press).
geted to the caregiver’s specific needs to op-
timize the health of both the patient and the Applications in Education
caregiver (Blum & Sherman, 2010). It helps Transitions Theory is used in graduate and
identify the barriers to, as well as facilitators undergraduate curricula in countries around
of, the transition, unique to each individual the world. Universities that have integrated
patient and caregiver, which in turn enhances Transitions Theory in their nursing education
the nurse’s or health-care provider’s ability to programs include the University of Connecti-
effectively guide them through the transition cut in Storrs and Clayton State University in
experiences. Morrow, Georgia. Clayton State University
The conceptual underpinnings of Transi- has used Transitions Theory in its curriculum
tions Theory have also been used to analyze the and has made it central to its nursing pro-
transitions that intensive care unit (ICU) pa- gram’s philosophy. On its website, Transi-
tients and their families encounter after they tions Theory is defined, and it is emphasized
are discharged from the ICU and the provision that “negotiating successful transitions de-
of nursing services needed for continuity of pends on the development of an effective re-
care. By digging deeper to fully comprehend lationship between the nurse and client. This
the stress patients and families experience relationship is a highly reciprocal process that
when being discharged from the ICU, includ- affects both the client and nurse” (Clayton
ing their potential feelings of abandonment, State University, 2012). The stated goals of
unimportance, or ambivalence, nurses can bet- the graduate curriculum at Clayton State Uni-
ter assist patients and families in the ICU versity are as follows:
transfer process and ensure the provision of
optimum health-care services to continue care The culmination of graduate nursing education is
(Chaboyer, 2006). the synthesis of advanced skills in order to pro-
Transitions Theory has also been used to vide excellent nursing care and to foster ongoing
understand and characterize the personal ex- professional development in order to promote
periences of perimenopausal and menopausal nursing research, ethical decision-making reflect-
women. Findings from this research have ing an appreciation of human diversity in health
been translated into practice in the clinical set- and illness among individuals, families, and com-
ting. Understanding women’s personal expe- munities experiencing life transitions. (Clayton
riences using Transitions Theory equips nurses State University, 2012)
to proactively educate women on what to ex- Transitions in health care, particularly
pect before perimenopausal or menopausal complex ones, require the intervention of mul-
symptoms begin, thus decreasing anxiety and tidisciplinary health-care provider teams. An
confusion and instead “normalizing the expe- interprofessional approach to the education
rience” (Marnocha, Bergstrom, & Dempsey, of health-care professionals is more likely to
2011). lead to the development of high-functioning
While not specifically citing Transitions health-care teams. Transitions Theory provides
Theory, considering the transition from pedi- a mechanism and a framework for interprofes-
atric to adult care as an important developmen- sional simulation to improve care transitions
tal step prompted a study to examine nurse from hospital to home (Sykes, Baillie, Thomas,
practitioners’ perspectives regarding the needs Scotter, & Martin, 2017).
of adolescents, parents, caregivers, clinicians, At the University of California San Francisco
and institutions in health-care transitions for (UCSF), I taught a graduate course on tran-
adolescents and/or young adults. The results un- sitions and health to respond to an increasing
covered a need for early preparation, education, educational demand of graduate students. Ad-
effective communication, and supportive health ditionally, many doctoral students in nursing and
7991_Ch20_349-370 12/08/19 5:20 PM Page 366
other disciplines around the world, including beliefs, patterns, and concepts of diverse groups
Spain, Portugal, Colombia, Sweden, and the of populations undergoing various types of
United States, have used Transitions Theory as transition experiences. A number of situation-
a basis for their doctoral dissertations. specific theories have evolved from Transitions
Theory. A situation-specific theory is a coher-
Integrating and Developing ent representation and depiction of a set of
Situation-Specific Theories concepts and their interrelationships to a set of
Transitions Theory provides opportunities to outcomes related to health and illness experi-
work in tandem with and complement other ences and responses, as well as to nursing
theories, as well as to develop situation-specific actions to prevent the effects of illness or ame-
theories. Geary and Schumacher (2012) inte- liorate the effects of interventions (Meleis,
grated Transitions Theory and complexity sci- 2010). For example, a situation-specific theory
ence concepts, which provided a powerful explaining the menopausal symptom experi-
framework to study care transitions and to en- ences of Asian immigrant women within the
hance positive outcomes. Transitions Theory sociocultural contexts in the United States was
combined with Acculturation Theory benefit- grounded in Transitions Theory (Im, 2010).
ted the design of predeparture and early-arrival Others include Helping Elderly Persons in Tran-
programs for immigrants (Toosi, Richter, & sition: A Framework for Research and Practice
Woytowich, 2017). Transitions Theory was (Schumacher, Jones, & Meleis, 1999) and “The
also used with Bronfenbrenner’s Bioecological Situation-Specific Theory of Pain Experience for
Theory of human development to inform un- Asian American Cancer Patients” (Im, 2008).
derstanding and successful intervention for the Baird (2012) developed a situation-specific the-
transition to adulthood for young individuals ory extending Transitions Theory to include
experiencing health-care complexities (Joly, the cultural transition for refugee women. In
2016), and with Mishel’s Uncertainty in Illness reviewing situation-specific theories based on
Theory to address the entire continuum of the middle-range Theory of Transitions, Im
chronic illness patient experiences (Moore, (2014) concludes that these theories were de-
Holaday, Meehan, & Watt, 2015). veloped not to deal with limitations, but instead
Transitions Theory continues to be further to advance and to add to the theory. She further
developed, tested, and refined to understand found that most of them used integrative ap-
and describe the relationships among the major proaches to advancing knowledge.
Practice Exemplar
Written by Diane L. Gullett, RN, PhD, MSN, MPH I can take it, I feel like I am at the end of my
In 2012, while volunteering at a charity care rope. I asked Wayne when the last time he had
clinic in New Orleans, I met Wayne. I re- any blood work done. Suddenly, Wayne
member how his clothes hung from his gaunt started pacing the floor, wringing his hands,
frame, the dark circles under his eyes, and de- looking at the door, and refused to make eye
spite being only 26 years old, he appeared contact with me and all but bolted for the
closer to 40. Wayne described feeling tired, door. As he went to leave, I gently asked
unable to sleep and sad ‘all the time’ as well him to stay while explaining I only wanted to
as waking up in a pool of sweat almost every help him.
night for the past 10 to 12 months. Wayne
pulled out a list of prescribed medications Debriefing
which included everything from antidepres- I proceeded to ask Wayne when he first
sants to benzodiazepines, but nothing that started having symptoms and if he could re-
was providing him any relief. He looked at member any significant changes that oc-
me and said, “I don’t know how much longer curred during the time his symptoms first
7991_Ch20_349-370 12/08/19 5:20 PM Page 367

started appearing (Intervention: question- New Orleans to get his life back to normal,
ing). Wayne told me his “problems” started but “even now after seven years, it’s not the
almost a month after Hurricane Katrina same … but it’s a driving force, this need to
(Change triggers: situational). get my life back to normal. You get a new
I asked if Wayne would share with me normal, but it isn’t what you had before … I
his story of moving to New Orleans and can’t describe how different it is” (Properties:
his experience following Hurricane Katrina. process).
Wayne was a high school honors student and
at 18 had received a full scholarship to attend Change Triggers
Tulane with the intention of majoring in In- In this exemplar there are two major situations
ternational Business (Condition: personal; that trigger transitions for Wayne. Hurricane
Change triggers: developmental). He moved to Katrina (external event) was the situation that
New Orleans and had just started his first se- caused immense change and triggered Wayne’s sit-
mester of college when Hurricane Katrina uational transition (internal process). Wayne’s
hit the city (Change trigger: situational). He role and phase of development as an 18-year-old
was forced to evacuate his apartment, com- adolescent living at home in Arkansas also
munity, and the city, returning home to live dramatically changed as he experienced a de-
with his stepfather in Arkansas (Properties: velopmental transition to a young adult living
process). It never occurred to him to take independently in a new state while attending col-
more than a few things when he evacuated, lege for the first time. Limited worldly experience
thinking he would return in only be a few and youth are personal conditions that inhibited
days or maybe a week at most (Properties: Wayne’s ability to cope with the reality of the
awareness). changes triggered by Hurricane Katrina. Wayne’s
Television and social media would serve inability to effectively reconcile his previous life
to inform Wayne about the severity and im- with his new one inhibited a healthy outcome re-
pact of Hurricane Katrina (Properties: time sponse, which led to his dropping out of school.
span). Later, Wayne learned his apartment This reflected a critical point of time in Wayne’s
and all his belongings were destroyed in the transition experience. The nurse recognizes Hur-
storm. Due to the extensive damage and im- ricane Katrina as the situational change trigger
pact of the storm, his college was unable to that contextually situates Wayne’s unique transi-
reopen for classes. Approximately three tion experience and serves as the foundation for
weeks after Hurricane Katrina, Wayne en- mutual meaning-making between the nurse and
rolled at Louisiana State University in Baton Wayne.
Rouge (Properties: process), dropping out al- I continued asking Wayne to tell me more
most immediately because he “couldn’t wrap about his life after the hurricane, seeking to
his head around it” (Properties: critical point). understand more about his need to get his life
I asked Wayne to explain a bit more about back to normal (Intervention: clarifying mean-
what he meant by not being able to “wrap his ing). Wayne described his overwhelming de-
head around it” (Intervention: clarifying sire to return to New Orleans to resume his
meaning). Wayne responded, “It was every- life as he had known it before Katrina. Wayne
thing … from my social life, to what I was stated, “I didn’t realize that the things that had
studying, to my financial situation. I just did- been part of my life, may not be there as they
n’t care. It seemed there were so many other had been before” (Properties: disconnectedness).
more important things than worrying about For instance, even though his old apartment,
my grades or what I was studying” (Proper- along with all his possessions, had been de-
ties: disconnectedness). Wayne explained that stroyed, Wayne moved into the same remod-
after dropping out of school he returned to eled building and apartment. He stated, “It
(continued)
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wasn’t the same, physically yes, but it wasn’t Conditions of Change
the same circumstances or the same people.” Wayne’s youth and lack of experience with natural
Also, Wayne found the city of New Orleans disasters are personal conditions that influenced his
dramatically altered in ways such as lacking responses to the situational change brought on by
grocery stores and having no electricity (Con- Hurricane Katrina. The disaster negatively af-
ditions: community). fected his developmental and situational transition
I asked Wayne how he coped with all experiences. Wayne naively returned to New Or-
the changes in his life, acknowledging that leans with the intent of getting his life back to nor-
it must have been very difficult (Interven- mal, only to be confronted with an irrevocably
tion: questioning). Wayne stated that the changed reality and his place in it. Wayne also ex-
first few years were hazy and recalls totaling presses feelings of isolation and disconnectedness
three cars within two weeks “I don’t know when discussing his belief that others, including his
where my head was.” Wayne recalls visiting family, could not relate to what he was going
bath houses and participating in unpro- through. Wayne’s lack of knowledge and skills,
tected sex, as well as drugs, (Properties: crit- poor planning, and increased sense of marginal-
ical points). Wayne believed he could escape ization reflect personal and community conditions
his reality by engaging in these risk taking that inhibited rather than facilitated a healthy
behaviors, stating, “When you are high, transition experience. The limited level of existing
when you are messed up, you are … getting community and social resources available within
away from all these pressures” (Properties: the city following Hurricane Katrina also inhib-
awareness). ited Wayne’s transition experience. Community
conditions, including cultural and social norms,
Properties of Transition were also dramatically altered by the catastrophic
Wayne’s process of transition signifies a dynamic conditions that existed in the city. These conditions
internal change evident in his struggle to regain for a young person such as Wayne may have pre-
his old life, his inability to do so, and his reluc- sented a loss of positive role-modeling essential to
tance to accept the new normal. Disconnected- developing effective coping strategies following
ness manifests in Wayne’s recognition of the such a traumatic experience and may have neg-
disruption Hurricane Katrina brought to his fa- atively affected his developmental transition.
miliar way of being in the world. The dynamic Wayne admits to engaging in unprotected sex with
nature of awareness is reflected in Wayne’s con- other men, using drugs, and hanging out with
tinual reinterpretation and willingness to find people who did not have his best interests at heart.
meaning in his experiences following Katrina. Feeling conflicted about his own behavior, espe-
The nurse recognizes the critical points or mile- cially in light of societal homophobia, may also
stones within Wayne’s transition experience, have prohibited Wayne from seeking support from
starting with his dropping out of school, crashing his family or friends, further perpetuating his feel-
multiple cars, using drugs and alcohol, and en- ings of marginalization and disconnectedness.
gaging in unprotected sex. I asked Wayne to describe his vision of
I assessed Wayne’s support system. Wayne moving forward (Intervention: visualizing differ-
revealed that he wasn’t getting support from ent scenarios). Wayne shared with me that he
his family because they couldn’t relate to wanted to leave New Orleans. He felt that the
what he was going through (Properties: dis- entire city marked his life as before and after
connectedness). He also told me there was no Katrina. His vision for the future included mov-
place to go to get help in the city, stating, ing away from the city and living somewhere
“A lot of people were in bad shape; I re- that did not remind him daily of the tragedy he
member hearing about a lot of people com- had experienced (Patterns of response: locating).
mitting suicide” (Conditions: community).
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After we had spoken for some time, of exploring his options and deciding how he
Wayne commented, “I feel better just talking wanted to move forward. (Intervention: mobi-
with someone about all this” (Patterns of lizing support and setting goals).
response: receiving support). Through authentic
presence, I could develop a relationship with Patterns of Response
Wayne grounded in trust and caring. Wayne Process patterns are assessed at different points
felt he could ask for and receive help and during the transition experience while outcome
support (Patterns of response: seeking support). patterns are assessed at a point determined to be
Wayne told me he was afraid he had ac- at the end of the transition process. Wayne’s re-
quired immunodeficiency syndrome (AIDS). sponses indicate he is still engaged in the transi-
He recounted having unprotected sex with tion process despite the years that have passed since
multiple male and female sexual partners. He Hurricane Katrina. Wayne’s willingness to stop
felt deeply ashamed and scared. He confided engaging in risk-taking behaviors and deciding
in me that he had taken a home human im- to have blood work to test his HIV status indicate
munodeficiency virus (HIV) saliva test sev- a conscious choice to modify his behavior and seek
eral months ago that was positive, but he was information. This suggests that Wayne is actively
too afraid to do anything about it or tell any- engaged in the process of transition (Patterns of
one (Properties: critical point). response: engaging and seeking and receiving
I told Wayne I thought he was brave for support). As the nurse, I am aware that he is con-
making the decision to talk to someone sistently comparing his actions before and after
(Intervention: providing expertise). He stated, Katrina to create new meaning from his experi-
“I don’t know what to do. I wasn’t like this ence, or “locate” himself. He is attempting to un-
before Katrina. I don’t know what happened derstand his new way of being in the world by
to me since then … I’m a mess” (Patterns comparing it to his old way of being in the world.
of response: being situated). I acknowledged These comparisons also provide Wayne with a
Wayne’s fears and engaged him in a process way of “situating” himself, or a way to assist him
of setting goals. The first step involved get- with explaining why he engaged in high-risk
ting blood work to test for HIV. I provided behaviors (Patterns of response: locating
him with the number to a local clinic and and being situated). Wayne was progressively
told him we could call together if he wished. moving toward increasing his confidence by de-
I explained the process and how the clinic veloping strategies for prioritizing needs and de-
had counselors available to support him veloping a sense of wisdom generated through the
through the process (Intervention: providing lived experience (Patterns of response: acquir-
resources). Next, I asked some questions to as- ing confidence).

sess his current risk (Intervention: providing I will continue to assess Wayne for outcome re-
expertise). Wayne assured me that he had sponses including mastery, fluid and integrative
stopped engaging in unprotected sex and identity, resourcefulness, health interactions, and
risk-taking behavior and expressed having perceived well-being which mark the completion
no desire to return to his previous patterns of his transition process. A fluid and integrative
(Patterns of response: awareness). identity may be assessed by asking Wayne to de-
I talked with Wayne about the impor- scribe his previous quality of life compared with
tance of exploring his feelings before and his current quality of life following intervention
after Hurricane Katrina in a safe environ- strategies. Wayne would demonstrate healthy in-
ment and explained that it might be helpful teraction and thereby affirm the completion of his
to see a counselor in addition to attending transition process by developing and maintaining
support groups and engaged him in a process meaningful and supportive relationships.
(continued)
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Meleis’ Transitions Theory served as the actions and interventions, Wayne could easily
lens through which the nurse could recognize have left the clinic not receiving the care he
Wayne’s symptoms as ineffective responses needed, resulting in delayed testing for HIV,
and outcomes to transition experiences that prolonged illness, ineffective treatment, and
required a holistic guided approach to care. perhaps suicide.
Without the preventive nursing therapeutic
Summary
Transitions Theory continues to be used and evidence-based practice and better-quality
reviewed (Bohner, 2017; Joly, 2016) nation- care in the 21st century. Transitional care is
ally and internationally to advance nursing considered an ethical priority in health care
knowledge about the experience and the re- (Naylor & Berlinger, 2016). It is for its poten-
sponses of the many transitions that individ- tial, its utility, and the research programs that
uals, families, communities, and organizations have and could emanate from it that we have
encounter, as well as the experiences, the redefined nursing as “facilitating transitions to
sponses, and the therapeutics that nurses use, enhance a sense of well-being” (Meleis &
translating the theory to policy, research, and Trangenstein, 1994).
Questions for Reflection ■ Explain one way in which Transitions

Theory can be used in your practice.
and Discussion What facilitates and prohibits using
■ Describe examples of health and illness, theory-based practice? What are the
developmental, situational, and organiza- advantages or disadvantages to using
tional transitions of patients or of your Transitions Theory in the caring of your
own transitions. How do these transitions patients, in the teaching of your courses,
use Meleis’ theoretical perspective to or in the managing of your administra-
affect health and well-being? tive responsibilities?
■ What are the origins of Transitions The-
ory? How do they inform the develop-
ment of the concepts of the theory?
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Katharine Kolcaba’s
CHAPTER
21
Comfort Theory
April A. Bice and
Katharine Kolcaba

Overview of the Theory Introducing the Theorist
Applications of the Theory Katharine Kolcaba was born and educated in
Practice Exemplar Cleveland, Ohio. In 1965, she received a
Summary diploma in nursing and practiced for many
Questions for Reflection and Discussion years in the operating room, medical–surgical
Appendix A 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), in
Cleveland, with a specialty in gerontology.
While attending graduate school, Kolcaba had
a head nurse position on a small dementia unit.
In the context of that unit, and because of a
graduate school assignment, she began theo-
rizing about comfort.
After completing her master’s degree in
nursing, Kolcaba joined the faculty at the Uni-
versity of Akron (UA) College of Nursing,
where her clinical expertise was gerontology and
dementia care. She returned to CWRU to pur-
sue her doctorate in nursing on a part-time basis
while teaching full time. Over the next 10 years,
she applied course work from her doctoral pro-
gram to further develop her theory. During that
time, Kolcaba published a framework for de-

mentia care (1992a), diagrammed the aspects of
comfort (1991), operationalized comfort as a
desirable outcome of care (1992b), contextual-
ized comfort in a middle-range theory (1994),
tested the theory in several intervention studies
(addressed later in the chapter), and further re-
fined the theory to include hospital-based out-
comes (2001). These articles described each step
in the process of theory development, most of
which have been compiled in her book Comfort
Theory and Practice (2003). Many publications
and comfort assessments/instruments are avail-
able at www.thecomfortline.com and through
Research Gate.
371
7991_Ch21_371-382 12/08/19 5:30 PM Page 372
Kolcaba taught future nurses at UA for The four contexts or domains in which
22 years and is now retired as an associate pro- comfort is experienced by individuals are
fessor emeritus. She is founder and member of physical, psychospiritual, environmental, and
an inner-city Parish Nurse program and volun- sociocultural. These contexts were developed
teers two mornings a week at that clinic. Here, following a review of the literature focused on
she is able to use her holistic nursing practices holism in nursing (Kolcaba, 1991, 2003).
to give hope, friendship, guidance, and practi- When these four contexts of experience were
cal supplies to folks living in poverty. She also juxtaposed with the three types of comfort on
represents her own company, The Comfort a 3 ( 4 grid, a taxonomic structure (TS) was the
Line, as a consultant. In this capacity, she result (Fig. 21-1). This grid delineated the
works with health-care agencies and hospitals nursing meaning of comfort as a patient out-
that choose to apply Comfort Theory on an income. The TS is used for (a) mapping the con-
stitutional-wide basis. Recently she participated tent of patient and family comfort content
in the preparation of a white paper on comfort so nurses can create a plan for holistic care,
in automotive seating. Kolcaba continues to
correspond with students at all levels and with
Relief Ease Transcendence
nurses who are conducting comfort studies. She
resides in the Cleveland area with her husband, Physical Pain
near her two daughters and their families. An-
other daughter resides in Chicago. Psychospiritual Anxiety
Environmental
Overview of the Theory Sociocultural

Comfort is a complex term that has several mean-
Type of comfort:
ings and usages in ordinary language. The use of
Relief: the state of having a specific
comfort as a noun and an outcome is specific to comfort need met.
Comfort Theory (CT) and different from its al- Ease: the state of calm or contentment.
ternative usages as a verb, adverb, adjective, and
Transcendence: the state in which one can rise above
process (Kolcaba, 1995). From the Oxford Eng- problems or pain.
lish Dictionary, Kolcaba learned that the original
Context in which comfort occurs:
definition of comfort meant “to strengthen
greatly.” Her assumptions included the follow- Physical: pertaining to bodily sensations,
homeostatic mechanisms, immune
ing: (1) the need for comfort is basic; (2) persons function, etc., with special attention to
experience comfort holistically; (3) self-comforting medical problems.
measures can be healthy or unhealthy; and Psychospiritual: pertaining to internal awareness of self,
(4) enhanced comfort, achieved in healthy ways, including esteem, identity, sexuality,
meaning in one’s life, and one’s
leads to greater productivity and/or well being. understood relationship to a higher
From the nursing literature, Kolcaba used order or being.
insight from three nursing theories to describe Environmental: pertaining to the external background
three distinct types of comfort (Kolcaba, of human experience (temperature,
light, sound, odor, color, furniture,
2003). Relief was synthesized from the work of landscape, etc.)
Orlando (1961/1990), who stated that nurses
Sociocultural: pertaining to interpersonal, family, and
relieved the needs expressed by patients. Ease societal relationships (finances,
was synthesized from the work of Henderson teaching, health care personnel, etc.)
(1978), who described 13 basic functions of Also to family traditions, rituals, and
religious practices.
humans that needed to be maintained for
homeostasis. Transcendence was derived from Adapted with permission from Kolcaba, K. & Fisher, E.
A holistic perspective on comfort care as an advance directive.
Paterson and Zderad (1976/1988), who be- Crit Care Nurs Q,18(4):66-76, (c)1996. Aspen Publishers.
lieved that patients could rise above their diffi- FIG 21-1 ■ Taxonomic structure of comfort (or
culties with the help of nurses. comfort grid).
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C H APTER 21 ■ Katharine Kolcaba’s Comfort Theory 373
(b) determining unmet comfort needs, (c) as- Proposition Discussion

sisting nurses in designing comfort interven- Comfort interventions address basic human
tions, and (d) creating measurements of needs, such as rest, homeostasis, therapeutic
holistic comfort for documentation in practice communication, and viewing patients holisti-
and research. Kolcaba defines comfort as the cally. These comfort interventions are often
immediate experience of being strengthened nontechnical and complement delivery of
through relief, ease, and transcendence in the technical care. Care providers, such as nurses,
four contexts of experience. In other words, may also be considered recipients if the insti-
enhanced comfort is experienced by individu- tution makes a commitment to improving
als when one or more of the types of comfort comfort for staff in their work setting. When
are addressed in the four contexts of experience comfort is not enhanced to the fullest extent
(see Fig. 21-1 for corresponding definitions). possible, nurses consider intervening variables
One way to think about the TS revolves for possible explanations as to why comfort in-
around comfort as an umbrella outcome terventions did not work. Abusive homes, lack
involving relief from discomforts such as anx- of financial resources, devastating diagnoses,
iety, distress, pain, fear, environmental stres- or cognitive/psychological impairments may
sors, social isolation, and more. Because the render ineffective the most appropriate inter-
TS represents a holistic definition of comfort, ventions and comforting actions. The aspect of
the cells on the grid are interrelated; comfort transcendence, however, guides nurses to help
interventions directed to one part of the grid patients “rise above” or be inspired to achieve
have effects on all parts of the grid. Total mutually determined goals regardless of life
comfort at any one time is also greater than circumstances. Holistic comfort is proactive,
the sum of its individual parts. Therefore, energized, intentional, and longed for by re-
comfort interventions to treat anxiety may cipients of care in all settings; it is a facet of
also reduce the dosage of analgesia needed for individual health and community health based
adequate pain relief. On a comfort contin- on present and/or future needs.
uum, the concept of total comfort (as much Health-seeking behaviors (HSBs) are sub-
as can be expected given the circumstances) sequent recipient goals and are negotiated be-
is at one end while suffering is at the other tween nurses and the recipients. In the practice
extreme end. of nursing administration, when the intended
Propositions of Comfort Theory recipients are bedside nurses, HSBs are nego-
tiated with nursing staff. As noted in the
Concepts are major ideas that act as compo-
propositions, HSBs lead to an increase in
nents of a theory, and these ideas are con-
institutional integrity (InI). Enhanced InI
nected by relationships or premises called
strengthens the institution and its ability to

propositions (Powers & Knapp, 2011). CT
gather evidence for best practices and best poli-
contains three intuitive parts (propositions) that
cies. Best practices and policies lead to quality
can be tested separately or as a whole:
care, which, in many ways, benefits the “bot-
1. Comforting interventions, when effective, tom financial line” of the institution. Many
result in increased comfort for recipients nurses deliver comforting care intuitively but
(patients and families), compared with a do not document its total effects on patients as
preintervention baseline. Increased comfort enhanced comfort. The explicit focus on and
is the immediate desired outcome for this documentation of this type of holistic care is
kind of care. called comfort management and, as shown in the
2. Increased comfort of recipients results in TS, includes more than relief of pain or anxiety.
their being strengthened for their tasks When enhanced comfort is documented,
ahead, which are called health-seeking be- nurses can also demonstrate evidence-based
haviors (HSBs). contributions to better institutional outcomes
3. Increased engagement in HSBs results in such as higher patient satisfaction, fewer read-
increased institutional integrity (InI). missions, or shorter length of stay.
7991_Ch21_371-382 12/08/19 5:30 PM Page 374
Theoretical Definitions for Diagram coaching, and comfort food for the soul. Tech-
Concepts nical interventions are those that are specified
by discipline protocol; they include medica-
CT has eight major concepts (components or
tions, treatments, monitoring schedules, inser-
ideas) connected to the aforementioned propo-
tion of lines, and so forth. For patients, nurse
sitions (statements of relationship). The con-
competency in the administration and docu-
ceptual diagram in Figure 21-2 shows the
mentation of technical interventions is a mini-
framework of relationships between concepts
mum expectation. Coaching consists of supportive
in the CT context. Health-care needs are de-
nursing actions, active listening, referrals to
fined as needs for comfort, arising from stress-
other members of the health-care team, advo-
ful health-care situations that cannot be met
cacy, and reassurance. Comfort food for the soul
by recipients’ traditional support systems. They
includes those extra special, holistic, and more
include physical, psychospiritual, sociocultural,
time-consuming nursing interventions such as
and environmental needs made apparent
back or hand massage, guided imagery, music
through (a) monitoring and verbal or nonver-
or art therapy, a walk outside, or special
bal reports, (b) needs related to pathophysio-
arrangements for family members. The latter
logical parameters, (c) needs for education and
two comfort interventions, coaching and comfort
support, and (d) needs for financial counseling
food for the soul, are what patients most remem-
and intervention.
ber; they are what Benner (1984) would ascribe
to “expert” nurses.
Comfort Interventions Intervening variables are defined as interact-
These interventions are defined as intentional ing forces that influence recipients’ perceptions
actions designed to address specific comfort of total comfort. These consist of variables such
needs of recipients, including physiological, so- as past experiences, age, attitude, emotional
cial, cultural, financial, psychological, spiritual, state, support system, prognosis, finances, ed-
environmental, and physical interventions. ucation, cultural background, and the totality
Within these contexts of experience, there are of elements in recipients’ experience. They are
three types of comfort interventions: technical, not easily influenced by nurses.
Best
practices
Health Intervening Health-

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

behaviors behaviors policies
Peaceful
death
FIG 21-2 ■ Conceptual framework for comfort theory.
7991_Ch21_371-382 12/08/19 5:30 PM Page 375
Comfort was defined technically earlier in is for patients, and one is for patients and family
this chapter. It is the state that is enhanced members, as defined by the patient. (Note: For
immediately by recipients of comfort inter- teaching and learning, it is not necessary to dis-
ventions. It entails the holistic experience of tinguish among relief, ease, and transcendence
being strengthened through having comfort when assessing and intervening for unmet com-
needs addressed. fort needs.) Institutional outcomes can be in-
The concept of health-seeking behaviors was cluded in the care plans even if these data are
developed by Dr. Rozella Schlotfeldt (1975) not accessible to students and beginning nurses
and represents the broad category of subse- (Kolcaba, 1995). These care plans can also be
quent outcomes related to the pursuit of applied in home care and in long-term care.
health. Schlotfeldt stated that HSBs could be
internal or external. She was ahead of her time
in thinking that a peaceful death could also be Applications of the Theory
an HSB (Schlotfeldt, 1975). Realistic HSBs As mentioned earlier, the three types of com-
are determined by recipients of care in collab- fort interventions are technical, coaching, and
oration with their health-care team. comfort food for the soul. Most nurses focus
Institutional integrity is defined as those cor- on technical interventions first and, when time
porations, communities, schools, hospitals, re- or experience permits, implement coaching
gions, states, and countries that possess quality techniques. Interestingly, charting usually ac-
health care which is complete, whole, sound, up- counts only for technical interventions and the
right, appealing, ethical, and sincere. When an effects of analgesia; there are no places in tra-
institution displays this type of integrity, it can ditional hospital records to record the more
produce valuable evidence for best practices and important healing interventions. However, pa-
best policies. Best practices are health-care inter- tients rarely remember the technical interven-
ventions that produce the best possible patient tions; the important interventions to patients
and family outcomes based on empirical evi- and their families are those that are not docu-
dence. Best policies are institutional or regional mented. These include coaching and comfort
policies, ranging from basic protocols for proce- food for the soul, the most important work of
dures and medical conditions to systems for ac- expert nurses. Thus, there is a perpetual dis-
cess to and delivery of health care. Best policies connect between legal charting and actions
are also determined from empirical evidence. that patients want and need from their nurses
As stated previously, the diagram and spe- and that we claim to be the essence of nursing.
cific definitions for the concepts in CT provide It is no wonder that, when pressed, nurses can-
a pattern and practical rationale for practicing not describe the impact they make with pa-
comfort management. This kind of care is tients and their families—coaching and comfort
individualized, efficient, holistic, and thera- food for the soul interventions are rarely valued
peutic. Importantly, the nurturing aspect of by administrators and are often not visible in
nursing provides the altruistic motivation for patient care records. This can result in the value
practicing comfort management. It is the of nursing being understated or even invisible.
traditional mission and passion of nursing CT provides the language and rationale to
(Kolcaba, 2003; Morse, 1992). But the practi- once again claim and document essential nurs-
cal rationale is important at the institutional ing activities that are most beneficial to patients
level because without administrative support and family members in stressful health-care sit-
for optimal staffing and employment practices, uations. It is also important to remember that
nurses often cannot give the kind of care that the outcome of enhanced comfort is a true
drew them to the profession. measure of quality care, rather than a measure
For teaching and learning purposes, care of what quality care is not, such as the currently
plans based on CT are provided on Kolcaba’s measured outcomes of nosocomial infections,
website and in her book (Kolcaba, 2003). One falls, decubitus ulcers, medication errors, and
7991_Ch21_371-382 12/08/19 5:30 PM Page 376
failure to rescue. Enhanced comfort is a posi- to reflect that they value this kind of care. Em-
tive, affirmative, and desired health outcome powering nurses to be advocates for patients and
that aids in progression to optimal wellness— implementing protocol and policy change can
unlike the damaging, unwanted, and harmful increase nursing adherence to pain and comfort
patient outcomes more often assessed in health- management (Bice, Gunther, & Wyatt, 2014).
care institutions. If administrators choose not to take on this
responsibility, practicing nurses can be self-
How to Be a Nurse advocates and begin to document comforting
CT guides nurses to detect comfort needs of interventions and their effects in narrative chart-
patients and families that are not being ad- ing. Preferences of patients and families are
dressed and to develop interventions to meet honored wherever possible. In appropriate set-
those needs. Their caring actions are intu- tings, comfort contracts (see Appendix A) with
itive, but in this theory, caring is a comfort documentation can be instituted and followed
intervention in and of itself. CT describes throughout a defined clinical situation such as
how to care and how to be a nurse, what is surgery, labor and delivery, acute care, long-
important to patients and families, and fac- term care, hematology/oncology care, or an
tors that facilitate healing. In addition, all acute psychiatric episode.
technical nursing interventions are delivered There are many suggestions for comfort
in a comforting way. documentation on Kolcaba’s website, each
Nurses and patients want to experience in- with varying degrees of evidence available to
tentional and meaningful moments with each support validity and reliability. These include
other and with family members, the kind that a verbal rating scale, a numeric diagram, com-
patients might call wow moments. But nurses fort daisies for children, a comfort behaviors
often fail to understand and share how the checklist for nonverbal or unresponsive pa-
wow moments intentionally came to be created, tients, and several questionnaires about pa-
especially if they practice without a theory. tient comfort for different research settings.
These special instances require appropriate These instruments can be downloaded from
theories to add both personal and disciplinary the website and used in practice and/or re-
structure and meaning to such experiences search, without permission because the web-
(Chinn, 1998). CT states that the process of site is in the public domain. The address is
comforting a patient entails the intention to www.thecomfortline.com. Institutions can
comfort, to be present, and to deliver comfort- additionally demonstrate commitment to
ing interventions based on the patient’s and comfort management by adding education on
loved ones’ unmet comfort needs (Kolcaba, comfort management to orientation, in-service
2003; see Kolcaba online at http://www. programs, performance reviews, and through
thecomfortline.com/). The nurse listens atten- creative methods of staffing and nursing
tively and provides culturally appropriate en- assignments.
couragement and body language (a comforting
intervention). The nurse stays focused on the Comfort Theory Innovation
whole person as a patient with aims of provid- and Application
ing comfort and soothing across the life span Institutions have adopted CT to enhance
in times of distress and sorrow. Such an expla- nurses’ work environments, such as in the
nation of how to be a nurse is lacking in many quest for national recognition such as Magnet
other theories. Status, the Baldrich Award, and the Beacon
Award. Many institutions discover that the
Institutional application process for these types of awards
It is not enough for institutional administrators is simplified when a professional practice
to state that they want nurses and other care model is adopted. The main benefit of doing
providers to practice comforting care. They so is that employees are on the “same page”—
must implement organizational policy changes in the case of CT, comforting patients and
7991_Ch21_371-382 12/08/19 5:30 PM Page 377
family members in their own personalized Johnson, 2014), (g) care of pregnant women
styles and capacities. Moreover, and perhaps (Barbosa et al., 2014), and (h) care of dialysis pa-
most important, administrative commitment tients (Estridge, Morris, Kolcaba, & Winkleman,
to CT includes sufficient staffing levels in all 2018). Recently, a systematic review of the lit-
departments to support this type of holistic erature on pediatric procedural holistic comfort
health care. Southern New Hampshire Med- interventions (Bice & Wyatt, 2016) led to the
ical Center adopted CT to undergird its ap- inductive (theory building) qualitative explo-
plication for Magnet Status and was successful ration of pediatric holistic comfort surrounding
shortly after implementation of institutional invasive procedures in children (Bice, Hall, &
comfort management (Kolcaba, Tilton, & Devereaux, 2017). Early dissemination of fea-
Drouin, 2006). sibility findings related to a newly developed in-
CT is supported by propositions and a strument, the Pediatric Procedural Holistic
working model that numerous researchers, Comfort Assessment (PPHCA), has also been
educators, and administrations have used for documented (Bice, Smith, Cowdrey, Clark, &
innovative strategies to enhance comfort in Naughton, 2018).
patients, students, and institutions. Various
research studies testing the comforting effects The Meaning of Comfort Theory
of physical, psychospiritual, sociocultural, or for Practice
environmental (contexts of comfort) interventions Kolcaba routinely asks nurses and students in
have been documented in the literature. her audiences about their experiences during
Kolcaba and Fox (1999) investigated effec- past hospitalizations, either as a patient or a
tiveness of guided imagery in women with family member. She asks if they remember any
early-stage breast cancer and found signifi- of their nurses, and if so, what do they remem-
cant overall increases in comfort level in the ber? The stories that emerge are usually about
treatment group. Efficacy of hand massage in nurses who demonstrated simple, nontechni-
hospice patients has also been found to in- cal, but very comforting acts of compassion
crease holistic comfort over time (Kolcaba, and understanding. Examples of these inter-
Dowd, Steiner, & Mitzel, 2004). Dowd, ventions include the following: a brief back
Kolcaba, Steiner, and Fashinpaur (2007) massage, helping a child make a phone call,
compared the effects, over time, of three in- sitting beside an anxious patient, making eye
terventions, including healing touch, and contact during an interaction, gently encour-
found better immediate results with healing aging ambulation, listening attentively to role-
touch on comfort and stress. In another study, change issues, holding a dying patient’s hand,
warming blankets were found to significantly washing a patient’s hair, and making a family
reduce anxiety and enhance thermal comfort in member comfortable during an overnight stay.
a sample of 126 preoperative patients (Wagner, Patients remember these types of interventions
Byrne, & Kolcaba, 2006). for years after a stressful health-care episode
Innovative works with psychometric inves- because emotions run high and encounters
tigations and recommendations for theory ap- with kindness are precious. Each is an example
plication also have been documented. These of a holistic comfort intervention that has
works include (a) CT propositions and validity greater positive effects on the patient’s total
of the Radiation Therapy Comfort Questionnaire comfort than could be imagined by the care-
(Kolcaba & Steiner, 2000); (b) CT in a fast- giver. These comforting interventions are ex-
track undergraduate nursing education pro- amples of “wow moments” for receivers, and
gram (Goodwin, Sener, & Steiner, 2007); and the exchange also renews the givers of such
(c) application of CT to perianesthesia nursing acts. Moreover, such comforting interventions
(Kolcaba & Wilson, 2002), (d) pediatric nurs- can be delivered by any member of the health-
ing (Kolcaba & DiMarco, 2005), (e) psychiatric care team or department within the context of
nursing (Parks, Morris, Kolcaba, & McDonald, their job description. But they need to be made
2015), (f) cardiac care (Krinsky, Murillo, & visible.
7991_Ch21_371-382 12/08/19 5:30 PM Page 378
How Comfort Theory Lives comfort levels routinely. Using this approach
in Practice facilitates individualized and efficient care and
more positive patient experience. Two exam-
Best Practices
ples of how CT is being used to enhance the
Currently, there is administrative interest in patient experience are at Children’s Hospital
improving the “patient experience,” a factor in Miami, Florida, and the Veterans Admin-
that typically is measured by items on patient istration Hospital in Saginaw, Michigan.
satisfaction instruments, the results of which
are posted on public websites. The quality of Best Policies
the “patient experience,” as rated by patients A previously cited example of how CT is used
after a hospital stay, determines choices by in- in the practice of perianesthesia nursing
surance companies for future coverage of their revolves around the creation of a policy for
enrollees, and in some circumstances affects re- Comfort Management by the American
imbursement for services already rendered. Society of PeriAnesthesia Nurses (ASPAN).
Often, these items are nursing sensitive, mean- This national association is composed of
ing that if nurses demonstrate simple comfort- nurses who work in the following areas: ambu-
ing techniques, patients will respond favorably latory surgery, perioperative staging, operating
to those “patient experience” questions. room, postanesthesia recovery, and step-down.
One administrative approach to enhancing ASPAN decided collectively to apply CT in
the patient experience has been to implement an explicit way throughout patients’ surgical
scripting, in which members of the health-care experiences.
team memorize specific prewritten statements First, ASPAN achieved national consensus
to use during common patient encounters. An about the development of Guidelines for
example is a standard script to be delivered on Comfort Management that would comple-
first introducing oneself to the patient, such as, ment its existing Guidelines for Pain Manage-
“Hello, I am Nurse Thomas, and I will be in ment. The process proceeded with a survey of
charge of your care for today. If you need any- its membership about providing comfort to pa-
thing at all, please let me know.” This approach tients, then with a report of findings, followed
may negate individualized care, the special by the conference about components of Com-
needs of the patient and family, and the par- fort Management, and finally the composition
ticular communication skills of the team mem- of the guidelines (Kolcaba & Wilson, 2002;
ber. And most patients can determine when Wilson & Kolcaba, 2004).
such statements are prescripted, especially The guidelines contain information about
when they hear the same statements several how to (1) perform a comfort assessment;
times from different caregivers over the course (2) create a comfort contract (see Appendix
of a hospital stay. A) with patients before surgery; (3) discover

In contrast, a theory-guided approach is to the interventions that patients and families
undergird all patient interactions with princi- use at home for specific discomforts not nec-
ples of CT, learned through orientation and essarily related to their surgery; (4) use a
in-service programs. Principles of CT that are checklist for common comfort management
relevant to the patient experience include the strategies; (5) document changes in comfort;
following: (1) each interaction entails thera- and (6) implement pre- and post-testing for
peutic use of self; (2) caregivers assess for com- contact hours in comfort management. The
fort needs of patients and family members and completed Guidelines for Comfort Manage-
design their interaction to meet those needs; ment are available on ASPAN’s website
(3) caregivers approach each patient and family (www.ASPAN.org). This is an example of a
member with the intent to comfort and make grassroots change (within a national associa-
a personal, culturally appropriate connection; tion of nurses) that was disseminated to all
and (4) caregivers regularly reassess comfort of perianesthesia settings and soon became a
patients and family members and document practice expectation. Most significant, the
7991_Ch21_371-382 12/08/19 5:30 PM Page 379
model was initiated by nurses and is now larger databases by a hospital system, at the
an expectation that The Joint Commission local, state, region, or country level. Although
reviews on recertification. there are at least 13 national databases for
nursing, and others for medicine, when hospi-
Digital Integration tal systems select and contribute data to a
To support CT in practice, components have mainstream system, documentation of patient
been incorporated into national electronic care problems, interventions, and outcomes
databases, such as the National Interventions can be more widely compared, leading to more
Classification and the National Outcomes consistent and higher quality patient care prac-
Classification systems (the Iowa Taxonomy), tices. In this regard, an important feature of
as well as the North American Nursing Diag- CT is the universality of its main concept, com-
nosis Association. Comforting interventions, fort. This is a word understood by all health-
comfort outcomes, and comfort diagnoses are related disciplines and it is translatable into
included in these data systems, meaning that most languages, as evidenced by the number
individualized comfort needs and the effective- of foreign language comfort tools available on
ness of interventions to meet those needs can Kolcaba’s website. Comfort management can
be charted electronically and entered into be integrated into any nursing practice.
Practice Exemplar
I received report from the day shift nurse at her bed watching television with her head in
6:45 p.m. that Kennedy Rosen, a 13-year-old the palm of her hand and guarding her abdomen
female, was admitted with recurrent bloody with mild facial grimacing. An IV pump, no
stools and significant weight loss. She was longer in use, was alarming for low battery. In
scheduled to have a colonoscopy at 8:00 a.m. her room I noted two trays (lunch and dinner)
the following day, and was receiving intra- with clear broth and Sprite untouched. I intro-
venous (IV) medications for pain, nausea, and duced myself and asked her to share how she
infection prophylaxis. Kennedy was on a clear was feeling with me. Kennedy reported she had
liquid diet until midnight, at which time she been very nauseous for the last couple of hours
would be on nothing by mouth (NPO) for the and that her “belly was hurting a lot,” 7 of
colonoscopy. Her IV catheter was removed 10 on a numeric scale. She also stated her hand
2 hours earlier for mild painful phlebitis, and was hurting where the previous IV catheter was
a new IV access would be needed on my shift. removed. She said the lights were “bright,” and
Kennedy was three hours past due for her pain she was “sick of the IV beeping.” Last, she said
medication, and the day nurse reported that that she wished she did not have to be “in the
she had recently complained of nausea. hospital alone” and that even though her belly
Mrs. Rosen, Kennedy’s mother, had to leave to hurt, she was hungry.
care for her other children at home because her I concluded that Kennedy had unmet com-
husband was at work for the evening. How- fort needs, including the following: (a) physical—
ever, Mrs. Rosen did sign the consent for pain alleviation, nausea relief, consideration of
the procedure, and had already visited with the cluster care (labs and IV), and prophylactic pro-
gastroenterologist who would be doing the cedural pain management; (b) psychospiritual—
procedure in the morning. Kennedy’s parents encouragement and explanation of what to
planned on returning before the procedure expect with surgery; (c) sociocultural—social
at 7:00 a.m. to meet with the anesthesiologist. support, listening, and human presence; and
Lab work was ordered and scheduled for (d) environmental—dimmer lighting, removal of
5:00 a.m. unwanted noise, and clean linens.
Upon entering the room, I noted a thin, I began to implement a comfort care plan
pale young female. She was alone, laying in immediately. I turned down the lights. I
(continued)
7991_Ch21_371-382 12/08/19 5:30 PM Page 380

plugged in the IV pump to stop the battery Kennedy’s room and immediately asked if the
alarm, and I changed Kennedy’s linens while warm pad helped her abdomen. She stated that
she used the bathroom. I left to gather supplies her pain had decreased to a 5 out of 10. Before
and paged the practitioner on call. Upon re- I started the IV I asked Kennedy what she nor-
turning to the room I placed topical anesthetic mally does to make herself feel better when she
cream on two potential IV sites. I administered is afraid or hurting. She said, “I like music.”
an oral disintegrating antiemetic tablet, and Instantly she put in ear buds, closed her eyes,
I placed a warm compress on Kennedy’s pre- and turned up her phone playlist of music and
vious IV site and her abdomen. I offered her a listened to this as I started her IV. Kennedy re-
grape popsicle. Her eyes lit up when I offered mained still and the IV was successful on the
the frozen pop and she followed that up with first attempt. I administered her IV pain med-
a comment: “I didn’t know I could have pop- ication, removed all topical anesthetic cream
sicles!” I explained that these were clear liquids residue, and told her I would be back to re-
and if she wanted I could even make her assess her pain in 30 minutes and that I would
a slushy. I told Kennedy I would return in sit with her for a while if she would like the
30 minutes when the numbing cream on her company. Kennedy smiled and said, “I would
arms took effect to insert the IV. really love that.” I had achieved the main goal
The doctor returned my page and I re- of my nursing care plan for Kennedy: meeting
ceived an order to cluster labs needed with some of her unmet comfort needs. I did this
the IV start so that Kennedy could be stuck through technical, coaching, and comfort food for
with a needle only once, hoping she could get the soul interventions. My patient responded
a bit of extra sleep at 5:00 a.m. I returned to well and her comfort was enhanced.
Summary
The middle-range Theory of Comfort was first Comfort Theory has also been applied fre-
published in 1994 and has been tested repeatedly quently by health agencies and hospitals for
by nurse scientists since that time. Each test of the purpose of enhancing the work environ-
the theory has supported the initial propositions, ment for staff and explicating a unifying
although many more tests need to be conducted theme for patient and family care. The theory
on the relationships between patient/family is popular because it describes what expert
goals and markers for institutional integrity. In- nurses already know: one of the most impor-
struments adapted and/or translated from the tant missions for nursing is still to bring com-
original General Comfort Questionnaire, the fort to our patients and families, no matter
newer Comfort Behaviors Checklist, Comfort what the circumstances. Comfort brings
Daisies, the Verbal Rating Scale, and the Gen- strength for those difficult health-care tasks
eral Comfort Questionnaire have been certified that we must all face.
by AHRQ as a quality measure since 2003.
Questions for Reflection ■ How does Kolcaba define total comfort and
how is this measured? What interventions
and Discussion would you employ to achieve total comfort?
■ What are the major theoretical concepts ■ What are the different propositions of
of Kolcaba’s Comfort Theory? How are Comfort Theory? How can these be used
these concepts defined within the context in clinical nursing practice to document
of Kolcaba’s Theory? nursing care?
7991_Ch21_371-382 12/08/19 5:30 PM Page 381
Appendix A: Example of a Comfort Contract Family visits (when anesthesia wears off)
Music
Thank you for taking the time to complete the Cold washcloth
comfort contract. The purpose of this contract Pillows—location: ___________
is to increase your comfort and pain manage- Massage
ment while you are hospitalized. Please rate Other ________________
your expectation of comfort from 0 to 10 (10 is (Circle all that apply.)
highest) for each situation listed. Please use the 3. In the past, I have required (small, moder-
comfort scale (Fig. 21-3) as directed for all ate, large) amounts of pain medication to
items except when indicated otherwise and take keep me comfortable.
your time and complete the following questions. 4. I have had success with the following
Developed by the following students at the Uni- medications during my previous admis-
versity of Akron and distributed with their permis- sions to the hospital ____________
sion: Robert Bearss, Brent Ferroni, Ryan Hartnett, 5. The following medications I had taken
Kristy Kuzmiak, and Brittney Stover, spring 2006. have resulted in undesirable outcomes:
_________________________________
The Comfort Experience The undesirable outcomes have included:
1. I expect a comfort level of: _________________________________
a. _______ when the anesthesia wears off. _________________________________
b. _______ on postoperative day 1.
c. _______ on postoperative day 3 (when Nursing Interventions
ambulating). 6. I prefer personal hygiene to be
d. _______ on postoperative day 5 (study performed during the (morning,
conclusion day). afternoon, evening).
2. These interventions might assist to increase 7. I prefer my family to be present (all the
my comfort: time, occasionally, not at all) during my
Warming blanket (recovery room) recovery.
Pet visitation 8. I wish to have the following family mem-
ber(s) present: _____________________.
9. I prefer to exclude the following persons
Extreme
from visiting my room: ______________.
Extreme
discomfort
Comfort 10. I prefer to have a fan present in my room.
comfort
(Yes/No)
1 2 3 4 5 6 7 8 9 10
11. I prefer updates regarding my status (only
FIG 21-3 ■ Comfort scale. when asked, daily, not at all).
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7991_Ch22_383-398 12/08/19 5:29 PM Page 383
Joanne Duffy’s
CHAPTER
22
Quality-Caring Model©
Joanne R. Duffy

Practice Exemplar Joanne R. Duffy, PhD, RN, FAAN, is the
Summary Executive Vice President and Senior Con-
Questions for Reflection and Discussion sultant at QualiCare in Winchester, Virginia,
and Adjunct Professor at Indiana University
School of Nursing in Indianapolis, Indiana.
She has directed five graduate nursing pro-
grams, a university department, and several
acute-care clinical divisions of nursing. She
consults with health systems leaders and
schools of nursing nationwide to advance
nursing excellence. Dr. Duffy graduated from
St. Joseph’s Hospital School of Nursing in
Providence, Rhode Island, completed her
BSN at Salve Regina College in Newport,
Rhode Island, and completed her master’s
and doctoral degrees at the Catholic Univer-
sity of America in Washington, DC.
Dr. Duffy has held clinical positions in
critical care and emergency services and was
a nursing director at two urban academic
medical centers, an urban public hospital, and
a large suburban health system, where she de-
veloped a nurse-run Cardiovascular Center
for Outcomes Analysis and administrated a
large transplant center. In academia, Dr. Duffy

teaches research, theory, and leadership in
graduate nursing programs and conducts
research.
Dr. Duffy has authored several versions of
caring assessment tools and the middle-range
Quality-Caring Model© to guide professional
practice and research. She was the first to
examine the link between nurse caring and pa-
tient outcomes and was the principal investiga-
tor on two national demonstration projects,
“Relationship-Centered Caring in Acute Care”
and “Interprofessional Collaborative Practice in
Vulnerable Acute Care Populations.” Dr. Duffy
has been the principal investigator for two
383
7991_Ch22_383-398 12/08/19 5:29 PM Page 384
caring-based intervention studies, served as a In 2002, it became apparent that there were
Robert Wood Johnson Foundation (RWJF) few nursing theories that could guide the de-
Nurse Faculty Mentor, and was a consultant to velopment of a caring-based nursing inter-
the American Nurses Association (ANA) in the vention while simultaneously addressing the
development and implementation of the Na- relationship between nurse caring and quality.
tional Database of Nursing Quality Indicators. As part of a research team, Drs. Duffy and
She was the former chair of the National Hoskins developed and tested the model in
League for Nursing’s Nursing Educational Re- a group of heart failure patients (Duffy,
search Advisory Council and is a Common- Hoskins, & Dudley-Brown, 2005). Caring re-
wealth Fund Executive Nurse Fellow, a recipient lationships were the core concept in this model
of several nursing awards, a Fellow in the and were believed to be integrated, although
American Academy of Nursing, a frequent often hidden, in the daily work of nursing. This
guest speaker, and a former Magnet Appraiser. form of caring was considered different from
Her text, Professional Practice Models in Nursing: the caring that occurs between family and
Successful Health System Integration (Duffy, friends since professional nurse caring requires
2016) uses the Quality-Caring Model to show- specialized knowledge, attitudes, and behav-
case the value of professional practice models. iors that are specifically directed toward health
The first edition of her book, Quality Caring in and healing. Through specialized and ongoing
Nursing: Applying Theory to Clinical Practice, Ed- interactions between patients and professional
ucation, and Leadership received the AJN book nurses, recipients feel “cared for,” which was
of the year award in 2009. The second and third theorized as a positive emotion necessary for
editions, Quality Caring in Nursing and Health taking risks, feeling safe, learning new healthy
Systems: Implications for Clinicians, Educators, behaviors, or participating effectively in deci-
and Leaders (2013a; 2018), focus on caring re- sion making based on evidence. This sense of
lationships as the central organizing principle of “feeling cared for” was considered an an-
health systems. The 3rd edition also received the tecedent necessary to influence improved in-
AJN book of the year award termediate and terminal outcomes, particularly
nursing-sensitive outcomes such as knowledge
(including self-knowledge), safety, comfort,
Overview of the Theory anxiety, adherence, human dignity, health,
The Quality-Caring Model© was initially de- confidence, engagement, and positive experi-
veloped in 2003 to guide practice and research ences of care. Furthermore, the model was
(Duffy & Hoskins, 2003). The seeds of the considered supportive to professional nursing
model were sown during discussions concern- because nurses themselves were theorized to
ing nursing interventions, but it was informed benefit. Blending societal needs for measurable
from earlier work on caring (Duffy, 1992). outcomes with the unique relationship-centered
While examining the outcomes variable of pa- processes central to daily nursing practice rep-
tient satisfaction in the late 1980s, Dr. Duffy resented a practical, postmodern approach.
discovered that hospitalized patients who were The major purposes of the Quality-Caring
dissatisfied often expressed, “Nurses just don’t Model© at that time were to
seem to care.” This concern was corroborated
■ Guide professional practice
in the literature and represented a clinical
■ Describe the conceptual–theoretical–em-
problem that anecdotally affected patients’ per-
pirical linkages between quality of care
ceptions of quality. Over time, Dr. Duffy con-
and human caring
tinued to study human interactions during
■ Propose a research agenda that would
illness, developing tools to measure caring
provide evidence of the value of nursing
(Duffy, 2002; Duffy, Brewer, & Weaver, 2014;
Duffy, Hoskins, & Seifert, 2007) and studying Because of the complexities of modern
the linkage between nurse caring and selected society, individuals, the health system, and
health-care outcomes (Duffy, 1992, 1993). the professionals who work in it, the Quality
7991_Ch22_383-398 12/08/19 5:29 PM Page 385
C H APTER 22 ■ Joanne Duffy’s Quality-Caring Model© 385
Caring Model© has evolved from its initiation Thus, caring is a process that involves a recipro-
in 2003. Since that time, the model has been cal relationship (characterized by caring behav-
revised three times (Fig. 22-1) to meet the de- iors) between human persons, whereby the
mands of the multifaceted, interdependent, positive emotion, “feeling cared for,” is at-
and global health system that “requires a more tained. It is this feeling of being “cared for”
sophisticated workforce, one that understands that matters in terms of enabling the condi-
the significance of systems thinking, whose tions for self-advancing systems. As such, it is
practice is based on knowledge, multiple and an essential performance indicator of quality
oftentimes competing connections, and one nursing care. Caring relationships also are the-
that values relationships as the basis for ac- orized to enhance interprofessional practice
tions and decision-making” (Duffy, 2009, and benefit nurses themselves by maintaining
p. 192). In this revised version, the link between congruence with professional values and con-
caring relationships and quality care is even tributing to meaningful work.
more explicit, challenging the nursing profes-
sion to use caring relationships as the basis for Concepts, Assumptions,
daily practice. The revised model is considered and Propositions
a middle-range theory because it draws on In the latest revision of the Quality-Caring
others’ work, is practical, and can be tested. In Model©, there are four main concepts. The
this theory quality is a dynamic, nonlinear first is humans in relationship. This idea refers
characteristic that is influenced by caring to the notion that humans are multidimen-
relationships. “Quality is not an endpoint sional beings with various characteristics that
per se, but a process of continuous learning make them unique. Recognizing human char-
and improvement … that treats patients as acteristics, including how they differ and yet
full partners … and is fully integrated into are the same, provides an understanding that
the work of health professionals” (Duffy, influences human interactions and, conse-
2013a, p. 31). quently, nursing interventions. In addition,
When caring relationships are the basis of humans are social beings connected to others
nursing work, positive human connections are through birth or in work, play, learning, wor-
formed with patients and families that shape ship, and local communities. It is through
future interactions and positively influence in- these connections that humans mature, en-
termediate and terminal health outcomes. hance their communities, and advance.
Patients
Families
Communities
Caring
Self
Self Feel Advancing
“Cared Systems
Relationship- For”
centered
Humans in Professional Health Professionals
Relationship Encounters Health Systems
Beh
Others and
a v i o rs
Communities
FIG 22-1 ■ Revised Quality-Caring Model©. (Copyright © 2018 J. Duffy. From Duffy, J.
[2018]. Quality caring in nursing and health systems: Implications for clinicians, educators, and
leaders [p. 49]. New York: Springer.)
7991_Ch22_383-398 12/08/19 5:29 PM Page 386
The concept of relationship-centered professional Assumptions of the revised Quality-

encounters consists of both the independent Caring Model© (Duffy, 2018, p. 48) include
relationship between the nurse and patient/ the following:
family and the collaborative relationship that
nurses establish with members of the health- ■ Humans are multidimensional beings
care team. When these relationships are of capable of growth and change.
a caring nature, the intermediate outcome of ■ Humans exist in relationship to them-
“feeling cared for” is generated in the recipients. selves, others, communities or groups, the
Embedded in this concept are the caring behav- environment (including the workplace),
iors that are discussed in the next section. Feel- and the larger universe.
ing cared for is a positive emotion that signifies ■ Humans evolve in a dynamic, intercon-
to patients and families that they matter. Car- nected continuum.
ing relationships prompt this feeling, inciting ■ Humans are inherently worthy.
the capabilities of persons, groups, and systems ■ Caring consists of interpersonal processes
to change, learn and develop, or self-advance. that are used individually or in combina-
In other words, “feeling cared for” allows one tion and often concurrently.
to relax, feel secure, and get engaged in his or ■ Caring is a social process that is done “in
her health-care needs. It is an important an- relationship.”
tecedent to quality health outcomes, particu- ■ Caring for self enhances caring for others.
larly those that are nursing sensitive. ■ Caring relationships are protective.
Patients and families who experience caring ■ Caring is embedded in the daily work of
relationships from health-care providers are professional nursing.
more apt to concentrate on their health, focus ■ Professional nursing work is done in the
on learning about it, modify lifestyles, adhere context of human relationships.
to the recommendations and regimens, and ac- ■ The display of caring relationships varies.
tively participate in health-care decisions. They ■ Caring is a tangible concept that can be
feel understood and more confident in their measured.
abilities. Over time, persons who experience ■ Caring relationships benefit both the carer
caring interactions with health professionals and the one being cared for.
progress or self-advance. Self-advancing systems
■ Caring relationships benefit society.
is the final concept in this model. It is a phe-
■ Caring relationships generate feeling
nomenon that emerges gradually over time and “cared for.”
in space reflecting dynamic positive progress
■ Feeling “cared for” is a positive emotion.
that enhances the systems’ well-being. Self-ad-
■ Feeling “cared for” is adaptive for individ-
vancing systems are stimulated by caring rela- uals, groups, and systems.
tionships, but the forward movement itself

■ Caring relationships influence advancement.
cannot be controlled directly; rather, it
■ Feeling “cared for” positively influences
emerges over time, driven by ongoing caring self-advancing systems.
connections. Self-advancing systems represent
■ Self-advancing systems evolve over time
quality in the model because it is a dynamic and in context.
concept that enhances an individual’s or sys- Propositions are those relational state-
tem’s well-being. ments that tie model concepts to each other
The overall purposes of the revised Quality- and, in some instances, can be the basis
Caring Model© are to (1) guide professional for hypothesis testing. Propositions of the
practice and (2) provide a foundation for nurs- Quality-Caring Model© (Duffy, 2018, p. 53)
ing research. It can also be used in nursing ed- include the following:
ucation (to guide curriculum development and
facilitate caring student–teacher relationships) ■ Human caring capacity can be improved.
and in nursing leadership as a basis for human ■ Caring relationships are composed of
interactions and decision making. processes or behaviors that can be observed.
7991_Ch22_383-398 12/08/19 5:29 PM Page 387
■ Caring relationships require intent, ■ Engage in continuous learning and

specialized knowledge, and time. practice improvement
■ Engagement in communities through ■ Use caring relationships to enhance the
caring relationships enhances self-caring. professional work environment
■ Independent caring relationships between ■ Use the expertise of caring relationships
patients and health-care providers influ- embedded in nursing to actively partici-
ence feeling “cared for.” pate in community groups
■ Collaborative caring relationships among ■ Contribute to the knowledge of caring
nurses and members of the health-care and, ultimately, to health systems using all
team enhance team cohesiveness. forms of knowing, including research
■ Caring relationships influence health ■ Maintain an open, flexible perspective
behaviors. ■ Use measures of caring to evaluate
■ Caring relationships influence feeling professional practice
“cared for” in the recipient.
■ Caring relationships facilitate change. Caring Relationships
■ Feeling “cared for” facilitates cooperation, There are four caring relationships essential to
engagement, and disclosure in recipients. quality caring (Fig. 22-2). The first is the rela-
■ Feeling “cared for” is an antecedent to tionship with self. Because humans are multi-
self-advancing systems. dimensional (comprising bio–psycho–social–
■ Self-advancing systems are naturally cultural–spiritual components) and continu-
self-caring or self-healing. ously interact in concert with the universe, their
■ Feeling “cared for” contributes to individ- fundamental nature is integrated or whole.
ual, group, and system self-advancement. The many seemingly different parts relate
to and depend on each other, generating an
Role of the Nurse orientation of the self that represents a source
of understanding often lost in the business of
The overall role of the professional nurse in
life. Individuals, particularly nurses, tend to go
this model is to engage in caring relationships
about their day habitually moving from one
so that self and others feel “cared for” (Duffy,
task to another without noticing their internal
2018, p. 53). Such actions positively influence
bodily processes, feelings, or connections with
intermediate and terminal health outcomes
others. This externally driven focus separates
(self-advancement), including those that are
nursing sensitive.
The revised Quality-Caring Model© specifi-
cally emphasizes the following responsibilities
of professional nurses (Duffy, 2018, pp. 53–54):

Self Community
■ Attain and continuously advance knowl-
edge and expertise in caring processes Relationship-
■ Initiate, cultivate, and sustain caring rela- centered
tionships with patients and families professional
practice
■ Initiate, cultivate, and sustain caring
relationships with other nurses and all Health care
members of the health-care team Patient/family
team
■ Maintain an ongoing awareness of the
patient’s and family’s point of view
■ Carry on self-caring activities, including
personal and professional development FIG 22-2 ■ Four relationships necessary for quality
caring. (Copyright © 2013 J. Duffy. From Duffy, J.
■ Integrate caring relationships with specific [2013a]. Quality caring in nursing and health systems:
evidence-based nursing interventions to Implications for clinicians, educators, and leaders [p. 53].
positively influence health outcomes New York: Springer.)
7991_Ch22_383-398 12/08/19 5:29 PM Page 388
individuals from those internal forces that hold intention, choice, specific knowledge and
a special knowledge of self. In nursing, profes- skills, and time (Duffy, 2009). Intending to
sionals care for others and their families with care depends on one’s attitudes and beliefs; it
ease, frequently “forgetting” to connect with shapes a nurse’s choice and resulting behaviors,
self. Yet allowing oneself to slow down enough specifically whether “to care” for another. Such
to access his or her own genuineness offers a choice is a conscious decision that is required
clarity that is life enhancing. Some would say for effective caring relationships. Deep aware-
such inner awareness is necessary for authentic ness of the self enhances caring intention, and
interaction and health (Davidson et al., 2003), consequential behaviors become more posi-
whereas others (Siegel, 2007) believe it is nec- tively focused toward the patient/family.
essary to adequately care for others. As human Collaborative relationships with members
beings, professional nurses who are regularly of the health-care team are essential to quality
“in touch” with themselves set up the condi- health care (Urisman, Garcia, & Harris, 2018)
tions for self-caring, a state that offers a rich and are depicted as an important relationship
supply of energy and renewal. in the Quality-Caring Model©. Nurses are
In nursing, remaining self-aware is a nec- already connected to one another by the work
essary prerequisite for caring relationships be- they do and with other members of the health
cause in knowing the self, it is possible to know team by the commonality of simultaneously
others. Regular mindfulness activities such as providing services to patients and families. But
prayer, meditation, quiet time, attention to real collaboration connotes mutual respect for the
physical health through regular exercise and work of other health professionals and occurs best
proper nutrition, and creative activities, when “in relationship.” Ongoing interaction is key to
performed in a conscious manner, promote in- collaboration in order to seek the other’s point
sight. Likewise, in the work environment, of view, validate the work, share responsibili-
short pauses, consciously remembering to cen- ties, and evaluate the care. The Quality-Caring
ter on the person being cared for, attending to Model© maintains that professional nurses
bodily needs such as nourishment and elimi- have a responsibility for implementing colle-
nation, and even short time-outs ensure that gial, caring interpersonal relationships with
the caring focus of nursing remains the prior- each other and members of the health-care
ity. Reflective awareness by actively soliciting team. Discussing specific clinical issues perti-
feedback about one’s performance is another nent to patients, participating in joint rounds,
method of attaining self-knowledge that improving quality or research projects, holding
may offer professional nurses a boost in self- family conferences, and discharging rounds are
confidence or specific learning opportunities. all examples of positive collaboration that ben-
Reflective analysis in which thoughts are actu- efit not only patients and families but the
ally documented in written or taped format health-care team as well. Affirming each other’s
and then analyzed for their subjective mean- unique contribution to patient care through
ings can be used to inform clinical practice. genuine collaboration contributes to a healthy
“Health professionals need to acknowledge work environment that may increase work
and allow themselves to feel the meanings as- satisfaction.
sociated with their work, including suffering” Finally, caring for the communities in
(Duffy, 2018, p. 77). Such self-caring may op- which nurses live and serve reflects another
timize the ability to care for others and build caring relationship essential to the revised
more positive workplaces. Quality-Caring Model.© This relationship is
As the primary focus of nursing, patients predicated on the belief that humans interact
and families who are ill are vulnerable and de- with groups beyond the family to connect,
pendent on nurses for caring. Initiating, culti- share similar history and customs, and enhance
vating, and sustaining caring relationships the lives of each other. Engaging in commu-
with patients and families is an independent nities provides professional nurses opportuni-
function of professional nursing that involves ties to use caring relationships as the basis for
7991_Ch22_383-398 12/08/19 5:29 PM Page 389
improving health or managing symptoms of Wolf, Zuzelo, Goldberg, Crothers, & Jacobson,
disease. Such activities contribute to the on- 2006). Mutual problem-solving refers to assisting
going vitality of the community and enrich patients and families to learn about, question,
nurses’ personal lives. The four underlying re- and participate in their health or illness. This is
lationships essential to quality caring, when accomplished reciprocally and requires profes-
well developed and practiced with knowledge sional interaction that is informed and engag-
of the caring factors, meets the needs of pa- ing. This behavior recognizes that patients and
tients and families and health professionals for families are the decision-makers in the health-
self-advancement. care process and facilitating informed alterna-
tives and adoption of their ideas is paramount.
The Caring Behaviors Attentive reassurance refers to being avail-
Caring is not just a mindset or simple acts of able and offering a positive outlook to patients
kindness; rather, clinical caring requires and families that helps them feel secure. Pro-
knowledge (Mayerhoff, 1971) and skills, jux- fessional nurses who use this behavior are able
taposed on caring values. Many have theorized to “be with” their patients long enough to con-
about the qualities necessary for therapeutic vey possibilities, focus on their unique needs,
relationships (Rogers, 1961; Yalom, 1975), listen, and present some cheerful dialogue.
but Watson (1979, 1985, 2011) identified Human respect implies valuing the human per-
10 carative factors (now modified to caritas son of the other by acting in such a way that
processes) necessary for human caring in the demonstrates that value. For example, calling
patient–nurse relationship. Eight behaviors, a patient by his or her preferred name, per-
reframed through research and clinical experi- forming tasks in a gentle manner, and main-
ence, are currently used to characterize caring taining eye contact show regard for the other.
in the Quality-Caring Model©. These behav- Using an encouraging manner or a supportive
iors are specifically defined, facilitating the demeanor during interactions conveys confi-
identification of specific cognitive and behav- dence and is expressed both verbally and non-
ioral abilities necessary for caring relationships, verbally. It is especially important to maintain
and are as follows (Duffy, 2018; Duffy, Hoskins, uniformity between messages expressed and
& Seifert, 2007): those implied by body language. Appreciation
of unique meanings helps a patient feel under-
■ Mutual problem-solving
stood because the nurse uses this behavior to
■ Attentive reassurance
acknowledge what is significant to patients and
■ Human respect
families. In other words, nurses aim to see
■ Encouraging manner
things from the patient’s point of view and use
■ Appreciation of unique meaning
his or her preferences and their sociocultural
■ Healing environment
meanings in care. In this way, nurses tailor in-
■ Affiliation needs
terventions to the patient’s frame of reference.
■ Basic human needs
Cultivating a healing environment, including
The caring behaviors were initially derived appealing surroundings, decreasing stressors
from Watson’s original work (Watson, 1979, (noise, lighting), ensuring patient privacy and
1985) and are consistent with the intentions of confidentiality, and practicing in a safe man-
other nursing theorists (Boykin & Schoenhofer, ner, are included in this behavior. The partic-
1993; Henderson, 1980; Johnson, 1990; King, ular norms and customs of a department in
1981; Leininger, 1981; Nightingale, 1992; which a patient receives care also have an im-
Orem, 2001; Peplau, 1988; Roach, 1984; Roy, pact. This caring behavior is especially impor-
1980; Swanson, 1991) and empirical research tant in acute care where adverse events remain
(Boudreaux, Francis, & Loyacano, 2002; a major source of harm, death, and disability
Campbell & Rudisill, 2006; Cossette, Cote, for Americans (Fineberg, 2012). Ensuring that
Pepin, Ricard, & D’Aoust, 2006; Mangurten basic human needs are attended to during an
et al., 2006; Paul, Hendry, & Cabrelli, 2004; illness (including the higher-order needs;
7991_Ch22_383-398 12/08/19 5:29 PM Page 390
Maslow, 1954) has been a major role of the As experts in caring, professional nurses are
professional nurse that today is often dele- in a unique position to profoundly benefit the
gated to unlicensed assistive personnel. Often health-care system. Uniting caring knowl-
this behavior is blended with other nursing ac- edge and caring action(s) in relationships
tivities such as assessments, teaching and with self, patients and families, coworkers,
learning, and emotional support. Providing and the community provides opportunities
for basic human needs is an opportunity to for creative innovations, improvements in
further the development of caring relation- practice, and a source of energy for future in-
ships. Finally, appreciating the significance of teractions. Furthermore, some nurses who
affiliation needs refers to making sure that pa- practice this way describe richer work experi-
tients are not only allowed access to their fam- ences that are naturally renewing (D’Antonio,
ilies, but also that families are included in care 2008).
decisions. Being open and approachable to
families and keeping them informed is impor- Applications of the Theory
tant to patients’ well-being and should be a
normal part of nursing care. Clinical Practice
The caring behaviors are used “in rela- The Quality-Caring Model© provides clini-
tionship” with others and comprise the basis cians, teams of health professionals, educa-
for the “knowledge and skills” required to tors, and leaders with a relationship centered
practice according to the Quality-Caring approach to health care. In doing so, it hon-
Model©. Using them is dependent on patient ors the interdependencies necessary for
needs and the context of the situation. Not human advancement. For individual clini-
all caring behaviors are necessarily used at cians, it provides a “way of being with” pa-
once; rather, the professional nurse uses his tients and families (through the caring
or her judgment to decide which are neces- behaviors) that can be used to guide interven-
sary for certain situations. When applied tions, practice improvements, and ongoing
with expertise, these behaviors are theorized learning about the self. For health-care
to positively affect recipients such that they teams, the model offers a way to relate to and
feel “cared for.” In fact, “feeling cared for” is engage with other health-care providers in
a calming influence, allowing patients to care that is “best for the patient.” The Qual-
concentrate on the meaning of their illnesses ity-Caring Model© offers health educators a
and the requirements for health and healing. caring pedagogy that honors caring relation-
“Feeling cared for … provides patients with ships that are lived out through the behaviors
the energy or drive to make behavioral of faculty members. In other words, teaching
changes, interact, learn, and maybe even fol- one “how to care” is dependent on the “caring
low through” (Duffy, 2018, p. 153). In other milieu” generated by faculty members them-
words, feeling cared for may be tied to one’s selves who notice and share “caring mo-
ability to progress, including attaining im- ments,” continuously reflect on the nature of
portant health outcomes. Performing nursing nursing, and who use cognitive, psychomotor,
in such a way that valuable time is spent pre- and affective experiences to help students ac-
dominantly in caring relationships with pa- quire the knowledge, skills, and attitudes of
tients and families (i.e., using the caring caring professionals. Likewise, relationship-
behaviors) ensures that patients and families centered leaders preserve the foundational
feel “cared for” and that health outcomes are caring patient–nurse relationship that gives
positively affected. nursing its identity, ensures ethical and legal
The caring behaviors are applicable to the services, and provides the nursing workforce
other three relationships pertinent to the with meaning.
Quality-Caring Model©. For example, collab- In Quality Caring in Nursing and Health
orative relationships founded on the caring Systems: Implications for Clinicians, Educators,
behaviors enhance teamwork and cooperation. and Leaders, Duffy (2013a, 2018) highlights
7991_Ch22_383-398 12/08/19 5:29 PM Page 391
how many health systems are using the Quality- BOX 22-1 Example Organizations Using the
Caring Model© to Quality-Caring Model© to Guide
Professional Nursing Practice
■ Provide a foundation for patient-
centered care Association of Women’s Health, Obstetrics,
■ Enhance interprofessional practice and Neonatal Nurses, Washington, DC
■ Facilitate staff-directed practice changes Banner Gateway Medical Center, Gilbert, AZ
■ Redesign professional workflow Children’s Mercy Hospital and Clinics, Kansas
■ Generate guiding principles for human City, MO
resource practices Forsyth Medical Center, Winston-Salem, NC
■ Guide nurse residency programs Hannibal Medical Center, Hannibal, MO
■ Improve collective relational capacity Holy Cross Hospital, Silver Spring, MD
■ Renew the meaning of nursing work International Association of Forensic Nurses,
■ Extend caring to others first Elkridge, MD
■ Build relationships with community Johns Hopkins, Bayview, Baltimore, MD
groups Lakeland Regional Medical Center,
Lakeland, FL
■ Create a legacy of caring
Lowell General Hospital, Lowell, MA
■ Sustain professionalism
McLaren, Northern Michigan Medical
■ Revise nursing curricula Center, Petoskey, MI
■ Balance “doing” with “being” MD Anderson Medical Center, Houston, TX
■ Leading through caring relationships Methodist Hospital, Henderson, KY
Box 22-1 lists example health-care systems Moffitt Cancer Center, Tampa Florida
and organizations that use the Quality-Caring Montefiore Health, New York, NY
Model© to guide professional nursing practice. Novant Health Presbyterian Hospital,
Charlotte, NC
Practice Improvement St. Joseph’s Medical Center, Towson, MD
Because caring relationships can be measured Swedish American Hospital, Rockford, IL
and their consequences assessed, the model af- Texas Health Resources, Arlington, TX
fords an evaluation design for improvement of Torrance Memorial Hospital, Torrance, CA
services. The Quality-Caring Model© main- West Virginia University Hospitals,
Morgantown, WV
tains that quality nursing care is based on the
use of best evidence and asserts the nursing re- Recent Additions
sponsibility to engage in continuous learning,
Banner Gateway Medical Center, Gilbert, AZ
use measures of caring, and contribute to car-
Massachusetts Department of Health and
ing knowledge and practice-based research.
Human Resources, National Telenursing

Evaluation of nursing practice is an ongoing Center, Boston, MA
process that is tied to nurses’ individual com- Miriam Hospital, Providence, RI
petency, as well as the processes used in daily Montefiore Health, New York, NY
practice and their subsequent outcomes (both St Barnabas Health System, Livingston,
intermediate and terminal). Using the caring New Jersey
behaviors as the basis for competency state- University of Colorado Anschutz Medical
ments or performance expectations from Campus
which individual nurses can complete self- Winchester Medical Center, Winchester, VA
evaluations, gather peer reviews, or be evalu-
ated by their supervisors is a first step. A more
comprehensive approach using the 360-degree for” (patients and families), the supervisor,
method (Edwards & Ewen, 1996; London & and colleagues (other nurses, physicians, other
Smither, 1995) provides assessments from members of the health-care team). This ap-
the perspective of the one being evaluated proach provides the one being evaluated with
(nurse self-evaluation), those being “cared information about his or her performance from
7991_Ch22_383-398 12/08/19 5:29 PM Page 392
the perspective of recipients of his or her care. the approach, how they are administered and
Thus, patients (those being “cared for”) and scored, whose view they are obtaining (e.g.,
colleagues (those within the health-care team) patients, nurses, or others), and validity and
offer direct information about the nature of reliability. Only a few directly gather informa-
caring displayed by the nurse. Using these per- tion from patients. This is an important com-
spectives, those being evaluated can reflect on ponent of assessment because the one being
this feedback, and then set personal goals for “cared for” is the direct source of knowledge
self-development, ultimately improving prac- and others’ opinions may not be consistent.
tice and benefitting themselves and others The revised Caring Assessment Tool© (CAT;
(self-advancement). The 360-degree approach Duffy, Hoskins, & Seifert, 2007; Duffy,
to evaluating individual caring competence is Kooken, Wolverton, & Weaver, 2012), a
thorough and relationship centered; it takes 27-item instrument designed to capture pa-
advantage of multiple sources and perspectives tients’ perceptions of nurse caring, has been used
to provide important feedback about nursing with success in several health-care institutions
practice. (Duffy, 2013a). This tool has established va-
Evaluating processes of care requires meas- lidity and reliability and is available in Eng-
uring the quality of caring relationships and lish, Spanish, and Japanese. Using this tool
using those data to efficiently revise practice. provides an evaluation of nurse caring behav-
Although many performance improvement iors as perceived by patients that can be used
activities are conducted in today’s health sys- for performance improvement and practice
tems, few focus on the patient–provider rela- revisions.
tionship. The lack of focus on this relationship Another instrument that was adapted from
as a quality indicator, combined with per- the CAT© is the Caring Assessment Tool for
formance reports that often do not represent Administration (CAT-admin; Duffy, 2002;
the patient’s perspective (Hudon, Fortin, Wolverton, 2016). This tool was recently re-
Haggerty, Lambert, & Poitras, 2011), pre- vised and consists of a 25-item questionnaire
cludes practice improvement. Furthermore, that assesses how nurses perceive nurse man-
nurses frequently do not receive performance ager caring behaviors and has become impor-
information for 3 or 4 months or longer after tant in the assessment of caring practice
patients are discharged. environments. Many other instruments exist
Real-time patient feedback may assist to measure caring; however, it is vital that the
providers to enhance performance, and in the conceptual base, population and setting, and
case of caring relationships, evaluate the pa- perspective of the respondent are consistent
tient’s perspective, particularly at the point of with individual and organizational values.
care. The use of technology in the form of Specific nursing-sensitive outcomes are
bedside mobile devices or more subjective ap- likely to be influenced through use of the
proaches provides real-time data for use by Quality-Caring Model©, so knowledge about
nurses and others to revise their practice, pro- these is necessary to improve and accelerate its
viding routine evaluation of caring relation- translation into practice. Explicitly relating
ships during the care process (Duffy, Kooken, outcome indicators to the process indicator of
Wolverton & Weaver, 2012; Indovina et al., nurse caring strengthens the understanding
2016). and evidence related to the importance of car-
At the microsystems level, assessing nurse ing relationships and the value of nursing. For
caring on a unit or departmental basis provides example, hospitalized older adults frequently
some evidence of how well the Quality-Caring leave the hospital with poorer physical func-
Model© is integrated into practice and points tion than when admitted. This is a national
to performance improvement recommenda- problem with significant cost and clinical bur-
tions. Many tools exist that are available to as- den (Goodwin, Howrey, Zhang, & Kuo,
sist this process (Watson, 2002). However, 2011), not to mention the personal burden it
they vary in terms of how they define caring, places on patients and families. Measuring and
7991_Ch22_383-398 12/08/19 5:29 PM Page 393
reporting differences in functional status from ideas can provide the basis for research. For ex-
admission to discharge for older adults on ample, the proposition “feeling ‘cared for’ is an
Quality-Caring units would add to the evi- antecedent to self-advancing systems” (Duffy,
dence base. Those with chronic illnesses, such 2018, p. 53) could be tested by linking the results
as heart failure, cancer, and chronic obstructive of an instrument measuring caring with a set of
pulmonary disease, often are readmitted within specific patient outcomes. In fact, nurse re-
30 days of discharge, financially draining the searchers have investigated this and found some
U.S. health-care system (Jackson, Trygstad, evidence that caring is linked to patient satisfac-
DeWalt, & DuBard, 2013). This burden may tion, postoperative recovery, and decreased anx-
be lessened if nurses worked, through caring iety (Burt, 2007; Swan, 1998; Wolf, Zuzelo,
relationships, to engage and activate patients Goldberg, Crothers, & Jacobson, 2006). Or the
in their care before discharge. Patient engage- proposition “caring relationships contribute to
ment is a measurable intermediate outcomes individual, group, and systems self-advance-
indicator (Hibbard, Stockard, Mahoney, & ment” (Duffy, 2018, p. 53) might be tested by
Tusler, 2004) that has been associated with de- examining the relationship between adoption of
creased readmissions (Coulter, 2012) and re- a caring professional practice model and staff
flects the relational aspect of nursing care, nurses’ work engagement.
potentially raising positive regard for nursing’s Others have developed caring nursing inter-
value. ventions and used them to study effects on spe-
Other nursing-sensitive intermediate out- cific patient outcomes (Duffy, Hoskins, &
comes indicators such as comfort, knowledge, Dudley-Brown, 2005; Erci et al., 2003). An ex-
dignity, optimistic mood, recovery time, ad- ample geared to optimizing patient-centered
herence, contentment (versus anxiety), conti- care for hospitalized older adults uses flexible
nence, cognition, empowerment, health-seeking education, rapid-cycle performance improve-
behaviors, mobility, symptom control, and ment, and facilitated group reflection to sup-
skin integrity are examples of affirming inter- port busy nurses to use the caring factors in a
mediate outcomes that could be used to complex environment (Duffy, 2013b). Such re-
demonstrate the effects of caring relation- search adds to the knowledge base and offers
ships. Many of these indicators have well- implications for the improvement of nursing
documented instruments that would easily practice. Schools of nursing have used the car-
translate to the clinical environment, rendering factors to develop and test caring compe-
ing measurement and reporting feasible. tencies of baccalaureate students longitudinally;
Routinely using such existing tools may vali- and students themselves, particularly those in
date the effects of nurse caring on important Doctor of Nursing Practice (DNP) programs,
intermediate outcomes and provide a basis for often use the Quality-Caring Model© to guide
improvement. their scholarly inquiries. Finally, nursing lead-

ers study caring behaviors of nurse managers
Researching Caring Relationships (using the CAT-admin) and evaluate imple-
Effectively appraising research informs nursing mentation of the model organizationally using
practice by providing evidence that can guide comparative designs of patient outcomes on
nursing interventions. Workplace journal clubs, implementation and control units.
nursing rounds, or even routine dialog can pro- Studying caring relationships is important
vide forums for such appraisal. With special to provide evidence of nursing’s contribution
attention to those studies that investigate as- to health care and to advance the profession.
pects of caring relationships, nurses can help Such evidence provides policymakers with
translate findings into practice and/or extend documentation of nursing’s value that may af-
the research itself. fect important decisions such as funding, job
Because the Quality-Caring Model© provides descriptions, promotion and advancement, and
a set of concepts, assumptions, and propositions, staffing. To that end, the Quality-Caring
questions generated from these theoretical Model© provides a foundation for continued
7991_Ch22_383-398 12/08/19 5:29 PM Page 394
research and model testing. Ensuring that re- nonprobability samples, have created gaps
sults are disseminated quickly to the nursing in caring knowledge. Linking caring to
community through publications and presen- nursing-sensitive patient outcomes, improv-
tations is a nursing responsibility that can ad- ing existing caring instruments, designing
vance caring science. caring-based interventions, educational car-
Up until now, weaknesses in caring eval- ing, and cost–benefit analyses are urgently
uation and research, including the lag time needed to provide evidence of nursing’s
behind caring theories and their application, value. Using rigorous methods, research that
the vagueness between specific study findings builds on the work of others and includes
and components of theory, measurement multiple patient populations and settings
issues, lack of theory validation studies, and demonstrates the validity of caring theories
poorly designed studies with small and/or and advances nursing practice.
Practice Exemplar
Mr. S is an 86-year-old man with chronic procedure—not only because of the surgery it-
obstructive pulmonary disease (COPD) who self but also because he knew he would most
lives with his daughter, her husband, and likely be in the intensive care unit (ICU) af-
their three children. He has been living with terward. That place scared him! After admis-
COPD for 15 years and is mostly home- sion, Mr. S was wheeled down to the preop
bound. Mr. S has home oxygen, a wheel- area. He sat in the wheelchair for 45 minutes
chair, and his own room on the second floor until a nurse arrived. The nurse returned with
of the home equipped with a TV, a DVD a clipboard and began her assessment, collect-
player, and books. He interacts with his ing pertinent history. Her resultant problem
grandchildren, who are teenagers, and relies list consisted of (1) shortness of breath due to
on his daughter for activities of daily living. COPD and (2) sleep pattern disturbance. She
Mr. S lost his wife several years earlier to told Mr. S a little about the upcoming surgery
cancer and was a computer programmer be- and asked his daughter to sign the consent pa-
fore retirement. He was a two pack per day pers. The anesthesiologist arrived to start the
smoker who rarely exercised and had been in anesthesia, so Mr. S’s daughter kissed him,
good health before his diagnosis. He com- and he was wheeled into the operating room.
municates well verbally and uses an intercom Three hours later, he was in the recovery area,
set up by his son-in-law when necessary. His and when Mr. S’s daughter saw her father, he
breathing has been gradually getting worse was on a ventilator, with multiple IVs, and ex-
(despite medications), and he produces quite tremely agitated. He was able to take his own
a bit of sputum daily. He is easily fatigued breaths but was obviously frightened. Because
and occasionally experiences wheezing. He he was “tied down” to the bed rails, his daugh-
takes both a short- and a long-acting bron- ter, who understood his anxiety, sat by his side
chodilator and is on steroid therapy. and softly talked to him.
Mr. S has been noticing increasing in- He used his eyes and facial grimaces to
somnia lately with some nocturnal dyspnea show her he felt like he couldn’t breathe. The
and a cough. His pulmonary function studies daughter, in turn, relayed this to the nurse,
have not changed, but his pulmonologist who asked her to tell him that this was a nor-
suggested that he consider elective lung mal feeling after this surgery. Mr. S continued
volume reduction surgery (LVRS) to help to experience anxiety, often coughing, and was
him breathe better and avert an emergency. eventually placed in the farthest bed so as to
Mr. S subsequently entered a large teach- not disturb the other patients. Unfortunately,
ing Magnet hospital to have this surgery his daughter could not allay his concerns, and
performed. He was nervous about the he continued to feel anxious and distressed.
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It was 5:00 p.m., and Mr. S was doing Through this process, Megan came to know
well according to the nurses in the postanes- Mr. S as a retired, widowed software engineer
thesia care unit (PACU). Unfortunately, living with his married adult daughter and
Mr. S had to stay in the PACU overnight three grandchildren, an avid reader of history,
until an ICU bed became available. The who was anxious and tired. She learned about
PACU nurses were unhappy and they were his experience living with COPD, his treat-
overheard talking to each other, saying, “If ment, and his medications. His vital signs
I had wanted to work on a surgical floor, I were stable, except that he was slightly tachy-
wouldn’t have applied to the PACU.” Mr. S cardic with a heart rate of 112; his dressing
continued to display anxiety, often gagging was dry, and his back showed evidence of a
and looking fearful with his eyes. The daugh- beginning pressure ulcer at the coccyx region.
ter asked the PACU nurses for help in fig- Mr. S’s daughter relayed her difficulty in car-
uring out what was wrong, but they saw that ing for Mr. S while also working part time,
his vital signs, blood gases, and dressing were raising three children, and maintaining a
normal. One nurse decided to suction him; home. This family had not been on a vacation
her technique was rather rough and Mr. S in several years. This assessment time provided
grimaced with pain. Mr. S remained anxious Megan with the opportunity to understand
throughout the night while his daughter sat the unique human being (Mr. S) in relation-
by his side; neither of them slept. He was ship to his family, his friends, and life role (ap-
taken to the intermediate respiratory care preciation of unique meanings) and to begin a
unit at 8:30 a.m. relationship-centered professional encounter
On this unit, Mr. S was cared for by a that was based on these findings.
young nurse named Megan who had gradu- She documented the results of the assess-
ated 2 years earlier. Taking a couple slow ment in the computer, looking frequently at
deep breaths, Megan focused her thoughts Mr. S so he could see her (attentive reassurance
toward Mr. S as she entered the room and and human respect). The problem list Megan
quickly scanned the environment and the pa- came up with included issues such as the fol-
tient to notice anything significant. She in- lowing: (1) airway maintenance, (2) anxiety,
troduced herself by name and then looked (3) impaired communication, (4) altered fam-
Mr. S in the eyes, smiled, and squeezed his ily processes, (5) potential skin breakdown,
hand lightly (human respect). Then she asked (6) inadequate knowledge, and (7) inadequate
what he would like to be called and wrote coping. Then, using the caring factor mutual
that name on a board on the wall opposite problem-solving, she explained to Mr. S and
his bed. Since he couldn’t talk, Megan asked his daughter what would happen on this unit,
Mr. S’s daughter to explain how she had including how long they might stay, and how
been communicating with him. The daugh- and when to contact her. She engaged them
ter was spelling words that were eventually in the dialogue by inviting questions and
incorporated into sentences; Megan said she asked them for guidance regarding Mr. S’s
would use this method of communication. normal routines (affiliation needs). She relayed
Using the Quality-Caring Model© as a that she would be there all day and gave them
frame of reference, Megan completed a her telephone number (attentive reassurance).
physical assessment that included physiolog- Then she asked them what they knew about
ical, emotional, sociocultural, and spiritual recovering from LVRS and listened atten-
components. Her goal was to use this oppor- tively to their responses. She sat a little toward
tunity to initiate a caring relationship with the patient and looked at him as he “talked.”
Mr. S and his family that could be sustained This took longer than usual because he was
throughout the hospitalization experience. using letters to spell out words (encouraging
(continued)
7991_Ch22_383-398 12/08/19 5:29 PM Page 396

manner). Together they decided to wait for family situation, the patient’s own routines,
more information about living with COPD and their joint interactions. Including Mr. S
until after they had some sleep to review care in the discussions, they asked how he was feel-
of the incision and other issues related to ing, and he communicated with Megan’s help.
COPD. Megan assured Mr. S that he had During a conversation at the nurses’ station,
the capacity to live well with this chronic dis- Megan and both physicians agreed that Mr. S
ease, using examples of what she had already could go home the next day with support. The
observed about the family (attentive reassur- surgeon relied on Megan’s judgment about
ance). Megan then asked the daughter if she Mr. S’s readiness for discharge because he had
wanted something to drink and made sure come to know her these last 2 years as a com-
Mr. S was comfortable (pain free) as well. petent and caring nurse whom he respected.
Then she offered him mouth care and turned Megan trusted her own recommendations;
him slightly to the side with a pillow behind their encounter was collaborative and friendly
his back (human needs). Megan closed the (caring collaborative relationships based on the
blinds and offered Mr. S’s daughter a pillow caring factors).
and a reclining chair and let them sleep for Later that day, Megan returned with a
2 hours, as they had been up all night (heal- written set of instructions about caring for
ing environment). She put a sign on the door chest incisions. She reviewed the instructions
reminding others that the patient was sleep- with both Mr. S and his daughter, answering
ing (basic human needs). For the first time in questions, allowing the daughter and Mr. S to
more than 24 hours, Mr. S was able to relax “practice.” She used a positive approach, reas-
and shut his eyes, showing some evidence of suring the daughter that she could do this and
feeling “cared for.” that she would be there in a couple of hours
Megan’s professional encounter with this to review the procedure again (attentive reas-
family was relaxed, genuine, and distin- surance and encouraging manner). Megan then
guished by the caring factors. Megan’s focus called the social worker and the home-care
and knowledge of herself provided the team to get things rolling for discharge.
strength to meet this family’s needs. During Megan also took the daughter aside to discuss
the time they were resting, Megan checked living and caring for an elderly man with
on them quietly and frequently (healing en- COPD. She provided the daughter with re-
vironment). At one of these opportunities, ferrals for a support group and a lung associa-
Mr. S’s daughter sought out Megan to relay tion program.
her anxieties about taking Mr. S home. During report, Megan reviewed Mr. S’s
Megan listened and encouraged the daughter problem list and her recommended interven-
to adjust first to this new environment while tions to the oncoming nurse using the caring
she (Megan) would come back later to help factors as a basis for the interaction. She felt
them understand how to live with COPD good that Mr. S and his family were learning
(affiliation needs; mutual problem-solving). about his needs and pleased that she had re-
During the next 2 days, Megan took care lieved some of their anxiety. She said good-
of Mr. S and spent time collaborating with bye to all her patients and went to her weekly
Mr. S’s pulmonologist and surgeon on his yoga class to unwind.
care plan. She listed his problems, and when Although this exemplar is typical in many
they came for rounds, Megan accompanied acute-care facilities, Mr. S is a unique individ-
them, and they conversed about Mr. S’s vital ual who experienced two different nursing en-
signs, his breathing (he had been extubated counters. In the first instance, one might say
after 24 hours), incision, and secretions while that his assessment focused only on the phys-
also discussing some interventions Megan ical dimension. He remained anxious for many
suggested based on her knowledge of his hours postoperatively, was isolated from others,
7991_Ch22_383-398 12/08/19 5:29 PM Page 397

didn’t sleep, overheard professional nurses and positive in her demeanor. She ensured
talking about not wanting to be there, was that his transition to home would occur safely.
treated roughly, and was not turned for 12 hours In essence, this nurse saw the patient as a
despite the fact that he was immediately whole person, not a physical body after sur-
postoperative. On the intermediate care unit, gery, and used her caring knowledge and skills
the nurse used the caring factors to initiate to build a relationship that generated trust and
and cultivate a caring relationship with him security. Through ongoing interaction, a con-
from admission. She used this relationship nection developed between the nurse and pa-
as the basis for care that included attention tient that provided the insight necessary for
to his basic needs for sleep, comfort, and nu- effectively following the nursing process, in-
trition. Megan helped Mr. S understand his cluding specific interventions and evaluation.
new situation and included his daughter, The caring relationship she established created
who was his caretaker. She was collaborative a higher-quality nursing care that benefited
with the physicians and other nursing staff both the patient and the nurse.
Summary
Practice-based knowledge is a hallmark of a pro- Implications of the revised Quality-Caring
fession; therefore, a strong alignment between a Model© exist for educators in terms of helping
theory and the practice of it enhances its signifi- students learn how to care well. Transforming
cance to society. Caring and quality in health the learning environment with meaningful
care are implicitly tied together. Because humans learning activities, clinical experiences, and fre-
exist in relation to others and caring is the con- quent reflection on the salience of caring rela-
text for practicing nursing, caring relationships tionships helps students share meanings,
provide the foundation for those patient–nurse elicit relevant data, listen, notice cues, establish
interactions so necessary for excellent health rapport, and develop mutually caring interac-
care. Independent and collaborative caring relations. Using evaluation techniques and frequent
tionships in health care contribute to patients’ caring student–teacher interactions, nurse ed-
welfare in that they promote comfort, safety, ucators can greatly enhance learning outcomes.
consistent communication, and learning. Clinical courses in which caring behaviors are
Professional nurses who regularly relate to valued and role-modeled by faculty are essen-
themselves and their communities are more tial. Similarly, it is crucial that those nurses
equipped to engage in genuine independent and in leadership positions create caring–healing–

collaborative caring relationships with patients protective environments for staff and patients
and families, as well as advance their own self- in a cost-effective manner. Redesigning pro-
caring. Spending time “in relationship” focuses fessional workflow so that its primary function
attention on the patient versus the disease or task is relationship centered and making deci-
and generates a meaningful practice that is the sions in a participatory manner are paramount
basis for joy. In essence, the model benefits both to quality caring. Finally, showing evidence of
patients and nurses, as well as the profession and nursing’s foremost professional purpose (car-
the health-care system. Theory-guided, evidence- ing) through ordinary everyday caring actions
based professional practice that is holistic and blended with a culture of continuous inquiry
meaningful can make a profound impact on creates novel possibilities for advancing the
patient outcomes. profession.
7991_Ch22_383-398 12/08/19 5:29 PM Page 398
Questions for Reflection ■ How can leaders in nursing assist health-

care professionals to stay focused on car-
and Discussion ing relationships as the central component
■ Discuss whether aspects of the Quality- of professional practice?
Caring Model© are visible at your ■ What patient outcomes do you attribute
organization. Is there an expectation to “feeling cared for”? How do you
that the caring behaviors are a significant know?
component of the work of professional
nurses?
7991_Ch23_399-408 12/08/19 5:29 PM Page 399
Pamela Reed’s Theory of

CHAPTER
23
Self-Transcendence
Pamela G. Reed

Practice Exemplar Pamela G. Reed is professor at the University
Summary of Arizona College of Nursing in Tucson. She
Questions for Reflection and Discussion received her academic degrees from Wayne
State University in Detroit, Michigan: a BSN
and an MSN with a double major in child and
adolescent psychiatric–mental health nursing
and nursing education, which prepared her
both as a clinical nurse specialist and a nurse
educator. In 1982, Dr. Reed received her PhD
from Wayne State University, majoring in
nursing research and theory with a minor in
life span developmental psychology and aging.
She also holds an MA in philosophy (2016)
from the University of Arizona.
Dr. Reed was one of the pioneers in study-
ing spirituality as an area of scientific inquiry
in nursing. Her research into spiritual per-
spectives, self-transcendence, mental health,
and well-being among older adults and at end
of life was strongly influenced by the theoret-
ical ideas of Martha Rogers and life span de-
velopmental science. In addition, Dr. Reed
developed two widely used research instru-
ments, the Spiritual Perspective Scale (Reed,
1987) and the Self-Transcendence Scale (Reed,

2009). Her recent scholarship focuses on
philosophical and theoretical developments in
21st-century nursing, including refining a
philosophy of nursing science and practice
called intermodernism, which emphasizes in-
tegration of practice as well as research find-
ings and other sources of knowledge into
theory development.
Dr. Reed is a fellow in the American
Academy of Nursing and is a member of a
number of professional organizations, includ-
ing the International Philosophy of Nursing
Society, Sigma Theta Tau International, the
American Nurses Association, and the Society
399
7991_Ch23_399-408 12/08/19 5:29 PM Page 400
of Rogerian Scholars. She serves on editorial Foundations of the Theory

review boards of numerous journals and is a Self-Transcendence Theory is based on onto-
contributing editor for Applied Nursing Re- logical assumptions about the nature of human
search and Nursing Science Quarterly. Dr. Reed beings and change, derived largely from two
is coeditor of a nursing theory text, Perspectives major perspectives. These two broad theoreti-
on Nursing Theory (Reed & Shearer, 2012), cal views originated in the mid-20th century
now in its sixth edition, and is coeditor, along and continue to be relevant today: Martha
with Dr. Nelma Shearer, of Nursing Knowl- Rogers’ (1970, 1980, 1990) nursing science con-
edge and Theory Innovation: Advancing the Sci- ceptual system about the human–environment
ence of Practice (Reed & Shearer, 2018), now process, and the life span developmental
in its second edition. science perspective articulated by Richard M.
Since January 1983, Dr. Reed has been on Lerner (e.g., Lerner, 2002; Lerner, Hershberg,
the University of Arizona faculty, where she Hilliard, & Johnson, 2015; Overton & Lerner,
enjoys being professor, teaching and mentor- 2014). Both frameworks are also congruent
ing doctoral students and engaging in research with tenets of complexity science described by
and various scholarly activities, and also where Stuart Kauffman (1995) and endure today
she served as Associate Dean for Academic across many disciplines, including the health
Affairs for seven years. Dr. Reed lives with her sciences.
husband in the Sonoran Desert of Tucson, One assumption underlying Self-Transcendence
Arizona, and they have two daughters. Theory is the developmental nature of ongoing
change in human beings and their environ-
ment, characterized by both complexity and
Overview of the Theory organization. As part of this process, individ-
The focus of Reed’s theory is facilitating the uals possess the potential for innovation, heal-
process of self-transcendence for the purpose ing, and well-being throughout the life span.
of supporting or enhancing well-being. Theo- This potential for well-being is described by
ries from other sciences, such as psychology, Reed (1997, 2018) most fundamentally as a
also address self-transcendence; however, what nursing process, analogous to, for example, chem-
distinguishes this particular theory as a nursing ical processes of chemistry or the social processes
theory is its focus on well-being in the context of interest to sociologists. Self-transcendence is
of difficult health-related experiences. The the- an example of a nursing process.
ory proposes that people’s capacity for self- A second philosophical assumption is that
transcendence is activated when they face humans, as open systems, impose conceptual
life-threatening illness or undergo health- boundaries on their openness to define their re-
related changes that intensify awareness of ality and provide a sense of identity and secu-
vulnerability or mortality. This capacity is evi- rity. This assumption is based on life span
dent in expansion of self-boundaries in various developmental psychology about the forma-
ways—inward and outward—that foster well- tion and differentiation of the self across
being. Individuals are able to expand self- development. For example, theorists have
boundaries on their own or with support from identified the diffuse boundary between infant
significant others, but in serious illness or other and parent. There is an increasing sense of
health-related life crises, nurses and other pro- identity and self-consciousness in children and
fessionals may be especially helpful in facilitat- adolescents as they attempt to clarify bound-
ing this process of self-transcendence. The aries between self and others while experienc-
scope of the theory has been extended beyond ing an increased differentiation of self. During
its original focus on later adulthood to address middle adulthood a more secure sense of sense
self-transcendence as a resource for well-being of identity is experienced. Adulthood and end
across the life span from adolescence to adult- of life are characterized by complex and ex-
hood and end of life, with potential applica- panded forms of connections to others and
tions to childhood. spirituality.
7991_Ch23_399-408 12/08/19 5:29 PM Page 401
C H APTER 23 ■ Pamela Reed’s Theory of Self-Transcendence 401
This assumption about openness was also others, nature, and surrounding environment),
influenced by Rogers’ (1970, 1980) conception transpersonally (to relate to dimensions beyond
of human beings as energy fields extending be- the ordinary, observable world), and temporally
yond the “discernible mass” of the physical (to integrate one’s past and future in a way that
body in not four-dimensional or even multidi- expands and gives meaning to the present). Ex-
mensional reality, but in pandimensional reality panded boundaries provide new opportunities
(Rogers, 1994) explained through her various to infuse one’s life with meaning. And there are
principles and concepts. For example, Rogers’ approaches to expanding self-boundaries yet
principle of integrality proposed a human– to be discovered. For example, in our increas-
environment process that transcended com- ingly technological world, expansion of self-
monly accepted distinctions such as those be- boundaries may also involve connectedness of
tween bio–psycho–social dimensions, person self with nonliving entities such as symbolic ob-
and environment, nature and nurture, living jects, memories, machines, and prosthetics that
and dying. Rogers’ concept of relative present influence well-being in profound ways.
challenged conventional distinctions among One caveat in understanding the theory is
past, present, and future to acknowledge both that the term self-transcendence may evoke
the individual’s temporal perspectives and new ideas about the mystical, supernatural, or other
discoveries in physics about spacetime (see experiences that disconnect self from others or
Reed, 2016). from the present. However, this is a misunder-
In summary, self-transcendence involves standing of the intent of the theory, which is
expanding and redefining personal and tem- to promote transcendence of personal bound-
poral boundaries during health events and is aries or limitations rather than to promote dis-
evident in connections to our inner life, to oth- connection of self from others or the world.
ers, to natural and technological environments, Also, any spiritual meanings associated with
and to imagined worlds. The theory is based self-transcendence in this theory refer mostly
on a pluralistic view of reality that accounts for to terrestrial, everyday practices of spirituality
the human capacity to expand self-boundaries that alter self-boundaries in meaningful ways
in innovative ways. that facilitate connection with rather than sepa-
ration from self, others, nature, and various
Concepts and Relationships aspects of the environment. Nevertheless, Self-
The Theory of Self-Transcendence, like theo- Transcendence Theory acknowledges the exis-
ries in general, is a compressed description and tence of mystery in life.
explanation of a process and does not catalog Regarding assessment, the 15-item Self-
every instance of self-transcendence. The the- Transcendence Scale (STS) was developed by
Dr. Reed (2009) to measure self-transcendence.
ory provides a coherent and research-based

description of three key concepts and their The measure is applicable to all individuals, in-
relationships, which researchers and practi- cluding those who are well or ill, with health
tioners can further specify and examine for problems or other limitations due to illness or
application to their unique situations. The disability. The STS is used widely in research
three major concepts in the theory are self- and may also be used by practicing nurses to
transcendence, vulnerability, and well-being. better understand areas for assessing patients.
The STS has been translated into several lan-
Self-Transcendence guages, including Spanish, Mandarin, Farsi,
The core concept of the theory is Self- Japanese, and Korean. The instrument is pub-
Transcendence. It refers to the capacity to ex- lished in Reed (2009).
pand self-boundaries in various and meaningful
ways that enhance well-being. For example, Vulnerability
self-boundaries can expand intrapersonally (to- Vulnerability is the initial concept in the the-
ward greater awareness of one’s beliefs, values, ory and refers to an increased awareness of
and dreams), interpersonally (to connect with personal mortality. A wide variety of human
7991_Ch23_399-408 12/08/19 5:29 PM Page 402
experiences can increase this awareness, but of successful aging, and end of life (e.g., Baltes &
note are health-related events that are life Baltes, 1990; Cosco, Prina, Perales, Stephan,
threatening or that involve loss. Chronic and & Brayne, 2014; Erikson, 1986; Frankl, 1963;
serious illness, disability, aging, bereavement, Marshall, 1996).
traumatic events, and facing end of life all are Self-transcendence in turn relates to and in-
contexts of vulnerability and increased aware- fluences increased well-being. More specifi-
ness of mortality. A variety of measures or cally, research findings consistently indicate
questions can be used to assess a person’s sense that self-transcendence functions as a resource
of vulnerability, including assessing perceived for well-being during increased vulnerability
risk for illness, concerns about potential loss or by mediating the relationship between in-
facing adversity, and perspectives on living creased vulnerability and well-being.
with a serious or life-threatening illness. In summary, self-transcendence can be a
correlate if not a predictor of well-being. In ad-
Well-Being dition, accumulated research findings support
Well-being is the third major concept in the self-transcendence as a mediator in the rela-
theory and may be regarded as an outcome tionship between vulnerability and well-being;
variable. Well-being is defined broadly as a it is a process that explains how in the context
subjective attitude or feeling of health or of increased vulnerability individuals can nev-
wholeness at a given point in time. It involves ertheless experience increased well-being. That
an existential judgment by the individual and is, expansion of boundaries in meaningful ways
is also influenced by one’s history, culture, val- (self-transcendence) can help the person trans-
ues, family and other significant relationships, form loss or difficulty (increased vulnerability)
and biophysical factors. into positive outcomes (well-being). Life expe-
There are many measures for the assessment riences of increased vulnerability would, with-
of well-being in nursing and other health and out self-transcendence, otherwise lead to
social sciences, revealing the diversity of values decreased well-being.
and perspectives associated with well-being. The model in Figure 23-1 depicts the three
Examples of indicators of well-being that have concepts and their relationships, including the
been found to be significantly related to self- mediating role of self-transcendence.
transcendence include life satisfaction, happi- Additional concepts in the theory include
ness, high morale in aging, self-care agency in personal and contextual factors that can influ-
chronic illness, sense of meaning in life, and ence the relationships among vulnerability,
specific indicators of mental health such as ab- self-transcendence, and well-being. Potential
sence of depression, decreased anxiety, subjec- factors include age, gender, ethnicity, years of
tive well-being, and happiness. And there are education, illness intensity, life history, and
many other indicators nurses may use to meas-

ure outcomes of well-being.
Relationships Among the Concepts Self-transcendence

Self-transcendence, as a nursing process, is
linked logically with positive, health-promoting
experiences, and can arise in situations of
increased vulnerability. From the assumption Personal and
that human beings have potential for innova- contextual factors
tive expansion of self-boundaries, it is theorized
that increased awareness of one’s vulnerability
or mortality can motivate positive, inner
strengths—in this case self-transcendence, an Vulnerability Well-being
idea long supported by classic theories and con- FIG 23-1 ■ Model of Reed’s self-transcendence
temporary research on life span development, nursing theory. (Copyright © 2012 by Pamela G. Reed.)
7991_Ch23_399-408 12/08/19 5:29 PM Page 403
social or spiritual support, as well as other fac- practice applications with patients, as well as
tors concerning the person’s social, cultural, among nurses, family caregivers and other
and physical environment. health-care providers, and healthy populations.
Research
Applications of the Theory Examples of research applications include the
Self-Transcendence Theory has applications in studies listed in Table 23-1. Another example is
both research and practice. In research, the a study by DiNapoli (2014) and colleagues who
theory is used as a broad framework for explor- proposed use of a computer-mediated self-help
ing ideas about self-transcendence in qualita- intervention to facilitate connecting over shared
tive studies and as a theoretical framework for interests among at-risk LGBTQ persons. Ad-
examining specific relationships using quanti- ditional studies may be found through databases
tative measures. Research results support the such as CINAHL, PubMed, and PsycInfo.
significance of self-transcendence as a correlate
or predictor of well-being across a variety of Practice
populations, particularly those experiencing Practice applications summarized from this
serious illness or other challenging life situa- and other research indicate various self-
tions. The theory also has been studied for its transcendence strategies that expand personal
Table 23-1 Application of Self-Transcendence Theory in Research
Research
Authors Topics Source
Haugan, Clinical de- Haugan, G., Rannestad, T., Hammervold, R., Garåsen, H., & Espnes,
Rannestad, pression and G. A. (2013). Self-transcendence in cognitively intact nursing-home
Hammervold, emotional patients: A resource for wellbeing. Journal of Advanced Nursing,
Garåsen, & well-being in 69(5), 1147–1160.
Espnes, older adults Hsu, Y. C., Badger, T., Reed, P., & Jones, E. (2013). Factors
2013 associated with depressive symptoms in older Taiwanese adults in
Hsu, Badger a long-term care community. International Psychogeriatrics, 25(6),
Reed, & 1013–1021.
Jones, 2013 Reed, P. G. (1991). Self-transcendence and mental health in the
Reed, 1991 oldest-old adults. Nursing Research, 40(1), 5–11.
Stinson & Stinson, C. K., & Kirk, E. (2006). Structured reminiscence: An

Kirk, 2006 intervention to decrease depression and increase self-transcendence
in older women. Journal of Clinical Nursing, 15(2), 208–218.
Chan & Chan, Bereavement Chan, W. C., & Chan, C. L. W. (2011). Acceptance of spousal death:
2011 The factor of time in bereaved older adults’ search for meaning. Death
Kausch & Studies, 35, 147–162.
Amer, 2007 Kausch, K. D., & Amer, K. (2007). Self-transcendence and depression
among AIDS memorial quilt panel makers. Journal of Psychosocial
Nursing, 45(6), 45–53.
Ramer, People diag- Ramer, L., Johnson, D., Chan, L., & Barrett, M. T. (2006). The effect
Johnson, nosed with of HIV/AIDS disease progression on spirituality and self-transcendence
Chan, & HIV/AIDS in a multicultural population. Journal of Transcultural Nursing, 17(3),
Barrett, 2006 280–289.
Sperry, 2011 Sperry, J. J. (2011). The relationship of self-transcendence, social
interest, and spirituality to well-being in HIV/AIDS adults. Unpublished
doctoral dissertation, Florida Atlantic University.
Continued
7991_Ch23_399-408 12/08/19 5:29 PM Page 404
Table 23-1 Application of Self-Transcendence Theory in Research—cont’d
Research
Bickerstaff, Chronic Bickerstaff, K. A., Grasser, C. M., & McCabe, B. (2003). How elderly
Grasser, & illness and nursing home residents transcend losses of later life. Holistic Nursing
McCabe, loss in later Practice, 17(3), 159–165.
2003 life Gusick, G. M. (2008). The contribution of depression and spirituality
Gusick, 2008 to symptom burden in chronic heart failure. Archives of Psychiatric
Nygren et al., Nursing, 22(1), 53–55.
2005 Nygren, B., Aléx, L., Jonsén, E., Gustafson, Y., Norberg, A., &
Lundman, B. (2005). Resilience, sense of coherence, purpose in
life and self-transcendence in relation to perceived physical and
mental health among the oldest old. Aging & Mental Health, 9(4),
354–362.
Coward, Women Coward, D. D. (2003). Facilitation of self-transcendence in a breast
2003 with breast cancer support group: Part II. Oncology Nursing Forum, 30(2),
Farren, 2010 cancer 291–300.
Matthews & Farren, A. T., (2010). Power, uncertainty, self-transcendence, and

Cook, 2009 quality of life in breast cancer survivors. Nursing Science Quarterly,
23(1), 63–71.
Thomas,
Burton, Quinn Matthews, E. E., & Cook, P. F. (2009). Relationships among
Griffin, & optimism, well-being, self-transcendence, coping, and social support
Fitzpatrick, in women during treatment for breast cancer. Psycho-Oncology, 18,
2010 716–726.
Thomas, J. C., Burton, M., Quinn Griffin, M. T., & Fitzpatrick, J. J.
(2010). Self-transcendence, spiritual well-being, and spiritual prac-
tices of women with breast cancer. Journal of Holistic Nursing, 28(2),
115–122.
Chen, 2012 Men with Chen, H. C. (2012). Self-transcendence, illness perception, and
oral cancer depression in Taiwanese men with oral cancer (unpublished doctoral
dissertation). The University of Arizona, Tucson.
Bean & Liver Bean, K. B., & Wagner, K. (2006). Self-transcendence, illness
Wagner, and stem distress, and quality of life among liver transplant recipients. The
2006 cell and Journal of Theory Construction & Testing, 10(2), 47–53.
Burns, Robb, transplant Burns, D. S., Robb, S. L., & Haase, J. E. (2009). Exploring the
recipients
& Haase, feasibility of a therapeutic music video intervention in adolescents

2009 and young adults during stem cell transplantation. Cancer Nursing,
Williams, 32(5), 8–16.
2012 Williams, B. J. (2012). Self-transcendence in stem cell transplantation
recipients: A phenomenologic inquiry. Oncology Nursing Forum, 39(4),
E41–E48.
Haugan, Older adults Haugan, G. (2014). Nurse-patient interaction as a resource for hope,
2014 both in the meaning in life and self-transcendence in nursing home patients.
McCarthy, community Scandinavian Journal of Caring Sciences, 28(1), 74–88.
2011 and in McCarthy, V. L. (2011). A new look at successful aging: Exploring
nursing a mid-range nursing theory among older adults in a low-income
homes retirement community. The Journal of Theory Construction & Testing,
15(1), 17–23
7991_Ch23_399-408 12/08/19 5:29 PM Page 405
Table 23-1 Application of Self-Transcendence Theory in Research—cont’d
Research
Chen & Walsh, Persons with Chen, S., & Walsh, S. M. (2009). Effect of a creative-bonding inter-
2009 dementia vention on Taiwanese nursing students’ self-transcendence and
Ho, Tseng, and other attitudes toward elders. Research in Nursing & Health, 32,
Hsin, Chou, progressive 204–216.
& Lin, 2016 or in- Ho, H. M., Tseng, Y. H., Hsin, Y. M., Chou, F. H., & Lin, W. T. (2016).
tractable Living with illness and self-transcendence: The lived experience of
Iwamoto, diseases
Yamawaki, & patients with spinal muscular atrophy. Journal of Advanced Nursing,
such as 72(11), 2695–2705.
Sato, 2011 multiple
JadidMilani, sclerosis and Iwamoto, R, Yamawaki, N., & Sato, T. (2011). Increased self-
Ashktorab, muscular transcendence in patients with intractable diseases. Psychiatry
AbedSaeedi, dystrophy and Clinical Neurosciences, 65(7), 638–647.
& AlayiMaid, JadidMilani, M., Ashktorab, T., AbedSaeedi, Z., & AlayiMaid, H.
2015 (2015). The impact of self-transcendence on physical health
status promotion in multiple sclerosis patients attending peer
support groups. International Journal of Nursing Practice, 2(6),
725–732.
Acton, 2002 Significance Acton, G. J. (2002). Self-transcendent views and behaviors: Exploring
Guo, Phillips, of self- growth in caregivers of adults with dementia. Journal of Gerontological
& Reed, 2010 transcendence Nursing, 28(12), 22–30.
among Guo, G., Phillips, L., & Reed, P. G. (2010). End of life caregiver
Kidd, caregivers
Zauszniewski, interactions with healthcare providers: Learning from the bad. Journal
of family of Nursing Care Quality, 25(3, July–Sept), 188–197.
& Morris, members
2011 with demen- Kidd, L. I., Zauszniewski, J. A., & Morris, D. L. (2011).
Kim, Reed, tia or other Benefits of a poetry writing intervention for family caregivers
Hayward, debilitating of elders with dementia. Issues in Mental Health Nursing,
Kang, & illness and 32, 598–604.
Koenig, 2011 at end of life Kim, S., Reed, P. G., Hayward, R. D., Kang, Y., & Koenig, H. G.
Reed & (2011). Spirituality and psychological well-being: Testing a theory of
Rousseau, family interdependence among family caregivers and their elders.
2007 Research in Nursing & Health, 34, 103–115.
Reed, P. G., & Rousseau, E. (2007). Spiritual inquiry and well-being
in life-limiting illness. Journal of Spirituality, Religion, and Aging,
19(4), 81–98.
Bajjani-Gebara Among Bajjani-Gebara, J., & Reed, P. G. (2016). Nursing theory as a guide
& Reed, 2016 nurses or into uncharted waters: Research with parents of children undergoing
Hunnibell, parents cancer treatment. Applied Nursing Research, 32, 14–17.
Reed, dealing with Hunnibell, L. S., Reed, P. G., Quinn-Griffin, M., & Fitzpatrick, J. J.
Quinn-Griffin, difficult (2008). Self-transcendence and burnout in hospice and
& Fitzpatrick, caregiving oncology nurses. Journal of Hospice and Palliative Nursing,
2008 situations 10(3), 172–179.
Palmer, Quinn Palmer, B., Quinn Griffin, M. T., Reed, P., & Fitzpatrick, J. J. (2010).
Griffin, Reed, Self-transcendence and work engagement in acute care staff registered
& Fitzpatrick, nurses. Critical Care Nursing Quarterly, 33(2), 138–147.
2010
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boundaries. These approaches are organized and physical activities from dancing to yoga.
below in terms of intrapersonal, interpersonal, Telephone or internet-based interactions can
and transpersonal approaches to boundary ex- help sustain home bound individuals through
pansion, but there may be some overlap across trajectories of illness and treatment. Interper-
these categories. Also, several of these activities sonal activities that expand personal bound-
expand temporal boundaries by helping the aries also include volunteer work and other
person focus on the present. opportunities to be of help to others and share
Intrapersonal approaches help the person one’s wisdom. Interpersonal relationships with
look inward to expand boundaries and inte- family and friends are central to the interper-
grate loss through self-knowledge and finding sonal dimension.
meaning or purpose. Examples of strategies Transpersonal approaches for self-transcendence
that nurses may suggest for patients are medi- are designed to help the person connect with a
tation, guided reminiscence and life review, power or purpose greater than self. The nurse’s
stress management and relaxation strategies, role in this process is often one of providing for
and artistic and other creative activities of self- a supportive environment, such as providing re-
expression such as expressive writing, reading sources to help the person identify and access de-
and reflection, and journaling. sired activities, including religious participation
Interpersonal activities that facilitate self- or spiritual exploration, meditation, prayer, and
transcendence to connect individuals to others guided visualization. Additional transpersonal
through formal or informal means include approaches include involvement in altruistic ac-
support groups and faith-based groups, partic- tivities, or work on artistic and other creative
ipating in community-based or senior center projects that connect one to something greater
activities, lifelong learning, and recreational than self and inspire meaning.
Practice Exemplar
This practice exemplar focuses on how to facili- family caregiver, visited her several times a
tate well-being outcomes through various strate- week. Recently, Emma experienced a worsen-
gies that support self-transcendence. The idea ing of her physical symptoms and more diffi-
behind the interventions is that facilitating culty breathing; so, with her daughter’s
self-transcendence promotes positive mental encouragement, Emma moved closer to her
health outcomes either by diminishing the nega- daughter. Even though Emma’s new apart-
tive effect that vulnerability has on well-being or ment was more modern than her old house
more directly by enhancing those perspectives on and her daughter could visit more often,
life that increase emotional well-being. Emma wasn’t as happy in her new surround-
ings as she had been in her old house, and her
Emma daughter was concerned about her depressed
Several years ago, Emma was diagnosed with mood during her frequent visits.
emphysema. In her youth and through The nurse worked together with Emma
young adulthood, Emma had been a profes- and her daughter to design a plan of care that
sional dancer on Broadway. But she now not only tended to Emma’s declining physical
found that what were once the strongest health needs and any other underlying health
parts of her body—her legs—were no longer problems but also focused on the complex
able to carry her around with grace and ease. needs surrounding Emma’s mental health, as
Her illness had advanced to the point that well as her emotional and social well-being.
she required supplemental oxygen and a Self-Transcendence Theory provided a frame-
walker at home. This made it difficult for her work for practice to address these latter needs.
to get out of the house as often as she de- The nurse acknowledged that Emma’s wors-
sired. She lived alone, but her daughter, her ening illness might be contributing to a
7991_Ch23_399-408 12/08/19 5:29 PM Page 407

heightened sense of vulnerability not only her former home and especially missed her
because it was life-threatening but also be- “mailbox neighbor” who also carried an oxy-
cause it diminished the quality of certain gen tank. The nurse suggested that Emma
areas of her life. The nurse practiced from the participate in a pulmonary rehabilitation pro-
basic assumption that nursing care could gram, particularly a program-sponsored sup-
help activate Emma’s inner strengths and port group where she might gain friends
potential to transcend some of the bound- among people who not only had similar illness
aries she was facing to attain a sense of well- experiences but who also, as Emma said,
being in the midst of vulnerability. The nurse “looked like [her] too!” As Emma was able to
applied Self-Transcendence Theory as a expand her self-boundary to integrate assistive
guide but not a recipe for intervention. The devices into her life, she became more accept-
nurse’s creative use of the theory increased ing of her illness and herself overall. Attend-
the likelihood that the nurse, Emma, and her ing the support group also provided her
daughter together would discover important opportunities to use her own experiences to
strategies of self-transcendence unique to help others. Sharing her wisdom with others
Emma’s situation and relevant to her needs. was very gratifying to Emma and enhanced
her well-being. The nurse also worked to en-
Intrapersonal sure that Emma and her daughter would lead
The nurse helped expand Emma’s bound- the health-care decisions and fully participate
aries on an interpersonal level through a vain health-care activities. She helped connect
riety of interactions. Emma explained that Emma and her daughter with resources to
she was a private person and didn’t like to navigate the health-care system and address
depend on others. The nurse’s openness and financial concerns. Information about the ill-
empathy supported Emma in expressing her ness and self-care strategies helped demystify
beliefs about quality of life, spiritual values, Emma’s health regimen and more fully inte-
goals for herself, and dreams for her daugh- grate the health experience into her life.
ter’s future. These insights were useful in
making health-care and other decisions. Transpersonal
Their discussions also helped Emma ac- Emma admitted that she was not particularly
knowledge and integrate difficult feelings religious but found herself praying each morn-
into her life. Whether Emma resolved all her ing and evening. This ritual was comforting.
concerns was not as important as acknowl- The nurse was aware that religious beliefs held
edging and accepting them for the time in youth can become important at the end of
being. The nurse acknowledged Emma’s and life, even if these beliefs had been eschewed dur-
her daughter’s fears and losses along the way, ing adulthood. The nurse acknowledged that
and supported their hope and faith that they Emma, like others, might find value in spiritual
could cope with and maybe even grow from perspectives that provided a connection between
these difficulties. herself and some thing, dimension, or purpose
larger than the individual self. Even though
Interpersonal Emma had difficulty believing in a life after
Besides the fact that the assistive devices death, the possibility offered some comfort and
Emma relied on confronted her with her helped Emma integrate awareness about her
mortality, Emma found it embarrassing to own mortality and being separated from her
use a walker and supplemental oxygen wher- family and friends. The nurse also guided
ever she went. She perceived these items as Emma through a spiritual history of her life to
foreign and undignified objects that an- uncover other sources of strength and perhaps
nounced her aging and disability to the make new discoveries about herself that Emma
world. Emma also missed her friends from could draw from as time progressed.
(continued)
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Temporal illness. Also, simply reminding Emma to try to
The illness initiated and intensified Emma’s engage in positive self-talk was sometimes help-
concerns about the future and fears about pain ful in getting her through a difficult moment.
and mortality. The nurse explored these con- Emma’s Self-Transcendence
cerns with Emma in a realistic yet empathetic
manner. A life review in which Emma re- Emma did not expect the nurse or her daughter
flected on her past, discussed anticipating the to create self-transcendent experiences for her.
unknown, and then connected these insights But their support and guidance buttressed her
to her present concerns provided a sense of own inner potential for healing through the ill-
meaning that Emma found emotionally satis- ness experience. Transcending self-boundaries
fying. The nurse also facilitated Emma’s fuller may require the support of others, even though
enjoyment in the present by encouraging pos- there is the assumption that self-transcendence
itive experiences such as planning enjoyable is a natural human capacity. Emma’s openness
activities, holding small celebrations, and tak- to accepting help and guidance from the nurse
ing pictures of important or memorable events. was a first step in expanding her self-bound-
These activities generated a legacy and a gift aries. By nurturing connections to her beliefs
that connected Emma’s present to her family’s and values, her spirituality, her support group
future. Expanding her self-boundary to incor- friends, and her daughter and nurse, Emma
porate other temporal dimensions gave Emma was able to expand her self-boundaries in ways
access to meaningful experiences that often that enhanced her well-being within the con-
sustained her across the trajectory of her text of her incurable illness.
Summary
The Theory of Self-Transcendence acknowl- more specifically in terms that fit their pa-
edges the human tendency to construct per- tients’ particular developmental and situa-
sonal boundaries, as well as the capacity to tional contexts.
transcend limiting views of self and the world. In closing, the Theory of Self-Transcendence
The theory’s key concepts (vulnerability, self- has been described as a Well-Being Theory (Reed,
transcendence, well-being) were designed to 2008). It proposes that self-transcendence is a
be clear and measurable, yet broad enough in (nursing) process that promotes well-being in
scope to allow nurses flexibility in applying the contexts of increased vulnerability. Practitioners
theory across a variety of research and practice and researchers are invited to creatively use the
situations. Practitioners and researchers who theory to build knowledge about facilitating
use the theory can define its general concepts well-being across a variety of health experiences.
Questions for Reflection your own self-boundaries and promote

well-being? Are there activities you would
and Discussion like to engage in if you had the time?
■ What are the three major concepts in the ■ What are two or three strategies (either
theory? How would you describe the rela- from those mentioned in the chapter or
tionships between these concepts? new ideas) to expand personal boundaries
■ What approaches are described by Reed to that could be helpful for patients in an
promote boundary expansion? What per- area of practice?
sonal strategies can you identify to expand
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Patricia Liehr and Mary

CHAPTER
24
Jane Smith’s Story Theory
Patricia Liehr and
Mary Jane Smith

Overview of the Theory Introducing the Theorists
Applications of the Theory Patricia R. Liehr, PhD, RN, graduated from
Practice Exemplar Ohio Valley Hospital School of Nursing in
Summary Pittsburgh, Pennsylvania. She completed her
Questions for Reflection and Discussion baccalaureate degree in nursing at Villa Maria
College, her master’s in family health nursing at
Duquesne University, and her PhD at the
University of Maryland–Baltimore School of
Nursing, with an emphasis on psychophysiol-
ogy. She completed postdoctoral studies at the
University of Pennsylvania as a Robert Wood
Johnson Scholar. Dr. Liehr is currently a
Distinguished Professor at the Christine E.
Lynn College of Nursing at Florida Atlantic
University. She has taught nursing theory to
master’s and doctoral students for over three
decades.
Mary Jane Smith, PhD, RN, FAAN, earned
her bachelor’s and master’s degrees from the
University of Pittsburgh and her PhD from
New York University. She has held faculty
positions at the following nursing schools:
University of Pittsburgh, Duquesne University,
Cornell University–New York Hospital, and
Ohio State University; and she is currently a
Professor at West Virginia University School of

Nursing. She has been teaching theory to nurs-
ing students for over four decades.

Story Theory evolved as the cocreators talked
about their practice–research experience with
pregnant teens and people recovering from a
cardiac event (Liehr & Smith, 2018). It was
clear to them that health-promoting change
was fostered when one’s story of pregnancy or
living through a cardiac event was embraced.
It was as though acceptance of these health
409
7991_Ch24_409-420 12/08/19 5:29 PM Page 410
circumstances energized new directions for dialogue, connecting with self-in-relation,

healing and health. Story Theory was first and creating ease. Bringing the theory to life in
published in 1999 (Smith & Liehr, 1999), and practice is described not only in these essential
it has continued to be used, tested, and shaped concepts, but also in the context of theory
for more than a decade (Liehr & Smith, method dimensions of complicating health
2018). challenge, developing story plot, and movement
Stories are integral to nursing practice. Prac- toward resolving; each is aligned respectively
tice decisions are informed both by bodily re- with the three theory concepts. Next, a seven-
sponses and by the stories that infuse these phase inquiry process for using the evidence
responses with unique personal meaning. To from practice stories is discussed as a means to
focus on one without attention to the other demonstrate the use of the process to grow the
contributes to less than optimal nursing care. substantive knowledge of the discipline. Last, a
There are times when either the bodily re- practice exemplar is used to highlight the po-
sponses or the story is foreground and the other tential of the theory for guiding practice
is background; this foreground–background through application of the seven-phase inquiry
interplay emerges over the course of each nurse– process.
person caring interaction. For instance, when a
person comes into the emergency department Emergence of Story as a Topic
with crushing chest pain and then suddenly be- of Interest
comes unconscious, physiology becomes the Story is not new to nursing. Nightingale im-
foreground. Heart rate, blood pressure, and res- plored nurses to stop chattering and begin lis-
piratory rate guide critical immediate action. tening (Nightingale, 1969). Nurse theorists
Within a short time, the nurse will want to (Boykin & Schoenhofer, 1991, 2001; Newman,
begin to gather the story, including dimensions 1999; Parse, 1981; Peplau, 1991; Watson, 1997)
such as what the person was doing when the have called attention to the central importance
chest pain began, whether this has ever hap- of listening to “what matters most” for those in
pened before, and what other life and health our care. Other nurse scholars (Banks-Wallace,
circumstances could have contributed to the 2002; Banks, 2014; Benner, 1984; Chinn &
chest pain. Stories are essential to even the Kramer, 1999; Dossey, 2015; Ford & Turner,
most technology-driven nursing practice, and 2001) have focused on the power of story to fa-
in some ways, the more technology-driven the cilitate understanding. Using Caring Theory as
practice, the more important the place of an overarching structure, Barry, Gordon, and
relevant health stories. King (2015) have compiled a book of nursing
Our linear-thinking culture often places situations, which are stories that can be used to
greater value on the physiology of bodily re- guide practice and to teach the next generation
sponses than on stories. In fact, precious stories of nursing scholars.

shared during nursing practice may be heard and In addition, physicians have emphasized
disregarded or heard and acted on without an- narrative medicine both as a way of learning
other thought about the evidence the story has clinical practice essentials and as a way of ap-
the potential to generate for practice. The overall proaching patients (Charon, 2006, 2012;
intent of this chapter is to describe Story Theory Charon & Montello, 2002; Cunningham et
as a framework informing story gathering and al., 2018). Diamond (2000), a psychotherapist,
story analysis, thereby positioning story as a addressed the long history of using narrative,
major thread of evidence in nursing practice, in forms such as personal testimony and letter
contributing to substantive nursing knowledge. writing, to treat alcoholism and addiction:
This chapter begins by addressing the emer- “Stories, not atoms, are the stuff that hold our
gence of story, or narrative, as a topic of interest lives and our world together” (p. 5). Diamond’s
for nurses and other health-care providers. Story view of stories resonates with the foundational
Theory is then summarized, including the es- assumptions of Story Theory and emphasizes
sential concepts of the theory such as intentional the value and importance of stories for health
7991_Ch24_409-420 12/08/19 5:29 PM Page 411
C H A P TER 24 ■ Patricia Liehr and Mary Jane Smith’s Story Theory 411
promotion. Charon (2006) describes the rela- inherently complex view (Newman, Sime, &
tionship between story and narrative indicating Corcoran-Perry, 1991), establishing a value
that narrative is a repository from which stories structure that creates a foundation for the
emerge. Our beliefs about story recognize an theory concepts.
intricate interplay between story and narrative The three concepts of the theory are inten-
with story moving beyond narrative to weave tional dialogue, connecting with self-in-relation,
remembered events, personal interpretations, and creating ease (Fig. 24-1). The related
and hopes and dreams that create the “now” method dimensions are complicating health
and guide choices in the moment (Liehr & challenge, developing story plot, and move-
Smith, 2018). ment toward resolving. The nurse engages a
Story Theory is one way to conceptualize an person through intentional dialogue (concept)
idea that has a long history in nursing. The about a complicating health challenge (related
authors believe that the structure of Story method dimension), while connecting with
Theory creates possibilities for application and self-in-relation (concept) as the developing story
evaluation that are critical to the endeavor of plot (related method dimension) surfaces
building disciplinary knowledge. through story sharing. As the story-sharer makes
explicit what may have been tacit (Polanyi,
Foundations of the Theory 1958), moments of ease (concept) accompany
Story Theory proposes that story is a narrative movement (related method dimension) toward
happening wherein a person connects with resolving the health challenge. Figure 24-1
self-in-relation through nurse–person inten- depicts the Story Theory model, indicating
tional dialogue to create ease (Liehr & Smith, relationships among the theory concepts and
2018). Ease emerges in the midst of accepting related method dimensions.
the whole story as one’s own—a process of The Story Theory model spreads a “wave”
attentively embracing the complexity of one’s across all concepts in the theory, expressive of
situation. Nursing encounters often occur the energy essential to story-sharing through
within the context of story. The stories of the intentional dialogue. The heavy dotted ellipse
nurse, patient, family, and other health-care between nurse and person highlights nurse–
providers are woven together to create the tap- person intentional dialogue, the core activity
estry of the moment—this is the whole story. enabling connecting with self-in-relation and
Each time a nurse engages a patient about what creating ease. There are three ellipses in the de-
matters most regarding a health challenge, sign of the model, mapping a vortex of a con-
Story Theory is applicable. By abandoning pre- tinually evolving process, encompassing all the
existing assumptions, respecting the story- concepts within the theory along with the
sharer as the expert, and querying vague story associated method dimensions. The links
directions, the nurse intentionally engages the

other, enabling connecting with self-in-relation
to create ease. Connecting with
The framework that underpins Story self-in-relation
Theory is based on three assumptions. These Developing story-plot
assumptions are that people (1) change as they
Intentional dialogue
interrelate with their world in a vast array of Nurse
Complicating health challenge
Person
flowing connected dimensions; (2) live in an
expanded present moment where past and Creating ease
future events are transformed in the here and Movement toward resolving
now; and (3) experience meaning as a res-
onating awareness in the creative unfolding
FIG 24-1 ■ Story Theory with method. (Reprinted
of human potential (Liehr & Smith, 2018). with permission of Smith M. J., & Liehr, P. (2014). Story
These assumptions are consistent with a theory. Middle range theory for nursing. New York:
unitary–transformative “view of the world,” an Springer, p. 234.)
7991_Ch24_409-420 12/08/19 5:29 PM Page 412
between essential elements of the model map environment. The nurse knows how to proceed
the phenomenon of the theory as an energy- only by querying what matters most about a
laden integrated whole. complicating health challenge.
Intentional Dialogue About a Connecting With Self-in-Relation
Complicating Health Challenge Through Developing Story Plot
Intentional dialogue is the central activity be- Connecting with self-in-relation occurs with
tween nurse and person that brings story to reflective awareness on personal history (Smith
life; it is querying emergence of a health chal- & Liehr, 1999). It is an active process of rec-
lenge story in true presence (Smith & Liehr, ognizing self as related with others in a devel-
1999). True presence is a fully immersed way oping story plot uncovered through intentional
of being with another, where authenticity and dialogue (Liehr & Smith, 2018). To connect
mindfulness prevail. This purposeful engage- with self-in-relation, people see themselves not
ment with another creates potential for as isolated individuals but as existing and
embracing the whole story in the moment as growing in a context, which includes aware-
the nurse summons the story-sharer’s narra- ness of other people and times, sensitivity to
tive focusing on what matters most about a bodily expression, and a sense of history and
complicating health challenge (Liehr & future in the present moment. One way to gain
Smith, 2018). The complicating health chal- insight into the story plot is to gather a health
lenge is a life circumstance in which life challenge story using a story-path approach.
change generates uneasiness. Understanding Story path begins with a focus on a present
the uneasiness refines the health challenge to health challenge; then it moves to the past,
enable meaningful nurse–person interaction. calling attention to the relationship between
For instance, getting married could be both a the past and the present challenge. The final
joyful and an uneasy transition. In this case, phase of story gathering, when using the story-
the complicating health challenge may be path approach, happens when the nurse asks
articulated as the transition from being single about hopes and dreams related to the current
to being married. What matters most to the health challenge. Sometimes this story-path ap-
anticipatory bride may be the uncertainty she proach is visually depicted as the nurse and the
is feeling in the midst of excited planning. story-sharer cocreate a picture of past-present-
This joyful–uneasy paradox will become the future along a horizontal line, and the line is
focus for the nurse using Story Theory to labeled “Your story of (health challenge).”
guide practice; the nurse will listen to the However, the authors have found that a visual
bride’s complaint of stomach pain within depiction is not as important as the consistent
the context of joy–uneasiness emerging in the focus on the time dimensions of past–present–
transition to married life. future when gathering the story of a health

In another example, for a woman facing the challenge.
complicating health challenge of a breast can- The story path is an expression of a devel-
cer diagnosis, it is possible that the thought of oping story plot with high points, low points,
losing her breast matters most. However, what and turning points. High points are times
matters most could also be the threat of a when things are going well by the story-
shortened life imposed by the cancer, the re- sharer’s evaluation; low points are times when
sponse of her husband to her changing body, they are not going so well; and turning points
or concern about who will care for her puppy are times when the story twists, sometimes
while she is in the hospital. There is an endless subtly, sometimes dramatically, creating a shift
list of possibilities known only to the person in the forward view. Often, we and our col-
who is living the health challenge. The nurse leagues have used a story-path approach to
can never assume to know what matters most gather stories for research (Liehr & Smith,
about a health challenge regardless of the 2018). The story path links present, past, and
extent of experience in a particular practice future (Liehr & Smith, 2000), often beginning
7991_Ch24_409-420 12/08/19 5:29 PM Page 413
with the question, “What matters most to you frenzy.” Mary believes that work-related stress
right now about (the health challenge you are is the strongest contributor to her hypertension.
facing)?” This question would be followed by The nurse clarifies with Mary, “So … are you
one that queries the past, asking how it saying that stress-induced high blood pressure is
contributes to the present. Finally, hopes and your pressing concern right now?” Mary says,
dreams would be elicited. “Yes.” What matters most to Mary about the
Figure 24-2 depicts a story path for Mary, a health challenge of hypertension on this visit is
29-year-old woman who has come to see the her stressful work life, which she feels unable to
nurse practitioner for hypertension. Her blood control. The nurse then moves to the past and
pressure was recorded as 180/110 mm Hg on asks Mary to identify situations and events on
the primary care visit. The nurse has drawn a line her story path that contributed to her current
on a sheet of paper labeled “Your story of living health challenge of stress-induced high blood
with hypertension” and asked Mary to tell her pressure, and then to the future, asking her to
where she is in her life path by marking the “pre- note hopes and dreams related to the health
sent” on the line. Then she asks Mary what mat- challenge. Mary notes story-path events related
ters most in this present moment. Mary talks to her father and identifies her desire to have a
about her discomfort with her elevated blood baby within the next 5 years. Each of these
pressure at her young age. She adds details about markings along the story path is discussed
her job as a project director for a research study with the story-sharer leading the way. The
while having just finished full-time study for her nurse makes notes on the story path so that
master’s degree and now beginning work on her both participants are engaged in the process,
doctoral degree in psychology. Mary’s home infusing the physiological indicator, a blood
situation is “stabilized” by her husband John, pressure of 180/110 mm Hg, with Mary’s
whom she describes as mellow and the strongest unique personal story.
supporter for “considering lifestyle changes to Before ending any visit where story has been
lower her high blood pressure.” She tells the pulled into the foreground, it is important that
nurse that the only time her blood pressure is the nurse ask if there is “anything else” about the
normal is on weekends, when she is away from health challenge that the story-sharer wants to
work. She provides great detail about her work discuss to enhance understanding. What matters
situation on this visit, describing work as an most about a health challenge may change from
“out-of-control stress” environment aggravated visit to visit, and any single visit may encompass
by people who “seem to enjoy her stressful more than one issue that matters most. Detailed
Mary’s Story Path

Master’s 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
FIG 24-2 ■ “Your story of living with hypertension”—Mary’s story path.
7991_Ch24_409-420 12/08/19 5:29 PM Page 414
story paths include bits of evidence gleaned from address what matters most about the health
what the story-sharer emphasized. This evidence challenge.
has the potential to guide nursing practice, in-
cluding the next steps the nurse will take during
this and upcoming visits. Applications of the Theory
Story path is just one approach to gathering Story Theory has been used to guide a story-
the story in a practice setting. We have sug- centered intervention in two studies: a study of
gested others such as photographs, family trees, people with stage 1 hypertension (Liehr et al.,
and pain diaries (Liehr & Smith, 2018). There 2006) and a study of adolescent disclosure
seems to be value in eliciting a story through a when visiting an urgent care clinic (Summers,
nurse–person collaborative creation that en- 2016). It has been used to guide structured
hances the telling and takes the story to a struc- data collection in qualitative studies with can-
ture such as story path. The possible approaches cer patients (Williams, 2007), hemodialysis
for story gathering are limitless. The creative patients (Hain, 2008), women suffering from
nurse will identify other unique approaches for migraine headaches (Ramsey, 2012), women
querying what matters most about a health veterans coming home from war (Maiocco &
challenge. Coming to grips with what matters Smith, 2016), and mothers of autistic children
most about the health challenge one is facing is (Walter & Smith, 2016). The story inquiry re-
a process of embracing story, where, paradoxi- search method has also been used for story
cally, embracing can release a person from story gathering and data analysis (Carpenter, 2014;
confines and engender a sense of ease. Hain, Wands, & Liehr, 2011; Kelley & Lowe,
2012; Liehr et al., 2011; Rateau, 2017;
Creating Ease While Moving Toward Songwathana & Liehr, 2015; Wands, 2013;
Resolving Walter, 2017). The authors are currently
In the context of Story Theory, creating ease is developing an instrument to measure ease, an
defined as remembering disjointed story mo- effort that will contribute to the practical use
ments to experience flow in the midst of anchor- of the theory in outcomes research. Details re-
ing (Smith & Liehr, 1999) to an understanding garding the use of Story Theory for research
of the whole story, even if for only one “aha” can be found in the textbook Middle Range
moment. As a person anchors for a moment, Theory for Nursing (Smith & Liehr, 2018).
embracing the comprehensible whole, flow en- Application of the theory to nursing prac-
sues as easiness-with-self situated in a complex tice often occurs through discussion of the the-
context. Ease is neither assured nor pervasive ory concepts, providing real-life examples that
during story-sharing. Sometimes it is elusive; enable a move from conceptual to empirical.
sometimes it is experienced as only a moment in In the next section, we describe a seven-phase
time. When story moments come together in a process that chronicles the development of
meaningful way for the person sharing a story, nursing knowledge from evidence collected
there is often some movement toward resolving during nursing practice. Advancing practice
the health challenge. Movement may be minus- scholarship through Story Theory will surface
cule, or it may be a leap; it enables a shift in one’s as the exemplar of “transitioning to a nursing
perspective usually accompanied by an action to home” is described.
Practice Exemplar
Seven phases of inquiry for practicing nurses phases are as follows: (1) gather a story about
who want to develop evidence in practice as a what matters most about a health challenge;
base for knowledge development are proposed (2) compose a reconstructed story; (3) connect
in this section (Smith & Liehr, 2005). The existing literature to the health challenge;
7991_Ch24_409-420 12/08/19 5:29 PM Page 415

(4) refine the name of the health challenge; exemplar for understanding the independent
(5) describe the developing story plot with living to nursing home living transition.
high points, low points, and turning points; Elizabeth was an 88-year-old woman who
(6) identify movement toward resolving; and enjoyed independent living in her bungalow
(7) collect additional stories about the health with her husband of 65 years. She and her
challenge (Liehr & Smith, 2018). For the pur- husband resided in the independent living
poses of this chapter, we address all phases of component of a continuing care community.
the inquiry process except the last, which takes Elizabeth had a long history of atrial fibrilla-
the nurse back to the practice environment to tion, chronic heart failure, and diabetes, but
substantiate what emerged while completing she managed to remain independent, using a
the first six phases. walker to get around. She attributed her inde-
pendence to the devotion of her husband, who
Phase One watched over her medication routine, diet,
The practicing nurse gathers a story of what and the balance between her activity/rest pat-
matters most about a health challenge. Query- terns. At the end of January, Elizabeth began
ing what matters most about the health chal- having difficulty moving her left leg, especially
lenge is coming to know the unique perspective when she awoke in the morning. It seemed to
of the person sharing the story. To gather the her that her leg had fallen asleep due to posi-
story, the nurse could use a structured approach tioning during the night. Then, one February
such as the story path, or story gathering could morning, Elizabeth’s lower leg was painful,
occur over time through attentive presence rec- cool to touch, and slightly discolored. Her
ognizing circumstances and life changes that husband called the community nurse, who im-
are continually shaping one’s story. Irrespective mediately sent Elizabeth to the hospital,
of how the nurse gathers the story, coming to where a popliteal clot was found to be occlud-
know the other in true presence with mindful ing the artery. Amputation was considered but
attention to what matters most culminates in a rejected due to the complexity of Elizabeth’s
reconstructed story. The nurse in the following health situation. Clot-buster was dripped di-
story queried the health challenge of transition- rectly into Elizabeth’s clot for seven hours
ing to a nursing home environment for older while she lay on her back and the clot dis-
adults who had been living independently. solved. Elizabeth was relieved because she had
always feared losing her leg after witnessing
Phase Two her grandmother’s double amputation as a
The nurse composes a reconstructed story, result of long-standing diabetes.
which is a narrative creation with a beginning, After 10 days in the hospital, Elizabeth en-
a middle, and an end that weaves together the tered into the continuing care community,
nurse’s and the story-sharer’s perspective of which, as part of her rehabilitation, involved
the health challenge. The reconstructed story placement in a nursing home. Shortly after
naturally incorporates what matters most admission, Elizabeth was diagnosed with the
about the health challenge. The reconstructed flu, delaying the start of her rehabilitation.
story shared in this chapter was written by a Once she began her rehabilitation, however,
nurse who cared for Elizabeth during the last the physical therapists referred to her as their
months of her life in a nursing home. The “energizer bunny” because of her spirited ap-
nurse had practiced in this nursing home for proach to therapy. Throughout this time, it
10 years, often witnessing the health challenge was very hard for Elizabeth to lift her left leg.
of transitioning from independent to nursing No matter how hard she tried, she couldn’t
home living. The story gathering occurred move it like she could move her right leg. Still,
over time, and story moments are synthesized she was anticipating returning home to her
as a reconstructed story to serve as a practice bungalow and getting on with everyday living
(continued)
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with her husband. While Elizabeth was in the debilitating and her blood sugar swings con-
nursing home, her husband visited every day tinued despite precise insulin dosing and
at mealtimes and when she was ready to go to measured carbohydrate intake. At this time,
sleep. She referred to these visits as the “best the doctor suggested hospice. Elizabeth and
times of her day.” her husband listened to the description of
As part of the discharge plan, the physical hospice services, and she signed the hospice
therapists took Elizabeth to her bungalow to try papers. While under hospice care, she stopped
out everyday activities. The difficulty moving her troubling over her failed effort to move her left
leg was magnified when Elizabeth was in her leg, continued to have blood sugar swings, and
usual environment, and the therapists began to never stopped trying to hide the twitching.
think that she might not be able to return to her Appearances mattered to Elizabeth, and
bungalow, which she considered “home.” About she continued to care about how she looked.
the same time, Elizabeth began to have dra- One time she told the nurse that she wore her
matic blood sugar swings accompanied by con- pink shirt as often as she could because her
fusion and twitching that engaged all parts of husband liked it. She asked to have her roots
her body. Her husband was anxious and looking done, and the nurse took her to the beauty
for answers as Elizabeth herself was consistently shop one floor away. When she returned, her
questioning: “What’s going to happen to me husband took her picture. She was wearing
now?” Elizabeth’s health challenge at this time her pink shirt, and her husband later included
was an arduous struggle to resume normal the picture in a memorial collage that was cre-
“independent” living in her bungalow with her ated when she died. The long loving relation-
husband, and what mattered most at this point ship between Elizabeth and her husband was
was the unfamiliar, uncontrollable bodily expe- most important to both of them in her last
rience and the uncertainty that ensued from days. She giggled with him while recalling fun
unfamiliarity. The question “What’s going to times they had over the years, and she asked
happen to me now?” was one the nurse had for hugs, an uncharacteristic request that
heard repeatedly over her years of nursing home became increasingly familiar to her husband
practice as residents began to understand that during this time.
they might not return home. She had begun to Elizabeth and her roommate told each other
view the question as a marker of transition that stories, shared chocolates, and looked out for
demanded her concentrated attention to what each other as well as they could. Her roommate
mattered most for the resident. called her “sweet pea.” On the day Elizabeth
Elizabeth didn’t understand why her leg died, the roommate asked Elizabeth’s husband
wouldn’t move even though she worked so and the nurse if she could pray with them.
hard in therapy; she tried to hide the twitch- Elizabeth had been in the nursing home
ing, which she had never experienced before. about 3 months before she died. The course of
The twitching and her attempts to move her her story shifted from one of expectation for
leg took a lot of energy, and she often said that familiar normalcy in her bungalow with her
she was tired. She never stopped saying that husband to one of peaceful going to what now
she wanted to “go home,” but at some point was accepted as home. The nurse in this situ-
the nurse suspected that the meaning of “going ation of caring for Elizabeth was attentively
home” had changed for Elizabeth. The nurse present to the shifting story, following Eliza-
asked her “Where is home?” and Elizabeth beth’s lead to pursue meaning during the last
responded that she wasn’t sure. Shortly there- months of her life.
after, Elizabeth stopped asking to go to her
bungalow, and instead she expressed wishes Phase Three
for a peaceful death. In this phase of the story inquiry process
It became clear that Elizabeth was not get- the nurse becomes familiar with the existing
ting better as her heart failure became more literature about the complicating health
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challenge—beginning, in this case, with The themes that emerged were becoming
“transitioning from independent to nursing homeless, getting settled, learning the ropes,
home living.” For the purposes of this chap- and creating a place. The first theme, becom-
ter, only the beginnings of a literature review ing homeless, contributed to the researchers’
are reported. However, the practicing nurse conclusion that “one cannot separate home,
interested in a particular health challenge memories, and friends from one’s very iden-
will stay abreast of related literature and tity. Each continuously shapes and is shaped
eventually develop a broad literature base in- by the other” (p. 41). Getting settled and
forming ongoing interpretation of stories learning the ropes characterized residents’
and bodily responses. For this example, the shift from unknown to known, invisible to vis-
literature search was guided by the search ible. Creating a place was a theme related to
phrases nursing home transition and elder; creating meaning in this new life situation. In
nursing home transition and older adult. In their conclusion, the authors note the impor-
addition, the search was limited to qualita- tant place of story: “The challenge for nursing
tive studies and systematic literature reviews. home staff is to create situations, a clearing for
Brandburg (2007) conducted an integrated sharing stories … that facilitate the cocreation
literature review intended to synthesize the of new meanings. … A staff that listens to
state of the science regarding transition to a what matters to residents can interpret a plan
nursing home for older adults. The 13 articles of care that is meaningful” (p. 41).
that met the inclusion criteria led to the cre- Listening was the major theme in a brief
ation of a “transition process framework” with by Maynes (2004). She shared the story of a
the foundational concepts of initial reaction, patient she met on a short hospitalization,
transitional influences, adjustment, and ac- during which his cancer diagnosis was con-
ceptance. Brandburg (2007) reported that firmed and he was evaluated as having a
the initial reaction and adjustment phases of “poor prognosis.” The nurse listened to the
the process require approximately 6 months. quiet man and honored his wish to return
During that time, people move from disor- “home” to the farm country where he was
ganization to reorganization and relationship raised. On the day he was to be transferred,
building. They also move from a sense of the nurse went to his bedside to say good-
homelessness to recognition of a new home bye, thankful that he would be returning to
where new relationships are developed and old the place he loved. When she approached the
ones are cultivated. She describes the “final” bed, she realized that he had died. “I sat next
or acceptance phase as one in which “reflect- to him, put his hand in mine, and whispered
ing on the transition experience in light of ‘good-bye’” (p. 32).

personal values helped many older adults ac- The experience of “home” occurring with
cept their new home because they could find transition to a nursing home was synthesized
meaning in their present situation” (p. 55). by Molony (2010) using a meta-ethnography
The theme of home that was noted by approach. Twenty-three studies were included
Brandburg (2007) was strongly described by in this synthesis. Home was described as both
Heliker and Scholler-Jaquish (2006) in a study a place and a process. As a place, it was an en-
of 10 newly admitted nursing home residents vironment that supported one’s sense of self.
who were interviewed multiple times over As a process, it was an ongoing experience of
their first 3 months of residency. Residents re- mastery with growing comfort steeped in a
sponded to the directive: “Tell me a story sense of being able to do what one wanted do
about what it is like for you to come here in everyday living. Relationship was described
and live.” Data from 32 interviews lasting as essential to “home” where individuals had
from 15 to 60 minutes were analyzed using a a sense of being part of a meaningful social
hermeneutical phenomenological approach. fabric.
(continued)
7991_Ch24_409-420 12/08/19 5:29 PM Page 418

Lane, Hirst, Hawranik, Reed, and story and the existing literature, the name
Rokhman (2017) extended the query about of the complicating health challenge was
transitioning to a nursing home to family changed to “yearning for home.” This health
members, interviewing six family members, challenge name is consistent with the original
who emphasized the value they placed on name of transitioning from independent to
showing respect for their loved one. “The sup- nursing home living, but it captures more
port wanted by family members was the knowl- clearly what “matters most” about the transi-
edge and evidence that the older adult was and tion for both the person who is transitioning
would be treated with respect and receive care and for family members. It is neither so high
that was individualized according to his/her that it cannot be applied in practice nor so low
need” (Lane et al., p. 11). Although “home” did that it applies to only a narrow subset of peo-
not explicitly occur in the research themes, ple. Because it is in the middle, it may also
there was a strong emphasis on personhood have applicability to other populations, such
with one theme addressing the importance of as people who have been evacuated from their
an environment that supports personhood. homes due to natural disasters or parents of
Elizabeth’s short nursing home stay fits premature newborns who find themselves
with the initial reaction phase described by enduring extended hospital stays.
Brandburg (2007) and the becoming homeless
theme described by Heliker and Scholler- Phase Five
Jaquish (2006). The idea of “home” emerged This phase of the story inquiry process focuses
strongly from the literature and story sources, on the developing story plot through identifi-
and a meaningful home experience as de- cation of high points, low points, and turning
scribed by Molony (2010) was one that en- points. Turning points are shifts in what is
abled independence with connection, threads happening to create a revision in the story-
that are apparent throughout Elizabeth’s sharer’s forward view. These are situations or
story. Both Elizabeth and the man in Maynes’ events that move the story along. High and
(2004) brief feel the pull of “home” as they ap- low points note times when things are going
proach death. Merging Elizabeth’s story with well or not so well. Table 24-1 records the
the relevant literature set the stage for the next turning points, high points, and low points in
step of the story inquiry process: refining the Elizabeth’s reconstructed story.
name of the health challenge. Turning points may also be high points or
low points, but this is not always the case.
Phase Four Sometimes turning points exist with no par-
The nurse refines the name of the health chal- ticular value assigned by the person living the
lenge, if necessary. There may be some times story. In Elizabeth’s story, turning points can
when the original name is confirmed as ade- be summarized as (1) diagnosed health issues,
quately expressive of the challenge, and there (2) treatment milestones, and (3) the hospice
are other times when the convergence of the decision. High points are (1) “favorable” (ac-
reconstructed story with the existing literature cording to Elizabeth) treatment milestones
demands that the health challenge name be and (2) relationship-centered moments of joy.
refined. We believe that “naming” is most im- Low points are (1) limitations in physical
portant for the continuing work, and we ad- movement, (2) unfamiliar bodily experiences
vocate that the health challenge name be with and without diagnoses, and (3) uncer-
neither too high nor too low in level of ab- tainty. As the practicing nurse collected more
straction. Names that are too high may be dif- stories of this nature, comparison, contrast,
ficult to apply to practice situations, and and synthesis of turning points, high points,
names that are too low may be meaningful for and low points would be possible, and the ev-
only a few people. Considering Elizabeth’s idence from stories could contribute to the
7991_Ch24_409-420 12/08/19 5:29 PM Page 419
Table 24-1 Turning Points, High Points, and Low Points in Elizabeth’s Story
Story Event TP HP LP
Difficulty moving leg beginning in January x
Change in leg pain, temperature, and color—leading to hospitalization x x
Decision not to amputate x x
Clot was dissolved x x
Return to nursing home for rehabilitation x
Diagnosed with flu x x
Couldn’t move leg, though she tried x
Husband’s 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
“What’s 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 x
roommate
TP = turning point; HP = high point; LP = low point.
knowledge base guiding practice with people indicated that she was on a different path, she
who are transitioning into a nursing home. signed the hospice papers. Finally, Elizabeth
One last phase of analysis considers the evi- enjoyed moments with her husband and her
dence from stories to identify how people get roommate and chose to do things that kept
through the health challenge. her appearance as she liked. Movement to-
ward resolving recounted in the reconstructed
Phase Six story included the approaches of (1) devoting
The practicing nurse identifies how an indi- energy to recovery, (2) accepting hospice,
vidual moved toward resolving the health (3) experiencing the joy of relationship, and
challenge. This phase of practice inquiry may (4) attending to self through personal appear-
be most instructive for the nurse’s continuing ance. The range of ways Elizabeth moved to-
work with a particular population because it ward resolving reflects the dynamic and
taps into the inherent wisdom of people living complex nature of story. What is character-
the challenge and attempts to understand ized as movement toward resolving emerges
“how they got by.” The question facing the as the story unfolds. At a higher level of ab-
nurse analyzing Elizabeth’s reconstructed straction, these approaches used by Elizabeth
story is, How does Elizabeth move toward re- may be conceptualized as (1) focusing energy
solving the complicating health challenge of to heal, (2) accepting the inevitable, (3) ap-
yearning to go home? Elizabeth put all her ef- preciating relationship, and (4) attending to
fort into her recovery so that her therapists self. At this higher level of abstraction, the
called her their “energizer bunny.” When four approaches extracted from the recon-
her efforts failed and her bodily experience structed story have implications for people
(continued)
7991_Ch24_409-420 12/08/19 5:29 PM Page 420

who are yearning to go home, regardless of to go home. Once again, there is guidance for
the context of their situation. The story de- nursing practice in the wisdom of people
scribes how one person created ease and offers living health challenges. The nurse could
an invitation to consider how others in similar use what is learned from this story analysis
situations may create ease as they move to- to guide current practice and frame further
ward resolving a health challenge of yearning inquiry.
Summary
This chapter has introduced the reader to Story process described in this chapter to access story
Theory as a way to guide nursing practice. In evidence for the contribution it can make to
an analysis of application of middle-range the- nursing knowledge and the guidance it can
ory to practice, Liehr and Smith (2018) re- provide for nursing practice. Each nurse at the
ported that there is a paucity of publications bedside, in the clinic, or in the office is
citing the use of middle-range theory to guide uniquely positioned to gather and analyze
practice. The authors hope that practicing practice stories, and Story Theory provides
nurses will use the theory-guided story inquiry guidance to accomplish this work.
Questions for Reflection ■ Write a 300-word story about one of your

patients. Identify what might be consid-
and Discussion ered high points, low points, and turning
■ Thinking about your practice environ- points from the patient’s perspective.
ment, identify the most common health ■ Reflect on the theory concept, “creating
challenge that you witness in your patient ease.” How is this defined in Story The-
population. Using Story Theory, articulate ory? Have you observed “ease” for patients
a question that you might ask of a patient in your practice setting?
to learn more about the health challenge
from his or her perspective.
7991_Ch25_421-436 12/08/19 5:28 PM Page 421
The Community Nursing

CHAPTER
25
Practice Model
Marilyn E. Parker, Charlotte D. Barry, and
Beth M. King

Overview of the Model Introducing the Theorists
Applications of the Model Marilyn E. Parker is professor emerita at the
Practice Exemplar by April Haukoos Christine E. Lynn College of Nursing at Florida
Summary Atlantic University and recently retired professor
Questions for Reflection and Discussion from the University of Kansas School of Nurs-
ing. 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 ad-
vance the discipline.
As the project director for a series of program
grants funded to create a Community Nursing
Practice Model (CNPM), Dr. Parker provided
leadership for the development of transdiscipli-
nary school-based wellness centers. The mission
of these centers was to provide health and social
services for children and families from under-
served multicultural communities, to teach uni-
versity students from several disciplines, and to
develop research and policy to promote commu-
nity well-being.
Dr. Parker’s 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 her Thai colleagues. Her commitment to
caring for underserved populations and to
health equity led to her being named a National
Public Health Leadership Institute Fellow and
to her election as a distinguished practitioner in
the National Academies of Practice in Nursing.
Dr. Parker is a fellow in the American Academy
of Nursing.
Dr. Parker and her colleagues Abhijit
Pandya, Sam Hsu, and Shihong Huang received
a patent for a nursing language system that
has the potential to inform the development of
421
7991_Ch25_421-436 12/08/19 5:28 PM Page 422
electronic health-care records that elaborate fully Overview of the Model

nursing’s contributions to caring and well-being.
The Community Nursing Practice Model
Charlotte D. Barry is a professor at the
(CNPM) began as and continues to be a blend
Florida Atlantic University Christine E. Lynn
of the ideal and the practical. The ideal was the
College of Nursing. Barry graduated from
commitment to develop and use nursing con-
Brooklyn College, New York, with an associate
cepts to guide nursing practice, education, and
degree in nursing; she holds a bachelor’s degree
scholarship, and a desire to develop a nursing
in health administration, a master’s degree in
practice as an essential component of a college
nursing from Florida Atlantic University, and a
of nursing. The practical was the effort to bring
PhD from the University of Miami, Florida. She
this CNPM to life within the context and
is nationally certified in school nursing and in
structures of an existing community health-care
2013 was recognized as one of the best 25 nurs-
system. The CNPM reflects the mission of the
ing professors in Florida. Dr. Barry is a fellow in
Christine E. Lynn College of Nursing at
the American Academy of Nursing.
Florida Atlantic University and the concept of
The focus of Dr. Barry’s scholarship has
nursing held by its faculty: Nursing is nurturing
been caring for persons in schools and commu-
the wholeness of persons and environments in car-
nities. As a co–project director with Dr. Parker,
ing (Florida Atlantic University Christine E.
Dr. Barry cocreated the Community Nursing
Lynn College of Nursing [FAU], 1994/2012).
Practice Model (CNPM) from the transdisci-
The concepts and relationships of the
plinary practice that unfolded at several school-
CNPM are the guiding forces for community
based wellness centers. Her current research
practice. Through various participatory-action
includes the usefulness of the CNPM to guide
approaches, including ongoing shared reflec-
practice in global communities, including the
tion, intuitive insights, and discoveries, the
United States, Uganda, and Haiti. Building on
CNPM has evolved and continues to develop.
a school-based wellness center in Uganda, a
The education of university students and the
replica program is being developed in a rural
conduct of student and faculty research have
community in Haiti.
been integrated with nursing and social work
Dr. Barry provides leadership in many com-
practice. Throughout the early development
munity and professional organizations, includ-
and ongoing refinement of the CNPM, there
ing Sigma Theta Tau, Iota XI Chapter, the
has been nurturing of collaborative community
International Association for Human Caring,
partnerships, evaluation and development of
the National Association of School Nursing,
school and community health policy, and de-
and the Florida Association of School Nurses.
velopment of an enriched community.
She also serves on the Board of the South
Florida Haiti Project.
Dr. Beth King is an assistant professor at Foundations of the Model

the Christine E. Lynn College of Nursing at Essential values that form the basis of the
Florida Atlantic University. Dr. King earned a CNPM are (1) persons are respected; (2) per-
diploma in nursing from Iowa Methodist sons are caring, and caring is understood as the
School of Nursing, a BSN from Grand View essence of nursing; and (3) persons are whole
College, a master’s in nursing from University and always connected with one another in
of Maryland, and a PhD from Iowa State Uni- families and communities. These essential or
versity. She is nationally certified as a Psychi- transcendent values are always present in nurs-
atric Mental Health Nurse Practitioner and ing situations, while other actualizing values
was awarded the Excellence in Research guide practice in certain situations.
Award by the American Psychiatric Nurses The principles of primary health care from
Association, Florida Chapter. Her current re- the World Health Organization (WHO,
search focuses on use of the CNPM with local 1978) focusing on health for all form the ac-
and global communities and development of tualizing values. These values are (1) access,
programs addressing mental health. (2) essentiality, (3) community participation,
7991_Ch25_421-436 12/08/19 5:28 PM Page 423
C H APTER 25 ■ The Community Nursing Practice Model 423
(4) empowerment, and (5) intersectoral col- community as whole rather than on an individ-
laboration. The WHO call for health for all ual (Barry, Nambozi, King, & Turkel, 2015).
continues to be heard within the platform of
the 17 Sustainable Development Goals (United Nursing
Nations, 2015). Goal 3, ensuring healthy lives The following descriptions of the unique par-
and promoting the well-being for all at all ages, adigmatic lens of the CNPM are congruent
continues to ignite the values of the CNPM. with Ubuntu philosophy and illuminate the
Concepts of nursing practice that have shared values embedded with the CNPM. The
emerged include transitional care and enhanc- unique focus of nursing is nurturing the whole-
ing care. The CNPM illuminates these values ness of persons and environments in caring
and each of the concepts in four interrelated (FAU, 1994/2012). Nursing practice, educa-
themes: nursing, person, community, and en- tion, and scholarship require creative integration
vironment, along with a structure of intercon- of multiple ways of knowing and understanding
necting services, activities, and community through knowledge synthesis within a context
partnerships (Parker & Barry, 1999). An in- of value and meaning. Nursing knowledge is
quiry group method has been designed and is embedded in the nursing situation, the lived
the primary means of ongoing assessment and experience of caring between the nurse and the
evaluation (Barry, Lange, & King, 2011; one receiving care. The nurse is authentically
Campbell et al., 2001; Clark et al., 2003; present for the other to hear calls for caring
Parker, Barry, & King, 2000; Ryan, Hawkins, and to create dynamic nursing responses. The
Parker, & Hawkins, 2004). community and school-based wellness centers
The CNPM continues to evolve as its use- become places for persons and families to ac-
fulness guides practice and research in various cess nursing and social services where they are
settings. The inclusion of Ubuntu philosophy in homes, at work camps, in schools, or under
into the CNPM was initiated by Grace Nam- trees in a community gathering spot. Nursing
bozi as a result of her research (personal com- is dynamic and portable; there is no predeter-
munication, September 19, 2013). She explains mined nursing and often no predetermined ac-
that most community nurse practice models cess place (Barry, Gordon, & King, 2015;
employed in resource-poor community-based Dyess & Chase, 2012; Parker, 1997; Parker &
nursing settings were not designed to fit com- Barry, 1999).
munities grounded in a non-Western culture, Nursing practice is further described within
thereby posing challenges to implementation the context of transitional care and enhancing
in communities such as those in Uganda (the care. Transitional care occurs as clients and
location of Nambozi’s study). The participants families are provided essential health care while
in her study offered unique experiences being referred to a more permanent source of
grounded in cultural beliefs and practices of health care in the community (Sternberg &
nurses and community stakeholders. Ubuntu Barry, 2011). Transitional care, an ideal for
philosophy, derived from the word ubuntu, nursing and social work practice, can be chal-
means “the quality of being human” and served lenging due to immigration status, a complex
as the philosophical foundation that guided and confounding health-care system, or issues
community collaboration and partnership in of the family. Enhancing care describes nursing
the study (Nambozi, 2014). The Ubuntu phi- and social work that is intended to assist per-
losophy enhances the CNPM approach to sons and families who need care in addition to
community care as an essential way of caring that provided by a local health-care provider.
for another. The CNPM approach makes ex-
plicit the values of respect, transparency, hon- Person
esty, trust, kindness, harmony, warmth, and Respect for person is present in all aspects of
responsibility for others and emphasizes a sense nursing, with clients, community members,
of belonging and obligation to one another, as colleagues, neighbors, or others. Respect in-
well as consideration for the welfare of the cludes a stance of humility that the nurse does
7991_Ch25_421-436 12/08/19 5:28 PM Page 424
not know all that can be known about a person (1987) existential, relational view. According to
and a situation, acknowledging that the person Smith and Maurer, a community is defined by
is the expert in his or her own care and know- its members and is characterized by shared val-
ing his or her experience. Respect carries with ues. This expanded notion of community moves
it an openness to learn and grow. Values and away from a locale as a defining characteristic
beliefs of various cultures are reflected in and includes self-defined groups who share
expressions of caring. The person as whole and common interests and concerns and who
connected with others, not the disease or prob- interact with one another.
lem, is the focus of nursing. Community, offered by Peck (1987), is a
Persons are empowered by understanding safe place for members and ensures the security
choices, how to choose, and how to live daily of being included and honored. His work
with choices made. The person defines what is focuses on building community through a web
necessary for well-being and what priorities of relationships grounded in acceptance of
exist in daily life of the family. Nursing and so- individual and cultural differences among fac-
cial work practice are based on practical, sound, ulty and staff and acceptance of others in the
culturally acceptable, and cost-effective methods widening circles, including colleagues within
that are necessary for well-being and the whole- the practice and discipline, other health-care
ness of persons, families, and communities. colleagues from varied disciplines, grant fun-
Early on, Swadener and Lubeck’s (1995) ders, and various collaborators. The notion of
work on deconstructing the discourse of risk was transdisciplinary care is an exemplar of this
a major influence on nursing practice. At risk approach to community. Another defining
connotes a deficiency that needs fixing; a doing characteristic of community, according to Peck,
to, rather than collaborating with. Thinking is willingness to risk and tolerate a certain lack
about children and families “at promise” instead of structure. The practice guided by the CNPM
of “at risk” inspires an approach to knowing the reflects this in fostering a creative approach to
other as whole and filled with potential. program development, implementation, evalu-
Respect and caring in nursing require full ation, and research. Ubuntu philosophy, high-
participation of persons, families, and commu- lighting caring for each other as well as
nities in assessment, design, and evaluation of community, is embedded in the understanding
services. Based on this concept, an inquiry of community from the perspective of the indi-
group method is used for ongoing appraisal of vidual and the collective (personal communica-
services and is defined as a “route of knowing” tion, September 19, 2013).
and “a route to other questions.” Each person Practice within the CNPM, whether un-
is a coparticipant, an expert knower in his or folding in a clinic or under a tree where persons
her experience; the facilitator is the expert have gathered, provides a welcoming and safe
knower of the process. The facilitator’s role is place for sharing stories of caring. The intention
to encourage expressions of knowing so that to know others as experts in their self-care while
calls for nursing and guidance for nursing re- listening to their hopes and dreams for well-
sponses can be heard. In this way, the essential being creates a communion between the person
care for persons and families can be known, and provider that guides the development of a
and care can be designed, offered, and evalu- nurturing relationship. Knowing others in rela-
ated (Acevedo, 2016; Barry, 1998; Barry, tionship to their communities, such as family,
Lange, & King, 2011; Gordon, Barry, Dunn, school, work, worship, or play, honors the com-
& King, 2011; Nongnut, Barry, Gordon, plexity of the context of persons’ lives and offers
Pipatsart, & Sirigulsatien, 2018; Parker, Barry, the opportunity to understand and participate
& King, 2000; Shutes, 2017). with them.
Community Environment
Community, as understood within the CNPM, The notion of environment within the CNPM
was formed from the classical definition offered provides the context for understanding
by Smith and Maurer (1995) and from Peck’s the wholeness of interconnected lives. The
7991_Ch25_421-436 12/08/19 5:28 PM Page 425
environment, one of the oldest concepts in person’s life that influence health and well-
nursing described by Nightingale (1859/1992), being in the services and activities provided.
is not only the immediate effects of air, odors, The Millennium Development Goals (MDG),
noise, and warmth on the reparative powers (UN, 2000) clarified goals toward health for all
of the patient but also indicates the social set- and inspired a continued focus on achieving
tings that contribute to health and illness such them. In 2015 the MDG expired and the
as those identified as the social determinants global humanitarian community developed
of health (WHO, 2007, 2012). Another nurs- and embraced the Sustainable Development
ing visionary, Lillian Wald, witnessed the Goals (SDGs; UN, 2015). These 17 goals pro-
hardships of poverty and disenfranchisement on vide a new platform for the continuing global
the residents of the lower Manhattan immi- efforts toward achievement of health for all
grant communities. She developed the Henry through the provision of care and the broader
Street Settlement House to provide a broad understanding of good governance needed to
range of care that included everything from progress. Goal 3 of the SDGs ensures healthy
direct physical care to finding jobs, obtaining lives and promotes well-being for all, at all
housing, and influencing the creation of child ages, and is enfolded into the CNPM. The
labor laws (Zaiger, 2013). connection between the CNPM and the SDG
Chooporian (1986) continues to re-inspire Goal 3 is evident through the noteworthy con-
nurses to expand the notion of environment tributions aimed at fostering health for all in
not only to include the immediate context of both the southeastern United States and global
patients’ lives but also to think of the relation- communities of Uganda, Thailand, Haiti, and
ship between health and social issues that Guatemala. Services and activities in this work
“influence human beings and hence create are grounded in nurturing wholeness by focus-
conditions for heath and illness” (p. 53). Re- ing on the well-being of persons and environ-
flecting on earth caring, Schuster (1990) urged ment and guided by the values of respect,
another look at the environment, inviting caring, and wholeness of persons.
nurses to consider a broader view that included The CNPM is envisioned as three concentric
nonhuman species and the nonhuman world. circles around a core. Envisioning the CNPM
Acknowledging the interrelatedness of all liv- as a watercolor representation, one can appre-
ing things energizes caring from this broader ciate the vibrancy of practice within the
perspective into a wider circle. Kleffel (1996) CNPM, the amorphous interconnectedness of
described this as “an ecocentric approach the core and the circles, and the “certain lack of
grounded in the cosmos. The whole environ- structure” that draws attention to the beauty in
ment, including inanimate elements such as creating responses to unique calls for nursing.
rocks and minerals, along with animate ani- The CNPM calls into the circles others to create
mals and plants, is assigned an intrinsic value” programs and environments that nurture well-
(p. 4). This perspective directs thinking about being and is reflected in Figure 25-1.
the interconnectedness of all elements, both
animate and inanimate. Teaching, practice, and Core Services
scholarship require a caring context that respects,
Core services, created from the results of in-
explores, nurtures, and celebrates the intercon-
quiry group methodology (Barry, Gordon, &
nectedness of all living things and inanimate
Lange, 2007; Barry, Lange, & King, 2011;
objects throughout the global environment.
Parker, Barry, & King, 2000), are provided to
Structure of Services and Activities nurture the wholeness of persons and environ-
ments in caring. The unique experiences of staff
The WHO call for health for all (1978) and
and faculty with the hopes and dreams for the
the social determinants of health (Office of
well-being of those receiving care create the
Disease Prevention and Health Promotion,
substance of the core:
2018) have provided a solid grounding and
strong thread throughout the CNPM, inspir- ■ Respecting self-care practice
ing consideration of all the elements of a ■ Honoring lay and indigenous care
7991_Ch25_421-436 12/08/19 5:28 PM Page 426
The Community Nursing Practice Model: sugar, blood pressure, clinical breast exami-
Concentric Circles of Empathetic Concern nations, lead levels, assessment, adminis-
tration of immunizations, and early
s with wider ju management of physical and mental
tion ris
niza di
ct health issues.
ga i
4. Tertiary prevention/primary care: Examples
d
ize indivi
r
on
n
O
rga du
s
o al include assessment, diagnosis, treatment,
nd s
a
n ity indiv and care management for chronic physical
an
mu
red
id
dg
m and mental health issues, as well as crisis
Structu
ua
o
roups
l and c
ls a
Nursing intervention and behavioral support.
Situation nd grou
hoo
First Circle
Sc
s
The first circle of the CNPM depicts a widening
circle of concern and support for the well-being
of persons and communities. This circle includes
persons and groups in each community who
share concern for the well-being of persons
served at the school-based wellness centers. This
FIG 25-1 ■ The Community Nursing Practice includes participants in inquiry groups, parents/
Model (CNPM): Concentric circles of empathic guardians, school faculty, noninstructional staff,
concern. (© Florida Atlantic University.) after-school groups, parent/teacher organiza-
tions, and school advisory councils and other
■ Inviting participation and listening to community-based groups. The services provided
stories of health and well-being within this circle might include the following:
■ Providing care that is essential for the 1. Consultation and collaboration: building
other relationships and community, answering
■ Supporting caring for self, family, and inquiries on matters of health and well-
community being, providing in-service and health edu-
■ Providing care that is culturally competent cation, serving on school and community
■ Collaborating with others for care committees and boards, reviewing policies
These services, provided to children and and procedures
2. Appraisal and evaluation: conducting com-
families from the community, occur in the fol-
lowing (and frequently overlapping) categories munity assessments, appraising care pro-
of care: vided, evaluating outcomes, and promoting
programs that enhance well-being for

1. Design and coordinate care: Examples in- individuals and communities
clude referrals, navigation to other health
services, home visits, and concepts of tran- Second Circle
sitional and enhancing care and are illumi- The second circle draws attention to the wider
nated here through the development of context of concern and influence for well-
collaborative relationships. being and includes structured and organized
2. Primary prevention and health education: groups whose members also share concern for
Examples include assessment of child- the education and well-being of the persons
development milestones, prenatal and served at the school-based wellness centers but
postnatal wellness, breast health, testicular within a wider range or jurisdiction such as a
health, and mental health services. district or county. Examples of these policy-
3. Secondary prevention/health screening/early making or advising groups include the school
intervention: Examples include screenings district and county public health department,
for hearing and vision, height/weight/body voluntary organizations such as the Red Cross,
mass index (BMI), cholesterol, blood funders, and legislators who influence and may
7991_Ch25_421-436 12/08/19 5:28 PM Page 427
offer support for school and community car- Connection of Core to Concentric
ing. The services provided in this circle include Circles
the following:
Connections of the core to the concentric
1. Consultation and collaboration: building re- circles of services illuminate the complexity of
lationships and community with members the practice within the CNPM. The core serv-
of these groups; contributing to policy ice of consultation and collaboration is a primary
appraisal, development, and evaluation; focus of practice, beginning with nursing and
leading and serving on teams and commit- social work colleagues and extending to partic-
tees responsible for overseeing the care of ipating clients, families, policymakers, funders,
students and families; providing school and elected officials and legislators. This value-
nurse education laden service has been essential to the viability
2. Research and evaluation: assessing school and sustainability of this CNPM. It promotes
health services, describing research findings the stance of humility that guides the respectful
for best practices related to school and question throughout the circles: “What matters
community health, and designing research most to you and how can we be helpful to you?”
projects focused on school/community The answer directs the creation of respectful,
health issues, and/or school/community individualized care and program development.
nursing practice Essential health-care services are created within
the core and extend into the first circle.
Third Circle Connections to the second circle unfold from
the collaborating relationships with colleagues
The third circle includes state, regional, na-
in the health department, school district, and
tional, and international organizations with
other groups taking the lead with school and
whom we are related in various ways. Serv-
community health. Committees of school-based
ices within this circle are focused on the
wellness center administrators and staff meet
following:
regularly to discuss school and community
1. Consultation and collaboration: building re- health issues and to seek consensus on possible
lationships and community with members, solutions. Health-care providers are consult-
including elected officials and legislators ants for medical questions and referrals, and
and collaborating about scholarship, policy, school nurse education may also be provided
outcomes, practice, research, educational for nurses to prepare them for community
needs of school nurses and advanced prac- nursing practice.
tice nurses; sustainability through ongoing Like the other circles, the third circle depicts
and additional funding the breadth of relationships developed at meet-
2. Appraisal and evaluation: school nursing ings and through publications and presentations
and advanced practice faculty organizations at local, regional, national, and international
offer a milieu for discussion and appraisal conferences. Administration and faculty have
of the services provided at the school-based been widely recognized for the contribution
wellness centers. Organizations in this cir- made to the health and well-being of children
cle may include national and international and families.
organizations such as universities, religious
organizations, the Centers for Disease
Control and Prevention, Department of Applications of the Model
Health and Human Services, Ministry of The CNPM has been used as the framework
Health, World Health Organization, na- for research, education, and practice across dis-
tional professional organizations and ciplines and with diverse foci. Some examples
boards, licensing agencies, and various include the study of nursing language in elec-
nongovernmental organizations (NGOs), tronic records; a framework for curriculum de-
such as Partners in Health and Doctors velopment for a master’s program in advanced
Without Borders. community nursing at Naresuan University,
7991_Ch25_421-436 12/08/19 5:28 PM Page 428
Phitsanulok, Thailand; and the use of the improve health care to patients. Additional
CNPM by faculty of nursing at Mbarara Uni- research using caring theory and nursing
versity of Science and Technology, Mbarara, language based on the community caring prac-
Uganda (Barry, Gordon, & Lange, 2007). tice within the CNPM is used as a framework
Additional initiatives using the CNPM have for patient human–robot interaction (Huang,
been used to develop the study of advanced Tanioka, Locsin, Parker, & Masory, 2011).
community nursing practice and to design and Acevado (2016) conducted a quality im-
operate the first school-based community nurs- provement program titled The Implementation
ing wellness center in Uganda, and a school- and Evaluation of the “Let’s Go!” Program (Let’s
based wellness center in Bondeau, Haiti (Barry, Go! 2012) using the 5-2-1-0 Toolkit with the
King, Goodman, Gullett, & Grumme, 2016; children enrolled in an endocrine clinic. She
Barry, King, Gullett, & Goodman, 2015). chose the CNPM (Parker, Barry, & King,
2015) as the framework for this program
Application in Research focused on childhood obesity prevention by
The CNPM guides a diverse, complex, and increasing healthy eating and physical activity
transdisciplinary practice of nursing and social and decreasing screen time. Acevedo used the
work in school-based and or community CNPM as a guide to reinforce a value-based
health/wellness centers serving children and system that emphasized valuing caring for the
families from diverse multicultural communi- whole person, a fundamental part of the suc-
ties. The collaborative approach of the CNPM cess of her project. The values that form the
fosters relationships and acceptance by local CNPM are respect for person, persons are car-
communities and providers as essential compo- ing, and caring is understood as the essence of
nents to the health-care system. The CNPM nursing; and persons are whole and always
was featured in a major community nursing text connected with one another in families and
(Clark, 2003) and a school nursing practice communities. Weight loss and lifestyle modi-
textbook (Barry & Gordon, 2006). fication are sensitive topics in any age group
The CNPM has been the guiding frame- and must be managed with respect, caring, and
work for a wide range of theses, dissertations, understanding of the unique cultural values
and Doctor of Nursing Practice (DNP) proj- placed on health, food, physical activity, and
ects, and in software development. In the field care of children. Listening to the participants
of computer science engineering, the CNPM and providing coaching support were key ele-
has been used to give voice to nursing through ments for success of the project. The call for
the development of a web-based classification nursing in this project includes caring and nur-
system, which quantifies the qualitative lan- turing the wholeness while acknowledging the
guage of nursing, specifically the concepts of participant’s decision and empowering his or
caring, knowing, connection, and respect. The her choices. The partnerships in the three con-
researchers analyzed nursing situations based centric circles of the CNPM were illuminated
on the CNPM to develop an electronic record in collaboration with the participants, their
that quantified the transcendent values of the parents/guardians, the agency nurses, commu-
CNPM (Chinchanikar, 2009; Dass, 2011; nity resources, and a state agency focused on
Parker, Pandya, Hsu, Noel, & Newlin, 2008; children’s health. A collaborative plan was
Tripathi, 2010). The U.S. Patent and Trade- formulated, and the 5-2-1-0 provider toolkit
mark Office issued patent number 8,799,017 (Let’s Go, 2015) was successfully implemented.
to Parker, Pandya, Hsu, and Huang (2014) for Shutes (2017) used the CNPM as a frame-
their invention titled “Apparatus and Method work to conduct an evaluation of the Self
for Managing Interaction-Based Services.” Health Advocacy Program (screening, educa-
The invention is a new software system that tion, linkage, and follow-up) for a population
manages patient health information gained of persons experiencing homelessness in the
from nurses’ perspectives—such as conversa- southeastern United States. The evaluation
tions, observations, and diagnoses—to better centered on the program outcomes focused on
7991_Ch25_421-436 12/08/19 5:28 PM Page 429
meeting the objective to educate and link per- techniques and ability to see the wholeness of
sons experiencing being homeless to outside self and other persons (King, Barry, Bamdas,
health-care organizations. The nurse practicing Bronner, & Edwards, 2017).
within the CNPM is in the center with the
person experiencing homelessness. From that Applications in Practice
place of respect and a stance of humility, The transcendent values of respect and caring
Shutes examined what could be known about provide the underpinnings of the inquiry
the participants and the whole situation to group method used by the CNPM to identify
evaluate services and outcomes of referrals to health concerns and community strengths
additional services. and assets. Several studies have identified the
Nongnut and colleagues (2018) used the usefulness of the inquiry group method as a
CNPM to guide a research study focused on valuable tool not only to gather perspectives
preventing hyperglycemic crises in persons with from community residents and partners as a
diabetes mellitus in Thailand. The researchers, way to understand and identify health needs
guided by the value of respect, gathered data and services but also to resolve problems
from multiple stakeholders, including patients, (Clark, 2003; Kasle, Wilhelm, & Reed, 2002;
family members, nurses, nurse practitioners, Plonczynski et al., 2007). This method has
physicians, and nutritionists. The results in- also been linked to increasing the likelihood
cluded the development and implementation of of acceptance of change by communities
a prevention program based on the CNPM. (Campbell et al., 2001). The value of includ-
Further results revealed this innovative CNPM ing community partners and stakeholders in
of care reduced the instances of hyperglycemic decision making was supported by the re-
crises for the participants in the study. search done by Dyess and Chase (2012) while
studying the role of faith-based community
Application in Education nursing practice.
The essential values that are the foundation of The actualizing values of access, essentiality,
the CNPM of respect, caring, and wholeness community participation, empowerment, and
of person are consistent with the model of intersectoral collaboration guide nursing prac-
nursing education at the Christine E. Lynn tice in the CNPM. An example of these values
College of Nursing. The caring concepts of in action can be found in the study by Barry
Roach (2002) and Mayeroff (1971) are incor- and colleagues (2011). The authors used the
porated in all undergraduate and graduate CNPM as the framework to develop a breast
courses and used to evaluate student’s clinical health promotion outreach for underserved
performance. Students learn nursing through women. The inquiry group method provided a
nursing situations (Barry, Gordon, & King, way to establish the participant as the expert
2015), focusing on “seeing” the person in his of her own care with dialogue and inclusive-
or her wholeness as part of a family and the ness grounded in the values of respect, caring,
local and global community. Using Carper’s and wholeness of persons. The value of com-
(1978) framework allows students to develop munity to enhance the care of the vulnerable
their nursing practice guided by the values of populations is highlighted in the research of
access, essentiality, community participation, Wallin, Barry, and Gordon (2016). This qual-
empowerment, and intersectoral collaboration. itative, descriptive study explored the mosquito
Another example of using the CNPM’s val- net usage and perceived barriers to sleeping
ues in nursing education is the incorporation under a net for underserved and vulnerable
of HeartMath®, a stress reduction and emo- participants living with Hansen’s disease (lep-
tional regulation technique, with all nursing rosy) in a remote area of Uganda. The partici-
students. Teaching HeartMath® at the time pants experienced stigmatization within their
students are admitted, and embedding the society due to having this condition and other
technique in classes and clinical practice, related stigmatizing health issues. Using com-
has developed the student’s use of self-care munity guides to provide access to these
7991_Ch25_421-436 12/08/19 5:28 PM Page 430
remote communities, the researcher was able this community starts with understanding cul-
to learn more about why mosquito nets may not turally sensitive barriers to integration as un-
be used, and the participants shared with the re- derstood by the persons living the experience.
searcher how their stigmatized health condi- Tables 25-1 and 25-2 highlight the tran-
tions drew them together as a community. scendent and actualizing values of the CNPM
Developing effective prevention strategies in and research using the CNPM.
Table 25-1 Illumination of the Transcendent and Actualizing Values of the Community Nursing
Practice CNPM
Value Category Description References

Transcendent Values: Present in All Nursing Situations
Respect Refers to honoring the inherent Barry & Gordon (2005); Barry, Gordon, &
dignity and uniqueness of each Lange (2007); Barry, Lange, & King (2011);
individual Chinchanikar (2009); Dass (2011); Nongnut et al.
(2018); Shutes (2017); Tripathi (2010); Wallin,
Barry, & Gordon (2016)
Caring Understand that to be human is Barry & Gordon (2005); Barry, Gordon, &
to be caring and also that caring Lange (2007); Barry, Lange, & King (2011);
is the essence of nursing Chinchanikar (2009); Dass (2011); Huang et al.
(2011); King & Barry (2017); Parker et al.
(2008); Parker & Newlin (2008); Shutes (2017);
Tripathi (2010)
Wholeness Views persons as whole in the Barry & Gordon (2005); Barry, Gordon, & Lange
moment and always connected (2007); Barry, Lange, & King (2011); Barry, Nam-
with others in families and bozi, King, & Turkel (2015); Chinchanikar (2009);
communities Dass (2011); Danyuthasilpe, Barry, & Locsin
(2015); Nongnut et al. (2018); Tripathi (2010)
Actualizing Values: Guide Practice in Specific Nursing Situations
Access Views as ongoing and constant Barry, Blum, Eggenberger, Palmer-Hickman, &
availability of health care that is Mosley (2010); Barry, Gordon, & Lange (2007);
competent, culturally acceptable, King & Barry (2017); Parker & Newlin (2008);
respectful, and cost-effective Sternberg (2009); Larson, Sandelowski, & Mc-
Quiston (2012); Wallin, Barry, & Gordon (2016)
Essentiality Described from the client’s Barry et al. (2010); Barry, Blum, & Purnell
view as what is necessary for (2007); Barry et al. (2011)
well-being
Community Described as the active engage- Barry et al. (2011); Barry, Lange, & King (2011);
participation ment with members of a commu- Parker, Locsin, & Longo (2006); Plonczynski et al.
nity fostered by openness to (2007); Wallin Barry, & Gordon (2016)
listen to calls for nursing and to
create nursing responses
Empowerment Understood as the client’s Barry, Gordon, & Lange (2007); Barry, Lange, &
awareness of making individual King (2011); Wallin, Barry, & Gordon (2016)
choices that influence health
and well-being
Intersectoral Refers to the openness to Acevedo (2016); Barry, Gordon, & Lange (2007);
collaboration seek and honor the expertise of Barry, Lange, & King (2011); Hill (2018); Pope
providers and agencies to potenti- (2011); Wallin, Barry, & Gordon (2016)
ate the outcomes of services
essential to well-being
7991_Ch25_421-436 12/08/19 5:28 PM Page 431
Table 25-2 Overview of Publications
Application to Research
Authors Application of CNPM Study Design/Focus/Hypothesis
Parker & Newlin (2008, Framework for study Qualitative research that facilitated
qualitative study) development of nursing language for
use in electronic health records
Chinchanikar (2009, Framework for study Document indexing framework for
master’s thesis/ automating classification of nursing
engineering) knowledge and language
Tripathi (2010, master’s Framework for study Development of a knowledge- based
thesis/engineering) decision-making and analyzing system
for nurses to capture and manage the
nursing practice
Dass (2011, master’s Framework for study Development of a nursing knowledge
thesis/engineering) management system
Huang, Tanioka, Locsin, Framework for study Development of a patient human–robot
Parker, & Masory (2011) interaction
Sternberg (2009, Part of the framework for study Qualitative research that explored the
doctoral dissertation/ experiences of Latinas living transna-
nursing) tional motherhood
Conrad (2010, doctoral Identified as faculty practice Evidence-based project that compared
dissertation) CNPM faculty practice CNPMs through com-
prehensive literature review of evi-
dence- based documents
Pope (2011, doctoral Drew grounding concepts from Social history research study that ex-
dissertation) the CNPM of interconnectedness plored the eugenic policies of the Pro-
to facilitate partnerships and en- gressive Era and the Social Security
hancement of relationships Act of 1935, specifically maternal and
child health services as it relates to
nursing
Barry, King, Gullett, & Framework for study Inquiry group method used that pro-
Goodman (2015) vided groundwork for further study
Wallin, Barry, & Gordon Framework for pilot research Qualitative pilot study that explored
(2016) study the barriers to using mosquito nets
in Africa with persons living with
Hanson’s disease (leprosy)

Danyuthasilpe, Barry, & Framework for study Phenomenological study that used
Locsin (2015) CNPM for development of teaching/
learning community practice
Application to Education
Barry, Blum, Eggenberger, Used transcendent values of re- Development of simulated community
Palmer-Hickman, & spect, caring, and wholeness of nursing situations with a high-fidelity
Mosley (2009) person in community nursing sit- simulator to guide students in under-
uation applied to a simulation standing the full experience of being
homeless to enable students to re-
spond holistically to the needs of the
homeless
Barry, Blum, & Purnell Used CNPM to help students Immersion experience with victims of
(2007) understand the lived experience Hurricane Katrina
of those affected by Hurricane
Katrina
Continued
7991_Ch25_421-436 12/08/19 5:28 PM Page 432
Table 25-2 Overview of Publications—cont’d

Parker, Locsin, & Longo Framework for development Development of first school health
(2006) school health program program in Uganda based on CNPM
Nongnut, Barry, Gordon, Framework for development of Used CNPM to develop Hyperglycemic
Pipatsart, & Sirigulsatien community nursing practice Crisis Prevention CNPM in community
(2018) practice in Thailand
Application to Practice
Barry & Gordon (2005) Framework for study Described use of CNPM in school nurs-
ing and settings
Barry, Lange, & Framework for study Qualitative descriptive study that devel-
King (2011) oped a community outreach program
for breast health promotion for under-
served women
Parker, Locsin, & Framework for development of Discussed development of social and
Logo (2006) social and health policy health policy based on CNPM
Parker, Pandya, Hsu, Framework for collaborative Used the CNPM concepts to illuminate
Noell, & Newlin (2008) project with computer science nursing’s voice in an electronic record
engineers
Plonczynski et al. Identified use of inquiry group Discussed use of inquiry group method
(2007) method and correlated to to be used by groups to define and
participatory action resolve problems
Gordon, Barry, Dunne, Framework for study Described the process of bringing com-
& King (2011) munity partners in a school health pro-
gram together to clarify a vision of
health literacy
Barry, Nambozi, King, Further research based on origi- Built on CNPM to include Ubuntu
& Turkel (2015) nal dissertation philosophy
Danyuthasilpe, Barry, Framework for development of Used CNPM to understand the lived ex-
& Locsin (2015) community practice perience of persons living with chronic
obstructive pulmonary disease
Acevedo (2016) Framework for development of Used CNPM concepts for program eval-
community practice uation of community endocrine clinic
Shutes (2017) Framework for Doctor of Nursing Used CNPM concepts to develop
Practice (DNP) project CNPM of care with vulnerable
populations
Hill (2018) Framework for DNP project Used CNPM in school setting for advo-
cacy, teaching, and practice
Practice Exemplar
Written by April Haukoos, MSN, CPNP-BC, PMHS-BC of what I have to offer. My practice now fo-
My practice mind-set has expanded after cuses on what others (the patient, the family,
learning what caring truly means through the other) have to offer in knowledge and ex-
studying Mayeroff and the Community Nurs- perience; their knowledge of themselves, their
ing Practice Model (CNPM). I can no longer children, their diagnoses, their fears and con-
approach advanced practice from a mind-set cerns, their experiences with treatment plans
7991_Ch25_421-436 12/08/19 5:28 PM Page 433

and medical providers. All of this plays a role accident (CVA) in utero, resulting in mild
in who they are. Viewing others as those who gross motor weakness on his right side that im-
not only need to be cared for, but are also car- proved and resolved with physical therapy.
ing for themselves as well, changes my out- Dawn then revealed how Billy had another
look. It allows me to enter into a mutual stroke while having surgery to repair his hy-
relationship rather than a hierarchical one pospadias. A neurologist diagnosed Billy with
with families. While I believe I have always autism; however, Dawn believed this diagnosis
understood this concept at some level and at- to be false.
tempted to apply it to my practice, it was not At this point, Dawn became tearful and
until I studied Mayeroff and the CNPM that distressed. I asked her to list her greatest fears
I truly understood these concepts of caring for Billy. Dawn told me she was afraid “that
and community, which have now solidified kids will make fun of him because they will
and ultimately changed my practice. think he’s retarded. I want him to be normal
Dawn is 19 years old and the mother of a and for everyone to make him normal again.”
28-month-old son named Billy. Dawn sched- A plan was developed that focused on ac-
uled a house call with me because she was knowledging and addressing Dawn’s fears and
concerned about Billy having repeated ear in- redirecting her fears toward a desire to act and
fections. An otolaryngologist (ENT) recom- advocate for Billy. Together, a schedule was
mended the placement of tympanostomy created with Dawn where we would meet
tubes (PE tubes). During the visit with Dawn, three times per week at her home for 10 to
I became concerned because Billy demon- 15 minutes each time. We agreed that I would
strated significant developmental delays. Billy stop by after lunch once I had finished with
was largely nonverbal with the exception of a my morning house calls. These visits would
few verbal gestures (grunting, referring to all not be in my official capacity as Billy’s pedi-
objects as “muh,” and making a high-pitched atric nurse practitioner, but instead as a fellow
squeal as a way to express happiness). Dawn mom in the community and a mom who had
informed me that Billy did not speak because used Birth to Three services for one of my own
he was “an introvert,” but he followed instruc- children.
tions and talked to her when no one was I began meeting with Dawn the following
around. From my observation of Billy, he was week. We discussed her “worst fear” that Billy
not pointing or using physical gesturing, he would not be “normal,” and how Birth to
did not make eye contact with me or his Three services are designed to help Billy catch
mother, and I observed him opening and clos- up and get closer to his target developmental
ing doors as a form of play. milestones before kindergarten. As our visits

I suggested a referral to Birth to Three: progressed, it became apparent that another
North Beaches District (a state program that barrier for Dawn accepting the services of the
provides early intervention services to infants Birth to Three program was the fact that she
and toddlers with disabilities, from birth up to would need to face the possibility that some-
age 3 years, and their families) for a develop- thing was genuinely wrong and that Billy
mental evaluation and therapy services. Dawn would have a diagnosis she was hoping to
declined. I suggested a referral for Billy to re- avoid. Our visits continued for 4 weeks. Each
turn to the ENT specialist. Dawn declined time gave Dawn an opportunity to be honest
again, stating Billy “just needs more time.” In about her fears and allowed me to point out
discussing the need for Billy to be evaluated, how getting services for Billy was actually a
Dawn stated, “I just want him to be normal. path of possibility to keeping her worst fears
He won’t be normal if he goes where kids aren’t from coming to fruition. Dawn was also pro-
normal.” Dawn then began to reveal more of vided a copy of From Emotions to Advocacy by
Billy’s history. Billy had a small cerebrovascular Pete and Pam Wright (2002), and we discussed
(continued)
7991_Ch25_421-436 12/08/19 5:28 PM Page 434

again moving her toward a role in which she and (3) persons are whole and always connected
could be a voice for Billy. with one another in families and communities
On the fifth week of our visits, Dawn (Parker, Barry, & King, 2015, p. 436).
greeted me by stating she wanted to contact Dawn was respected as she was allowed to
Birth to Three services, and I sat with her as progress in gaining trust of me and others at
she made the phone call and went through the her own pace. Dawn was recognized as a
intake procedures. During this time, the pos- mother who deeply cared for her son, not as a
sibility of Billy needing PE tubes continued to mother withholding care. Finally, Dawn was
be discussed, but Dawn was too fearful to con- viewed not only as Billy’s mother, but as part
sider the possibility, and a “wall” came up each of a community of mothers. Barry and Gor-
time there was an attempt to discuss it. don (2005) point out that part of the CNPM
However, as Billy began to receive Birth to is respecting persons. This comes from a place
Three services, his speech therapist reiterated of unknowing, which requires a level of hu-
the possibility that recurrent ear infections mility. The person is the one who determines
could interfere with hearing and speech devel- what is needed for her or his own well-being
opment. Dawn then called and requested a and the one who determines her or his prior-
referral to return to the ENT specialist. ities (Barry & Gordon, 2005). This captures
In approaching Dawn, I had to be willing the time spent with Dawn in that the nurse
to see her and her parenting style as distinct being aware of her level of unknowing opened
from my own and to do so without judgment. the path for the trust building.
She did not approach her child’s delays in the Barry, Gordon, and Lange (2007) describe
same manner that others did, but it was im- the role of nursing in the CNPM as “nurtur-
perative for me to trust that she would get to ing the wholeness of persons and environ-
the place of doing what her son needed if ments through caring” (p. 175), and Barry,
supported, informed, and able to believe that Lange, and King (2011) describe caring as the
obtaining services for Billy was a path leading “shared lived experience of caring between the
to hope rather than hopelessness. nurse and the one nursed.” It was the use of
shared experience that helped me to reach
The Theoretical Perspective Dawn and build a trusting relationship. Dawn
The Community Nursing Practice Model learned to advocate for Billy as she became ex-
(CNPM) by Parker and Barry is the theory perienced and gained a greater understanding
most congruent with this nursing situation. The of his developmental needs. All of these fac-
CNPM is built on three premises: (1) persons tors come together to support the use of
are to be respected; (2) persons are caring and CNPM as the appropriate theoretical basis for
caring is understood as the essence of nursing; caring for both Dawn and Billy.
Summary
The fundamental beliefs and commitment to relationships with colleagues, clients, and com-
the discipline and unique practice of nursing munity members. Through use of this CNPM,
provided for both creating and sustaining the the ideals of the discipline are brought into the
CNPM. This CNPM provides the environ- reality of care for wholeness and well-being of
ment in which nursing and social work are prac- persons and families in multicultural commu-
ticed from the core beliefs of respect, caring, and nities. The use of the CNPM contributes to
wholeness. Nurses and social workers are en- the Sustainable Development Agenda and the
couraged to reach out through the concentric Sustainable Development Goals to ensure
circles, strengthening and widening the web of healthy lives and promote well-being for all ages.
7991_Ch25_421-436 12/08/19 5:28 PM Page 435
Questions for Reflection ■ How is each circle within the CNPM

connected to the other?
and Discussion ■ Why is the nursing situation situated at
■ How are the definitions of nursing, per- the center of the CNPM model as shown
son, and environment described within in Figure 25-1?
the CNPM? How does this fit with the
metaparadigm of nursing?
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7991_Ch26_437-448 12/08/19 5:28 PM Page 437
Rozzano Locsin’s
CHAPTER
26
Technological Competency
as Caring in Nursing
Knowing as Process and
Technological Knowing as Practice
Rozzano C. Locsin Introducing the Theorist

Rozzano C. Locsin is Professor Emeritus
of Nursing at Florida Atlantic University’s
Christine E. Lynn College of Nursing, and in-
augural International Nursing Professor at the
Institute of Biomedical Sciences, Tokushima
Practice Exemplar written by Hirokazu Ito
University, in Tokushima, Japan. His program
Summary
of research focuses on life transitions in the
health–illness experience. He holds baccalau-
reate and master’s degrees in nursing from
Silliman University in the Philippines and a
Doctor of Philosophy in Nursing degree from
the University of the Philippines. Dr. Locsin
was a Fulbright Scholar in Uganda in 2000, a
recipient of the 2004 to 2006 Fulbright
Alumni Initiative Award to Uganda, and
the Fulbright Senior Specialist in Global and
Public Health and International Development
Award. He was inducted as a Fellow of the
American Academy of Nursing in 2006 and re-
ceived the prestigious Edith Moore Copeland
Excellence in Creativity Award from Sigma
Theta Tau International Honor Society of Nurs-
ing and two lifetime achievement awards from
premier schools of nursing in the Philippines. In
addition, Locsin received the first University

Researcher of the Year Award in 2006 in the
Scholarly/Creative Works category as Profes-
sor at Florida Atlantic University. Published
in 2001, his edited book Advancing Technology,
Caring, and Nursing introduced the germinal
work of relating technology with caring in
nursing. His middle-range nursing theory,
Technological Competency as Caring in Nursing:
A Model for Practice, was published by Sigma
Theta Tau International Press in 2005 and
translated into Japanese. It is now in its third
printing. In 2007, his coedited book, Technol-
ogy and Nursing: Practice, Process and Issues,
illustrated the critical nature of technology in
437
7991_Ch26_437-448 12/08/19 5:28 PM Page 438
nursing practice. A fourth book, A Contempo- a framework of nursing that guides its practice,
rary Process of Nursing: The (Unbearable) Weight grounded in the theoretical construct of techno-
of Knowing in Nursing, was published in 2009. logical competency as caring in nursing (Locsin,
This book provides essential chapters defining 2005), this model of practice illuminates the
and describing the concept of “knowing per- harmonious relationship between technological
sons.” In 2017, he coedited the quintessential competency and caring in nursing. In this the-
book Nursing Robots: Robotic Technology and oretical model, the emphasis of nursing is on
Human Caring for the Elderly, and in 2018, the knowing the person as caring, a human being
book on the evolution of the theory was whose hopes, dreams, and aspirations are
published, The Evolution of the Theory of focused on living life more meaningfully as a
Technological Competency as Caring in Nursing. caring person (Boykin & Schoenhofer, 2001).
Dr. Locsin’s interest in global nursing and As a model of practice, technological compe-
human care initiatives enhances his apprecia- tency as caring in nursing (Locsin, 2005) is as
tion of the dynamic nature of persons and of valuable today as it has been in the past and will
nursing as the practice of continuously know- continue to be in the future. Technological ad-
ing persons through emerging technologies vances in health care demand expertise with
within a caring framework. technology. Often, such expertise is perceived
as the antithesis of caring, particularly in situa-
tions in which the focus of attention is on the
Overview of the Theory technology rather than on the person. Nonethe-
There is a great demand for a practice of nursing less, it is the premise of this chapter that being
based on an authentic intention to know human technologically competent is being caring.
beings fully as persons and as participants in Technological competency as caring in nursing
their care rather than as objects of our care. is a middle-range theory illustrated in the prac-
Nurses want to use creative, imaginative, and tice of nursing and grounded in the harmo-
innovative ways of affirming, appreciating, and nious coexistence between technology and
celebrating humans as whole persons. In pres- caring in nursing. The assumptions of the the-
ent-day health and human care, advancing ory are informed by Boykin and Schoenhofer’s
technologies claim a stronghold. Often the best (2001) work and include the following:
way to realize intended nursing care outcomes ■ Persons are caring by virtue of their
is the excellent and competent use of nursing
humanness.
technologies (Locsin, 1998). Frequently per-
■ Persons are whole or complete in the
ceived as the practice of using machines in nurs-
moment.
ing (Locsin, 1995), technological competency
■ Knowing persons is a process of nursing
as caring in nursing is the process of knowing
that allows for continuous appreciation of

persons as whole (Locsin, 2001), while fre-
persons moment to moment.
quently engaging technological advancements.
■ Technology is used to know persons as
Contemporary definitions of technology in-
persons moment to moment.
clude (1) a means to an end, (2) an instrument,
■ Nursing is a discipline and a professional
(3) a tool, or (4) a human activity that increases
practice.
or enhances efficiency (Heidegger, 1977). Con-
ceptualizing caring and technology within nurs- The ultimate purpose of technological com-
ing practice is challenging. However, viewing petency in nursing is to acknowledge that the
them in harmonious coexistence is crucial so that person is the focus of nursing and that various
mutual caring occurs, fostering the understand- technologies can and should be used in the
ing of technological competency as an expression service of knowing the person. This acknowl-
of caring in nursing (Locsin, 2005). edgment of persons brings together the rela-
The purpose of this chapter is to explain tively abstract concept of wholeness-of-person
“knowing persons as caring” through techno- with the more concrete concept of technology.
logical competency as a process of nursing. As Such acknowledgment compels the redesigning
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CHAPTER 26 ■ Rozzano Locsin’s Technological Competency as Caring in Nursing 439
of nursing processes—ways of expressing, cel- Inherent in humans as unpredictable, dy-

ebrating, and appreciating the practice of nurs- namic, and living beings is the regard for self-
ing as continuously knowing persons as caring as-person. This appreciation is like the human
and whole moment to moment. concern for security, safety, self-esteem, and self-
In this practice of nursing, technology is actualization popularized by Maslow (1943) in
used not to know the person as object to be his quintessential theoretical model on the hier-
controlled and manipulated but rather to know archy of needs. More important, however, is the
who the person is as an experiencing subject in understanding that being human is being a per-
her or his wholeness. Appropriately, knowing son, regardless of biophysical parts or technolog-
person as object alludes to an expectation of ical enhancements.
knowing empirical aspects and facts about the Because the future may require relative ap-
composite person, whereas knowing person as preciation of persons, if the ultimate criterion
subject requires the understanding of an un- of being human today is being wholly natural,
predictable, irreducible person who is more organic, and functional, then being human may
than and different from the sum of his or her not be so easy to determine or appreciate. The
empirical parts. In this way, technology is used purely natural human being may be rare. The
to understand the uniqueness and individuality understanding that technology-supported life
of persons as humans who continuously unfold is artificial, and therefore is not natural, stimu-
and who, therefore, require continuous know- lates discussions among practitioners of nursing
ing (Locsin, 2005). (Locsin & Campling, 2005), particularly when
the subject of concern is technology-dependent
Persons as Persons, Whole and care and technological competency as an ex-
Complete in the Moment pression of caring in nursing. Hudson (1988)
One of the earlier definitions of the word person suggests that
appeared in Hudson’s 1988 publication claim-
ing that the “emphasis on inclusive rather than false comfort may be offered whenever it is implied
sexist language has brought into prominence that this life and this body are significantly less im-
the use of the word ‘person’” (p. 12). The origin portant than the “spiritual body” and the “next
of the word person is from the Greek word life” … the time has come to enhance an aware-
prosopon, which means the actor’s mask of ness of the post human or spiritual future. (p. 13)
Greek tragedy; of Roman origin, persona
What structural requirements will the next-
indicated the role played by the individual in
generation human possess? Today, some hu-
social or legal relationships. Hudson (1988)
mans have anatomic and/or physiological
also declares that “an individual in isolation is
components that are already electronic and/or
contrary to an understanding of ‘person’”
mechanical, such as mechanical cardiac valves,

(p. 15). A necessary appreciation of persons re-
self-injecting insulin pumps, cardiac pacemak-
quires the view that humans are whole or com-
ers, or artificial limbs, all appearing as excellent
plete in the moment. As such, there is no need
facsimiles of the real. Yet the idea of a “whole
to fix them or to make them complete again
person” and being natural continues to per-
(Boykin & Schoenhofer, 2001). There is noth-
sist as a requirement of what a human being
ing missing that requires nurses’ intervening to
should be.
make persons “whole or complete” again, or
for nurses to assist in this completion. Persons
are complete in the moment. Their varying sit- How Are Persons Known?
uations of care call for creativity, innovation, Often, questioning in order to know the per-
and imagination from nurses so that they son is limited to inquiry about his or her body
may come to know the nursed as a “whole” parts. For example, “How are your knees?” in-
person. The uniqueness of the person emerges stead of “How are you doing with your knees?”
in the response to being called forth in partic- Of what purpose is the question? Is it to know
ular situations. the person or to know the condition of the
7991_Ch26_437-448 12/08/19 5:28 PM Page 440
specific component part? Perhaps inadver- In an episode of the television series The
tently, unconsciously, or both, one inquires Twilight Zone, a woman perceived herself as
about the body part because of a culturally so hideous that she thought she was unwor-
founded reason or because the customary focus thy to be seen; she had to hide her face
on another’s bodily features defines that person. behind a veil. She was shunned by her family.
How are persons known as human beings? It was an unbearable life for her and for her
Historically, humans were depicted through family as well. In the end, the moral of
drawings and paintings. Colorful artworks rep- the story focused on the adage “beauty is in
resented the human being in imaginative ways the eye of the beholder” (Serling, 1960). The
as conceptualized by painters and illustrators. people who shunned the woman had faces
Artists and their works became commodities, like those of pigs, while she had more
and Leonardo da Vinci may top this list as, “human-like” features. In fact, she was a
perhaps, the most prized of illustrators and beautiful human woman whom everyone
painters. Studying the human being as an found to be ugly, embarrassing, pitiful, and
object allowed Leonardo to illustrate the com- a misfit, advised to move to a distant colony
posite of the human being through dissected with a small population of people like her.
remains. Illustrations such as these may have This particular story addresses the impact of
influenced Michelangelo in his creation of prejudice in considering what a person ought
masterful artworks such as David and Moses. to be. In essence, it marginalizes those who
The clarity, definition, and fidelity of these are not like others and in doing so prevents
representations reveal the utmost appreciation the understanding of nursing as the process
of the human being. Yet the question remains: of knowing persons as whole and complete
Does the human being become a person, or is in the moment.
he always a person? Is the composition of the In an Associated Press news article, “The An-
human being the ultimate descriptor, charac- drogynous Pharaoh? Akhenaten Had Feminine
teristic, and quality of a whole and complete Physique” (USA Today, May 2, 2008), writer
person? What happens when the human being Alex Dominguez presented Dr. Irwin Braver-
has no limbs, or has limbs that are not func- man’s findings on the controversial “feminine”
tional? Is this human being a person? features of the pharaoh Akhenaten. Dominguez
Consider the case of a baby born without wrote, “Akhenaten wasn’t the most manly
limbs but otherwise alive and well. When the pharaoh, even though he fathered at least a half-
baby became ill, he was rushed to a hospital. dozen children. In fact, his form was quite fem-
To the chagrin of the nurses and physicians, inine, which has puzzled experts for years. And
they were at first unable to care for the baby. he was a bit of an egghead.” The pharaoh had
Their main question was “How can we initiate “an androgynous appearance. He had a female
IVs when there are no extremities?” They may physique with wide hips and breasts, but he was
also have wondered, “On growing up, will this male and he was fertile and he had six daugh-
baby be concerned about what it is like to have ters,” Braverman is quoted as saying. “But
no limbs, or will he wish he had limbs so he nevertheless, he looked like he had a female
could ‘go’ places like others?” (Barnard & physique.” Apparently, what constitutes “know-
Locsin, 2007, p. 17). ing” whether a human being is a man or a
Consider also the “Girl with Eight Limbs” woman is the physical appearance. This makes
(PBS) from a province in India, who was Braverman’s study of the Pharaoh Akhenaten
subjected to intense surgical intervention to re- most meaningful.
move the other “nonfunctional” limbs that An example of person as object, known
were putting her life in a precarious situation. as a composite of physical elements, is the
What does this girl think now? “Am I com- legendary Frankenstein monster, an entity
plete or incomplete? Am I normal or abnor- assembled from various human parts. The
mal, just because I am like everyone else—with monster was created and made human in the
two upper limbs and two lower limbs?” (PBS). sense of being a composite of parts but also
7991_Ch26_437-448 12/08/19 5:28 PM Page 441
in the sense of his essence of being energy The nurse’s responsibility is immeasurable
(electricity). in creating conditions that demand technolog-
ical competency and care. In creating a nursing
The Process of Knowing Persons situation of care, there is a requisite compe-
Persons possess the prerogative and the choice tency to know persons fully, to understand,
of whether to allow nurses to know them fully. and to appreciate the important nuances of the
Entering the world of the other is a critical person’s dreams and desires.
requisite to knowing as a process of nursing. There are many ways of interpreting the con-
Establishing rapport, trust, confidence, com- cept of “person as whole.” We will look at three
mitment, and the compassion to know interpretations that shape the popular under-
others fully as persons is integral to this crucial standing of the concept. One of these interpre-
positioning. tations is the mind–body dualism ascribed to
Wholeness is the idealized condition or sit- Descartes, which describes the connection be-
uation of the one who is nursed. This idealiza- tween mind and body. In nursing, the mind–
tion is held within the nurse’s understanding body–spirit connection is popularized by Jean
of persons as complete human beings “in the Watson (1985) in her theory of transpersonal
moment.” Expressions of this completeness caring. Another version of the mind–body
vary from moment to moment. These expres- connection, the simultaneity paradigm (Parse,
sions are human illustrations of living and 1998), categorizes the human–environment
growing. Using technology alone and focusing mutual connection as the relationship that best
on the received technological data rather than serves the nursing perspective and grounds
on continually “knowing” the other fully as theoretical frameworks and models of practice,
person can lead to the nurse thinking of the including many of those in caring science. These
person as an object who needs to be completed contemporary and popular elucidations regard
and made whole again. Paradoxically, because humans as the focus of nursing and knowing
of the idea that humans are unpredictable, it is persons in their wholeness as the practice
not entirely possible for the nurse to fully know of nursing.
another human being—except in the moment Knowing persons as the process of nursing is
and only if the person allows the nurse to know a dynamic encounter between the nurse and
him or her by entering the other’s world. nursed in which nursing situations unfold to-
In this perspective, the condition in which ward an encompassing practice of knowledge-
the nurse and the other allow knowing each based nursing. The meaning of the process is
other exists as the nursing situation, the shared characterized by knowing, being with, doing for,
lived experience between the nurse and nursed enabling, and maintaining belief as described by
(Boykin & Schoenhofer, 2001). Swanson (1991). The following descriptions ex-
In this relationship, trust is established that emplify the process of knowing persons as nurs-
the nurse will know the other fully as person; ing practice within the theory of Technological
the trust that the nurse will not judge the per- Competency as Caring in Nursing (Locsin,
son or categorize the person as just another 2016a, 2016b, 2017):
human being or experience but rather as a
unique person who has hopes and aspirations ■ Technological Knowing: The process of
that are singularly his or her own. knowing a person is guided by technologi-
It is the nurse’s responsibility to know the cal knowing in which persons are appreci-
person’s hopes and aspirations. Technological ated as participants in their care rather
competency as caring allows for this understand- than as objects of care. The nurse enters
ing. In doing so, the nurse also sanctions the the world of the other. In this process,
other (the nursed) to know him or her as person. technology is used to magnify the aspect
The expectation is that the nurse is to use mul- of the person that requires revealing—
tiple ways of knowing competently in using a representation of the real person. The
technologies to know the other fully as person. person’s state may change moment to
7991_Ch26_437-448 12/08/19 5:28 PM Page 442
moment—the person is dynamic and engaging as primary process. Knowledge

alive, and his or her actions cannot be about the person that is derived from tech-
predicted. This provides the opportunity nological knowing, mutual designing, and
for nurses to continuously know the participative engaging informs the nurse in
person as whole from moment to appreciating the patient. In knowing persons,
moment. one comes to understand that more knowing
■ Mutual Designing: Both the nurse and the about the persons and about their being
one nursed (patient) plan a care process allows the nurse to affirm, support, and cel-
from which a conjointly rewarding prac- ebrate their dreams and aspirations in the
tice can evolve that is responsive to their moment. Supporting this process of knowing
desires for care. in nursing is the understanding that persons
■ Participative engaging: This encounter are unpredictable, that they simultaneously
provides a simultaneous practice of conceal and reveal themselves as persons
mutual activities that are crucial to from one moment to the next (Parse, 2014).
knowing persons as caring. This aspect The nurse can know the person fully only in
of the process is characterized by contin- the moment. This knowing occurs when per-
uous knowing, implementation, and sons allow the nurse to enter their world.
participation that reflects the cyclical When this happens, the nurse and nursed be-
but recursive process of knowing persons come vulnerable as they move toward further
as caring (Fig. 26-1). continuous knowing.
Vulnerability allows participation so that
Figure 26-1. The Process of Knowing the nurse and nursed continue knowing each
Persons as Caring, and the Nursing other from moment to moment. Daniels (1998)
Encounter explained that in such situations, the “nurse’s
Notice in the process of knowing persons as work is to ameliorate vulnerability” (p. 191).
caring shown in Fig. 26-1 that knowing is Further, Daniels declared that “vulnerable in-
comprised of the persons, technological dividuals seek nursing care, and nurses seek
knowing, mutual designing, and participative those who are vulnerable” (p. 192). By entering
Knowing Persons
as Caring
Nursing
encounter
Legend
Patient/Client/Person
Designing
Technological knowing
FIG 26-1 ■ The process of knowing persons
Participative Engaging
as caring, and the nursing encounter.
7991_Ch26_437-448 12/08/19 5:28 PM Page 443
the world of the one nursed, the nurse shares and nursed. The notion of complexity and
“power with” rather than having “power complex dynamics within the UTD therefore
over” the patient through a created hierarchy opens the realm to discovery and advancing
(Daniels, 1998). The nurse does not know knowing. Through this lens, nursing occurring
more about the person than the person within the universal technological domain is
knows about himself or herself. No one firmly focused on preserving the humanness of
knows the lived experience of the patient persons in their care (Locsin & Purnell, 2015).
better than the patient. The UTD is where all technological concep-
Although it can be assumed that with the tualizations reside. The continuous demonstra-
process of “knowing persons,” opportunities to tion of ever-changing dynamics of knowing
continuously know the other become limitless, is expressly illuminated in the dynamics of
there is also a much greater likelihood that the UTD. Anything that is technological
having “already known” the one nursed, the within the health-care system is encompassed
nurse will predict and prescribe activities for in the UTD (Locsin & Purnell, 2015). Knowl-
the one nursed, ultimately causing objectifica- edge about the person through technological
tion of the person (Fig. 26-2). knowing informs the nurse about mutually
satisfying nursing care in which engagements
Figure 26-2. The Dynamic Nursing occur as participating in knowing each other
Process Events in Nursing: The as persons.
Universal Technological Domain.
As a conceptualization of the multidimen- To Know and Knowing
sional nature of technology embedded within The verb “know” has common definitions. Of
nursing in contemporary practice, the universal these definitions, some are appropriate de-
technological domain (UTD) is boundaryless scriptions that explain the intended use of the
as signified by the Mobius-like wave in word in nursing, thereby facilitating its under-
Figure 26-2 and coextensive with the nurse standing for the purpose and process of com-
petently using technologies in nursing. While
the verb know sustains the notion that nurs-
ing is concerned with activity and that the
Knowing Person: Process of Nursing
one who acts is knowledgeable (in the sense
of understanding the rationales behind the
activities), the word knowing is a key concept
Universal that alludes to the focus of an action from a
technological cognitive perspective requiring description.
domain
Technological Knowing perfectly describes this process in

knowing nursing because it is transpiring continuously.
Patient It is the use of the word knowing in which the
Client process of nursing as knowing persons is lived.
Person
The framework for practice clearly shows
Designing Participative
Engaging the circuitous and continuous and recursive
process of knowing persons in the practice of
nursing.
We hope that nurses practice nursing from
a theoretical perspective rather than from tra-
dition or from blind obedience to instructions
FIG 26-2 ■ Illustrating the dynamic nursing and directions. Nevertheless, processes of nurs-
process events in nursing. (Locsin, R. [2017]. The ing that are derived from extant theories of
co-existence of technology and caring in the theory of
Technological Competency as Caring in Nursing. The nursing continue to dictate and prescribe how
Journal of Medical Investigation, 64, 160–164. a nurse should nurse. Contrary to this popular
(Used with permission.) conception, knowing persons as a model of
7991_Ch26_437-448 12/08/19 5:28 PM Page 444
practice using technologies of nursing achieves technological competency as caring in nursing

for the nurse an appreciation of expertise and (Locsin, 2005).
the knowledge of persons in the moment. Regardless, the idea of knowing persons
Technologies allow nurses to know about the guiding nursing practice is novel in the sense
person only as much as the person permits that there is no ideal prescription; rather there
the nurse to know. It can be true that tech- is the wholesome appreciation of an informed
nologies detect the anatomical, physiological, practice that allows the use of multiple ways of
chemical, and/or biological conditions of a knowing such as described by Phenix (1964)
person. This identifies the person as a living and expanded by Carper (1978). These ways of
human being. However, with knowing per- knowing involve the empirical, ethical, personal,
sons, the nurse can understand and anticipate and aesthetic. Aesthetic expressions document,
the ever-changing person from moment to communicate, and perpetuate the appreciation
moment. of nursing as transpiring moment to mo-
The purpose of knowing persons is derived ment. Popular aesthetic expressions include
from the nurse’s intention to nurse (Purnell & storytelling; poetry; visual expressions as in
Locsin, 2000)—a continuing appreciation of drawings, illustrations, and paintings; and
persons as ever-changing and unpredictable, aural renditions such as music. Encountering
who are dynamic human beings. Knowing the aesthetic expressions again allows the nurse
person is only relevant for the moment, for and the nursed to relive the occasion anew.
the person’s “state” can change moment to Reflecting on these experiences using the
moment. Importantly, knowing the “who or fundamental patterns of knowing (Carper,
what” of persons make nurses realize that a 1978) enhances learning, motivates the fur-
person is more than simply the physiochemical therance of knowledgeable practice, and in-
and anatomical being. Knowing persons allows creases the valuing of nursing as a professional
the nurse to know “who and what” is the per- practice grounded in a legitimate theoretical
son. “Who” is the subjective knowing of the perspective of nursing.
person as whole and “what” is objective know- Technological competency in nursing fosters
ing of the person as parts. the recognition of persons as participants in their
care rather than as objects of care. The idea of
Knowing When Using Technology participation in their care stems from active en-
It may seem that the process of knowing is gagement, in which the nurse enters the world
possible only when using technologies in nurs- of the one nursed through available appropriate
ing. This perception, which is not necessarily technologies, attempting to know the nursed
true, is supported by the idea that nursing is more fully in the moment. In this practice, the
technology when technology is appreciated as assumption is understood that the one nursed
anything that creates efficiency, whether this is allows the nurse to enter his or her world so that
an instrument or a tool, such as machines, or the together they may mutually support, affirm, and
activity of nurses when nursing. Sandelowski celebrate each other’s being. In this relationship
(1993) has argued about the metaphorical of the knower and the one known, technology
depiction of nursing as technology, or with provides the efficiency and the valuing that
technology as nursing, and the semiotic rela- marks their mutual and momentary reality
tionship of these concepts. Locsin and Purnell (Locsin, 2009).
(2007, 2015) have declared that accompanying Technology currently encompasses the bulk
the nurse’s rapture with technologies in nurs- of functional activities that nurses are expected
ing is the consequent suffering or the price of to perform, particularly when the practice is in
advancing dependency on technologies that a clinical setting. Clinical nursing is firmly
critically influence contemporary human lives. rooted in the clinical health model (Smith,
With increased use of technologies and ensu- 1983) in which the organismic and mechanis-
ing technological dependency experienced by tic views of humans as persons convincingly
recipients of care, the imperative is to provide dictate the practice of nursing. Nevertheless,
7991_Ch26_437-448 12/08/19 5:28 PM Page 445
the process of knowing persons will prevail, for circuitous and recursive process, the practice of
the model of technological competency as car- technological knowing begins anew. The model
ing in nursing provides the nurse the fitting in Figure 26-2 illustrates the process of tech-
stimulation and motivation (and the prospec- nological knowing in nursing within the UTD.
tive autonomy to judge critically) a mode of
action that desires an appreciation of persons Calls and Responses for Nursing
as whole. Calls for nursing are illuminations of the per-
Continuing to know persons deters objecti- sons’ hopes, dreams, and aspirations. Calls for
fication, a process that ultimately regards nursing are individual expressions by persons
human beings as “stuff” to care about, rather who seek ways toward affirmation, support, and
than as knowledgeable participants in their care. celebration as person. The nurse appreciates the
Participating in his or her care frees the per- uniqueness of persons. In doing so, the nurse
son from having to be “assigned” care that he sustains and enhances the wholeness of the
or she may not want or need. This relationship human being, while facilitating the realization
signifies responsiveness of the cared for by the of the person’s completeness through acting for
person who is caring for (Hudson, 1988). Con- or with the person. This is affirming, support-
tinuous knowing results when findings ob- ing, and celebrating the person’s wholeness.
tained through knowing further increase the The nurse relies on the person for calls for
desire to know “who” and “what” the person is. nursing. These calls are specific mechanisms
Continuous knowing overpowers the motiva- that the persons use, allowing the nurse to re-
tion to prescribe and direct the person’s life by spond with authentic intentions to know them
affirming, supporting, and celebrating his or fully as persons in the moment. Calls for nurs-
her hopes, dreams, and aspirations as a person. ing may be expressed in various ways, often as
The use of technologies in nursing is con- hopes and dreams, such as the hope to be with
sequent to the contemporary demands for friends while recuperating in the hospital, the
nursing actions requiring technological know- desire to play the piano when the fingers are
ing (Locsin, 2009). Technological knowing is well enough to function effectively, or simply
demanded for the ultimate purpose of know- the ultimate desire to go home or to die peace-
ing the real person. It is defined as the practice fully. As uniquely as these calls for nursing are
of using technologies of care to know the one expressed, the nurse knows the person contin-
nursed more fully as person. Important along uously moment to moment. Nursing responses
with technology use in nursing is the condition to these calls may be to monitor patterns of in-
that the one nursed allows himself or herself formation, such as those derived from an elec-
to be known as a person. trocardiogram to know the physiological status
Technological knowing in nursing illus- of the person in the moment or to administer
trates the shared practice of using technologies lifesaving medications, to institute transfer
to know persons as whole and using technolo- plans, or to refer patients for services to other
gies of care for the purpose of understanding health-care professionals.
persons more fully. The circuitous and recur- The entirety of nursing is to direct, focus,
sive engagement that occurs in technological attain, sustain, and maintain the person. In
knowing includes the following: doing so, hearing calls for nursing is continu-
ous and momentarily complete. Knowing per-
■ Appreciating the person’s humanness
sons allows the nurse to use technologies in
■ Engaging in mutual knowing—between
articulating calls for nursing. The empirical,
the nurse and nursed
personal, ethical, and aesthetic ways of know-
■ Participating in dynamic relating within
ing that are fundamental to understanding
caring nursing relationships
persons as whole increase the likelihood of
■ Furthering knowing of persons
knowing persons in the moment.
Through technological knowing, further Unpredictable and dynamic, human beings
knowing of persons is achieved. Because it is a are ever-changing moment to moment. This
7991_Ch26_437-448 12/08/19 5:28 PM Page 446
characteristic challenges the nurse to know conversations and through personal commu-
persons continuously as a whole, rejecting the nications via e-mail, these positive declarations
traditional concept of possibly knowing persons continue to provide and affirm that the theory
completely at once, to prescribe and predict is useful, particularly in nursing practice de-
their expressions of wholeness. In continuously manding technological proficiency such as in
knowing persons as whole through articulated critical care settings. Likewise, during class
technologies in nursing, the nurse can perhaps presentations and in scholarly/academic confer-
intervene to facilitate patients’ recognition of ences, students and participants express their
their wholeness in the moment. claims that the theory resonates well in their
practice, affirming their understanding of nurs-
ing, and confirming their appreciation of know-
Applications of the Theory ing persons through technologies as practice.
Locsin’s theory is relatively new. Applications There has been an absence of comments from
of the theory of Technological Competency as practitioners who have signified that the theory
Caring in Nursing have been documented, al- has guided their practice. However, research has
though mostly anecdotal references exist as been done and disseminated using the theory
these are shared and its utility explained. as framework (Borvornluck, Kongsuwan, &
Through these anecdotes received in various Locsin, 2012; Kongsuwan & Locsin, 2011;
occasions, especially after presentations and Koszalinski & Locsin, 2013).
Practice Exemplar
written by Hirokazu Ito (2018) vein. Finally, exasperated, Yukiko exclaimed,
“Please call nurse A” who was able to insert
Knowing Persons in the Moment Yukiko’s IV drip on first try, and maintained
The following is a nursing situation involving a continuous IV drip. This made Yukiko very
a nurse’s act to direct care to what was impor- happy and praised Nurse A.
tant for the patient. One day, a woman in her However, at some point in her hospitaliza-
60s visited a university hospital due to paraly- tion, Yukiko found out that she had metasta-
sis of half of her body and aphasia. Let us call tic brain tumor originating from her lungs.
her Yukiko. She has two daughters who are When her day of treatment came Yukiko
very busy with work, making it hard for them asked to see Nurse A, pleading him to accom-
to bring her to the hospital. She was urgently pany her and explain to her about the disease
admitted to the neurosurgical ward. cause, treatments, and consequences. Yukiko
Nurse A happened to be in charge of her. expressed the desire for Nurse A to decide the
He was quick to administer steroids medica- treatment method for her, exclaiming that if
tions as ordered and prepared her for required “you decide the treatment instead of me, I can
examinations such as blood specimen sam- accept it as well.” But Nurse A could not
pling. While at the bedside, Nurse A provided decide for her. Later, however, Yukiko told
Yukiko with TV cards which were left behind him, “I decided that radiation will be the best
by other patients so that she can watch TV treatment for me” making him so happy and
and keep her from being lonely. TV cards are pleased for her decision.
required for televisions at bedside to work. On the day Yukiko was transferred out
Unfortunately, at this time, Yukiko’s IV of the ward Yukiko waved to Nurse A, while
drip catheter was not infusing well and showing a tender smile. Then one of her daugh-
needed to be reinserted. Some physicians ters secretly came to Nurse A’s ward and said
tried to insert the IV catheter many times, “Thank you very much for caring for my
but failed to effect a continuously patent mother.” It made all the difference for her.
7991_Ch26_437-448 12/08/19 5:28 PM Page 447
Summary
The purpose of this chapter is to describe and human beings as persons, nursing as caring,
explain “knowing persons as whole,” a frame- and technological competency are presented as
work of nursing guiding a practice grounded foundational to the process of knowing per-
in the theoretical construct of technological com- sons as whole in the moment—a process of
petency as caring in nursing (Locsin, 2005). This nursing grounded in the perspective of tech-
framework of practice illuminates the harmo- nological competency as caring in nursing.
nious relationship between technological com- The process of knowing persons as whole is
petency and caring in nursing. In this model, explicated as technological knowing—efficiency
the focus of nursing is the person. The chapter in using clinical nursing practices. The model of
introduces technological knowing, a way of practice is illustrated through the understanding
knowing in nursing engaging the competent of technology and caring as coexisting in
use of technologies of care to come to know nursing.
persons as whole. Through technological The process of knowing persons is continu-
knowing, both the nurse and one nursed are ous. In this process of nursing, with calls and
appreciated as whole persons whose hopes, responses, the nurse and nursed come to know
dreams, and aspirations matter most in living each other more fully as persons in the moment.
their lives fully as whole persons. Grounding the process is the appreciation of
Critical to understanding the phenomenon persons as whole and complete in the moment,
of technological competency as caring in nurs- of human beings as unpredictable, of techno-
ing are the conceptual descriptions of technol- logical competency as an expression of caring in
ogy, caring, and nursing. Assumptions about nursing, and of nursing as critical to health care.
Questions for Reflection How can Locsin’s theory help us to

think about this?
and Discussion ■ Computers and monitors help us to access
■ How can the use of technology enhance or information about persons for whom we
detract from knowing the whole person, care. What other patterns of knowing
family, or community for which you are help nurses to apprehend the wholeness of
caring? the person/family/community?
■ Humanoid nurse robots are being used
to replace or supplement nursing care.
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7991_Ch27_449-468 12/08/19 5:28 PM Page 449
Marilyn Anne Ray’s Theory

CHAPTER
27
of Bureaucratic Caring
Marilyn Anne Ray and
Marian C. Turkel

Applications of the Theory Marilyn Anne (Dee) Ray, RN, PhD, CTN,
Practice Exemplar FAAN, is a Professor Emerita at Florida
Summary Atlantic University (FAU), Christine E. Lynn
Questions for Reflection and Discussion College of Nursing, in Boca Raton, Florida.
She holds a Bachelor of Science and a Master
of Science in Nursing from the University of
Colorado in Denver, Colorado; a Master of
Arts in cultural anthropology from McMaster
University in Hamilton, Canada; and a PhD
from the University of Utah in transcultural
nursing. She retired as a colonel in 1999 and
is a veteran after 30 years of service with the
U.S. Air Force Reserve Nurse Corps. As a tran-
scultural nursing scholar and certified advanced
transcultural nurse (CTN-A), she has published
widely on the subjects of caring in organiza-
tional cultures, caring theory and inquiry devel-
opment, transcultural caring, and transcultural
and communitarian ethics. She has held fac-
ulty positions at the University of California
San Francisco, University of San Francisco,
McMaster University, University of Colorado,
and FAU, and Scholar positions at FAU and
Virginia Commonwealth University. Ray has
enjoyed many diverse teaching and learning

assignments around the world. She holds fel-
lowships in the American Society for Applied
Anthropology, American Academy of Nursing,
European Society for Person-Centered Health-
care, and National Academies of Practice.
Ray has conducted phenomenological,
ethnographic, and grounded theory research
related to nursing administration and practice.
Ray’s initial research revolved around the study
of caring in the culture of organizations that in-
cluded technological, political, legal, and eco-
nomic structures and issues related to caring in
complex organizations. This research resulted
in the discovery of the Theory of Bureaucratic
449
7991_Ch27_449-468 12/08/19 5:28 PM Page 450
Caring in 1981 (Ray, 1989, 2010, 2017, 2018). was discovered and developed from insight and
Her research over the past three decades, con- interpretation of the initial qualitative data and
ducted with Dr. Marian Turkel, focused on the data related to complex systems, such as tenets
complex nurse–patient relational caring process of bureaucracy. The culture of the hospital was a
and its impact on economic and patient dynamic unity illustrating caring as not only hu-
outcomes in hospitals. Ray and Turkel (2012) manistic (including physical), ethical, spiritual/
advanced the Theory of Relational Caring religious, social–cultural, and educational but
Complexity. As well as the discovery of the also as part of the structural—political, eco-
Theory of Bureaucratic Caring (Ray, 2010, nomic, legal, and technological—characteristics
2016; Ray & Turkel, 2015), Ray developed the of a complex organization. These codetermining
theory and model of Transcultural Caring processes related to the thesis of caring and the
Dynamics in Nursing and Health Care (2016) antithesis of bureaucracy were synthesized into
in her book by the same name. In her role as the Theory of Bureaucratic Caring (Fig. 27-1).
professor emerita, Ray is actively engaged in The initial research and model revealed that
mentoring new faculty members and guiding economic and political patterns of meaning
doctoral students. were more dominant, followed by the technical
and legal dimensions, and finally, the social
and ethical/spiritual dimensions within the
Overview of the Theory complex system of the hospital. Subsequently,
This chapter presents a discussion of contem- the model was pictured with coequal dimen-
porary nursing practice environments and shares sions. After additional research and continued
theoretical views in nursing and those related to reflection on what was occurring in science and
the authors’ theoretical vision and development in nursing science, Ray revisited the theory and
of professional nursing practice informed by discovered that the theory itself incorporated
nursing theory. The Theory of Bureaucratic many concepts from the new sciences of complex-
Caring is discussed first as a grounded theory ity (the science of change, interconnectedness,
(both substantive and formal) and then as a wholeness [holography], and emergence). The
Holographic Theory. theory, as shown in Figure 27-2, was subse-
quently revealed as holographic (Coffman,
The Generation of Bureaucratic 2010, 2014, 2018; Ray & Turkel, 2015).
Caring Theory
The Theory of Bureaucratic Caring was gener-
ated in a hospital organizational culture from a
qualitative research study using three research
Spiritual/
approaches more than 30 years ago (Ray, 1981, Ethical
religious
2010, 2013). The theory has been published in
the book by Ray (2010), A Study of Caring
Educational/
Within an Institutional Culture: The Discovery of social Economic
the Theory of Bureaucratic Caring. Data analysis CARING
involved the description of the hospital as a cul-
ture (ethnography), the meaning of caring in the
Technological/
life world (phenomenology), and the discovery of Political
physiological
conceptual categories (dimensions) and subcat-
egories and theories of the structure and Legal
process of caring in the complex organization
(grounded theory method). Substantive theory
called differential caring was discovered from
the diversity and dominant meanings of caring FIG 27-1 ■ Grounded Theory of Bureaucratic
expressed by participants on different units and Caring (differential caring and bureaucratic caring
in different roles in the hospital. Formal theory theories).
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C H A P T ER 27 ■ Marilyn Anne Ray’s Theory of Bureaucratic Caring 451
model facilitates and increases our understand-

ing of the practice of nursing in complex con-
temporary health-care environments.
Social-
Physical
cultural
Holographic Emergence in the Theory
of Bureaucratic Caring
Educational
Legal The holographic paradigm in complexity sci-
SPIRITUAL-
ETHICAL ence(s) and emergent in the theory of bureau-
CARING cratic caring recognizes the following (Cannato,
2006; Davidson, Ray, & Turkel, 2011):
Political Technological
■ The ontology or “what is” of the universe
Economic or creation is the interconnectedness of
all things.
■ Reality is composed of neither wholes nor
parts but of wholes/parts or holons—the
whole is in the part and the part in the
FIG 27-2 ■ Holographic Theory of Bureaucratic whole.
Caring. ■ The epistemology or knowledge that exists
is in the relationship rather than in the
objective world or the subjective experi-
The current holographic model depicts the
ence of it.
primacy of caring as spiritual–ethical and the ■ Uncertainty is inherent in the relationship
other dimensions as equal, indicating the holis-
because everything is in process and
tic nature of the interface between the spiritual
emerging.
and ethical and the bureaucratic dimensions. In ■ Information and choice hold the key to
the holographic model, caring (the center of the
grasping the holistic and complex nature of
model) is highlighted as spiritual and ethical in
the meaning of holography or the whole.
relation to the physical (humanistic), the social–
cultural and educational, and the more struc- Holography thus means that the implicate
tural dimensions of a complex organization: the order (the whole) and explicate order (the part)
political, economic, legal, and technological. are interconnected, that everything is a holon,
Thus, spiritual–ethical caring honors the good including humans, in the sense that everything
of caring, commits to the moral position of car- is a whole in one context and a part in
ing and virtue, the ethics of compassion, in- another—each part being in the whole and the
tegrity, courage, and humility (Coffman, 2018). whole being in the part (Cannato, 2006). For
Moreover, spiritual–ethical caring engages the example, “The molecule depends on the atom,
theological, including the virtues of faith, hope, the cell depends on the molecule, and all
and love. The process is creative and describes depend on the stability of the interconnected
the integration of the networks of relationships system in order to thrive” (Cannato, 2006,
in complex organizational or bureaucratic sys- p. 98). All cycles of activities are linked coher-
tems. This holographic model illustrates that ently together; the more energy is stored
spiritual–ethical caring is multidimensional, within systems, the more subcycles there are.
complex, holistic, and dynamic. Interactions It is the relational and reciprocal aspect of re-
and symbolic systems of meaning by nurses and lationship itself, information and choice, that
others are formed and reproduced from the makes it holistic rather than mechanistic,
constructions or dominant values held and which subsequently opens all systems to diversity
evolving within the human–environment organ- and emergence (integrated sets of possibilities;
ization. In some respect, the holographic model Davidson et al., 2011; Ray, 1998; Thoma, 2003).
depicts that “we are the organization.” The The- Holistic science is a human–environmental
ory of Bureaucratic Caring as a holographic mutual process and a dynamic unity and a

7991_Ch27_449-468 12/08/19 5:28 PM Page 452
transformative or emergent process. Holistic environment (context), moving in relationship,

science (and art) thus captures the idea that and continually transforming (emerging—
all systems, including health-care systems, are growing and developing; Thoma, 2003). Be-
living systems, are both wholes and parts, and cause of the knowledge of complexity science(s)
depend on networks of relationships, informa- as holography (holistic science and art), we all
tion, choice, and communication flow. need to become more aware of the meaning of
The human–environment mutual process is participatory life and ways of relating to the re-
not a new idea to nursing. It was a central the- ality of complex organizations or bureaucra-
oretical perspective of Martha Rogers (1970) cies. Rather than continuing mechanistic
and central to beliefs in anthropology and approaches of prediction and control that may
transcultural nursing advanced by Leininger have worked to some extent to gain precise
(1991), and it was a foundation for other the- knowledge in the past, we must now give
ories, such as those of Parse, Newman, and way to new understanding. Nurses and other
Reed (Alligood, 2014, 2018). This notion is professionals must be open to change, to the
seen again at a different time and through a integral nature of the dynamic unity of the
different lens. In the author’s work, the focus human and environment, and to phenomena
is on the caring patterns of the nurse–patient– that are coherent and emergent wholes (body,
administrator relationship within the bureau- mind, spirit, and context) that make up our
cratic context of a hospital. The Bureaucratic world of caring, health, healing, and well-
Caring Theory, already considered paradoxical being (Coffman, 2018; Davidson et al., 2011;
(bureaucratic caring), identified the linkage Rogers, 1970).
between caring as humanistic, social–cultural,
educational, and spiritual–ethical and the
Contemporary Nursing Practice as
organizational hospital system as political, eco-
Complex, Dynamic, Relational,
nomic, legal, and technological. Caring is a Caring, and Emergent: Foundations
relational pattern; it is the flow of nurses’ and of the Theory of Bureaucratic Caring
others’ own experiences in the structural con- The practice of nursing is dynamic, always
text of the organization. This simultaneous changing, and emerging with new possibilities
process illuminates the idea that the whole and as people relate to each other. Contemporary
parts are one and the same; all cycles of activ- nursing practice, however, continues to occur
ities are linked coherently together, but each in organizations that are generally bureaucratic
may be doing different things at different or systematic in nature. Although there has
paces; all the parts are participating in the whole, been much discussion about the “end of
and the whole is participating as a part in differ- bureaucracy” to cope better with 21st-century
ent contexts of meaning (Coffman, 2018; innovation and work life within complex sys-
Davidson et al., 2011; Rogers, 1970; Turkel, tems (Sorbello, 2008), bureaucracy remains a
2013a, 2013b). Information (caring and system valuable tool to identify and understand the
data) unfolds and emerges at the same time in fundamentally different structural principles
the same space without contradicting itself. that undergird coordinated and relational
organizational systems. Bureaucracies are orga-
The Theory of Bureaucratic Caring nizational systems that can be viewed as cultures.
as a Holographic Theory Organizational cultures have a rich heritage and
The Theory of Bureaucratic Caring as a Holo- have been studied as both formal and informal
graphic Theory furthers the vision of nursing systems since the 1930s in the United States
and organizations as complex, dynamic, rela- (Porter-O’Grady & Malloch, 2007; Ray, 1981,
tional, integral, informational, and emergent— 1989, 2010, 2013; Ray in Coffman, 2010,
open to sets of possibilities because of the 2014, 2018; Ray & Turkel, 2012, 2014, 2015;
synchronicity of interacting parts and the Wheatley, 2006). Informal organizational culture
whole. Everything interconnects; we are all integrates codes of ethics and conduct encom-
creative manifestations of the oneness of the passing commitment, identity, character,

7991_Ch27_449-468 12/08/19 5:28 PM Page 453
coherence, and a sense of community in of nations. Values that drive a nation are ex-
social–cultural interaction and the social envi- perienced in the health-care arena. For exam-
ronment. The informal organizational culture ple, for the most part, “cost and profit” have
is considered essential to the successful func- transformed health care in the United States.
tioning or the administering of the formal Health-care organizations continually are
organization: political power and authority, affected by issues of cost and profit and poli-
technology and technological computation, tics, and this prompts health-care systems to
economic exchange and legal methods and undergo immense change, such as the health-
judgments. Thus, the formal organization com- care reforms or political crises of the Patient
prises political, economic, legal, and technical Protection and Affordable Care Act (PPACA,
systems within organizational cultures (the 2010). Over recent years, confidence in major
typical phenomena of bureaucracies). Bureau- health-care institutions and their leaders has
cracies themselves create their own cultural fallen so low as to put the legitimacy of execu-
orientations, patterns, goals, rituals, languages, tives who manage health-care systems at
and norms within the structural elements of risk. Trust is a major issue (Ray & Turkel,
the political, economic, legal, and technologi- 2012, 2014). Old rules of loyalty and commit-
cal dimensions (Britain & Cohen, 1980; ment to employees, investment in the worker,
Ray, 2010, 2018). fairness in pay, and the need to provide good
What distinguishes “organizations as benefits are in flux. Health-care systems
cultures” from other paradigms, such as organ- have fallen victim to the corporatization of
izations as machines, brains, or other images human enterprise. Consequently, the conflict
(Morgan, 1997), is its foundation in anthro- between health care as a business and caring as
pology or the study of how people act in com- a human need has resulted in a crisis in pro-
munities or formalized structures and the fessional nursing, patient safety issues, and the
significance or meaning of work life (Cuilla, quality of care provided by health-care organ-
2000). Organizational cultures, therefore, are izations (Davidson, et al., 2011; Institute of
viewed as social constructions, symbolically Medicine, 2010).
formed and reproduced through interaction The actual work of nurses, although under-
(Sawyer, 2005). valued in terms of both cost and worth (Ray &
The beliefs about work emerge in organiza- Turkel, 2012), is currently being evaluated in
tions through relationships and organizational terms of issues of patient safety and clinical
mission and policy statements. A nation’s pre- nurse leadership. Since the Institute of Medi-
vailing tenets and expectations about the nature cine (2010) report, a resurgence of interest is
of work, leisure, and employment are pivotal to taking place in the meaningfulness of work
the work life of people; hence, there is interplay and patient safety in many hospitals. Nursing
between the macrocosm of a national/global cul- education and the clinical nurse leader role are
ture and the microcosm of specific organizations highlighted as bridges to quality (Sherman,
(Wheatley, 2006). In recent years, organizational Edwards, Giovengo, & Hilton, 2009). As
cultures have emerged as globalizing corporate such, the language of trust and morally worthy
systems with multiple descriptions of meaning. work (Cuilla, 2000; Ray & Turkel, 2014) is
However, economics, or the “bottom line,” is the beginning to replace the language of downsiz-
potent equalizer of most macrocultures and ing and restructuring at the same time that
microcultures. There is an ever-greater concen- mergers and acquisitions still hold sway in
tration of economic and political power in a contemporary corporate environments. Cuilla
handful of corporations, which separate their (2000) stated that the “most meaningful jobs
interests (usually profit-driven) from the inter- are those in which people directly help others
ests of humans, which are life-centered (Ray, [provide care] or create products that make life
2010; Ray, Turkel, & Cohn, 2011). better for people” (p. 225). Although the tra-
Health care and its activities are tightly in- ditional work of nurses is defined as directly
terwoven into the social and economic fabric helping others through knowledgeable caring

7991_Ch27_449-468 12/08/19 5:28 PM Page 454
(Watson, 2018), contemporary nurses’ work 2013, 2017, 2018; Ray & Turkel, 2012, 2014,
and its meaning are also defined by and within 2015). The social theorist Max Weber (1999)
the organizational context—the structural di- actually predicted that the future belonged to
mensions of political, economic, legal, and the bureaucracy and not to the working class.
technological systems (Coffman, 2018; Ray, Weber, who saw bureaucracy as an efficient
1989, 2013, 2017, 2018; Ray & Turkel, 2012, and superior form of organizational arrange-
2015). Urging nurses, physicians, and admin- ment, predicted that the bureaucratization of
istrators to find cohesion among these dimen- enterprise would dominate the world (von
sions in organizations and the dynamics of Mises, 2017; Weber, 1999). This, of course, is
unity of human beings (body, mind, and spirit evidenced by the current globalization of com-
integration) call for the reinvention of work merce and technical information systems. In
(Fox, 1994). In health care, there is a move- terms of global commerce, recent acquisitions
ment underway for advancing interprofessional and mergers of industrial firms and even
education and practice (Keller, Eggenberger, health-care systems, especially in the United
Belkowitz, Sarsekeyeva, & Zito, 2013). Through States, are larger and hold more power than
incorporating business principles, creativity, some world governments. Yet, to maintain the
and the “work of the soul” or spiritual–ethical integrity of large-scale, for-profit corporations,
caring, an emancipatory praxis and relational often governments have to step in with in-
self-organization emerges (Ray, 1998; Ray & creased regulation and infuse systems with
Turkel, 2014) leading to a new way (Porter- monetary guarantees. Information technology
O’Grady & Malloch, 2007; Ray, 2010; Ray & systems often are in the hands of a few who
Turkel, 2012, 2014; Turkel, 2014). Spiritual– direct and guide knowledge. The concept of
ethical caring is a witness to the power and bureaucratization is thus a worldwide phenom-
depth of transformation in nursing and complex enon (Ray, 1989, 2010). Although bureaucra-
organizations—“re-seeing” the good of nursing, cies are considered less effective than other
searching for meaning in life and society, creat- forms of organization, Britain and Cohen
ing caring organizations, and finding new (1980) stated that
meaning in the complexities of work itself.
like it or not, humankind is being driven to a bu-
Organizational Cultures as reaucratized world whose forms and functions,
Transformational Bureaucracies whose authority and power must be understood
The transformation of nursing toward a greater if they are ever to be even partially controlled. …
understanding of relational self-organization and The study of bureaucracies is, in effect, the study
creativity (work of the soul—spiritual–ethical of the most salient and powerful organizations of
caring) is not necessarily a new pursuit for the the contemporary world. (p. 27)
profession; what it reveals is a focus on and
As bureaucracies grow, so too will the
movement from invisibility to visibility. Identi-
importance of family, kin, community, organi-
fying professional nurse caring work as having
zational life, culture, ethnicity, and what is now
spiritual–ethical value and being an expression
termed panethnicity, and an understanding of
of one’s soul or one’s creative self at work, while
diversity within wholeness, ethics, healing,
at the same time understanding and identifying
and caring (Britain & Cohen, 1980; Ray,
nurses’ value as an economic resource, replaces
2010, 2016).
the notion of nursing as performing only
The characteristics of bureaucracies are as
machine-like tasks.
follows (von Mises, 2017):
Bureaucracy, still considered by some as a
machine-like metaphor, as we have identified, ■ A division of labor based on roles, depart-
continues to play a significant role in the ments, leadership, and authority
meanings and symbols of health-care organi- ■ A hierarchy of offices (bureaus or units)
zations (Coffman, 2014, 2018; Ray, 2010, with diverse social–cultural orientations

7991_Ch27_449-468 12/08/19 5:28 PM Page 455
■ A set of general policies and rules that continue to thwart the participative movement
govern performance toward decentralization. Even the new clinical
■ A separation of the personal from the nurse leader role sets a nursing leader apart
official from his or her peers in terms of knowledge
■ A selection of personnel on the basis of and role responsibility (Prestia, Sherman, &
technical/professional qualifications Demezier, 2017; Sherman & Touhy, 2017).
■ A movement toward interprofessionalism Power is still in the hands of a few. As local
and collaboration and global economic markets rule, there is a
■ Equal treatment of all employees or call for creating a “caring economics” and a
standards of fairness, ethical applications, need to be creative and ethical in terms of the
and reimbursement worldwide technological and economic trans-
■ Employment viewed as a career by formation taking place (Ray, 2010, 2017, 2018;
participants Ray & Turkel, 2012, 2014, 2015; Turkel,
■ Protection of dismissal by tenure or 2013a, 2013b). We have to look at the social,
evaluation psychological, and spiritual factors that shape
our societies and organizations. As a result, the
Bureaucracy thus incorporates within the
concept of bureaucracy does not seem as bad
human and ethical dimension the political
as was once thought because it addresses
(power and authority), legal (policies and
human, and in many respects, humane, action.
rules), economic (cost systems), and technical
It can be considered as a much less radical par-
(professional, informational, and computa-
adigm than the business paradigm that focuses
tional) dimensions. At the same time, bureau-
only on competition and response to market
cracies integrate the whole social and cultural
forces, subsequently eradicating standards of
system. Bureaucracy, although condemned by
fairness or social justice for humans in the
some as associated with red tape and inflexi-
workplace (Ray & Turkel, 2014).
bility, continues to provide the most reason-
able way in which to view systems and
facilitate the preservation, understanding, and Caring as the Unifying Focus
transformation of organizations. In the past of Nursing
two decades, there has been a call for decen- Caring in nursing speaks of relationships, com-
tralization and the “flattening” of organiza- passion, human dignity, ethics, justice, and com-
tional structures—to become less bureaucratic petent and knowledgeable caring practice (Ray,
and more participative or heterarchical (Porter- 1981, 2010, 2013; Roach, 2002; Smith, Turkel,
O’Grady & Malloch, 2007). Many firms have & Wolf, 2013; Watson, 2018). Caring science
begun to hold to new principles that honor and art is holistic, humane, and dynamic; thus,
creativity and imagination, and a vision of spirit facilitates growth and development of human
itual and ethical caring and healing (Morgan, persons and helps to make things work in
1997; Ray & Turkel, 2014). Even nursing has health-care agencies. As such, caring science and
advanced in a more collaborative or decentral- art is considered by many nurse scholars to be
ized structure by its focus on patient-centered the essence of nursing (Boykin, Schoenhofer, &
nursing and a movement from more central- Valentine, 2013; Leininger, 1991, 1997; Ray,
ized control and administration to more de- 1989; Ray & Turkel, 2012; Smith et al., 2013;
centralized self-governance (Allen, 2013; Watson, 2018). Although not uniformly ac-
Wheatley, 2006). But creative views still need cepted, Newman, Sime, and Corcoran-Perry
to be marked with understanding of structural (1991) characterized the social mandate of the
systems of bureaucracy as globalization, infor- discipline of nursing as caring in the human
mation, and economics sweep the world (von health experience. Newman, Smith, Pharris, and
Mises, 2017). Jones (2008) further emphasized her initial idea
Leadership models, which are fundamen- that relationship is the focus and health is the
tally hierarchical because of the need for order, rhythmic fluctuations of the life process, as well

7991_Ch27_449-468 12/08/19 5:28 PM Page 456
as caring, consciousness, mutual process, pat- love, compassion, empathy, attentiveness, and
terning, presence, and meaning. Caring and divine love. Ethical relates to respect for per-
health thus are influential concepts. The expres- sons and our moral obligation to the well-
sion “caring” in the human health experience being of others and focuses on awareness,
emphasizes the social mandate to which nursing understanding, and moral choices in complex
has responded throughout its history and en- health-care and social structures. The theory
compasses the scope of the discipline (Roach, was discovered via grounded theory research of
2002; Watson, 2018). Caring, with multiple the meaning of caring in a complex hospital/
meanings, however, is manifested in different health-care organization. Illuminated were the
and complex ways in the nursing discipline and interconnection of paradoxical patterns holo-
profession (Morse, Solberg, Neander, Bottorff, graphically of compassion, lovingness, empa-
& Johnson, 2013; Smith et al., 2013). thy, communication, religious, and ethical/
moral caring with physical and social structural
Evolution and Development of the characteristics of systems—political, legal, eco-
Theory of Bureaucratic Caring nomic, physical, technological, educational,
Facing the challenge of the economic and pa- and sociocultural dimensions (Coffman, 2018;
tient safety crises in health care and nursing, Ray, 1989, 2010, 2016, 2018). Table 27-1
the disillusionment of registered nurses about describes the dimensions of the Theory of
the disregard for their caring services, and the Bureaucratic Caring.
concern of the nursing profession and the pub-
lic about the effects of the shortage of nurses Complexity and Nursing Theory
(Institute of Medicine, 2010), working for the To understand the significance and holographic
good of the profession and preservation of the nature of the Theory of Bureaucratic Caring, an
nurse–patient caring relationship is imperative. overview of complexity science(s) is necessary.
Running away from the chaos of hospitals or “Complexity theory is a scientific theory of dy-
misunderstanding the meaning of work life namical systems collectively referred to as the
cannot become the norm. Wherever nurses go, sciences of complexity” (Ray, 1998, p. 91). They
they will be “haunted” by bureaucracies, some illuminate the nature and creativity of science
functional, many problematic. What, then, is itself. Revolutionary approaches to new scien-
the deeper reality of nursing practice? The tific theory development have transpired, such
following is a presentation of theoretical as quantum theory and actually “beyond the
views that relate to the Theory of Bureaucratic quantum,” the science of wholeness, holo-
Caring, culminating in a vision for understand- graphic and chaos theories, fractals or the idea
ing the deeper significance of nursing life as of self-similarity, networks of relationships and
holistic, spiritual and ethical, relational, cultural, complex information systems, and the concepts
contextual, and the dynamics of complexity. of choice and self-organization/relational self-

The Theory of Bureaucratic Caring is a di- organization (Davidson et al., 2011; Ray, 1998;
alectical and dynamical theory of awareness Ray & Turkel, 2012; Wheatley, 2006).
that interconnects potentially opposing phe- Complexity Theory is replacing other the-
nomena into a synthesis of spiritual–ethical– ories, such as Newtonian physics and even
organizational caring. Everything in the Einstein’s beliefs and those of other scientists
organization is a holograph, infused with as well, that the physical world is governed by
spiritual–ethical caring (the center of the model); laws and order. New scientific views illustrate
thus, everything is a whole in one context and a that the fundamental force in the universe is
part in another, with each part being in the dynamic (always changing), chaotic, nonlinear,
whole and whole being in the part. Spiritual– nonpredictable, relational, moving toward
ethical caring is defined as a complex and dy- self-organization, and open to possibilities. As
namic transcultural relational caring process in such, phenomena that are antithetical actually
an ethical, spiritual context. Spirituality relates coexist—determinism with uncertainty and
to creativity and choice and is highlighted as reversibility with irreversibility. “Opposing

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Table 27-1 Dimensions of the Theory of Bureaucratic Caring
Dimension Characteristics
Social–cultural Values, beliefs, behaviors, and attitudes regarding ethnicities, identities, family systems,
communities, and social–structural patterns of interaction between/among people; an
organization is a complex social–cultural system
Physical Relates to the physical and mental states of being wherein each pattern influences the
other
Legal Refers to accountability and judiciousness in relation to principles, rules, policies,
procedures, and factors that are created to govern practice, such as issues of quality
of care, patient safety, malpractice, liabilities, autonomy, rights to privacy, human
resources, licensure standards, human and gender rights, and justice (fairness)
Educational Deals with formal and informal patterns of communication and dialogue, knowledge,
and skill in providing care and programs using diverse media to convey caring knowl-
edge and information competently for the well-being of patients, caregivers, and
administrators in complex systems
Technological Refers to the use of nonhuman resources, such as computer and internet technologies,
social media, machinery to sustain or enhance physical and mental well-being, diag-
nostic tests, pharmaceutical agents, and electronic health records, with the knowledge
and skill to use these resources competently
Political Deals with governance and moral decisions (uses of authority, power, privilege, and
control) of all persons in relationships, roles and stratification, unions, resources, and
the ability to negotiate fairly in complex health-care systems
Economic Refers to the exchange and allocation of scarce human and material resources to sus-
tain the economic viability of the organizational system, such as attention to money,
goods and services, value-based services, budgets, employee pay, insurance systems
and payments, and government systems (e.g., PPACA, Medicare/Medicaid, veterans’
services)
things can happen at the same time, in the information about the environment, and emer-
same space, without contradicting each other” gence (Davidson et al., 2011; Fox, 1994). The
(Thoma, 2003, p. 17). Thus, both linear and conception of the interconnectedness and re-
nonlinear, and simple (e.g., gravity) and com- lational reality of all things, the interdepend-
plex (economic and cultural), systems exist ence of all human–environmental phenomena,
together (for example, the paradoxical nature and the discovery of order in a chaotic world
of the Theory of Bureaucratic Caring). One of demonstrate the pioneering story of 20th-
the tools or metaphors in the studies of com- century science and how the insightful idea of
plexity is Chaos Theory. Chaos deals with life belongingness and relationality (a powerful
at the edge, or the notion that the concept of nursing concept) is shaping the science of the
order exists within disorder at the system com- 21st century.
munication or choice point phases where old Within nursing, certain nursing theorists
patterns disintegrate, or new patterns emerge have embraced the notion of nursing as
(Davidson et al., 2011; Newman et al., 2008). complexity in which consciousness, human–
This new science, which signifies interrelation- environmental mutual relationship, caring, and
ship of mind and matter, interconnectedness choice-making are central concepts (Davidson
and choice, carries with it a moral responsibility et al., 2011; Newman et al., 2008; Ray, 1998;
and the quest toward wisdom, which includes Ray & Turkel, 2011; Rogers, 1970). Given the
awareness, information systems, networks of nature of nursing as unitary, holistic, relational,
relationships, patterns of energy, creativity, and caring, and of health as expanding

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consciousness (Newman et al., 2008; Pharris, The bureaucracy represented a living system.
2006), there is a coherent link between the im- Caring was expressed not only in the more in-
portance of theory as wakefulness (awareness) terpersonal relational patterns of humanness
and professional practice. Ray and Turkel hold and compassion but also in the official struc-
the position that nurses need to be exposed to tures of the bureaucracy, especially the political
ideas and diverse nursing theories to stimulate and economic structures, and both expressions
thinking. The only way that nursing can cri- were infused into the meaning system of pro-
tique itself is by understanding the intellectual fessionals. Even patients saw the “system” as
views of scholars in the complex world of nurs- affecting how they understood caring in their
ing science, research, education, and practice. own health-care experiences (Ray, 1981, 2010,
Theories, as the integration of knowledge, 2018; Ray & Turkel, 2012, 2014; Ray et al.,
research, and experience, highlight the way in 2011). The substantive theory (grounded)
which scholars and practitioners of nursing emerged as differential caring theory and showed
interpret their world and the context where that caring in the complex organization of the
nursing is lived (Potter & Wilson, 2017; hospital was complex and differentiated itself
Turkel, Fawcett, et al., 2018; Turkel, Watson, in terms of meaning by its specific context—
& Giovannoni, 2018). Theories in this sense dominant caring dimensions related to areas of
are also philosophies or ideologies that serve a practice or units wherein professionals worked,
practical purpose. Thus, the idea that theories and patients resided. Differential Caring The-
are the pure viewing of truth, wakefulness, or ory showed that professionals and patients on
awareness (Van Manen, 2014), and that they different units espoused different and dominant
can be judged in light of their practical conse- caring meanings based on their professional
quences, underscores the importance of nurs- roles and personal and organizational goals and
ing theory as both a scholarly enterprise and a values. For example, participants in the oncol-
wise practice that identifies and participates in ogy unit espoused caring as intimate and spir-
the complexities of inquiry about relationships, itual; in contrast, participants in the intensive
knowledgeable caring, health, healing, com- care unit espoused caring as more technological;
plex organizations, and the universe. and in administration, participants espoused
caring as maintaining economic viability. The
Description of Bureaucratic formal Theory of Bureaucratic Caring symbol-
Caring Theory ized a dynamic structure of caring, which was
In the original qualitative study of caring in synthesized from a dialectic using the tenets of
the organizational context conducted by Ray the philosophy of Hegel (thesis, antithesis, and
(1981, 1989, 2010), the research revealed that synthesis); the dialectic between the thesis of
nurses and other professionals struggled with caring as humanistic, social, educational, ethical,
the paradox of serving the bureaucracy and and religious/spiritual (dimensions of human-
serving humans, especially patients, through ism, morality, and spirituality); and the antithe-
caring. Caring, however, had multiple mean- sis of caring as economic, political, legal, and
ings and was expressed differently in terms of technological (dimensions of bureaucracy)
the way a particular unit was organized. The (Coffman, 2014, 2018; Ray, 1981, 2010, 2017,
system phenomena of political, economic, 2018; Ray et al., 2011; Ray & Turkel, 2012,
legal, and technological became integrated into 2014, 2015).
the meaning system of caring just as the
humanistic, social, educational, ethical, and spir- The Theory of Bureaucratic Caring
itual had. The discovery of bureaucratic caring as Holographic Theory
resulted in both substantive theory (grounded in How can the Theory of Bureaucratic Caring
the context of meaning) and formal theory be viewed as a Holographic Theory? As pre-
(integrated from the substantive theory and gen- viously discussed, the theory arose initially
eral understanding of dimensions of complex from interpretations and choices that were
bureaucracies) (Ray, 1981, 1989, 2010). made about the meaning and structure of

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caring in organizational life. The process par- make excellent and ethical choices at the “edge
allels ideas from complexity sciences and of chaos” where possibilities exist in relation-
specifically holography: consciousness or aware- ships and systems/organizations to either
ness; intentionality of the mutual human– transform or disintegrate. Understanding of
environmental caring relationships; quality of spiritual–ethical caring in the Holographic
the caring transactions; and the effective ability Theory of Bureaucratic Caring helps us to con-
to analyze, negotiate, make choices, and rec- nect at our deepest level. Nurses and others in
oncile paradoxes between caring and the sys- complex systems can reclaim higher ground by
tem demands. The humanistic nurse–patient doing the “work of the soul” (understanding
care needs and professional responsibilities in and engaging creatively, spiritually, and lov-
terms of the structural considerations of the ingly, and taking ethical responsibility for self
system (political, economic, legal, and tech- and other and the organizational system). Our
nological dimensions) were always emerging choices depend on a commitment and ethical
from sets of caring possibilities. Awareness of social action to cocreate caring–healing relation-
belongingness/interconnectedness, the mutual ships and communities (Ray & Turkel, 2014;
human–environmental relationship, the im- Watson, 2018). The model (see Fig. 27-2) pres-
plicate (the whole) and explicate (the part) ents a vision of nursing as spiritual–ethical
order (the whole is reflected in the part, and part caring, but it is also based on the reality of
reveals the whole), respect for the good of all practice. Through continuous research and
things, and communication, choice, and observation, the model emphasizes a direction
emergence—all of these are central to holistic toward the unity of experience. Spirituality in-
science. Similarly, as revealed through this volves creativity and choice and refers to gen-
research, these concepts were central to the uineness, vitality, and depth of soul/spirit. It is
interpretation of caring as a whole in the com- revealed in attachment, love, and community
plex organization. The dialectic of caring (the and comprehended within each of us as intimacy
thesis, the implicate order, or the whole of and an unfolding of virtue and the sacred art of
caring as humanistic and spiritual–ethical) in divine love (Secretan, 1997). Ethics deals with
relation to the various organizational struc- our moral accountability to self and caring for
tures (the antithesis of the system, explicit self, and responsibility to one another and to the
order, or part, the organization as political– organizations within which we work. Secretan
economic–technical–legal) is reconciled and states: “Most of us have an innate understanding
transformed by a synthesis of the polar oppo- of soul, even though each of us might define it
sites into the theory of bureaucratic caring. in a very different and personal way” (p. 27).
The synthesis of the theory of bureaucratic As such, Fox (1994) calls for the theology
caring shows that everything is intercon- of work—a redefinition of work as spiritual
nected, even humanistic spiritual–ethical car- and ethical. Because of the crisis in our work
ing and the organizational system. The whole life mainly due to economic and political con-
is in the part, and the part is in the whole; straints, and in general our relationship to
therefore, nursing in the system is a holon, work, we are challenged to reinvent it. For
and the theory is holographic. nursing, this is important because work puts
us in touch with others, not only in terms of
Transforming the Organization personal gain, but also at the level of service to
The Theory of Bureaucratic Caring reveals that humanity or the community of patients/clients
knowledge of holistic caring interconnected- and other professionals. Work must be spiri-
ness is possible to motivate nurses to continue tual and ethical, with recognition of the cre-
to embrace the human dimension within the ative spirit at work in us. Nurses must be the
current political, economic, legal, and techno- “custodians of the human spirit” (Secretan,
logic bureaucratic environment of health care. 1997, p. 27).
Can higher ground thus be reclaimed for the The ethical imperatives of caring that join
21st century? Higher ground requires that we with the spiritual relate to questions or issues

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about our moral obligations to others. The heart. This conversion is intensified by the sense
ethics of caring involve never treating people that the end of the age of oppression is at hand.
simply as a means to an end or as ends in (p. 207)
themselves but rather as beings that have the
This end of the age of oppression, however,
capacity to make choices about the meaning
is making its way slowly in health care. Prestia
of life, health, healing, and caring. Ethical
and colleagues (2017) remarked in a study of
content—principles of doing good, doing
chief nursing officer’s complex health-care sys-
no harm, allowing choice, being fair, and
tems that moral distress looms large when nurse
promise-keeping—functions as the compass
executives or managers are unable to advocate
directing our decisions to sustain humanity in
adequately for patients, staff, or themselves,
the context of the bureaucracy—the political,
leaving them feeling powerless in the wake of
economic, legal, and technological issues and
organizational misconduct, financial con-
situations within organizations. Roach (2002)
straints, and increasing nurse-to-patient ratios.
pointed out that ethical caring is operative at
the level of discernment of principles, in the
commitment needed to carry them out, and in Applications of the Theory
the decisions or choices to uphold human dignity The Theory of Bureaucratic Caring illuminated
through love and compassion. Furthermore, in this chapter is a response to the end of the
Roach (2002) remarked that health is a com- age of oppression. The theory is holistic with a
munity responsibility, an idea that is rooted practical purpose, thus responding to the call
in ancient Hebrew ethics. The expression of for a translational science, translating caring
human caring as an ethical act is inspired by theory into practice or facilitating theory-
spiritual traditions that emphasize charity. For guided practice (Ray & Turkel, 2012; Smith
nursing, spiritual–ethical caring does not ques- et al., 2013; American Academy of Nursing,
tion whether or not to care in complex systems 2018). Ray (1989) warned that the “transforma-
but intimates how sincere deliberations and ul- tion of American and other health-care systems
timately the facilitation of ethical choices for the to corporate enterprises emphasizing competi-
good of others can or should be accomplished. tive management and economic gain seriously
By integrating knowledgeable caring creatively, challenges nursing’s humanistic philosophies
by staying intentional and conscious of dynamic and theories, and nursing’s administrative and
movements within the circle of life, love, and clinical policies” (p. 31). As nurses know, for
relationships, and by leading in a new way in more than 30 years, there has been an intense
complex systems/bureaucracies, nurses are en- focus on operating costs and the bottom line
gaging in new and exciting work (Davidson in the American health-care environment, and
et al., 2011; Porter-O’Grady & Malloch, 2007; caring is often not valued within the organiza-
Ray & Turkel, 2012, 2014). The Theory of tional culture. However, caring scientists,
Bureaucratic Caring as a holistic science and nurse researchers, nurse leaders, and nurses in
art bears witness to the power and depth of practice have sought out principles of caring
transformation: “re-seeing” the good of nurs- science (Watson, 2018), transcultural caring
ing as spiritual and ethical, believing in human dynamics (Ray, 2016), and relational caring
potential, continually searching for meaning in complexity (Ray & Turkel, 2012). The appli-
life, creating caring organizations, cocreating cation of the Theory of Bureaucratic Caring as
new possibilities, and finding new meaning in a framework to guide practice and ethical de-
the complexities of work life itself. The scien- cision making (Ray, 2010; Ray & Turkel,
tist Sheldrake (1991) remarked: 2012; Smith et al., 2013; Turkel, 2013b) will
transform a complex organization to a com-
The recognition that we need to change the way munity of caring where caring for self, and
we live [work] is gaining ground. It is like waking thoughtfulness for others through compassion,
up from a dream. It brings with it a spirit of re- integrity, courage, and humility, can thrive
pentance, seeing in a new way, a change of (Smith et al., 2013).

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Nurses must be encouraged to continue the the theory has been used as a foundation for
struggle not only to be caring but to respond additional research and observational studies of
with confidence to the economic issues and the nurse–patient caring relationship and sys-
engage the political, legal, and technological tem issues, such as in public health administra-
questions and trials facing them. With hospital tion, curriculum development, correctional
system goals of decreasing length of stay and facility health care, technology and information
increasing staffing ratios, nurses need to be technology, economics of caring, nurse exec-
committed to establishing trust and initiate a utives, the clinical nurse leader role, the charge
caring relationship during their first encounter nurse role, ethics and the moral community,
with a patient. As this relationship is being es- legal caring, pediatric pain, medication errors
tablished, nurses need to focus on “being, in complex organizations, perioperative do not
knowing, and doing all at once” (Turkel, resuscitate orders, the transtheoretical devel-
2013a) within what Watson (2013, 2018) calls opment of relational caring complexity theory,
the “caring moment.” From a patient perspec- primary care, nursing administration, the
tive, “being there” means completing a task role of the nurse in shared governance, and
while simultaneously engaging caringly with within the United States Air Force Inter-
them. This approach to practice means not only Professional Person-Centered Caring Practice
viewing the patient as a person in all of his or her Model (Allen, 2013; Coffman, 2014, 2018;
complexity but viewing the patient and the Eggenberger, 2011; O’Brien, 2008; Potter &
needs of professional nursing competently Wilson, 2017; Prestia et al., 2017; Sherman
within the complex organizational environment. & Touhy, 2017; Ray, 2018; Ray & Turkel,
Staff nurses can hold close their core value 2012; United States Air Force, Office of the
that caring is the essence of nursing while still Surgeon General, 2018).
retaining a focus on meeting the issues of the Over the past three decades, Ray and Turkel
bottom line (economics). Empirical studies have conducted research and used dimensions
have firmly established a link between caring of the Theory of Bureaucratic Caring to exam-
and positive patient outcomes. And positive ine the paradox between the concept of human
patient outcomes are needed for organizational caring and political, economic, legal, and tech-
survival in this competitive and political era of nological dimensions in complex organiza-
health care. Given this, professional nursing tions, and more specifically studies of the
practice must embrace and illuminate the car- economics of caring. Their research showed
ing philosophy in relation to complex organi- that staff nurses value the caring relationship
zational phenomena. As expressed, explicitly between nurse and patient and identified that
linking caring to patient and organizational trust is a critical component in complex sys-
outcomes is integral. For the first time since tems (Ray & Turkel, 2012, 2014). However,
the inception of value-based purchasing, one- nurses are practicing in an environment where
third of hospital reimbursement will be linked the economics and costs of health care perme-
to patient satisfaction data and two-thirds to ate discussions and clinical decisions. The focus
patient quality/safety data. This is the time for on costs is not a transient response to shrinking
the economic value of caring to be actualized reimbursement; instead, it has become the cat-
with the organization (Ray & Turkel, 2009). alyst for change within health-care organiza-
Moving away from just focusing on patient tions. Between 2002 and 2004, Relational
care to the economic justification of nursing and Caring Questionnaires were distributed to reg-
health-care systems has prompted professionals istered nurses, patients, and administrators in
to desire a fuller understanding of just how to five hospitals (Ray & Turkel, 2009, 2012, 2014,
preserve humanistic caring within the educa- 2019). Overall mean scores on the question-
tional, business, or corporate (economic and naires were then compared to economic and
political) culture (Boykin et al., 2013; Turkel, patient outcome data. It is of interest to note
2013a; see also Watson Caring Science Insti- that the hospital with the highest mean score of
tute, www.wcsi.org). In terms of application, 3.30 for the professional questionnaire had the

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lowest number (3.36) of full-time employees 2014. The current (2018) model has five com-
per adjusted occupied bed and the lowest ponents: transformational leadership; struc-
number of patient falls. The hospital with the tural empowerment; exemplary professional
highest patient mean score of 4.50 had the nursing practice; new knowledge, innovation,
lowest cost ($1,265) per adjusted patient day. and improvements; and empirical outcomes.
These findings validate what registered nurses The Theory of Bureaucratic Caring can be in-
verbalized in the qualitative research. “Living tegrated into each of these components.
the caring values in everyday practice makes a Transformational leadership reflects nurs-
difference in nursing practice and patient out- ing leadership that is transformational and
comes” (Ray & Turkel, 2009; Ray & Turkel, visionary. The chief nurse executive (CNE)
2019. Through their focused research on uses the Theory of Bureaucratic Caring as the
economic caring, they advanced the Theory of theoretical framework when creating the nurs-
Relational Caring Complexity (Ray & Turkel, ing strategic plan and achieving the goal of
2012), which is beginning to be used to balancing caring and economics in clinical and
improve the practice of nursing. It is a chal- administrative decision making. The economic
lenge for nurses to combine the science and art dimension of the Theory of Bureaucratic
of caring within the complex health-care Caring and tenets from relational caring com-
environment. However, these research efforts plexity serve as research-based references for
illustrate how this can be done to help reshape the CNE in advocating how the limited re-
organizations and the health-care system in sources within the organization will be allo-
the United States and other countries, such as cated. Nursing leaders may not be able to
Canada, Australia, Japan, China, Columbia, change reimbursement from the federal or state
Chile, and some countries in Scandinavia, the government, but they can influence organiza-
Middle East, and Africa. tional decision making for the improvement of
the patient experience. Transformational lead-
Application of Theory of Bureaucratic ers use ideas from direct care registered nurses
Caring to Excellence in Contemporary to improve the practice environment, which in-
Professional Nursing Practice cludes formal integration of self-care practices
In addition to the earlier discussion of applica- (Ray & Turkel, 2012).
tion of the theory to practice, the American Structural (professional and organiza-
Nurses Credentialing Center (ANCC, 2018) tional) empowerment represents professional
Magnet Recognition Program® recognizes engagement, commitment to professional de-
excellence in professional nursing practice. velopment, teaching and role development,
Organizations provide written narratives and commitment to community involvement, and
sources of evidence related to the development, recognition of nursing. The CNE can advocate
dissemination, and enculturation of best prac- for involvement in the conferences sponsored
tices, quality care, practice expertise, and patient by the International Association for Human
experience. This emphasis on professional nursing Caring and Watson Caring Science Institute
practice within the Magnet Recognition Pro- (WCSI), where nurses at all levels have an op-
gram has resulted in organizations integrating portunity to disseminate caring scholarship
evidence-based practice, nursing research, and and research related to caring theory changing
professional models of care delivery informed by practice and informing nursing education and
nursing theory into the practice setting. research. Registered nurses can make presen-
In the past, organizations provided sources tations to boards of trustees and executive
of evidence and written narratives illustrating leadership on how caring science and nursing
the dissemination, enculturation, and sustain- theory advance practice in terms of organiza-
ability of the Fourteen Forces of Magnetism tional, registered nurse, and patient outcomes.
across the organization (ANCC, 2005). A new Ongoing education including interactive
model was developed in 2008 (ANCC, 2008), dialogue and reflective practice related to the
and a revision to this model was released in theory and self-care practices can be part of

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internal professional development for nurses at The component of new knowledge, innova-
all levels in the organization. As part of commu- tion, and improvements includes quality im-
nity involvement, registered nurses are integral provement. Unit-based patient care projects,
to community caring. Being in the community evidence-based best practice, and qualitative and
requires integration of the social, political, and quantitative findings related to the theory serve
cultural dimensions of the theory. Having a for- as exemplars included under this component.
mal practice theory supports the professional The fifth component of the Magnet Recog-
image of nursing within the organization and nition Program®, empirical outcomes, recog-
makes visible the outcomes and contributions of nizes the contribution of nursing in terms of
nursing practice to the organization. patient, nursing, and organizational outcomes.
Exemplary professional practice includes Results from nursing theory–guided research
having a professional practice model and care de- and evidence-based projects related to the di-
livery system in place in complex organizations mensions of the Theory of Bureaucratic Caring
for registered nurses. Sources of evidence relate validating the difference in patient and organi-
to how the Theory of Bureaucratic Caring is se- zational outcomes serve as evidence for this
lected and guides nursing practice. For example, component.
the United States Air Force (USAF), Office of
the Surgeon General (2018) has selected the Relevance of the Theory of
Theory of Bureaucratic Caring as the structural Bureaucratic Caring to
framework to guide the interprofessional per- Nursing Education
son-centered caring model for research and The theory is relevant to nursing education be-
practice. Nursing situations reflecting profes- cause of its focus on caring in nursing practice
sional and interprofessional clinical decision and the conceptualization of the health-care
making in research and practice, and examining system (Coffman, 2010, 2014, 2018). When
staffing patterns balancing caring and econom- developing the curriculum for a baccalaureate
ics, serve as examples of evidence to support a program, the faculty at Nevada State College
professional model of care (Potter & Wilson, combined Ray’s Theory of Bureaucratic Caring
2017). For consultation and resources, reference with theoretical constructs from Watson
can be made to external consultation with (2018) and Johns (2000) as a conceptual
nursing scholars and theorists, dissertation framework. According to this framework, the
supervisors, or consultants. Attendance at pro- Holographic Theory of Caring recognizes the
fessional conferences or webinars can make a interconnectedness of all things and that
difference in nursing research, practice, and everything is a whole in one context and a part
patient outcomes. of the whole in another context. Spiritual–
Under autonomy as a principle of the Code ethical caring, the focus for communication,
of Ethics with Interpretive Statements (American infuses all nursing phenomena including phys-
Nurses Association, 2001/2015), the compo- ical, social–cultural, legal, technological, eco-
nent of spiritual–ethical caring illustrates how nomic, political, and educational forces
nurses promoting self-organization serve as ad- (Nevada State College, 2003, p. 2).
vocates for patients and families. The educa- Turkel (2013a) used the Theory of Bureau-
tional dimension of the theory advances the care cratic Caring to guide curriculum development
delivery system as the professional nurse devel- in the masters of science program in nursing ad-
ops innovative, individualized, evidence-based ministration at FAU and the theory continues
patient education initiatives. Organizations to be taught in the FAU Nursing Leadership
truly focused on innovation or transformational Program (Sherman, 2018, personal communi-
leadership can expand the theory to be interdis- cation). Dimensions from the theory, including
ciplinary or interprofessional (as exemplified in ethical, spiritual, economic, technological, legal,
the USAF) and serve as the interdisciplinary political, and social, serve as a framework for the
plan of care for the patient, the family, and the exploration of current health-care issues. The
health-care system as a whole. economic dimension of the theory is a central

7991_Ch27_449-468 12/08/19 5:28 PM Page 464
component in several courses. Students analyze (Ray, 2018; Ray & Turkel, 2012, 2014, 2015;
the current economic and reimbursement struc- Turkel, 2013a). Findings from additional qual-
ture of health care from the perspective of a itative and quantitative research studies will
caring lens. continue to support the Theory of Bureaucratic
The application of the Theory of Bureau- Caring as a middle-range theory, a Holographic
cratic Caring and the practice exemplar illus- Practice Theory, and a general/universal theory
trate that the foundation for professional (Ray, 2017, 2018).
nursing is the blending of the humanistic and Nurses need ongoing education related to
empirical/organizational aspects of care— the politics, economics, and costs associated
understanding caring science and art in com- with health care, as well as knowledge of com-
plex organizations. In today’s environment, the plex technological organizational environments.
nurse needs to integrate caring, knowledge, Lack of knowledge in these areas allows others
and skills “all at once” (being, knowing, and outside of nursing to continue to make the
doing). Given political and economic con- political and economic decisions concerning
straints, the art of caring cannot occur in the practice of nursing. Having an in-depth
isolation from meeting the physical needs of knowledge of the politics and economics of
patients and must incorporate economic, health care allows nurses to use innovation and
political, technological, and spiritual–ethical creativity to both challenge and transform the
caring dimensions. When caring is defined system. A new theory-guided model created
solely as science or as art—empirical or aesthetic for nursing practice that supports human car-
nursing, respectively—neither is adequate to re- ing in relation to the organization’s economic,
flect the reality of current practice. Nurses technical, and political values is an exemplar of
must be able to understand and articulate the such innovation. The multiple dimensions of
politics and the economics of as well as caring the Theory of Bureaucratic Caring serve as a
in nursing practice and health care. Classes philosophical/theoretical framework to inform
that examine the environment of practice gen- both contemporary and future research and
erally, and the politics and the economics of theory-guided nursing practice. Having this in-
health care in relation to caring, must be inte- depth knowledge allows nurses to continually
grated into nursing education and staff devel- question and transform complex health-care
opment curricula. Nurses need to search organizations.
continually for different approaches to profes- Ray and Turkel (2012) continue to advance
sional practice that will incorporate caring in their collaborative ideas related to theory
an increasingly political, technical, and cost- development, caring science, and the paradox
driven environment. Doing more with less no between caring and economics within complex
longer works; nurses must “move outside of systems. A metatheory emerged from the
the box” to create innovative practice models integration of the following: the Theory of
informed by nursing theory. Nurses need to, Bureaucratic Caring (Ray, 1981); “Struggling
in essence, move nursing from being viewed as to Find a Balance: The Paradox Between
a “bed rate” in hospitals to nursing as a human Caring and Economics” (Turkel, 2001); and
caring science and practice and valuable central relational complexity (Ray & Turkel, 2012).
economic resource within an organization and The metatheory is relational caring complexity,
the health-care system. and it reveals the complexity of today’s nursing
Administrative nursing research needs to practice situation while providing a foundation
continue to focus on the relationship among for emerging professional practice models fo-
nursing, caring, patient outcomes, and complex cused on caring and healing, and innovative
organizational economic outcomes. Ongoing transdisciplinary research looking at caring and
research is required to firmly establish the economics. Continually giving voice to the
nurse–patient relationship as an economic re- value of caring in nursing within and as part of
source in the new paradigm of evidence-based complex organizations allows for spiritual–
(informed) practice of health-care delivery ethical caring to occur.

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This presentation of the Theory of Bureau- connection to the structures of complex organi-
cratic Caring is a creative enterprise. The theory zations. Spiritual–ethical caring is both a part
reflects spiritual and ethical caring, bureaucratic and a whole, and every part secures its purpose
system principles, and incorporation of tenets and meaning from each of the other parts that
of the new sciences of complexity highlighting can also be considered wholes. In other words,
holography. Holographic Theory illuminates the theoretical model shows how spiritual–eth-
holistic science and art, the interconnectedness ical caring is involved with qualitatively differ-
of all things, human–environment integral ent yet similar processes or systems, be they
relationships, scientific chaos theory, holo- political, economic, technological, or legal. The
graphic patterning (the whole is in the part, and systems, when integrated and presented as
the part in the whole), informational networks, open and interactive, are a whole and must op-
relational self-organization, transformation, erate as such by conscious choice, especially by
change, choice, and emergence (Coffman, the ethical choice making of nursing, which al-
2018; Davidson et al., 2011; Ray, 1998, 2010, ways has, or should have, the interest of hu-
2017, 2018; Thoma, 2003). In the Theory of manity at heart.1
Bureaucratic Caring, everything is infused
with spiritual–ethical caring (the center of 1For additional practice applications, see the bonus chapter
the model) by its integrative and relational content available at http://davisplus.fadavis.com.
Practice Exemplar
Kimberly Jones, RN, PhD, NEA-BC, The group selected Ray’s Theory of
FAAN, was recently hired as the chief nurse Bureaucratic Caring because it was based on
executive (CNE) for an inner-city multihos- research from a hospital organization and
pital system. The five hospitals within the sys- publications by the theorist and other scholars,
tem have different levels of reimbursement, which brought clarity to how the theory could
including private insurance, Medicare, and “live in the real world of practice.” Kimberly
Medicaid. All the hospitals have patients ad- was committed to being an advocate for nurs-
mitted via the emergency department in crit- ing while recognizing her professional account-
ical condition with no insurance. With the ability to consider the economic perspectives of
current emphasis on value-based purchasing, her decision making, which interfaced with
and reimbursement being based on the patient the structural dimensions of the Theory of
experience and quality outcomes, Kimberly Bureaucratic Caring. Kimberly met with the
recognized the need to integrate the concepts chief executive officer (CEO) to share the
of human caring and economics into the pro- budgetary needs of implementing a nursing
fessional practice model and to ground the theory across all five hospitals. Her first prior-
professional practice model within a nursing ity was to hire two PhD-prepared nurse re-
theoretical framework. Kimberly met with the searchers to collect and analyze data as the
nursing staff and discussed the need to have a nursing theory was implemented and to have
nursing theoretical framework to guide nurs- a part-time PhD faculty member work with
ing practice, and the economic value of mak- the registered nurses on integration of the
ing explicit the link among nursing, patient, nursing theory. The CEO was hesitant to al-
and system outcomes. Kimberly collaborated locate additional financial resources. Kimberly
with the nursing shared governance leaders to explained that nursing research would validate
have them review various nursing theories and the economic value of nursing theory and of
to select one nursing theory to guide profes- practicing from a framework of human caring
sional nursing practice across all five hospitals. throughout the organization. This would
(continued)

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result in increased employee satisfaction, which The percent of patients who reported YES,
positively correlates with an increase in Hos- they would recommend, ranged from 64% to
pital Consumer Assessment of Health Care 68%, with national average being 72%. After
Providers and Systems (HCAP) scores. reviewing the data, the CEO approved the re-
Kimberly presented the CEO with latest quests. Twelve months after nursing theory
publicly reported HCAP scores and the nurs- implementation, four of the hospitals received
ing research linking caring practices to out- 4 stars and one received 3 stars. The number
comes. The overall star ratings for the five of falls, pressure ulcers, central line–associated
hospitals were 2 out of 5 stars for three hospi- bloodstream infections (CLABSIs), and
tals and 3 out of 5 stars for two hospitals. The catheter-associated urinary tract infections
percentage of patients who gave the hospitals (CAUTIs) decreased. Employee satisfaction
a rating of 9 or 10 ranged from 58% to 65%, improved by an average of 10% to 15% across
with the current national average being 73%. all five hospitals.
Summary
The values of nursing are deepening, and as a bureaucratic systems. In nursing, the critical
discipline and profession, nursing is expanding task is to comprehend the meaning of the net-
its consciousness (Newman et al., 2008; Ray, works and complexity of relationships, be-
2017, 2018; Ray & Turkel, 2014). Nursing tween what is given in culture (the norms) and
is being shaped by the historical revolution what is chosen (the moral and spiritual). In
occurring in science, social sciences, and the- nursing, the unitary-transformative paradigm
ology, as well as the revolution of its own com- and the state of the science (Newman et al.,
mitment to caring science, health care for all, 2008), including unitary caring science, are
and understanding of holism and complex sys- challenging nurses to become more aware and
tems (Davidson et al., 2011; Newman et al., understand their future in terms of the com-
2008; Ray, 1998, 2010, 2016, 2017, 2018; plexity of human–environment relationship.
Watson, 2018). Freeman (in Appell & Triloki, The unitary-transformative paradigm of nurs-
1988) pointed out that human values are a ing and its holographic tenets are consistent
function of the capacity to make choices and with new science(s) of complexity. The other
called for a paradigm giving recognition to reality of nursing is that there continue to be
awareness and choice. As noted in this chapter, threats by the business/economic model over
a revision toward this end is taking place in its long-term human interests for facilitating
nursing based on the science(s) of complexity health, healing, and well-being of patients,
and a new holographic scientific worldview, as nurses and other professionals, and organiza-
well as specific theories of nursing, especially the tions (Davidson et al., 2011; Ray, 1998; Ray
Holographic Theory of Bureaucratic Caring. & Turkel, 2012) However, the creative, intu-
Nursing has the capacity to make creative itive, ethical, and spiritual mind is unlimited
and moral choices for a preferred future. Con- and through “authentic conscience” we must
structs of consciousness and choice are central find hope in our creative powers.
and demonstrate that phenomena of the uni- Envisioning the Theory of Bureaucratic
verse, including society and what happens in Caring as holographic from its initial substan-
nursing, organizations, and societies, arise tive and formal grounded theories shows that
from the choices that are or are not made through research, creativity, and imagination,
(Davidson et al., 2011; Newman et al., 2008). nursing can build the profession it wants. Nurses
The Theory of Bureaucratic Caring has rein- are calling for opportunities for expression of
forced caring as the primordial construct and their own spiritual and ethical existence, a
consciousness of nursing within complex reinvention of work. Nurses are also calling

7991_Ch27_449-468 12/08/19 5:28 PM Page 467
for understanding of the nurse–patient caring politically driven atmosphere of today. The deep
relationship in complex organizations. The new values that underlie caring and choice to do good
scientific, spiritual–ethical, and experiential ap- for the many will be felt both inside and outside
proach to nursing theory as holographic will organizations. We must awaken our consciences
have positive effects— and that reality has been and act on this awareness and no longer surren-
illustrated in this presentation. The union of der to injustices and oppressiveness of systems
complexity science, ethics, and spirituality will that focus primarily on the good of a few (Ray
engender a new sense of hope for transforma- & Turkel, 2014). The Holographic Theory of
tion in the work world. This transformation Bureaucratic Caring—idealistic yet practical,
toward relational caring organizations and com- visionary yet real—can give direction and impe-
munities of caring can occur in the economic and tus to lead the way.
Questions for Reflection nursing/organizational economics, and

contemporary nursing practice?
and Discussion ■ Review the practice exemplar. How can
■ Describe the major dimensions of Ray’s Ray’s Theory of Bureaucratic Caring
Theory of Bureaucratic Caring. How do inform nursing research in the practice
these concepts connect to the wholeness setting? How can Ray’s Theory of
of Ray’s Theory of Bureaucratic Caring? Bureaucratic Caring inform a professional
■ What is the connection between the holo- practice model? How can Ray’s Theory of
graphic model of Ray’s Theory of Bureaucratic Caring inform or transform
Bureaucratic Caring, complexity science, nursing leadership?

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Troutman-Jordan’s Theory
CHAPTER
28
of Successful Aging
Meredith Troutman-Jordan

Practice Exemplar Dr. Troutman-Jordan began her nursing career
Summary after graduating from Presbyterian Hospital
Questions for Reflection and Discussion School of Nursing in Charlotte, North Carolina.
She earned her BSN from Queens College, and
her master’s degree in Psychiatric Mental Health
Nursing from the University of North Carolina
at Charlotte. Her doctoral degree is in nursing
science from the University of South Carolina
at Columbia. She is certified as psychiatric
mental health clinical nurse specialist from the
American Nurses Credentialing Center.
Dr. Troutman-Jordan was inspired to
develop a middle-range Theory of Successful
Aging from her clinical practice with older
adults in home care. The theory (Flood, 2002,
2006a) originated early during Dr. Troutman-
Jordan’s doctoral studies, and her subsequent
research has been based on testing and refining
this theory, developing and testing an instru-
ment to measure successful aging, and devel-
opment and testing of strategies to help people
age successfully. Her current research involves
a mixed-methods study to explore the meaning
of life events and features of gerotranscendence
in older adults with chronic conditions, and to

begin examining the relationships between life
events, successful aging, and gerotranscen-
dence in older adults.

Although there are several theories detailing
what successful aging is (Baltes & Smith, 2003;
Crowther, Parker, Achenbaum, Larimore &
Koenig, 2002; Jest, Depp, & Vahia, 2010;
Kahana, Kahana & Lee, 2014; Pruchno, Wilson-
Genderson, Rose, & Cartwright, 2010; Rowe &
Kahn, 1998), there remains rather limited the-
oretical work that provides practical guidelines
469
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for promoting successful aging. Therefore, the accepting physical changes, actively managing
impetus for developing the Theory of Successful chronic health conditions, and staying socially
Aging was to provide enhanced understanding engaged. Many of us have encountered similar
of successful aging, captured from the older older adults. So, the question became, “What
adult’s perspective, and identification of foci for describes the state of being of the more favorably
interventions to foster successful aging. aging individual, and how can nurses help older
One goal of Healthy People 2020 is to im- adults move toward this state of being?”
prove the health, function, and quality of life Walker and Avant’s (1995) framework was
of older adults (HealthyPeople.gov, 2019). used for this concept analysis, resulting in a
Objectives include increasing the proportion conceptual definition for successful aging: an
of older adults with one or more chronic health individual’s perception of a favorable outcome
conditions who report confidence in managing in adapting to the cumulative physiological and
their conditions, reducing the number of older functional alterations associated with the pas-
adults who have moderate to severe functional sage of time, while experiencing spiritual con-
limitations, and increasing the proportion of nectedness and a sense of meaning and purpose
older adults with reduced physical or cognitive in life. Older adults encountered in clinical
function who engage in light, moderate, or practice and research have validated this idea,
vigorous leisure-time physical activities. emphasizing the importance of both coping
Optimal health and well-being of older mechanisms that mediate chronic illness and
adults across multiple domains (that is, the best the older adult’s perspective of his or her own
possible health and well-being for a particular aging. Over the course of several years, the
individual)—physical health; mobility; social, Theory of Successful Aging was developed.
spiritual, and emotional well-being—is consis- Existing knowledge obtained deductively
tent with successful aging. Although there are from the Roy Adaptation Model (Roy &
commonly used definitions of old age, there is Andrews, 1999) was synthesized with ideas
no general agreement on the age at which a from Tornstam’s (1996) Sociological Theory
person becomes old; the United Nations agreed of Gerotranscendence and other literature
cutoff is 60+ years to refer to the older popula- relevant to concepts of successful aging (e.g.,
tion (World Health Organization, 2018). So, healthy aging, aging well, meaning in life,
the Healthy People 2020 goal aims to improve adaptation). Adaptation is a process in which
health and quality of life of individuals age 60 individuals use conscious awareness and choice
and older. Similarly, the impetus for the Theory to assimilate to their environment (Roy, 2013).
of Successful Aging was this age group, while The theory was established based on the follow-
the intention was for the theory to be applied ing assumptions derived from the literature:
to adults of any age, to help them age more suc-
cessfully and have more meaningful later years. ■ Aging is a progressive process requiring
Development of the Theory of Successful from simple to increasingly complex
Aging began with a concept analysis of success- adaptation.
ful aging that clarified the phenomenon. The ■ Aging may be successful or unsuccessful,
concept analysis was sparked by the question, depending on where a person is along the
“What was it that could make such a dramatic continuum of progression from simple to
difference for two older adults with similar health, more complex adaptation and the exten-
environmental, and social situations?” Although sive use of coping processes.
in similar circumstances, one might give up, for ■ Successful aging is influenced by the aging
example, refusing help from others or trying to do person’s choices.
for oneself, avoiding health-care measures, with- ■ The self is not ageless (Tornstam, 1996).
drawing from relationships, or becoming em- ■ Aging people experience changes, which
bittered and avoidant. Another could maintain an uniquely characterize their beliefs and
optimistic, intrepid attitude and find meaning, perspectives as different from those of
purpose, and satisfaction in life, for example, younger adults (Flood, 2006a).

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C H A PTER 28 ■ Troutman-Jordan’s Theory of Successful Aging 471
Roy Adaptation Model functional changes occurring over their life-

The Roy Adaptation Model was the context for time, while maintaining a sense of spirituality,
development of the theory because of the theo- connectedness, and meaning and purpose in
retical fit of the successful aging assumptions life. The Theory of Successful Aging comprises
within the Roy model. The Roy Adaptation various degrees of coping processes, the complex
Model is based on Helson’s (1964) Adaptation dynamics within the person according to Roy
Theory and von Bertalanffy’s (1968) General and Andrews (1999). Every older adult has
Systems Theory. Roy (1997) referenced Erikson’s some capacity for coping, and this is unique to
(Erikson, Erikson, & Kivnick, 1986) Develop- the individual. Consider various older adults
mental Theory, and stated that specific medical you have encountered in clinical practice; each
problems may arise with age and consideration individual had potential for some growth
should be given to the age of the patient. Scien- through enhanced adaptation. For some people,
tific and philosophical assumptions underlying this might have been rather limited; perhaps
the Roy Adaptation Model inform the theory of they tended to “see the glass as half full,” but
successful aging and are explicated in the chapter you have probably encountered others who
on the Roy Adaptation Model in this text (see managed to persevere through considerable
Chapter 10). health, financial, or psychosocial challenges.
Three adaptation levels (the condition of life Three coping processes make up the foun-
processes, according to Roy, 2013) represent dation of the theory: functional performance
the condition of the life processes: integrated, mechanisms, intrapsychic factors, and spiri-
compensatory, and compromised. One who is tuality. These coping processes, shown in
aging successfully has integrated adaptation Figure 28-1, describe the ways one responds
levels; he or she has effectively functioning cop- to the changing environment (Flood, 2006a).
ing mechanisms and experiences physical, Constructs within each of these coping
mental, and spiritual well-being. A compensa- processes are measurable output (cognitive,
tory adaptation level in someone who experi- behavioral, or affective) responses, which
ences illness, but who is aging successfully, provide feedback to the person and are thus
might be seeking social support from friends interconnected by arrows. Solid arrows de-
and family to cope. An older adult with com- note those exchanges that occur initially, and
promised adaptation could be someone who broken arrows indicate exchanges that occur
experiences a cerebrovascular accident and re- subsequently (Flood, 2006a).
fuses physical therapy or social support from Functional Performance Mechanisms
family, becomes hopeless, depressed, stops eat-
ing, and ends up at increased risk for a throm- Functional performance mechanisms are the use
of conscious awareness and choice as an adap-
bus related to immobility. Within the context

of the Theory of Successful Aging, this person tive response to cumulative physiological and
could still age successfully if he or she adapts to physical losses with subsequent functional
health and other circumstances according to his deficits occurring because of aging. Simply put,
or her optimum potential. This person can be this foundational coping process captures the
best supported through a multidisciplinary typical age-related declines that occur, such as
approach including nursing, medicine, social decreasing cardiovascular reserve, increasing
work, physical therapy, pastoral care, and nu- joint stiffness, and rise in blood pressure, and
trition counseling to promote successful aging. what people do to manage them, if anything.
Everyone will experience change as a part of
aging. Think of an older adult you know and
The Theory of Successful Aging think of one age-related physiological or func-
The Theory of Successful Aging describes the tional change he or she experienced. How did
process by which individuals use various cop- he or she respond to this change?
ing mechanisms to progress toward desirable Indicators of the functional performance
adaptation to the collective physiological and mechanism coping process are health promotion

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Successful Aging
Meaning
Purpose in life
Gerotranscendence
Decreased death
anxiety
Purpose in life
Functional Performance
Mechanisms Spirituality
Health promotion Spiritual perspective
activities
Religiosity
Physical health
Physical activities Intrapsychic Factors
Creativity
(Low level) negative
affectivity
Personal control
FIG 28-1 ■ Model for the Theory of Successful Aging.
activities, physical health, and physical mobility. to problem-solving (Flood, 2006a). Intrapsy-
Therefore, by assessing an older adult’s participa- chic factors refer to an older adult’s use of these
tion in health promotion activities (e.g., annual inherent character traits to respond to environ-
health examinations, good nutrition, regular ex- mental stimuli. Output responses indicative of
ercise), physical health state (history of illnesses, intrapsychic factors include creativity, low lev-
current chronic and acute disease processes), and els of negativity, and personal control.
physical mobility (e.g., gait stability and speed, To assess an older adult’s intrapsychic
use of assistive devices), the nurse determines the factors, the nurse could engage him or her in a
adaptive state of his or her functional perform- discussion about creative activities he or she
ance mechanisms. Each of these output re- enjoys or explore problem-solving skills that
sponses is a manifestation of the human adaptive have been useful. For example, the nurse
response of functional performance mecha- might note, “You did a pretty impressive job
nisms. A broad array of functional performance supporting three children after losing your
mechanisms is possible, and the mix and extent husband. How did you manage?”
of functional performance mechanism indicators
is perhaps limitless. Therefore, each older adult Creativity
is unique, and becomes increasingly complex There are numerous creativity assessments, and
across the life span as changes occur over time. the best way for measuring or assessing creativ-
As individuals, older adults could be viewed as ity is debated. Some well-known methods of
unique histories to be explored, understood, and measuring creativity include the Torrance
valued by the nurse. (1974) Tests of Creative Thinking, Guilford’s
(1967) Alternative Uses Tasks, and Wallach
Intrapsychic Factors and Kogan’s (1965) Creativity Test. Although
Intrapsychic factors are the innate and enduring the Torrance tests require a fee and special
character features that may enhance or impair training to administer, the others do not. These
an individual’s ability to adapt to change and tests, as well as others, can be accessed free

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online (www.indiana.edu/~bobweb/Handout/ from the article in which the authors published

d3.ttct.htm). Administering one of these as- its initial use (Participation and Quality of Life
sessments might stimulate conversation with Project, 2012).
the older adult, which could lead to discussion Assessing the degree of negative affectivity
on problem-solving skills and/or exploration in the older adult could be an initial step toward
of enjoyable, creative leisure activities. Further- increasing self-awareness of feelings and how
more, these tests might even be fun for the often and intensely they are experienced. A tool
older adult. such as the PANAS might be used to initiate a
conversation about this self-awareness, with
Positive and Negative Affect subsequent counseling or referral to an ad-
Isen, Daubman, and Nowicki (1987) proposed vanced practice psychiatric–mental health
that positive affect should be viewed as influ- nurse if indicated.
encing the way in which material is processed,
suggesting that good feelings increase the ten- Personal Control
dency to combine material in new ways and see Personal control reflects individuals’ beliefs re-
the relatedness between divergent stimuli. garding the extent to which they are able to
Similarly, the Theory of Successful Aging control or influence outcomes (MacArthur
proposes that low levels of negative affectivity Research Network on SES and Health, 2008).
enhance or increase creativity. Personal control expectancies relate to judg-
The nurse might recognize the need to eval- ments about whether actions can produce a
uate personal control or negative affectivity. given outcome (e.g., a widow’s expectations
The extent of these features presented over about how she will manage her household after
time could facilitate or detract from successful losing her spouse, or a man’s expectations of
aging. Negative affect is defined as a general his ability to reduce body mass index to a nor-
dimension of subjective distress and unplea- mal range). Greater levels of personal control
surable engagement that includes a variety of are proposed to contribute to successful aging.
unpleasant mood states, such as anger, con- Although personal control can vary depending
tempt, disgust, guilt, fear, and nervousness on the specific domain of interest (e.g., health
(Watson & Clark, 1984), not just the opposite versus marital longevity or occupational suc-
of positive affect; in fact, the two are quite dis- cess), it can also be considered from a more
tinct and nearly independent of each other global perspective.
(Naragon & Watson, 2009). Low negative affect Pearlin and Schooler’s (1978) Mastery Scale
is characterized by a state of calmness and seren- has become perhaps the most widely used
ity. Watson and Clark (1984) described negative measure of personal control in health research.
affectivity as a mood-dispositional dimension This tool could be quite useful in clinical prac-
that reflects pervasive individual differences in tice as well, and it was used in the MacArthur
negative emotionality and self-concept. Successful Aging Study (MacArthur Research
A nurse might assess for negative affectivity Network on SES and Health, 2008). The
by administering the Positive and Negative Mastery Scale consists of seven items that are
Affect Schedule (PANAS; Watson, Clark, & answered on a 4-point Likert scale.
Tellegen, 1988), a 20-item self-report measure Nurses may encounter patients who
of positive and negative affect that includes demonstrate little personal control, verbalizing
two subscales. The negative affect subscale in- helplessness with limited or no ability to effect
cludes descriptors such as distressed, guilty, change in their life. For example, a person with
and afraid. Individuals self-rate the extent to a perception of limited personal control might
which they feel these emotions at the time they state, “Well, I am 67; it’s too late to change,”
complete the PANAS, or they may respond or, “I am too old to exercise with my arthritis.”
based on the degree of their feelings over the Although low levels of personal control do not
past week (Watson et al., 1988). The PANAS enhance the likelihood of successful aging,
is in the public domain and can be obtained their presence is not entirely detrimental. The

7991_Ch28_469-478 12/08/19 5:28 PM Page 474
breadth and extent of personal control (or lack intrapsychic factors and functional perform-
thereof) must be considered. If the older adult ance mechanisms in a way that is facilitative of
has little sense of control over her ability to successful aging. Spirituality encompasses the
hike Mount Everest, this may be realistic, de- personal views and behaviors that express a
pending on her physical health, mobility, and sense of relatedness to something greater than
past or present health promotion activities oneself; the feelings, thoughts, experiences,
such as exercise involvement. But, more im- and behaviors arising from the search for the
portant, this task may not be relevant if the older sacred (Flood, 2006a). Spirituality is essential
adult does not need or aspire to climb Mount to successful aging; the sense of connection
Everest. Therefore, the individual and his or and beliefs about a higher power helps shape
her aspirations must be considered. the older adult’s values, beliefs, and behaviors
Think of an older adult with little sense of while living, especially in terms of what one
control over learning about a new medication. believes happens after death. Acceptance of
Perhaps this person does feel empowered to the reality of death and one’s own mortality are
mentor his or her grandchildren or complete part of being able to age successfully.
some household project. Focusing on areas of Output responses indicative of spirituality
greater personal control could help increase the are spiritual perspective, prayer, and religiosity.
older adult’s confidence in the ability to self- Spiritual perspective refers to beliefs in the ex-
manage other areas of health and well-being. istence of something beyond what is concrete
The nurse might encourage this patient to en- and immediate without devaluing the self
list the help of his or her grandchildren to set (Reed & Larson, 2006). A spiritual perspective
up a pill organizer or remember details about is an important resource for helping individuals
taking the medication. transcend difficulties faced in aging (Reed &
Older adults vary widely in their adaptation Rousseau, 2007) and may or may not include
to functional performance mechanisms as well religious expression (Reed & Larson, 2006).
as in their intrapsychic factors. One 77-year- Indicators of spiritual perspective are con-
old man may be post–cerebrovascular accident nectedness (with others, nature, the universe,
(CVA; physical health) but actively engage in or God); belief in something greater than the
physical therapy and walking around his farm self, in an intangible domain, or in a positively
for exercise (mobility, health promotion). This life-affirming faith; and a constant, dynamic
man might view his CVA as a challenge (low creative energy (Haase, Britt, Coward, Leidy,
levels of negative affect) rather than a frustra- & Penn, 1992). Although these attributes can
tion and threat to his masculinity. He might be considered aspects of inherent spirituality,
be determined to overcome (high levels of per- it is the realization and development of these
sonal control) his limitations and use garden- features that are represented by the term
ing as a (creative) means of range-of-motion spiritual perspective (Haase et al., 1992). More-
exercise. A similar 77-year-old man could also over, spiritual perspective is believed to enable
be post-CVA and resist physical therapy be- and motivate one to find meaning and purpose
cause it is “too painful and difficult,” believing in life (Banks, 1980; Hiatt, 1986; Highfield &
there is little he can do at his age to help the Caison, 1983; Hungleman, Kenkel-Rossi,
situation. This man might avoid visitors, stop Klassen, & Stollenwerk, 1985; Jourard, 1974;
physical therapy, and refuse to ambulate, re- Moberg, 1971), a key indicator of successful
maining in a wheelchair. Thus, two individuals aging (Troutman, 2011).
in similar situations could respond quite differ- The nurse could assess spiritual perspective
ently, depending on their intrapsychic factors, by administering the Spiritual Perspective Scale
resulting in very different aging trajectories. (Reed, 1986), a 10-item, self-administered or
structured-interview formatted scale that meas-
Spirituality ures one’s perspectives on the extent to which
Another foundational coping mechanism is spirituality permeates life and engages one in
spirituality, which is proposed to interact with spiritually related interactions. Other means of

7991_Ch28_469-478 12/08/19 5:28 PM Page 475
assessing spirituality include inquiring about one develops a new outlook on and under-
the older adult’s engagement in prayer or standing of life, with broad existential changes;
meditation; church (or other religious func- changes in one’s view of the present self and
tion) attendance; and discussing and/or en- the self in retrospect; and developmental
couraging religious rituals (what these mean to changes (related to existential changes and
the older adult, ways these practices might be changes in the self; Tornstam, 2011). Gerotran-
healthful, etc.). scendence is associated with positive aging
Integrated use of foundational coping (Tornstam, 2005) and has been theorized as a
processes is unique for each individual and is precursor to successful aging (Tornstam, 1994).
the initial adaptive process of successful aging. Gerotranscendence occurs when there is a
People who are more creative and who have major shift in the person’s worldview, where a
lower levels of negative affectivity and greater person examines her or his place within the
degrees of personal control will have more world and in relation to others (Tornstam,
effective adaptation of functional performance 1997). This means there is a radical change of
mechanisms; they will be more likely to engage one’s outlook on life from a concern with
in health promotion activities and mainte- mundane issues to a concern with universal
nance of physical mobility. Physical health can values (Tornstam, 1989). The older adult ex-
be affected by intrapsychic factors, the rela- amines values held, and these may change
tionship between immune function and emo- from what they were when that person was
tions, for example. Physical health also affects younger. Three kinds of age-related change
intrapsychic factors (such as how one responds occur with gerotranscendence.
psychologically to illness or accident).
The elements of successful aging interact Cosmic Dimension
and reciprocate, creating a strong, flexible web The cosmic dimension of life relates to the feel-
of support. More creativity, less negative affec- ing of being part of and at one with the uni-
tivity, and the extent and nature of personal verse. There is a redefinition of one’s sense of
control enhance spirituality through greater his or her place in the physical world as well as
spiritual perspective and more religiosity. If one the more global universe. Furthermore, an in-
is more creative, one is likely to be more recep- creased understanding of the spirit of the uni-
tive to new ideas and innovative problem-solv- verse results in a redefinition of the perception
ing methods. Lower negative affectivity also of time and, therefore, lessens one’s concerns
makes one more accepting of circumstances regarding the future (Tornstam, 1989). Thus,
and people, able to consider a broader range of one has decreased concern or fear of death
possible outcomes to a situation, and it in- because of a sense of continuity with the
creases the possibility of pleasant, positive in- universe; a newfound recognition of meaning
teractions with others. Greater personal control and sense of purpose in the greater scheme of
means that someone is more likely to be proac- things occurs.
tive in health promotion activities, problem-
solving, and disease management. A stronger Self Dimension
or deeper sense of spirituality contributes to A second kind of gerotranscendent change
one’s valuation of self and how one interprets deals with one’s self-perception. Gerotran-
life events such as hardships, celebrations, and scendence is believed to cause a new under-
the unknown. standing of fundamental questions regarding
one’s existence and a change in the way one
Gerotranscendence perceives one’s self and the world. The dimen-
Gerotranscendence is a shift in metaperspective, sion of perception of self concerns how one
from a materialistic and rationalistic perspec- perceives self and the surrounding world.
tive to a more mature and existential one that Tornstam (1997) observed that many older
accompanies the process of aging (Tornstam, adults look at their bodies with aversion,
2005). Experiencing gerotranscendence means perceiving them as an indication of overall

7991_Ch28_469-478 12/08/19 5:28 PM Page 476
decline, and concluding that both their mind see they have changed since age 50. The GS is
and their sense of self-worth have likewise brief and easily administered; it may also pro-
declined. The gerotranscendent person, in con- vide an opportunity to initiate discussions
trast, recognizes the separateness of spiritual about gerotranscendence with older adults.
growth and development apart from physical Another means of assessing gerotranscendence
deterioration. Tornstam suggests this ability to is by evaluating the older adult’s affective and
separate physical and spiritual concerns pro- emotional response to specific interventions.
vides a new feeling of freedom, which might For example, does the older adult seem to
result in finding the courage to be oneself and enjoy solitude? Does he or she talk about death
to no longer fear both social norms and ex- without fear, and as a transition, rather than
pected roles. The gerotranscendent person feels an endpoint? If the nurse finds that an older
freedom to self-discover new and perhaps un- adult patient does these things, the nurse could
expected aspects of himself or herself. The in- initiate further conversation with the patient
dividual may also show an increase in time about his or her perspectives and feelings or
spent alone in meditation or contemplation. even describe the topic of gerotranscendence
as Wadensten (2005) did, finding that older
Social Dimension adults recognized features of gerotranscen-
The third kind of change experienced in gero- dence in themselves.
transcendence deals with an increase in a sense A reasonable and well-balanced integration
of interrelatedness with others. The gerotran- of the outputs of each foundational coping
scendent person will begin to have greater need process for each individual, rather than an ideal
to view the self as a social being and will reeval- or set extent of features from within the foun-
uate the meaning behind relationships with dational coping processes, must be present for
family, friends, and other relationships. There the aging person to experience gerotranscen-
is a stronger sense of needing to feel part of the dence. The successful ager does not necessarily
human race. Tornstam (1989, 1997) suggests have ideal physical health; he or she likely has
this need results in an increased feeling of kin- one or more age-related chronic conditions but
ship or connection with past and future gener- manages them as well as possible, participating
ations, along with a decreased interest in in health promotion activities (such as physical
superficial or casual social interactions. So, the activity and good nutrition) and maintaining
gerotranscendent older adult may become more physical mobility to the best of his or her abil-
open and responsive to other people while at ity. This person finds innovative ways to deal
the same time becoming more selective with with struggles and may be involved in more
whom they engage and interact. traditional creative activities such as painting
Tornstam (1989, 1997) asserts that gero- or woodwork. On most days, the successful
transcendence is closely associated with wis- ager maintains low negative affectivity, seeing
dom because gerotranscendence and wisdom the glass as “half full rather than half empty.”
both involve a transcendence beyond right and The successfully aging individual feels empow-
wrong, accompanied by an increased broad- ered to influence his or her own health and
mindedness and tolerance, usually followed by aging (personal control), while recognizing
an increase in life satisfaction. In the Theory of that God or some Higher Power has a role in
Successful Aging, indicators of gerotranscen- life also. The balance of intrapsychic factors en-
dence are decreased death anxiety, engagement hances the older adult’s spirituality. These
in meaningful activities, changes in relation- foundational coping mechanisms increase the
ships with others, self-acceptance, and wisdom. possibility of experiencing gerotranscendence,
Gerotranscendence could be assessed using in which the older adult has a major shift in
the Gerotranscendence Scale (GS) (Tornstam, metaperspective and reevaluates where he or
1994). The GS consists of 10 items designed she is in the larger scheme of the world and
to capture what Tornstam (2005) calls “retro- what lies beyond. There may be pervasive
spective change” (p. 93), or how older adults change, as the older adult self-examines values,

7991_Ch28_469-478 12/08/19 5:28 PM Page 477
aspirations, and fundamental existential be- increase creativity levels or successful aging,
liefs. The older adult values time in solitude racial differences were observed, with black
and often thinks of relatives or loved ones who participants scoring higher on creativity and
have passed away, but also has concern for the successful aging compared with white partici-
well-being of upcoming generations. When pants. In a subsequent study, Flood (2006b) ex-
these foundational coping processes and gero- amined the relationships between creativity,
transcendent changes occur, greater life satis- depression, and successful aging. Level of de-
faction and a sense of purpose and meaning in pressive symptoms had a moderating effect on
life ensue. This person is aging successfully. the relationship of creativity to successful aging;
Nurses could assess successful aging with the that is, the presence of depressive symptoms
Successful Aging Inventory (SAI), a 20-item weakened the relationship between creativity
questionnaire with a 5.9 grade reading level. and successful aging. Significant differences in
Each statement is brief, positively worded, and creativity, depressive symptoms, and successful
numbered 0 to 4 with higher values indicating aging were found by racial group and education
more frequent/stronger responses. For example, level, with black participants having higher cre-
one statement is, “I have been able to cope with ativity levels and more depressive symptoms
the changes that have occurred to my body as I compared with white participants.
have aged.” Respondents indicate the point to McCarthy (2010) used the Theory of Suc-
which they agree or disagree with the statement cessful Aging as a guiding framework to inves-
or the extent to which they believe the state- tigate adaptation, transcendence, and successful
ment applies to them. Higher scores are indica- aging. She found that adaptation and gerotran-
tive of more successful aging. scendence were significant predictors of suc-
cessful aging (measured with the SAI).
Adaptation and transcendence together ac-
Applications of the Theory counted for almost half of the variance in suc-
A growing number of studies have used or cessful aging. Thus, McCarthy’s study provided
expanded on the Theory of Successful Aging. support for the Theory of Successful Aging and
Initial research (Flood & Scharer, 2006) inves- demonstrated sound psychometric properties
tigated the relationship between functional for the SAI. Other research has also supported
performance, creativity, and successful aging. the tenets of the theory (Barnes, 2012; Cozort,
Although the creativity intervention (story- 2008; McCarthy, 2010; Westman, Troutman-
telling, writing poetry, reminiscing) did not Jordan, & Nies, 2013; White, 2013).
Practice Exemplar
Mr. P., a 69-year-old man, suddenly and un- lot of a church near his home every day with
expectedly lost his wife after she had a pul- the aid of a cane. Remaining in the home was
monary embolus. He had known her since she very important to him; his ability to be as in-
was 15. Mr. P. had a third-grade education, dependent as possible permitted him a greater
limited literacy, and a very modest income. He sense of personal control. Therefore, he let his
was devastated by this loss. Although he had daughters help by delivering meals and doing
recently become the primary homemaker be- his laundry regularly, although he “really didn’t
cause of Mrs. P.’s surgery and declining health, like” to give up these tasks or rely on others. But
he had rather advanced macular degeneration, he recognized that he had to make this conces-
postherpetic neuralgia, and arthritis. Despite sion to remain in his home. He had figured out
these limitations, he had been his wife’s pri- innovative ways to live alone without his wife;
mary caregiver, maintained the home, and still for example, he placed toiletries in bottles of
preached occasionally at the church where he certain shapes and sizes because he could no
had been a pastor. After her death, although it longer see well enough to read labels to deter-
was a struggle, he managed to walk in the parking mine contents. He devised an organization
(continued)

7991_Ch28_469-478 12/08/19 5:28 PM Page 478

system for storing food items in the kitchen so Despite his health limitations and significant
that he could locate things by memory. He car- loss, he continues to engage in health promo-
ried “a big stick” when he went walking in case tion activities and strives to maintain his
he encountered any strange dogs. Mr. P. no- mobility. He demonstrates creativity in the ef-
ticed that if he tried to focus on “what I do have forts and modifications to do these things. He
and not what I don’t,” it seemed easier to cope also makes decisions that optimize his sense
day to day. of personal control and makes a conscious ef-
Although the loss of his wife was almost fort to have low levels of negative affect
unbearable, Mr. P. grew to accept the notion through positive self-talk. His spirituality has
that “it was her time, and the Lord took her,” deepened since the death of his wife; he now
and he found comfort and strength in prayer sees death as a transition to some other state
and listening to prerecorded sermons several of being rather than an end. Similarly, he finds
times a week. Mr. P. found himself thinking a new appreciation of his life and his views of
of his wife often, as he now lived alone. Some- the world, with a newfound sense of who he
times he talked to her because he sensed she is, his purpose, and the meaning in his life.
could hear him. He began to enjoy having his Mr. P. appears to be aging successfully.
home to himself, after having raised six chil- The nurse could encourage continued walking
dren there, and the freedom of “not having to (health promotion and maintenance of physical
set an example for anyone.” Sometimes he mobility) and regular contact with his primary
would put on his nightclothes early and eat ce- care provider. Likewise, the nurse could engage
real for dinner. Despite his chronic health con- him in problem-solving about home mainte-
ditions and the loss of his wife, Mr. P. grew to nance and activities of daily living. The nurse
enjoy his solitude and the freedom to “just be could encourage continued time spent in prayer
myself,” although he derived great satisfaction and assist Mr. P. to negotiate transportation to
from spending time with his grandchildren. church services. Mr. P. might also benefit from
Superficially, Mr. P. might seem like an av- introduction to the idea of gerotranscendence
erage, or perhaps disadvantaged, older adult. and time spent reminiscing or quietly reflecting.
Summary
The Theory of Successful Aging offers a frame- 2006; McCarthy, 2010; Troutman, Bentley, &
work for understanding a multidimensional, Nies, 2011; Troutman, Nies, & Mavellia,
complex phenomenon and for planning nurs- 2011) organizing framework for assessment,
ing interventions geared toward promoting planning, interventions, and evaluation of older
successful aging, making successful aging a adults that is individualized to the needs and
possibility for a broader range of older adults. situations of unique individuals and sensitive to
The theory provides an empirically supported the importance that the older adult places on
(Cozort, 2008; Flood, 2006b; Flood & Scharer, various aspects of aging.
Questions for Reflection ■ Based on the theory, how can the nurse
engage with an older adult to promote
and Discussion successful aging? Provide a specific
■ What grand theories provide a foundation example.
for the Theory of Successful Aging?
■ What instruments can be used to assess
the successful aging of an older adult?

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Barrett’s Theory of Power

CHAPTER
29
as Knowing Participation
in Change®
Elizabeth Ann Manhart Barrett

Overview of the Theory Elizabeth Ann Manhart Barrett, RN, LMHC,
Applications of the Theory PhD, FAAN, is Professor Emerita, Hunter
Practice Exemplar College, City University of New York; a re-
Summary search consultant; and a Health Patterning
Questions for Reflection and Discussion Therapist in private practice in New York City.
From the University of Evansville in Indiana,
she holds a BSN, summa cum laude, an MA,
and an MSN; she earned a PhD in nursing sci-
ence from New York University. Dr. Barrett has
more than 50 years of experience as a practi-
tioner, educator, researcher, and administrator
at universities and medical centers in New York
and Indiana. She is one of the founders and first
president of the Society of Rogerian Scholars.
Dr. Barrett’s scholarly endeavors have
evolved from her commitment to carry forward
Martha E. Rogers’ Science of Unitary Human
Beings. The primary focus of her research has
been the Barrett Theory of Power as Knowing
Participation in Change® and the Power as
Knowing Participation in Change Tool
(PKPCT). Colleagues have conducted more
than 100 studies using the theory and/or meas-
urement instrument. The PKPCT has been
translated into Japanese, Korean, Swedish,

Danish, Portuguese, French, and German.
Dr. Barrett has authored nearly 100 publica-
tions, including articles and book chapters, and
has coedited three books. Two years after she
crafted the first Rogerian practice methodol-
ogy, she edited Visions of Rogers’ Science-Based
Nursing, which received the American Journal
of Nursing Book of the Year Award. This was
one of the first books to provide chapters on
research, education, and practice focused en-
tirely on one nursing conceptual framework/
nursing theory. Dr. Barrett has presented her
work on power in Australia, Scotland, Canada,
the Netherlands, Germany, South Korea, and
479
7991_Ch29_479-492 12/08/19 5:27 PM Page 480
the Philippines, as well as throughout the The postulates of the SUHB are energy
United States. Her article in Nursing Science fields, openness, pattern, and pandimension-
Quarterly that won the best paper award for ality. We don’t have energy fields; we are
2012 was the lead article in an issue devoted to energy fields. There are two fields: the human
her work. Dr. Barrett’s website can be viewed and the environment. The environment en-
at www.drelizabethbarrett.com. compasses all that the individual or group is
not. These basic units of the living and nonliv-
ing are irreducible; they are unitary (Rogers,
Overview of the Theory 1992). Parse (1998) defined unitary as ever
Certain things happen that sometimes change changing, indivisible, and unpredictable.
the entire direction of our lives. So it was that I We live in a universe of openness, so fields
transplanted myself from Indiana to begin are open—all the way, all the time. There are
doctoral studies with Martha E. Rogers at no boundaries. Pattern is the distinctive defin-
New York University more than 40 years ago. ing characteristic of energy fields. Pattern is
Studying with Martha changed my professional what makes you “you” and me “me.” Pattern
and personal thinking, values, and actions, as cannot be directly observed; we observe man-
she became my teacher, my dissertation advisor, ifestations of pattern. Pandimensionality is a
my mentor, and later my colleague and friend. way of perceiving reality; it is a nonlinear do-
And so, the Power Theory journey began and main without temporal or spatial attributes
continues to this day. The passion and excite- (Rogers, 1992).
ment I experienced in those early days is still The three principles of the SUHB are about
with me and moves onward, primarily through change. Resonancy is how change takes place:
the work of other nurses. from long, slow waves to short, fast waves.
Rogers wove the conceptual framework Helicy is the nature of change, and integrality
of the Science of Unitary Human Beings is the mutual process of humans and their
(SUHB) as threads in the irreducible, unpre- environments (Phillips, 1994). These four pos-
dictable tapestry of the universe and many, tulates and three principles are the blueprint.
like myself, continue to weave this changing All work developed from this theoretical per-
fabric of our participatory world. In this spective needs to be consistent with them.
chapter, I describe the flow from Rogers’ Sci-
ence to the Power Theory to the research and Concepts of Barrett’s Theory of Power
practice applications. Figure 29-1 provides an as Knowing Participation in Change®
overview of this process. Although it appears Rogers did not write about power in the
to be linear, in truth, it is a nonlinear, evolv- SUHB, but she did emphasize that human be-
ing, mutual process. Figure 29-1 also serves ings can knowingly participate in change. Even
as an outline that tracks the unfolding of the though continuous participation in change is
theory and practice developments described a given, participation in that change may not
in this chapter. It will be helpful to refer to it take place in a knowing manner. I searched for
frequently. a definition of power that would be consistent
Butcher and Malinski discuss the theoreti- with the postulates and principles of the
cal matrix of the postulates and principles of SUHB and connect with the literature where,
the SUHB in depth elsewhere in this book, for centuries, the primary propositions main-
and so only a cursory overview will be pre- tained that power was about change and about
sented here. Keep in mind that development causality, although there was some meager
of the Power Theory required theoretical con- support for an acausal view of power. Finally,
sistency with the postulates and principles of the light bulb turned on. Power is the capacity
Rogerian science. This is one of the most diffi- to participate knowingly in change. Initially, I
cult and yet critically important aspects in- connected this definition with the literature in
volved in creating both theoretical and practice terms of change, but not in terms of causality
applications of the SUHB. because my purpose was to derive an acausal

7991_Ch29_479-492 12/08/19 5:27 PM Page 481
CHAPTER 29 ■ Barrett’s Theory of Power as Knowing Participation in Change 481
Acausal worldview
Postulates Energy fields Openness Pattern Pandimensionality
Principles Resonancy Helicy Integrality
Causal worldview
Theory Power-as-freedom Power-as-control
Awareness Choices Freedom Involvement Awareness Choices Freedom Involvement

to act in creating to act in creating
intentionally change intentionally change
Numerous forms Numerous forms

(some same, some different) (some same, some different)
Research Hypothesis testing
Supported Rejected
Application Practice
Health patterning
Practice methodology
Health patterning modalities
Power prescriptions
Living power-as-freedom
FIG 29-1 ■ Barrett’s Theory of Power as Knowing Participation in Change®. (Copyright © Elizabeth Ann
Manhart Barrett, RN, LMHC, PhD, FAAN.)
theory of power consistent with Rogers’ con- of power were identified as awareness, choices,
ceptual model. This acausal theory was differ- freedom to act intentionally, and involvement
entiated from other causal power theories that in creating change. These concepts were vali-
can be summarized by May’s (1972) definition dated as consistent with the SUHB through a
that power is the ability to cause or prevent judges’ study with New York University fac-
change. Only much later did it become clear ulty, who were considered knowledgeable in
that the definition of power as the capacity to Rogerian thought.
participate knowingly in change also described Power is the capacity to participate know-
causal ideas of power. ingly in change by being aware, making
Through readings in various relevant areas choices, feeling free to act intentionally, and
and synthesizing my own ideas, the conceptual involvement in creating change. In a nutshell,
manifestations of the inseparable dimensions power is being aware of what one is choosing

7991_Ch29_479-492 12/08/19 5:27 PM Page 482
to do, feeling free to do it, and doing it in- power with its four dimensions of awareness,
tentionally (Barrett, 1986, 1989, 1990a, choices, freedom to act intentionally, and
2010). The theory describes power in groups involvement in creating change, along with
as well as in individuals. The inseparable as- the 12 characteristics used to measure power as
sociation of a person’s or a group’s power knowing participation in change. It is important
strengths or weaknesses is known as their to note that these new insights changed noth-
Power Profile. ing I had previously written concerning power,
but they expanded the theory to describe
Power-as-Freedom and how power operates in the two worlds we live
Power-as-Control in—the causal and acausal worlds. Of course,
While my initial interest was in developing an although practice applications continue to focus
acausal view of power, I was often puzzled re- on power-as-freedom, clients more easily un-
garding why the four dimensions of awareness, derstand how to live power-as-freedom when
choices, freedom to act intentionally, and in- it is contrasted with power-as-control, the
volvement in creating change seemed to also usual way people understand power and witness
describe power from a causal perspective. After it in our everyday world. Power-as-control is
many years and for the second time, the power often described in terms of force, dominance,
light bulb turned on. One day while walking or manipulation in subtle or not-so-subtle
down the street, I realized that the Power The- varieties of control. Figure 29-2 contrasts these
ory did indeed describe two types of power. The two worldviews.
difference is simply that one reflects an acausal
worldview and the other reflects a causal The Power as Knowing Participation
worldview. We live in two worlds, and power in Change Tool (PKPCT, Version II)
as a phenomenon that exists in the universe Following a second judges’ study, a paper-and-
lives in both of them. So, I named these two pencil research instrument using semantic dif-
types of power—power-as-freedom and power- ferential technique was developed to measure
as-control. For example, in the extreme situa- power as knowing participation in change. The
tion of murder, if the murderer is aware of PKPCT, Version II consists of the four power
what she is choosing to do and feels free to act dimensions, each measured by 12 bipolar ad-
on that intention and is involved in creating jective pairs randomly reversed and randomly
that change, this is power as surely as the ordered for each dimension. A thirteenth ad-
acausal type of power that does not interfere jective pair is not included in the score because
with another person’s freedom. Freedom is in- it is a retest reliability item that is used only for
compatible with causality since causality allows research purposes. A complete accounting of
for control, prediction, and reduction. Some of the tool development, along with a copy of the
the forms in which power manifests can be for PKPCT, Version II and the Scoring Guide is
purposes of control, such as money that can be presented elsewhere (Barrett, 1990b, 2003),
used to control people, places, or things. On so only a summary is discussed here to aid
the other hand, money can be used for pur- understanding of how it is used in practice.
poses of freedom through such things as phi- Although the adjective pairs appear to be lin-
lanthropy, education, meeting basic needs, but ear, in truth they are not to be conceptualized
never interfering with the freedom of others. in that manner when one attempts to move
Knowledge can also be used for purposes of from the less powerful adjective to the more
control or freedom. powerful adjective. “In a world where time and
I would further suggest that we can view the space exist, the words from and to would be a
many variations of power theories, such as so- linear process. However, in a pandimensional
cial power, political power, positional power, universe, change takes place throughout the
personal power, empowerment, and others as human and environmental fields that are with-
forms in which power manifests. They can be out spatial or temporal attributes” (Phillips,
further understood in terms of the definition of 2010, p. 57).

7991_Ch29_479-492 12/08/19 5:27 PM Page 483
Barrett’s Theory of Power as Knowing Participation in Change:

Spiritual and Material Worldviews
Spiritual worldview Material worldview

Power-as-freedom Power-as-control
Awareness Choices Freedom Involvement Awareness Choices Freedom Involvement

to act in creating to act in creating
intentionally change intentionally change
Numerous forms Numerous forms
FIG 29-2 ■ Barrett’s Theory of Power as Knowing Participation in Change®: spiritual and material
worldviews. (Copyright © Elizabeth Ann Manhart Barrett, RN-BC, LMHC, PhD, FAAN.)
After a pilot study of 267 men and women, Applications of the Theory
revised versions of the PKPCT, Version I and
Version II, were further tested in a national
Research
study using a volunteer sample of 625 men and I have completed eight additional studies, both
women with participants from every state. The quantitative and qualitative, most with col-
response rate was 61%, and the sample com- leagues, both funded and unfunded. In 1998,
prised men and women with a minimum of a Caroselli and I published a review of the Power
high school education who were diverse in as Knowing Participation in Change® research
terms of age (21–60 years), marital status, city literature (Caroselli & Barrett, 1998); and Kim
size, geographic residence, and occupation. (2009) published an update of the power as
This sample was used to test the dissertation knowing participation in change research in
hypothesis that human field motion and power 2009. Currently, more than 100 studies have
were correlated. I reasoned that the greater the been conducted using the theory and/or
effortless, rhythmic flow of human field mo- measurement instrument. The tool has been
tion in one’s life, the greater one’s capacity to translated into Japanese, Korean, Swedish,
participate knowingly in creating change. The Danish, Portuguese, French, and German.
hypothesis was supported with two statistically These translations allow for testing a basic prem-
significant moderately strong canonical corre- ise of the Power Theory: that the capacity to par-
lations of .61 and .16. Reliability, measured as ticipate knowingly in change is a quality of all
the variances of factor scores, ranged from .63 to people, regardless of race, ethnicity, nationality,
.99; and validity coefficients, computed as fac- or country of residence.
tor loadings, ranged from .56 to .70 (Barrett,

1986, 1990b, 2003). The findings from these Practice Methodology
studies provided support for using the theory Shortly before finishing my doctoral studies,
and measurement tool in nursing practice. I completed a postgraduate program in holis-
Most other researchers who have used the tically oriented psychotherapy to enhance the
PKPCT, Version II computed reliability using knowledge gained through a MSN in psychi-
Cronbach’s alpha with the majority reporting atric/mental health nursing and experience
higher coefficients than what I had found teaching students and working in mental
(Caroselli & Barrett, 1998; Kim, 2009). health settings. So, I began a private nursing
Although I use Version II in my practice practice called Health Patterning as an alter-
and most researchers select this version as well, native to traditional psychotherapy.
Version I also has acceptable reliability and Soon I developed the first practice method-
validity (Barrett, 1986). The difference is that ology for Rogerian nursing practice (Barrett,
in Version I the power dimensions are meas- 1988). In the revised version, it consisted of
ured in relation to self, family, and work. two processes: pattern manifestation knowing

7991_Ch29_479-492 12/08/19 5:27 PM Page 484
and voluntary mutual patterning (Barrett, helps people change limiting beliefs, disturb-
1998). Butcher (2006) modified the methodol- ing emotions, and other difficulties in living.
ogy to include Cowling’s (1990, 1997) method- Most people easily understand ideas of whole-
ology from his theory of unitary pattern ness, unitary human beingness, and the mutual
appreciation. Incorporating Butcher’s revision, process with the entirety of their environment,
the two phases are termed pattern manifestation including other people, places, and things. We
knowing and appreciation and voluntary mutual are not in charge of how things turn out as that
patterning. There is no sequential order; both involves everyone and everything else partici-
processes are continuously shifting and/or pating, knowingly or unknowingly, in the
going on simultaneously. mutual process. Our power concerns what we
think, feel, say, and do.
Phase I: Pattern Manifestation Knowing
and Appreciation Health Patterning
My first question when someone sits down in Quite simply, health patterning is exploring
my office is “What do you want?” I’m interested with people ways to make the changes they
in knowing what changes people want in their want to make. More formally, health pattern-
lives since that will be the focus of the health ing is a power enhancement therapy that
patterning sessions. Relevant historical infor- guides people to use their power-as-freedom
mation will unfold as our dialogue proceeds; to participate knowingly in creating the
I do not take a typical initial health history. changes they want to make in their lives by
becoming increasingly aware, making more
Phase II: Voluntary Mutual Patterning powerful choices, feeling free to act on their
Another initial question is “Where do you see intentions, and involving themselves in creat-
yourself in your life right now?” If a person is ing change. It is not talk therapy. It is pattern
having difficulty zeroing in, I might ask, “If manifestation knowing and appreciation and
you only had one sentence rather than 45 min- voluntary mutual patterning coming alive in a
utes, what would you say?” As you can see, the moment-by-moment unfolding process. How
three principles of change are operating as we is that different from talk therapy? The focus is
mutually explore the nature of change in their not on simply “talking about”; rather, the focus
lives (helicy) as well as the mutual process is on the person’s intentions and involvement
through which the change occurs (integrality) in participating knowingly in change. There are
and how that change evolves (resonancy) as we no labels, no agendas, and no expectations.
focus our intention on creating change without My clients, for the most part, are people
attachment to outcomes or results. Intentions, who want some sort of change in their lives
aims, or directions are consistent with the that they haven’t been able to accomplish, even
acausal postulates and principles of the SUHB, when the change means accepting what cannot
whereas setting goals involves end points and, be changed in ways they desire. Often there is
like outcomes, end points are not appropriate. a crisis revolving around one or more of four
Clients learn quickly that there is no causal “If major areas of life: oneself, health, relation-
I do this, then that will happen.” They are ships or career. My intention is to teach people
often relieved to learn that the way this works how to find the authority and clarity in them-
is that “If I do this, then I will see what hap- selves by becoming aware of their intentions,
pens.” The phenomenology of the moment is by making choices from the options that are
present-oriented with little focus on the past, open to them, and learning to give themselves
which is gone, or the future, which hasn’t been the freedom to carry through on their choices
created yet, nevertheless recognizing that we as they go about creating change in their lives.
are actually using our power to participate in After initiating a dialogue of meaning and
creating that future at every moment. There is asking clients to identify what they want to
no focus on pathology or diagnosis. The idea accomplish in our work together by telling
of power as knowing participation in change me specifically three things, I ask clients to

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complete the PKPCT. I tell them nothing opposites using various health patterning
about the tool except how important it is to modalities and Power Prescriptions. This is not
follow the instructions. It is important that the work of a day, yet the power tool can be a
they respond to the items honestly and frankly valuable entrée to defining the person’s Power
in order to get an accurate, meaningful read- Profile of greater and lesser areas of strength
ing. I point out that the tool is a reflecting mir- and providing direction for working with dif-
ror; it reflects to people who they tell it they ferent modalities, such as creating a shift to the
are. Afterward, I inquire about their notion opposite, for example, from chaotic to orderly
about what the tool is assessing; they are usu- or from constrained to free.
ally shocked to learn it is power. This provides
an opportunity to teach them the power theory Health Patterning Modalities
by briefly describing the definition, the two When clients, like all of us, are attempting to
types, the four dimensions, and a few examples create an intended change, it is helpful for
of the numerous forms in which both types of them to understand the acausal nature of the
power manifest. In the following session, I will universe and appreciate the patterning mani-
have scored the power tool and can discuss the festing in their experiences, perceptions, and
person’s Power Profile strengths and weak- expressions (Cowling, 1997). Interestingly,
nesses as well as ways our work together may clients grasp simple examples of acausality
enhance their Power Profile and facilitate ac- quickly as they, like most of us, have learned
complishment of what they are seeking that wanting something to happen, certainly
through health patterning. For those who do does not mean that it will. It is often a relief to
not wish to complete the tool, there are many realize none of us is the sole generator of what
other optional modalities. occurs in our lives, and yet we can use our
This process is quite different from using power to knowingly participate in the relative
the PKPCT in quantitative research in which present. That’s where health patterning modal-
the interest is in group scores and what is ities come in, yet these avenues for creating
learned is about the group, and group scores change in a knowing way are not magic bullets.
can be compared with scores of other groups, Nor does one size fit all.
and all the other possibilities available through Even though the battle between free will and
quantitative methods. In Health Patterning, determinism is believed to go back as far as the
the PKPCT scores provide the Power Profile pre-Socratics and continues to rage on, the
for one individual. This is a qualitative, phe- SUHB and Barrett’s power theory accept the
nomenological process. I do not tell or show acausality of free will as a given. Power-as-
the person his or her scores. The scores are freedom is just that—freedom to powerfully
used only to help the nurse or clinician assess the create change without interfering with the free-
relative strengths and weaknesses not only of the dom of someone else. Nor is power-as-freedom
four dimensions but also of the 12 opposite ad- about forcing yourself to do something you
jective pairs used to measure the dimensions. don’t want to do; rather, it is about making
These 12 characteristics are pattern manifesta- aware choices, feeling free to carry out those
tions of power and often represent a person’s choices, and then doing so in a way that is true
belief systems concerning power. Dwelling to your values, such as those that pertain to
with this data is quite a complex process. In health and well-being. This approach requires
the power-imagery process (described later in practice methods and modalities to be consis-
the chapter), sophisticated algorithms fine- tent with this worldview. It does not, however,
tune the mechanics of the method. The point require clients to view the world in this way.
here is that using the tool with an individual is Health patterning modalities are general ap-
a mutual process of the client and the nurse; a proaches used to help people use their power in
computer cannot duplicate this human en- new ways. The general focus includes lifestyle
counter. Power enhancement occurs when the changes, struggles with illness, difficulties in living,
weaker areas are reversed toward their stronger and enhancement of power-as-freedom through

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involvement in the healing encounter. These Breathe out one time. See yourself choosing
modalities are selected within the context of what with awareness.
is happening in a person’s life and in relation to Breathe out one time. See yourself acting
the nurse’s knowledge and skill in using them as freely.
well as the client’s personal preferences. They take Breathe out one time. See how you are involv-
place in a life affirming, caring environment, de- ing yourself in participating in creating the change
scribed by Rogers as unconditional love. you want to see in your life.
Examples of health patterning modalities in- Breathe out and open your eyes.
clude imagery, Therapeutic Touch (TT), med-
It is important after completion of any
itation, dream reading, love-power resonance,
imagery exercise to ask the client how she is
centering, prayer, power-imagery process, Power
feeling. If the person is uncomfortable in any
Profile process, and techniques of will. Imagery
way, it is necessary to continue voluntary
exercises can often be created from the content
mutual patterning to explore her experience,
of what comes up during the session. However,
perception, and expression until comfort
here is an exercise that can be used to focus on
returns.
any intention that the client wants to manifest.
Health patterning modalities can be used in
The title is health patterning, and it incorporates
most situations that nurses encounter. People
light, sound, color, and motion. These are
often come to me seeking relief from emo-
modalities Rogers believed would be frequently
tional pattern manifestations related to physi-
used in the future. The intention for this health
cal illness. Other people come with conditions
patterning imagery is a change the person wants
that include pattern manifestations such as
to make in her life.
anxiety, depression, grief, anger, fear, guilt,
Health Patterning Imagery Exercise troubling human field image, meaninglessness,
creative blocks, substance use dependency, dis-
Sit up straight. Get comfortable. Do not cross your ease prevention, eating disorders, many types
arms or legs. Place your hands on the arms of the of pain, presurgical/postsurgical procedures,
chair or on your lap with palms down. Close your prosperity or employment career concerns,
eyes. Find yourself breathing in an even and reg- spiritual distress, end-of-life issues, or a com-
ular way with long, slow out-breaths through your bination of these or other difficulties in living.
mouth and briefer in-breaths through your nose. The focus is on people as unitary wholes
Breathe out with a long, slow breath through your with their unique perceptions, experiences, and
mouth, releasing pain and suffering, and through expressions. The practice arena is ripe with
your nose breathe in love and light. After breathing opportunities for nurses to research how the
out with another slow, releasing breath letting go power theory can be used to advance practice
of any distress you may be experiencing, breathe by investigating ways health patterning modal-
in the blue of the sky and the gold of the sun in ities can promote healing.
beautiful blue-golden light. Breathe out slowly one
more time and then breathe any way you like. Power Prescriptions
Now, see and know that your hands are made Power Prescriptions are the specific ways the
of sky and earth. With these hands, you are able health patterning modalities are used with
to weave your own life. Know that you intend to a particular individual or group, as opposed
weave your own life with the threads and colors to the general category of health patterning
you choose. See and recognize the working out modalities. Again, they are designed to en-
of the health patterning that your own weaving is hance power-as-freedom and are individual-
creating. In doing so, know that by freely making ized depending on each person’s wants and
choices with awareness, you are finding your own needs. As power-as-freedom grows, the person
way to powerfully participate knowingly in bring- is less vulnerable to power-as-control tactics
ing about change. Now think of your intention to from others or from themselves with others
create a specific change. and with themselves. This is one way people

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heal. With enhanced power-as-freedom, they The Power-Imagery Process

find the strength to change limiting or detri- The power-imagery process, or PIP as Gerald
mental beliefs and behaviors. N. Epstein, MD, and I named it when we de-
Power Prescriptions are not like medical veloped it several years ago, basically works like
prescriptions. It is not as if you follow the pre- this. A person completes the PKPCT. The
scribed regimen expecting a particular result. findings, called the Power Profile, identify
Rather than “if this, then that,” the aim of the stronger and weaker areas of power. Then,
Power Prescriptions is to guide people toward the client begins working through imagery
developing awareness, making more powerful exercises and techniques of will created to en-
choices, feeling free to act on their intentions, hance the weaker areas in both the four power
and becoming involved in creating specific dimensions and the 12 power characteristics.
changes in their lives. This is a three-step, 21-day process designed
Sometimes clients create their own Power to enhance people’s power through imagery.
Prescriptions. A client whom we will call Julia In the first week, imagery exercises are focused
came to see me when she finished chemother- on the four dimensions. In the second week,
apy for non-Hodgkin’s lymphoma. Sometimes the focus is on the 12 characteristics. We call
she creates her own exercises that often come this process the Power Plan, which is a way to
as images to her during Therapeutic Touch create a shift from lesser to greater power pat-
treatments. Along with other clients, she tern manifestations, for example, from chaotic
shares her remarkable story on my website or orderly or from constrained to free. In the
(www.drelizabethbarrett.com) to contribute to third week, the process involves the Power-
the well-being of others. There you will find an Gram exercises that put together the power
example of an imagery exercise she created dimension exercises from the first week with
called “The Hapuna Chair.” To access “The the exercises for the characteristics that were
Hapuna Chair,” click on “What I Do” on the focus during the second week. We have
the menu bar. Then click “Real Stories. Real used this process with groups in the corporate
People. Real Power—Julia’s Story” on the and nonprofit worlds, with individuals in our
drop-down menu. private practices, and with group workshops.
Practice Exemplar
True Stories of the Power-as- Love-power resonance is a health patterning
Freedom Journey of Two Friends modality I developed to further understand the
nurse–client healing process—a way to capture

Although all nursing experiences are meaning-
the meaning of the love that goes on between
ful, some remain with us forever. So, it was with
the nurse and client. It is well known that love
Allison and Kay. Allison and Kay struggled
heals—both the giver and the receiver—while
with their own illnesses and yet maintained
hate destroys, and the absence of love hinders
a healing partnership with each other even
healing and can be deadly. Love is the most po-
though their illnesses took quite different direc-
tent form of power-as-freedom, and hate may
tions; it was a mutual process partnership that
be the most intense emotion motivating ex-
manifested love-power resonance. Although it
treme forms of power-as-control, such as abuse,
was many years ago when these two young
oppression, and murder. Love and freedom are
women crossed the threshold of my office door
intimately connected, as are hate and control.
to begin health patterning, the memory lingers
I believe that love is the fire that lights the
on. Love-power resonance was the glue that
power-as-freedom furnace. In love-power res-
united the three of us. Both gave me permission
onance, the frequency vibrations of both love
to use their names and share their stories.
(continued)

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and power accelerate one another, and healing patterning session occasionally for what she calls
manifests through resonating waves of her “power boost.”
change. The illusion of separation disappears, Allison learned the power-as-freedom way
and the will is used for intentional healing using imagery exercises, techniques of will,
events that enliven health. Love-power reso- prayer, and dream reading as her health pat-
nance teaches people to become “in power” in terning modalities, individualized as Power
the same sense as being “in love,” where two Prescriptions, to transcend the initial devasta-
people become part of something greater than tion she experienced with the cancer and
themselves and healing manifests through res- CMT. She used a daily imagery exercise in
onating waves of change. Helicy describes the which she imagined a magic wand tapping her
nature of this change, resonancy describes legs, ankles, and feet and bringing the nerves
how this change takes place, and integrality is to life. She remains cancer free, yet she still
the process whereby the change occurs struggles with the pattern manifestations of
(Phillips, 1994). CMT. She and her husband have two chil-
In love-power resonance, love is like power dren, even though she was told if she had a
without effort—it just flows. It taps into child she would spend the rest of her life in a
consciousness and spirituality, where con- wheelchair.
sciousness is defined as the Spirit in all that is, By the end of our formal time together,
was, and will be, and spirituality is defined as Allison had decided to channel her fighting
experiencing the Spirit in all that is, was, and will spirit and advocacy for others toward starting
be. Phillips (2010) uses the term energyspirit to a foundation, the Hereditary Neuropathy
describe consciousness. I hypothesized that Foundation (HNF), to search for a “cure” for
love-power resonance created an opportunity CMT. HNF is now a thriving client advocacy
for change by accelerating the momentum of and research-oriented nonprofit organization
commitment to go forward with one’s inten- that provides educational information to per-
tions, while acknowledging that the outcome sons living with CMT, professionals, and the
is unknown and unpredictable. general public. Allison had this to say: “Health
First came Allison shortly after she had patterning helped me view my illnesses as
finished surgery, chemotherapy, and radiation opportunities for learning how to deal with life
for treatment of synovial sarcoma of the hip. circumstances, not as tragedies, but as experi-
Allison’s picture and story are published on ences that helped me become a more powerful
my website at www.drelizabethbarrett.com. person who can help others who have CMT”
Pattern manifestation knowing and appreci- (www.drelizabethbarrett.com). You can find
ation revealed that Allison was experiencing bi- the HNF website at http://hnf-cure.org.
lateral foot drop and that she was walking with Allison met Kay as they entered the eleva-
an awkward gait that she perceived, experi- tor of the building where they both lived. By
enced, and expressed as painful. It was apparent the time they arrived at their floors, they had
that this was affecting her human field image. revealed to each other that they both had can-
After the chemotherapy, her latent genetic pre- cer; the seeds for love-power resonance be-
disposition to Charcot-Marie-Tooth disease tween them had been planted. Soon Allison
(CMT) had emerged. Voluntary mutual pat- referred Kay to me.
terning included discussion of this degenerative Kay began her almost-continuous, 10-year
nerve demyelination disorder and how it had battle with cancer when she was 21. First, can-
produced a progressive muscle atrophy of her cer claimed her left breast, then the right
legs, hands, and feet. A year later the sarcoma breast, then it went to the spine and other
reoccurred, and she again underwent surgery bones and then the lungs and finally the brain.
and radiation. We worked together for another Kay came to me for health patterning fo-
year, and since then she has come for a health cused on Therapeutic Touch and imagery to

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relieve pain at the time the cancer had spread Kay: These new ideas are hopeful, and they are
to her spine. Later, she became paraplegic and giving me courage.
was told by her physicians that she would have Allison: It’s hard not to ask, “Why me?” Why
to spend the rest of her life in a wheelchair. do Kay and I have to struggle with these
She refused to accept this ultimatum, just as devastating diseases?
Allison had rejected it. When she was no Elizabeth: Illness and disease can have many
longer able to come to my office, I began sources and many meanings, and sometimes
going to her home to give her TT treatments, those sources remain a mystery.
and she also began to work with a physical (Allison hands Kay a tissue to wipe her eyes.)
therapist. During one of the TT treatments,
My efforts were not to get Kay to face her
she suddenly cried out, “I can feel sensations
so-called death or work through stages of
in my spine.” As the tears rolled down her
death and dying. My purpose was to help her
cheeks, she looked up at me and said, “This is
live the way she chose, and live she did. She
what I prayed for.” Soon she could walk with
lived her dying in a power-as-freedom way
a walker and for short distances with a cane,
that was uniquely her own.
and she said “goodbye” to the wheelchair. She
On a few occasions, she asked me to tell
was living in the moment. She shocked the
her what I thought it would be like “at the
physicians the first time she walked into their
end.” I told her for me there is no end, as we
offices on her husband’s arm, using just a cane.
never die; our energy simply transforms. We
During those sessions at Kay’s apartment,
talked about the fact that some persons who
Allison would often join us. Pattern manifes-
have had a near-death experience describe a
tation knowing and appreciation and voluntary
deep sense of peace and well-being and they
mutual patterning kept the sessions focused
sometimes describe passing through a tunnel
on a dialogue of meaning. Here’s a brief sam-
of great darkness into a bright light on the
ple of how the health patterning conversations
other side, where a world of indescribable
would take place.
beauty awaits. She asked questions such as,
Kay: Why do we have to be sick when we want “How can I stay alive while dying?” and
so much to be healthy? “What about people without illness who are
Elizabeth: Are illness and health incompatible? dying or may be almost already dead?”
Allison: What is health, anyway? Many times, Kay talked about feeling a
Kay: I’m confused. sense of closeness with her spirituality that for
Elizabeth: I see health as a process of actualiz- her connected healing with a sense of holiness.
ing possibilities for well-being by participat- This was a new way she was experiencing her
ing knowingly in change. power-as-freedom, as a kind of prayerful

Allison: Can health be different for different reverence. She often asked me to pray with
people? her. During this time, she also returned to
Elizabeth: Yes. Health is a value that people her religious roots and developed a personal
define for themselves, so different people see it relationship with her God.
differently. Kay needed frequent TT treatments, and it
Kay: I’ve known people who are sick or at least wasn’t possible for me to go to her home that
have some disease, and I think they are often. So, I decided to offer her an opportunity
healthy in what I’ve been seeing as the to try a love-power resonance experiment.
bigger picture. I explained that imagery and TT are pow-
Allison: Me, too. erful nonlinear Power Prescriptions that do not
Elizabeth: Illness can simply be a way a depend on physical proximity and that healing
person’s health is manifesting at a certain possibilities are enhanced when we leave the
time, sometimes serving as a wake-up call visible realm of ordinary time and space and
or a trigger for transformation. enter the invisible realm of pandimensionality,
(continued)

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which is a domain where there are no temporal I asked Kay to remind herself that she was
or spatial attributes. I invited Kay to meet with living her power-as-freedom by repeating
me over the phone for 5 minutes daily. We daily the following power mantra: “I am free
agreed that during this 5 minutes we would to choose with awareness how I participate in
unite our intentions for her healing to manifest changes I intend to create.” The days turned into
in whatever way that might happen. We were weeks, months, and eventually over 2 years. She
both clear that there could be no attachment to often would tell me during our 5-minute ex-
outcomes; yet the pattern manifestations that change that she was going into the hospital for
emerged included decreased pain, improved another gamma knife treatment or radiation
memory, less disturbed sleep, unlabored or chemotherapy, procedures she considered
breathing, and an uplifted spirit. Over time, she helpful and “no big deal,” and amazingly she
came to understand that healing is far more quickly bounced back to her optimistic self.
than curing a disease; it is about healing the Early on, Allison made a commitment to con-
whole person, and it is not defined by the tact Kay several times a week and was a source
presence or absence of disease. of strength to Kay in ways that I could not be
Some days, our 5-minute love-power since they had both experienced cancer.
resonance experiment consisted of a brief Finally, Kay’s husband called to tell me she
imagery exercise lasting less than a minute had been admitted to the hospital. When I ar-
before doing healing at a distance with my rived, she was propped up in bed in a sitting
hands hovering over a Polaroid photograph of position, but hunched over with her forehead
her. The imagery often incorporated the near her chest. She was semiconscious and
powerful, pandimensional healing modalities hadn’t spoken for the 2 days she had been
of light, sound, color, and motion. Some days, there, although her husband and parents
I asked her to define a specific intention for thought she recognized them. Her family left
her healing for that session. In keeping with the room so that we could have private time
our previous discussions, her intentions did together. I asked her if she wanted to do “our
not focus on outcomes. thing,” and she nodded her head. When I told
For the first year, we did what we called her we were finished, I was amazed that she
“our thing” almost daily and after that three looked over at me with a slight smile. I held
or four times a week. Kay found this love- her hand. Soon her husband came into the
power resonance experiment a meaningful room, and he and I were talking softly. All of
way to maintain her optimistic courage and a sudden, Kay rose up and called out her hus-
relieve pain and other symptoms despite the band’s name, saying, “I love you. I love you so
progression of the disease. She was an inspi- very much.” He was overcome with joy and
ration to me, and we shared what Parse calls ran out of the room to tell her parents and
“meaning moments” many times as she con- brother, who returned immediately. Kay
tinued her healing journey. Although she did- called out first to her father, “Daddy, Daddy,
n’t deny her illness, she was healthy in spite of I love you” and then to her mother and
it. Cancer may have ravaged her body, but not brother. These were moments of love-power
her soul—not her energy field. resonance. She passed on 3 days later having
Rumi (1988) described the transformation completed a 10-year healing journey. In the
I witnessed as the months went by when he words of my imagery teacher of blessed mem-
said: Journeys bring power and love back into ory Colette Aboulker-Muscat, “The bridge be-
you. If you can’t go somewhere, move in the tween us will always exist—now and forever”
passageways of yourself. They are like shafts of (Laura Goldstein, personal communication,
light, always changing and you change when January 10, 2004). For me, what I witnessed
you explore them. that day at the hospital was evidence that

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imagery, Therapeutic Touch, and prayer used Love is a higher frequency vibration rip-
during the love-power resonance experiment pling through the universe; it has greater
had made a difference in her healing. power to impact the universe than the lower
The love-power resonance experiment was frequency vibrations of negative phenomena.
not a scientific experiment testing the princi- Everything we do makes a difference in
ple of resonancy; it was simply a process of terms of our mutual process with all that is.
discovery that I sometimes experienced like a The more love we manifest, the stronger the
laser moving in unison between us, focused on power to bring peace and well-being to the
our intention for her healing. world.
Summary
In closing, I am grateful that for more than The definition of power as the capacity to
50 years, I have been privileged to be a profes- participate knowingly in change was derived
sional nurse and to have experienced my profes- from Rogers’ conceptual model and describes
sion by participating in the roles of practitioner, both power-as-freedom and power-as-control.
teacher, administrator, and researcher. Although The PKPCT measurement instrument and the
all these roles were meaningful, practice has al- research basis for practice are reviewed. Health
ways been my first love, and Allison and Kay are patterning is a power enhancement therapy
two of the many clients that remain in my heart. that guides people to use their power-as-free-
In this chapter a description of the flow dom to participate knowingly in creating the
from Rogers’ Science of Unitary Human Be- changes they want to make in their lives by be-
ings to Barrett’s Power Theory to research and coming increasingly aware, making more pow-
practice applications is presented. Major as- erful choices, feeling free to act on their
sumptions include (1) power is a phenomenon intentions, and involving themselves in creat-
that exists in the universe; (2) human beings ing change. Health Patterning modalities are
are born with power; (3) no one can give power individualized by using Power Prescriptions.
to another, and no one can take power away; A practice exemplar illustrates the way the the-
and (4) human beings have free will and can ory is used to teach people how to live power-
knowingly participate in creating change. as-freedom.
Questions for Reflection ■ How does Barrett define health and how
does this definition correspond with other
and Discussion ways of viewing health?
■ How do Health Patterning modalities ■ What are the two phases of Barrett’s prac-
compare and contrast with conventional tice methodology? Describe these phases
approaches to lifestyle change? in your own words.

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Marlaine Smith’s Theory

CHAPTER
30
of Unitary Caring
Marlaine C. Smith

Practice Exemplar Marlaine C. Smith is currently the Helen K.
Summary Persson Eminent Scholar at the Christine E.
Questions for Reflection and Discussion Lynn College of Nursing at Florida Atlantic
University. She served as Dean of the College
from 2011-2019. Dr. Smith has been a nurse
since 1972 and has practiced in acute care,
long-term care, and public health settings from
metropolitan areas to rural small towns. She
graduated from Duquesne University with a
BSN; the University of Pittsburgh with two
master’s degrees, one in public health and the
other in nursing with a specialty in oncology
and nursing education; and New York Univer-
sity with a PhD in nursing. Dr. Smith held
faculty and academic administrative positions
at Duquesne University, Penn State Univer-
sity, 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, Parse’s Man-Living-Health

(now Humanbecoming), Watson’s Theory of
Transpersonal Caring, and Newman’s Health
as Expanding Consciousness, and has written
many commentaries on issues related to the
development of nursing theory. 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 impor-
tant outcomes for persons in acute and long-
term care settings. The last completed study
was funded by the National Institutes of
Health, National Center for Complementary
and Alternative Medicine.
493
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Dr. Smith has been interested in transthe- referents of the theory, applications of the the-
oretical work—that is, looking across nursing ory, and a practice exemplar that illustrates the
theories for points of convergence. This Theory major concepts.
of Unitary Caring was developed while study-
ing the literature on caring in nursing, and Process of Theory Development
analyzing this literature through the theoretical This process of developing a middle-range the-
lens of the Science of Unitary Human Beings. ory was guided by the question: “What is the
Dr. Smith was the recipient of the National substantive domain of caring knowledge from
League for Nursing’s Martha E. Rogers Award a unitary perspective?” Through a unitary lens
for the Advancement of Nursing Science, is a the question was framed as: What is the qual-
Distinguished Alumna of New York Univer- ity of being in mutual process that is called
sity’s Division of Nursing Alumni Association, “caring” within other theoretical contexts? This
and is a fellow in the American Academy of question was answered through a process of
Nursing. concept clarification that evolved from Paley’s
assertion that concepts were niches within the-
ories. This concept clarification involved the
Overview of the Theory following processes: (1) identifying the existing
A significant body of literature in nursing meanings of the concept in context, (2) iden-
explicates caring as a phenomenon that is central tifying theoretical niches, (3) synthesis of the
to nursing’s focus as a discipline and profession concept through identifying constitutive
(Boykin & Schoenhofer, 1993, 2001; Leininger, meanings, and (4) instantiation of the concept
1977; Roach, 1987; M. C. Smith, Turkel, & (M. C. Smith, 1999). Identification of the ex-
Wolf, 2013; Stevenson & Tripp-Reimer, 1990; isting meanings of the concept occurred through
Watson, 1979, 1985). At the same time, there reviewing the literature on caring that described
has been a corresponding body of literature cri- it as a way of being. Exemplar sources (Boykin
tiquing the assertion that caring is an identifying & Schoenhofer, 1993; Eriksson, 1997; Gadow,
concept for the discipline and that the existing 1980, 1985, 1989; Gaut, 1983; Gendron, 1988;
literature related to caring is ambiguous and pro- Leininger, 1990; Mayeroff, 1971; Montgomery,
vides no direction for meaningful inquiry 1990; Rawnsley, 1990; Ray, 1981, 1997; Roach,
(Morse, Solberg, Neander, Bottorf, & Johnson, 1987; Sherwood, 1997; Swanson, 1991; Watson,
1990; Paley, 2001; Rogers in Smith, 1988; 1979, 1985) were reviewed in this process.
M. J. Smith, 1990). An analysis of the caring lit- From these sources semantic expressions, or
erature revealed that caring was a multidimen- phrases that captured the essential meaning of
sional concept that assumed multiple meanings caring as a way of being, were listed. Next, the
depending on the framework within which it literature written by unitary scholars (Barrett,
was situated, or the lens through which it was 1990; Cowling, 1990, 1993a, 1997; Krieger,
viewed (M. C. Smith, 1999). Paley (1996) ar- 1979; Madrid, 1997; Madrid & Barrett, 1992;
gued that a concept acquires its meaning within Newman, 1994; Quinn, 1992; Rogers, 1994)
the context of the theory within which it resides. was examined for existing concepts that corre-
Concepts are theoretical niches, and to under- sponded to the semantic expressions of caring.
stand a concept fully, the theory in which the These were identified as theoretical niches in
concept lives and derives its meaning must be the unitary literature. Constitutive meanings,
clearly explicated. This chapter is the explication phrases that captured the meaning of a cluster
of a middle range theory of caring within the per- of semantic expressions, were named using
spective of the unitary–transformative paradigm. language consistent with a unitary perspective.
For this reason, the theory is called Unitary Five constitutive meanings were developed
Caring. This chapter contains a description of (M. C. Smith, 1999). Since the initial publi-
the theory development process, the assump- cation, the work was expanded with assump-
tions underpinning the theory, the concepts tions and empirical referents (Cowling, Smith,
and propositions of the theory, the empirical & Watson, 2008) to form a middle-range

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C H APTER 30 ■ Marlaine Smith’s Theory of Unitary Caring 495
theory. The theory is connected philosophically concepts were developed from an analysis of
to the unitary–transformative paradigm, has literature on caring and similar concepts de-
five concepts that describe the phenomenon of scribed by unitary scholars. The theoretical
caring from a unitary perspective, and can guide concepts have their underpinnings in each of
practice behaviors and research questions at the the assumptions.
empirical level (M. J. Smith & Liehr, 2008).
Manifesting Intentions
Assumptions Manifesting intentions is the first concept in
Assumptions of the Theory of Unitary Caring the Theory of Unitary Caring; it was originally
come from Rogers’s Science of Unitary Human defined as creating, holding, and expressing
Beings (1992, 1994), Newman’s Theory of thoughts, feelings, images, beliefs, desires, will,
Health as Expanding Consciousness (1994, purpose and actions that affirm possibilities for
2008), and Watson’s Theory of Transpersonal human health and healing (Smith, 1999).
Caring (1985, 2005, 2008; Watson & Smith, From this point of view, the nurse is a healing
2002). To fully understand the meaning of the environment, creating sacred space through
theory, readers will benefit from studying the her or his thoughts, feelings, intentions, and
references cited in this paragraph. actions (Quinn, 1992). Understanding inten-
tionality in this way comes with an assumption
1. Human beings are unitary or irreducible, in that underlying the world of form that is
mutual process with an environment that is accessed by sensory perception, there is the
coextensive with the Universe, participat- primary reality that is pandimensional (Rogers,
ing knowingly in patterning, and ever- 1994) and beyond access through the five
evolving through expanding consciousness senses alone. David Bohm’s (1980) concept
(Barrett, 1989; Newman, 1994; Rogers, of the holographic universe with implicate–
1992). explicate orders of reality is consistent with this
2. Caring is a quality of knowing participa- point of view. The implicate order is the pri-
tion in human–environment field pattern- mary, unseen pattern, whereas the explicate
ing (M. C. Smith, 1999). order is the manifestation of this underlying
3. Caring is the process through which pattern that is accessible through the senses.
human wholeness is affirmed. Caring is engaging with both orders of reality,
4. Caring potentiates the emergence of holding intentions through affirmations and
innovative patterning and possibilities images, and expressing these intentions through
(Cowling et al., 2008, p. E44). actions. Thoughts, feelings, perceptions, and
5. Caring is a manifestation and reflection of images are as potent as our words and actions.
expanding consciousness potentiating Intentions are meaningful energetic blueprints
greater meaning, insight, and transforma- for transformation (M. C. Smith, 1999). What
tive ways of relating (Cowling et al., we hold in our hearts matters (Cowling et al.,
Smith, & Watson, 2008). 2008, p. E46). Manifesting intentions encom-
6. Caring consciousness is resonating with passes actions that create healing environments,
the pandimensional universe (Rogers, preserve dignity, humanity, and reverence for
1994; Watson, 2005; Watson & Smith, personhood, focus attention to and concern for
2002). the other, and facilitate authentic presence.
7. Healing is the dynamic, ongoing process of
remembering wholeness or one’s unitary Appreciating Pattern
nature. Appreciating pattern is the second concept in
this theory. It is apprehending and under-
Concepts standing the mysteries of human wholeness
After establishing the theoretical linkages to and diversity with awe. This concept was ref-
the unitary-transformative paradigm, the five erenced by both Dolores Krieger (1979) and
concepts of this theory are explicated. The five Richard Cowling (1990, 1993a, 1993b, 1997),

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and defined by Cowling (1997) as “seeing shifting perspectives and patterns of response
underneath all that is fragmented to the real (Mayeroff, 1971), relating in a complex syn-
existence of wholeness and acknowledging that chronized integration (Gendron, 1988), and
with awe” (p. 136). Cowling (1997) describes experiencing energetic resonance (Quinn,
the process of approaching knowing the other 1992). It is hearing the call that may be spoken
with gratitude and enjoyment. This contrasts or unspoken. Newman (2008) describes the
with a clinical problem-solving approach. process of resonance as a way of knowing that
While appreciating pattern is an existing con- presents itself through intuitive insights and
cept in Unitary Theory, it corresponds to many feelings. Intellectualization can actually break
important meanings within caring theories in- this resonant field created through true pres-
cluding valuing and celebrating the wholeness ence. Caring is not taking the lead and telling
and uniqueness of persons, acknowledging the person what he or she needs to do. It is un-
pattern without attempting to change it, rec- derstanding where the other wants to go and
ognizing the person as perfect in the moment, being with him or her through the struggle to
being sensitive to the unfolding pattern of the get there. It is going to the relationship with-
whole, and coming to know the other. Pattern out an agenda, a plan, or a bag of tricks, but
is reflected in meaning, so finding out what is trusting in the transformative power of healing
meaningful to the other becomes primary in presence.
knowing pattern (Newman, 2008). Appreciat-
ing pattern is coming to know the uniqueness Experiencing the Infinite
of the other. It is grasping the wholeness of the The next concept in the theory is experiencing
other (individual, family, and community) not the Infinite. This concept is defined as “pandi-
through analysis, but through sensing, coex- mensional awareness of coextensiveness with
ploring experiences, and listening to the other’s the universe occurring in the context of human
story. This happens through letting go of relating” (M. C. Smith, 1999, p. 24). This is
preconceptions and the need to categorize, described by many caring theorists as spiritual
classify, diagnose, or judge. When we resist union (Watson, 1985), Divine Love (Ray,
labeling and diagnosing we can glimpse the 1997), or an actual caring occasion (Watson,
dynamic being that is sharing this moment 1985). Experiencing the Infinite is the recog-
with us. Appreciating pattern is being-with in nition that the nurse–person relationship is
wonder at this work of art before us, this life sacred, we meet the Holy in it, and when we
that reflects the diversity of creation. are with others in this way, there are no limits
to the possibilities. Miracles happen! There are
Attuning to Dynamic Flow miracles of healing that happen with our patients
Attuning to dynamic flow is the third concept every day that can be potentiated through love
in this Theory of Unitary Caring. Attuning to and caring. This can be recognizing who one re-
dynamic flow is sensing where to place focus ally is, appreciating the Oneness of Being with
and attention in mutual process. It was origi- all there is, and finding hope in the darkest of
nally described as “dancing to the rhythms hours. All of this is mediated by our outlook,
within continuous mutual process” (M. C. Smith, how we view our world, and what we entertain
1999, p. 23). Caring is flowing with the as possibilities. William Blake (1790–1793) said,
cocreated rhythms of relating in the moment. “The tree which moves some to tears of joy is in
It happens by being truly present in the the eyes of others only a green thing that stands
moment and is a back and forth movement of in the way” (DeSelincourt, 1909/1911, p. 70).
relationship building through a “vibrational Experiencing the Infinite occurs in moments of
sensing of where to place focus and attention” grace, experiencing a transcendent presence in
(M. C. Smith, 1999, p. 23). This includes ex- relationship with others. In those moments,
pressions of caring and unitary relating from there is an experience of connectedness to all-
the literature such as attuning to the subtle that-is extending beyond space–time boundaries
cues in the moment (Montgomery, 1990), that defies description in ordinary language.

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Inviting Creative Emergence ■ Acknowledging what is without attempt-

The final concept in this Theory of Unitary ing to change or fix.
Caring is inviting creative emergence. It is ■ Exploring what is meaningful in the
attending the birth of innovative, emergent moment.
patterning through affirming the potential for ■ Coming to know by listening to the
change, nurturing the awareness of possibili- other’s story.
ties, imagining new directions, and clarifying Attuning to dynamic flow is:
hopes and dreams. This concept was taken ■ Being truly present in the flow of relating.
from Quinn’s (1992) description of healing ■ Attending to the subtleties of meaning.
and Newman’s (1994, 2008) descriptions of ■ Synchronizing rhythms of self with other.
transforming presence. Descriptions of caring ■ Trusting intuition in the mutual process.
in the literature that correspond to this concept
are a “transformative experience wherein the Experiencing the Infinite is:
■ Acknowledging the sacred in human
constant birthing of love in caring actions is
the growth of spiritual life within” (Roach, relating.
■ Affirming limitless possibilities.
1987), allowing a person to grow in his or her
■ Igniting hope in despair.
own time and way (Mayeroff, 1971), and call-
■ Embracing pandimensional awareness.
ing to a deeper life, the spiritual life, of each
person (Ray, 1997). Caring is inspiring the other Inviting creative emergence is:
to birth oneself anew in the moment. It might ■ Honoring the unique timing, pace, and
be through an activity, realization, decision, a direction of change.
new role, a new life pattern. The nurse creates a ■ Calling attention to possibilities and
safe space for this new life to emerge through potentialities hidden from view.
supporting, coaching, and providing confidence ■ Inspiring new life to emerge in the
when it is lacking. This concept relates caring to moment.
healing. Caring is the vehicle through which ■ Supporting decisions based on values.
healing occurs. Caring takes trust and patience. ■ Trusting in the wisdom of knowing one’s
People change and grow in their own ways and own way.
in their own time. They know their way; we, as
nurses, help them to discover it and then journey Empirical Indicators
with them. This invitation for creative emer-
An empirical indicator is a “concrete and spe-
gence is gentle and encouraging, Quinn (1992)
cific real world proxy for a middle range theory
calls it being a midwife to healing.
concept” (Fawcett, 2000, p. 20). It is taking a
Propositions conceptual abstraction and moving it to a place
The following are propositional statements where it lives … where it can be seen, heard,
that further clarify concepts of the theory. felt, experienced, or measured. There are
empirical indicators for both practice and
Manifesting intention is: research. Those for practice are useful in trans-
■ Preparing self to participate knowingly in
lating the theoretical concept to guide for
cocreating an environment for healing. nursing practice. Those for research can be
■ Focusing images, thoughts, and intentions
used to generate research questions, develop
for well-being and healing. measures of the concept, or develop paths of
■ Expressing intentions in actions that
inquiry where the concept might be explicated
support well-being and healing. through experiences. Each of the concepts is
Appreciating pattern is: discussed at the empirical level.
■ Seeing wholeness in perceived
fragmentation. Manifesting Intentions

■ Valuing uniqueness and diversity of As far as the concept of manifesting intentions,
patterning with wonder. nurses enter a caring relationship with intention,

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through preparing to become the energetic en- Reiki, Therapeutic Touch, or prayer as inten-
vironment that potentiates healing. Nurses pre- tionality is integral to these practices.
pare by centering or connecting to the True Self,
going to that place within where it is possible to Appreciating Pattern
hear the still small voice. Nurses prepare by fo- In the Theory of Unitary Caring, nurses would
cusing on the present moment, leaving behind approach coming to know their patients in an
the thoughts racing in their heads that interfere entirely different way. The nursing process, or
with being truly present. Nurses prepare for car- the problem-solving process, would not be
ing by holding intentions that change the vibra- consistent with Unitary Caring. It would in-
tory pattern of the energy field. Marcus Aurelius volve knowing the other through using the
(171–175) said, “The soul becomes dyed by the sensory and extrasensory abilities to grasp
color of its thoughts.” The soul of our practice is wholeness. Nursing assessments would in-
dyed by our pattern of thinking. If we cultivate clude exploring the unique life patterns of the
the habit of focusing, centering, and setting in- person, exploring what is most important in
tentions before any encounter; we can create the the moment, and hearing the person’s story.
space for caring and healing. This way of being- Perhaps the first questions that we ask our pa-
with can be developed through self-reflection, tients should be “What is important to you
expressing intentions through touch and energy right now?” and “What matters most in this
work, centering exercises, spiritual practices such moment?” (Boykin & Schoenhofer, 2006).
as meditation and prayer, mantra repetition, and Cowling (1997) and Newman (1994, 2008)
experiences in nature (Cowling et al., 2008). have both developed clear praxis methods that
The development of an inner life is critical focus on pattern appreciation and pattern
to the full expression of caring in nursing. If recognition. Nurses need to develop their abil-
caring is a way of being, nurses must develop ities to appreciate pattern. Skills of pattern
these competencies as much as any other to seeing, listening, grasping the essence, and art
evolve as caring beings. Rituals can structure and music appreciation correspond to this
the process of setting intentions that are ability of appreciating pattern (Cowling et al.,
manifest in the nursing situation. Watson 2008). In interdisciplinary team conferences,
(2008) gives an example of creating a hand- nursing is the voice that represents the whole-
washing ritual in which nurses use this daily ness of the person; no other discipline does
practice as a way of centering and leaving be- this. Instead of describing a community by its
hind any thoughts that might interrupt pres- census and health statistics, we can come to
ence. Morning huddles are used in some know it by asking its members to describe the
settings as a ritual to come together as a team essence of the community. Nurses can use
and set the intentions for the day. Nurses can bulletin boards or digital displays in patient
develop rituals related to giving report that rooms as places for persons and families to
signify the duty to care (Cowling et al., express their uniqueness and what is most
2008). important to them.
The concept of manifesting intentions can Research related to pattern appreciation al-
be studied. Activities such as centering, set- ready exists (Cowling, 2005; Repede, 2009)
ting an intention, affirmations, meditations, Cowling’s Unitary Pattern Appreciation is a
prayers, values-based decision making, and praxis method (combines research and prac-
use of mantras could be tested using any vari- tice) in which he and the participant/client ex-
ety of outcomes associated with nurses or their plore patterning together; this is then captured
patients. One could explore how nurse center- and shared through aesthetic expressions.
ing before caring for others influences out- Through using Newman’s praxis method,
comes related to patient safety or how the nurses engage persons in an exploration of the
hand-washing ritual described above might meaningful events and relationships in their
improve patient satisfaction. One could study lives toward recognizing pattern and making
if there were healing outcomes associated with choices about those patterns.

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Attuning to Dynamic Flow and the necessity for nurses to provide skilled
Attuning to dynamic flow is lived in practice evidence based care with hands guided by the
through sensing the readiness to begin to talk hearts and spirits of the students to promote
about sensitive issues or the willingness to take healing in everyone they touch” (Ball &
on a major life change. An example is how a McGahee, 2013, p. 61). Another way to expe-
nurse stays engaged with a person and family rience the Infinite in practice is to validate its
members as they struggle together with the de- existence through practice stories. Nurses often
cision to transition to hospice care. Another fail to take the time to really appreciate the
example is knowing when a person needs the incredible caring moments experienced with
nurse to be tough, urging him or her to get out others. The sensitivity to experience the Infi-
of bed and walk after surgery or to be soft, fa- nite in our practice may be developed through
cilitating some quiet space for a person to be spiritual practice or a practice that fosters deep
alone. Nurses need to cultivate their abilities reflection. This could be meditation, prayer,
related to attuning to dynamic flow through centering, being in nature, or walking a
sensing, hearing and moving with rhythms, labyrinth (Cowling et al., 2008, p. E48).
presencing, and focusing. Learning to listen The research questions that are related to
for shifts and pauses and learning to listen and this concept might be studying nurses’ and
trust intuitive insights is important. There are patients’ stories of the extraordinary moments
hospital myths about the nurse who walks by experienced in nursing practice.
a patient’s room and knows the patient is going
Inviting Creative Emergence
to code. This may be an example of being sen-
sitive to changes and shifts within a situation, There are many examples in nursing practice
attuning to the information that is embedded that can illustrate how caring can invite
in the field of consciousness. creative emergence. This can happen when we
There are research possibilities related to help women become mothers through teaching
this concept. It would be interesting to study them the necessary skills to care for their babies
how nurses attune to the dynamic flow of re- and help them to grow, or when we connect
lationship with an unconscious person or a people to resources in the community that allow
neonate. What are the cues that they pick up them to live with greater ease in the midst of a
and act on? What are ways that nurse’s attune family crisis. It is helping others live their lives
beyond the five senses to understand what is differently and discover new ways of becoming.
happening or what is communicated to them? The empirical indicators for research might
The study of intuition in practice is an example be developing an instrument to measure satis-
of an empirical indicator of this concept. faction or pride associated with life changes.
Studies could be structured to explore differences
Experiencing the Infinite in outcomes when lifestyle change is approached

One example of experiencing the Infinite is with a nondirective model suggested by this con-
seeing the sacred in mundane activities. It is cept, rather than a structured directive approach
recognizing the extraordinary in the ordinari- to lifestyle change.
ness of our activities. Practice rituals can help
us to recognize and celebrate the ordinary/ex-
traordinary work of nursing. One such ritual is Applications of the Theory
the “blessing of the hands,” a ceremony that The middle-range Theory of Unitary Caring
symbolically links the art and science of health has been advanced as a model for palliative
care and allows nurses to reflect on the inter- care practice. Reed (2010), a palliative care
connectedness of their humanity and the priv- clinical nurse specialist, described how Unitary
ilege to provide holistic care to their patients Caring is used as a guide for his practice.
(Bleizeffer, 2014). This “blessing of the hands” Reed’s (2011) dissertation explored experi-
has also been used in educational settings to ences in providing and receiving massage and
emphasize “the art and the sciences of nursing simple touch at end of life. The study was a

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secondary analysis of qualitative interviews in Houston, Texas. This program has a unique
from persons with advanced cancer who had curriculum model built on the tenets of
received massage or simple touch as part of Unitary Caring.
their participation in a research study. Three Recently, Unitary Caring Science has been
themes were identified from the data that advanced by Watson (2018) as an emergent
describe their experiences of receiving touch: reformation in the field of Caring Science. She
(1) pattern recognition and wholeness, (2) car- synthesizes some of the constructs from
ing relationships, and (3) transformation and Unitary Science with the Caritas Processes®.
transcendence. These themes were related to Unitary Caring Science is broader than the
Unitary Caring, the theoretical framework for middle-range theory of Unitary Caring, and a
the study. Grumme (2016) used aspects of a recent publication by Watson, Smith, and
Unitary Caring framework in her study on Cowling (2019) articulates the philosophical
virtual connections in support groups. and theoretical foundations that include the
Unitary Caring is used as a guiding theory Theory of Unitary Caring but go beyond the
for studying nursing at St. Thomas University middle-range theory.
Practice Exemplar
Sue is a family nurse practitioner working in We were having a relaxing time, and as I was
a community-based family practice with a getting out of the car I felt myself go into atrial
physician colleague. She practices from a nurs- fibrillation. My heart rate went way up like it
ing model, using the Theory of Unitary Caring does to around 200, and I felt just awful, like
as a guide for her practice. Beth is a 55-year- I couldn’t breathe, lightheaded … I thought I
old attorney who has been seeing Sue for her was going to die.”
primary care for some time. She is waiting in “Oh, how scary … that’s awful.”
the examining room. “I know. I ended up in the emergency
Sue has had a busy morning with time room of this tiny hospital where they treated
pressures and some difficult patient encoun- me with IV antiarrhythmic drugs, and finally
ters. She is “backed up” with two patients my heart rate went down, and I converted to
waiting for her. She approaches the exam sinus rhythm in about 3 hours. But this is the
room and pulls out the chart. She smiles as she third time that this has happened to me, and
sees Beth’s name. In front of the door, she the second time when I’ve been away from
pauses, closes her eyes, takes several deep home. I just need to get to the bottom of this.
breaths and centers herself, repeating her I’m frustrated and scared.”
mantra. She sets an intention to be fully and “Of course, you are,” Sue continues. “OK
authentically present with Beth in this en- tell me generally how things are going for you
counter and to enter a relationship with her and did anything unusual happen while you
that facilitates their mutual well-being. were on vacation that might have precipitated
Sue opens the door and finds Beth sitting this episode.”
on the chair fully clothed. Sue approaches her “Well, you know I had that episode of di-
warmly, holding out her hand and touching verticulitis before I left for vacation, and you
her on the shoulder. She pulls up her chair and prescribed the Cipro for me. I also was not
puts the chart aside. “OK, Beth, what’s going feeling great on vacation, the pain was better,
on? How are you?” but I was constipated. I took Miralax and fiber
Beth talks rapidly, wringing her hands and which is what I always take for constipation I
tugging on her sleeve. “I was on vacation last went on a boat trip with my friends the day
week in North Carolina with my friends. before the episode occurred and took some

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Dramamine. Also, my friends and I were diverticulitis and weren’t feeling great. But, we
drinking wine every night. That’s all I can also need to focus on this distress that you are
think of.” experiencing related to your work. I’d like you
“What about home and work?” to do some journaling for a period of two
Beth looks down at her hands. “Well, Bob weeks. Write down the things that you love,
still can’t find a job, and things have been your passions, what makes your heart sing?
crazy at work. I just can’t seem to get ahead. I Don’t overthink it, Beth. If you have images
have a major brief due in a couple of weeks … or messages that come to you, jot them down.
It was hard to leave for vacation. I love being Make an appointment in two weeks, and we’ll
with my friends, but I was also very stressed talk about what you discover. OK?
about taking the time off with so much going “Yes, OK.” Beth nods tentatively.
on at work.” “Before you leave I’m 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.” Beth’s heart sounds and measures her blood
“I guess I’m in that space a lot lately, Sue.” pressure. “Everything is fine. Your heart rate
Beth begins crying. “I don’t think I’m doing is regular at 60, and your blood pressure is
what I love to do … I feel like I’m not in 130/82 which is OK, but a bit higher than I
control of my life.” would like it to be. I know you experience
Sue hands Beth some tissues and sits qui- some ‘white-coat hypertension.’ We’ll check
etly with her, gently touching her arm as Beth it again next week. You check it too at the ma-
sobs. In the moment, Beth sobs for the loss of chine in the grocery store and keep track.
joy in her life and at the memory of her Bring that back in two weeks also.”
mother telling her she had to go into a prac- Sue puts her hands on Beth’s shoulders.
tical career like law, rather than fiction writ- “I’m in this with you. You’ll figure this out.
ing. In the moment, Sue imagines holding Change can be hard, but it’s how we grow.
and rocking Beth in the space between them. Anything else that we need to talk about
In her mind’s eye she whispers comforting today?”
words. In silence, they both experience an “No, I feel better … thanks, Sue.”
intimacy that is beyond language. “Thank you! I’ll 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
“Let’s take care of the A-fib issue first, Caring were evident. First, manifesting inten-
Beth. Are you still on the same dose of the tion was visible in the preparation before Sue
beta-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 she
tion or other antiarrhythmics. You might said, “I’m in this with you,” and in her use of
want to talk with an electrophysiologist as touch and eye contact to communicate her de-
well. I’ll make a referral. Also, I just checked sire 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 asked Beth about what was going on with her,
have triggered this event given your history. how she was, and if there was anything differ-
And of course, Dramamine and alcohol may ent about the time that led up to the episode
have contributed. Additionally, at the time of atrial fibrillation. Sue values the uniqueness
this happened you were just getting over of Beth’s experience and Beth’s own insights
(continued)

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about events that led up to the episode, affirm- awareness of past–present–future in the
ing that Beth’s knowledge of her own pattern moment. This is an example of the concept of
had validity. Intuitively, Sue asked the ques- experiencing the Infinite. Finally, when Beth
tions, “What about home and work?” and expresses that she is not doing what she loves,
“Tell me more about this feeling of being torn Sue is inviting creative emergence by asking her
between what you love to do and what you to attend to any cues she may receive about
have to do.” This second question emerged what she would love to do and to record this
from Sue’s tuning into meaning and resonat- in a journal. She asks her to return for a
ing with the whole, illustrating the concept of follow-up visit in 2 weeks.
attuning to dynamic flow. This led to the reve- Often, the argument is advanced that
lation of Beth’s life pattern that could have re- “there is no time to care in this way,” but this
mained undisclosed had Sue not attended to encounter took 15 minutes, no longer than a
the intuitive insight. As Sue silently sat with conventional, medically focused primary care
Beth as she sobbed, they both experienced an visit. It isn’t the time we have; it is what we
intimacy beyond words, and a pandimensional do with that time that counts.
Summary
The Theory of Unitary Caring provides a con- emergence. Assumptions of the theory were ex-
stellation of concepts that describe caring from plicated, each concept was described, and ex-
a unitary perspective. The theory is constituted amples of empirical indicators for practice and
with five concepts: manifesting intentions, ap- research were offered. The unitary theory of car-
preciating pattern, attuning to dynamic flow, ing is new; it can grow through those who invest
experiencing the Infinite, and inviting creative in it through testing it in practice and research.
Questions for Reflection ■ Reflecting on the Practice Exemplar, what

differentiated nursing practice guided by
and Discussion the Theory of Unitary Caring from a typi-
■ Reflect on a situation when you experi- cal visit to the primary care practitioner?
enced being cared for or caring for an- ■ What are some examples of research ques-
other. Describe how one of the concepts tions that could emerge from the Theory
in the Theory of Unitary Caring was
of Unitary Caring?
present in that situation.

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Kristen Swanson’s Theory

CHAPTER
31
of Caring
Kristen M. Swanson

Summary Kristen M. Swanson, RN, PhD, FAAN, is
Questions for Reflection and Discussion Dean and Professor at Seattle University
College of Nursing. Former administrative
posts include Chair of the Department of
Family and Child Nursing at the University of
Washington and Dean of the School of Nurs-
ing at the University of North Carolina at
Chapel Hill. She currently serves as Chair of the
Board of Trustees for Swedish Health System
in Seattle, WA and a Board Member-at-Large
for the Board of Directors for the American
Association of Colleges of Nursing. She was a
Robert Wood Johnson Executive Nurse Fellow.
The Swanson Caring Theory (SCT) was
developed during her doctoral studies at the
University of Colorado and refined during
her postdoctoral studies at the University
of Washington. The theory was generated
through phenomenological studies with par-
ents and providers in the context of perinatal
loss (Swanson-Kauffman, 1986; Swanson,
1990, 1991, 1993). In 1999, Dr. Swanson
performed a meta-synthesis of the caring lit-
erature and found considerable evidence that
the SCT had utility beyond the perinatal con-

text. Dr. Swanson’s research using the SCT
has included two NIH, NINR funded inves-
tigations of the impact of caring-based inter-
vention on healing after miscarriage. Today
the SCT is internationally applied through
practice, education, and research.

The Connection Between Caring
and Healing
The SCT defines caring as “a nurturing way of
relating to a valued other toward whom one
feels a personal sense of commitment and
503
7991_Ch31_503-508 12/08/19 5:27 PM Page 504
responsibility” (Swanson, 1991, p. 162). There Swanson Caring Theory

are five processes that underlie actions that
Recipient healing
come across as caring: knowing, being with, response
doing for, enabling, and maintaining belief.
When a caregiver takes time to understand the Being with Enabling Capable
meaning of an event in the life of the other,
this is referred to as knowing (what it is like for Valued
me). Being with (me/us) goes beyond under-
standing, to recognizing and honoring the Maintaining belief Hopeful
emotions of the other. When caregivers are
emotionally present to the sorrow, joy, fear, or Understood
frustration of the other, the recipient “gets the Safe and
Knowing Doing for
message” that he or she matters. Doing for comforted
(me/us) is acting on behalf of the other and Copyright: Kristen M. Swanson
doing it as well as the other would do for him-
FIG 31-1 ■ Swanson Caring Theory.
self or herself if he or she had the knowledge
or physical capacity to do so. Enabling (me/us)
is providing the information, support, and
validation necessary to facilitate the other’s understood, but also understanding their own
capacity to get through an event or transition. experiences more fully. When the provider is
Maintaining belief (in me/us), although de- able to be with recipients through times of sor-
scribed last, is actually the core caring process row, frustration, suffering, and joy, recipients
that undergirds the other four processes of car- feel valued and perceive that they and their ex-
ing. It is the ability to sustain faith in the other, periences matter to the provider. When the
recognizing that the other has it in him or her provider seeks to do for others as others would
to come through an event or transition and do independently for themselves if they pos-
face a future with meaning. sessed the knowledge, time, energy, capacity,
The SCT was first proposed 35 years ago. or skills to do so, the recipients feel safe and
There are now scientists, practitioners, and ed- comforted. When the provider enables others’
ucators around the world who apply the SCT capacity to manage a situation by providing in-
in their work. Reflecting back over the years formation, validation, and support, the recipi-
on the work done to understand how couples ents feels capable of meeting and getting
evaluated caring interventions, considering the through challenges that might be facing them.
lessons learned through consulting with nurses Last, and at the very core of caring, when the
and other providers seeking to change the cul- provider maintains belief in the others’ capac-
ture of care, and integrating the writings and ity to come through an event or transition and
findings of others who have explored the car- face a future with meaning, the recipients feel
ing processes and their impact, I believe there hopeful (as opposed to hopeless). This hope
are logical links between the caring processes does not mean that sickness, sorrow, fear, or
and healing outcomes. Using the language of loss will not unfold as it must; rather, it is hope
provider to mean the one who is practicing that the recipient will be able to get through
caring and recipient to mean the one who is the situation and find meaning and purpose in
receiving caring, I offer the following model whatever comes next. In summary, when a
(Fig. 31-1) and thoughts about the connec- provider takes the time to know, be with, do for,
tions between the caring processes and expe- enable, and maintain belief in the other, the re-
riences of healing. cipient feels a sense of healing/wholeness—
When providers strive to understand the re- wherein the recipient feels understood, valued,
cipients’ experiences (e.g., knowing), the recip- safe and comforted, capable, and hopeful for the
ients have the potential of not only feeling future. I believe caring and healing are possible

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C H APTER 31 ■ Kristen Swanson’s Theory of Caring 505
whenever a provider acts with the recipient’s Parent perceptions of how nurse encounters
best interests in mind. can provide caring support for the family dur-
ing the acute-care stage following a severe
traumatic brain injury (TBI) in children was
Applications of the Theory studied by Roscigno (2016). Twenty-nine par-
The SCT has been used to guide qualitative ents of 25 children hospitalized for a severe
and quantitative research. Below are three re- TBI described encounters with nurses whom
cent studies conducted by my former doctoral they perceived as either caring or noncaring. The
students, now colleagues. These applications of initial interviews occurred within 36 months
research provide evidence that the SCT has (M = 27 months) of injury; the second round
applicability beyond the original perinatal loss of interviews occurred 12 to 15 months after
context from which it was first derived. this. Using directed content analysis, guided
Wei, Roscigno, and Swanson (2017) inter- by SCT, evidence supported ways the SCT
viewed 11 parents twice within 6 weeks of their could capture parents’ desires for safe and hu-
child having congenital heart surgery. Using di- mane care of themselves and their children.
rected content analysis (guided by the SCT), Roscigno described how nurse knowing was
the data revealed how knowing was evident equated with nurses seeking to provide a safe
when providers spoke with tenderness, an- cultural and psychological space for parents to
swered questions, and included all family mem- process both their initial grief and muster the
bers. Being with was particularly evident when resilience needed to get through the experi-
families felt providers were “alongside them” ence. Being with was conveyed when nurses at-
during four crucial moments: at diagnosis, when tempted to understand who the child was
parents handed their child over for surgery, as before the injury, when nurses were willing to
families waited during surgery, and during the authentically enter into an interpersonal rela-
first post-surgical visit when the news of surgical tionship with the family, and when nurses
outcomes was revealed. When parents perceived clearly conveyed, through their actions, that
all caregivers worked together as a team cover- their job was more than performing medical
ing for each other when parental or child needs tasks (e.g., the nurse was ready to be involved
arose, doing for was revealed. Parents especially with patients and their families, nurses liked
appreciated when their needs were anticipated their jobs, and nurses enjoyed what they did
and attended to. Parents felt enabled when their every day). Doing for was perceived when par-
roles as parents and decision-makers were hon- ents felt the nurse protected their child’s opti-
ored and protected. The parents described feel- mal health and dignity by caring for the child
ing traumatized when handing over care of their with the same respect and commitment that
child to others (God, surgeons, nurses) and by parents themselves would if they could, and
witnessing all of the equipment surrounding that the nurses were doing all that was possible
their child. Parents relied on prayer to help (including removing barriers such as visitation
them hand over control along with careful di- rules) to restore parents to their proper roles as
rections from nurses about ways they would primary caregivers. Similarly, enabling meant
safely take back their parental caregiving roles. anticipating parent needs and coaching them
Last, maintaining belief was conveyed when on how to parent within the acute-care envi-
caregivers demonstrated belief in the parents’ ronment, including pragmatically helping par-
ability to get through the experience, reassured ents to prepare in advance; engaging in
parents of their ability to participate, and ulti- medical rounds to ensure parental understand-
mately prepared parents to provide full posting of their child’s care; encouraging parents
surgical care for their child. Parents felt providers to care for themselves; and providing safe
encouraged their resilience and positive outlook spaces for parents to process what was going
through provision of emotional support and on within and around them. Maintaining belief
anticipatory guidance. was grounded not in pitying parents but rather

7991_Ch31_503-508 12/08/19 5:27 PM Page 506
in treating them as competent caregivers capa- and (5) parent caring behaviors, particularly
ble of enduring hardship. While parents nonverbal behaviors, reduce the child’s behav-
needed empathy and compassion, they also ioral and verbal distress. Parent caring interac-
needed realistic optimism supporting their abil- tion behaviors were significantly correlated
ity to rise to meet the challenges before them. with parent distress, child distress, and child
A complex longitudinal observational study cooperation during repeated port accessing,
of 43 parent–child dyads was conducted by with analysis showing that children were sig-
Bai, Harper, Penner, Swanson, and Santacroce nificantly less likely to display behavioral and
(2017). The children were undergoing cancer- verbal distress following parent caring behav-
related central line port access procedures. iors than at any other time (Bai et al., 2017,
Through videotaped interactions researchers p. 675). This study emphasizes the need for ad-
assessed parents’ verbal and nonverbal caring ditional research on nonverbal caring behaviors
behaviors and children’s distress during the in relation to children’s distress during painful
procedure. Two trained coders rated parent procedures.
caring and noncaring behaviors and child re- The SCT has been integrated into the pro-
sponses. Parental caring was measured using fessional practice models of many health-care
the 18-item Parent Caring Response Scoring organizations. Typically, as nurses prepare
System (P-CaReSS) (Bai, Swanson, Harper, their organization for initial review or renewal
Penner, & Santacroce, 2017), an observational for Magnet status, the team undergoes an ex-
measure capturing verbal behaviors (present/ ercise in selecting a nursing theory that aligns
absent), nonverbal behaviors (duration, if with the facility’s mission, vision, values, and
present), and emotional valence of interaction organizational norms. The SCT is often se-
(caring/positive emotions, neutral, noncaring/ lected for its simplicity and face validity
negative emotions). Observational items for (meaning it “rings true” with nurses that the
the P-CaReSS were generated to reflect Swan- theory captures the essence of their practice).
son’s five caring processes: knowing (1 item); The following are examples of how two hospi-
being with (3 items); doing for (3 items); tal systems integrated a caring theory, the
enabling (4 items); and maintaining belief SCT, to make practice changes specifically
(2 items), plus one noncaring domain (4 items). aimed at linking theory to real-world nursing
Additional brief observational or self-report practice improvements and clinical outcomes
measures were used to quantify parent distress, (Tonges & Ray, 2011).
child distress, and child cooperation. Mixed Nurses at the University of North Carolina
modeling with generalized estimating equa- Hospitals (UNCH) adopted the SCT in 2008
tions were used to examine associations be- as the theoretical basis for their Professional
tween parent behaviors, parent distress, child Practice Model (PPM). In 2009, confronted
distress, and child cooperation. Time-window with a need to improve patient satisfaction
sequential analyses facilitated examination scores as measured by the Press Ganey, nurse
of child responses to parent caring within a leaders developed a model translating caring
5-second window. Findings suggest the fol- theory into specific caring behaviors capable of
lowing: (1) it is possible to infer parent caring being incorporated into practice. The overall
through nonverbal indicators (eye contact, revision for the nurse leaders was “for congru-
maining close enough to touch the child or be ence between the PPM and caring behaviors
touched by the child); (2) child distress can that was sufficiently strong that it could distin-
trigger an “uptick” in parent caring behaviors, guish the caring provided at UNCH” (Tonges
and parent responses can modulate child re- & Ray, 2011, p. 374). The nurse leaders devel-
sponses; (3) as child cooperation went up, less oped the Carolina Care Model, a model of
parent caring behaviors occurred; (4) children caring, using the five components of SCT as
were least likely to display behavioral and ver- follows: compassion was reflected in knowing
bal distress following parental caring behaviors; and being with; competence was depicted in

7991_Ch31_503-508 12/08/19 5:27 PM Page 507
C H APTER 31 ■ Kristen Swanson’s Theory of Caring 507
doing for and enabling; and maintaining belief described strategies taken to broaden and sus-
was the core of the model (Tonges & Ray, tain the positive outcomes known to the
2011). All components of their caring model Chapel Hill campus as an example of estab-
were aimed at patient well-being. The caring lishing a culture of excellence and of nursing
theoretical focus was then “branded” within a identity across an ever-expanding affiliated care
practice framework labeled “Carolina Care.” network (Tonges, Ray, Herman, & McCann,
Carolina Care operationalizes caring through 2018).
implementation of evidence-driven strategies Another example of translating SCT or
that are known to affect nurse-sensitive out- theory into practice was observed with nurse
comes. Key components of Carolina Care in- leaders (managers, directors, clinical nurse
cluded the following: specialists) working in an acute-care setting
concerned with the ongoing challenge of pa-
■ Multilevel rounding (being with and doing
tient falls, especially within the neurological
for) included five levels of rounding, which
care unit (Gould, Mann, Martin, Erwin, &
can be summarized using the acronym
Swanson, 2018). Colleagues within the same
R (pain), O (positioning), U (toileting),
health-care system used an auditing system
N (need anything), D (privacy), and
consisting of a checklist of evidence-driven ac-
S (safety) (Tonges & Ray, 2011, p. 376).
tions called Kamishibai cards developed by Lean
■ Words and Ways that Work (enabling and
Manufacturing Systems (Gould et al., 2018,
being with) are key action items adopted
p. 254) that when implemented demonstrated
and communicated across caregivers for
positive outcomes with an overall reduction in
use in frequently occurring care moments
patient falls. While the nurse leaders at the
(e.g., sharing wisdom about the best way
acute-care facility appreciated the importance
to greet a specific patient).
of standardized expectations and practices,
■ Relationship/Service Components are en-
they feared this approach was much like audit-
hancement strategies including moment
ing and might become rote and be perceived
of caring (each patient, each shift, 3 to
by staff as punitive. After some brainstorming,
5 minutes to focus on care desires—
the leaders chose to blend the evidence-driven
knowing and being with); no-passing zone
strategies (the “how”) with the SCT (the
(a well-advertised commitment that no
“why”). The Kamishibai cards were adapted
one will pass by a patient who calls for
and redesigned to visually link known-to-
help—doing for).
be-effective falls prevention strategies to the
■ Partnership with Support Services
five caring processes found in the SCT and
(engaging others in patient-centered
were redefined as “Caring Cards.” The deploy-
teamwork—doing for), which included
ment of the “Caring Cards” consisted of lead-
blameless apology (being with and enabling

ers demonstrating caring and respect for the
through actively listening to concerns and
critical thinking of their nurse colleagues.
taking action without blaming).
Application involved using the cards to solicit
Carolina Care has led to sustained and im- the nurses’ thoughts about obstacles they
pressive improved care outcomes. Patient sat- experienced in trying to provide care. This
isfaction scores with nursing and overall care dialogue, grounded in caring, provided nurse
have risen sharply; hospital-acquired pressure leaders with information about the problems
injuries significantly dropped; satisfaction with that needed to be solved and the staff nurses
pain control increased; and promptness in an- felt their voices were being heard. Over time
swering call bells improved. In 2014, the those with nurse administrative roles handed
UNCH Care System expanded considerably over the coach role to more senior nursing staff
and “Carolina Care,” grounded in the SCT, members. In summary, the deployment of
was adopted across eight affiliated hospitals. Caring Cards tied purpose to actions, honored
In a 2018 article, Tonges and colleagues the wisdom and critical thinking of the nurses

7991_Ch31_503-508 12/08/19 5:27 PM Page 508
closest to the point of care, gave nurse leaders methodology with the heart of nursing to
firsthand understanding of opportunities for improve patient care (Gould et al., 2018, p. 254).
system improvements necessary to support The ultimate outcome of this blend of a caring-
care, made nursing theory more visible at based theory-guided process with evidence-
the bedside, and proved to be a respectful way driven actions was a 50% reduction in unassisted
to adapt the best of Lean Kamishibai card falls over the course of 12 months.
Summary
The SCT was initially developed in 1983 as summary, when a provider takes the time to
part of my doctoral dissertation at the Univer- know, be with, do for, enable, and maintain
sity of Colorado School of Nursing. Dr. Jean belief in the other, the recipient feels a sense
Watson served as my dissertation chair. Upon of wholeness—that is, the recipient feels un-
hearing that I wanted to understand what it derstood, valued, safe and comforted, capable,
was like for women to miscarry, Jean advised and hopeful for the future. I believe caring and
me to ask women what caring meant in that healing are possible whenever a provider acts
context. After completing my PhD, I went on with the recipient’s best interests in mind.
to postdoctoral studies with Dr. Kathryn Caring can be enacted at the bedside, in
Barnard at the University of Washington the community, in the boardroom, or in the
(UW), where my focus on interpreting caring legislature. The measure of caring’s worth is
in the context of perinatal loss continued. determined by whether it leads to the recipi-
While at UW, Dr. Barnard challenged me to ent feeling seen and intact (or enhanced)
“do something” rather than keep interpreting versus diminished and dismissed. The SCT is
what caring meant, which resulted in the now used globally in nursing practice, educa-
development of the Theory of Caring. In tion, and research.
Questions for Reflection mitigate against burnout, monitor com-

passion fatigue, and create a healthy work
and Discussion environment?
■ How might the SCT be incorporated into ■ What are the five processes that underlie
self, peer, and supervisor evaluations of actions in SCT? What makes Swanson’s
work performance? theory a caring theory?
■ How could the SCT be used to motivate
teamwork, enhance staff cohesiveness,

7991_Ch32_509-522 12/08/19 5:27 PM Page 509
Adeline Falk-Rafael’s
CHAPTER
32
Critical Caring Theory
Adeline Falk-Rafael

Practice Exemplar I completed my original nursing program in a
Summary midsize hospital in an urban Canadian mid-
Questions for Reflection and Discussion western province in the early 1960s. Although
I remember a textbook that referred to nursing
science in its title, nursing care was organized
around medical diagnoses, treatments, and
specialties. For the next 25 years, I worked as
a staff nurse initially, and later in administra-
tive roles, in a variety of medical–surgical and
specialty units in a number of institutions
throughout Ontario. As a nursing administra-
tor in a large facility for developmentally chal-
lenged persons that was moving away from a
biomedical model, I felt inadequate to the task
of articulating the scope, nature, and value of
nursing beyond the provision of biomedical
care. I began reading books written by nursing
theorists but, experiencing limited success in
understanding them, enrolled in a post-RN
BScN program at the University of Western
Ontario. Graduating in 1989, the degree I had
earned qualified me for a position as a public
health nurse (my career goal since my hospital
diploma program), but the program had also
whet my appetite for more nursing knowledge.

While working as a public health nurse, I
completed an accessible MScN program at
D’Youville College in Buffalo, New York. In
that program I was challenged to use different
nursing theories to guide each of three clinical
practica (all done in public health) and found
Watson’s Human Caring Science (Watson,
1988) to be the best fit for public health nurs-
ing. Upon completing my MScN in 1992, I
took on a faculty position at D’Youville Col-
lege and, the following summer, began studies
in the PhD (Nursing) program at the Univer-
sity of Colorado Health Sciences Center,
509
7991_Ch32_509-522 12/08/19 5:27 PM Page 510
which at the time offered a summers-only pro- health care, and social, economic, and political
gram. That program allowed me to delve more determinants of health, I realized that my pub-
deeply into Human Caring Science. lic health nursing practice had never been
After graduating from that program in 1997, guided solely by Watson’s theory but also by
I continued an academic career at the University Nightingale’s writings and critical social theo-
of Western Ontario and York University, where ries, including feminist theories. That paper
I became Director of the Nursing School in first proposed the middle-range Theory of
2008–2009. During my time at York, I also Critical Caring (Falk-Rafael, 2005a). A follow-
served as President of the Registered Nurses up paper served to explicate the carative health
Association of Ontario from 2002 to 2004. promoting process (CHPP) of contributing to
the creation of supportive and sustainable phys-
ical, social, political, and economic environ-
Overview of the Theory ments (Falk-Rafael, 2005b).
Development of the Theory I had learned public health nursing
In retrospect, the seeds for development of through mentorship, example, experience, and
Critical Caring Theory were sown during my research. I believed Critical Caring Theory
graduate research. My master’s thesis exam- represented the practice of experienced public
ined public health nurses’ perceptions of power health nurses with whom I had worked or
and powerlessness (Rafael, 1992), and my doc- studied. However, further research was needed
toral dissertation research was an oral history to develop the theory and examine its relevance
of public health nursing in Southern Ontario to expert public health nursing practice more
(Rafael, 1997). It was in interviewing public generally.
health nurses that I realized the large degree In 2005, using a comparative and collective
to which the scope and nature of their practice case study design (Reinharz, 1992), I studied
were shaped by administrative and medical di- public health nurses, each with 10 or more years
rectives (Falk-Rafael, 1997, 1999; Rafael, of public health nursing experience, and work-
1999). I also observed that nurses responded ing in three different cities in Ontario, Canada
in different ways to those directives (Falk- (Falk-Rafael & Betker, 2012a, 2012b). Personal
Rafael, 2000a) and that their responses corre- and administrative circumstances did not permit
sponded to their abilities to articulate and resumption of the study until early 2011 when
differentiate nursing knowledge from that of Dr. Betker joined the study and two focus
other disciplines (Falk-Rafael, 1998). But I groups were held, both as a form of member-
was disturbed that so many of the nurses pro- checking and to ensure temporal relevance of
fessed no need for nursing theoretical knowl- the 2005 data. The findings are reported in
edge while unquestioningly adopting practices Falk-Rafael and Betker (2012a and 2012b).
informed by theories from other disciplines, Critical Caring Theory is a practice- and
including but not limited to medicine. As a research-based middle-range theory of public
faculty member I continued to study public health nursing, building on the concept of em-
health nursing (Falk-Rafael, 2001; Falk- powered caring (Falk-Rafael, 1998, 2001). The
Rafael, Fox, & Bewick, 1998) and taught theory posits that critical caring is a way of being
theory-guided community health nursing. I (ontology), knowing (epistemology), choosing
developed guidelines, using Watson’s theory, (ethics), and doing (praxis). Figure 32-1 is a
to assist and guide students in meeting health model of Critical Caring Theory depicted as a
goals when working in their communities, tree, consisting of roots, trunk, and branches.
eventually publishing those guidelines (Rafael, The theory’s roots in Watson’s Caring
2000). In 2004, I began work on a manuscript Science, Nightingale’s writings, and feminist,
to update the original paper and provide ex- critical social theories are evident in the
amples of students’ experiences. As I began to model. Critical caring is derived from Watson’s
articulate the consistencies of Watson’s theory Human Caring Science for use in public health
with global thinking about health, primary nursing settings. Nightingale’s writings are not

7991_Ch32_509-522 12/08/19 5:27 PM Page 511
C H APTER 32 ■ Adeline Falk-Rafael’s Critical Caring Theory 511
Critical Caring Theory Model
Providing, creating,
and/or maintaining
supportive and
sustainable
Meeting needs
Engaging in environments
and building
transpersonal
capacity
teaching-learning
Being open and

Using systematic attending to spiritual-
reflexive approach mysterious and existential
ing
dimensions
os
hip
cho
ns
tio
ing,
ela
gr
now
stin
ng, k
-tru
ng
y of bei
lpi
he
Developing and maintaining a
Critical Caring as wa
Preparing Self
em
F
ce
n in is
ie t Cri
g Sc
le
Carin tical Th
ga
t son ’s eo ries
Wa
tin
gh
Ni
FIG 32-1 ■ Critical Caring Theory Model. (Previously published online [https://ansjournalblog.com/2013/01/09/critical-
caring-model-update/] as an updated version of the model originally published in Falk-Rafael, A., & Betker, C. [2012]. The
primacy of relationship: A study of public health nursing practice from a critical caring perspective. Advances in Nursing Science,
35[4], 315–332.)
only congruent with human caring science but theory (Kellner, 1992). Although feminist the-
also emphasize the importance of “health nurs- ories share many commonalities with critical
ing” (Falk-Rafael, 1999). Her example in po- social theories, their focus is on the experience
litical activism to address social and economic and value of women and systematic injustices
conditions resulting in poor health are particu- related to gender (Chinn & Wheeler, 1985).
larly relevant to a critical caring approach (Falk- These theories are essential in a population-
Rafael, 1999, 2005b). Nightingale’s critique of focused practice, which, by definition, requires
social structures and the systems that afford an examination of social, economic, and politi-
some members of society an advantage at the cal determinants of health and action to address
expense of others and the goal of emancipation them (Cohen, 2006; Fawcett & Ellenbecker,
from these systems is the essence of critical 2015).

7991_Ch32_509-522 12/08/19 5:27 PM Page 512
The ways of being, knowing, and choosing interfere with the ability to work to the full
are part of the trunk of the tree, as are two car- scope of their practice in promoting client
ative health promoting processes (CHPPs): the health? Is nursing knowledge valued equally
preparation of self and developing and maintain- with that of other health professionals (e.g.,
ing helping, trusting relationships. The five medical knowledge)? At a societal level, do
branches represent nursing praxis through the barriers such as inadequate housing, food in-
remaining five CHPPs: incorporating a system- security, illiteracy, poverty, discrimination, or
atic, reflexive approach; engaging in transper- social exclusion pose challenges to the client’s
sonal teaching–learning; providing, creating, health equity? In short, who is advantaged and
and/or maintaining supportive and sustainable who is disadvantaged in the relationship, in the
social, political, and economic environments; organization, or in the larger society? Further-
meeting the needs and building capacity of more, as the goal of feminist critical social the-
communities and their members; and being ories is emancipatory, what actions are
open and attending to spiritual–mysterious and required? While many of these issues require
existential dimensions of human existence. The long-term policy solutions at organizational
roots stabilize and nourish the tree; the trunk and/or societal levels, actions to address them
transports nourishment to the praxis branches can only begin with awareness. At an interper-
and supports them. The praxis branches reflect sonal level, awareness allows a nurse to take
various aspects of nursing practice, some of measures to reduce possible power imbalances
which may be more prominent than others, de- within the nurse–client relationship.
pending on the focus of the work in which a Relationship is so fundamental to public
nurse is engaged. health nursing (Falk-Rafael & Betker, 2012b)
that the second CHPP, developing and main-
The “Tree Trunk”: Support for Praxis taining a helping–trusting relationship, is also
As Critical Caring Theory is a relational way situated in the “tree trunk” and contributes to
of being, the first carative health promoting the support of nursing praxis. Having pre-
process begins with preparing the self to be in pared self, the nurse seeks to establish a dis-
relation. Preparation of self may include activ- traction-free and safe environment in which
ities such as centering prior to meeting with a the privacy of clients is protected. Establishing
client to rid oneself of distractions. Engaging a trusting relationship may also involve con-
in clarification of personal values to deal with sideration of the client’s physical comfort to
possible biases or prejudices is another form of the extent possible, for example, addressing
preparing self to be in relation with client and issues such as seating arrangements, room
allows for the creation of an open, nonjudg- temperature, and lighting. The psychological
mental environment. Similarly, assessment of well-being of the client is also important and
one’s strengths and weaknesses relative to the requires building trust, often over time, with
anticipated situation might lead to seeking a respectful, nonjudgmental, authentic, and
guidance from an experienced mentor and/or, affirming approach in which the nurse is fully
for more long-term benefits, upgrading one’s present with and actively listens to clients,
own knowledge with formal or informal learn- taking cues from them, attending to the
ing. Preparation may also involve more general meaning they ascribe to a situation, and hon-
measures, such as self-care to maintain one’s oring their values and belief systems. In some
physical and psychological health. Finally, the instances, nurses may disclose an aspect of
roots of Critical Caring Theory suggest that their personal lives; sharing something in
preparation of self must acknowledge relevant common serves the goal of finding a point of
power structures and relationships to the situ- connection with the client.
ation. For instance, might a power imbalance Maintaining a helping–trusting relation-
between nurse and client jeopardize the rela- ship requires a continuation of the respectful,
tionship on an interpersonal level? Do nurses nonjudgmental, authentic way of being present
face constraints at an organizational level that first required to establish the relationship. The

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nurse–client relationship is one of mutuality personal knowing includes spiritual

(Falk-Rafael, 2001); that is, nurses work with understanding, which corresponds well to
clients in identifying the clients’ health priori- CHPP 7: being open and attending to
ties and formulating health goals. They then spiritual–mysterious and existential di-
negotiate the role each will play in meeting mensions. Moch’s (1990) identification of
those goals. As the relationship develops, trust experiential, interpersonal, and intuitive
may deepen as the nurse follows through on ways of knowing as components of per-
promised actions. Clients may well gain skills sonal knowing are consistent with the
and confidence, becoming increasingly em- accounts of public health nurses’ experi-
powered to assume more or even full respon- ences (Community Health Nurses of
sibility for their health. At all stages of the Canada, 2017; Falk-Rafael & Betker,
nurse–client relationship, protection and en- 2012b).
hancement of human dignity is a primary ■ Critical caring as a way of choosing refers
nursing concern. to ethical knowing that, like personal
Critical Caring Theory as a way of knowing knowing, comes from being in a caring
refers to the knowledge gained through a critical relationship with another human being in
caring approach to practice. It augments other which the protection and enhancement of
knowledge nurses learn through other means, human dignity is a primary concern. As
such as basic and ongoing formal and informal such it takes the form of a relational,
education, ethical codes and professional stan- situational ethics (Falk-Rafael & Betker,
dards, and mentorship of experienced nurses. 2012a), which is consistent with
As a way of knowing, Critical Caring Theory MacDonald’s (2013) recommendation
encompasses the five ways of knowing described that feminist, relational ethics serve as
by Chinn and Kramer (2019). an appropriate ethical framework for
public health nursing. While ethical
■ Aesthetic knowing involves recognizing codes and standards are knowledge that
the uniqueness and honoring the lived ex- nurses also use, critical caring as a way
perience of each individual and situation, of ethical knowing comes from knowing
recognizing patterns that have meaning what is the right thing to do within a
and responding verbally or nonverbally to relationship and a specific circumstance.
them. Chinn and Kramer (2019) point Because public health nurses are often
out that often when acting artfully, one witness to social injustices that diminish
can never explain exactly what one did. human dignity and create health in-
Falk-Rafael and Betker (2012b) relate equities, the amelioration of social
the story of a school nurse working with injustices and advocacy for health equity
a group of 9th- and 10th-grade girls at become an expression of caring praxis

risk for expulsion due to their trouble- (Falk-Rafael & Betker, 2012a), charac-
some behavior. Over time she noticed terized by Watson (2008) as sacred
positive changes in the girls’ mood and activism.
behavior, and at the end of the school ■ Recognizing the social injustices prevalent
year received spontaneous hugs and in the communities and experienced by
thanks from some. In reflecting on the individuals for whom public health nurses
incident, the nurse said, “I didn’t do care is emancipatory knowing. It is the
much of anything” (p. 326). form of knowing in which the critical
■ Personal knowing comes from introspec- social theories roots of Critical Caring
tion and reflective practice. It stems from Theory are most prominent. It requires
being in relation with another person in understanding historical, social, economic,
which both are empowered (Chinn & and political contexts that perpetuate so-
Kramer, 2019; Falk-Rafael, 2001). Chinn cial injustices and health inequities so
and Kramer’s conceptualization of that the appropriate actions (CHPP 5)

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may be taken to change them (Chinn & as required by circumstances. The focus is on
Kramer, 2019). facilitating authentic client self-determination
■ Empirical knowing occurs through a sys- (Schroeder & Gadow, 2000) through capacity
tematic reflexive approach to caring building.
(CHPP 3). It involves processing infor- In a population-focused practice, the as-
mation gained through sensory perception sessment of strengths and barriers of necessity
and other ways of knowing, ordering it includes consideration of social, economic, and
logically within the context of existing rel- political factors that contribute to or adversely
evant knowledge (Chinn & Kramer, affect health. Consider Exemplar I in Falk-
2019), and determining rationally what Rafael (2005) in which a group of students was
nursing actions are needed (Falk-Rafael & assigned to the adolescent unit of a psychiatric
Betker, 2012b). facility to provide sex education. The student
team began to develop a relationship with the
The “Tree Branches”: Critical Caring youth and could validate that sex education
as Praxis was indeed a priority for them. As the team
Five branches of the “tree” represent critical addressed this concern over the term, a num-
caring as a way of doing or taking nursing ac- ber of the adolescents confided that they were
tions that are consistent with its theoretical lonely because the distance of the facility to
underpinnings. Depending on a nurse’s posi- their family homes was too great to allow fre-
tion and job responsibilities, some of the praxis quent visits. In gathering more information as
CHPPs may be more prominent than others. to why this was the case, the student team
The principles apply to a population-focused learned of the economic and political factors
practice, whether the client is an individual, that were involved in determining catchment
group, aggregate, or community, although the areas and lobbied the provincial government
nature of the interactions may vary widely. As for change.
in nature, where the tree is energized through The example shows the importance of
the leaves absorbing energy from the sun, the- openness and reflexivity as well as an awareness
ory becomes energized through praxis. And, as of broader health determinants. It is not clear
in nature, where branches of trees are not static from the example whether there was time in
but moving in the wind, not separate from the term not only to deliver the sex education
each other but overlapping, so it is with the as requested but also to build the capacity of
five foci of praxis. For heuristic purposes, the the youth for political advocacy on their own
seven CHPPs are discussed separately, but in in the future. The example also shows an as-
practice they are neither a linear sequence nor sessment that is quite focused; assessments of
do they exist as entities separate from one communities are much broader but should
another. also be focused on strengthening its capacity

to care for its members. The appendix in Rafael
CHPP 3—Incorporating a Systematic (2000) provides a community assessment tool
Reflexive Approach based on Watson’s Human Caring Science
An ongoing, systematic, reflexive approach is that is useful when using a Critical Caring
used in identifying the client’s health goals, Theory approach.
then mutually assessing strengths and barriers
to reaching them; planning together for a CHPP 4—Engaging in Transpersonal
course of action, then negotiating the respon- Teaching–Learning
sibilities of the nurse and client in carrying out Health promotion is often mistaken for health
those actions; acting in accordance with the teaching, especially by those entering the
plans, and jointly evaluating their effectiveness profession. One example in the literature
in meeting the goals. These are not linear steps depicts the dilemma of students who were per-
that, when completed, lead to the next step. plexed about what they could “health-teach” a
This is an ongoing process that can be modified group of elders to alleviate their loneliness

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(Falk-Rafael, 2005a). Yet there certainly are nurse characterized the learning as “synergis-
times when learning skills or gaining knowl- tic with a positive health effect” (p. 20).
edge is critical to clients’ health goals. At those
times, nurses engage in transpersonal teaching– CHPP 5—Providing, Creating, and/or
learning with clients within the context of a Maintaining Supportive and Sustainable
helping–trusting relationship. A systematic, Environments
reflexive approach guides decision making re- Nursing’s legacy is both caring for vulnerable
garding the desired outcomes, approach, and people and advocating for changes to lessen
level and amount of information desired by the their vulnerability and reduce, or preferably
client. Teaching–learning is situated in clients’ eliminate, health inequities (Falk-Rafael,
lived realities—building on knowledge and 1999, 2005b; Falk-Rafael & Betker, 2012a).
skills they already have and with a sensitivity This CHPP attends to that legacy and
to ongoing feedback, verbal and nonverbal, restores political advocacy and activism as
about the relevance and comprehensibility of a central feature of public health nursing.
information, practicality of suggestions, and/or Environment may be interpreted as the im-
distractions that might interfere with the mediate surroundings in which care of an
teaching–learning process. individual takes place, in which case this
A teaching–learning approach occurs within CHPP would lead a nurse to addressing
the context of a trusting–caring relationship, as issues such as a client’s safety, comfort, and
can be observed in the previous exemplar. A privacy. But both the nature of public health
critical caring approach recognizes that the nursing and the feminist critical social theo-
nurse has clinical expertise that may be of value ries roots of Critical Caring Theory call for
to clients in meeting their health goals but that broadening that interpretation and shifting
clients also have expertise on their lives, on the emphasis to the social, economic, politi-
living with a certain health condition, or in cal, and natural environments that so pro-
circumstances that adversely affect their health. foundly influence health and its prerequisites
Building on that knowledge is important. For (World Health Organization, Canadian
example, persons recently diagnosed with HIV Public Health Association, 1986).
infection might have a goal of protecting them- It is worth reflecting momentarily on the
selves from opportunistic infections. Beginning changes that brought about the shift in nursing
the conversation with “What steps have you focus. This nursing shift started with Nightin-
already taken?” or “Tell me what you already gale’s emphasis on social and economic factors
know” might be useful approaches to initiate that were known experientially by nurses to
dialogue. present-day understanding of how these fac-
It is in being open to acknowledging the tors adversely affect health (Falk-Rafael,
expertise of clients that nurses’ learning oc- 2005b). With the emergence and then domi-
curs. Nurses often incorporate the knowledge nance of the biomedical model of health, the
they gain into their practice, so that client so- majority of nursing care shifted from commu-
lutions to a problem that have been shared nities to hospitals, and health became equated
with the nurse might be incorporated into with a disease-free state. Health promotion it-
practice and offered to others experiencing self became widely confused with disease pre-
the same difficulty. Falk-Rafael and Betker vention. For example, the influential medical
(2012b) reported an example in which nurses model introduced by Leavell and Clark (1979),
wanted to create a pamphlet about safer crack and still used today, considers health promo-
use and engaged a group of women who used tion a primary prevention strategy. By 1978, in
crack to tell them what should be in it. In one recognition that the biomedical model of
of the nurse’s words, “We were saying to “health” care was too narrow, an international
them, ‘You are the experts here and we want consensus was reached at Alma-Ata that pro-
to help people be safer when they use [crack] moted a model of primary health care (World
and we need your advice’” (pp. 319–320). The Health Organization, Regional Office for

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Europe, 1978). The proposed primary health- Strategies for political activism can take any
care model included the biomedical model but number of forms: letter writing, meeting with
also recognized that health was influenced by politicians, organizing or attending protests,
much more than “health” care and introduced and/or writing a resolution for a professional
ideas later formulated into social determinants nursing organization or union to address a par-
of health. Several years later, the World ticular issue. Realistically, to be effective at cor-
Health Organization (WHO) held the first in- porate, provincial/state, and/or federal levels,
ternational conference on health promotion, political advocacy most often requires more
which produced the Ottawa Charter (WHO, than an individual effort. For such purposes,
1986). The Ottawa Charter identified nine nurses can become involved in building or
prerequisites of health: peace, shelter, educa- joining coalitions that might be within or
tion, food, income, a stable ecosystem, sustain- across disciplines and/or other sectors inter-
able resources, social justice, and equity. Eight ested in achieving the same goal. Although
subsequent global conferences have been held community members will hopefully be in-
since then, and the most recent in Shanghai volved in such efforts, mobilizing communities
has again affirmed those original nine prereq- to participate in political advocacy related to
uisites (WHO, 2016). issues affecting their health is not only effective
In the context of this CHPP, the usefulness but may also help communities develop their
of the WHO documents is to expand the focus own capacity for political activism.
of the nurse on the role that these prerequisites Kosiorowski (2014) reports a study that
of health play in the health of their clients. identified five tips for successful advocacy: sus-
Addressing insufficiency in any one of them is taining a sharp focus on the goals and anticipat-
likely to require political activism for change ing that, with few exceptions, the process may
at the policy level of an organization or appro- take years; investing in building relationships
priate level of government. For example, in with public officials; considering the motiva-
school nursing, activism might be directed to- tions of those officials by learning background
ward lobbying for school policies to provide ex- information about them; galvanizing coalitions
clusively healthy choices in vending machines, to achieve short-term goals; and ensuring strong
ensure playground safety, or develop bullying high-integrity leadership. Although directed at
prevention strategies. At a local community school nurses, these tips are relevant for nurses
level, activism might take the form of advocating in any sector. The personal and emancipatory
for bylaws that would reduce public exposure to knowing that public health nurses gain through
secondhand smoke. From a population-focused working “at the intersection of personal lives
perspective, efforts would be directed at gov- and public policy” (Falk-Rafael, 2005a, p. 45)
ernments with the jurisdiction to create or compels them to promote health through po-
modify a specific policy, such as minimum litical action. Public health nurses’ ability to bear
wage levels, staffing levels in nursing homes, witness to the lived realities of their clients also
or efforts to protect the natural environment. provides them with considerable credibility in
That is, the major focus of this CHPP is po- the political arena (Falk-Rafael & Betker,
litical activism to address the broader social, 2012a).
economic, and political factors that adversely
affect health, usually resulting in health in- CHPP 6—Meeting Needs and Building
equities. Because poverty has implications for Capacity
being unable to meet even necessities of life, The nature and scope of public health nursing
such as food and housing, a nurse might be can vary significantly depending on the focus
involved in advocacy at the appropriate level of the position. It can also vary with geograph-
of government for policies such as ensuring ical region and has in some jurisdictions varied
food security, increasing minimum wages, intro- significantly over time (Rafael, 1999). Regard-
ducing basic income guarantees, or creating less, the focus of public health nursing is on
affordable housing. health promotion. In some situations, public

7991_Ch32_509-522 12/08/19 5:27 PM Page 517
health nurses may directly meet client needs and people cannot afford the fresh produce and
build their capacity through providing health intake political action to lobby for policy changes
formation and developing their skills; they may at the appropriate level.
indirectly meet other needs through linking As in individual care, the goal at the commu-
clients with existing community services. In nity level is to develop the community’s capacity
other situations, for example, street health, to care for its members, including those most
school health clinics, sexual health clinics, or vulnerable. Zinkan-McKee and Falk-Rafael
mother and infant programs, nurses may work (2017) relate the example of working in an
directly with clients to address a broader range HIV/AIDS program in its early days. Over
of health needs. Regardless of the nature of the time, a number of their clients expressed the
position, nurses provide care within the context desire to meet with others in similar circum-
of a helping–trusting relationship. In addressing stances. The nurses worked with a local clergy-
specific health needs, nurses work toward poten- man in establishing first one, then three support
tiating wholeness and strengthening the client’s groups in the county. When much of the time
capacity for self-care. Falk-Rafael and Betker in those meetings began to be spent in discus-
(2005b) provide the example of a nurse working sions of how the groups might provide HIV pre-
with a young woman with an Oxycontin addic- vention education to the community, the groups
tion who overcame her addiction and went on evolved into a HIV/AIDS Committee, which,
to educate others about addiction. The nurse at- over time, developed the skills and resources
tributed the dramatic change to “the relationship both for educational outreach and support of
we developed, mostly because I listened to her people affected by and infected with HIV.
entire story and worked with that” (Falk-Rafael Questions may be asked whether time is not
& Betker, 2005b, p. 326). better spent in capacity building (an upstream
Often public health nurses promote health approach) than in meeting needs of individuals
at the level of a community. In such cases it is (considered a downstream approach). The criti-
also advantageous to assess the community’s cal caring approach must ethically be both. It is
capacity to meet the needs of its members not only the example set by early nursing leaders,
(Falk-Rafael, 2000). Such an assessment fol- such as Nightingale and Wald (Falk-Rafael,
lows the principles in CHPP 3 and involves 2005b), but also from a practical perspective, this
working with key informants in the commu- approach enables nurses to understand client’s
nity. In addition to the assessment, public lived experiences, making them more effective
health nurses working in and with communi- political advocates, as noted above. Furthermore,
ties may be the first to identify emerging as one nurse noted, “capacity building only hap-
health patterns that suggest the need for addi- pens on a full stomach” (Falk-Rafael & Betker,
tional services. For example, a nurse may be- 2012, p. 327). Most important, it is the ethical
come aware of an increasing number of approach. As Watson (2005) observes, “reaching

persons or families who struggle to afford fresh out to another in his or her vulnerability involves
fruits and vegetables. This might result in ex- making one’s self vulnerable, but to do other-
ploring the issue with community members wise, to turn one’s face away … can be an act of
and assisting them in finding solutions, for ex- cruelty” (p. 55).
ample, establishing community gardens and/or
working with community grocers and food CHPP 7—Being Open and Attending
banks to ascertain whether it is possible to do- to Spiritual/Mysterious and Existential
nate produce approaching its best-before date Realms of Finding Meaning.1
to the local food bank. Or, if the community This CHPP acknowledges that caring science
does not have a food bank, the nurse might is indeed a sacred science (Watson, 2005). It
work with community leaders in establishing
one. Using a population-focused approach, the 1The change in wording of this CHPP from previous pub-
public health nurse and community might ex- lications adds clarity and reflects changes in Watson’s
plore the reasons why increasing numbers of (2008a) language.

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acknowledges the privilege and sacredness of a model for public health nurses to practice
being in a caring relationship and is illustrated accordingly. Reutter and Kushner (2010), in
in one nurse’s characterization of her experi- examining the implications for nursing of the
ence of caring for a person dying with AIDS WHO Commission on Social Determinants
as a “spiritual journey we’re on together” (Falk- of Health (WHO CSDH, 2008), considered
Rafael & Betker, 2012b, p. 327). Smith’s assertions and advocated that nurses
CHPP 7 focuses on being open and attend- meet the CSDH challenge by using a critical
ing to the spiritual, mysterious, and existential caring approach.
realms within which individuals and commu- Critical Caring Theory has been included in
nities find meaning, often in the face of suffer- the discussion of theoretical foundations for
ing, calamity, or death. In happy events, such community health nursing in the latest edition
as recovery from illness or the birth of a baby, of a Canadian community health nursing text-
meaning-making also occurs and might be ex- book (Betker, MacDonald, Hill, & Kirk, 2015).
pressed as a miracle, a gift from a Supreme The authors examined the theory within the
Being or answer to prayer, for example. As a context of the Canadian Community Health
nurse, being open to clients’ usual ways of mak- Nursing Standards of Practice and found a con-
ing meaning is a characteristic of a respectful, nection with all seven standards. They provided
nonjudgmental way of being in relation. the Nurse–Family Partnership (NFP) program
Attending to those ways allows nurses, when as an example of the theory’s use in practice.
clients are traumatized by events, to be able to Dr. Susan Jack, a nurse-researcher at
offer comfort within the context of a client’s McMaster University, was instrumental in
own belief system or patterns of making mean- bringing the NFP model to Canada (personal
ing and/or facilitate the process. communication, January 29, 2018). The NFP
This CHPP is also closely linked to cultural model is a home visitation program in which
sensitivity. Consider the exemplar in Falk- nurses regularly visit young, socially and eco-
Rafael (2005a) in which a group of students nomically disadvantaged first-time mothers
was assigned to work with an Aboriginal com- from early pregnancy to the infant’s second
munity to address the high prevalence of tuber- birthday. It is the model first developed by
culosis within that community. The students David Olds (Olds & Kitzman, 1993) in the
invited an elder to open the workshop, which United States and has been adapted for deliv-
he did with prayer and a smudging circle, in ery by Canadian public health departments.
which the students participated. They then fol- Dr. Jack and her colleagues developed an
lowed the elders’ suggestions for presenting the extensive three-phase educational program to
information in a way that it could be used by prepare nurses for practice in the NFP pro-
the Aboriginal health educators in a train-the- gram. Although the program uses a multithe-
trainer model. oretical approach to guide NFP practice, one

full module is devoted to Critical Caring
Applications of the Theory Theory. Dr. Jack noted that the inclusion of
Critical Caring Theory is a unique adaptation
Smith (2007) has argued that in the Canadian curriculum. She provided
when its capacity for caring is healthy and intact,
comments from two of the NFP educators.
One emphasized that Critical Caring Theory
nursing is the health profession best suited for
was important because it underscored the
leadership in reducing inequities … because [it]
important role of nurses in the program. The
is the discipline for which caring—in its fullest
second NFP educator noted that Critical Car-
and most elaborated and profound meaning—
ing Theory “should be introduced to any home
is absolutely central to theory and practice.
visiting program … because it resonates so
(pp. 285–286)
completely with the work that public health
Critical Caring Theory elaborates the full nurses do.” This educator further remarked
and profound meaning of caring and provides that the theory “captures the work that didn’t

7991_Ch32_509-522 12/08/19 5:27 PM Page 519
have language before” and named “some of the Dickson and Lobo (2018) explored the useful-
skill and formerly invisible work” of public ness of the theory in advocating for compre-
health nurses.” The educator concluded that hensive sexual health education (CSHE) and
before the addition of Critical Caring Theory, provided examples of how public health nurses
“it always felt like you were adding nursing as- might use each of the CHPPs in advocating
sessment pieces or adding nursing knowledge for CSHE. They concluded that the theory
from school … without a formal theory to help helps explain, guide, and provide clarity for
integrate that.” Finally, Dr. Jack reported that public health nurses in this work. A critical
one of the public health nurses who completed caring approach was also proposed as a useful
the NFP education program particularly val- model to guide global health nursing (Falk-
ued the integration of Critical Caring Theory Rafael, 2006) and refocusing a conceptualiza-
because of its emphasis on social justice and tion of international health to one of global
addressing the social determinants of health. health (Austin, 2001).
Critical Caring Theory has been presented Critical Caring Theory has been integrated
at international, national, and provincial nurs- with other theories. Shearer (2017) used it in de-
ing conferences. Often feedback from non– velopment of the Critical Caring Theory of Pro-
public health nurses has been that they also see tection for migrant and seasonal farm workers
a relevance of the theory to inform their own (MSFWs), using theory synthesis. She found
practice. In numerous presentations at public that a critical caring perspective raised awareness
health nursing conferences, both national and of risks, built trust, and was effective in building
regional, responses by public health nurses capacity among the community of MSFWs.
have enthusiastically echoed those of the NFP Critical Caring Theory has also been used in
educators referred to above. By invitation, the a model for nursing education. Chinn and Falk-
theory has also been presented at numerous Rafael (2018) developed a nursing pedagogy that
public health units/departments. Nurses in integrated Critical Caring Theory, Chinn and
several workplaces have indicated an interest Falk-Rafael’s (2015) Theory of Peace and
in their agency adopting Critical Caring The- Power, and Noddings’ (1998) philosophy of ed-
ory as a theoretical model for public health ucation. The premise behind the integrated
nursing practice, but to date, I am not aware model is that when students experience nurse
of any that have. It is possible, however, that educators using a pedagogy grounded in nursing
individual public health nurses may be using disciplinary knowledge, they will both gain an
the theory to guide their own practice. appreciation for that knowledge and be more
Some nursing scholars have used critical likely to use disciplinary knowledge to guide and
caring as a framework for their own work. inform their own nursing practice.
Practice Exemplar
Carolyn is a public health nurse working in Learning that Minja was aware of the referral,
the family health program of an inner-city she asks her how she and the baby are doing.
health department. She has received a referral When the answer is a polite “okay,” she ascer-
from the local hospital to visit a single, 17- tains that the baby is feeding and sleeping sat-
year-old first-time mother and newborn male isfactorily and asks Minja if she has any
infant. She calls the number on the referral immediate concerns. Hearing of none that are
form and when a young woman answers the urgent, Carolyn confirms an appointment for
phone, Carolyn identifies herself and confirms the next morning, suggesting that Minja write
she is speaking to Minja. Carolyn tells Minja down any questions or concerns that occur to
that she has received a referral from the her in the interim. In preparing herself for
hospital to check in with her and her baby. the next day’s visit, Carolyn reviews some
(continued)

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information about common beliefs and prac- ensure the infant’s strength. Carolyn is able to
tices related to mother/infant health of several hide any reaction but gently explains that the
of the cultural groups in the neighborhood shears could pose a serious risk for injury,
and spends a few minutes clarifying her own being so close to the infant, and asks whether
values related to the diverse practices. they could be placed elsewhere in the crib and
The next morning, Carolyn drives to the told that would be acceptable.
address, which is in an older part of the neigh- During the visit, Carolyn watches the in-
borhood. The street looks a little run down, teraction between Minja and the infant and
but the house at the referral address looks to positively reinforces her tender, loving, and
be in fairly good repair from the outside and competent care for her infant. She asks if she
the small yard is tidy, with a tended flower may undress the baby and examine him, find-
bed. Before leaving her car, the nurse takes a ing him to be thriving and well cared for.
moment to center herself to be fully present, Satisfied that at this point the physical needs
open, and nonjudgmental with the new mom of Minja and her infant son are being met,
and baby. A young woman answers the door Carolyn asks Minja if she has any further con-
and when Carolyn identifies herself, she is cerns. Minja shyly admits to feeling a little
greeted with the Namaste gesture, which she isolated and afraid she won’t know how to
returns. The young woman invites her into cope as the baby grows. She also expresses
the house, which also appears clean and tidy. concerns about the expense of the prebottled
Carolyn can hear what sounds like someone formula and wonders about some of the advice
doing dishes in another room. Minja ushers she receives from her grandmother. Her
Carolyn into a sitting room and motions for mother, who works during the day to support
her to sit down. Carolyn begins with asking the family, doesn’t hold as firmly to the “old”
Minja how being a new mother has been for beliefs but is often too exhausted to “get in-
her and hears that she feels somewhat over- volved.” She further reveals that her parents
whelmed and finds being up every 3 hours to divorced 10 years ago and before the preg-
be exhausting. After establishing that Minja nancy she had been living with her father and
is experiencing no other physical health con- his current wife about an hour away from her
cerns of her own, and that she has a follow- present home. She tearfully relates that she
up appointment with her physician in a few was shunned at school and at her father’s
weeks, Carolyn reassures her that it is very house when the pregnancy became obvious.
common to feel that way. She asks Minja The baby’s father has been prohibited by his
about what supports she has in caring for the parents from contacting her.
infant and learns that she lives with her Carolyn informs Minja of a mother–infant
mother and grandmother and that they pro- group that meets in the neighborhood and asks
vide “a bit” of assistance with the actual care if she would be interested in attending. Finding
of baby, along with much advice! that she is, Carolyn offers to go with her the first
Carolyn next asks if she can see the baby time and introduce her to the group. Carolyn
and Minja takes her to an upstairs bedroom also informs Minja of cheaper alternatives to
and quietly opens the door. Carolyn notes the prebottled formula and offers to bring her a
baby is sleeping on his back in a crib. She sample. At the next visit, Carolyn shows Minja
comments that the crib looks to be quite new and her grandmother, who had indicated to
and observes that lead paint is unlikely to be Minja that she also wanted to learn, how to pre-
an issue and that the slats are appropriately pare the formula. Carolyn confirms that Minja
close together to meet safety standards. But in has applied for the monthly child assistance or
the crib, close to the baby’s head, are a pair “baby bonus” provided by the government. She
of shears. When Carolyn asks about them, reflects with satisfaction on her involvement
Minja replies that her grandmother and with an antipoverty group that lobbied success-
mother insist that this practice is necessary to fully for increases to the government’s child

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benefit program. Because of that, Minja will re- about it, thinking they believe she has brought
ceive just over $500 per month, tax free, to assist shame and an increased financial burden upon
with raising her child. them. Carolyn asks Minja whether her father
Over the next few weeks and several visits, is paying her mother child support for her
including one to the mother–infant group since she moved back to her mother’s house.
(which Minja finds helpful for practical and Minja doesn’t know but agrees to explore this
social reasons), Carolyn learns that Minja des- option with her mother. Carolyn suggests that
perately wants to complete high school and her mother may be entitled to support and
eventually go to University but believes it to be confirms that Minja has the contact number of
impossible because she is forbidden from re- the social worker assigned to her, as well as a
turning to her father’s house. On Carolyn’s number for the legal aid office, should she and
final visit, she and Minja explore educational her mother need it. Finally, Carolyn and Minja
alternatives such as high school correspon- rehearse how Minja might approach her
dence and summer courses offered through the mother and grandmother about her educa-
Ministry of Education. Initially, Minja is tional goals in a respectful but direct way and
afraid to speak to her mother and grandmother use role-play to rehearse the scenario.
Summary
Critical Caring is a middle-range theory of caring, as well as the five caritas health promot-
public health nursing that is rooted in Watson’s ing processes through which doing, or critical
caring science, Nightingale’s example and writ- caring praxis, take place. It holds potential for
ings, and feminist, critical theories. It holds the guiding nursing practice at the level of indi-
potential to root public health nursing firmly in vidual, family, community, and population-
nursing science at a time when theories from focused care. A review of the application of
other disciplines often overshadow public critical caring shows promise in both practice
health nursing’s disciplinary knowledge, and and scholarship. The theory has been wel-
administrative pressures have narrowed the na- comed by Canadian public health nurses, in
ture and scope of nursing practice (Falk-Rafael part, because it provides language for previ-
& Betker, 2012a, 2012b). ously invisible public health nursing work. The
At its core, Critical Caring Theory is a re- uniqueness of the theory in articulating a nurs-
lational way of being, knowing, choosing, and ing role in addressing social determinants of
doing. Its five ways of knowing are both con- health and using political activism to redress
sistent with nursing literature and inform its social injustices has been endorsed by a num-
ethics of social justice as an expression of ber of nursing scholars.
Questions for Reflection ■ Identify specific examples of how nurses

can apply Critical Care Theory to guide
and Discussion nursing practice.
■ Describe the appropriateness of Critical ■ What are the seven carative health promot-
Care Theory to nursing practice in a ing processes (CHPPs) described by Falk-
variety of settings other than public Rafael? Provide specific examples of how
health. these can be applied to nursing practice.

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Katie Eriksson’s Theory

CHAPTER
33
of Caritative Caring
Diane Lee Gullett and
Camilla Koskinen

Applications of the Theory Over the past 50 years Katie Eriksson has
Practice Exemplar worked to clarify the discipline of caring
Summary science. Born in 1943, Eriksson completed
Questions for Reflection and Discussion both her basic and public health specialty nurs-
ing education at Helsinki Swedish School of
Nursing in 1965 and 1967, respectively, and
graduated in 1970 from the nursing teacher
education program at Helsinki Finnish School
of Nursing. Eriksson received her MA degree
in philosophy in 1974, her licentiate degree in
1976, and defended her doctoral dissertation
in pedagogy in 1982 at the University of
Helsinki. Her scientific career and professional
experience started in 1970 at Helsinki Swedish
School of Nursing where she worked as a
teacher, leader, and dean of the educational
program in caring science and nursing. During
this period, she developed an educational pro-
gram for nurse educators (caring science didac-
tics) in collaboration with the University of
Helsinki. In 1986, Eriksson was nominated to
start an educational program for health care
and a research program for caring science at
Åbo Akademi University in Vasa, Finland. For
nearly 30 years, she served at Åbo Akademi

University as professor and dean. Over those
30 years, more than 80 doctoral theses were
published, contributing to new knowledge on
the essence and substance of caring.
Eriksson’s lifework has been in teaching
and research while also being a pioneer,
leader, and mentor for countless nurses and
students in Nordic countries, and she is recog-
nized as a renowned caring science researcher
in the Nordic countries. She has pioneered and
guided the foundation of basic research in
caring science, to maintain caring science
as a human science and as an independent
523
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academic discipline. Since the 1970s, Eriksson or made explicit through statements on the
has systematically developed an ideal model nature of reality (Eriksson, 2001).
for caring, the Caritative Caring Theory. Katie The foundation for innovative knowledge de-
Eriksson’s passion to answer the fundamental velopment depends on clear and well-articulated
questions of caring, along with her sincere and theoretical foundations and concepts (Eriksson,
tireless search for knowledge about the core of 2001). By creating a theoretical basis and a con-
caring and ethos, inspired her to develop the ceptual order, a common conceptual starting
Caritative Caring Theory. The mission of her point is formed, making it possible to investi-
research has been to seek answers to the time- gate, apply, and implement models and theories
less and eternal questions about the essence of of caring within various health-care contexts
caring, human being and living, health and with context-specific features. Eriksson states
suffering, in order to relieve human suffering that the better we clarify the foundational con-
and promote health. cepts and theories, the better we can understand
caring actions (Eriksson & Bergbom, 2017). A
clear theoretical perspective and conceptual
Overview of the Theory order are, therefore, foundational to Eriksson’s
Theoretical Foundation Caritative Caring Theory.
Katie Eriksson, along with her staff, re-
searchers, and doctoral and master students, Assumptions
has developed a solid evidence-based theoret-
Eriksson formulated a scientific theory
ical foundation within the discipline of caring
through the development of fundamental val-
science essential for the provision of good
ues, axioms, and presuppositions creating an
caring and care work. In a scientific theoret-
“ontological core” that serves as the basis for
ical sense, Eriksson’s theory adopts a hu-
furthering theoretical and clinical research
manistic and hermeneutic approach, which
in caring (Eriksson & Bergbom, 2017). The
means that the form of knowledge stems from
foundation of Eriksson’s caring science theory
a search for a deeper understanding about
stems from ontological concepts and assump-
human caring. The principal methodology of
tions; thereby, creating a theory of caring sci-
hermeneutics seeks a deeper and expanded
ence recognized as an autonomous discipline
understanding of knowledge through an in-
(Eriksson & Bergbom, 2017). Ontological ax-
terpretive movement between the whole and
ioms are conceptions of the world and funda-
its parts, between pre-understanding and new
mental statements about the nature of caring
understanding and through the union of the-
science. These axioms also support the de-
ory and empirics. The research seeks to un-
scription of the theoretical perspective. Basic
derstand glimpses of human reality beyond
assumptions of Eriksson’s (2002) Caritative

the experience, searching for a deeper mean-
Caring Theory are as follows:
ing beyond that which appears immediately
visible and obvious. Hermeneutic interpreta- ■ The human being is fundamentally an
tion constitutes silence and listening for a entity of body, soul, and spirit.
deeper view of the reality of humanity (Eriksson ■ The human being is fundamentally a spiri-
& Lindström, 2007). tual being, but all human beings have not
Eriksson (2001) asserts the importance of recognized this dimension.
caring sciences as an independent scientific ■ The human being is fundamentally
discipline. This involves a constant demand for holy. Human dignity means accepting
academic research to develop meaningful knowl- the human obligation of serving with
edge, be visionary, and have a desire to create love, of existing for the sake of others.
innovations in clinical practice. Eriksson devel- ■ Health means a movement in becoming,
oped her theory within the scientific discipline being, and doing, and striving for integrity
of caring science understood as a human science and holiness, which is compatible with
and, as such, her theory is defined by its ontology bearable suffering.

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C H APTER 33 ■ Katie Eriksson’s Theory of Caritative Caring 525
■ The basic category of caring is suffering. practical concepts the leaves of the tree while
■ The basic motive of caring is the caritas we, the authors, interpret the evidence con-
motive. cepts as the bark of the tree.
■ Caring implies alleviating suffering in
charity, love, faith, and hope. Key Concepts of the Theory
■ A caring relationship forms the meaning- of Caritative Caring
ful context of caring and derives its origin
To understand the basic assumptions of the
from the ethos of love, responsibility, and
Theory of Caritative Caring requires first an un-
sacrifice.
derstanding of some of Eriksson’s key concepts
including caritas, caring, caring communion,
Eriksson’s Caritative Caring Theory
caritative caring ethics, ethos, caring culture,
(Eriksson & Bergbom, 2017) is constructed
suffering, suffering human being, and health.
using a conceptual system consisting of core
Through further examination and analysis of
concepts, ethos concepts, foundation con-
these key theoretical concepts, one comes to
cepts, practical concepts, and evidence con-
better understand Eriksson’s caring science
cepts. Core concepts denote the innermost and
work and research.
original meanings and reflect deep structures
of a concept that are original and unchange-
able, regardless of context. These core concepts Caritas, Caring, and Caring
in Eriksson’s theory are (1) caritas, (2) the Communion
human being as an entity, (3) suffering and Eriksson’s (2018) Theory of Caritative Caring
health as an entity, and (4) caring. Ethos con- recognizes caring as the essence and core of
cepts are concepts transcended by the values caring science and nursing. The theory as-
and defenses of human dignity. Ethos con- sumes that all true care is based on community,
cepts help caregivers to make ethical choices human love, and responsibility for the other,
and reflect a willingness to do good in a con- including a deep will to take care of and convey
crete situation for the patient and reflect the faith, hope, love, and mercy to the sick and suf-
discipline’s ethos or inner value base. Foun- fering human being in distress. The purpose
dation concepts reflect deep structures and add of caring is to alleviate suffering, serve life,
to the substance or essence and shades of the and support health and well-being (Eriksson,
core concepts. Foundation concepts extend 2006). Caring relates to the innermost core of
the scope and depth of the core concepts. nursing whereas, nursing refers to the actual
Practical concepts are the specific and clinical work of nurses suggesting not all nursing is car-
concepts that focus on the patient and clini- ing (Eriksson, 1997a). To provide caring nurs-
cal situations, serving to expand both core ing care, nursing must be grounded in caring
and foundation concepts. Practical concepts nursing which describes the innermost core of
constitute the force in caring and care activ- caring. Caring involves a deep respect for the
ities. Evidence concepts are concepts that vi- dignity of the human being and the willingness
sualize and expose caring and caring science. to be genuinely present for the suffering human
All research projects based on Eriksson’s being. The suffering human being is conceptu-
thinking and research tradition, therefore, alized as a person who is a patient for whom
have connections to the core concepts of car- the caregiver can care and alleviate suffering
ing, suffering, and health, and thus con- (Arman et al., 2015, p. 293). Eriksson (2003)
tribute to the conceptual order and to theory recognizes genuine caring not as a behavior or
development of Eriksson’s Caritative Caring a feeling or even a state of being but rather as
Theory. Figuratively, theory development is an ontology, a way of living, an ethos of caring.
like a concept tree, in which the core con- The motive of caring, what invites us to care, is
cepts constitute the trunk of the tree, the caritas, defined as a union of compassion and
ethos concepts the roots of the tree, the foun- mercy. The caritas motive implies the core,
dation concepts the branches of the tree, the the caregiver’s responsibility for the other, to

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employ caritas in caring for the human being determines the caring reality (Eriksson, 2006).
in health and suffering. Eriksson (2018) stated Caring communion is considered one of the
that it is not enough to just be present, but in- most profound forms of communion as it gives
stead it is the way or the spirit in which caring caring its significance and arises from an un-
is done that matters, and this spirit is caritative, selfish relation with another, forming the means
meaning with love and charity. to create possibilities for the other, and stems
Caring serves as the communion between from a genuine desire to alleviate suffering
the nurse and the patient where human beings’ (Eriksson, 2002). Originating from the existen-
dignity comprises the fundamental worth tial caring relationship, there is the opportu-
(Eriksson, 2007, p. 201). The nurse can engage nity for transformation in a caring communion
in caring meaning-creation encounters with when the caregiver is touched by the vulnera-
another’s suffering and in doing so forms a car- bility of the suffering human being (the patient).
ing communion (Eriksson, 1997a, 2006). The The caregiver through tenderness, sensitivity,
caring relationship forms the meaningful con- and responsibility to the needs of a patients
text of caring and derives its origin from the suffering creates a space which invites the pa-
ethos of love, compassion, responsibility, and tient to enter into a caring relationship. Caring
sacrifice, or a caritative caring ethic (Eriksson, arises from a form of emotional ability, an eth-
2006). The caring encounter becomes the cat- ical motive, and a willingness to do something
alyst by which suffering can be understood as special, to give the whole self. Caring com-
bearable, a means by which the nurse can bear munion is characterized by intensity, vitality,
witness and see the patient’s suffering from the and an openness to listen and find new possi-
patient’s perspective as a unique human being bilities. Fundamental entities include care, eye
(Eriksson, 1997a, 2006). True caring com- contact, listening, and finding a common lan-
munion implies the nurse as a caregiver has a guage (Eriksson & Lindström, 2003). Caring
genuine understanding that goes beyond su- communion between the caregiver and patient
perficial understanding to a true sharing of the is characterized by struggling together, suc-
patient’s world. Caring becomes natural when ceeding, being together, and going through
the caregiver focuses on the patient while es- something together.
tablishing an unselfish relationship and feels a
responsibility to alleviate the patient’s suffering Ethics, Ethos, and Caring Culture
as perceived and understood from the patient’s Eriksson (1992) defined caritas caring ethics as
world. comprising the ethics of caring and is defined
Eriksson (2002) recognized caring as natu- by the caritas motive. An approach based on
rally human and the human being as “an invi- Eriksson’s (2006) caring ethics means that the
olable divine entity, suffering as a part of life, caregiver sees the patient as a unique human
and caring as a manifestation of the human being with respect and confirms a person’s
person’s ability to feel compassion and uncon- absolute dignity while also being willing to
ditional love, belong together” (Eriksson, sacrifice something of themselves in the care
1997b, p. 68). Theoretical pre-understanding of the patient. According to Nordic caring sci-
in the Caritative Caring Theory recognizes that ence tradition, dignified caring relates to meet-
communion is fundamental for all human life. ing the patient as a unique human being and
Human beings seek fellowship with others, to respecting human values (Eriksson, 2002). The
give and receive love, which in turn serves to deepest ethical motive in all caring, the caritas
make them aware of their existence in the motive, involves respect for dignity, respect for
here and now and through caring and com- the human being, and autonomy in care.
munion find meaning (Lindström, Lindholm Caring ethics interlinks to a caring ethos,
Nyström & Zetterlund, 2014). Caring com- as ethics that are not rooted in ethos appear to
munion is the relationship between the care- be a more superficial without a deeper value
giver and the patient, the source of power and base (Eriksson, 2003). In accordance with
meaning in caring and is the structure that Eriksson’s thinking, ethos is the characteristic

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of basic values of the individual caregiver that life-giving, open, and inviting. In a caring cul-
becomes visible in the caregiver’s character, at- ture, caregiver responsibility is described by see-
titude, and action. A caregiver’s caring ethos ing the patient as a suffering human being and
grows through being responsive to the inner bearing a health-promoting attitude toward the
voice of one’s heart, courageously choosing to patient. Caregiver knowledge and understand-
be whom one is intended to be, one’s inten- ing determine how the care develops and forms
tions to relate to other human beings, and a caring culture. When caregivers dedicate to
doing one’s utmost to take responsibility for an ethical value base, the caring culture changes
other human beings. When the caregiver is en- and important foundations and values can
gaged in ethical decision making, there must guide the entire care organization. To develop
be a vigilance to align thinking with values. a caring culture requires a deeper understand-
Ethos becomes visible in how the caregiver re- ing of how ‘caring’ care is interpreted and given
sponds to the patient, in showing respect for meaning by those involved in patient care in-
human dignity, or restoring injured dignity. cluding caregivers, organizations, patients and
An ethic that develops without anchoring itself their significant others.
in an ethos or value base of caring becomes
easily empty and only superficial. Even though Suffering as a Category of Caring
most caregivers are prepared to assert the im- Eriksson’s Theory of Caritative Caring recog-
portance of human dignity as ethos or as an nizes suffering as a category of caring wherein
ethical ideal, the violation of human dignity the underlying reason for caring is the presence
represents the most prominent ethical offense. of suffering (Eriksson, 1992). Eriksson (1997a)
Ethos also creates the core of a caring cul- defined suffering as an “ontological concept and
ture and an internal value hierarchy (Eriksson, a human being’s struggle between good and
2003). Eriksson’s caring culture replaces envi- evil in a state of becoming” (p. 8). Suffering is
ronment in the metaparadigm of nursing sci- a unique, isolated total experience; not a
ence. A culture can be healing or shattering, feeling or a pain, but rather something more
good or evil where evil is the suffering related fundamental—it is a state of being (Eriksson,
to care that emerges in different cultures; how- 1997b). Eriksson (2006) presented three forms
ever, awareness of this suffering is more visible of patient suffering: suffering related to illness,
in caring cultures (Eriksson, 1997a). In essence, suffering related to care, and suffering related
a good caring culture requires reflection on to life. Suffering related to illness is suffering
both good and evil because being aware of evil experienced in relation to illness and treat-
and its consequences allows for an awareness of ment. Suffering related to care is experienced
the good that can emerge. To alleviate suffering during the actual caring situation, and refers to
related to care calls for a better understanding the suffering caused by care or the absence of
of the patient’s world. Eriksson (2018; Eriks- caring, and is considered a violation of a patient’s
son & Lindström, 2003) emphasized the need dignity. Eriksson suggests that all categories of
for nurses to critically reflect and develop re- professional caregivers may unconsciously cause
search focused on patient care grounded in suffering in caring as a “result of an absence of
clinical caring science originating from the pa- reflection and lack of knowledge of human
tient’s (the suffering human being’s) perspec- suffering” (Eriksson, 2006, p. 89). The suffer-
tive. Scientific knowledge; however, is not ing from life is suffering experienced from an
sufficient to make clinical decisions in nursing individual’s own unique life. Eriksson suggests
care but also requires values which are aimed at to alleviate suffering in care can be done in the
what is best for the patient. A culture that is following ways: developing a culture of caring
completely remote from its original ethos is for patients; through patients feeling loved,
dead. A culture loses its autonomous value if it confirmed, and understood; and through get-
becomes a pure practice, if it prioritizes quan- ting the care and treatment for the patient’s ill-
tity instead of quality. Human beings together ness and individual needs, which are unique to
cocreate the ethos, creating a culture that is the individual.

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Eriksson’s (1981) Theory of Caritative ultimate purpose of caring is to alleviate suffer-

Caring recognizes suffering within a lens of caring (Eriksson, 2006). The motive for care or
ing. The suffering human being is described by the caregiver’s understanding of life is an es-
Eriksson (2006) as the patient or human being sential component for recognizing another’s un-
who suffers: “The word ‘patient’ derives from a derstanding of life and suffering and involves
word for suffering” (Eriksson, 1997b, p. 73). All helping that person find meaning, and through
suffering “has one common denominator; suf- this meaning the suffering becomes bearable
fering is in some sense a dying” (Eriksson, (Eriksson, 1992). According to Eriksson (2006),
1997b, p. 73) in which something definitive is caring in its original form entails the preserva-
taken from us, “in concrete or symbolic mean- tion of life, the alleviation of suffering, and
ing” (Eriksson, 2006, p. 8). In suffering there supporting the patient as a whole human
is sorrow over what has been lost or about to being. When caregivers confirm the human
be lost; however, through suffering a human being’s suffering, they convey that they see the
being can be “transformed, created or disinte- person’s suffering, which in turn gives the per-
grated” (Eriksson, 2006, p. 8). In dying there is son comfort and a confidence that someone is
paradoxically a possibility for new life (e.g., rec- willing to share in the struggle with them.
onciliation). Reconciliation refers to the drama Through conscious awareness of suffering as a
of suffering and implies a change through which normal state of existence, the nurse can engage
a new sense of wholeness is formed in the life in caring through helping the other create
of the human being (Eriksson, 2006). In rec- meaning in suffering (Eriksson, 2006).
onciliation, according to Eriksson (1994), the
importance of sacrifice emerges and allows the Ontological Health Model
person to see a way forward and find meaning Health is more than the absence of illness; it is,
in his or her suffering. in the deepest sense, “an ontological concept,
The alleviation of suffering within Eriksson’s that is, it is a question of the individual person’s
Theory of Caritative Caring is not an absence ‘becoming’ and reality” (Eriksson, 1997b, p. 76).
of suffering, but rather the ability of the nurse Every human being, every patient, is ontologi-
to alleviate the suffering of others to make cally seen as someone who longs for something
suffering bearable and endurable (Eriksson beyond themselves, a god or abstract other
1981, 2006). Suffering may become unen- (Eriksson, 2002, p. 63). Eriksson (1994) recog-
durable when it is unmotivated or in conflict nizes the human being as an integrated entity
with the person’s sense of goodness, of ethics that unites body, mind, and spirit and as such
(Eriksson, 1997b). The suffering human being, defines health as being whole as human being in
the patient, needs care that makes the suffering body, soul, and spirit. Health as a concept means
endurable. Through suffering and love a person wholeness and holiness. Health is also seen as a
is able to grow into wholeness and a deeper constant movement between health and suffer-
holiness, to a wisdom of life and harmony and ing. In this movement between health and suf-
holiness that is recognized by Eriksson (1997b) fering, there is both strength and will to live
as a person’s deep consciousness of uniqueness one’s life in all its nuances of happiness and de-
and responsibility as a fellow human being sire, suffering and pain. This healing and health-
(p. 75). Suffering is inevitable, and alleviating giving power resides in the human being, but it
another’s suffering always involves stepping into is through encounters with other people, with
the unknown (Eriksson 1992). Eriksson (1981, an abstract other, or with nature that this inner
2006) made the distinction between bearable source of strength can be released. The source
and unbearable suffering in which unbearable and power of health are found within the human
suffering can paralyze a human being, prevent- being, and when human beings can become rec-
ing the person from growing, whereas bearable onciled with their circumstances in life they
suffering is compatible with health. Alleviating grow as human beings.
human suffering implies that the caregiver is Eriksson (1997b, 2006) summed up the
a co-actor in the drama of suffering, and the substance of health in an ontological health

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model that recognizes health as a movement and object of research, rather than primarily
among three different levels—health as doing, nursing practice or activity. To recognize the
health as being, and health as becoming—and scope and impact of Eriksson’s thinking to the
this movement is expressed in a person’s expe- application of caring in all areas of research,
rience of different problems, needs, or de- theory, education, administration, and clinical
mands. In the health as doing level, health is practice requires an understanding of caring
judged through external objective criteria; in science as a basic category of research. What is
the health as being level, the human being detailed below is by no means an exhaustive
strives for a form of balance and harmony in review of the applications of Eriksson’s work;
life; and in health as becoming level, the however, it provides the reader with the foun-
human being is not a stranger to suffering but dation for understanding the direction and
instead struggles to reconcile with the circum- evolution of her lifework on caring, health, and
stances of life and move toward a deeper suffering.
wholeness.. Health is an entity through its Clinical practice grounded in Eriksson’s the-
connection to suffering, and when suffering is oretical foundation of caring has generated nu-
viewed as a natural experience of the human merous research studies looking at how to
person, suffering becomes a dimension of provide ‘care’ from the perspective of clinical
health. Suffering is therefore experienced in practice (Koskinen & Nyström, 2017). Nyholm,
three dimensions: suffering as doing means Salmela, Nyström, and Koskinen (2018) utilized
being estranged from one’s own inner de- a hermeneutical application research design to
mands and possibilities and being driven in- gain further understanding of the ethical values
stead by external conditions; suffering as being central to the realization of an organization’s sus-
means a looking for something more harmo- tainability in care and to create an ethical practice
nious instead of acknowledging suffering, that model for care practice. The study used dialogues
is, the human being attempts to overcome it between Caring Science researchers and clinical
by satisfying needs; and suffering as becoming is researchers to create the Ethical Practice Model
a struggle between hope and hopelessness, be- for Sustainability of Care (EPM) and to gain a
tween life and death, and the human being is further understanding of ethically sustainable
able to reconcile with his or her suffering care that can become perceptible and imple-
(Eriksson, 1997b, p. 77). Suffering and health mented in practice. The study findings identified
are, therefore, two different sides of the process the concept of common ethos as the core of the
of life and are always present in a person’s life model, reflecting the ethos of care as the funda-
(Eriksson, 1997a). The human being is seen as mental value base for care. The common ethos
constantly engaged in a continued struggle and within the EPM is surrounded by the five ethical
living in a tension between being and nonbeing values of dignity (maintained when carers had a
(Lindström, Nyström & Zetterlund, 2014). clear view of their mission, which involved
Health is a dynamic movement toward integra- working for the patient’s best), respect (for each
tion and presupposes that human beings dare and every human being in daily care work was
to ask spiritual and existential questions about considered to be important and entailed showing
life and health choices. respect for differences), responsibility (perceived
as an all-encompassing responsibility for the
human being in care), invitation (the ability to
Applications of the Theory receive and meet others in a welcoming manner,
Eriksson emphasized the need for a curriculum that is, the creation of a welcoming atmosphere),
based on a caring science model to be inte- and vows (described as the importance of keep-
grated into every educational program for ing the ethical vow that one, as a professional
health-care professionals with its own scien- carer, has taken) considered central to sustain-
tific foundation. Additionally, she emphasized ability in care. The EPM model also identified
that the starting point of academic education the tangible tools and new habits that an organ-
and research is knowledge about the field ization can employ to create sustainability in care

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and includes the following: ethics during re- to assess suffering related to care in a sample of
cruitment, a handbook detailing the organi- 130 nurses with the ultimate goal of developing
zation’s value base, ethical compass, ethical a scale that could be used for continuous evalu-
conversations, and ethics during developmen- ation of quality of care and to preserve the
tal conversations. The study resulted in a new patients’ dignity. The researchers suggest that
understanding and consensus about ethical val- suffering related to care is not only related to the
ues that enables sustainable care while the de- internal world of the patient but also is con-
velopment of the EPM helped caregivers better nected to the hospital organization and the
understand an organization’s common value nurse–patient relationship. The instrument in
base and what these values mean for sustainabil- this study was therefore validated from nurses’
ity in care. perspectives. The study employed principal
Recognizing how the theoretical basis of component analysis to test validity and internal
Eriksson’s (1997, 2001) caring theory could be consistency and Cronbach’s alpha to test the re-
reflected in clinical practice gave rise to liability of the instrument. The analysis yielded
research exploring a model for nursing care a four-factor solution including lack of unique-
documentation. One study used an adaptation ness, desire for confidence, exposed to punish-
of Gadamer’s hermeneutic method to apply ment, and threat to dignity, which demonstrated
Eriksson’s theory to a way of thinking about a reasonable level of consistency and reliability.
clinical practice generating a hermeneutic A confirmatory factor analysis would be the
dialogue between Eriksson’s caring science next step to cross-validate and refine the theory
texts and clinical nursing practice (Kärkkäinen of suffering related to care. The results of this
& Eriksson, 2004a). Another dialogical re- study advance the conceptualization of suffering
search study was conducted to structure a doc- related to care and contribute to the field of
umentation system of nursing care on the basis caring and nursing care.
of Eriksson’s theoretical caring process model Eriksson’s (2006) theoretical work on suf-
(Kärkkäinen & Eriksson, 2004b). This method fering related to care has been the focus of a
of research highlights dimensions of patients’ number of research studies in clinical practice
health and suffering allowing patients’ views and contexts such as psychiatry (Sjöstedt,
and experiences to be revealed in nursing doc- Dahlstrand, Severinsson, & Lutzen, 2001),
umentation. An interventional study demon- disasters (Roxberg, Dahlberg, Stolt, & Frid-
strated to what extent documentation based on lund, 2009), elderly care, childbirth, breast
the theory of caring revealed patients’ experi- cancer (Arman & Rehnsfeldt, 2003; Arman,
ence and views of care (Kärkkäinen & Eriksson, Rehnsfeldt, Lindholm, Hamrin, & Eriksson,
2005). Following intervention, improvement 2004), and transcultural nursing (Nyback,
was seen in documentation of the content of 2007; Wikberg & Eriksson, 2008). For in-
the nursing process, with the greatest improve- stance, research has focused on exploring how
ment found in the recording of the patients’ nurses experience consolation and how these
experiences, patients’ health behavior, and experiences relate to suffering and nursing care
attending to the patients’ learning (facility) and (Roxberg, Eriksson, Rehnsfeldt, & Fridlund,
readiness; however, consideration of the patients’ 2008). The study intent was to clarify the un-
significant others remained minimal in the derstanding of consolation from the perspec-
documentation. Almost 41% of the nurses found tive of practicing nurses in a home health
the concept of “caring” a weak description of setting using an exploratory, qualitative re-
actual practice, unfamiliar and difficult to search design. The question asked in this study
understand. concerns the nature of consolation, its place,
Other research aimed at improving care in and its role in relation to care. Again, deeper
the clinical setting can be seen in the pilot study understanding of theory-guided practice can
done by Nordman, Santavirta, and Eriksson be drawn from seeking to understand the car-
(2008). This study sought to test the reliability ing concepts. Arman and Rehnsfeldt (2007)
and validity of a newly constructed instrument conducted a study to determine empirical

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clinical indications of good ethical care and to and is crucial to becoming in health, while
investigate the substance of ideal nursing care having a positive attitude and recreating mean-
in praxis. The study provided clinical evidence ing in life may enhance health (Hemberg,
that symbolic acts such as giving the little extra 2017, p. 47).
may work to bridge gaps in human interaction; Other research has focused on using the
“little things” have the power to preserve dig- ontological health model to seek a deeper un-
nity and make patients feel they are valued, derstanding of the dimensions of doing, being,
which offers hope. and becoming in relation to health and suffer-
Adding context to this research is the aim ing for women’s health and young people
to clarify concepts on suffering and alleviated (Lindholm & Eriksson, 1998). A phenome-
suffering from the perspectives of both care nological study of the lived experience of preg-
providers and patients to advance caring nancy was conducted with 40 women and
science in relation to suffering. Vatne and Colaizzi’s method was used for data analysis
Naden (2014) explored the experience of being (Bondas & Eriksson, 2001). The study identi-
suicidal, including encounters with health-care fied 10 emerging themes, which were clus-
providers. The study reveals the patients’ expe- tered into three comprehensive categories: the
riences of suffering through absence of care perfect child, an altered mode of being, and
that was triggered by lack of awareness and ig- striving for family communion. The research
norance by health-care providers and their lack identified the essential structure or the invari-
of confirmation of this suffering, thereby per- ant meaning of the lived experience of preg-
petuating feelings of loneliness and emptiness, nancy as “the pregnant woman wished for a
overshadowing their hope. The authors empha- perfect baby in an altered mode of being while
sized the need for health-care professionals to striving for family communion” (p. 835). The
acknowledge vulnerability and preserve dignity findings of the study suggest the joy and suf-
in suicidal patients as key to relieving suffering. fering in pregnancy is based on being there for
Another study focused on persons suffering another and in light of this there is a need to
from addiction (Thorkildsen, Eriksson, & incorporate the women’s experiences as a basis
Raholm, 2015) and how nurses’ perspectives for perinatal care and to include the women,
about this population grounded in love might as well as their families, as active participants
offer new clinical approaches for addressing in care. Additionally, women desire to share
the suffering from addiction. The study re- their experiences with other pregnant women
vealed that caregivers required an understand- and women with newborns because this may
ing of love from within a caring science help alleviate worries. Additionally, women
perspective; one in which sacrifice is the key to need compassion and want to show compas-
alleviate suffering, promote health, and pro- sion to other women who are in the same
vide competent care with patients suffering situation.

from addiction. Hemberg (2017) conducted a Another research study explored the exis-
study of 10 adults who lived through personal tential character of pregnancy by searching for
suffering and regained health, in order to reach aspects of its health dimensions as described in
an understanding of the alleviation of human the Eriksson’s ontological health model to
suffering. Findings indicate that the first deepen knowledge of women’s own experi-
movement toward health is learning to let go ences of pregnancy (Larsson, Warnå-Furu, &
and, rather than seeking perfection, learn to Näsman, 2016). The data were analyzed using
love oneself unconditionally. Additionally, en- a hermeneutic approach inspired by Gadamer;
hancing health requires continuous individual the results were presented in nine themes on a
action in the form of looking ahead, seeking rational and contextual level that were then
the positive aspects in life, and recreating clustered into three main themes at an existen-
meaning, joy of living, and vitality. Letting go tial level: a new life stage, the new life takes
of one’s need to control and experiencing com- shape, and health is jeopardized. Then the
munion eliminates the feelings of being lonely content of these themes was interpreted within

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Eriksson’s ontological health model and re- synthesis of articles using an abductive ap-
vealed expecting a child means to do, be, and proach was conducted to further explore the
become in the expectation of the new life. essence of love when encountering suffering
Suffering and health are two different dimen- (Thorkildsen, Eriksson, & Råholm, 2013). The
sions in a woman’s life during pregnancy that research starts with love as the basic motive
are integrated with one another and ever pres- and the synthesis was undertaken by the inter-
ent (p. 757). Expecting a child is an essential pretation of 15 articles focusing on love in
life event that involves all the human dimen- different aspects using a hermeneutical per-
sions: body, soul, and spirit are involved, asking spective. The findings indicate that the sub-
questions and demanding answers about exis- stance of love, when encountering suffering,
tence and meaning (p. 762). The experience reveals itself in three themes: love as a holy
provides an opportunity for deepened health power, love as fundamental for being, and love
as “becoming” while suffering is present in the as an ethical act, which are found, respectively,
form of anxiety and discomfort or risk of dis- in three dimensions—love as holiness, love as
ease and illness. The final interpretation reveals communion, and love as an art. Love is a holy
gravity, vulnerability, and longing as concepts power that encompasses everything and serves
that express the ontological health dimensions as a well of strength that heals; no human can
during pregnancy. In the convergence of suf- exist without love, which points to the ethical
fering and health, vulnerability exists, and it is responsibility one has as a neighbor. In the
in the meeting with the inevitable, life-changing ethical act, love is revealed in concrete caring
gravidity that the integrative movement creates actions. The core of the substance of love
the new. Longing is the desire that provides within the three dimensions can be understood
motivation to continue and expecting a child as agape. Agape connects the dimensions and
means to long for life, to do, be, and become stems from and moves toward holiness, en-
in expectation of the new. abling love to be the ethical foundation when
Caring science as a credible discipline must encountering suffering. Through the dimen-
be based on knowledge and data relevant to sions of love as communion and love as an art,
the core concepts and epistemological ques- agape intertwines with eros forming caritas, en-
tions from which it stems. Ericksson devised a abling human being to move toward the di-
model of concept development and semantic mension of holiness, which signifies becoming
analysis (Eriksson, 2010) to conduct basic re- through suffering. Other research explored
search in a human science tradition. This love in connectedness as a core category of
method provides a foundation by which new spirituality and sought to contribute to the
and more nuanced concepts can emerge to ad- theoretical knowledge development of the
vance caring science while remaining rooted in concept of human spirituality from a caring
the disciplines ontological, hermeneutic, and science perspective (Rykkje, Eriksson, & Ra-
epistemological origins. The use of hermeneu- holm, 2015). This study used a Gadamerian-
tic epistemology involving methodology of text based hermeneutical approach to analyze 20
interpretation is foundational to this caring articles about connectedness and love, with the
science tradition and allows for open and flex- results revealing the emerging themes of con-
ible approaches in the search for knowledge on nectedness with oneself, with others, and with
caring. A number of the research studies have something larger than oneself, as well as com-
focused on further exploring caring concepts passion and the risk of losing love in caring for
as a way to advance caring science research the patient. Additionally, the researchers re-
through text interpretation including the con- flect on love and ethics based on the writings
cepts of suffering and relieved suffering, of Tillich (1954); according to Tillich, love is
health, love virtue, space, time, body, respon- a drive toward unity of the separated and this
sibility, reconciliation, listening, longing, con- drive becomes evident in the themes of con-
solation, encounter, movement, technology, nectedness. The authors conclude from the
joy, play, and care for. An interpretive research findings that both connectedness and love are

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key concepts in caring for the patient; “con- being transformed. These six relational themes
nectedness is found to be central in spirituality are illuminated and aesthetically re-presented
and the literature supports that love under- in six watercolor paintings. The constitutive
stood as compassion is relational and thus fun- pattern Suffering With and For Others expressed
damental to connectedness” (Rykkje, Eriksson, the meaning of suffering for participants
& Raholm, 2015, p. 10). The researchers con- through the 2010 earthquake in Haiti as a
clude that love in connectedness is a resource in lived experience. Participants described their
a patient’s ability to maintain human dignity own suffering in relation to the earthquake;
and “becoming in health” (p. 10). however, despite their individual journeys, it
Fredriksson (1999) analyzed articles to in- was the suffering participants felt with and for
crease and deepen the understanding of the others that lent authentic meaning to the lived
significance of presence, touch, and listening experience of suffering through the 2010
in a caring conversation and to nurse–patient earthquake in Haiti. The meaning of suffering
communication in general. Further, Koskinen through the earthquake finds depth and richer
and Lindström (2015) sought to make visible expression as a lived phenomenon through
other dimensions of caring in listening aesthetic re-presentations in the form of wa-
through readings of Dostoyevsky’s literary tercolor paintings. According to Eriksson
works. The findings suggest that listening takes (2007), the language and words used to help
patients out of their loneliness and unbearable health-care providers describe the concepts of
suffering into communion and a life worth liv- health and suffering will require newer and
ing, and has the potential to improve the care richer forms of expression. In this study, the
of the suffering human being, the patient. complex nature of suffering through the 2010
Karlsson, Nyström, and Bergbom (2012) con- earthquake in Haiti required a more nuanced
ducted research to describe the meaning of the form of expression to capture the complex
concepts “care for” and “not care for” from the nature of suffering as lived by the participants.
carer’s perspective using a critical incident The investigator re-presented the study find-
method of data collection and hermeneutic ings in six watercolor paintings as a way to
text interpretation in four readings. This recapture the complex nature of the authentically
search about “care for” and “not care for” has lived experience of participants’ suffering
uncovered and shown traces of caritative caring through the experience of the earthquake and
theory through the discovery of an ethical speak to multiple ways of knowing in nursing.
dimension in caring. A number of studies have been conducted to
The essence of nursing is caring and, as understand the lived experience of victims and
such, nurses capable of addressing suffering relatives of the 2004 tsunami disaster in South-
through natural disasters will require nursing east Asia. These studies have specifically
knowledge grounded in the understanding focused on concepts of caring and suffering

of caring as a way to alleviate suffering and using Eriksson’s theory of caritative caring to
has been the subject of other research explore ontological and existential aspects of
grounded in Eriksson’s Theory of Caritative the tsunami disaster experience. The research
Caring (Gullett, 2017; Raholm, Arman, & has provided essential insight into how suffer-
Rehnsfeldt, 2008; Rehnsfeldt, & Arman, ing, when seen and validated by another person
2012, 2015). A qualitative study to explore the following the disaster, is the first step toward
lived experience of suffering through the 2010 progression of suffering. Additionally, reshap-
earthquake in Haiti using Heideggerian ing suffering with family adds a valuable dimen-
hermeneutical phenomenology was the focus sion to life. Raholm, Arman, and Rehnsfeldt
of research done by Gullett (2017). The rela- (2008) stated that the immediate lived experi-
tional themes that were interpreted were: ences of the tsunami disaster from an existen-
Experiencing the unimaginable, awakening to tial and ontological perspective constitute an
a changed reality, agonizing for others, com- important aspect of understanding the whole
pounding losses, finding a way forward, and phenomenon. Concepts such as communion,

7991_Ch33_523-538 13/08/19 3:30 PM Page 534
understanding life, and progression of suffer- dependent variations” (p. 346). Levy-Malmberg
ing can help health-care providers construct an and Hilli (2014) conducted a theoretical re-
image of this previously unresearched dimen- search study in which the authors propose a
sion. Rehnsfeldt and Arman (2012, 2015) process of dialogical assessment as a learning
conducted additional research to acquire an in- event to enhance the graduate’s clinical com-
depth understanding of the significance of nat- petence. The findings suggest that combining
ural close relationships for survivors of the clinical capability in a judgmental manner to-
tsunami disaster. What is evident is how the gether with the dialogical humanistic approach
ontological aspects are expressed in data in re- of caring science may create a genuine
lation to the existential and relational aspects. platform to promote educational goals, which
When the findings on communion as an ut- generates a different type of assessment. Inte-
terance of interdependence were read compre- grating caring science insight into nursing abil-
hensively, it was seen that human encounters ity is recognized as a growth-building process
in the aftermath of a disaster are not only in which a bidirectional flow of insight via gen-
about relationships, but inherently affect peo- uine dialogue occurs and serves to unite and
ple’s entire understanding of life. To conclude, seal the relationship between nursing science
in line with the aim of the study, the data sug- and caring science, that is, unite nursing capa-
gest that relationships and communion with bility with caring values. Through this dialogue
other people helped the survivors of the tsunami the students delivering the care develop their
to discover a new understanding of life. awareness to a degree in which they attain
Recognizing ways caring is taught and un- their goals by means of ethical awareness
derstood within nursing education from the achieved during the development for assessing
perspective of students and educators is impor- the unassessable quality via dialogue. However,
tant to advancing caring science. Eriksson’s the conditions for promoting a dialogical as-
theoretical approach was used by Lejonqvist, sessment relate to the conceptual level and this
Eriksson, & Meretoja (2012) to address what means understanding and motivating in a
constitutes clinical competence in nursing and reflective way instead of a judgmental one,
how to strengthen it. The authors conducted a through feedback rather than grading. The
cross-sectional research study to explore evi- research suggests that “caring science insight
dence of clinical competence in practice from as the incentive for enhancing clinical compe-
the view of nursing students, clinical precep- tence among registered nursing graduates
tors, and teachers in nursing. The study sought comes into existence as a process of the non-
to determine how clinical competence was judgmental dialogical assessment of the ability
characterized and experienced, what con- of nursing students to integrate know-how
tributes to it, and how it is maintained. It also and emotional readiness” (Levy-Malmberg &
examined the relationship between clinical Hilli, 2014, p. 865).

competence and evidence-based care (p. 340). Additional research sought to deepen the
The results of the study have important impli- understanding of student nurses’ process of
cations to nursing education in the distinction understanding and becoming nurses from
between an ontological and a contextual clini- three focus groups in Finland and Sweden
cal competence in nursing. Becoming clinically (Sandvik, Eriksson, & Hilli, 2015). The re-
competent is a process involving students, nurs- search used a phenomenological-hermeneutic
ing students, and preceptors. Achieving clini- design and revealed how students perceived a
cal competence in nursing is grounded in growth-promoting environment as one that
ontological clinical competence, which is “time was supportive and inclusive as well as facili-
persistent and quite independent of clinical tated by a caring student–preceptor relationship
practice, and of which the contextual clinical serving as the frame in which the hermeneutic
competence shows different contextually movement from student to becoming nurse

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emerged. Responsibility acts as a catalyst in the discovering nurse leaders’ perceptions of an ap-
student’s movement toward a deeper under- proaching organizational change. The study
standing and becoming as a nurse, and with revealed that nurse leaders were not considered
enhanced knowledge and ethical awareness a resource in the change process, placing them
comes increasing responsibility. These findings in a difficult situation. Additional research was
suggest that student preceptors should be eval- reported in a qualitative study exploring how
uated with greater emphasis on their ethical nurse leaders described and understood their
dimension and emphasize the importance of main tasks and roles during the change process
preceptors recognizing the level of student and resulted in a model of leading change in
knowledge in an effort to challenge and broaden health care that focuses on good patient care
student learning. and consists of three dimensions: leading
Nurse leaders are essential to serving the relationships, leading processes, and leading a
cause of caring and must continue to provide culture (Salmela, Eriksson, & Fagerström,
the best care to patients. According to Eriksson, 2013). The study emphasizes how nurse lead-
the nurse leader’s role should be based in a ers need guidance and knowledge from upper-
culture of love and charity and serves to de- level management regarding the expectation of
velop evidence-based caring cultures (Salmela, their roles and tasks throughout the structural
Koskinen & Eriksson, 2017). Additional re- change process.
search has explored the distinctive foundation The emphasis on sustaining ethically sus-
of Eriksson’s theory and thinking in nursing tainable caring cultures is important to good
leadership and nursing administration in rela- patient care. As nurse leaders are responsible
tion to creating a caring culture. Rudolfsson for developing and promoting good care, ad-
and Flensner (2012) researched the meaning ditional research needs to recognize how nurse
of suffering from the perspective of periopera- leaders can create and manage these ethically
tive nurse leaders. The meaning of suffering for sustainable caring cultures (Salmela, Koskinen,
nurse leaders includes struggling and is a path & Eriksson, 2017). A mixed-methods study
to learning and personal growth. The study re- revealed how “ethics together with respectful
veals the need for developing a caring culture and dignified care that is both evidence-based
that permeates an entire organization at all and economically stable comprise the basis of
levels where suffering can be experienced as a good care, patient safety and sustainability”
positive force leading to learning and growth. (Salmela, Koskinen, & Eriksson, 2017,
Other research focused on the role of nurse p. 880). Nurse leaders, by serving as role
leaders during an organizational change and models through management, have the re-
was part of a longitudinal research project, sponsibility to nurture and protect the core
consisting of two different research studies. of caring using common good as a founda-
The first study used questionnaires with the tion. Nurse leaders, as managers, should cre-
staff at two health-care organizations before, ate contextual, professional, and cultural
during, and after the merger of two health-care prerequisites to maintain the core and art of
organizations (Salmela & Fagerström, 2008). caring through good traditions, which also
The results demonstrated that respondents ensure the care of the staff’s ethical and pro-
were ready to carry the merger through but fessional competence. Additional research
were unsure of the vision. The study also em- examining the terms caregivers use when
phasized that the role of leaders of change referring to the human beings in their care
process was to be aware of staff concerns, and (e.g., patient versus customer) as part of an
also emphasized the role of nurse managers to organizational caring culture was conducted
facilitate the change process. The second part of by Salmela and Nyström (2017) and provides
this study was conducted by Salmela, Eriksson, a discussion on suffering, nursing, caring
and Fagerström (2013) with the aim of culture, and ethical values.

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Practice Exemplar
Mrs. B is a patient who was previously seen in care at home. Mrs. B confessed her guilt and
the dermatology–oncology outpatient clinic embarrassment in asking for help, mainly
for wound management. She called the clinic feeling disgusted by her wound and herself in
requesting an urgent same-day visit due to general. Mrs. B had attempted to discuss her
complaints of a “gnawing feeling” in her chest. situation during a prior visit to the clinic but
Mrs. B had difficulties articulating her specific the doctor had been in a hurry, mentioning
concerns and admitted she had not looked at he was overbooked. The doctor instructed
the wound and therefore could not describe Mrs. B a nurse would come to dress the
it to the nurse over the phone. Mrs. B was wound, to continue doing what she was doing
scheduled for a same-day visit with the nurse. at home, and to schedule a follow-up visit;
The nurse recognized that Mrs. B was angry then the doctor hurriedly left the room. An
and uncomfortable when she arrived. As the hour later, a nurse arrived stating she was very
nurse began to remove the dressings, Mrs. B busy. The nurse quickly dressed the wound
looked away with an unpleasant expression without providing instructions, told Mrs. B
(suffering human being). The nurse discovered to schedule a follow-up visit, and then quickly
maggots within the wound accompanied by a left the room. Mrs. B did not want to bother
very foul odor. The nurse removed the mag- the staff with her problems, and she believed
gots, took photos, and prepared to perform the reason the caregivers were in such a hurry
additional wound care. was due to the disgusting nature of her wound.
Internally, the nurse felt overwhelmed, not Mrs. B, feeling alienated and alone, decided
truly understanding how this could have oc- not to return to the clinic for follow-up (suf-
curred, and unsure of her next steps. How- fering related to care).
ever, she remained calm and supportive with The nurse reached over and touched Mrs. B’s
Mrs. B. While the nurse cleansed the wound, hand, authentically listening and hearing
applied a new bandage, and educated Mrs. B the suffering expressed by Mrs. B (caritas).
about how to perform wound care at home Mrs. B told the nurse that she lived alone, was
(caring ethics), she gently and calmly talked to retired, a widow with no children or family
the patient about her life and needs. After living nearby (suffering related to life). The
performing the dressing change the nurse sat nurse continued to ask Mrs. B about her life
and faced Mrs. B and began to ask some and desires, what she liked to do, and some
questions, seeking to better understand of her hobbies (caring communion). Before
Mrs. B’s situation and suffering. Mrs. B ad- becoming ill, Mrs. B was active in her church
mitted to having difficulties accepting her and played cards regularly with a group of
wound, not wanting to look at or care for the friends; however, since developing the wound,
wound because it would validate her reality she had stopped leaving her home altogether
(suffering related to illness). The wound dis- and had no contact with others. She was too
gusted Mrs. B; the odor made her feel “less embarrassed by the odor of the wound and
than human” (unbearable suffering). Mrs. B’s feared rejection. The nurse acknowledged
at-home regimen consisted of showering Mrs. B not as an illness to be treated but
daily with a bandage still in place. After her rather as a suffering human being whose world
shower, she would remove the saturated is currently being defined by her diagnosis of
bandage and immediately replace it with a cutaneous breast cancer and fungating wound
new bandage without assessing the wound. to her left chest.
Mrs. B cried while she expressed frustration Tears formed in the nurse’s eyes as she lis-
with her diagnosis and how this has signifi- tened to Mrs. B’s story, genuinely touched by
cantly affected her life. Her solution was ig- Mrs. B’s suffering, and recognizing her needs
noring her wound, which meant poor wound and problems. After listening to Mrs. B, the

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nurse felt as if she had formed a caring rela- (doing in health). As their caring relationship
tionship with Mrs. B, which would help her evolved, the nurse observed Mrs. B asking
provide compassionate and supportive care about and looking at her wound. After a
(caring communion). The nurse started by month, Mrs. B informed the nurse that she
helping Mrs. B to look at her wound, paying had joined the support group that the nurse
careful attention to Mrs. B’s reactions and had suggested (reconciliation). Mrs. B found
emotions, rather than the wound itself. She that being around others with similar concerns
assisted Mrs. B to visualize the wound as just and problems made her feel less alone and of-
that, a wound, one that needed proper treat- fered her some comfort in working through
ment to heal. The nurse quietly told Mrs. B her suffering regarding her illness. Mrs. B had
that her illness and wound did not define who also started attending church again and re-
she was, and perhaps she would be open to at- sumed her weekly card games with friends
tending a support group for others who suf- (being in health). Her church group provided
fered from the same condition. The nurse took additional support by bringing meals to her
the time to acknowledge and inform Mrs. B house and checking on her regularly. After
that she was a person who was suffering and 5 months, Mrs. B’s wound still had not fully
who had needs, problems, and desires. While healed and she continued to battle her illness;
helping Mrs. B to look at the wound, the however, upon visiting the nurse Mrs. B
nurse gently educated her on the new wound stated she had started training to be a coun-
care regimen for home care and provided a de- selor for the support group she attended, and
tailed clinical follow-up. Additionally, since by helping others like herself, she felt she
Mrs. B does not have family nearby to assist was able to give something back (endurable or
with wound care, the nurse set up visiting bearable suffering). Mrs. B stated she felt as if
nurse services, arranged a consultation for there was something bigger than herself in the
social work, and provided information about universe and she would no longer be defined
the support group. by her illness but recognized what she could
Mrs. B started to make regular visits to the give to others, which made her feel good
wound clinic, seeing the same nurse each visit about herself and her life (becoming in health).
Summary
Eriksson (2001) asserts the importance of Dignity means to be there for the other person
caring sciences as an independent scientific in both lay and professional care and is
discipline. This involves a constant demand grounded in caritas, that is, a union of com-
for academic research to develop meaningful passion and mercy. Health concerns a person’s
knowledge, be visionary, and have a desire to growth toward wholeness, uniqueness, and in-
create innovations in clinical practice. There is tegration in one’s movement between the di-
an ever-growing body of literature demon- mensions of doing, being, and becoming.
strating the application of Eriksson’s caring Health and suffering are two poles of human
science and concepts to practice and research. life, and health can be connected to endurable
Rather than focusing on disease and illness, suffering. Human beings experience suffering
the Theory of Caritative Caring recognizes the and health in relation to their living condi-
human being as an integrated entity that unites tions, their will to live, and their endeavor to
body, soul, and spirit; an indivisible whole in find meaning in life. Human beings strive for
which health can be fostered and suffering joy and health despite experiencing strain and
alleviated through caring, an ethical way of suffering. Suffering presupposes caring, and
being there for the other (Eriksson, 1997b). the basic structure for caring is the relationship

7991_Ch33_523-538 13/08/19 3:30 PM Page 538
between the patient and the caregiver. Eriksson’s by which clinicians and researchers can ad-
(2018) Theory of Caritative Caring recog- vance caring science grounded in the con-
nizes caring as the essence and core of caring cepts of caring, suffering, whole person, and
science and provides a theoretical foundation human dignity.
Questions for Reflection ■ How does preserving human dignity relate

to suffering in Eriksson’s theory? In the
and Discussion Practice Exemplar above, how does the
■ What is the difference between “ethics” nurse preserve human dignity?
and “ethos” according to Eriksson?
■ How does the nurse address or alleviate a
person’s suffering?

7991_Index_539-560 12/08/19 5:26 PM Page 539
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 APT. See Active parenting today (APT) program

Acculturation theory, 366 AQAL, 218f, 222–223, 222t, 231
Achievement subsystem of behavior, 95t Arousal, 190
Action demand, 116 Art of Nursing in Hospital Service: An Analysis, The
Active listening, 70 (Orem), 110
Active parenting today (APT) program, 141 ASA Scale. See Appraisal of Self-Care Agency
Activism, 516 (ASA Scale)
Actualizing values, 430t ASA-R-CHI, 121
Adaptation, 470 Asian American cancer patients, 366
Adaptation-level theory, 151 ASPAN. See American Society of PeriAnesthesia
Adaptive modes, 152 Nurses (ASPAN)
Adaptive potential, 189–190 Assessing and Measuring Caring in Nursing and Health
Adaptive potential assessment model (APAM), 189 Science (Watson), 318
Adaptive reorganization, 93 Assessment of dream experience scale, 251
Addiction, 531 Attachment objects, 190
Advanced directives, 140 Attentive reassurance, 389
Advances in Nursing Science, 10 Attuning to dynamic flow, 496, 497, 499
Advocacy, 516 Augustana’s health model for partnership in
Aesthetic expressions, 444 community, 269
Aesthetic knowing, 27–28, 220t, 513 Aurelius, Marcus, 498
Affiliated-individuation, 188 Awareness, 357–358, 361
Affiliation needs, 390
Affiliative subsystem of behavior, 95t B
Agape, 532 Barbara Bates Center for the Study of the History
Aggressive-protective subsystem of behavior, 95t of Nursing, 178
Aging. See Theory of successful aging Barnum, Barbara, 215
AHNA. See American Holistic Nurses Association Barrett, Elizabeth Ann Manhart, 479. See also Barrett’s
(AHNA) theory of power as knowing participation in change
Akhenaten, 440 Barrett’s Rogerian practice methodology, 245
Alligood and McGuire’s theory of aging, 242 Barrett’s theory of power as knowing participation in
American Holistic Nurses Association (AHNA), change, 479–491
213, 215 applications of the theory, 483–487
American Holistic Nurses Credentialing Corporation assumptions, 491
(AHNCC), 215 material worldview, 482, 483f
American Nurses Credentialing Center (ANCC), 462 overview (flowchart), 481f

American Society of PeriAnesthesia Nurses PKPCT, 482–483
(ASPAN), 378 power-as-control, 482, 483f
ANCC. See American Nurses Credentialing Center power-as-freedom, 482, 483f, 487–491
(ANCC) practice exemplar, 487–491
“Androgynous Pharaoh? Akhenaten Had Feminine science of unitary human beings (SUHB), 480–481
Physique, The” (Dominguez), 440 spiritual worldview, 482, 483f
Anti-contagionism, 43 Barry, Charlotte D., 422. See also Community
APAM. See Adaptive potential assessment model nursing practice model (CNPM)
(APAM) Basic conditioning factors (BCFs), 113
Apathetic indifference, 77 Basic human needs, 389–390
“Apparatus and Method for Managing Interaction- Basic needs, 190
Based Services,” 428 Basic nursing care, 58–59
Applications of the theory. See Educational applications; Basic Principles of Nursing (Henderson), 62
Practice applications; Research applications Bass’s transactional transformational leadership
Appraisal of Self-Care Agency (ASA Scale), 121 model, 145
Appreciating pattern, 495–496, 497, 498 Bates Center for the Study of the History of
Appreciation of unique meanings, 389 Nursing, 178
539
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540 Index
BCFs. See Basic conditioning factors (BCFs) Watson’s unitary caring science and human caring
Beck’s Spiral Dynamics Second Tier Turquoise stage theory, 311–331
of development, 229 Caring assessment tool (CAT), 318, 392
Behavioral set, 97 Caring assessment tool for administration
Behavioral system balance, 93 (CAT-admin), 392
Behavioral system imbalance, 98 Caring behaviors, 389–390
Being orientation, 192 Caring between, 337
“Being there,” 461 Caring cards, 507
Being with, 504, 505 Caring communion, 526
Bentov, Itzhak, 274, 277 Caring culture, 527
Biennial Neuman Systems Model International Caring economics, 455
Symposium, 178 Caring ethics, 526
Binding, 281, 282f Caring ethos, 526–527
Blake, William, 496 Caring from the heart, 344
“Blessing of the hands,” 499 Caring-healing-loving consciousness, 321
Body (outer self), 226t Caring-in-action indicators, 325–326
Bohm, David, 279 Caring occasion, 320
Bowlby’s stages of grief, 191t Caring relationships, 387–389, 387f
Boykin, Anne, 333–334. See also Theory of nursing Caring science, 321–323
as caring Caritas, 525–526
Braverman, Irwin, 440 Caritas-communitas peacemakers, 314
Breastfeeding, 140 Caritas literacy/illiteracy, 323
Bronfenbrenner’s bioecological theory of human Caritas processes, 316–317
development, 366 Caritas/veritas praxis process, 321–322
Bultemeier’s theory of perceived dissonance, 242 Caritative caring theory. See Theory of caritative caring
Bureaucratic caring theory. See Theory of bureaucratic Carolina care model, 506–507
caring CAT. See Caring assessment tool (CAT)
Butcher’s theory of aging as emerging brilliance, 242 CAT-admin. See Caring assessment tool for
Butcher’s theory of kaleidoscoping in life’s administration (CAT-admin)
turbulences, 242 Causal body, 223
CCT, 294. See also Theory of culture care diversity
C and universality
Call for nursing, 336 Centering, 281, 282f, 498
Capacity building, 517 Chaos theory, 242, 457
CAPS. See Coping and Adaptation Processing Characteristics of operational Rogerian inquiry, 252
Scale (CAPS) Charcot-Marie-Tooth disease (CMT), 488
CAPS Short Form. See Coping and Adaptation Chief nurse executive (CNE), 462
Processing Scale (CAPS)—Short-Form Choice, 282, 282f
Carative factors, 314–316 Choice point, 280
Carative health promoting processes (CHPPs), 512, CHPPs. See Carative health promoting processes
514–518 (CHPPs)
Care, cure, and core model. See Hall’s care, cure, Client/client system, 167t
and core model Client-family-centered care, 140

Care/caring Client outcomes, 141
community nursing practice model (CNPM), 430t Client potentials, 249
differential caring theory, 450, 458 Client system-centered care, 174
Duffy’s quality-caring model, 383–398 Client system safety, 175
economic caring, 461–462 Clinical Nursing: A Helping Art (Wiedenbach), 61
Eriksson’s theory of caritative caring, 523–538 CMT. See Charcot-Marie-Tooth disease (CMT)
Falk-Rafael’s critical caring theory, 509–521 CNE. See Chief nurse executive (CNE)
Hall’s care, cure, and core model, 59, 61 CNPM. See Community nursing practice model
Leininger’s culture care theory (CCT), (CNPM)
293–309 Coaching, 374
Nightingale, Florence, 36, 38, 41, 49, 51 Cognator-regular coping processes, 152
Ray’s theory of bureaucratic caring, 449–467 Colaizzi’s method, 531
Smith’s theory of unitary caring, 493–502 Comfort theory (CT), 371–381
spiritual-ethical caring, 451, 456, 459, 463 applications of the theory, 375–379
Swanson caring theory (SCT), 503–508 coaching, 374
theory of nursing as caring, 333–347 comfort, defined, 373
Travelbee’s human-to-human relationship model, 76 comfort continuum, 373

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Index 541
comfort food for the soul, 374 Coping processes, 471

comfort interventions, 374–375 Core concepts, 525
conceptual framework, 374, 374f Cosmic dimension of life, 475
digital integration, 379 Cosmic unity, 152
ease, 372, 372f Cowling, Richard, 283
guidelines for comfort management, 378 Cowling’s Rogerian practice, 245
health-care needs, 374 Cowling’s unitary pattern appreciation, 498
health-seeking behaviors (HSBs), 373, 375 Created environment, 167t, 170–171
institutional integrity, 373, 375 Creating ease, 414
patient experience, 378 Creativity, 472–473
perianesthesia nursing, 377, 378 Criteria of Rogerian inquiry, 252
practice exemplar, 379–380 Critical caring theory, 509–521
relief, 372, 372f applications of the theory, 518–519
taxonomic structure of comfort, 372–373, 372f being open and attending to spiritual and existential
transcendence, 372, 372f, 373 realms, 517–518
Community nursing practice model (CNPM), 421–435 carative health promoting processes (CHPPs), 512,
actualizing values, 430t 514–518
applications of the theory, 427–432 cultural sensitivity, 518
community, 424 diagrammatic representation, 511f
concentric circles of emphatic concern, 425, helping-trusting relationship, 512–513
426–427, 426f meeting needs and building capacity, 516–517
core services, 425–426 practice exemplar, 519–521
enhancing care, 423 preparation of self, 512
environment, 425–426 supportive and sustainable environments, 515–516
foundations of the model, 422–423 systematic reflexive approach, 514
nursing, 423 transpersonal teaching-learning, 514–515
person, 423–424 ways of knowing, 513–514
practice exemplar, 432–434 Critical incident stress management, 363
research studies, 431–432t Critical points, 362
respect, 423–424, 430t Cronbach’s alpha, 530
transcendent values, 430t Csikszentmihalyi’s theory of flow, 242
transdisciplinary care, 425 CT. See Comfort theory (CT)
transitional care, 423 Cultural feminism, 45
Ubuntu philosophy, 423, 425 Cultural sensitivity, 518
Compassion, 246, 326 Culture Care Diversity and Universality: A Worldwide
Compensatory adaptation, 154 Nursing Theory (McFarland/Wehbe-Alamah), 294
Complexity science concepts, 366 Culture care theory (CCT), 294. See also Theory
Complexity theory, 456–457 of culture care diversity and universality
Compromised adaptation, 154
Concentric circles of emphatic concern, 425, D
426–427, 426f da Vinci, Leonardo, 440
Concept, 137 Dance of caring persons, 337
Concept Formalization: Process and Product (NDCG), 110 Data aggregation, 195–196
“Concept of Dynamic Nursing, A” (Wiedenbach), 61 Data analysis, 196
“Conceptual Frame of Reference for Nursing, A” Data interpretation, 195
(King), 135 Debriefing, 363
Conceptual frameworks, 13, 148 Decentering, 282, 282f
Conceptual models, 13 Decentralization, 455
Conceptual set, 97 Deep interconnectedness, 241
Conceptual structure, 6 Deficit orientation, 192
Conceptual system, 13. See also King’s conceptual Dehumanization, 76
system (KCS) Deliberate action, 114
Connecting-separating, 263t, 264 Deliberative nursing process, 83
Connecting with self-in-relation, 412–414 Dependency subsystem of behavior, 96t
Conscious dying, 322 Dependent care, 113–114
Consciousness, 276 Dependent care agency, 114
Contagionism, 43 Dependent care deficit, 118
Coping and Adaptation Processing Scale (CAPS), 155 Dependent care demand, 116
Coping and Adaptation Processing Scale (CAPS)— Dependent care system, 118
Short-Form, 155 Descartes’s mind-body dualism, 441

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542 Index
Despairful not-caring, 77 Empathy, 78

Developmental residual, 192 Empirical indicator, 497
Developmental self-care requisites (DSCRs), 116–117 Empirical knowing, 27, 220t, 514
Developmental tasks, 192 Empirical outcomes, 463
Developmental transitions, 356 Enabling, 504, 505
Developmental variable, 167t Enabling-limiting, 263t, 264
Dialectical contradiction, 94 Encouraging manner, 389
Dialogical humanistic approach of caring science, 534 End of Materialism: How Evidence of the Paranormal Is
Dietary salt reduction self-care behavioral scale, 122 Bringing Science and Spirit Together, The (Tart), 241
Dietary sodium reduction self-care agency scale, 122 Endo, Emiko, 280, 284
Differential caring theory, 450, 458 Energy fields, 239, 480
Difficult-to-care situations, 339 Energyspirit, 488
Dignity, 524, 527, 537 Engagement, 359
Direct invitation, 336 Engel’s stages of grief, 191t
Disciplinary community, 335 Enhancing care, 423
Discipline, 335 Environment
Discipline and Teaching of Nursing Process, The community nursing practice model (CNPM),
(Orlando), 82 425–426
Disconnectedness, 357 critical caring theory, 515–516
Diversity of human field pattern scale, 251 Johnson behavioral system model (JBSM), 97–98
Divine love, 496 Nightingale, Florence, 49, 50, 51f, 52
Documentation system, 138–139 Roy adaptation model, 154
Doing for, 504, 505 theory of integral nursing, 219t
Domain of nursing, 4–5 Epigenesis, 193
Dossey, Barbara M., 211. See also Theory of integral EPM. See Ethical practice model for sustainability
nursing of care (EPM)
Dossey, Larry, 230 Epstein, Gerald N., 487
DSCRs. See Developmental self-care requisites Equilibrium, 189
(DSCRs) Erickson, Helen L., 183–184. See also Modeling and
Duffy, Joanne R., 383–394. See also Quality-caring role-modeling (MRM)
model Eriksson, Katie, 523–524. See also Theory of caritative
Dunn, David, 276 caring
Dynamic nurse-patient relationship. See Orlando’s ERM, 294. See also Theory of culture care diversity and
dynamic nurse-patient relationship universality
Dynamic Nurse-Patient Relationship: Function, Process Ethic of belonging, 314
and Principles (Orlando), 82 Ethical knowing, 27, 220t, 341, 513
Dynamic nursing, 61 Ethical practice model for sustainability of care (EPM),
529–530
E Ethnohistory, 300
Earthquake in Haiti, 533 Ethnonursing research method (ERM), 294. See also
Ease, 372, 372f, 414 Theory of culture care diversity and universality
Economic caring, 461–462 Ethos concepts, 525
Educational applications Eudemonistic health, 188

Barrett’s power theory, 483 Evaluative statistics, 47
community nursing practice model (CNPM), 429, Evidence-based practice (EBP)
431–432t King, Imogene, 145
Johnson behavioral system model (JBSM), 101 Roy adaptation model, 159
Neuman systems model (NSM), 176 Evidence concepts, 525
self-care deficit nursing theory (SCDNT), 121 Evolving human-centered care, 323
theory of bureaucratic caring, 463–464 Exemplary professional practice, 463
theory of integral nursing, 231–232 Expanding consciousness, 276–277
theory of nursing as caring, 343–344 Expectancy theory, 145
transitions theory, 365–366 Experiencing the infinite, 496, 497, 499
Educational Revolution in Nursing (Rogers), 238 Extrapersonal stressors, 168t
Eight beatitudes, 269
Eliminative subsystem of behavior, 96t F
Emancipatory knowing, 28, 513–514 Facilitating client’s story, 194t, 195
Emerging identities, 77–78, 79 Falk-Rafael, Adeline, 509–510. See also Critical caring
Emotional detachment, 76 theory
Emotional intelligence, 140 Falkenstern, Sharon, 286

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Index 543
Family health theory, 140 cure, 60, 61

“Feeling cared for,” 385f, 386 overlapping circles, 59f
Feminism practice exemplar, 64–65
critical caring theory, 511, 511f Handwashing ritual, 498
cultural, 45 Harvey, Kathi Voege, 343
Nightingale, Florence, 44–46 Hastings-Tolsma’s diversity of human field pattern
Feminist postcolonialism, 355 scale, 247
Ference’s human field motion tool, 247 HCAHPS. See Hospital Consumer Assessment of
Fermentation, 43 Healthcare Providers and Systems (HCAHPS)
First-tier thinking, 223 HDSCRs. See Health deviation self-care requisites
Flanagan, Jane, 285 (HDSCRs)
Flexible line of defense, 167t Healing
Fluid and integrative identity, 360 theory of integral nursing, 216, 217f, 229
Follow-up, 359 Zahourek’s theory of intentionality, 242
Formal organization, 453 Healing environment, 389
Foundation concepts, 525 Health
Foundations of Professional Nursing: Care of Self and modeling and role-modeling (MRM), 188–189
Others (Renpenning et al.), 110 ontological health model, 528–529, 531
Fourth Generation Evaluation, 250 Roy adaptation model, 154
Frankenstein monster, 440 theory of integral nursing, 219t
Functional adequacy, 30 Health as expanding consciousness (HEC). See Theory
Functional performance mechanisms, 471–472, 472f of health as expanding consciousness (HEC)
Health as Expanding Consciousness (Newman), 272,
282
G Health-care needs, 374
Gadamer’s hermeneutic method, 530–532
Health Care System Transformation for Nursing and
Geary and Schumacher’s integrated transitions
Health Care Leaders: Implementing a Culture
theory, 366
of Caring (Boykin et al.), 342
General systems theory
Health deviation self-care requisites (HDSCRs), 118
Johnson behavioral system model (JBSM), 92,
Health Goal Attainment instrument, 140
94, 97
Health-illness situation, 356
King, Imogene M., 136
“Health of houses,” 47
Roy adaptation model, 151
Health patterning, 284, 484–486
Generating Middle Range Theory: From Evidence to
Health patterning imagery, 486
Practice (Roy), 150
Health-related quality of life (HRQOL) indicators,
Gerotranscendence, 273, 475–477
159
Gerotranscendence scale (GS), 476
Health-seeking behaviors (HSBs), 373, 375
“Girl with Eight Limbs” (PBS), 440
Healthy People 2020, 470
Goal attainment scale, 139
Heart-centered transpersonal caring moment, 318
Goal attainment theory. See Theory of goal
HeartMath, 312, 318, 429
attainment
HEC theory. See Theory of health as expanding
Grand theories, 13
consciousness (HEC)
Gravidity, 532
Heideggerian hermeneutical phenomenology, 533
Grief of Miscarriage, The (video), 270
Helicy, 240, 480
Grieving, 190–192
Helping-trusting relationship, 512–513
Gross body, 222
Henderson, Virginia
Group-identity mode, 153, 155
applications of the theory, 61–63
Growth needs, 190
basic nursing care, 58–59
GS. See Gerotranscendence scale (GS)
biographical sketch, 56
Guides for Developing Curriculum for the Education
definition of nursing, 58
of Practical Nurses (Orem), 110
nursing research, 62
Guilford’s alternative uses tasks, 472
practice exemplar, 63–64
Henry Street Settlement House, 425
H Hereditary Neuropathy Foundation (HNF), 488
Haiti, earthquake in, 533 Hermeneutic methodology, 524, 529–533
Hall, Lydia, 56–57 Hess, Darlene, 232
Hall’s care, cure, and core model HFMT. See Human field motion test (HFMT)
applications of the theory, 63 Hierarchic interaction, 94
care, 59, 61 HIV/AIDS, 276, 358, 517
core, 60, 61 HNF. See Hereditary Neuropathy Foundation (HNF)

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544 Index
Hoff’s theory of critical intervention, 79 Humanbecoming teaching-learning model, 267

Holistic approach to healthcare. See also Wholeness Humanistic nursing, 335
American Holistic Nurses Association (AHNA), Humanoid nurse robots, 447. See also Technological
213, 215 competency as caring in nursing
comfort management, 373 Humans in relationships, 385, 385f
emotional intelligence, 140 Husserlian phenomenology, 250
holism vs. wholism, 187, 187f
modeling and role-modeling (MRM), 183–209 I
Nightingale, Florence, 43, 49, 51, 52 “I Care For Him” (Collins), 337–338
pediatric procedural holistic comfort assessment “I” space, 221t, 222, 224
(PPHCA), 377 I-Thou relationship, 319
theory of integral nursing, 211–234 ICC. See International Caritas Consortium (ICC)
Holographic theory of bureaucratic caring, 451, 451f, Identity integrity, 153, 155
452, 458–459 I’m Still Here (video), 270
Holography, 451 Imaging, 263t, 264
Homeodynamics, 238–239 Imbalanced energy field, 244
Homeorhesis, 93 Immediate reaction, 83
Homeostasis, 93 Implementation and Evaluation of the “Let’s Go!”
Hope, 77 Program, The, 428
Hope: An International Human Becoming Perspective Impoverishment, 190
(Parse), 265 Influenza Initiative (New York City), 84
Hospital Consumer Assessment of Healthcare Informal organizational culture, 452–453
Providers and Systems (HCAHPS), 71–72, Ingestive subsystem of behavior, 96t
145 Initiating the nurse-patient relationship, 193–195
Howland and McDowell conceptual framework, Innate drive, 187, 188t
136 Innate instinct, 187, 188t
Howland systems model, 136 Inner self, 226t
HRQOL indicators. See health-related quality Instability, 98
of life (HRQOL) indicators Institute of Heart Math, 312
HSBs. See Health-seeking behaviors (HSBs) Institutional integrity, 373, 375
Human Becoming School of Thought: Living the Art of Integral healing process, 214t, 224
Human Becoming, The (DVD), 269 Integral presence, 243
Human Becoming School of Thought, The (Parse), Integral process, 215
262 Integrality, 240, 480
Human caring processes, 313. See also Watson’s Integrated adaptation, 154
theory of unitary caring science and theory Integrative-interactive paradigm, 12
of human caring Integrative Nurse Coach Certificate Program (INCCP),
Human dignity, 524, 527, 537 232
Human-environment mutual process, 451–452 Intentional dialogue, 412
Human field, 239 Interactive theory of breastfeeding, 140
Human field image, 243 Interdependence mode, 153
Human field image metaphor scale, 251 Intermodernism, 399
Human field motion test (HFMT), 250 International Association of Human Caring, 335,
Human instincts and drives, 187, 188t 462
Human needs, 190 International Caritas Consortium (ICC),
Human respect, 389 324–325
Human thermoregulation, 93 Interpersonal Aspects of Nursing (Travelbee), 76
Human-to-human relationship. See Travelbee’s Interpersonal Relations in Nursing (Peplau), 67
human-to-human relationship model Interpersonal stressors, 168t
Humanbecoming community model, 267 Interprofessional practice, 18
Humanbecoming concept inventing model, Intervention in Psychiatric Nursing: Process in the
267 One-to-One Relationship (Travelbee),
Humanbecoming family model, 267 76, 78
Humanbecoming hermeneutic method, 264–265 Intrapersonal stressors, 168t
Humanbecoming hermeneutic sciencing, 261–262, Intrapsychic factors, 472–474, 472f
265 Introduction to the Theoretical Basis of Nursing,
Humanbecoming leading-following model, 267 An (Rogers), 238
Humanbecoming mentoring model, 267 Intuitiveness, 188
Humanbecoming paradigm, 12, 261–262, 261t. See also Inviting creative emergence, 497, 499
Parse’s humanbecoming paradigm “It” space, 221t, 222, 225

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Index 545
Item response theory, 155 Laws of health, 48–49

“Its” space, 221t, 223, 225 Lean Kamishibai card methodology, 507, 508
Legitimate nursing, 111–112
Leininger, Madeleine M., 293–294. See also Theory
J of culture care diversity and universality
Jack, Susan, 518–519
Let’s Go!, 428
JBSM. See Johnson behavioral system model (JBSM)
Level of confidence, 359
Johnson, Dorothy, 91–92, 150
Liehr, Patricia R., 409. See also Story theory
Johnson behavioral system model (JBSM), 91–108
Life orientation, 192
applications of the theory, 100–102
Lines of resistance, 167t
dialectical contradiction, 94
Listening, 417, 533
environment, 97–98
Litchfield, Merian, 284
hierarchic interaction, 94
Lived experience, 354–355
nursing and nursing therapeutics, 99–100
Living a Caring-based Program (Boykin), 344
person, 94–95
Living the art of humanbecoming, 265–269
reorganization, 93–94
Living the commitment to care, 339–341
stabilization, 93
Location and being situated, 359
subsystems, 95–97
Locsin, Rozzano C., 437–438. See also Technological
systems theory, 92, 94, 97
competency as caring in nursing
wholeness and order, 93
Loeb Center for Nursing and Rehabilitation, 56–57, 63
Johnson’s human image metaphor scale, 247
Logotherapy, 76
“Journey’s End” (Cooper), 341
Long-arm affect, 205
Justice making, 36
Longing, 532
Love, 532–533
K Love-power resonance, 487–488
Kamishibai cards, 507, 508 Lowry-Jopp Newman Model Evaluation Instrument,
KCS. See King’s conceptual system (KCS) 176
Kickoff event, 31
King, Beth M., 422. See also Community nursing M
practice model (CNPM) MacArthur Successful Aging Study, 473
King, Imogene M., 135–148 Magnet recognition, 17, 326, 462–463
applications of the theory, 139–145 Magnet therapy, 249
biographical sketch, 135–136 Maintaining belief, 504, 505–506
conceptual system, 136–137 Managerial coaching, 140
documentation system, 138–139 Manifestations of field patterning, 242
general systems theory, 136 Manifesting intentions, 495, 497–498
goal attainment scale, 139 Mastery, 360
goal attainment theory. See Theory of goal attainment Mastery scale, 473
practice exemplar, 146–148 Mayeroff’s caring ingredients, 335, 338, 340–341
transaction process model, 138, 138f McFarland, Marilyn, 294. See also Theory of culture
vision of future of nursing, 139 care diversity and universality
King International Nursing Group, 145 McWhinney, Will, 276
King’s conceptual system (KCS), 136–137 Medical model, 23

Kissick framework, 84 Medication adherence, 140
Knowledge Meditation, 241
knowing (Swanson caring theory), 504, 505 Meeting needs and building capacity, 516–517
knowing self as caring person, 338–339 Meeting the Realities in Clinical Teaching
patterns of knowing (theory of integral nursing), 216, (Wiedenbach), 57
217f, 219, 220t Meleis, Afaf I., 48, 353–354. See also Transitions theory
structure of, 11–14 Metaparadigm, 5, 11
ways of knowing (critical caring theory), 513–514 Metaphoric unitary landscape narratives, 249
ways of knowing and reflecting, 27–28 Micro theory, 14
Knowles adult learning theory, 143 Middle-range theories
Kolcaba, Katharine, 371–372. See also Comfort theory (CT) Barrett’s power theory, 479–491
Kübler-Ross’ stages of grief, 191t community nursing practice model (CNPM),
421–435
L Duffy’s quality-caring model, 383–398
Lamendola, Frank, 276 Eriksson’s theory of caritative caring, 523–538
Languaging, 263t, 264 Falk-Rafael’s critical caring theory, 509–521
Latham and Locke’s expectancy theory, 145 goals, 140

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546 Index
Kolcaba’s comfort theory, 371–381 unconditional acceptance of other people, 189

Liehr and Smith’s story theory, 409–420 understanding the data, 195–196
Locsin’s technological competency as caring in Morbid grief, 191–192
nursing, 437–447 Morning huddles, 498
Meleis’ transitions theory, 353–370 Morristown Hospital, 156
overview of theories included in this text, 350–351 MRM. See Modeling and role-modeling (MRM)
Ray’s theory of bureaucratic caring, 449–467 MSFWs. See Migrant and seasonal farm workers
Reed’s theory of self-transcendence, 399–408 (MSFWs)
Roy adaptation model, 157–159 Mutual designing, 442
Smith’s theory of unitary caring, 493–502 Mutual exploration of the healing human field-
Swanson caring theory (SCT), 503–508 environmental field relationship creative
Troutman-Jordan’s theory of successful aging, measurement instrument, 251, 252
469–478 Mutual patterning strategies, 248
what are they?, 13 Mutual problem-solving, 389
Middle Range Theory for Nursing (Smith/Liehr), 414
Migrant and seasonal farm workers (MSFWs), 519 N
Milestones, 358, 362 Nambozi, Grace, 423
Mind-body connection, 441 Nature of Nursing, The (Henderson), 62
Mindfulness activities, 388 Need satisfaction
Mindset, 194, 194t life orientation, 192
“Mirror, The” (Werthman), 345–346 object attachment process, 190–192
Mishel’s uncertainty in illness theory, 366 Needs-attachment-development-loss-reattachment
Modeling and role-modeling (MRM), 183–209 model, 190, 191f
adaptive potential, 189–190 Needs status scale, 190f
affiliated-individuation, 188 Negative affect, 473, 475
agencies using or teaching MRM, 197t Nelson, Watson, and Inova Health Instrument Caring
applications of the theory, 196–206 Factor Survey, 318
developmental processes, 192–193 Neuman, Betty, 165–166. See also Neuman systems
epigenesis, 193 model (NSM)
grieving, 190–192 Neuman systems model (NSM), 165–181
health, 188–189 applications of the theory, 172–178
holism vs. wholism, 187, 187f biennial symposium, 178
human instincts and drives, 187, 188t client system as social issue, 168, 170, 170b
human needs, 190 comprehensive, wholistic perspective of health
initiating the relationship, 193–195 care, 172
long-arm affect, 205 concepts and definitions, 167–168t
modeling, 184–185 created environment, 167t, 170–171
morbid grief, 191–192 Neuman Archives, 178
MRM practice strategies, 193–196 Neuman Systems Model Research Institute, 178
need satisfaction and life orientation, 192 NSM diagnostic taxonomy, 173
need satisfaction and object attachment process, NSM Education Academy, 176
190–192 NSM Practice Center, 173
needs-attachment-development-loss-reattachment NSM practice methodology tool, 173, 174b

model, 190, 191f NSM tool for nursing and organizational systems,
person and environment, 187–188 177
philosophical assumptions, 186–189 overview, 167–168t, 169f
practice exemplar, 206–208 practice exemplar, 179–181
practice/intervention studies, 197–205t reconstitution, 168t, 169f, 171
proactive nursing care, 196 relational propositions, 171–172, 172f
relations among principles, data categories, spiritual variable, 167t, 170
intervention goals, and aims, 185t unique features, 172
role-modeling, 185 Neuman Systems Model, The (Neuman/Fawcett), 165,
SAMRM, 196, 205 166, 177
self-care knowledge, 188, 195 New knowledge, innovation, and improvements,
self-care resources, 188 463
sequential development, 192–193 Newman, Margaret, 271–273. See also Theory of health
social justice, 189 as expanding consciousness (HEC)
theoretical constructs, 189–192 NFP. See Nurse-family partnership (NFP)
theoretical linkages, 193 NIGH. See Nightingale Initiative for Global Health
theoretical propositions, 186t (NIGH)

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Index 547
Nightingale, Florence, 35–54, 42f structure of knowledge, 11–14

applications of the theory, 50–52 syntactical and conceptual structures, 6
biographies, 35 systems of education, 6
caring, 36, 38, 41, 49, 51 tradition, 6
“chattering hopes and advice,” 49 values and beliefs, 6
critical caring theory, 510–511, 511f Nursing: Concepts of Practice (Orem), 110
definition of nurse, 49 Nursing: The Philosophy and Science of Caring (Watson),
definition of nursing, 4 318
digital collection of Nightingale’s work, 52 Nursing agency, 120
empiricism and experiential knowledge, 49 Nursing as Caring: A Model for Transforming Practice
environmental theory, 49, 50, 51f, 52 (Boykin/Schoenhofer), 335
evaluative statistics, 47 Nursing as caring theory. See Theory of nursing as caring
feminism, 44–46 Nursing Care Interpersonal Relationship Questionnaire,
goal of nursing, 48 140
“health of houses,” 47 Nursing Center for Health Promotion with the
holistic approach to healthcare, 43, 49, 51, 52 Charlotte Rainbow PRISM model, 269
ideas about nursing, 46–50 Nursing Development Conference Group (NDCG),
laws of health, 48–49 110
medical milieu, 42–44 Nursing diagnosis, 155
moral authority, 41 Nursing education. See Educational applications
“mother of modern nursing,” 9 Nursing practice, 2. See also Practice applications
Nightingale Initiative for Global Health (NIGH), 52 Nursing process, 141–142
Nightingale’s assumptions, 48 Nursing qua nursing, 313, 314
Nightingale’s 13 canons, 50f Nursing research. See Research applications
nursing as art and science, 49 Nursing Research, 9
observation, 48 Nursing response, 336–337
practice exemplar, 53–54 Nursing Robots: Robotic Technology and Human Caring
spirituality, 37–38, 41 for the Elderly (Locsin), 438
theory of integral nursing, 213 Nursing Science Quarterly, 10
war, 38–42 Nursing-sensitive patient outcome, 141
“woman methodologist,” 47 Nursing situation, 336
Nightingale Declaration for a Healthy World, 213 Nursing system, 118–120
Nightingale Initiative for Global Health (NIGH), Nursing terminologies, 141–142
52, 213 Nursing theory
Nightingale model, 43, 48, 49 artificial separation of nursing theory and practice, 21
Nonlocality, 223, 241 choosing a theory to study, 25–28
Normal line of defense, 167t defined, 7
Not knowing, 220t evaluation of, 28–30
Notes on Nursing: What It Is and What It Is Not functional adequacy, 30
(Nightingale), 4, 36, 38, 42, 44, 46, 47 future directions, 14–16
NSM. See Neuman systems model (NSM) grand theories, 13
Nurse-family partnership (NFP), 518–519 guide for study of theory, 19–20
Nurse healer, 224 implementing theory-guided practice, 30–31

Nurse-patient relationship theories middle-range theories, 13
Orlando, 82–87. See also Orlando’s dynamic practice-level theories, 13–14
nurse-patient relationship purpose, 7–9, 21
Peplau, 67–75. See also Peplau’s nurse-patient significance of, for practice, 22–25
relationship structural integrity, 30
Travelbee, 82–87. See also Travelbee’s human- substantive foundation, 30
to-human relationship model ways of knowing and reflecting, 27–28
Nursing Nursing theory think tanks, 10
defined, 4, 5, 58, 68–69 Nurturer, 60
domain, 4–5 Nurturing space, 194–195, 194t
evolution of nursing science, 9–11
expression of human imagination, 4 O
goal, 48, 154 Observation
professional nursing practice focus and components, Nightingale, Florence, 48
61f Travelbee’s human-to-human relationship model, 77
scope of nursing practice, 18 OIS. See Orem International Society (OIS)
specialized language and symbols, 6 Olds, David, 518

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548 Index
One Heart-One Spirit-One Soul-One Life Force, 322 sciencing, 261–262, 265
One Mind (Dossey), 230 true presence, 266
One Mind-One Health-One Planet, 212, 231, 232, 322 Parsesciencing, 261–262, 265
Oneness of being, 496 Participative engaging, 442
Ontological health model, 528–529, 531 Particulate-deterministic paradigm, 12
Openness, 239, 514 Partly compensatory system, 119, 119f
Ordered to Care: The Dilemma of American Nursing Paterson and Zderad’s existential phenomenological
(Reverby), 44 theory of humanistic nursing, 335
Orem, Dorothea E., 109–110. See also Self-care deficit “Patient-Centered Care: Best Practices with
nursing theory (SCDNT) Rooming-In,” 174
Orem International Society (OIS), 110 Patient experience, 378
Orem’s three-step process of nursing, 119, 119f Patient safety and satisfaction, 145
Organizational change, 535 Pattern, 239, 480
Organizational cultures, 452–455 Pattern and meaning, 278–280
Organizational transitions, 357 Pattern appreciation, 245, 498
Organizing principle, 83 Pattern manifestation knowing and appreciation,
Originating, 263t, 264 246–247, 484
Orlando-Pelletier, Ida Jean, 82 Pattern manifestations, 239
Orlando’s dynamic nurse-patient relationship, 82–87 Pattern recognition, 282–283, 284–285
applications of the theory, 84–85 Pediatric procedural holistic comfort assessment
deliberative nursing process, 83 (PPHCA), 377
first theory of nursing process, 84 Peplau, Hildegard, 67–75
immediate reaction, 83 Peplau’s nurse-patient relationship, 67–75
improvement, 83–84 active listening, 69, 70
organizing principle, 83 applications of the theory, 71–73
practice exemplar, 85–87 definition of nursing, 68–69
presenting behavior, 83 exploitation phase, 71
resolution, 83, 84 goal/objective of nurse-patient relationship, 69, 70
Ottawa Charter, 516 orientation phase, 70
Outcome identification, 141 practice exemplar, 73–75
Outcome patterns of response, 360–361 resolution phase, 71
Outer self (body), 226t social chit-chat, 69
supervision meetings, 69
P working phase, 70–71
P-CaReSS. See Parent caring response scoring system Perceived well-being, 360
(P-CaReSS) Perianesthesia nursing, 377, 378
PANAS. See Positive and negative affect schedule Perseveratory set, 97
(PANAS) Personal control, 473–474, 475
Pandimensional awareness-integral presence, 243 Personal knowing, 27, 220t, 513
Pandimensional unitary process report, 252 Personhood, 336
Pandimensionality, 239, 241–242, 480 Phenomenological-hermeneutic design, 534
Paradigm, 11–13 Phillips’ theory of pandimensional awareness-integral
Paranormal experiences, 241 presence, 242

Parent caring response scoring system (P-CaReSS), 506 Philosophical assumptions
Parker, Marilyn E., 421. See also Community nursing modeling and role-modeling (MRM), 186–189
practice model (CNPM) Parse’s humanbecoming paradigm, 262–263, 263t
Parse, Rosemarie Rizzo, 259–260 Roy adaptation model, 151b
Parse method, 264, 265 theory of integral nursing, 215
Parse’s humanbecoming paradigm, 259–270 Physical mode, 153
applications of the theory, 264–270 Physiological mode, 152, 154–155
concepts and paradoxes, 263t, 264 Physiological variable, 167t
discipline of nursing, 260–261 PIP. See Power-imagery process (PIP)
DVDs/videos, 269–270 PKPCT. See Power as knowing participation in change
humanbecoming hermeneutic method, 264–265 tool (PKPCT)
humanbecoming paradigm, 261–262, 261t Planetary citizenship, 229, 231
living-the-arts projects, 265–269 Political activism, 516
Parse method, 264, 265 Positive affect, 473
philosophical assumptions, 262–263, 263t Positive and negative affect schedule (PANAS), 473
postulates and principles, 263–264, 263t Postnatal debriefing, 363
profession of nursing, 260 Potential freedom, 281, 282f

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Index 549
Power-as-control, 482, 483f caring assessment tool (CAT/CAT-admin), 392

Power-as-freedom, 482, 483f, 487–491 caring behaviors, 389–390
Power as knowing participation in change tool caring relationships, 387–389, 387f
(PKPCT), 247, 251, 482–483 “feeling cared for,” 385f, 386
Power enhancement, 485 health-care systems and organizations using the
Power-imagery process (PIP), 487 model, 391b
Power plan, 487 humans in relationships, 385, 385f
Power prescriptions, 486–487 propositions, 386–387
Power profile, 485, 487 purposes, 384, 386
Power theory. See Barrett’s theory of power as knowing relationship-centered professional encounters, 385f,
participation in change 386
PPHCA. See Pediatric procedural holistic comfort revisions, 385, 385f
assessment (PPHCA) role of nurse, 387
Practical concepts, 525 self-advancing systems, 385f, 386
Practice applications Quarantine, 43
Barrett’s power theory, 483–487
community nursing practice model (CNPM), R
429–430, 432t Radiation therapy comfort questionnaire, 377
Johnson behavioral system model (JBSM), 101–102 Radin, Dean, 241
King’s theory of goal attainment, 140–141 Rapport, 78
modeling and role-modeling (MRM), 193–196 Ray, Marilyn Anne, 449–450. See also Theory of
Neuman systems model (NSM), 173–176 bureaucratic caring
quality-caring model, 390–393 Reaction paradigm, 12
Roy adaptation model, 154–155 Real freedom, 282, 282f
self-care deficit nursing theory (SCDNT), 122, 128–129t Reciprocal interaction worldview, 12
theory of health as expanding consciousness (HEC), Reconciliation, 528
283–284 Reconstitution, 168t, 169f, 171
theory of integral nursing, 231–232 Reed, Pamela G., 399–400. See also Theory of
theory of nursing as caring, 339–343 self-transcendence
theory of self-transcendence, 403, 406 Reference groups, 362, 363
transitions theory, 364–365 Reflective analysis, 388
Practice-level theories, 13–14 Reflective awareness, 388
Practice stories, 499 Reflective practice, 14
Practice tradition of theory, 14 Reflective practices: body-mind-spirit-cultural-
Pregnancy, 531–532 environmental dimensions, 228, 228t
Preparation of self, 512 Reflexivity, 514
Preparatory set, 97 Relational caring complexity, 462, 464
Prescriptive theory, 14. See also Wiedenbach’s Relational integrity, 153
prescriptive theory Relational self, 227t
Presenting behavior, 83 Relationship-centered professional encounters, 385f, 386
Prigogine’s theory of dissipative structures, 280, 281f Relief, 372, 372f
Primary prevention, 168t, 169f Reorganization, 93–94
“Primary Prevention Targeting Safety of Children with Research applications

Type 1 Diabetes Mellitus (T1DM) in a Public community nursing practice model (CNPM),
School System,” 175 428–429, 431t
Principal component analysis, 530 Johnson behavioral system model (JBSM), 100–101
Principles and Practice of Nursing (Henderson/Nite), 62 King’s theory of goal attainment, 143–145
PRISM model, 269 Neuman systems model (NSM), 177–178
Proactive nursing care, 196 practice exemplar, 394–397
Process patterns of response, 359–360 quality-caring model, 393–394
Professional-technological characteristics, 120 Roy adaptation model, 157–159
Psychological adaptation in death and dying, 157 science of unitary human beings, 249–255
Psychological variable, 167t self-care deficit nursing theory (SCDNT), 121–122,
123–127t
Q theory of health as expanding consciousness (HEC),
Quality Caring in Nursing and Health Systems: Implications 283–284
for Clinicians, Educators, and Leaders (Duffy), 390 theory of integral nursing, 232
Quality-caring model, 383–398 theory of nursing as caring, 344–345
applications of the theory, 390–394 theory of self-transcendence, 403, 403–405t
assumptions, 386 transitions theory, 363–364

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550 Index
Research traditions, 14 Schlotfeldt, Rozella, 375

Resolution, 83, 84 Schoenhofer, Savina O., 334. See also Theory of nursing
Resonancy, 240, 480 as caring
Resonating with the whole, 278 Science of unitary human beings (SUHB), 237–257
Respect, 423–424, 430t applications of the theory, 249–255
Restorative subsystem of behavior, 96t Barrett’s power theory, 480–481
Revealing-concealing, 263t, 264 Barrett’s Rogerian practice methodology, 245
Reveille in Nursing (Rogers), 238 Cowling’s Rogerian practice, 245
Rituals, 498 homeodynamics, 238–239
RN-to-BSN program, 232 manifestations of field patterning, 242
Roach’s six Cs of caring, 338–339 pattern manifestation knowing and appreciation,
Robotic technology. See Technological competency 246–247
as caring in nursing postulates of Rogerian nursing science, 237–238
Rogerian ethics, 248 practice exemplar, 255–257
Rogerian process of inquiry, 252 Rogerian ethics, 248
Rogers, Martha E., 237–328, 274, 275. See also Science Rogerian process of inquiry, 252
of unitary human beings (SUHB) theory of accelerating change, 240–241
Role clarity, 153 theory of emergence of paranormal phenomena,
Role function mode, 153 241–242
Role-modeling, 185 unitary field pattern portrait (UFPP) research method,
Role modeling, 362 252–255
Role rehearsal, 362 unitary pattern-based praxis method, 245–246, 245f
Role supplementation, 354 voluntary mutual patterning, 248–249
Role theory, 354 Sciencing, 261–262, 265
Rosa, William, 322 Scope of nursing practice, 18
Rosemarie Rizzo Parse: Human Becoming (video), 270 SCT. See Swanson caring theory (SCT)
Roy, Callista, 149–150. See also Roy adaptation model SDGs. See Sustainable Development Goals (SDGs; UN,
Roy adaptation model, 149–163 2015)
applications of the theory, 154–159 Second-tier thinking, 223
assumptions, 151, 151b Secondary prevention, 168t, 169f
cognator-regular coping processes, 152 Self-advancing systems, 385f, 386
Coping and Adaptation Processing Scale (CAPS), Self-awareness, 388
155 Self-Care, Dependent-Care & Nursing, 110
cosmic unity, 152 Self-care agency (SCA), 114–115
environment, 154 Self-care deficit, 118
evidence-based practice (EBP), 159 Self-care deficit nursing theory (SCDNT), 109–134
generating middle-range theory, 157–158, 158b, 159f applications of the theory, 121–122
global/international uses of the model, 156–157 basic conditioning factors (BCFs), 113
goal of nursing, 154 deliberate action, 114
group-identity mode, 153, 155 dependent care, 113–114
health, 154 dependent care agency, 114
historical development, 150–151 dependent-care deficit, 118
interdependence mode, 153 dependent-care demand, 116

physical mode, 153 dependent-care system, 118
physiological mode, 152, 154–155 developmental self-care requisites (DSCRs), 116–117
practice exemplar, 160–162 health deviation self-care requisites (HDSCRs), 118
role function mode, 153 legitimate nursing, 111–112
self-concept mode, 152–153, 155 multiple-person units, 120–121
stabilizer-innovator coping processes, 152 nursing agency, 120
theory of successful aging, 471 nursing system, 118–120
veritivity, 151 Orem’s three-step process of nursing, 119, 119f
Roy Adaptation Model, The (Roy), 150 overview, 113f
Ruka, Susan, 285 practice exemplar, 130–133
self-care, 113–114
S self-care agency (SCA), 114–115
SAI. See Successful aging inventory (SAI) self-care deficit, 118
SAMRM. See Society for the Advancement of Modeling social dependency, 111
and Role-Modeling (SAMRM) theory of dependent care (TDC), 111
SCA. See Self-care agency (SCA) theory of nursing systems (TNS), 112
SCDNT. See Self-care deficit nursing theory (SCDNT) theory of self-care deficit (TSCD), 111–112

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theory of self-care (TSC), 111 Spirituality

therapeutic self-care demand (TSCD), 116 Nightingale, Florence, 37–38, 41
universal self-care requisites (USCRs), 116 theory of successful aging, 474–475
Self-care demand, 116 Stabilization, 93
Self-care knowledge, 188, 195 Stabilizer-innovator coping processes, 152
Self-care requisites scale (schizophrenia), Standardized nursing language (SNL), 141–142
121 Story path, 412–414
Self-care resources, 188 Story theory, 409–420
Self-Care Science, Nursing Theory, and Evidence-based applications of the theory, 414
Practice (Taylor/Renpenning), 110 assumptions, 411
Self-Care Theory in Nursing: Selected Papers of Dorothea connecting with self-in-relation, 412–414
Orem, 110 creating ease, 414
Self-concept mode, 152–153, 155 diagrammatic representation, 411f
Self-management, 122 foundations of the theory, 411–412
Self-management behavior for collaborative research and intentional dialogue, 412
practice, 122 practice exemplar, 414–420
Self-perception, 475–476 story path, 412–414
Self-performance scale for patients (stomach cancer), Stressors, 168t, 169f
122 Structural empowerment, 462
Self-transcendence, 401 Structural integrity, 30
Self-transcendence scale (STS), 401 STS. See Self-transcendence scale (STS)
Self-transcendence theory. See Theory of Study of Caring Within an Institutional Culture: The
self-transcendence Discovery of the Theory of Bureaucratic Caring,
Sequential development, 192–193 A (Ray), 450
Sexual subsystem of behavior, 96t Substantive foundation, 30
Shared decision making, 72 Subsystems of behavior, 95–97
Sieloff-King-Friend Assessment of Group Subtle body, 222
Empowerment within Educational Organizations Successful aging inventory (SAI), 477
(SKFAGEEO), 140 Suffering, 77, 527–528, 529, 530–531, 533, 535
Significant others, 361, 362 SUHB. See Science of unitary human beings (SUHB)
Simultaneity paradigm, 12, 261, 261t, 441 Suicidal patients, 531
Simultaneous-action worldview, 12–13 Sunrise Enabler, 301–303
Situation-specific theory, 14, 366 Supervision meetings, 69
Situational transitions, 356–357 Supportive and sustainable environments, 515–516
Six lines of development, 225–228 Supportive-educative system, 119, 119f
SKFAGEEO. See Sieloff-King-Friend Assessment Sustainable Development Goals (SDGs; UN, 2015),
of Group Empowerment within Educational 230t, 425
Organizations (SKFAGEEO) Swain, Mary Ann, 184. See also Modeling and
Smith, Marlaine C., 493–494. See also Theory of unitary role-modeling (MRM)
caring Swanson, Kristen M., 503
Smith, Mary Jane, 409. See also Story theory Swanson caring theory (SCT), 503–508
Smith, T. D., 278 applications of the theory, 505–508
SNL. See Standardized nursing language (SNL) being with, 504, 505
Social chit-chat, 69 diagrammatic representation, 504f
Social-contractual characteristics, 120 doing for, 504, 505
Social dependency, 111 enabling, 504, 505
Social justice, 189 knowing, 504, 505
Social milieu, 155 maintaining belief, 504, 505–506
Social needs, 190 Sympathy, 78
Society for the Advancement of Modeling and Syntactical and conceptual structures, 6
Role-Modeling (SAMRM), 196, 205 Syrian Muslims in Midwestern U.S., 305–306
Sociocultural orientation, 113 Systems-Based Assessment Tool for Child Day
Sociocultural variable, 167t Care, 177
Sociopolitical knowing, 220t Systematic reflexive approach, 514
Spiritual-ethical caring, 451, 456, 459, 465 Systems theory, 92, 94, 97
Spiritual perspective, 474
Spiritual perspective scale, 474 T
Spiritual union, 496 Talk walks, 176
Spiritual variable, 167t, 170 TBI. See Traumatic brain injury (TBI)
Spiritual well-being in illness, 80 TDC. See Theory of dependent care (TDC)

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552 Index
Teaching-learning, 514–515 ontological health model, 528–529, 531

Teamwork and collaboration, 175 practical concepts, 525
Technological competency as caring in nursing, 345, practice exemplar, 536–537
437–447 reconciliation, 528
applications of the theory, 446 suffering, 527–528, 529, 530–531, 533, 535
assumptions, 438 theoretical foundation, 524
calls for nursing and nurses’ responses, 445–446 Theory of culture care diversity and universality,
know/knowing, 443–444 293–309
knowing persons (framework for nursing), 442–443, applications of the theory, 304–306
442f assumptions, 299
knowing persons (process of nursing), 443, 443f current status of theory, 304
knowing when using technology, 444–445 definitions, 299–301
mind-body connection, 441 diversities and similarities, 297
mutual designing, 442 newest addition of theory, 303–304
participative engaging, 442 practice exemplar, 307–308
practice exemplar, 446 professional and generic care, 298
technological knowing, 441–442, 445 rationale for transcultural nursing, 296–297
universal technological domain (UTD), 443, 443f Sunrise Enabler, 301–303
wholeness, 441 Syrian Muslims in Midwestern U.S., 305–306
Technological knowing, 441–442, 445 three modalities, 298
Telehealth, 360 worldview and social structure factors,
Temporal experience scale, 251 297–298
Tertiary prevention, 168t, 169f Theory of dependent care (TDC), 111
Textbook of the Principles and Practice of Nursing Theory of emergence of paranormal phenomena,
(Harmer/Henderson), 58, 62 241–242
Theoretical Nursing: Development and Progress (Meleis), Theory of enfolding health-as-wholeness-and-harmony,
354 242
Theory, 7. See also Nursing theory Theory of enlightenment, 242
Theory for Nursing: Systems, Concepts, Process, A (King), Theory of goal attainment
135 documentation system, 138–139
Theory-guided practice, implementing, 30–31 goal attainment scale, 139
Theory of accelerating change, 240–241 multicultural applications, 142–143
Theory of bureaucratic caring, 449–467 nursing process, 141, 142
applications of the theory, 451, 456, 459–465 research applications, 143–145
caring as unifying focus of nursing, 455–456 transaction process model, 138, 138f
chaos theory, 457 Theory of group empowerment within organizations,
characteristics of bureaucracy, 454–455 140, 144
complexity theory, 456–457 Theory of health as expanding consciousness (HEC),
differential caring theory, 450, 458 271–289
dimensions, 457t academic and philosophical influences, 273–274
grounded theory of bureaucratic caring, 450, 450f applications of the theory, 276–287
holographic theory of bureaucratic caring, 451, 451f, basic assumptions, 274, 276
452, 458–459 expanding consciousness, 276–277

human-environment mutual process, 451–452 gerotranscendence, 273
organizational cultures, 452–455 global reach of HEC theory, 283
practice exemplar, 465–466 health patterning, 284
spiritual-ethical caring, 451, 456, 459, 465 HEC research as praxis, 283–284
Theory of caritative caring, 523–538 HIV/AIDS, 276
applications of the theory, 529–535 Orlando’s deliberative nursing approach, 273
assumptions, 524–525 pattern and meaning, 278–280
caring, 526 pattern recognition, 282–283, 284–285
caring communion, 526 practice exemplar, 287–289
caring culture, 527 Prigogine’s theory of dissipative structures, 280,
caring ethics, 526 281f
caring ethos, 526–527 resonating with the whole, 278
caritas, 525–526 Rogers, Martha, 274, 275
core concepts, 525 time and presence, 277–278
ethos concepts, 525 unitary-transformative paradigm, 275
evidence concepts, 525 Young’s spectrum of evolution of consciousness,
foundation concepts, 525 281–282, 282f

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Theory of human caring. See Watson’s theory of unitary Theory of self-transcendence, 399–408
caring science and theory of human caring applications of the theory, 403–406
Theory of integral nursing, 211–234 foundations of the theory, 400–401
aims, 214–215 interpersonal activities, 406
applications of the theory, 224–232 intrapersonal approaches, 406
AQAL, 218f, 222–223, 222t, 231 practice exemplar, 406–408
content, 215–223 relationships among the concepts, 402–403, 402f
context, 224 research studies, 403, 403–405t
definitions, 214t self-transcendence, 401
global health and planetary sustainability, self-transcendence scale (STS), 401
228–230 temporal boundaries, 406
healing, 216, 217f, 229 transpersonal approaches, 406
“I” space, 221t, 222, 224 vulnerability, 401–402
integral process, 215 well-being, 402
“It” space, 221t, 222, 225 Theory of successful aging, 469–478
“Its” space, 221t, 223, 225 applications of the theory, 477
metaparadigm of nursing, 216, 217f, 219t assumptions, 470
most frequently used interventions, 216t coping processes, 471
Nightingale, Florence, 213 creativity, 472–473
One Mind-One Health-One Planet, 212, diagrammatic representation, 472f
231, 232 functional performance mechanisms, 471–472,
patterns of knowing, 216, 217f, 219, 220t 472f
philosophical assumptions, 215 gerotranscendence, 475–477
philosophical foundation, 213 intrapsychic factors, 472–474, 472f
practice exemplar, 232–234 personal control, 473–474, 475
process, 224 positive and negative affect, 473, 475
quadrants, 217f, 219–221, 221t practice exemplar, 477–478
six lines of development, 225–228 Roy adaptation model, 471
structure, 223–224 spirituality, 474–475
textbooks, 215 successful aging inventory (SAI), 477
“We” space, 221t, 223, 224–225 Theory of unitary caring, 493–502
Theory of nursing as caring, 333–347 applications of the theory, 499–500
applications of the theory, 339–345 appreciating pattern, 495–496, 497, 498
assumptions, 335, 338–339 assumptions, 495
call for nursing, 336 attuning to dynamic flow, 496, 497, 499
caring, 335 experiencing the infinite, 496, 497, 499
caring between, 337 inviting creative emergence, 497, 499
Collins’s poem (“I Care For Him”), 337–338 manifesting intentions, 495, 497–498
dance of caring persons, 337 practice exemplar, 500–502
direct invitation, 336 propositional statements, 497
focus and intention of nursing, 335–336 unitary caring science, compared, 500
historical overview, 334–335 Theory of weight management, 122
knowing self as caring person, 338–339 Therapeutic self-care demand (TSCD), 116
lived meaning of nursing as caring, 337 Therapeutic Touch (TT), 241, 249, 250, 488–489
living the commitment to care, 339–341 Thermoregulation, 93
nursing response, 336–337 Third-tier level of stages of consciousness, 224
nursing situation, 336 Thompson, William Irwin, 276
paradigms which guided development of the TNS. See Theory of nursing systems (TNS)
theory, 335 Tomlin, Evelyn, 184. See also Modeling and
personhood, 336 role-modeling (MRM)
practice exemplar, 345–346 Tommet, Patricia, 285
website, 347 Torrance tests of creative thinking, 472
Theory of nursing in hypertension care, 122 Totality paradigm, 12, 260–261, 261t
Theory of nursing systems (TNS), 112 Towards a Theory for Nursing: General Concepts of Human
Theory of pandimensional awareness-integral presence, Behavior (King), 135, 136
243 Trade vs. profession, 59–60
Theory of perceptual awareness, 140 Transaction process model, 138, 138f
Theory of relational caring complexity, 462, 464 Transactional transformational leadership model, 145
Theory of self-care (TSC), 111 Transactive relationship theory of nursing (TRETON),
Theory of self-care deficit (TSCD), 111–112 345

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Transcendence, 372, 372f, 373 Troutman-Jordan, Meredith, 469. See also Theory of
Transcendent values, 430t successful aging
Transcultural nursing, 297. See also Theory of culture True presence, 266
care diversity and universality Tsarnas, Elizabeth, 343
Transcultural Nursing: Concepts, Theories, and Practices TSC. See Theory of self-care (TSC)
(McFarland/Wehbe-Alamah), 294, 303 TSCD. See Theory of self-care deficit (TSCD);
Transdisciplinary care, 425 Therapeutic self-care demand (TSCD)
Transformational leadership, 462 Tsunami disaster, 534
Transforming, 263t, 264 TT. See Therapeutic Touch (TT)
Transitional care, 423 Turkel, Marian, 450. See also Theory of bureaucratic caring
Transitional objects, 191 Twilight Zone, The (TV), 440
Transitions theory, 353–370 2030 United Nations Agenda for Sustainable
applications of the theory, 363–366 Development, 229
assumptions, 355 Type 1 diabetes mellitus, 175
awareness, 357–358, 361
change triggers, 356–357 U
conditions of change and transitions, 358–359 Ubuntu philosophy, 423, 425
critical points, 362 UFPP. See Unitary field pattern portrait (UFPP)
debriefing, 363 research method
disconnectedness, 357 Unbinding, 282, 282f
goals, 358 UNCH care system, 506–507
major areas of investigation, 361t Unconditional acceptance of other people, 189
milestones, 358, 362 Unit champions, 30–31
overview (flowchart), 356f Unitariology, 243
paradigms which guided development of the theory, Unitary appreciative inquiry, 252
354–355 Unitary caring science, 321–323, 500
patterns of responses, 359–361 Unitary Caring Science: The Philosophy and Praxis of
practice exemplar, 366–370 Nursing (Watson), 321
process, 357 Unitary caring theory. See Theory of unitary caring
role supplementation, 354 Unitary field pattern portrait (UFPP) research method,
significant others, 361, 362 252–255
situation-specific theories, 366 Unitary pattern-based practice, 246, 248, 249. See also
supportive resources, 362–363 Science of unitary human beings
time span, 357 Unitary pattern-based praxis method, 245–246, 245f
transition, defined, 355 Unitary-transformative paradigm, 12, 275, 466
Translational science, 460 United Nations 17 Sustainable Development Goals,
Transpersonal caring moment, 320 230t, 425
Transpersonal caring relationship, 318–321 United States Air Force interprofessional person-
Transpersonal teaching-learning, 514–515 centered caring practice model, 461
Traumatic brain injury (TBI), 505 Universal self-care requisites (USCRs), 116
Travelbee, Joyce, 75–76 Universal technological domain (UTD), 443, 443f
Travelbee’s human-to-human relationship model, 75–82
University of North Carolina Hospitals (UNCH) care

applications of the theory, 79–80 system, 506–507
caring, 76 USCRs. See Universal self-care requisites (USCRs)
dehumanization, 76 User participation, 140
emerging identities, 77–78, 79 UTD. See Universal technological domain (UTD)
emotional detachment, 76
empathy, 78
five stages of nursing care, 77 V
hope, 77 Vail, John, 283
logotherapy, 76 Valuing, 263t, 264
main concepts, 76 Veritivity, 151
observation stage of nursing care, 77 Victoria, Queen, 46
original encounter, 77 Voluntary mutual patterning, 248–249, 484
practice exemplar, 80–81 Vulnerability, 401–402, 532
pre-interaction phase, 78
rapport, 78 W
suffering, 77 Wald, Lillian, 425
sympathy, 78 Wallach and Kogan’s creativity test, 472
TRETON. See Transactive relationship theory of Watson, Jean, 311–312, 441. See also Watson’s theory of
nursing (TRETON) unitary caring science and theory of human caring

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Index 555
Watson Caring Science Institute (WCSI), 324, 461, 462 Well-being picture scale for children, 247
Watson caritas patient score, 318 Wholeness. See also Holistic approach to healthcare
Watson’s assessment of dream experience scale, 247 community nursing practice model (CNPM), 430t
Watson’s National Caring Science Affiliates, 31 holographic theory of bureaucratic caring, 451, 451f,
Watson’s theory of unitary caring science and theory 452, 458–459
of human caring, 311–331 Johnson behavioral system model (JBSM), 93
applications of the theory, 323–326 nursing’s role in interdisciplinary team conferences,
carative factors, 314–316 498
caring-healing-loving consciousness, 321 resonating with the whole, 278
caring-in-action indicators, 325–326 technological competency as caring in nursing, 441
caring occasion, 320 theory of enfolding health-as-wholeness-and-
caritas-communitas peacemakers, 314 harmony, 242
caritas literacy/illiteracy, 323 Wholeness and order, 93
caritas processes, 316–317 Wholism, 172, 187, 187f
caritas/veritas praxis process, 321–322 Wholly compensatory system, 119, 119f
conscious dying, 322 Wiedenbach, Ernestine, 55–56
ethic of belonging, 314 Wiedenbach’s prescriptive theory
evolving human-centered care, 323 applications of the theory, 61
heart-centered transpersonal caring moment, 318 essential ingredients, 57–58
I-Thou relationship, 319 explanation of the theory, 57
International Caritas Consortium (ICC), 324–325 practice exemplar, 63
major conceptual elements, 314 Wilber, Ken, 213, 219–224
nursing qua nursing, 313, 314 Wisdom, 476
practice exemplar, 326–330 Women Founders of the Social Sciences, The
Smith’s theory of unitary caring, compared, 500 (McDonald), 47
transpersonal caring moment, 320 Women methodologists, 47
transpersonal caring relationship, 318–321 Worldly self, 227t
unitary caring science, 321–323, 500 Worldviews, 12
Watson Caring Science Institute (WCSI), 324 Wow moments, 376
WCSI. See Watson Caring Science Institute (WCSI)
“We” space, 221t, 223, 224–225
Weber, Max, 454
Y
Young’s spectrum of evolution of consciousness,
Wehbe-Alamah, Hiba, 294. See also Theory of culture
281–282, 282f
care diversity and universality
Well-becoming, 243
Well-being, 113–114, 402 Z
Well-being picture scale for adults, 247 Zahourek’s theory of intentionality in healing, 242

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7991_Ch01_001-016 12/08/19 5:19 PM Page 1

Smith, M. C. (2019). Nursing theories and nursing practice. F. A. Davis Company.

I An Introduction to Nursing Theory

Nursing Theory and the

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

treatments in an acute care setting. In a

4 S E C T IO N I ■ An Introduction to Nursing Theory

ing knowledge guides its professional practice;

Smith, M. C. (2019). Nursing theories and nursing practice. F. A. Davis Company.

C H APTER 1 ■ Nursing Theory and the Discipline of Nursing 5

3. Concern with the processes through structure to organize knowledge and

Smith, M. C. (2019). Nursing theories and nursing practice. F. A. Davis Company.

6 S E C T IO N I ■ An Introduction to Nursing Theory

nication among members of the discipline.

Smith, M. C. (2019). Nursing theories and nursing practice. F. A. Davis Company.

C H APTER 1 ■ Nursing Theory and the Discipline of Nursing 7

Deﬁnitions of Nursing Theory of science. The following deﬁnitions of theory

ceptual system or framework invented for some

Smith, M. C. (2019). Nursing theories and nursing practice. F. A. Davis Company.

8 S E C T IO N I ■ An Introduction to Nursing Theory

Smith, M. C. (2019). Nursing theories and nursing practice. F. A. Davis Company.

C H APTER 1 ■ Nursing Theory and the Discipline of Nursing 9

Smith, M. C. (2019). Nursing theories and nursing practice. F. A. Davis Company.

10 S E C T IO N I ■ An Introduction to Nursing Theory

Smith, M. C. (2019). Nursing theories and nursing practice. F. A. Davis Company.

C H APTER 1 ■ Nursing Theory and the Discipline of Nursing 11

Smith, M. C. (2019). Nursing theories and nursing practice. F. A. Davis Company.

12 S E C T IO N I ■ An Introduction to Nursing Theory

on the metaparadigm or disciplinary domain. two paradigms, or worldviews, outside the

nition that science is the work of a community Change is characterized by fluctuating

Smith, M. C. (2019). Nursing theories and nursing practice. F. A. Davis Company.

C H APTER 1 ■ Nursing Theory and the Discipline of Nursing 13

a belief that humans are known by pattern Middle-Range Theories

ports of nursing theory developed at this level

Smith, M. C. (2019). Nursing theories and nursing practice. F. A. Davis Company.

14 S E C T IO N I ■ An Introduction to Nursing Theory

Smith, M. C. (2019). Nursing theories and nursing practice. F. A. Davis Company.

C H APTER 1 ■ Nursing Theory and the Discipline of Nursing 15

Smith, M. C. (2019). Nursing theories and nursing practice. F. A. Davis Company.

16 S E C T IO N I ■ An Introduction to Nursing Theory

Questions for Reﬂection middle-range theories, and practice-level

■ In your own words, deﬁne “theory” and

Smith, M. C. (2019). Nursing theories and nursing practice. F. A. Davis Company.

A Guide for the Study of

exploration.1 The questions in this guide can

1For additional information, see the bonus chapter content

18 S E C T IO N I ■ An Introduction to Nursing Theory

Smith, M. C. (2019). Nursing theories and nursing practice. F. A. Davis Company.

CHAPTER 2 ■ A Guide for the Study of Nursing Theories for Practice 19

Study of Theory for Nursing ■ What is the place of nursing in interpro-

concepts within the theories, as well as on nursing care?

book; other literature, such as books and jour- a nursing scholar?

Theory for Use in Practice development of this theory?

practicing nursing? What were major external influences

enced the development of the theory?

What are the boundaries or limits for nursing? these persons?

health-related professions? how does one become one?

and services? authorities?

Smith, M. C. (2019). Nursing theories and nursing practice. F. A. Davis Company.

20 S E C T IO N I ■ An Introduction to Nursing Theory

Questions for Reﬂection ■ Describe in your own words how you

Smith, M. C. (2019). Nursing theories and nursing practice. F. A. Davis Company.

Choosing, Evaluating, and

appreciate the day-to-day practice of nurses.