Concept and Theories in Nursing 8

This week, you will develop a PowerPoint presentation reviewing the theories from each module. Please select one theory from each module (1-8) and answer the following questions. You should have two slides per theory:

  • Describe the theory
  • Provide 3 examples of how the theory applies to current practice (Obstetrics)
  • Provide 3 positive patient outcomes resulting from utilizing the theory
  • Explain 3 benefits to nursing satisfaction when utilizing the theory
  • Describe two barriers to using the theory in practice and at least one method for overcoming each barrier (support methods with sources)
  • Support from literature clearly noted throughout

The PowerPoint presentation should include at least two outside references and the textbook. The presentation should contain 2 to 4 slides per theory, for a total of 16 to 32 slides.

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Mod 1 – Nightingale 

Module 2- peplau, Henderson and orem 

Module 3- Johnson and Orlando

Module 4- King and Rogers

Module 5- Roy and Neuman 

Module 6- Leininger, Newman and Watson

Module 7- Parse, Erickson and Swain

Module 8- Theories of 1980’s and 1990’s

Nursing Theories & Nursing Practice
Fourth Edition
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3312_FM_i-xx 26/12/14 5:51 PM Page ii

Nursing Theories & Nursing Practice
Fourth Edition
Marlaine C. Smith, PhD, RN, AHN-BC, FAAN
Marilyn E. Parker, PhD, RN, FAAN
3312_FM_i-xx 26/12/14 5:51 PM Page iii

F. A. Davis Company
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Philadelphia, PA 19103
Copyright © 2015 by F. A. Davis Company
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Publisher, Nursing: Joanne Patzek DaCunha, RN, MSN; Susan Rhyner
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Library of Congress Cataloging-in-Publication Data
Nursing theories and nursing practice.
Nursing theories & nursing practice / [edited by] Marlaine C. Smith, Marilyn E. Parker. — Fourth edition.
p. ; cm.
Preceded by Nursing theories and nursing practice / [edited by] Marilyn E. Parker, Marlaine C. Smith.
3rd ed. c2010.
Includes bibliographical references and index.
ISBN 978-0-8036-3312-4 (alk. paper)
I. Smith, Marlaine C. (Marlaine Cappelli), editor. II. Parker, Marilyn E., editor. III. Title.
[DNLM: 1.  Nursing Theory—Biography. 2.  Nurses—Biography.  WY 86]
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3312_FM_i-xx 26/12/14 5:51 PM Page iv

Preface to the Fourth Edition
This book offers the perspective that nursing is
a professional discipline with a body of knowl-
edge that guides its practice. Nursing theories
are an important part of this body of knowl-
edge, and regardless of complexity or abstrac-
tion, they reflect phenomena central to the
discipline, and should be used by nurses to
frame their thinking, action, and being in the
world. As guides, nursing theories are practical
in nature and facilitate communication with
those we serve as well as with colleagues, stu-
dents, and others practicing in health-related
services. We hope this book illuminates for the
readers the interrelationship between nursing
theories and nursing practice, and that this un-
derstanding will transform practice to improve
the health and quality of life of people who are
recipients of nursing care.
This very special book is intended to honor
the work of nursing theorists and nurses who
use these theories in their day-to-day practice.
Our foremost nursing theorists have written
for this book, or their theories have been de-
scribed by nurses who have comprehensive
knowledge of the theorists’ ideas and who have
a deep respect for the theorists as people,
nurses, and scholars. To the extent possible,
contributing authors have been selected by
theorists to write about their work. Three
middle-range theories have been added to this
edition of the book, bringing the total number
of middle-range theories to twelve. Obviously,
it was not possible to include all existing
middle-range theories in this volume; how-
ever, the expansion of this section illustrates
the recent growth in middle-range theory de-
velopment in nursing. Two chapters from the
third edition, including Levine’s conservation
theory and Paterson & Zderad’s humanistic
nursing have been moved to supplementary on-
line resources at
This book is intended to help nursing stu-
dents in undergraduate, masters, and doctoral
nursing programs explore and appreciate nurs-
ing theories and their use in nursing practice
and scholarship. In addition, and in response
to calls from practicing nurses, this book is in-
tended for use by those who desire to enrich
their practice by the study of nursing theories
and related illustrations of nursing practice.
The contributing authors describe theory de-
velopment processes and perspectives on the
theories, giving us a variety of views for the
twenty-first century and beyond. Each chapter
of the book includes descriptions of a theory,
its applications in both research and practice,
and an example that reflects how the theory
can guide practice. We anticipate that this
overview of the theory and its applications will
lead to deeper exploration of the theory, lead-
ing students to consult published works by the
theorists and those working closely with the
theory in practice or research.
There are six sections in the book. The first
provides an overview of nursing theory and a
focus for thinking about evaluating and choos-
ing a nursing theory for use in practice. For
this edition, the evolution of nursing theory
was added to Chapter 1. Section II introduces
the work of early nursing scholars whose ideas
provided a foundation for more formal theory
development. The nursing conceptual models
and grand theories are clustered into three
parts in Sections III, IV, and V. Section III
contains those theories classified within the
interactive-integrative paradigm, and those in
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the unitary-transformative paradigm are in-
cluded in Section IV. Grand theories that are
focused on the phenomena of care or caring
appear in Section V. The final section contains
a selection of middle-range theories.
An outline at the beginning of each chapter
provides a map for the contents. Major points
are highlighted in each chapter. Since this
book focuses on the relationship of nursing
theory to nursing practice, we invited the
authors to share a practice exemplar. You will
notice that some practice exemplars were writ-
ten by someone other than the chapter author.
In this edition the authors also provided
content about research based on the theory.
Because of page limitations you can find
additional chapter content online at http:// While every attempt
was made to follow a standard format for each
of the chapters throughout the book, some of
the chapters vary from this format; for exam-
ple, some authors chose not to include practice
The book’s website features materials that
will enrich the teaching and learning of these
nursing theories. Materials that will be helpful
for teaching and learning about nursing theo-
ries are included as online resources. For exam-
ple, there are case studies, learning activities,
and PowerPoint presentations included on
both the instructor and student websites. Other
online resources include additional content,
more extensive bibliographies and longer biog-
raphies of the theorists. Dr. Shirley Gordon
and a group of doctoral students from Florida
Atlantic University developed these ancillary
materials for the third edition. For this edition,
the ancillary materials for students and faculty
were updated by Diane Gullett, a PhD candi-
date at Florida Atlantic University. She devel-
oped all materials for the new chapters as well
as updating ancillary materials for chapters that
appeared in the third edition. We are so grate-
ful to Diane and Shirley for their creativity and
leadership and to the other doctoral students for
their thoughtful contributions to this project .
We hope that this book provides a useful
overview of the latest theoretical advances of
many of nursing’s finest scholars. We are
grateful for their contributions to this book. As
editors we’ve found that continuing to learn
about and share what we love nurtures our
growth as scholars, reignites our passion and
commitment, and offers both fun and frustra-
tion along the way. We continue to be grateful
for the enthusiasm for this book shared by
many nursing theorists and contributing
authors and by scholars in practice and
research who bring theories to life. For us, it
has been a joy to renew friendships with col-
leagues who have contributed to past editions
and to find new friends and colleagues whose
theories enriched this edition.
Nursing Theories and Nursing Practice, now
in the fourth edition, has roots in a series of
nursing theory conferences held in South
Florida, beginning in 1989 and ending when
efforts to cope with the aftermath of Hurricane
Andrew interrupted the energy and resources
needed for planning and offering the Fifth
South Florida Nursing Theory Conference.
Many of the theorists in this book addressed
audiences of mostly practicing nurses at these
conferences. Two books stimulated by those
conferences and published by the National
League for Nursing are Nursing Theories in
Practice (1990) and Patterns of Nursing Theories
in Practice (1993).
For me (Marilyn), even deeper roots of this
book are found early in my nursing career,
when I seriously considered leaving nursing for
the study of pharmacy. In my fatigue and frus-
tration, mixed with youthful hope and desire
for more education, I could not answer the
question “What is nursing?” and could not dis-
tinguish the work of nursing from other tasks
I did every day. Why should I continue this
work? Why should I seek degrees in a field
that I could not define? After reflecting on
these questions and using them to examine my
nursing, I could find no one who would con-
sider the questions with me. I remember being
asked, “Why would you ask that question? You
are a nurse; you must surely know what nurs-
ing is.” Such responses, along with a drive for
serious consideration of my questions, led me
to the library. I clearly remember reading se –
veral descriptions of nursing that, I thought,
could just as well have been about social work
or physical therapy. I then found nursing
vi Preface to the Fourth Edition
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defined and explained in a book about educa-
tion of nurses written by Dorothea Orem.
During the weeks that followed, as I did my
work of nursing in the hospital, I explored
Orem’s ideas about why people need nursing,
nursing’s purposes, and what nurses do. I
found a fit between her ideas, as I understood
them, with my practice, and I learned that I
could go even further to explain and design
nursing according to these ways of thinking
about nursing. I discovered that nursing shared
some knowledge and practices with other serv-
ices, such as pharmacy and medicine, and I
began to distinguish nursing from these related
fields of practice. I decided to stay in nursing
and made plans to study and work with
Dorothea Orem. In addition to learning about
nursing theory and its meaning in all we do, I
learned from Dorothea that nursing is a unique
discipline of knowledge and professional prac-
tice. In many ways, my earliest questions about
nursing have guided my subsequent study and
work. Most of what I have done in nursing has
been a continuation of my initial experience of
the interrelations of all aspects of nursing
scholarship, including the scholarship that is
nursing practice. Over the years, I have been
privileged to work with many nursing scholars,
some of whom are featured in this book.
My love for nursing and my respect for our
discipline and practice have deepened, and
knowing now that these values are so often
shared is a singular joy.
Marlaine’s interest in nursing theory had
similar origins to Marilyn’s. As a nurse pursu-
ing an interdisciplinary master’s degree in pub-
lic health, I (Marlaine) recognized that while
all the other public health disciplines had some
unique perspective to share, public health
nursing seemed to lack a clear identity. In
search of the identity of nursing I pursued a
second master’s in nursing. At that time nurs-
ing theory was beginning to garner attention,
and I learned about it from my teachers and
mentors Sr. Rosemary Donley, Rosemarie
Parse, and Mary Jane Smith. This discovery was
the answer I was seeking, and it both expanded
and focused my thinking about nursing. The
question of “What is nursing?” was answered
for me by these theories and I couldn’t get
enough! It led to my decision to pursue my
PhD in Nursing at New York University
where I studied with Martha Rogers. During
this same time I taught at Duquesne University
with Rosemarie Parse and learned more about
Man-Living-Health, which is now humanbe-
coming. I conducted several studies based on
Rogers’ conceptual system and Parse’s theory.
At theory conferences I was fortunate to
dialogue with Virginia Henderson, Hildegard
Peplau, Imogene King, and Madeleine
Leininger. In 1988 I accepted a faculty posi-
tion at the University of Colorado when Jean
Watson was Dean. The School of Nursing was
guided by a caring philosophy and framework
and I embraced caring as a central focus of the
discipline of nursing. As a unitary scholar, I
studied Newman’s theory of health as expand-
ing consciousness and was intrigued by it, so
for my sabbatical I decided to study it further
as well as learn more about the unitary appre-
ciative inquiry process that Richard Cowling
was developing.
We both have been fortunate to hold faculty
appointments in universities where nursing the-
ory has been valued, and we are fortunate today
to hold positions at the Christine E. Lynn Col-
lege of Nursing at Florida Atlantic University,
where faculty and students ground their teach-
ing scholarship and practice on caring theories,
including nursing as caring, developed by Dean
Anne Boykin and a previous faculty member at
the College, Savina Schoenhofer. Many faculty
colleagues and students continue to help us
study nursing and have contributed to this book
in ways we would never have adequate words to
acknowledge. We are grateful to our knowl-
edgeable colleagues who reviewed and offered
helpful suggestions for chapters of this book,
and we sincerely thank those who contributed
to the book as chapter authors. It is also our
good fortune that many nursing theorists and
other nursing scholars live in or visit our lovely
state of Florida. Since the first edition of this
book was published, we have lost many nursing
theorists. Their work continues through those
refining, modifying, testing, and expanding the
theories. The discipline of nursing is expanding
as research and practice advances existing theories
and as new theories emerge. This is especially
Preface to the Fourth Edition vii
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important at a time when nursing theory can
provide what is missing and needed most in
health care today.
All four editions of this book have been nur-
tured by Joanne DaCunha, an expert nurse and
editor for F. A. Davis Company, who has shep-
herded this project and others because of her
love of nursing. Near the end of this project
Joanne retired, and Susan Rhyner, our new ed-
itor, led us to the finish line. We are both grate-
ful for their wisdom, kindness, patience and
understanding of nursing. We give special
thanks to Echo Gerhart, who served as our con-
tact and coordinator for this project. Marilyn
thanks her husband, Terry Worden, for his
abiding love and for always being willing to help,
and her niece, Cherie Parker, who represents
many nurses who love nursing practice and
scholarship and thus inspire the work of this
book. Marlaine acknowledges her husband
Brian and her children, Kirsten, Alicia, and
Brady, and their spouses, Jonathan Vankin and
Tori Rutherford, for their love and understand-
ing. She honors her parents, Deno and Rose
Cappelli, for instilling in her the love of learning,
the value of hard work, and the importance of
caring for others, and dedicates this book to her
granddaughter Iyla and the new little one who
is scheduled to arrive as this book is released.
Marilyn E. Parker, Marlaine C. Smith,
Olathe, Kansas Boca Raton, Florida
viii Preface to the Fourth Edition
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Nursing Theorists
Elizabeth Ann Manhart Barrett, PhD, RN, FAAN
Professor Emerita
Hunter College
City University of New York
New York, New York
Charlotte D. Barry, PhD, RN, NCSN, FAAN
Professor of Nursing
Christine E. Lynn College of Nursing
Florida Atlantic University
Boca Raton, Florida
Anne Boykin, PhD, RN*
Dean and Professor Emerita
Christine E. Lynn College of Nursing
Florida Atlantic University
Boca Raton, Florida
Barbara Montgomery Dossey, PhD, RN, AHN-BC, FAAN,
Co-Director, International Nurse Coach
Core Faculty, Integrative Nurse Coach
Certificate Program
Miami, Florida
Joanne R. Duffy, PhD, RN, FAAN
Endowed Professor of Research and
Evidence-based Practice and Director
of the PhD Program
West Virginia University
Morgantown, West Virginia
Helen L. Erickson*
Professor Emerita
University of Texas at Austin
Austin, Texas
Lydia Hall†
Virginia Henderson†
Dorothy Johnson†
Imogene King†
Katharine Kolcaba, PhD, RN
Associate Professor Emeritus Adjunct
The University of Akron
Akron, Ohio
Madeleine M. Leininger†
Patricia Liehr, PhD, RN
Christine E. Lynn College of Nursing
Florida Atlantic University
Boca Raton, Florida
Rozzano C. Locsin, PhD, RN
Professor Emeritus
Christine E. Lynn College of Nursing
Florida Atlantic University
Boca Raton, Florida
Afaf I. Meleis, PhD, DrPS(hon), FAAN
Professor of Nursing and Sociology
University of Pennsylvania
Philadelphia, Pennsylvania
Betty Neuman, PhD, RN, PLC, FAAN
Beverly, Ohio
Margaret Newman, RN, PhD, FAAN
Professor Emerita
University of Minnesota College of Nursing
Saint Paul, Minnesota
Dorothea E. Orem†
Ida Jean Orlando (Pelletier)†
Marilyn E. Parker, PhD, RN, FAAN
Professor Emerita
Christine E. Lynn College of Nursing
Florida Atlantic University
Boca Raton, Florida
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Rosemarie Rizzo Parse, PhD, FAAN
Distinguished Professor Emeritus
Marcella Niehoff School of Nursing
Loyola University Chicago
Chicago, Illinois
Hildegard Peplau†
Marilyn Anne Ray, PhD, RN, CTN
Professor Emerita
Christine E. Lynn College of Nursing
Florida Atlantic University
Boca Raton, Florida
Pamela G. Reed, PhD, RN, FAAN
University of Arizona
Tucson, Arizona
Martha E. Rogers†
Sister Callista Roy, PhD, RN, FAAN
Professor and Nurse Theorist
William F. Connell School of Nursing
Boston College
Chestnut Hill, Massachusetts
Savina O. Schoenhofer, PhD, RN
Professor of Nursing
University of Mississippi
Oxford, Mississippi
Marlaine C. Smith, PhD, RN, AHN-BC, FAAN
Dean and Helen K. Persson Eminent Scholar
Christine E. Lynn College of Nursing
Florida Atlantic University
Boca Raton, Florida
Mary Jane Smith, PhD, RN
West Virginia University
Morgantown, West Virginia
Mary Ann Swain, PhD
Professor and Director, Doctoral Program
Decker School of Nursing
Binghamton University
Binghamton, New York
Kristen M. Swanson, PhD, RN, FAAN
Seattle University
Seattle, Washington
Evelyn Tomlin*
Joyce Travelbee†
Meredith Troutman-Jordan, PhD, RN
Associate Professor
University of North Carolina
Chapel Hill, North Carolina
Jean Watson, PhD, RN, AHN-BC, FAAN
Distinguished Professor Emeritus
University of Colorado at Denver—Anschutz
Aurora, Colorado
Ernestine Wiedenbach†
x Nursing Theorists
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Patricia Deal Aylward, MSN, RN, CNS
Assistant Professor
Santa Fe Community College
Gainesville, Florida
Howard Karl Butcher, PhD, RN, PMHCNS-BC
Associate Professor
University of Iowa
Iowa City, Iowa
Lynne M. Hektor Dunphy, PhD, APRN-BC
Associate Dean for Practice and Community
Christine E. Lynn College of Nursing
Florida Atlantic University
Boca Raton, Florida
Laureen M. Fleck, PhD, FNP-BC, FAANP
Associate Faculty
Christine E. Lynn College of Nursing
Florida Atlantic University
Boca Raton, Florida
Maureen A. Frey, PhD, RN*
Shirley C. Gordon, PhD, RN
Professor and Assistant Dean Graduate Practice
Christine E. Lynn College of Nursing
Florida Atlantic University
Boca Raton, Florida
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xii Contributors
Diane Lee Gullett, RN, MSN, MPH
Doctoral Candidate
Christine E. Lynn College of NursingFlorida
Atlantic University
Boca Raton, Florida
Donna L. Hartweg, PhD, RN
Professor Emerita and Former Director
Illinois Wesleyan University
Bloomington, Illinois
Bonnie Holaday, PhD, RN, FAAN
Clemson University
Clemson, South Carolina
Beth M. King, PhD, RN, PMHCNS-BC
Assistant Professor and RN-BSN Coordinator
Christine E. Lynn College of Nursing
Florida Atlantic University
Boca Raton, Florida
Lois White Lowry, DNSc, RN*
Professor Emerita
East Tennessee State University
Johnson City, Tennessee
Violet M. Malinski, PhD, MA, RN
Associate Professor
College of New Rochelle
New Rochelle, New York
Mary B. Killeen, PhD, RN, NEA-BC
Evidence Based Practice Nurse Consultants,
Howell, Michigan
Ann R. Peden, RN, CNS, DSN
Professor and Chair
Capital University
Columbus, Ohio
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Contributors xiii
Margaret Dexheimer Pharris, PhD, RN, CNE, FAAN
Associate Dean for Nursing
St. Catherine University
St. Paul, Minnesota
Maude Rittman, PhD, RN
Associate Chief of Nursing Service for Research
Gainesville Veteran’s Administration
Medical Center
Gainesville, Florida
Christina L. Sieloff, PhD, RN
Associate Professor
Montana State University
Billings, Montana
Jacqueline Staal, MSN, ARNP, FNP-BC
PhD Candidate
Christine E. Lynn College of Nursing
Florida Atlantic University
Boca Raton, Florida
Marian C. Turkel, PhD, RN, NEA-BC, FAAN
Director of Professional Nursing Practice
Holy Cross Medical Center
Fort Lauderdale, Florida
Pamela Senesac, PhD, SM, RN
Assistant Professor
University of Massachusetts
Shrewsbury, Massachusetts
Hiba Wehbe-Alamah, PhD, RN, FNP-BC, CTN-A
Associate Professor
University of Michigan-Flint
Flint, Michigan
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xiv Contributors
Terri Kaye Woodward, MSN, RN, CNS, AHN-BC, HTCP
Cocreative Wellness
Denver, Colorado
Kelly White, RN, PhD, FNP-BC
Assistant Professor
South University
West Palm Beach, Florida
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Ferrona Beason, PhD, ARNP
Assistant Professor in Nursing
Barry University – Division of Nursing
Miami Shores, Florida
Abimbola Farinde, PharmD, MS
Clinical Pharmacist Specialist
Clear Lake Regional Medical Center
Webster, Texas
Lori S. Lauver, PhD, RN, CPN, CNE
Associate Professor
Jefferson School of Nursing
Thomas Jefferson University
Philadelphia, Pennsylvania
Elisheva Lightstone, BScN, MSc
Department of Nursing
Seneca College
King City, Ontario, Canada
Carol L. Moore, PhD, APRN, CNS
Assistant Professor of Nursing, Coordinator,
Graduate Nursing Studies
Fort Hays State University
Hays, Kansas
Kathleen Spadaro, PhD, PMHCNS, RN
MSN Program Co-coordinator & Assistant
Professor of Nursing
Chatham University
Pittsburgh, Pennsylvania
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3312_FM_i-xx 26/12/14 5:51 PM Page xvi

Section I An Introduction to Nursing Theory, 1
Chapter 1 Nursing Theory and the Discipline of Nursing, 3
Marlaine C. Smith and Marilyn E. Parker
Chapter 2 A Guide for the Study of Nursing Theories for Practice, 19
Marilyn E. Parker and Marlaine C. Smith
Chapter 3 Choosing, Evaluating, and Implementing Nursing Theories
for Practice, 23
Marilyn E. Parker and Marlaine C. Smith
Section II Conceptual Influences on the Evolution of Nursing
Theory, 35
Chapter 4 Florence Nightingale’s Legacy of Caring and Its Applications, 37
Lynne M. Hektor Dunphy
Chapter 5 Early Conceptualizations About Nursing, 55
Shirley C. Gordon
Chapter 6 Nurse-Patient Relationship Theories, 67
Ann R. Peden, Jacqueline Staal, Maude Rittman, and Diane Lee Gullett
Section III Conceptual Models/Grand Theories in the Integrative-
Interactive Paradigm, 87
Chapter 7 Dorothy Johnson’s Behavioral System Model and Its
Applications, 89
Bonnie Holaday
Chapter 8 Dorothea Orem’s Self-Care Deficit Nursing Theory, 105
Donna L. Hartweg
3312_FM_i-xx 26/12/14 5:51 PM Page xvii

Chapter 9 Imogene King’s Theory of Goal Attainment, 133
Christina L. Sieloff and Maureen A. Frey
Chapter 10 Sister Callista Roy’s Adaptation Model, 153
Pamela Sensac and Sister Callista Roy
Chapter 11 Betty Neuman’s Systems Model, 165
Lois White Lowry and Patricia Deal Aylward
Chapter 12 Helen Erickson, Evelyn Tomlin, and Mary Ann Swain’s
Theory of Modeling and Role Modeling, 185
Helen L. Erickson
Chapter 13 Barbara Dossey’s Theory of Integral Nursing, 207
Barbara Montgomery Dossey
Section IV Conceptual Models and Grand Theories in the
Unitary–Transformative Paradigm, 235
Chapter 14 Martha E. Rogers Science of Unitary Human Beings, 237
Howard Karl Butcher and Violet M. Malinski
Chapter 15 Rosemarie Rizzo Parse’s Humanbecoming Paradigm, 263
Rosemarie Rizzo Parse
Chapter 16 Margaret Newman’s Theory of Health as Expanding
Consciousness, 279
Margaret Dexheimer Pharris
Section V Grand Theories about Care or Caring, 301
Chapter 17 Madeleine Leininger’s Theory of Culture Care Diversity
and Universality, 303
Hiba Wehbe-Alamah
Chapter 18 Jean Watson’s Theory of Human Caring, 321
Jean Watson
Chapter 19 Theory of Nursing as Caring, 341
Anne Boykin and Savina O. Schoenhofer
Section VI Middle-Range Theories, 357
Chapter 20 Transitions Theory, 361
Afaf I. Meleis
xviii Contents
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Chapter 21 Katharine Kolcaba’s Comfort Theory, 381
Katharine Kolcaba
Chapter 22 Joanne Duffy’s Quality-Caring Model©, 393
Joanne R. Duffy
Chapter 23 Pamela Reed’s Theory of Self-Transcendence, 411
Pamela G. Reed
Chapter 24 Patricia Liehr and Mary Jane Smith’s Story Theory, 421
Patricia Liehr and Mary Jane Smith
Chapter 25 The Community Nursing Practice Model, 435
Marilyn E. Parker, Charlotte D. Barry. and Beth M. King
Chapter 26 Rozzano Locsin’s Technological Competency as Caring
in Nursing, 449
Rozzano C. Locsin
Chapter 27 Marilyn Anne Ray’s Theory of Bureaucratic Caring, 461
Marilyn Anne Ray and Marian C. Turkel
Chapter 28 Troutman-Jordan’s Theory of Successful Aging, 483
Meredith Troutman-Jordan
Chapter 29 Barrett’s Theory of Power as Knowing Participation
in Change, 495
Elizabeth Ann Manhart Barrett
Chapter 30 Marlaine Smith’s Theory of Unitary Caring, 509
Marlaine C. Smith
Chapter 31 Kristen Swanson’s Theory of Caring, 521
Kristen M. Swanson
Index, 533
Contents xix
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3312_FM_i-xx 26/12/14 5:51 PM Page xx

Section I
An Introduction to Nursing Theory
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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 human health and
healing through caring. Nursing practice is based on the knowledge of nursing,
which consists of its philosophies, theories, concepts, principles, research findings,
and practice wisdom. 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.
The first chapter in this section focuses on nursing theory within the context of
nursing as an evolving professional discipline. We examine the relationship of
nursing theory to the characteristics of a discipline. You’ll learn new words that
describe parts of the knowledge structure of the discipline of nursing, and we’ll
speculate about the future of nursing theory as nursing, health care, and our global
society change. Chapter 2 is a guide to help you study the theories in this book.
Use this guide as you read and think about how nursing theory fits in your prac-
tice. 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 evaluating or critiquing
a nursing theory. Evaluation is coming to some judgment about value or worth
based on criteria. Various sets of criteria exist for you to use in theory evaluation.
We introduce some that you can explore further. Finally, we offer reflections on
the process of implementing theory-guided practice models.
I An Introduction to Nursing Theory
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Chapter 1Nursing Theory and the
Discipline of Nursing
The Discipline of Nursing
Definitions of Nursing Theory
The Purpose of Theory in a Professional
The Evolution of Nursing Science
The Structure of Knowledge in the
Discipline of Nursing
Nursing Theory and the Future
Marilyn E. ParkerMarlaine C. Smith
What is nursing? At first glance, the question
may appear to be one with an obvious an-
swer, but when it is posed to nurses, many
define nursing by providing a litany of func-
tions and activities. Some answer with the
elements of the nursing process: assessing,
planning, implementing, and evaluating. Oth-
ers might answer that nurses coordinate a
patient’s care.
Defining nursing in terms of the nursing
process or by functions or activities nurses per-
form is problematic. The phases of the nursing
process are the same steps we might use to
solve any problem we encounter, from a bro-
ken computer to a failing vegetable garden.
We assess the situation to determine what is
going on and then identify the problem; we
plan what to do about it, implement our plan,
and then evaluate whether it works. The nurs-
ing 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 per-
form 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
resources for a child with special needs. Mul-
tiple professionals and nonprofessionals may
perform the same tasks as nurses, and persons
with the ability and authority to perform cer-
tain tasks change based on time and setting.
For example, both physicians and nurses may
listen to breath sounds and recognize the pres-
ence of rales. Both nurses and social workers
might do discharge planning. Both nurses
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and family members might change dressings,
monitor vital signs, and administer medications,
so defining nursing based solely on functions or
activities performed is not useful.
To answer the question “What is nursing?”
we must formulate nursing’s unique identity
as a field of study or discipline. Florence
Nightingale is credited as the founder of mod-
ern nursing, the one who articulated its dis-
tinctive focus. In her book Notes on Nursing:
What It Is and What It Is Not (Nightingale,
1859/1992), she differentiated nursing from
medicine, stating that the two were distinct
practices. She defined nursing as putting the
person in the best condition for nature to act,
insisting that the focus of nursing was on
health and the natural healing process, not on
disease and reparation. For her, creating an
environment that provided the conditions for
natural healing to occur was the focus of nurs-
ing. Her beginning conceptualizations were
the seeds for the theoretical development of
nursing as a professional discipline.
In this chapter, we situate the understand-
ing of nursing theory within the context of
the discipline of nursing. We define the dis-
cipline of nursing, describe the purpose of
theory for the discipline of nursing, review
the evolution of nursing science, identify the
structure of the discipline of nursing, and
speculate on the future place of nursing the-
ory in the discipline.
The Discipline of Nursing
Every discipline has a unique focus that directs
the inquiry within it and distinguishes it from
other fields of study (Smith, 2008, p. 1). Nurs-
ing knowledge guides its professional practice;
therefore, it is classified as a professional disci-
pline. Donaldson and Crowley (1978) stated
that a discipline “offers a unique perspective, a
distinct way of viewing . . . phenomena, which
ultimately defines the limits and nature of its
inquiry” (p. 113). Any discipline includes net-
works of philosophies, theories, concepts, ap-
proaches to inquiry, research findings, and
practices that both reflect and illuminate its dis-
tinct perspective. The discipline of nursing is
formed by a community of scholars, including
nurses in all nursing venues, who share a
commitment to values, knowledge, and
processes to guide the thought and work of
the discipline.
The classic work of King and Brownell
(1976) is consistent with the thinking of nurs-
ing scholars (Donaldson & Crowley, 1978;
Meleis, 1977) about the discipline of nursing.
These authors have elaborated attributes that
characterize all disciplines. As you will see in
the discussion that follows, the attributes of
King and Brownell provide a framework that
contextualizes nursing theory within the dis-
cipline of nursing.
Expression of Human Imagination
Members of any discipline imagine and create
structures that offer descriptions and explana-
tions of the phenomena that are of concern to
that discipline. These structures are the theories
of that discipline. Nursing theory is dependent
on the imagination of nurses in practice, ad-
ministration, research, and teaching, as they
create and apply theories to improve nursing
practice and ultimately the lives of those they
serve. To remain dynamic and useful, the dis-
cipline requires openness to new ideas and in-
novative approaches that grow out of members’
reflections and insights.
A professional discipline must be clearly
defined by a statement of its domain—the
boundaries or focus of that discipline. The do-
main of nursing includes the phenomena of in-
terest, problems to be addressed, main content
and methods used, and roles required of the
discipline’s members (Kim, 1997; Meleis,
2012). The processes and practices claimed by
members of the disciplinary community grow
out of these domain statements. Nightingale
provided some direction for the domain of the
discipline of nursing. Although the discipli-
nary focus has been debated, there is some
degree of consensus. Donaldson and Crowley
(1978, p. 113) identified the following as the
domain of the discipline of nursing:
1. Concern with principles and laws that
govern the life processes, well-being, and
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optimal functioning of human beings, sick
or well
2. Concern with the patterning of human
behavior in interactions with the environ-
ment in critical life situations
3. Concern with the processes through
which positive changes in health status
are affected
Fawcett (1984) described the metapara-
digm as a way to distinguish nursing from
other disciplines. The metaparadigm is very
general and intended to reflect agreement
among members of the discipline about the
field of nursing. This is the most abstract level
of nursing knowledge and closely mirrors be-
liefs held about nursing. By virtue of being
nurses, all nurses have some awareness of
nursing’s metaparadigm. However, because
the term may not be familiar, it offers no di-
rect guidance for research and practice (Kim,
1997; Walker & Avant, 1995). The metapara-
digm consists of four concepts: persons, envi-
ronment, health, and nursing. According to
Fawcett, nursing is the study of the interrela-
tionship among these four concepts.
Modifications and alternative concepts for
this framework have been explored throughout
the discipline (Fawcett, 2000). For example,
some nursing scholars have suggested that
“caring” replace “nursing” in the metaparadigm
(Stevenson & Tripp-Reimer, 1989). Kim
(1987, 1997) set forth four domains: client,
client–nurse encounters, practice, and environ-
ment. In recent years, increasing attention has
been directed to the nature of nursing’s rela-
tionship with the environment (Kleffel, 1996;
Schuster & Brown, 1994).
Others have defined nursing as the study
of “the health or wholeness of human beings
as they interact with their environment”
(Donaldson & Crowley, 1978, p. 113), the life
process of unitary human beings (Rogers,
1970), care or caring (Leininger, 1978; Watson,
1985), and human–universe–health interrela-
tionships (Parse, 1998). A widely accepted focus
statement for the discipline was published
by Newman, Sime, and Corcoran-Perry
(1991): “Nursing is the study of caring in the
human health experience” (p. 3). A consensus
statement of philosophical unity in the disci-
pline was published by Roy and Jones (2007).
Statements include the following:
• The human being is characterized by
wholeness, complexity, and consciousness.
• The essence of nursing involves the nurse’s
true presence in the process of human-
to-human engagement.
• Nursing theory expresses the values and be-
liefs of the discipline, creating a structure to
organize knowledge and illuminate nursing
• The essence of nursing practice is the nurse–
patient relationship.
In 2008, Newman, Smith, Dexheimer-
Pharris, and Jones revisited the disciplinary
focus asserting that relationship was central
to the discipline, and the convergence of
seven concepts—health, consciousness, car-
ing, mutual process, presence, patterning, and
meaning—specified relationship in the pro-
fessional discipline of nursing. Willis, Grace,
and Roy (2008) posited that the central uni-
fying focus for the discipline is facilitating
humanization, meaning, choice, quality of
life, and healing in living and dying (p. E28).
Finally, Litchfield and Jondorsdottir (2008)
defined the discipline as the study of human-
ness in the health circumstance. Smith (1994)
defined the domain of the discipline of nurs-
ing as “the study of human health and healing
through caring” (p. 50). For Smith (2008),
“nursing knowledge focuses on the wholeness
of human life and experience and the
processes that support relationship, integra-
tion, and transformation” (p. 3). Nursing
conceptual models, grand theories, middle-
range theories, and practice theories explicate
the phenomena within the domain of nurs-
ing. In addition, the focus of the nursing dis-
cipline is a clear statement of social mandate
and service used to direct the study and prac-
tice of nursing (Newman et al., 1991).
Syntactical and Conceptual Structures
Syntactical and conceptual structures are
essential to any discipline and are inherent
in nursing theories. The conceptual structure
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delineates the proper concerns of nursing,
guides what is to be studied, and clarifies ac-
cepted ways of knowing and using content of
the discipline. This structuṙe is grounded in the
focus of the discipline. The conceptual struc-
ture relates concepts within nursing theories.
The syntactical structures help nurses and
other professionals to understand the talents,
skills, and abilities that must be developed
within the community. This structure directs
descriptions of data needed from research, as
well as evidence required to demonstrate the
effect on nursing practice. In addition, these
structures guide nursing’s use of knowledge in
research and practice approaches developed by
related disciplines. It is only by being thor-
oughly grounded in the discipline’s concepts,
substance, and modes of inquiry that the bound-
aries of the discipline can be understood and
possibilities for creativity across disciplinary
borders can be created and explored.
Specialized Language and Symbols
As nursing theory has evolved, so has the need
for concepts, language, and forms of data that
reflect new ways of thinking and knowing spe-
cific to nursing. The complex concepts used in
nursing scholarship and practice require lan-
guage that can be specific and understood. The
language of nursing theory facilitates commu-
nication among members of the discipline.
Expert knowledge of the discipline is often
required for full understanding of the meaning
of these theoretical terms.
Heritage of Literature and
Networks of Communication
This attribute calls attention to the array
of books, periodicals, artifacts, and aesthetic
expressions, as well as audio, visual, and elec-
tronic media that have developed over cen-
turies to communicate the nature of nursing
knowledge and practice. Conferences and fo-
rums on every aspect of nursing held through-
out the world are part of this network. Nursing
organizations and societies also provide critical
communication links. Nursing theories are
part of this heritage of literature, and those
working with these theories present their work
at conferences, societies, and other communi-
cation networks of the nursing discipline.
The tradition and history of the discipline is ev-
ident in the study of nursing over time. There
is recognition that theories most useful today
often have threads of connection with ideas
originating in the past. For example, many the-
orists have acknowledged the influence of
Florence Nightingale and have acclaimed her
leadership in influencing nursing theories of
today. In addition, nursing has a rich heritage
of practice. Nursing’s practical experience and
knowledge have been shared and transformed
as the content of the discipline and are evident
in many nursing theories (Gray & Pratt, 1991).
Values and Beliefs
Nursing has distinctive views of persons and
strong commitments to compassionate and
knowledgeable care of persons through nurs-
ing. Fundamental nursing values and beliefs
include a holistic view of person, the dignity
and uniqueness of persons, and the call to care.
There are both shared and differing values and
beliefs within the discipline. The metapara-
digm reflects the shared beliefs, and the para-
digms reflect the differences.
Systems of Education
A distinguishing mark of any discipline is the
education of future and current members of
the community. Nursing is recognized as a
professional discipline within institutions of
higher education because it has an identifiable
body of knowledge that is studied, advanced,
and used to underpin its practice. Students of
any professional discipline study its theories
and learn its methods of inquiry and practice.
Nursing theories, by setting directions for the
substance and methods of inquiry for the dis-
cipline, should provide the basis for nursing
education and the framework for organizing
nursing curricula.
Definitions of Nursing Theory
A theory is a notion or an idea that explains
experience, interprets observation, describes
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relationships, and projects outcomes. Parsons
(1949), often quoted by nursing theorists,
wrote that theories help us know what we
know and decide what we need to know. The-
ories are mental patterns or frameworks cre-
ated to help understand and create meaning
from our experience, organize and articulate
our knowing, and ask questions leading to new
insights. As such, theories are not discovered
in nature but are human inventions.
Theories are organizing structures of our re-
flections, observations, projections, and infer-
ences. Many describe theories as lenses because
they color and shape what is seen. The same
phenomena will be seen differently depending
on the theoretical perspective assumed. For
these reasons, “theory” and related terms have
been defined and described in a number of
ways according to individual experience and
what is useful at the time. Theories, as reflec-
tions of understanding, guide our actions, help
us set forth desired outcomes, and give evi-
dence of what has been achieved. A theory, by
traditional definition, is an organized, coherent
set of concepts and their relationships to each
other that offers descriptions, explanations,
and predictions about phenomena.
Early writers on nursing theory brought
definitions of theory from other disciplines to
direct future work within nursing. Dickoff and
James (1968, p. 198) defined theory as a “con-
ceptual system or framework invented for
some purpose.” Ellis (1968, p. 217) defined
theory as “a coherent set of hypothetical, con-
ceptual, and pragmatic principles forming a
general frame of reference for a field of in-
quiry.” McKay (1969, p. 394) asserted that
theories are the capstone of scientific work and
that the term refers to “logically interconnected
sets of confirmed hypotheses.” Barnum (1998,
p. 1) later offered a more open definition of
theory as a “construct that accounts for or or-
ganizes some phenomenon” and simply stated
that a nursing theory describes or explains
Definitions of theory emphasize its various
aspects. Those developed in recent years are
more open and conform to a broader concep-
tion of science. The following definitions of the-
ory are consistent with general ideas of theory
in nursing practice, education, administration,
or research:
• Theory is a set of concepts, definitions, and
propositions that project a systematic view
of phenomena by designating specific inter-
relationships among concepts for purposes
of describing, explaining, predicting, and/or
controlling phenomena (Chinn & Jacobs,
1987, p. 71).
• Theory is a creative and rigorous structuring
of ideas that projects a tentative, purposeful,
and systematic view of phenomena (Chinn
& Kramer, 2004, p. 268).
• Nursing theory is a conceptualization
of some aspect of reality (invented or
discovered) that pertains to nursing. The
conceptualization is articulated for the
purpose of describing, explaining, predict-
ing, or prescribing nursing care (Meleis,
1997, p. 12).
• Nursing theory is an inductively and/or de-
ductively derived collage of coherent, cre-
ative, and focused nursing phenomena that
frame, give meaning to, and help explain
specific and selective aspects of nursing re-
search and practice (Silva, 1997, p. 55).
• A theory is an imaginative grouping of
knowledge, ideas, and experience that are rep –
resented symbolically and seek to illuminate
a given phenomenon.” (Watson, 1985, p. 1).
The Purpose of Theory in
a Professional Discipline
All professional disciplines have a body of
knowledge consisting of theories, research, and
methods of inquiry and practice. They organize
knowledge, guide inquiry to advance science,
guide practice and enhance the care of patients.
Nursing theories addre ss the phenomena of in-
terest to nursing, human beings, health, and
caring in the context of the nurse–person rela-
tionship1. On the basis of strongly held values
and beliefs about nursing, and within con-
texts of various worldviews, theories are pat-
terns that guide the thinking about, being,
and doing of nursing.
CHAPTER 1 • Nursing Theory and the Discipline of Nursing 7
1Person refers to individual, family, group, or community.
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Theories provide structures for making
sense of the complexities of reality for both
practice and research. Research based in nurs-
ing theory is needed to explain and predict
nursing outcomes essential to the delivery of
nursing care that is both humane and cost-
effective (Gioiella, 1996). Some conceptual
structure either implicitly or explicitly directs
all avenues of nursing, including nursing edu-
cation and administration. Nursing theories
provide concepts and designs that define the
place of nursing in health care. Through
theories, nurses are offered perspectives for
relating with professionals from other disci-
plines, who join with nurses to provide
human services. Nursing has great expecta-
tions of its theories. At the same time, the-
ories must provide structure and substance
to ground the practice and scholarship of
nursing and must also be flexible and dynamic
to keep pace with the growth and changes in
the discipline and practice of nursing.
The major reason for structuring and
advancing nursing knowledge is for the sake
of nursing practice. The primary purpose
of nursing theories is to further the develop-
ment and understanding of nursing practice.
Because nursing theory exists to improve prac-
tice, the test of nursing theory is a test of its
usefulness in professional practice (Colley,
2003; Fitzpatrick, 1997). The work of nursing
theory is moving from academia into the
realm of nursing practice. Chapters in the re-
maining sections of this book highlight the
use of nursing theories in nursing practice.
Nursing practice is both the source and the
goal of nursing theory. From the viewpoint of
practice, Gray and Forsstrom (1991) suggested
that theory provides nurses with different ways
of looking at and assessing phenomena, ratio-
nales for their practice, and criteria for evalu-
ating outcomes. Many of the theories in this
book have been used to guide nursing practice,
stimulate creative thinking, facilitate commu-
nication, and clarify purposes and processes in
practice. The practicing nurse has an ethical re-
sponsibility to use the discipline’s theoretical
knowledge base, just as it is the nurse scholar’s
ethical responsibility to develop the knowledge
base specific to nursing practice (Cody, 1997,
2003). Engagement in practice generates the
ideas that lead to the development of nursing
At the empirical level of theory, abstract
concepts are operationalized, or made concrete,
for practice and research (Fawcett, 2000; Smith
& Liehr, 2013). Empirical indicators provide
specific examples of how the theory is experi-
enced in reality; they are important for bringing
theoretical knowledge to the practice level.
These indicators include procedures, tools, and
instruments to determine the effects of nursing
practice and are essential to research and man-
agement of outcomes of practice (Jennings &
Staggers, 1998). The resulting data form the
basis for improving the quality of nursing care
and influencing health-care policy. Empirical
indicators, grounded carefully in nursing con-
cepts, provide clear demonstration of the utility
of nursing theory in practice, research, admin-
istration, and other nursing endeavors (Allison
& McLaughlin-Renpenning, 1999; Hart &
Foster, 1998).
Meeting the challenges of systems of care
delivery and interprofessional work demands
practice from a theoretical perspective. Nurs-
ing’s disciplinary focus is important within
the interprofessional health-care environment
(Allison & McLaughlin-Renpenning, 1999);
otherwise, its unique contribution to the in-
terprofessional team is unclear. Nursing ac-
tions reflect nursing concepts from a nursing
perspective. Careful, reflective, and critical
thinking are the hallmarks of expert nursing,
and nursing theories should undergird these
processes. Appreciation and use of nursing
theory offer opportunities for successful col-
laboration with colleagues from other disci-
plines and provide definition for nursing’s
overall contribution to health care. Nurses
must know what they are doing, why they are
doing it, and what the range of outcomes of
nursing may be, as well as indicators for doc-
umenting nursing’s effects. These theoretical
frameworks serve as powerful guides for ar-
ticulating, reporting, and recording nursing
thought and action.
One of the assertions referred to most often
in the nursing-theory literature is that theory is
born of nursing practice and, after examination
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and refinement through research, must be re-
turned to practice (Dickoff, James, & Wieden-
bach, 1968). Nursing theory is stimulated by
questions and curiosities arising from nursing
practice. Development of nursing knowledge
is a result of theory-based nursing inquiry. The
circle continues as data, conclusions, and rec-
ommendations of nursing research are evalu-
ated and developed for use in practice. Nursing
theory must be seen as practical and useful to
practice, and the insights of practice must in
turn continue to enrich nursing theory.
The Evolution of
Nursing Science
Disciplines can be classified as belonging to
the sciences or humanities. In any science,
there is a search for an understanding about
specified phenomena through creating some
organizing frameworks (theories) about the
nature of those phenomena. These organizing
frameworks (theories) are evaluated for their
empirical accuracy through research. So sci-
ence is composed of theories developed and
tested through research (Smith, 1994).
The evolution of nursing as a science has
occurred within the past 70 years; however,
before nursing became a discipline or field
of study, it was a healing art. Throughout
the world, nursing emerged as a healing min-
istry to those who were ill or in need of sup-
port. Knowledge about caring for the sick,
injured, and those birthing, dying, or expe-
riencing normal developmental transitions
was handed down, frequently in oral tradi-
tions, and comprised folk remedies and prac-
tices that were found to be effective through
a process of trial and error. In most societies,
the responsibility for nursing fell to women,
members of religious orders, or those with
spiritual authority in the community. With
the ascendency of science, those who were
engaged in the vocations of healing lost their
authority over healing to medicine. Tradi-
tional approaches to healing were marginal-
ized, as the germ theory and the development
of pharmaceuticals and surgical procedures
were legitimized because of their grounding
in science.
Although there were healers from other
countries who can be acknowledged for their
importance to the history of nursing, Florence
Nightingale holds the title of the “mother of
modern nursing” and the person responsible
for setting Western nursing on a path toward
scientific advancement. She not only defined
nursing as “putting the person in the best con-
dition for nature to act,” she also established a
phenomenological focus of nursing as caring
for and about the human–environment rela-
tionship to health. While nursing soldiers dur-
ing the Crimean War, Nightingale began to
study the distribution of disease by gathering
data, so she was arguably the first nurse-scientist
in that she established a rudimentary theory
and tested that theory through her practice and
Nightingale schools were established in the
West at the turn of the 20th century, but
Nightingale’s influence on the nursing profes-
sion waned as student nurses in hospital-based
training schools were taught nursing primarily
by physicians. Nursing became strongly influ-
enced by the “medical model” and for some
time lost its identity as a distinct profession.
Slowly, nursing education moved into in-
stitutions of higher learning where students
were taught by nurses with higher degrees. By
1936, 66 colleges and universities had bac-
calaureate programs (Peplau, 1987). Graduate
programs began in the 1940s and grew signifi-
cantly from the 50s through the 1970s.
The publication of the journal Nursing Re-
search in 1952 was a milestone, signifying the
birth of nursing as a fledgling science (Peplau,
1987). But well into the 1940s, “many text-
books for nurses, often written by physicians,
clergy or psychologists, reminded nurses that
theory was too much for them, that nurses did
not need to think but rather merely to follow
rules, be obedient, be compassionate, do their
‘duty’ and carry out medical orders” (Peplau,
1987, p. 18). We’ve come a long way in a mere
70 years.
The development of nursing curricula stim-
ulated discussion about the nature of nursing
as distinct from medicine. In the 1950s, early
nursing scholars such as Hildegard Peplau,
Virginia Henderson, Dorothy Johnson, and
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Lydia Hall established the distinct character-
istics of nursing as a profession and field
of study. Faye Abdellah, Ida Jean Orlando,
Joyce Travelbee, Ernestine Wiedenbach, Myra
Levine, and Imogene King followed during
the 1960s, elaborating their conceptualizations
of nursing. During the early 1960s, the federally-
funded Nurse Scientist Program was initiated
to educate nurses in pursuit of doctoral degrees
in the basic sciences. Through this program
nurses received doctorates in education, soci-
ology, physiology, and psychology. These grad-
uates brought the scientific traditions of these
disciplines into nursing as they assumed faculty
positions in schools of nursing.
By the 1970s, nursing theory development
became a priority for the profession and the
discipline of nursing was becoming estab-
lished. Martha Rogers, Callista Roy, Dorothea
Orem, Betty Newman, and Josephine Pater-
son and Loraine Zderad published their theo-
ries and graduate students began studying and
advancing these theories through research.
During this time, the National League for
Nursing required a theory-based curriculum as
a standard for accreditation, so schools of nurs-
ing were expected to select, develop, and im-
plement a conceptual framework for their
curricula. This propelled the advancement of
theoretical thinking in nursing. (Meleis, 1992).
A national conference on nursing theory and
the Nursing Theory Think Tanks were formed
to engage nursing leaders in dialogue about the
place of theory in the evolution of nursing sci-
ence. The linkages between theory, research,
and philosophy were debated in the literature,
and Advances in Nursing Science, the premiere
journal for publishing theoretical articles, was
In the 1980s additional grand theories such
as Parse’s man-living-health (later changed
to human becoming); Newman’s health as
expanding consciousness; Leininger’s tran-
scultural nursing; Erickson, Tomlinson, and
Swain’s modeling and role modeling; and
Watson’s transpersonal caring were dissemi-
nated. Nursing theory conferences were con-
vened, frequently attracting large numbers of
participants. Those scholars working with the
published theories in research and practice
formalized networks into organizations and
held conferences. For example the Society for
Rogerian Scholars held the first Rogerian
Conference; the Transcultural Nursing Society
was formed, and the International Association
for Human Caring was formed. Some of these
organizations developed journals publishing
the work of scholars advancing these concep-
tual models and grand theories. Metatheorists
such as Jacqueline Fawcett, Peggy Chinn, and
Joyce Fitzpatrick and Ann Whall published
books on nursing theory, making nursing
theories more accessible to students. Theory
courses were established in graduate programs
in nursing. The Fuld Foundation supported a
series of videotaped interviews of many theo-
rists, and the National League for Nursing dis-
seminated videos promoting theory within
nursing. Nursing Science Quarterly, a journal
focused exclusively on advancing extant nurs-
ing theories, published its first issue in 1988.
During the 1990s, the expansion of con-
ceptual models and grand theories in nursing
continued to deepen, and forces within nurs-
ing both promoted and inhibited this expan-
sion. The theorists and their students began
conducting research and developing practice
models that made the theories more visible.
Regulatory bodies in Canada required that
every hospital be guided by some nursing the-
ory. This accelerated the development of nurs-
ing theory–guided practice within Canada and
the United States. The accrediting bodies of
nursing programs pulled back on their require-
ment of a specified conceptual framework
guiding nursing curricula. Because of this,
there were fewer programs guided by specific
conceptualizations of nursing, and possibly
fewer students had a strong grounding in the
theoretical foundations of nursing. Fewer
grand theories emerged; only Boykin and
Schoenhofer’s nursing as caring grand theory
was published during this time. Middle-range
theories emerged to provide more descriptive,
explanatory, and predictive models around
circumscribed phenomena of interest to nurs-
ing. For example, Meleis’s transition theory,
Mishel’s uncertainty theory, Barrett’s power
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theory, and Pender’s health promotion model
were generating interest.
From 2000 to the present, there has been
accelerated development of middle-range the-
ories with less interest in conceptual models
and grand theories. There seems to be a de-
valuing of nursing theory; many graduate pro-
grams have eliminated their required nursing
theory courses, and baccalaureate programs
may not include the development of concep-
tualizations of nursing into their curricula. This
has the potential for creating generations of
nurses who have no comprehension of the im-
portance of theory for understanding the focus
of the discipline and the diverse, rich legacy
of nursing knowledge from these theoretical
On the other hand, health-care organiza-
tions have been more active in promoting at-
tention to theoretical applications in nursing
practice. For example, those hospitals on the
magnet journey are required to select a guiding
nursing framework for practice. Watson’s the-
ory of caring is guiding nursing practice in a
group of acute care hospitals. These hospitals
have formed a consortium so that best prac-
tices can be shared across settings.
Although nursing research is advancing and
making a difference in people’s lives, the re-
search may not be linked explicitly to theory,
and probably not linked to nursing theory. This
compromises the advancement of nursing sci-
ence. All other disciplines teach their founda-
tional theories to their students, and their
scientists test or develop their theories through
There is a trend toward valuing theories
from other disciplines over nursing theories.
For example, motivational interviewing is a
practice theory out of psychology that nurse re-
searchers and practitioners are gravitating to in
large numbers. Arguably, there are several sim-
ilar nursing theoretical approaches to engaging
others in health promotion behaviors that pre-
ceded motivational interviewing, yet these
have not been explored. Interprofessional prac-
tice and interdisciplinary research are essential
for the future of health care, but we do not do
justice to this concept by abandoning the rich,
distinguishing features of nursing science over
If nursing is to advance as a science in its
own right, future generations of nurses must re-
spect and advance the theoretical legacy of our
discipline. Scientific growth happens through
cumulative knowledge development with cur-
rent research building on previous findings. To
survive and thrive, nursing theories must be
used in nursing practice and research.
The Structure of Knowledge
in the Discipline of Nursing
Theories are part of the knowledge structure
of any discipline. The domain of inquiry (also
called the metaparadigm or focus of the disci-
pline) is the foundation of the structure. The
knowledge of the discipline is related to its
general domain or focus. For example, knowl-
edge of biology relates to the study of living
things; psychology is the study of the mind;
sociology is the study of social structures and
behaviors. Nursing’s domain was discussed
earlier and relates to the disciplinary focus
statement or metaparadigm. Other levels of
the knowledge structure include paradigms,
conceptual models or grand theories, middle-
range theories, practice theories, and research
and practice traditions. These levels of nursing
knowledge are interrelated; each level of devel-
opment is influenced by work at other levels.
Theoretical work in nursing must be dynamic;
that is, it must be continually in process and
useful for the purposes and work of the disci-
pline. It must be open to adapting and extend-
ing to guide nursing endeavors and to reflect
development within nursing. Although there
is diversity of opinion among nurses about the
terms used to describe the levels of theory, the
following discussion of theoretical develop-
ment in nursing is offered as a context for
further understanding nursing theory.
Paradigm is the next level of the disciplinary
structure of nursing. The notion of paradigm can
be useful as a basis for understanding nursing
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knowledge. A paradigm is a global, general
framework made up of assumptions about
aspects of the discipline held by members to
be essential in development of the discipline.
Paradigms are particular perspectives on the
metaparadigm or disciplinary domain. The
concept of paradigm comes from the work of
Kuhn (1970, 1977), who used the term to
describe models that guide scientific activity
and knowledge development in disciplines.
Because paradigms are broad, shared perspec-
tives held by members of the discipline, they
are often called “worldviews.” Kuhn set forth
the view that science does not always evolve as
a smooth, regular, continuing path of knowl-
edge development over time, but that period-
ically there are times of revolution when
traditional thought is challenged by new ideas,
and “paradigm shifts” occur.
Kuhn’s ideas provide a way for us to think
about the development of science. Before any
discipline engages in the development of theory
and research to advance its knowledge, it is
in a preparadigmatic period of development.
Typically, this is followed by a period of time
when a single paradigm emerges to guide
knowledge development. Research activities
initiated around this paradigm advance its the-
ories. This is a time during which knowledge
advances at a regular pace. At times, a new par-
adigm can emerge to challenge the worldview
of the existing paradigm. It can be revolution-
ary, overthrowing the previous paradigm, or
multiple paradigms can coexist in a discipline,
providing different worldviews that guide the
scientific development of the discipline.
Kuhn’s work has meaning for nursing and
other scientific disciplines because of his recog-
nition that science is the work of a community
of scholars in the context of society. Paradigms
and worldviews of nursing are subtle and pow-
erful, reflecting different values and beliefs
about the nature of human beings, human–en-
vironment relationships, health, and caring.
Kuhn’s (1970, 1977) description of scientific
development is particularly relevant to nursing
today as new perspectives are being articulated,
some traditional views are being strengthened,
and some views are taking their places as part
of our history. As we continue to move away
from the historical conception of nursing as
a part of biomedical science, developments
in the nursing discipline are directed by at
least two paradigms, or worldviews, outside
the medical model. These are now described.
Several nursing scholars have named the ex-
isting paradigms in the discipline of nursing
(Fawcett, 1995; Newman et al., 1991; Parse,
1987). Parse (1987) described two paradigms:
the totality and the simultaneity. The totality
paradigm reflects a worldview that humans are
integrated beings with biological, psychological,
sociocultural, and spiritual dimensions. Humans
adapt to their environments, and health and ill-
ness are states on a continuum. In the simultane-
ity paradigm, humans are unitary, irreducible,
and in continuous mutual process with the
environment (Rogers, 1970, 1992). Health is
subjectively defined and reflects a process of
becoming or evolving. In contrast to Parse,
Newman and her colleagues (1991) identi-
fied three paradigms in nursing: particulate–
deterministic, integrative–interactive, and unitary–
transformative. From the perspective of the
particulate–deterministic paradigm, humans are
known through parts; health is the absence
of disease; and predictability and control
are essential for health management. In the
integrative–interactive paradigm, humans are
viewed as systems with interrelated dimensions
interacting with the environment, and change
is probabilistic. The worldview of the unitary–
transformative paradigm describes humans as
patterned, self-organizing fields within larger
patterned, self-organizing fields. Change
is characterized by fluctuating rhythms of
organization–disorganization toward more
complex organization. Health is a reflection of
this continuous change. Fawcett (1995, 2000)
provided yet another model of nursing para-
digms: reaction, reciprocal interaction, and si-
multaneous action. In the reaction paradigm,
humans are the sum of their parts, reaction is
causal, and stability is valued. In the reciprocal
interaction worldview, the parts are seen within
the context of a larger whole, there is a reciprocal
nature to the relationship with the environment,
and change is based on multiple factors. Finally,
the simultaneous-action worldview includes a
belief that humans are known by pattern and are
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in an open ever-changing process with the
environment. Change is unpredictable and
evolving toward greater complexity (Smith,
2008, pp. 4–5).
It may help you to think of theories being
clustered within these nursing paradigms.
Many theories share the worldview established
by a particular paradigm. At present, multiple
paradigms coexist within nursing.
Grand Theories and
Conceptual Models
Grand theories and conceptual models are at
the next level in the structure of the discipline.
They are less abstract than the focus of the dis-
cipline and paradigms but more abstract than
middle-range theories. Conceptual models and
grand theories focus on the phenomena of con-
cern to the discipline such as persons as adaptive
systems, self-care deficits, unitary human be-
ings, human becoming, or health as expanding
consciousness. The grand theories, or concep-
tual models, are composed of concepts and re-
lational statements. Relational statements on
which the theories are built are called assump-
tions and often reflect the foundational philoso-
phies of the conceptual model or grand theory.
These philosophies are statements of enduring
values and beliefs; they may be practical guides
for the conduct of nurses applying the theory
and can be used to determine the compatibility
of the model or theory with personal, profes-
sional, organizational, and societal beliefs and
values. Fawcett (2000) differentiated conceptual
models and grand theories. For her, conceptual
models, also called conceptual frameworks or
conceptual systems, are sets of general concepts
and propositions that provide perspectives on
the major concepts of the metaparadigm: per-
son, environment, health, and nursing. Fawcett
(1993, 2000) pointed out that direction for re-
search must be described as part of the concep-
tual model to guide development and testing of
nursing theories. We do not differentiate be-
tween conceptual models and grand theories
and use the terms interchangeably.
Middle-Range Theories
Middle-range theories comprise the next level
in the structure of the discipline. Robert Merton
(1968) described this level of theory in the field
of sociology, stating that they are theories
broad enough to be useful in complex situa-
tions and appropriate for empirical testing.
Nursing scholars proposed using this level of
theory because of the difficulty in testing grand
theory (Jacox, 1974). Middle-range theories
are narrower in scope than grand theories and
offer an effective bridge between grand theo-
ries and the description and explanation of
specific nursing phenomena. They present con-
cepts and propositions at a lower level of ab-
straction and hold great promise for increasing
theory-based research and nursing practice
strategies (Smith & Liehr, 2008). Several
middle-range theories are included in this
book. Middle-range theories may have their
foundations in a particular paradigmatic per-
spective or may be derived from a grand theory
or conceptual model. The literature presents a
growing number of middle-range theories.
This level of theory is expanding most rapidly
in the discipline and represents some of the
most exciting work published in nursing today.
Some of these new theories are synthesized
from knowledge from related disciplines and
transformed through a nursing lens (Eakes,
Burke, & Hainsworth, 1998; Lenz, Suppe,
Gift, Pugh, & Milligan, 1995; Polk, 1997).
The literature also offers middle-range nursing
theories that are directly related to grand the-
ories of nursing (Ducharme, Ricard, Duquette,
Levesque, & Lachance, 1998; Dunn, 2004;
Olson & Hanchett, 1997). Reports of nursing
theory developed at this level include implica-
tions for instrument development, theory test-
ing through research, and nursing practice
Practice-Level Theories
Practice-level theories have the most limited
scope and level of abstraction and are developed
for use within a specific range of nursing situa-
tions. Theories developed at this level have a
more direct effect on nursing practice than do
more abstract theories. Nursing practice theories
provide frameworks for nursing interventions/
activities and suggest outcomes and/or the effect
of nursing practice. Nursing actions may be
described or developed as nursing practice
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theories. Ideally, nursing practice theories are
interrelated with concepts from middle-range
theories or developed under the framework of
grand theories. A theory developed at this level
has been called a prescriptive theory (Crowley,
1968; Dickoff, James, & Wiedenbach, 1968), a
situation-specific theory (Meleis, 1997), and a
micro-theory (Chinn & Kramer, 2011). The
day-to-day experience of nurses is a major
source of nursing practice theory.
The depth and complexity of nursing
practice may be fully appreciated as nursing
phenomena and relations among aspects of
particular nursing situations are described and
explained. Dialogue with expert nurses in
practice can be fruitful for discovery and de-
velopment of practice theory. Research find-
ings on various nursing problems offer data
to develop nursing practice theories. Nursing
practice theory has been articulated using
multiple ways of knowing through reflective
practice (Johns & Freshwater, 1998). The
process includes quiet reflection on practice,
remembering and noting features of nursing
situations, attending to one’s own feelings,
reevaluating the experience, and integrating
new knowing with other experience (Gray
& Forsstrom, 1991). The LIGHT model
(Andersen & Smereck, 1989) and the atten-
dant nurse caring model (Watson & Foster,
2003) are examples of the development of
practice level theories.
Associated Research and
Practice Traditions
Research traditions are the associated meth-
ods, procedures, and empirical indicators that
guide inquiry related to the theory. For exam-
ple, the theories of health as expanding con-
sciousness, human becoming, and cultural care
diversity and universality have specific associ-
ated research methods. Other theories have
specific tools that have been developed to
measure constructs related to the theories. The
practice tradition of the theory consists of the
activities, protocols, processes, tools, and prac-
tice wisdom emerging from the theory. Several
conceptual models and grand theories have
specific associated practice methods.
Nursing Theory and the Future
Nursing theory is essential to the continuing
evolution of the discipline of nursing. Several
trends are evident in the development and use
of nursing theory. First, there seems to be
more agreement on the focus of the discipline
of nursing that provides a meaningful direction
for our study and inquiry. This disciplinary di-
alogue has extended beyond the confines of
Fawcett’s metaparadigm and explicates the im-
portance of caring and relationship as central
to the discipline of nursing (Newman et al.,
2008; Roy & Jones, 2007; Willis et al., 2008).
The development of new grand theories and
conceptual models has decreased. Dossey’s
(2008) theory of integral nursing, included in
this book, is the only new theory at this level
that has been developed in nearly 20 years. In-
stead, the growth in theory development is at
the middle-range and practice levels. There has
been a significant increase in middle-range
theories, and many practice scholars are work-
ing on developing and implementing practice
models based on grand theories or conceptual
Several changes in the teaching and learning
of nursing theory are troubling. Many bac-
calaureate programs include little nursing the-
ory in their curricula. Similarly, some graduate
programs are eliminating or decreasing their
emphasis on nursing theory. This alarming
trend deserves our attention. If nursing is to
continue to thrive and to make a difference
in the lives of people, our practitioners and
researchers need to practice and expand knowl-
edge within the structure of the discipline.
As health care becomes more interprofessional,
the focus of nursing becomes even more im-
portant. If nurses do not learn and practice
based on the knowledge of their discipline, they
may be co-opted into the practice of another
discipline. Even worse, another discipline could
emerge that will assume practices associated
with the discipline of nursing. For example,
health coaching is emerging as an area of prac-
tice focused on providing people with help
as they make health-related changes in their
lives. However, this is the practice of nursing,
as articulated by many nursing theories.
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On a positive note, nursing theories are
being embraced by health-care organizations
to structure nursing practice. For example,
organizations embarking on the journey to-
ward magnet status (www.nursecredentialing
.org/magnet) are required to identify a theo-
retical perspective that guides nursing practice,
and many are choosing existing nursing mod-
els. This work has great potential to refine and
extend nursing theories.
The use of nursing theory in research is in-
consistent at best. Often, outcomes research
is not contextualized within any theoretical
perspective; however, reviewers of proposals
for most funding agencies request theoretical
frameworks, and scoring criteria give points for
having one. This encourages theoretical think-
ing and organizing findings within a broader
perspective. Nurses often use theories from
other disciplines instead of their own and this
expands the knowledge of another discipline.
We are hopeful about the growth, continu-
ing development, and expanded use of nursing
theory. We hope that there will be continued
growth in the development of all levels of nurs-
ing theory. The students of all professional dis-
ciplines study the theories of their disciplines
in their courses of study. We must continue to
include the study of nursing theories within our
baccalaureate, master’s, and doctoral programs.
Baccalaureate students need to understand the
foundations for the discipline, our historical de-
velopment, and the place of nursing theory in
its history and future. They should learn about
conceptual models and grand theories. Didactic
and practice courses should reflect theoretical
values and concepts so that students learn to
practice nursing from a theoretical perspective.
Middle-range theories should be included in
the study of particular phenomena such as self-
transcendence, sorrow, and uncertainty. As they
prepare to become practice leaders of the disci-
pline, doctor of nursing practice students should
learn to develop and test nursing theory-guided
models. PhD students will learn to develop and
extend nursing theories in their research. New
and expanded nursing specialties, such as nurs-
ing informatics, call for development and use
of nursing theory (Effken, 2003). New, more
open and inclusive ways to theorize about nurs-
ing will be developed. These new ways will ac-
knowledge the history and traditions of nursing
but will move nursing forward into new realms
of thinking and being. Reed (1995) noted
the “ground shifting” with the reforming of
philosophies of nursing science and called for
a more open philosophy, grounded in nursing’s
values, which connects science, philosophy, and
practice. Gray and Pratt (1991, p. 454) pro-
jected that nursing scholars will continue to de-
velop theories at all levels of abstraction and
that theories will be increasingly interdepend-
ent with other disciplines such as politics, eco-
nomics, and ethics. These authors expect a
continuing emphasis on unifying theory and
practice that will contribute to the validation of
the nursing discipline. Theorists will work in
groups to develop knowledge in an area of con-
cern to nursing, and these phenomena of inter-
est, rather than the name of the author, will
define the theory (Meleis, 1992). Newman
(2003) called for a future in which we transcend
competition and boundaries that have been
constructed between nursing theories and in-
stead appreciate the links among theories, thus
moving toward a fuller, more inclusive, and
richer understanding of nursing knowledge.
Nursing’s philosophies and theories must
increasingly reflect nursing’s values for under-
standing, respect, and commitment to health
beliefs and practices of cultures throughout
the world. It is important to question to what
extent theories developed and used in one
major culture are appropriate for use in other
cultures. To what extent must nursing theory
be relevant in multicultural contexts? Despite
efforts of many international scholarly soci-
eties, how relevant are American nursing the-
ories for the global community? Can nursing
theories inform us about how to stand with
and learn from peoples of the world? Can we
learn from nursing theory how to come to
know those we nurse, how to be with them, to
truly listen and hear? Can these questions be
recognized as appropriate for scholarly work
and practice for graduate students in nursing?
Will these issues offer direction for studies
of doctoral students? If so, nursing theory
CHAPTER 1 • Nursing Theory and the Discipline of Nursing 15
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will prepare nurses for humane leadership in
national and global health policy. Perspec-
tives of various times and worlds in relation to
present nursing concerns were described by
Schoenhofer (1994). Abdellah (McAuliffe,
1998) proposed an international electronic
“think tank” for nurses around the globe to di-
alogue about nursing theory. Such opportuni-
ties could lead nurses to truly listen, learn, and
adapt theoretical perspectives to accommodate
cultural variations.
16 SECTION I • An Introduction to Nursing Theory
■ Summary
This chapter focused on the place of nursing
theory within the discipline of nursing. The re-
lationship and importance of nursing theory
to the characteristics of a professional disci-
pline were reviewed. A variety of definitions of
theory were offered, and the evolution and
structure of knowledge in the discipline was
outlined. Finally, we reviewed trends and spec-
ulated about the future of nursing theory de-
velopment and application. One challenge of
nursing theory is that theory is always in the
process of developing and that, at the same
time, it is useful for the purposes and work of
the discipline. This paradox may be seen as
ambiguous or as full of possibilities. Continu-
ing students of the discipline are required to
study and know the basis for their contribu-
tions to nursing and to those we serve; at the
same time, they must be open to new ways
of thinking, knowing, and being in nursing.
Exploring structures of nursing knowledge and
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McAuliffe, M. (1998). Interview with Faye G. Abdellah
on nursing research and health policy. Image: Journal
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McKay, R. (1969). Theories, models and systems for
nursing. Nursing Research, 18(5), 393–399.
Meleis, A. (1992). Directions for nursing theory develop-
ment in the 21st century. Nursing Science Quarterly, 5,
Meleis, A. (1997). Theoretical nursing: Development and
progress. Philadelphia: Lippincott.
Meleis, A. (2012). Theoretical nursing: Development and
progress (5th ed.). Philadelphia: Lippincott, Williams
and Wilkins.
Merton, R. (1968). Social theory and social structure.
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A perspective for nurses and other health professionals.
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18 SECTION I • An Introduction to Nursing Theory
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Chapter 2A Guide for the Study of
Nursing Theories for Practice
Study of Theory for Nursing Practice
A Guide for Study of Nursing Theory for
Use in Practice
Marlaine C. SmithMarilyn E. Parker
Nursing is a professional discipline, a field of
study focused on human health and healing
through caring (Smith, 1994). The knowledge
of the discipline includes nursing science, art,
philosophy, and ethics. Nursing science in-
cludes the conceptual models, theories, and re-
search specific to the discipline. As in other
sciences such as biology, psychology, or soci-
ology, the study of nursing science requires a
disciplined approach. This chapter offers a
guide to this disciplined approach in the form
of a set of questions that facilitate reflection,
exploration, and a deeper study of the selected
nursing theories.
As you read the chapters in this book, use
the questions in the guide to facilitate 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 pub-
lished articles related to the use of the theories
in practice and research. This book’s online re-
sources can provide 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. Health-care 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
1For additional information please go to bonus chapter
content available at FA Davis
3312_Ch02_019-022 26/12/14 10:04 AM Page 19

by the American Nurses Credentialing Cen-
ter ( in-
cludes the selection of a theoretical model for
practice. The list of questions in this chapter
can be useful to nurses as they select theories
to guide practice.
Increasingly, nurses are practicing in diverse
settings and often develop organized nursing
practices through which accessible health care
to communities can be provided. Community
members may be active participants in select-
ing, designing, and evaluating the nursing
they receive. In these situations, it is important
for nurses and the communities they serve to
identify the approach to nursing that is most
consistent with the community’s values. The
questions in this chapter can be helpful in the
mutual exploration of theoretical approaches
to practice.
In the current health-care environment, in-
terprofessional practice is the desired standard.
This does not mean that practicing from a
nursing-theoretical base is any less important.
Interprofessional practice means that each dis-
cipline brings its own lens or perspective to the
patient care situation. Nursing’s lens is essen-
tial for a complete picture of the person’s
health and for the goals of caring and healing.
The nursing theory selected will provide this
lens, and the questions in this chapter can as-
sist nurses in selecting the theory or theories
that will guide their unique contribution to the
interprofessional team.
Theories and practices from a variety of dis-
ciplines inform the practice of nursing. The
scope of nursing practice is continually being
expanded to include additional knowledge
and skills from related disciplines, such as
medicine and psychology. Again, this does
not diminish the need for practice based on a
nursing theory, and these guiding questions
help to differentiate the knowledge and prac-
tice of nursing from those of other disciplines.
For example, nurse practitioners may draw on
their knowledge of pathophysiology, pharma-
cology, and psychology as they provide primary
care. Nursing theories will guide the way of
viewing the person,2 inform the way of relating
with the person, and direct the goals of prac-
tice with the person.
Groups of nurses working together as col-
leagues to provide care often realize that they
share the same values and beliefs about nurs-
ing. The study of nursing theories can clarify
the purposes of nursing and facilitate build-
ing a cohesive practice to meet them. Re-
gardless of the setting of nursing practice,
nurses may choose to study nursing theories
together to design and articulate theory-
guided practice.
The study of nursing theory precedes the
activities of analysis and evaluation. The eval-
uation of a theory involves preparation, judg-
ment, and justification (Smith, 2013). In the
preparation phase, the student of the theory
spends time coming to know it by reading and
reflecting on it. The best approach involves
intellectual empathy, curiosity, honesty, and
responsibility (Smith, 2013). Through reading
and dwelling with the theory, the student tries
to understand it from the point of view of the
theorist. Curiosity leads to raising questions in
the quest for greater understanding. It involves
imagining ways the theory might work in prac-
tice, as well as the challenges it might present.
Honesty involves knowing oneself and being
true to one’s own values and beliefs in the
process of understanding. Some theories may
resonate with deeply held values; others may
conflict with them. It is important to listen to
these inner messages of comfort or discomfort,
for they will be important in the selection of
theories for practice.
Each member of a professional discipline
has a responsibility to take the time and put in
the effort to understand the theories of that dis-
cipline. In nursing, there is an even greater re-
sponsibility to understand and be true to those
that are selected to guide nursing practice.
Responses to questions offered and points
summarized in the guides may be found in
nursing literature, as well as in audiovisual
and electronic resources. Primary source ma-
terial, including the work of nurses who are
recognized authorities in specific nursing the-
ories and the use of nursing theory, should
be used.
20 SECTION I • An Introduction to Nursing Theory
2“Person” refers to individual, family, groups and com-
munities throughout the chapter.
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Study of Theory for Nursing
Four main questions (described in the next
section) have been developed and refined to
facilitate the study of nursing theories for use
in nursing practice (Parker, 1993). They focus
on concepts within the theories, as well as on
points of interest and general information
about each theory. This guide was developed
for use by practicing nurses and students in un-
dergraduate and graduate nursing education
programs. Many nurses and students have used
these questions and contributed to their con-
tinuing development. As you study each the-
ory, answer the questions and address the
points in the following guide. You will find the
information you need in the chapters of this
book; other literature, such as books and jour-
nal articles authored by the theorists and other
scholars working with the theories; and audio-
visual and electronic resources.
A Guide for Study of Nursing
Theory for Use in Practice
1. How is nursing conceptualized in the
Is the focus of nursing stated?
• What does the nurse attend to when
practicing nursing?
• What guides nursing observations,
reflections, decisions, and actions?
• What illustrations or examples show
how the theory is used to guide
What is the purpose of nursing?
• What do nurses do when they are
practicing nursing based on the theory?
• What are exemplars of nursing assess-
ments, designs, plans, and evaluations?
• What indicators give evidence of the
quality of nursing practice?
• Is the richness and complexity of nursing
practice evident?
What are the boundaries or limits for nursing?
• How is nursing distinguished from other
health-related professions?
• How is nursing related to other disci-
plines and services?
• What is the place of nursing in interpro-
fessional practice?
• What is the range of nursing situations
in which the theory is useful?
How can nursing situations be described?
• What are the attributes of the recipient
of nursing care?
• What are characteristics of the nurse?
• How can interactions between the
nurse and the recipient of nursing be
• Are there environmental requirements
for the practice of nursing? If so, what
are they?
2. What is the context of the theory development?
Who is the nursing theorist as person and as nurse?
• Why did the theorist develop the
• What is the background of the theorist
as a nursing scholar?
• What central values and beliefs does the
theorist set forth?
What are major theoretical influences on this theory?
• What previous knowledge influenced
the development of this theory?
• What are the relationships between this
theory and other theories?
• What nursing-related theories and
philosophies influenced this theory?
What were major external influences on development of the
• What were the social, economic, and
political influences that informed the
• What images of nurses and nursing
influenced the development of the
• What was the status of nursing as a dis-
cipline and profession at the time of the
theory’s development?
3. Who are authoritative sources for information about
development, evaluation, and use of this theory?
Which nursing authorities speak about, write about, and use
the theory?
• What are the professional attributes of
these persons?
• What are the attributes of authorities,
and how does one become one?
• Which others can be considered
CHAPTER 2 • A Guide for the Study of Nursing Theories for Practice 21
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What major resources are authoritative sources on the theory?
• What books, articles, and audiovisual
and electronic media exist to elucidate
the theory?
• What nursing organizations share and
support work related to the theory?
• What service and academic programs are
authoritative sources for practicing and
teaching the theory?
4. How can the overall significance of the nursing theory
be described?
What is the importance of the nursing theory over time?
• What are exemplars of the theory’s use
that structure and guide individual
• How has the theory been used to guide
programs of nursing education?
• How has the theory been used to
guide nursing administration and
• How does published nursing scholarship
reflect the significance of the theory?
What is the experience of nurses who report consistent use of
the theory?
• What is the range of reports from
• Has nursing research led to further
theoretical formulations?
• Has the theory been used to develop
new nursing practices?
• Has the theory influenced the design of
methods of nursing inquiry?
• What has been the influence of the
theory on nursing and health policy?
What are projected influences of the theory on nursing’s
• How has the theory influenced the com-
munity of scholars?
• In what ways has nursing as a professional
practice been strengthened by the theory?
• What future possibilities for nursing
have been opened because of this theory?
• What will be the continuing social value
of the theory?
22 SECTION I • An Introduction to Nursing Theory
Parker, M. (1993). Patterns of nursing theories in practice.
New York: National League for Nursing.
Smith, M. C. (1994). Arriving at a philosophy of nursing:
Discovering? Constructing? Evolving? In J. Kikuchi &
H. Simmons (Eds.), Developing a philosophy of nursing
(pp. 43–60). Thousand Oaks, CA: Sage.
Smith, M. C. (2013). Evaluation of middle range theo-
ries for the discipline of nursing. In M. J. Smith
& P. Liehr (Eds.), Middle range theory for nursing
(3rd ed., pp. 3–14). New York: Springer.
■ Summary
This chapter contains a guide designed for the
study of nursing theory for use in practice. As
members of the professional discipline of nurs-
ing, nurses must engage in the serious study of
the theories of nursing. The implementation of
theory-guided practice models is important for
nursing practice in all settings. The guide pre-
sented in this chapter can lead students on a
journey from a beginning to a deeper under-
standing of nursing theory. The study of nursing
theory precedes its analysis and evaluation. Stu-
dents should approach the study of nursing the-
ory with intellectual empathy, curiosity, honesty,
and responsibility. This guide is composed of
four main questions to foster reflection and fa-
cilitate the study of nursing theory for practice.
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Chapter 3Choosing, Evaluating, and
Implementing Nursing
Theories for Practice
Significance of Nursing Theory
for Practice
Responses to Questions from Practicing
Nurses About Using Nursing Theory
Choosing a Nursing Theory to Study
A Reflective Exercise for Choosing
a Nursing Theory for Practice
Evaluation of Nursing Theory
Implementing Theory-Guided Practice
Marlaine C. SmithMarilyn E. Parker
The primary purpose of nursing theory is
to improve nursing practice and, therefore,
the health and quality of life of the persons, fam-
ilies, and communities served. Nursing theories
provide coherent ways of viewing and approach-
ing the care of persons in their environment.
When a theoretical model is used to organize
care in any setting, it strengthens the nursing
focus of care and provides consistency to the
communication and activities related to nursing
care. The development of nursing theories and
theory-guided practice models advances the dis-
cipline 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 responsibility
to study and value nursing theories, just as
nursing theory scholars must understand and
appreciate the day-to-day practice of nurses.
Nursing theory informs and guides the practice
of nursing, and 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
3312_Ch03_023-034 26/12/14 10:08 AM Page 23

of nursing benefit, and nursing service to our
clients is enhanced. There are many examples
throughout this book of how nursing theories
have been, or can be, used to guide nursing
practice. Many of the nursing theorists in this
book developed or refined their theories based
on dialogue with nurses who shared descrip-
tions of their practice. This kind of work must
continue for nursing theories to be relevant
and meaningful to the discipline.
The need to bridge the gap between nurs-
ing theory and practice is highlighted by con-
sidering the following brief encounter during
a question-and-answer period at a conference.
A nurse in practice, reflecting her experience,
asked a nurse theorist, “What is the meaning
of this theory to my practice? I’m in the real
world! I want to connect—but how can con-
nections be made between your ideas and my
reality?” The nurse theorist responded by de-
scribing the essential values and assumptions
of her theory. The nurse said, “Yes, I know
what you are talking about. I just didn’t know
I knew it, and I need help to use it in my prac-
tice” (Parker, 1993, p. 4). To remain current
in the discipline, all nurses must join in com-
munity to advance nursing knowledge in prac-
tice and must accept their obligations to
engage in the continuing study of nursing the-
ories. Today, many health-care organizations
that employ nurses adopt a nursing theory as
a guiding framework for nursing practice. This
decision provides an excellent opportunity for
nurses in practice and in administration to
study, implement, and evaluate nursing theo-
ries for use in practice. Communicating the
outcomes of this process with the community
of scholars advancing the theories is a useful
way to initiate dialogue among nurses and to
form new bridges between the theory and
practice of nursing.
The purpose of this chapter is to describe
the processes leading to implementation of
nursing theory-guided practice models. These
processes include choosing possible theories
for use in practice, analyzing and evaluating
these theories, and implementing theory-
guided practice models. The chapter begins
with responses to the questions: Why study
nursing theory? What do practicing nurses
gain from nursing theory? Then, methods of
analysis and evaluation of nursing theory set
forth in the literature are presented. Finally,
steps in implementing nursing theory in prac-
tice are described.
Significance of Nursing
Theory for Practice
Nursing practice is essential for developing,
testing, and refining nursing theory. The devel-
opment of many nursing theories has been en-
hanced by reflection and dialogue about actual
nursing situations. The everyday practice of
nursing enriches nursing theories. When nurses
think about nursing, they consider the content
and structure of the discipline of nursing. Even
if nurses do not conceptualize these elements
theoretically, their values and perspectives are
often consistent with particular nursing theo-
ries. Making these values and perspectives ex-
plicit through the use of a nursing theory results
in a more scholarly, professional practice.
Creative nursing practice is the direct
result of ongoing theory-based thinking,
decision-making, and action. Nursing prac-
tice must continue to contribute to thinking
and theorizing in nursing, just as nursing theory
must be used to advance practice.
Nursing practice and nursing theory often
reflect the same abiding values and beliefs.
Nurses in practice are guided by their values
and beliefs, as well as by knowledge. These val-
ues, beliefs, and knowledge often are reflected
in the literature about nursing’s metaparadigm,
philosophies, and theories. In addition, nurs-
ing theorists and nurses in practice think about
and work with the same phenomena, including
the person, the actions and relationships in the
nurse–person (family/community) relation-
ship, and the context of nursing. It is no won-
der that nurses often sense a connection and
familiarity with many of the concepts in nurs-
ing theories. They often say, “I knew this, but
I didn’t have the words for it.” This is another
value of nursing theory. It provides a vehicle
for us to share and communicate the important
concepts within nursing practice.
It is not possible to practice without some
theoretical frame of reference. The question is
24 SECTION I • An Introduction to Nursing Theory
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what frame of reference is being used in prac-
tice. As stated in Chapter 1, theories are ways
to organize our thinking about the complexi-
ties of any situation. Theories are lenses we se-
lect that will color the way that we view reality.
In the case of nursing, the theories we choose
to use will frame the way we think about a par-
ticular person and his or her health situation.
It will inform the ways that we approach the
person, how we relate, and what we do. Many
nurses practice according to ideas and direc-
tions from other disciplines, such as medicine,
psychology, and public health. If your approach
to a person is framed by his or her medical di-
agnosis, you are influenced by the medical
model that focuses your attention on diagnosis,
treatment, and cure. If you are thinking about
disease prevention as you work with a commu-
nity group, you are influenced by public health
theory and approaches. Although we use this
knowledge in practice, nursing theory focuses
us on the distinctive perspective of the disci-
pline, which is more than, and different from,
these approaches.
Historically, nursing practice has been
deeply rooted in the medical model, and this
model continues today. The depth and scope
of the practice of nurses who follow notions
about nursing held by other disciplines are lim-
ited to practices understood and accepted by
those disciplines. Nurses who learn to practice
from nursing perspectives are awakened to the
challenges and opportunities of practicing
nursing more fully and with a greater sense of
autonomy, respect, and satisfaction for them-
selves. Hopefully, they also provide different
and more expansive opportunities for health
and healing for those they serve. Nurses who
practice from a nursing perspective approach
clients and families in ways unique to nursing.
They ask questions, receive and process infor-
mation about needs for nursing differently, and
create nursing responses that are more holistic
and client-focused. These nurses learn to re-
frame their thinking about nursing knowledge
and practice and are then able to bring knowl-
edge from other disciplines within the context
of their practice—not to direct, their practice.
Nurses who practice from a nursing theo-
retical base see beyond immediate facts and
delivery systems; they can integrate other
health sciences and technologies as the back-
ground or context and not the essence of their
practice. Nurses who study nursing theory
realize that although no group actually owns
ideas, professional disciplines do claim a unique
perspective that defines their practice. In the
same way, no group actually owns the tech-
nologies of practice, although disciplines do
claim them for their practice. For example, be-
fore World War II, nurses rarely took blood
pressure readings and did not give intramus-
cular injections. This was not because nurses
lacked the skill, but because they did not claim
the use of these techniques within nursing
practice. Such a realization can also lead to un-
derstanding that the things nurses do that are
often called nursing are not nursing at all. The
skills and technologies used by nurses, such as
taking blood pressure readings, giving injec-
tions, and auscultating heart sounds, are actu-
ally activities that are part of the context, but
not the essence, of nursing practice. Nursing
theories provide an organizing framework that
directs nurses to the essence of their purpose
and places the use of knowledge from other
disciplines in their proper perspective.
If nursing theory is to be useful—or
practical—it must be brought into practice. At
the same time, nurses can be guided by nursing
theory in a full range of nursing situations.
Nursing theory can change nursing practice: It
provides direction for new ways of being pres-
ent with clients, helps nurses realize ways of
expressing caring, and provides approaches to
understanding needs for nursing and designing
care to address these needs. The chapters of
this book affirm the use of nursing theory in
practice and the study and assessment of the-
ory to ultimately use in practice.
Responses to Questions from
Practicing Nurses about Using
Nursing Theory
Study of nursing theory may either precede or
follow selection of a nursing theory for use in
nursing practice. Analysis and evaluation of
nursing theory follow the study of a nursing
CHAPTER 3 • Choosing, Evaluating, and Implementing Nursing Theories for Practice 25
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theory. These activities are demanding and
deserve the full commitment of nurses who
undertake the work. Because it is understood
that the study of nursing theory is not a simple,
short-term endeavor, nurses often question
doing such work. The following questions about
studying and using nursing theory have been
collected from many conversations with nurses
about nursing theory. These queries also identify
specific issues that are important to nurses who
consider the study of nursing theory.
My Nursing Practice
• Does this theory reflect nursing practice as
I know it? Can it be understood in relation
to my nursing practice? Will it support what
I believe to be excellent nursing practice?
Conceptual models and grand theories can
guide practice in any setting and situation.
Middle-range theories address circumscribed
phenomena in nursing that are directly related
to practice. These levels of theory can enrich
perspectives on practice and should foster an
excellent professional level of practice.
• Is the theory specific to my area of nursing?
Can the language of the theory help me ex-
plain, plan, and evaluate my nursing? Will I
be able to use the terms to communicate
with others?
• Can this theory be considered in relation to
a wide range of nursing situations? How
does it relate to more general views of
nursing people in other settings?
• Will my study and use of this theory support
nursing in my interprofessional setting?
• Will those from other disciplines be able
to understand, facilitating cooperation?
• Will my work meet the expectations of
those I serve? Will other nurses find my
work helpful and challenging?
Conceptual models and grand theories are
not specific to any nursing specialty. Theories
in any discipline introduce new terminology
that is not part of general language. For exam-
ple, the id, ego, and superego are familiar terms
in a particular psychological theory but were
unknown at the time of the theory’s introduc-
tion. The language of the theory facilitates
thinking differently through naming new con-
cepts or ideas. Members of disciplines do share
specific language that may be less familiar to
members outside the discipline. In interprofes-
sional communication, new terms should be
defined and explained to facilitate communica-
tion as needed. Nursing’s unique perspective
needs to be represented clearly within the in-
terprofessional team. The diversity of each dis-
cipline’s perspective is important to provide the
best care possible for patients. People deserve
and expect high-quality care. Nursing theory
has the potential to bring to bear the impor-
tance of relationship and caring in the process
of health and healing; the interrelationship of
the environment and health; an understanding
of the wholeness of persons in their life situa-
tions; and an appreciation of the person’s expe-
riences, values, and choices in care. These are
essential contributions to a multidisciplinary
My Personal Interests, Abilities,
and Experiences
• Is the study of nursing theories consistent
with my talents, interests, and goals? Is this
something I want to do?
• Will I be stimulated by thinking about and
trying to use this theory? Will my study of
nursing be enhanced by use of this theory?
• What will it be like to think about nursing
theory in nursing practice?
• Will my work with nursing theory be worth
the effort?
The study of nursing theory does take an in-
vestment in time and attention. It is a respon-
sibility of a professional nurse who engages in
a scholarly level of practice. Learning about
nursing theory is a conceptual activity that can
be challenging and intellectually stimulating.
We need nurses who will invest in these activ-
ities so that knowledgeable theory-guided prac-
tice is the standard in all health-care settings.
Resources and Support
• Will this be useful to me outside the
• What resources will I need to understand
fully the terms of the theory?
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• Will I be able to find the support I need to
study and use the theory in my practice?
The purpose of nursing theory goes beyond
its study within courses. Nursing theory be-
comes alive when the ideas are brought to prac-
tice. The usefulness of theory in practice is one
way that we judge its value and worth. It is
helpful to read about the theory from primary
sources or the most notable scholars and prac-
titioners who have studied the theory. Nurses
interested in particular theories can join online
discussion groups where issues related to the
theory are discussed. Many of the theory groups
have formed professional societies and hold
conferences that support lifelong learning and
growing with those applying the theory in prac-
tice, administration, research, and education.
The Theorist, Evidence, and Opinion
• Who is the author of this theory? What
background of nursing education and experi-
ence does the theorist bring to this work? Is
the author an authoritative nursing scholar?
• How is the theorist’s background of nursing
education and experience brought to this
• What is the evidence that use of the theory
may lead to improved nursing care? Has the
theory been useful to guide nursing organi-
zations and administrations? What about
influencing nursing and health-care policy?
• What is the evidence that this nursing the-
ory has led to nursing research, including
questions and methods of inquiry? Did
the theory grow out of research findings
or out of practice issues and concerns?
• Does the theory reflect the latest thinking
in nursing? Has the theory kept pace with
the times in nursing? Is this a nursing
theory for the future?
Approaching the study of nursing theory
with openness, curiosity, imagination, and
skepticism is important. Evaluation of any the-
ory should include evidence that practicing
based on the theory makes a difference in the
lives of people. Theories must have pragmatic
value; that is, they need to generate research
questions and provide models that can be ap-
plied in practice. In the nursing literature, you
will find examples of how a theory has been
used in research and in practice. In some cases,
especially with newly formed theories, this ev-
idence may be unavailable. In these situations,
you will need to imagine how the theory might
work in practice. Theories have heuristic, or
problem-solving, value in that they can lead to
new ways of thinking about situations. Con-
sider the heuristic value of the theory as you
read it. The theory should ignite your passion
about nursing.
Choosing a Nursing Theory
to Study
It is important to give adequate attention to
the selection of theories. Results of this deci-
sion will have lasting influences on your nurs-
ing practice. It is not unusual for nurses who
begin to work with nursing theory to realize
that their practice is changing and that their
future efforts in the discipline and practice of
nursing are markedly altered.
There is always some measure of hope mixed
with anxiety as nurses seriously explore nursing
theory for the first time. Individual nurses who
practice with a group of colleagues often won-
der how to select and study nursing theories.
Nurses in practice and nursing students in the-
ory courses have similar questions. Nurses in
new practice settings designed and developed
by nurses have the same concerns about getting
started as do nurses in hospital organizations
who want more from their practice.
The following exercise is grounded in the
belief that the study and use of nursing theory
in nursing practice must have roots in the
practice of the nurses involved. Moreover, the
nursing theory used by particular nurses must
reflect elements of practice that are essential
to those nurses, while at the same time bring-
ing focus and freshness to that practice. This
exercise calls on the nurse to think about the
major components of nursing and bring forth
the values and beliefs most important to
nurses. In these ways, the exercise begins to
parallel knowledge development reflected in
the nursing metaparadigm (focus of the disci-
pline) and nursing philosophies described in
Chapter 1. Throughout the rest of this book,
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the reader is guided to connect nursing theory
and nursing practice in the context of nursing
A Reflective Exercise for
Choosing a Nursing Theory
for Practice
Select a comfortable, private, and quiet place
to reflect and write. Relax by taking some
deep, slow breaths. Think about the reasons
you went into nursing in the first place. Bring
your nursing practice into focus. Consider your
practice today. Continue to reflect and, while
avoiding distractions, make notes to record
your thoughts and feelings. When you have
been thinking for a time and have taken the
opportunity to reflect on your practice, pro-
ceed with the following questions. Continue
to reflect and to make notes as you consider
each one.
Enduring Values
• What are the enduring values and beliefs
that brought me to nursing?
• What beliefs and values keep me in nursing
• What are the personal values that I hold
most dear?
• How do my personal and nursing values
connect with what is important to society?
Reflect on an instance of nursing in which
you interacted with a person, family, or com-
munity for nursing purposes. This can be a sit-
uation from your current practice or may be
from your nursing in years past. Consider the
purpose or hoped-for outcome.
Nursing Situations
• Who was this person, family, or commu-
nity? How did I come to know him, her,
or them as unique?
• What were the person’s, family’s, or com-
munity’s hopes and dreams for their own
health and healing?
• Who was I as a person in the nursing
• Who was I as a nurse in the situation?
• What was the relationship between
the person, family, or community and
• What nursing actions emerged in the
context of the relationship?
• What other nursing actions might have
been possible?
• What was the environment of the nursing
• What about the environment was impor-
tant to the person, family or community’s
hopes and dreams for health and healing
and my nursing actions?
Nursing can change when we consciously
connect values and beliefs to nursing situa-
tions. Consider that values and beliefs are the
basis for our nursing. Briefly describe the con-
nections of your values and beliefs with your
chosen nursing situation.
Connecting Values and the
Nursing Situation
• How are my values and beliefs reflected in
any nursing situation?
• Are my values and beliefs in conflict or
frustrated in this situation?
• Do my values come to life in the nursing
Cultivating Awareness
and Appreciation
In reflecting and writing about values and
nursing situations that are important to us,
we often come to a fuller awareness and ap-
preciation of our practice. Make notes about
your insights. You might consider these ini-
tial notes the beginning of a journal in which
you record your study of nursing theories and
their use in nursing practice. This is a valu-
able way to follow your progress and is a
source of nursing questions for future study.
You may want to share this process and ex-
perience with your colleagues. Sharing is a
way to explore and clarify views about nursing
and to seek and offer support for nursing val-
ues and situations that are critical to your
practice. If you are doing this exercise in a
group, share your essential values and beliefs
with your colleagues.
28 SECTION I • An Introduction to Nursing Theory
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Multiple Ways of Knowing and
Reflecting on Nursing Theory
Multiple ways of knowing are used in theory-
guided nursing practice. Carper (1978) studied
the nursing literature and described four essen-
tial patterns of knowing in nursing. Using the
Phenix (1964) model of realms of meaning,
Carper described personal, empirical, ethical,
and aesthetic ways of knowing in nursing.
Chinn and Kramer (2011) use Carper’s pat-
terns of knowing and a fifth pattern, called
emancipatory knowing, to develop an inte-
grated framework for nursing knowledge de-
velopment. Additional patterns of knowing in
nursing have been explored and described, and
the initial four patterns have been the focus
of much consideration in nursing (Boykin,
Parker, & Schoenhofer, 1994; Leight, 2002;
Munhall, 1993; Parker, 2002; Pierson, 1999;
Ruth-Sahd, 2003; Thompson, 1999; White,
1995). Each of the patterns of knowing and
its relationship to theory-guided practice are
articulated in the following paragraphs.
Empirical knowing is the most familiar of
the ways of knowing in nursing. Empirical
knowing is how we come to know the science
of nursing and other disciplines that are used
in nursing practice. This includes knowing the
actual theories, concepts, principles, and re-
search findings from nursing, pathophysiology,
pharmacology, psychology, sociology, epidemi-
ology, and other fields. Nursing theory is within
the pattern of empirical knowing. The theoret-
ical framework for practice integrates the con-
cepts, principles, laws, and facts essential for
Personal knowing is about striving to know
the self and to actualize authentic relationships
between the nurse and person. Using this pat-
tern of knowing in nursing, the client is not
seen as an object but as a person moving to-
ward fulfillment of potential (Carper, 1978).
The nurse is recognized as continuously learn-
ing and growing as a person and practitioner.
Reflecting on a person as a client and a person
as a nurse in the nursing situation can enhance
understanding of nursing practice and the cen-
trality of relationships in nursing. These in-
sights are useful for choosing and studying
nursing theory. Knowing the self is essential in
selecting a nursing theory to guide practice.
Ultimately, the choice of theoretical perspec-
tive reflects personal values and beliefs.
Ethical knowing is increasingly important to
the study and practice of nursing today. Ac-
cording to Carper (1978), ethics in nursing is
the moral component guiding choices within
the complexity of health care. Ethical knowing
informs us of what is right, what is obligatory,
and what is desirable in any nursing situation.
Ethical knowing is essential in every action of
the nurse in day-to-day practice.
Aesthetic knowing is described by Carper
(1978) as the art of nursing; it is the creative
and imaginative use of nursing knowledge in
practice (Rogers, 1988). Although nursing is
often referred to as art, this aspect of nursing
may not be as highly valued as the science and
ethics of nursing. Each nurse is an artist, ex-
pressing and interpreting the guiding theory
uniquely in his or her practice. Reflecting on
the experience of nursing is primary in under-
standing aesthetic knowing. Through such re-
flection, the nurse understands that nursing
practice has in fact been created, that each in-
stance of nursing is unique, and that outcomes
of nursing cannot be precisely predicted. Be-
sides the art of nursing, knowing through artis-
tic forms is part of aesthetic knowing. Often
human experiences and relationships can best
be appreciated and understood through art
forms such as stories, paintings, music, or po-
etry. Some assert that aesthetic knowing allows
for understanding the wholeness of experience.
Examples of this most complete knowing are
frequent in nursing situations in which even
momentary connection and genuine presence
between the nurse and the person, family, or
community is realized.
Emancipatory knowing as described by
Chinn and Kramer (2011 ) is realized in praxis,
the integration of knowing, doing and being.
Paulo Freire’s (1970) definition of praxis is si-
multaneous reflection and action intended to
transform the world. In this pattern knowing
is inseparable from action and is integral to the
being of the nurse. The transformative action
alters the power dynamics that maintain dis-
advantage for some and privilege for others,
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and is directed toward goals for social justice
(Kagan, Smith, & Chinn, 2014). The nurse
using this pattern cultivates awareness of how
social, political and economic forces shape
assumptions and opinions about knowledge
and truth. Unveiling the dynamics that sustain
inequity creates freedom to see and act in a
way that improves the health of all. Emanci-
patory knowing reminds us of the contextual
nature of knowing, and that through praxis
(reflection and action) all patterns of knowing
are integrated.
Using Insights to Choose Theory
The notes describing your experience will help
in selecting a nursing theory to study and con-
sider for guiding practice. You will want to
answer these questions:
• What nursing theory seems consistent
with the values and beliefs that guide my
• What theories are consistent with my
personal values and beliefs?
• What do I hope to achieve from the use of
nursing theory?
• Given my reflection on a nursing situation,
how can I use theory to support this descrip-
tion of my practice?
• How can I use nursing theory to improve
my practice for myself and for my patients?
Evaluation of Nursing Theory
Evaluation of nursing theory follows its study
and analysis and is the process of making a
determination about its value, worth, and sig-
nificance (Smith, 2013). There are many sets
of criteria for evaluating conceptual models
and grand theories (Chinn & Kramer, 2007;
Fawcett, 2004; Fitzpatrick & Whall, 2004;
Parse, 1987; Stevens, 1998). Smith (2013)
has published criteria for evaluating middle-
range theories. After reading and studying
the primary sources of the theory, the re-
search and practice applications of the theory,
and other critiques and evaluations of the the-
ory, it is important for the evaluator to come
to his or her own judgments supported by
logical analysis and examples from the theory.
The whole theory must be studied. Parts of
the theory without the whole will not be fully
meaningful and may lead to misunderstanding.
Before selecting a guide for theory evalua-
tion, consider the level and scope of the theory.
Is the theory a conceptual model or grand nurs-
ing theory? A middle-range nursing theory? A
practice theory? Not all aspects of theory de-
scribed in an evaluation guide will be evident
in all levels of theory. Whall (2004) recognized
this in offering particular guides for analysis
and evaluation that vary according to three
types of nursing theory: models, middle-range
theories, and practice theories. Fawcett’s (2004;
Fawcett & DeSanto-Madeya, 2012) criteria for
analysis and evaluation pertain to conceptual
models and grand theories. Smith’s (2013)
criteria specifically address the evaluation of
middle-range theories.
Theory analysis and evaluation may be
thought of as one process or as a two-step
sequence. It may be helpful to think of analy-
sis of theory as necessary for in-depth study
of a nursing theory and evaluation of theory
as the assessment of a theory’s significance,
structure, and utility. Guides for theory eval-
uation are intended as tools to inform us
about theories and to encourage further
development, refinement, and use of theory.
No guide for theory analysis and evaluation
is adequate and appropriate for every nursing
Johnson (1974) wrote about three basic cri-
teria to guide evaluation of nursing theory.
These have continued in use over time and
offer direction today. These criteria state that
the theory should:
• Define the congruence of nursing practice
with societal expectations of nursing
decisions and actions
• Clarify the social significance of nursing,
or the effect of nursing on persons receiving
• Describe social utility, or usefulness, of the
theory in practice, research, and education
Following are summaries of the most fre-
quently used guides for theory evaluation.
These guides are components of the entire
work about nursing theory of the individual
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nursing scholar and offer various interesting
approaches to theory evaluation. Each guide
should be studied in more detail than is offered
in this introduction and should be examined
in context of the whole work of the individual
nurse scholar.
The approach to theory evaluation set forth
by Chinn and Kramer (2011) is to use guide-
lines for describing nursing theory that are
based on their definition of theory as “a cre-
ative and rigorous structuring of ideas that
projects a tentative, purposeful, and systematic
view of phenomena” (p. 58). The guidelines
set forth questions that clarify the facts about
aspects of theory: purpose, concepts, defini-
tions, relationships and structure, and as-
sumptions. These authors suggest that the
next step in the evaluation process is critical
reflection about whether and how the nursing
theory works. Questions are posed to guide
this reflection:
• How clear is this theory?
• How simple is this theory?
• How general is this theory?
• How accessible is this theory?
• How important is this theory?
Fawcett (2004; Fawcett & DeSanto-
Madeya, 2012) developed two frameworks for
the analysis and evaluation of conceptual mod-
els and theories. The questions for analysis of
conceptual models address:
• Origins of the nursing model
• Unique focus of the nursing model
• Content of the nursing model
The questions for evaluation of conceptual
models address:
• Explication of origins
• Comprehensiveness of content
• Logical congruence
• Generation of theory
• Credibility of nursing model
The framework for analysis of grand and
middle-range theories includes:
• Theory scope
• Theory context
• Theory content
The questions for evaluation of grand and
middle-range theories address:
• Significance
• Internal consistency
• Parsimony
• Testability
• Empirical adequacy
• Pragmatic adequacy
Meleis (2011) stated that the structural
and functional components of a theory should
be studied before evaluation. The structural
components are assumptions, concepts, and
propositions of the theory. Functional com-
ponents include descriptions of the following:
focus, client, nursing, health, nurse–client
interactions, environment, nursing problems,
and interventions. After studying these dimen-
sions of the theory, critical examination of
these elements may take place, summarized
as follows:
• Relations between structure and function
of the theory, including clarity, consistency,
and simplicity
• Diagram of theory to elucidate the theory
by creating a visual representation
• Contagiousness, or adoption of the theory by
a wide variety of students, researchers, and
practitioners, as reflected in the literature
• Usefulness in practice, education, research,
and administration
• External components of personal, profes-
sional, social values, and significance
Smith (2013) developed a framework for
the evaluation of middle-range theories that
includes the following criteria:
Substantive foundation relates to meaning or
how the theory corresponds to existing
knowledge in the discipline. The questions
for evaluation ask about its fit with the
disciplinary focus of nursing; its specifica-
tion of assumptions; its substantive mean-
ing of a phenomenon; and its origins in
practice and/or research.
Structural integrity relates to the structure or
internal organization of the theory. Ques-
tions for evaluation ask about the clarity of
definitions of concepts, the consistency of
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level of abstraction, the simplicity of the
theory, and the logical representation of
relationships among concepts.
Functional adequacy refers to the ability of the
theory to be used in practice and research.
Questions are related to its applicability to
practice and client groups, the identifica-
tion of empirical indicators, the presence
of published examples of practice and re-
search using the theory and the evolution
of the theory through inquiry (p. 41 x).
Implementing Theory-Guided
Every nurse should develop a practice that is
guided by nursing theory. Most conceptual
models or grand theories have actual practice
methods or processes that can be adopted. The
scope and generality of middle-range theories
makes them less appropriate to guide nursing
practice within a unit or hospital. Instead, they
can be used to understand and respond to phe-
nomena that are encountered in nursing situa-
tions. For example, Boykin and Schoenhofer’s
Nursing as Caring theory has been adopted as
a practice model by several hospitals (Boykin,
Schoenhofer & Valentine, 2013). Reed’s middle-
range theory of self-transcendence can be used
to guide a nurse who is leading a support group
for women with breast cancer. Hospital units
or entire nursing departments may adopt a
model that guides nursing practice within their
unit or organization. The following are sugges-
tions that can facilitate this process of adoption
and implementation of theory-guided practice
within units or organizations:
Gaining administrative support. Organiza-
tional leaders need to support the initiative to
begin the process of implementing nursing
theory-guided practice. Although the impetus
to begin this initiative might not originate in
formal leadership, the organizational leaders
and managers need to be on board. If it is to
succeed, the implementation of a model for
practice requires the support of administration
at the highest levels.
Selecting the theory or model to be used in prac-
tice. The entire nursing staff should be fully
involved and invested in the process of decid-
ing on the theoretical model that will guide
practice. This can be done is several ways. An
organization’s governance structure can be
used to develop the most appropriate selection
process. As stated previously, the selection of
a nursing theory or model is based on values.
Some nursing organizations have used their
mission, values, and vision statements as a
blueprint that helps them select nursing theo-
ries that are most consistent with these values.
Another approach is to survey all nurses about
the practice models they would like to see im-
plemented. The nursing staff can then study the
top three or four in greater detail so that an in-
formed decision can be made. Staff develop-
ment can be involved in planning educational
offerings related to the models. A process of
voting or gaining consensus can be used for the
final selection.
Launching the initiative. Once the model
has been selected, the leaders (formal and in-
formal) begin to plan for its implementation.
This involves creating a timeline, planning the
phases and stages of implementation including
activities, and using all methods of communi-
cation to be sure that all are informed of these
plans. Unit champions, informal leaders who
are enthusiastic and positive about the initia-
tive, can be key to the building excitement for
the initiative. A structure to lead and manage
the implementation is essential. Consultants
who are experts in the theory itself or who
have experience in implementing the theory-
guided practice model can be very helpful.
For example, Watson’s International Caritas
Consortium1 consists of hospitals that have
experience implementing the theory in prac-
tice. New hospitals can join the consortium for
consultation and support as they launch initia-
tives. A kickoff event, such as an inspirational
presentation, can build excitement and visibility
for the initiative.
Creating a plan for evaluation. It is impor-
tant to build in a systematic plan for evaluation
of the new model from the beginning. An
evaluation study should be designed to track
32 SECTION I • An Introduction to Nursing Theory
For additional information, visit http://watsoncaring-
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process and outcome indicators. Consultation
from an evaluation researcher is essential.
For example, outcomes of nurse satisfaction,
patient satisfaction, nurse retention, and core
measures might be considered as outcomes to
be measured before and after the implementa-
tion of the model. Focus groups might be held
at intervals to identify nurses’ experiences and
attitudes related to implementation of the
Consistent and constant support and educa-
tion. As the model is implemented, a process
to support continuing learning and growth
with the theory needs to be in place. The
nurses implementing the model will have
questions and suggestions, so resident experts
should be available for this education and sup-
port. Those working with the model will grow
in their expertise, and their experiences need
to be recorded and shared with the commu-
nity of scholars advancing the theory in prac-
tice. Ways to foster staying on track must be
developed. Some hospitals have created unit
bulletin boards, newsletters, or signage to pre-
vent reverting to old behaviors and to cement
new ones. Staff members need opportunities
to dialogue about their experiences: what is
working and what is not. They need the free-
dom to develop new ways of implementing
the model so that their scholarship and cre-
ativity flourish.
Periodic feedback on outcomes and oppor-
tunities for reenergizing is essential. Planned
change involves anticipating the ebb and flow
of enthusiasm. In the stressful health-care
environment, it is important to find opportu-
nities to provide feedback on how the project
is going, to reward and celebrate the successes,
and to fan any dying embers of enthusiasm for
the project. This can be accomplished by invit-
ing study champions to attend regional or
national conferences, bringing in speakers, or
holding recognition events.
Revisioning of the theory-guided practice
model based on feedback. Any theory-guided
practice model will become richer through its
testing in practice. The nurses working with
the model will help to modify and revise the
model based on evaluation data. This revision-
ing should be done in partnership with theo-
rists and other practice scholars working with
the model.
CHAPTER 3 • Choosing, Evaluating, and Implementing Nursing Theories for Practice 33
■ Summary
This chapter focused on the important con-
nection between nursing theory and nursing
practice and the processes of choosing, eval-
uating, and implementing theory for prac-
tice. The selection of a nursing theory for
practice is based on values and beliefs, and a
reflective process can help to identify the
most important qualities of practice that
need to be present in a chosen theory. Eval-
uation of nursing theory is a judgment of its
value or worth. Several models of theory eval-
uation are available for use. Implementing a
theory-based practice model in a health-care
setting can be challenging and rewarding.
Suggestions for successful implementation
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Analysis and evaluation of practice, middle-range,
and grand theory. In J. Fitzpatrick & A. Whall
(Eds.), Conceptual models of nursing: Analysis and
application (4th ed., pp. 5–20). Stamford, CT:
Appleton & Lange.
White, J. (1995). Patterns of knowing: Review, critique
and update. Advances in Nursing Science, 17(4), 73–86.
34 SECTION I • An Introduction to Nursing Theory
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Section II
Conceptual Influences on
the Evolution of Nursing Theory
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The second section of the book has three chapters that describe conceptual in-
fluences on the development of nursing theory. Thomas Kuhn calls the stage of
scientific development before formal theories are structured the “preparadigm
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, Dr. 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 by at-
tending 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 systematic inquiry.
Her spiritual nature and vision of nursing as an art continue to influence practice
today. The emphasis on optimal healing environments in today’s health-care sys-
tems can be related to Nightingale’s ideas. The quality of the human–environment
relationship is related to health and healing.
In Chapter 5, Dr. Shirley Gordon summarized the work of Ernestine
Wiedenbach, Virginia Henderson, and Lydia Hall. Wiedenbach emphasized
the importance of reverence for life, respect for 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 the patient needed to heal or maintain health.
Lydia Hall is an inspiration to all who envision nursing as an autonomous dis-
cipline 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, written by a group of authors, focused on three nursing leaders who
described the nurse–patient relationship: Hildegard Peplau, Ida Jean Orlando, and
Joyce Travelbee. A psychiatric nurse, Peplau viewed the purpose of nursing as help-
ing the patient gain the intellectual and interpersonal competencies necessary to
heal. She articulated stages of the nurse–patient relationship, a framework for anxiety
and nursing interventions to decrease anxiety. Travelbee emphasized the human-
to-human relationship between nurse and person and spoke of the purpose of nursing
as assisting the person(s) to prevent or cope with the experience of illness and suf-
fering. Orlando described attributes of the nurse–patient relationship. She valued re-
lationship as central to the practice of nursing and was the first to describe nursing
process as identifying and responding to needs.
II Conceptual Influences on the Evolution of Nursing Theory
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Chapter 4Florence Nightingale’s Legacy
of Caring and Its Applications
Introducing the Theorist
Early Life and Education
Introducing the Theory
The Medical Milieu
The Feminist Context of Nightingale’s
Ideas About Nursing
Nightingale’s Legacy for 21st Century
Nursing Practice
Florence Nightingale
Introducing the Theorist
Florence Nightingale, the acknowledged founder
of modern nursing, remains a compelling and
transformative figure. Not a year goes by in
which new scholarship on Nightingale does
not 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 new biography of Nightingale,
Nightingales: The Extraordinary Upbringing and
Curious Life of Miss Florence Nightingale by
Gillian Gill, was published. In 2008, another
new biography, Florence Nightingale: The Mak-
ing of an Icon by Mark Bostridge, was pub-
lished. 2013 saw yet another biography, very
finely written and presented, Florence Nightingale,
Feminist by Judith Lissauer Cromwell. Squarely
in the camp of viewing Nightingale as a
“feminist”—a term that was non-existent dur-
ing the years that Nightingale was alive—it is
a fine work, told from a post-feminist perspec-
tive. Lynn McDonald’s prodigious, ambitious,
and long overdue Collected Works of Florence
Nightingale consists of 16 volumes. In 2005,
the American Nurses Association published
Florence Nightingale Today: Healing, Leader-
ship, Global Action, an ambitious casting of
Nightingale as 21st century nursing’s inspira-
tion and savior. At the time you are perusing
this chapter, it will be more than a century
since the death of Florence Nightingale in
1910 and almost 200 hundred years since her
birth on May 12 in 1820.
Nightingale transformed a “calling from
God” and an intense spirituality into a new so-
cial role for women: that of nurse. Her caring
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was a public one. “Work your true work,” she
wrote, “and you will find God within you”
(Woodham-Smith, 1983, p. 74). A reflection
on this statement appears in a well-known
quote from Notes on Nursing (Nightingale,
1859/1992): “Nature [i.e., the manifestation of
God] alone cures . . . what nursing has to
do . . . is put the patient in the best condition
for nature to act upon him” (Macrae, 1995,
p. 10). Although Nightingale never defined
human care or caring in Notes on Nursing, there
is no doubt that her life in nursing exemplified
and personified an ethos of caring. Jean Watson
(1992, p. 83), in the 1992 commemorative edi-
tion of Notes on Nursing, observed, “Although
Nightingale’s feminine-based caring-healing
model has transcended time and is prophetic for
this century’s health reform, the model is yet to
truly come of age in nursing or the health
care system.” In a reflective essay, Boykin and
Dunphy (2002) extended this thinking and
related Nightingale’s life, rooted in compassion
and caring, as an exemplar of justice making
(p. 14). Justice making is understood as a mani-
festation of compassion and caring, “for it is our
actions that bring about justice” (p. 16).
This chapter reiterates Nightingale’s life
from the years 1820 to 1860, delineating the
formative influences on her thinking and pro-
viding historical context for her ideas about
nursing as we recall them today. Part of what
follows is a well-known tale, yet it remains one
that is irresistible, casting an age-old spell on
the reader, like the flickering shadow of
Nightingale and her famous lamp in the dark
and dreary halls of the Barrack Hospital, Scu-
tari, on the outskirts of Constantinople, circa
1854 to 1856. It is a tale that carries even more
relevance for nursing practice today.
Early Life and Education
A profession, a trade, a necessary occupation,
something to fill and employ all my faculties, I
have always felt essential to me, I have always
longed for, consciously or not. . . . The first thought
I can remember, and the last, was nursing work.
(1913, p. 106)
Nightingale was born in 1820 in Florence,
Italy—the city she was named for. The
Nightingales were on an extended European
tour, begun in 1818 shortly after their mar-
riage. This was a common journey for those of
their class and wealth. Their first daughter,
Parthenope, had been born in the city of that
name in the previous year.
A legacy of humanism, liberal thinking, and
love of speculative thought was bequeathed
to Nightingale by her father. His views on the
education of women were far ahead of his time.
W. E. N., as her father, William, was called,
undertook the education of both his daughters.
Florence and her sister studied music; gram-
mar; composition; modern languages; classical
Greek and Latin; constitutional history and
Roman, Italian, German, and Turkish history;
and mathematics (Barritt, 1973).
From an early age, Florence exhibited in-
dependence of thought and action. The sketch
(Fig. 4-1) of W. E. N. and his daughters was
38 SECTION II • Conceptual Influences on the Evolution of Nursing Theory
Fig 4 • 1 A sketch of W. E. N. and his daughters
by one of his wife Fanny’s sisters, Julia Smith.
Source: Woodham-Smith (1983), p. 9, with permission of
Sir Henry Verney, Bart.
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done by Nightingale’s beloved aunt, Julia
Smith. It is Parthenope, the older sister, who
clutches her father’s hand and Florence who,
as described by her aunt, “independently
stumps along by herself” (Woodham-Smith,
1983, p. 7).
Travel also played a part in Nightingale’s
education. Eighteen years after Florence’s
birth, the Nightingales and both daughters
made an extended tour of France, Italy, and
Switzerland between the years of 1837 and
1838 and later Egypt and Greece (Sattin,
1987). From there, Nightingale visited
Germany, making her first acquaintance with
Kaiserswerth, a Protestant religious commu-
nity that contained the Institution for the
Training of Deaconesses, with a hospital
school, penitentiary, and orphanage. A Protes-
tant pastor, Theodore Fleidner, and his young
wife had established this community in 1836,
in part to provide training for women dea-
conesses (Protestant “nuns”) who wished to
nurse. Nightingale was to return there in 1851
against much family opposition to stay from
July through October, participating in a period
of “nurse’s training” (Cook, Vol. I, 1913;
Woodham-Smith, 1983).
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
Kaiserswerth training lacked in expertise it
made up for in a spirit of reverence and dedi-
cation. Florence 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, touring
hospitals and keeping notes on various institu-
tions 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 “Establishment for
Gentlewomen in Distressed Circumstances
during Illness,” located at 1 Harley Street,
London. After 6 months at Harley Street,
Nightingale wrote in a letter to her father: “I
am in the hey-day of my power” (Nightingale,
cited in Woodham-Smith, 1983, p. 77).
By October 1854, larger horizons beckoned.
Today I am 30—the age Christ began his Mis-
sion. Now no more childish things, no more vain
things, no more love, no more marriage. Now,
Lord let me think only of Thy will, what Thou
willest me to do. O, Lord, Thy will, Thy will.
1850, CITED IN WOODHAM-SMITH (1983, p. 130)
By all accounts, Nightingale was an intense
and serious child, always concerned with the
poor and the ill, mature far beyond her years.
A few months before her 17th birthday,
Nightingale recorded in a personal note dated
February 7, 1837, that she had been called to
God’s service. What that service was to be was
unknown at that point in time. This was to be the
first of four such experiences that Nightingale
The fundamental nature of her religious
convictions made her service to God, through
service to humankind, a driving force in her
life. She wrote: “The kingdom of Heaven is
within; but we must make it without”
(Nightingale, private note, cited in Woodham-
Smith, 1983).
It would take 16 long and torturous years,
from 1837 to 1853, for Nightingale to actualize
her calling to the role of nurse. This was a revo-
lutionary choice for a woman of her social stand-
ing and position, and her desire to nurse met
with vigorous family opposition for many years.
Along the way, she turned down proposals of
marriage, potentially, in her mother’s view, “bril-
liant matches,” such as that of Richard Monckton
Milnes. However, her need to serve God and to
demonstrate her caring through meaningful ac-
tivity proved stronger. She did not think that she
could be married and also do God’s will.
Calabria and Macrae (1994) noted that for
Nightingale, there was no conflict between
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science and spirituality; actually, in her view,
science is necessary for the development of a
mature concept of God. The development of
science allows for the concept of one perfect
God Who regulates the universe through uni-
versal laws as opposed to random happenings.
Nightingale referred to these laws, or the or-
ganizing principles of the universe, as
“Thoughts of God” (Macrae, 1995, p. 9). As
part of God’s plan of evolution, it was the re-
sponsibility of human beings to discover the
laws inherent in the universe and apply them
to achieve well-being. In Notes on Nursing
(1860/1969, p. 25), she wrote:
God lays down certain physical laws. Upon his car-
rying out such laws depends our responsibility (that
much abused word). . . . Yet we seem to be contin-
ually expecting that He will work a miracle—i.e.
break his own laws expressly to relieve us of respon-
Influenced by the Unitarian ideas of her
father and her extended family, as well as by
the more traditional Anglican Church she at-
tended, Nightingale remained for her entire
life a searcher of religious truth, studying a
variety of religions and reading widely. She
was a devout believer in God. Nightingale
wrote: “I believe that there is a Perfect Being,
of whose thought the universe in eternity is
the incarnation” (Calabria & Macrae, 1994,
p. 20). Dossey (1998) recast Nightingale in
the mode of “religious mystic.” However, to
Nightingale, mystical union with God was
not an end in itself but was the source of
strength and guidance for doing one’s work
in life. For Nightingale, service to God was
service to humanity (Calabria & Macrae,
1994, p. xviii).
In Nightingale’s view, nursing should be a
search for the truth; it should be a discovery of
God’s laws of healing and their proper appli-
cation. This is what she was referring to in
Notes on Nursing when she wrote about the
Laws of Health, as yet unidentified. It was the
Crimean War that provided the stage for her
to actualize these foundational beliefs, rooting
forever in her mind certain “truths.” In the
Crimea, she was drawn closer to those suffer-
ing injustice. It was in the Barracks Hospital
of Scutari that Nightingale acted justly and re-
sponded to a call for nursing from the pro-
longed cries of the British soldiers (Boykin &
Dunphy, 2002, p. 17).
I stand at the altar of those murdered men and
while I live I fight their cause.
(1951, P. 182)
Nightingale had powerful friends and had
gained prominence through her study of hos-
pitals and health matters during her travels.
When Great Britain became involved in the
Crimean War in 1854, Nightingale was en-
sconced in her first official nursing post at 1
Harley Street. Britain had joined France and
Turkey to ward off an aggressive Russian ad-
vance in the Crimea (Fig. 4-2). A successful
advance of Russia through Turkey could
threaten the peace and stability of the Euro-
pean continent.
The first actual battle of the war, the Battle
of Alma, was fought in September 1854. It
was written of that battle that it was a “glorious
and bloody victory.” The best communication
technology of the times, the telegraph, was to
have an effect on what was to follow. In previ-
ous wars, news from the battlefields trickled
home slowly. However, the telegraph enabled
war correspondents to transmit reports home
with rapid speed. The horror of the battlefields
was relayed to a concerned citizenry. Descrip-
tions of wounded men, disease, and illness
abounded. Who was to care for these men?
The French had the Sisters of Charity to care
for their sick and wounded. What were the
British to do (Goldie, 1987; Woodham-
Smith, 1951)?
The minister of war was Sidney Herbert,
Lord Herbert of Lea, who was the husband of
Liz Herbert; both were close friends of
Nightingale. Herbert had an innovative solu-
tion: appoint Miss Nightingale and charge her
to head a contingent of nurses to the Crimea
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to provide help and organization to the dete-
riorating battlefield situation. It was a brave
move on the part of Herbert. Medicine and
war were exclusively male domains. To send a
woman into these hitherto uncharted waters
was risky at best. But, as is well known,
Nightingale was no ordinary woman, and she
more than rose to the occasion. In a passionate
letter to Nightingale, requesting her to accept
this post, Herbert wrote:
Your own personal qualities, your knowledge and
your power of administration, and among greater
things, your rank and position in society, give you
advantages in such a work that no other person pos-
sesses. (Dolan, 1971, p. 2)
At the same time, such that their letters actu-
ally crossed, Nightingale wrote to Herbert, offer-
ing her services. Accompanied by 38 handpicked
CHAPTER 4 • Florence Nightingale’s Legacy of Caring and Its Applications 41
Fig 4 • 2 The Crimea and the Black Sea, 1854 to 1856. Source: Huxley, E. (1975). Designed by Manuel
Lopez Parras.
3312_Ch04_035-054 26/12/14 2:28 PM Page 41

“nurses” who had no formal training, she
arrived on November 4, 1854 to “take
charge” and did not return to England until
August 1856.
Biographer Woodham-Smith and Nightin-
gale’s own correspondence, as cited in a num-
ber of sources (Cook, 1913; Goldie, 1987;
Huxley, 1975; Summers, 1988; Vicinus &
Nergaard, 1990), paint the most vivid picture
of the experiences that Nightingale sustained
there, experiences that cemented her views on
disease and contagion, as well as her commit-
ment to an environmental approach to health
and illness:
The filth became indescribable. The men in the cor-
ridors lay on unwashed floors crawling with vermin.
As the Rev. Sidney Osborne knelt to take down
dying messages, his paper became thickly covered
with lice. There were no pillows, no blankets; the
men lay, with their heads on their boots, wrapped
in the blanket or greatcoat stiff with blood and filth
which had been their sole covering for more than a
week . . . [S]he [Miss Nightingale] estimated . . . .
there were more than 1000 men suffering from
acute diarrhea and only 20 chamber pots. . . .
[T]here was liquid filth which floated over the floor
an inch deep. Huge wooden tubs stood in the halls
and corridors for the men to use. In this filth lay the
men’s food—Miss Nightingale saw the skinned car-
cass of a sheep lie in a ward all night . . . the stench
from the hospital could be smelled outside the walls.
(Woodham-Smith, 1983)
On her arrival in the Crimea, the immedi-
ate priority of Nightingale and her small band
of nurses was not in the sphere of medical or
surgical nursing as currently known; rather,
their order of business was domestic manage-
ment. This is evidenced in the following ex-
change between Nightingale and one of her
party as they approached Constantinople: “Oh,
Miss Nightingale, when we land don’t let there
be any red-tape delays, let us get straight to
nursing the poor fellows!” Nightingale’s reply:
“The strongest will be wanted at the wash tub”
(Cook, 1913; Dolan, 1971).
Although the bulk of this work continued to
be done by orderlies after Nightingale’s arrival
(with the laundry farmed out to the soldiers’
wives), it was accomplished under Nightingale’s
eagle eye: “She insisted on the huge wooden
tubs in the wards being emptied, standing
[obstinately] by the side of each one, sometimes
for an hour at a time, never scolding, never rais-
ing her voice, until the orderlies gave way
and the tub was emptied” (Woodham-Smith,
1951, p. 116).
Nightingale set up her own extra “diet
kitchen.” Small portions, helpings of such
things as arrowroot, port wine, lemonade, rice
pudding, jelly, and beef tea, whose purpose was
to tempt and revive the appetite, were provided
to the men. It was therefore a logical sequence
from cooking to feeding, from administering
food to administering medicines. Because no
antidote to infection existed at this time, the
provision—by Nightingale and her nurses—of
cleanliness, order, encouragement to eat, feed-
ing, clean bed linen, clean bodies, and clean
wards was essential to recovery (Summers,
Mortality rates at the Barrack Hospital in
Scutari fell. In February, at Nightingale’s in-
sistence, the prime minister had sent to the
Crimea a sanitary commission to investigate
the high mortality rates. Beginning their work
in March, they described the conditions at the
Barrack Hospital as “murderous.” Setting to
work immediately, they opened the channel
through which the water supplying the hospi-
tal flowed, where a dead horse was found. The
commission cleared “556 handcarts and large
baskets full of rubbish . . . 24 dead animals and
2 dead horses buried.” In addition, they
flushed and cleansed sewers, lime-washed
walls, tore out shelves that harbored rats, and
got rid of vermin. The commission, Nightin-
gale said, “saved the British Army.” Miss
Nightingale’s anti-contagionism was sealed as
the mortality rates began showing dramatic
declines (Rosenberg, 1979).
Figure 4-3 illustrates Nightingale’s own
hand-drawn “coxcombs” (as they were referred
to), as Nightingale, always aware of the neces-
sity of documenting outcomes of care, kept
copious records of all sorts (Cook, 1913;
Rosenberg, 1979; Woodham-Smith, 1951).
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Florence Nightingale possessed moral author-
ity, so firm because it was grounded in caring
and was in a larger mission that came from her
spirituality. For Miss Nightingale, spirituality
was a much broader, more unifying concept than
that of religion. Her spirituality involved the
sense of a presence higher than humanity, the
divine intelligence that creates, sustains, and or-
ganizes the universe, and an awareness of our
inner connection to this higher reality. Through
this inner connection flows creative endeavors
and insight, a sense of purpose and direction.
For Miss Nightingale, spirituality was intrinsic
to human nature and was the deepest, most po-
tent resource for healing. In Suggestions for
Thought (Calabria & Macrae, 1994, p. 58),
Nightingale wrote that “human consciousness is
tending to become what God’s consciousness
is—to become One with the consciousness of
God.” This progression of consciousness to unity
with the divine was an evolutionary view and not
typical of either the Anglican or Unitarian views
of the time (Calabria & Macrae, 1994; Macrae,
1995; Rosenberg, 1979; Slater, 1994; Welch,
1986; Widerquist, 1992).
There were 4 miles of beds in the Barrack
Hospital at Scutari, a suburb of Constantino-
ple. A letter to the London Times dated
February 24, 1855, reported the following:
“When all the medical officers have retired for
the night and silence and darkness have settled
upon those miles of prostrate sick, she may be
observed, alone with a little lamp in her hand,
making her solitary rounds” (Kalisch &
Kalisch, 1987, p. 46).
In April 1855, after having been in Scutari
for 6 months, Florence wrote to her mother,
“[A]m in sympathy with God, fulfilling the
purpose I came into the world for” (Woodham-
Smith, 1983, p. 97). Henry Wadsworth
Longfellow authored “Santa Filomena” to
commemorate Miss Nightingale.
Lo! In That House of Misery
A lady with a lamp I see
Pass through the glimmering gloom
And flit from room to room
And slow as if in a dream of bliss
The speechless sufferer turns to kiss
Her shadow as it falls
Upon the darkening walls
As if a door in heaven should be
Opened and then closed suddenly
The vision came and went
The light shone and was spent.
A lady with a lamp shall stand
In the great history of the land
A noble type of good
Heroic womanhood (Longfellow, cited in Dolan,
1971, p. 5)
Miss Nightingale slipped home quietly, ar-
riving at Lea Hurst in Derbyshire on August
7, 1856, after 22 months in the Crimea and
after sustained illness from which she was
never to recover, after ceaseless work and after
witnessing suffering, death, and despair that
would haunt her for the remainder of her life.
Her hair was shorn; she was pale and drawn
(Fig. 4-4). She took her family by surprise. The
CHAPTER 4 • Florence Nightingale’s Legacy of Caring and Its Applications 43
Diagram Representing the Mortality in the Hospitals
at Scutari and Kulali from Oct. 1st 1854 to Sept. 30th 1855
Oct. 1 to Oct.10
Oct. 15 to Nov. 11
Nov. 12 to Dec. 9
Dec. 10 to Jan. 6, 1855
Jan. 7 to Jan. 31
Feb. 1 to Feb. 28
Feb. 25 to Mar. 17
Mar. 18 to Apr.7
Apr. 8 to Apr. 28
Apr. 29 to May 19
May 20 to June 9
June 10 to June 30
July 1 to Sept. 30, 1855
22 per 100
85 per 100
155 per 100
179 per 100
321 per 100
427 per 100
315 per 100
144 per 100
107 per 100
52 per
48 per
100 22
22 per 100
Commencement of Sanitary Improvements
Fig 4 • 3 Diagram by Florence Nightingale
showing declining mortality rates. Source:
Cohen (1981).
3312_Ch04_035-054 26/12/14 2:28 PM Page 43

next morning, a peal of the village church bells
and a prayer of Thanksgiving were, her sister
wrote, “‘all the innocent greeting’ except for
those provided by the spoils of war that had
proceeded her—a one-legged sailor boy, a
small Russian orphan, and a large puppy found
in some rocks near Balaclava. All England was
ringing with her name, but she had left her heart
on the battlefields of the Crimea and in the
graveyards of Scutari” (Huxley, 1975, p. 147).
Introducing the Theory
In watching disease, both in private homes and
public hospitals, the thing which strikes the ex-
perienced observer most forcefully is this, that the
symptoms or the sufferings generally considered
to be inevitable and incident to the disease are
very often not symptoms of the disease at all, but
of something quite different—of the want of
fresh air, or light, or of warmth, or of quiet, or
of cleanliness, or of punctuality and care in the
administration of diet, of each or of all of these.
NURSING (1860/1969, p. 8)
The Medical Milieu
To gain a better understanding of Nightin-
gale’s ideas on nursing, one must enter the par-
ticular 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; chemistry
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
understanding of disease-specificity symp-
toms. It was this shift in thought—a para-
digm shift of the first order—that gave us the
triumph of 20th-century medicine, with all
its attendant glories and concurrent sterility.
The 18th century was host to two major tra-
ditions or paradigms in the healing arts: one
based on “empirics” or “experience,” trial and
error, with an emphasis on curative remedies;
the other based on Hippocratic notions and
learning. Evidence of both these trends per-
sisted into the 19th century and can be found
in Nightingale’s philosophy.
Consistent with the philosophical nature
of her superior education (Barritt, 1973),
Nightingale, like many of the physicians of her
time, continued to emphatically disavow the
44 SECTION II • Conceptual Influences on the Evolution of Nursing Theory
Fig 4 • 4 A rare photograph of Florence taken on
her return from the Crimea. Although greatly
weakened by her illness, she refused to accept her
friends’ advice to rest, and pressed on relentlessly
with her plans to reform the army medical serv-
ices. Source: Huxley (1975), p. 139.
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reality of specific states of disease. She insisted
on a view of sickness as an “adjective,” not a
substantive noun. Sickness was not an “entity”
somehow separable from the body. Consistent
with her more holistic view, sickness was an
aspect or quality of the body as a whole. Some
physicians, as she phrased it, taught that dis-
eases were like cats and dogs, distinct species
necessarily descended from other cats and
dogs. She found such views misleading
(Nightingale, 1860/1969).
At this point in time, in the mid-19th cen-
tury, there were two competing theories re-
garding the nature and origin of disease. One
view was known as “contagionism,” postulating
that some diseases were communicable, spread
via commerce and population migration. A
strategic consequence of this explanatory model
was quarantine, and its attendant bureaucracy
aimed at shutting down commerce and trade
to keep disease away from noninfected areas.
To the new and rapidly emerging merchant
classes, quarantine represented government
interference and control (Ackernecht, 1982;
Arnstein, 1988).
The second school of thought on the nature
and origin of disease, of which Nightingale
was an ardent champion, was known as “anti-
contagionism.” It postulated that disease re-
sulted from local environmental sources and
arose out of “miasmas”—clouds of rotting filth
and matter, activated by a variety of things
such as meteorological conditions (note the
similarity to elements of water, fire, air, and
earth on humors); the filth must be eliminated
from local areas to prevent the spread of dis-
ease. Commerce and “infected” individuals
were left alone (Rosenberg, 1979).
William Farr, another Nightingale associate
and avid anti-contagionist, was Britain’s statis-
tical superintendent of the General Register
Office. Farr categorized epidemic and infec-
tious diseases as zygomatic, meaning pertaining
to or caused by the process of fermentation.
The debate as to whether fermentation was a
chemical process or a “vitalistic” one had been
raging for some time (Swazey & Reed, 1978).
The familiarity of the process of fermentation
helps to explain its appeal. Anyone who
had seen bread rise could immediately grasp
how a minute amount of some contaminating
substance could in turn “pollute” the entire at-
mosphere, the very air that was breathed. What
was at issue was the specificity of the contami-
nating substance. Nightingale, and the anti-
contagionists, endorsed the position that a
“sufficiently intense level of atmospheric con-
tamination could induce both endemic and
epidemic ills in the crowded hospital wards
[with particular configurations of environ-
mental circumstances determining which]”
(Rosenberg, 1979).
Anti-contagionism reached its peak be-
fore the political revolutions of 1848; the re-
sulting wave of conservatism and reaction
brought contagionism back into dominance,
where it remained until its reformulation into
the germ theory in the 1870s. Leaders of the
contagionists were primarily high-ranking
military physicians, politically united. These
divergent worldviews accounted in some
part for Nightingale’s clashes with the mili-
tary physicians she encountered during the
Crimean War.
Given the intellectual and social milieu in
which Nightingale was raised and educated, her
stance on contagionism seems preordained and
logically consistent (Rosenberg, 1979). Likewise,
the eclectic religious philosophy she evolved
contained attributes of the philosophy of Uni-
tarianism with the fervor of Evangelicalism, all
based on an organic view of humans as part of
nature. The treatment of disease and dysfunction
was inseparable from the nature of man as a
whole, and likewise, the environment. And all
were linked to God.
The emphasis on “atmosphere” (or “environ-
ment”) in the Nightingale model is consistent
with the views of the “anti-contagionists” of her
time. This worldview was reinforced by
Nightingale’s Crimean experiences, as well as
her liberal and progressive political thought. In
addition, she viewed all ideas as being distilled
through a distinctly moral lens (Rosenberg,
1979). As such, Nightingale was typical of a
number of her generation’s intellectuals. These
thinkers struggled to come to grips with an in-
creasingly complex and changing world order
and frequently combined a language of two dis-
parate realms of authority: the moral realm and
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the emerging scientific paradigm that has as-
sumed dominance in the 20th century. Tradi-
tional religious and moral assumptions were
garbed in a mantle of “scientific objectivity,”
often spurious at best, but more in keeping with
the increasingly rationalized and bureaucratic
society accompanying the growth of science.
The Feminist Context of
Nightingale’s Caring
I have an intellectual nature which requires sat-
isfaction and that would find it in him. I have a
passionate nature which requires satisfaction and
that would find it in him. I have a moral, an ac-
tive nature which requires satisfaction and that
would not find it in his life.
1849, CITED IN WOODHAM-SMITH (1983, p. 51)
Florence Nightingale wrote the following
tortured note upon her final refusal of Richard
Monckton Milnes’s proposal of marriage: “I
know I could not bear his life,” she wrote,
“that to be nailed to a continuation, an exag-
geration of my present life without hope of
another would be intolerable to me—that vol-
untarily to put it out of my power ever to be
able to seize the chance of forming for myself
a true and rich life would seem to be like sui-
cide” (Nightingale, personal note cited in
Woodham-Smith, 1983, p. 52). For Miss
Nightingale there was no compromise. Mar-
riage and pursuit of her “mission” were not
compatible. She chose the mission, a clear re-
pudiation of the mores of her time, which
were rooted in the time-honored role of fam-
ily and “female duty.”
The census of 1851 revealed that there were
365,159 “excess women” in England, meaning
women who were not married. These women
were viewed as redundant, as described in an
essay about the census titled “Why Are Women
Redundant?” (Widerquist, 1992, p. 52). Many
of these women had no acceptable means of
support, and Nightingale’s development of a
suitable occupation for women, that of nursing,
was a significant historical development and a
major contribution by Nightingale to women’s
plight in the 19th century. However, in other
ways, her views on women and the question of
women’s rights were quite mixed.
Notes on Nursing: What It Is and What It Is
Not (1859/1969) was written not as a manual
to teach nurses to nurse but rather to help all
women to learn how to nurse.
Nightingale believed all women required
this knowledge to take proper care of their
families during times of sickness and to pro-
mote health—specifically what Nightingale re-
ferred to as “the health of houses,” that is, the
“health” of the environment, which she es-
poused. Nursing, to her, was clearly situated
within the context of female duty.
In Ordered to Care: The Dilemma of American
Nursing, historian Susan Reverby (1987) traces
contemporary conflicts within the nursing pro-
fession back to Nightingale herself. She asserts
that Nightingale’s ideas about female duty and
authority, along with her views on disease
causality, brought about an independent
field—that of nursing—that was separate, and
in the view of Nightingale, equal, if not supe-
rior, to that of medicine. But this field was
dominated by a female hierarchy and insisted
on both deference and loyalty to the physi-
cian’s authority. Reverby (1987) sums it up as
follows: “Although Nightingale sought to free
women from the bonds of familial demand, in
her nursing model she rebound them in a new
context.” (p. 43)
Does the record support this evidence? Was
Nightingale a champion for women’s rights or
a regressive force? As noted earlier, the answer
is far from clear.
The shelter for all moral and spiritual values,
threatened by the crass commercialism that was
flourishing in the land, as well as the spirit of
critical inquiry that accompanied this age of ex-
panding scientific progress, was agreed upon:
the home. All considered this to be a “sacred
place, a Temple” (Houghton, 1957, p. 343).
And who was the head of this home? Woman.
Although the Victorian family was patriarchal
in nature in that women had virtually no eco-
nomic and/or legal rights, they nonetheless
yielded a major moral authority (Arnstein,
1988; Houghton, 1957; Perkins, 1987).
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There was hostility on the part of men as
well as some women toward women’s emanci-
pation. Many intelligent women—for exam-
ple, Beatrice Webb, George Eliot, and, at
times, Nightingale herself—viewed their gen-
der’s emancipation with apprehension. In
Nightingale’s case, the best word might be
“ambivalence.” There was a fear of weakening
women’s moral influence, coarsening the fem-
inine nature itself.
This stance is best equated with cultural
feminism, defined as a belief in inherent gen-
der differences. Women, in contrast to men,
are viewed as morally superior, the holders of
family values and continuity; they are refined,
delicate, and in need of protection. This
school of thought, important in the 19th cen-
tury, used arguments for women’s suffrage
such as the following: “[W]omen must make
themselves felt in the public sphere because
their moral perspective would improve cor-
rupt masculine politics.” In the case of
Nightingale, these cultural feminist attitudes
“made her impatient with the idea of women
seeking rights and activities just because men
valued these entities” (Bunting & Campbell,
1990, p. 21).
Nightingale had chafed at the limitations
and restrictions placed on women, especially
“wealthy” women with nothing to do: “What
these [women] suffer—even physically—
from the want of such work no one can tell.
The accumulation of nervous energy, which
has had nothing to do during the day, makes
them feel every night, when they go to bed,
as if they were going mad.” Despite these
vivid words, authored by Nightingale
(1852/1979) in the fiery polemic “Cassan-
dra,” which was used as a rallying cry in
many feminist circles, her view of the solu-
tion was measured. Her own resolution,
painfully arrived at, was to break from her
family and actualize her caring mission, that
of nurse. One of the many results of this was
that a useful occupation for other women to
pursue was founded. Although Nightingale
approved of this occupation outside of the
home for other women, certain other occu-
pations—that of doctor, for example—she
viewed with hostility and as inappropriate
for women. Why should these women not
be nurses or nurse midwives, a far superior
calling in Nightingale’s view than that of a
medicine “man” (Monteiro, 1984)?
Welch (1990) termed Nightingale a
“Christian feminist” on the eve of her depar-
ture to the Crimea. She returned even more
skeptical of women. Writing to her close
friend Mary Clarke Mohl, she described
women whom she worked with in the Crimea
as being incompetent and incapable of inde-
pendent thought (Welch, 1990; Woodham-
Smith, 1983). According to Palmer (1977), by
this time in her life, the concerns of the British
people and the demands of service to God took
precedence over any concern she had ever had
about women’s rights.
In other words, Nightingale, despite the
clear freedom in which she lived her own life,
nonetheless genderized the nursing role, leaving
it rooted in 19th-century morality. Nightingale
is seen constantly trying to improve the exist-
ing order and to work within that order; she
was above all a reformer, seeking to improve
the existing order, not to change the terrain
In Nightingale’s mind, the specific “scien-
tific” activity of nursing—hygiene—was the
central element in health care, without which
medicine and surgery would be ineffective:
The Life and Death, recovery or invaliding of patients
generally depends not on any great and isolated
act, but on the unremitting and thorough perform-
ance of every minute’s practical duty. (Nightingale,
This “practical duty” was the work of
women, and the conception of the proper di-
vision of labor resting on work demands inter-
nal to each respective “science,” nursing and
medicine, obscured the professional inequality.
The later successes of medical science height-
ened this inequity. The scientific grounding
espoused by Nightingale for nursing was
ephemeral at best, as later 19th-century dis-
coveries proved much of her analysis wrong,
although nonetheless powerful. Much of her
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strength was in her rhetoric; if not always log-
ically consistent, it certainly was morally reso-
nant (Rosenberg, 1979).
Despite exceptional anomalies, such as
women physicians, what Nightingale effec-
tively accomplished was a genderization of
the division of labor in health care: male
physicians and female nurses. This appears to
be a division that Nightingale supported. Be-
cause this “natural” division of labor was
rooted in the family, women’s work outside
the home ought to resemble domestic tasks
and complement the “male principle” with
the “female.” Thus, nursing was left on the
shifting sands of a soon-outmoded “science”;
the main focus of its authority grounded in
an equally shaky moral sphere, also subject to
change and devaluation in an increasingly
secularized, rationalized, and technological
20th century.
Nightingale failed to provide institution-
alized nursing with an autonomous future, on
an equal parity with medicine. She did, how-
ever, succeed in providing women’s work in
the public sphere, establishing for numerous
women an identity and source of employ-
ment. Although that public identity grew out
of women’s domestic and nurturing roles in
the family, the conditions of a modern society
required public as well as private forms of
care. It is questionable whether more could
have been achieved at that point in time
(King, 1988).
A woman, Queen Victoria, presided over
the age: “Ironically, Queen Victoria, that
panoply of family happiness and stubborn ad-
versary of female independence, could not help
but shed her aura upon single women.” The
queen’s early and lengthy widowhood, her “re-
lentlessly spreading figure and commensurately
increasing empire, her obstinate longevity
which engorged generations of men and the
collective shocks of history, lent an epic quality
to the lives of solitary women” (Auerbach,
1982, pp. 120–121). Both Nightingale and the
queen saw themselves as working through
men, yet their lives added new, unexpected,
and powerful dimensions to the myth of
Victorian womanhood, particularly that of a
woman alone and in command (Auerbach,
1982, pp. 120–121).
Nightingale’s clearly chosen spinsterhood
repudiated the Victorian family. Her unmar-
ried life provides a vision of a powerful life
lived on her own terms. This is not the spin-
sterhood of convention—one to be pitied, one
of broken hearts—but a radically new image.
She is freed from the trivia of family com-
plaints and scorns the feminist collectivity; yet
in this seemingly solitary life, she finds union
not with one man but with all men, personified
by the British soldier.
Lytton Strachey’s well-known evocation of
Nightingale, iconoclastic and bold, is perhaps
closest to the decidedly masculine imagery she
selected to describe herself, as evidenced in
this imaginary speech to her mother written
in 1852:
Well, my dear, you don’t imagine with my “talents,”
and my “European reputation” and my “beautiful let-
ters” and all that, I’m going to stay dangling around
my mother’s drawing room all my life! . . . [Y]ou must
look upon me as your vagabond son . . . I shan’t
cost you nearly as much as a son would have done,
or had I married. You must consider me married or
a son. (Woodham-Smith, 1983, p. 66)
Ideas About Nursing
Every day sanitary knowledge, or the knowledge
of nursing, or in other words, of how to put the
constitution in such a state as that it will have
no disease, or that it can recover from disease,
takes a higher place.
NURSING (1860/1969), PREFACE
Evelyn R. Barritt, professor of nursing and
Nightingale scholar, suggested that nursing
became a science when Nightingale identified
the laws of nursing, also referred to as the laws
of health, or nature (Barritt, 1973; Nightin-
gale, 1860/1969). The remainder of all nursing
theory may be viewed as mere branches and
“acorns,” all fruit of the roots of Nightingale’s
ideas. Early writings of Nightingale, compiled
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in Notes on Nursing: What It Is and What It Is
Not (1860/1969), provided the earliest system-
atic perspective for defining nursing. Accord-
ing to Nightingale, analysis and application of
universal “laws” would promote well-being and
relieve the suffering of humanity. This was the
goal of nursing.
As noted by the caring theorist Madeline
Leininger, Nightingale never defined human
care or caring in Nightingale’s Notes on Nursing
(1859/1992, p. 31), and she goes on to wonder
if Nightingale considered “components of care
such as comfort, support, nurturance, and
many other care constructs and characteristics
and how they would influence the reparative
process.” Although Nightingale’s conceptual-
izations of nursing, hygiene, the laws of health,
and the environment never explicitly identify
the construct of caring, an underlying ethos of
care and commitment to others echoes in her
words and, most importantly, resides in her ac-
tions and the drama of her life.
Nightingale did not theorize in the way to
which we are accustomed today. Patricia
Winstead-Fry (1993), in a review of the 1992
commemorative edition of Nightingale’s
Notes on Nursing (1859/1992, p. 161), states:
“Given that theory is the interrelationship of
concepts which form a system of propositions
that can be tested and used for predicting
practice, Nightingale was not a theorist.
None of her major biographers present her as
a theorist. She was a consummate politician
and health care reformer.” And our emerging
21st century has never been more in need of
nurses who are consummate politicians and
health-care reformers. Her words and ideas,
contextualized in the earlier portion of this
chapter, ring differently than those of the
other nursing theorists you will study in this
book. However, her underlying ideas con-
tinue to be relevant and, some would argue,
Lynn McDonald, Canadian professor of
sociology and editor of the Collected Works of
Florence Nightingale, a 16-volume collection,
places Nightingale among the most promi-
nent “Women Methodologists” identified in
The Women Founders of the Social Sciences
(McDonald, 1994). McDonald notes that
Nightingale was firmly committed to “a deter-
mined, probabilistic social science” and goes
on to state that “Indeed, she [Nightingale] de-
scribed the laws of social science as God’s laws
for the right operation of the world” (p. 186).
Nightingale was convinced of the necessity for
evaluative statistics to underpin rational ap-
proaches to public administrations. Consis-
tently she used the presentation of statistical
data to prove her case that the costs of disease,
crime, and excess mortality was greater than the
cost of sanitary improvements. In later life,
Nightingale endeavored to establish a chair
or readership at Oxford University to teach
Quetelet’s statistical approaches and probability
theory. In today’s world, this would translate to
a commitment to evidence-based practice as
justification for nursing’s value.
Karen Dennis and Patricia Prescott (1985)
noted that including Nightingale among the
nurse theorists has been a recent development.
They make the case that nurses today continue
to incorporate in their practice the insight,
foresight, and, most important, the clinical
acumen of Nightingale’s more than century
and a half vision of nursing. As part of a larger
study, they collected a large base of descrip-
tions from both nurses and physicians describ-
ing “good” nursing practice. More than 300
individual interviews were subjected to content
analysis; categories were named inductively
and validated separately by four members of
the project staff.
Noting no marked differences in the de-
scriptions obtained from either the nurses or
physicians, the authors report that despite
their independent derivation, the categories
that emerged during the study bore a striking
resemblance to nursing practice as described
by Nightingale: prevention of illness and pro-
motion of health, observation of the sick, and
attention to the physical environment. Also
referred to by Nightingale as the “health of
houses,” this physical environment included
ventilation of both the patient’s rooms and the
larger environment of the “house”: light,
cleanliness, and the taking of food; attention
to the interpersonal milieu, which included
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variety; and not indulging in superficialities with
the sick or giving them false encouragement.
The authors noted that “the words change
but the concepts do not” (Dennis & Prescott,
1985, p. 80). In keeping with the tradition
established by Nightingale, they noted that
nurses continue to foster an interpersonal
milieu that focuses on the person while ma-
nipulating and mediating the environment
to “put the patient in the best condition for
nature to act upon him” (Nightingale, 1860/
1969, p. 133).
Afaf I. Meleis (1997), nurse scholar, does
not compare Nightingale to contemporary
nurse theorists; nonetheless, she refers to her fre-
quently. Meleis stated that it was Nightingale’s
conceptualization of environment as the
focus of nursing activity and her de-emphasis
of pathology, emphasizing instead the “laws
of health” (which she said were yet to be
identified), that were the earliest differenti-
ation of nursing and medicine. Meleis (1997,
pp. 114–116) described Nightingale’s con-
cept of nursing as including “the proper use
of fresh air, light, warmth, cleanliness, quiet,
and the proper selection and administration
of diet, all with the least expense of vital
power to the patient.” These ideas clearly had
evolved from Nightingale’s observations and
experiences. The art of observation was iden-
tified as an important nursing function in the
Nightingale model. And this observation was
what should form the basis for nursing ideas.
Meleis speculates on how differently the the-
oretical base of nursing might have evolved
if we had continued to consider extant nurs-
ing practice as a source of ideas.
Pamela Reed and Tamara Zurakowski
(1983/1989, p. 33) called the Nightingale
model “visionary.” They stated: “At the core of
all theory development activities in nursing
today is the tradition of Florence Nightingale.”
They also suggest four major factors that influ-
enced her model of nursing: religion, science,
war, and feminism, all of which are discussed
in this chapter.
The following assumptions were identified
by Victoria Fondriest and Joan Osborne
Nightingale’s Assumptions
1. Nursing is separate from medicine.
2. Nurses should be trained.
3. The environment is important to the
health of the patient.
4. The disease process is not important to
5. Nursing should support the environment
to assist the patient in healing.
6. Research should be used through observa-
tion and empirics to define the nursing
7. Nursing is both an empirical science and
an art.
8. Nursing’s concern is with the person in
the environment.
9. The person is interacting with the
10. Sickness and wellness are governed by the
same laws of health.
11. The nurse should be observant and
The goal of nursing as described by
Nightingale is assisting the patient in his or her
retention of “vital powers” by meeting his or
her needs, and thus, putting the patient in the
best condition for nature to act upon
(Nightingale, 1860/1969). This must not be in-
terpreted as a “passive state” but rather one that
reflects the patient’s capacity for self-healing
facilitated by nurses’ ability to create an envi-
ronment conducive to health. The focus of this
nursing activity was the proper use of fresh air,
light, warmth, cleanliness, quiet, proper selec-
tion and administration of diet, monitoring the
patient’s expenditure of energy, and observing.
This activity was directed toward the environ-
ment and the patient (see Nightingale’s
Health was viewed as an additive process—
the result of environmental, physical, and psy-
chological factors, not just the absence of
disease. Disease was the reparative process of
the body to correct a problem and could pro-
vide an opportunity for spiritual growth. The
laws of health, as defined by Nightingale, were
those to do with keeping the person, and the
population, healthy. They were dependent on
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proper environmental control, for example,
sanitation. The environment was what the
nurse manipulated; it included the physical
elements external to the patient.
Nightingale isolated five environmental
components essential to an individual’s health:
clean air, pure water, efficient drainage, clean-
liness, and light.
The patient is at the center of the
Nightingale model, which incorporates a ho-
listic view of the person as someone with
psychological, intellectual, and spiritual com-
ponents. This is evidenced in her acknowl-
edgment of the importance of “variety.” For
example, she wrote of “the degree . . . to
which the nerves of the sick suffer from see-
ing the same walls, the same ceiling, the same
surroundings” (Nightingale, 1860/1969). Like-
wise, her chapter on “chattering hopes and
advice” illustrates an astute grasp of human
nature and of interpersonal relationships. She
remarked on the spiritual component of dis-
ease and illness, and she felt they could pres-
ent an opportunity for spiritual growth. In
this, all persons were viewed as equal.
A nurse was defined as any woman who
had “charge of the personal health of some-
body,” whether well, as in caring for babies
and children, or sick, as an “invalid”
(Nightingale, 1860/1969). It was assumed
that all women, at one time or another in
their lives, would nurse. Thus, all women
needed to know the laws of health. Nursing
proper, or “sick” nursing, was both an art and
a science and required organized, formal ed-
ucation to care for those suffering from dis-
ease. Above all, nursing was “service to God
in relief of man”; it was a “calling” and
“God’s work” (Barritt, 1973). Nursing activ-
ities served as an “art form” through which
spiritual development might occur (Reed &
Zurakowski, 1983/1989). All nursing actions
were guided by the nurses’ caring, which was
guided by underlying ideas about God.
Consistent with this caring base is
Nightingale’s views on nursing as an art and a
science. Again, this was a reflection of the mar-
riage, essential to Nightingale’s underlying
worldview, of science and spirituality. On the
surface, these might appear to be odd bedfel-
lows; however, this marriage flows directly
from Nightingale’s underlying religious and
philosophic views, which were operational-
ized in her nursing practice. Nightingale was
an empiricist, valuing the “science” of obser-
vation with the intent of using that knowl-
edge to better the life of humankind. The
application of that knowledge required an
artist’s skill, far greater than that of the
painter or sculptor:
Nursing is an art; and if it is to be made an art, it re-
quires as exclusive a devotion, as hard a prepara-
tion, as any painter’s or sculptor’s work; for what is
the having to do with dead canvas or cold marble,
compared with having to do with the living body—
the Temple of God’s spirit? It is one of the Fine Arts;
I had almost said, the finest of the Fine Arts. (Florence
Nightingale, cited in Donahue, 1985, p. 469)
Nightingale’s ideas about nursing health,
the environment, and the person were
grounded in experience; she regarded one’s
sense observations as the only reliable means
of obtaining and verifying knowledge. The-
ory must be reformulated if inconsistent with
empirical evidence. This experiential knowl-
edge was then to be transformed into empir-
ically based generalizations, an inductive
process, to arrive at, for example, the laws
of health. Regardless of Nightingale’s com-
mitment to empiricism and experiential
knowledge, her early education and religious
experience also shaped this emerging knowl-
edge (Hektor, 1992).
According to Nightingale’s model, nursing
contributes to the ability of persons to maintain
and restore health directly or indirectly through
managing the environment. The person has a
key role in his or her own health, and this
health is a function of the interaction among
person, nurse, and environment. However, nei-
ther the person nor the environment is dis-
cussed as influencing the nurse (Fig. 4-5).
Although it is difficult to describe the inter-
relationship of the concepts in the Nightingale
model, Figure 4-6 is a schema that attempts
to delineate this. Note the prominence of
CHAPTER 4 • Florence Nightingale’s Legacy of Caring and Its Applications 51
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52 SECTION II • Conceptual Influences on the Evolution of Nursing Theory
Health of houses
Cleanliness of rooms
Ventilation and warming
Bed and bedding
Taking food
What food?
Chattering hopes
and advices
Personal cleanliness
Petty management
Fig 4 • 5 Perspective on Nightingale’s 13 canons.
Illustration developed by V. Fondriest, RN, BSN, and
J. Osborne, RN, C BSN in October 1994.
Ventilation & warming
Health of houses (pure air, water & light)
of rooms &
Taking food
What food ?
Bed &
noise &
hopes &
Fig 4 • 6 Nightingale’s model of nursing and the environment. Illustration developed by V. Fondriest, RN, BSN,
and J. Osborne, RN, C BSN.
“observation” on the outer circle (important to
all nursing functions) and the interrelationship
of the specifics of the interventions, such as
“bed and bedding” and “cleanliness of rooms
and walls,” that go into making up the “health
of houses” (Fondriest & Osborne, 1994).
Nightingale’s Legacy for 21st
Century Nursing Practice
Philip Kalisch and Beatrice Kalisch (1987,
p. 26) described the popular and glorified im-
ages that arose out of the portrayals of Florence
Nightingale during and after the Crimean
War—that of nurse as self-sacrificing, refined,
virginal, and an “angel of mercy,” a far less
threatening image than one of educated and
skilled professional nurses. They attribute
nurses’ low pay to the perception of nursing as
a “calling,” a way of life for devoted women
with private means, such as Florence Nightingale
(Kalisch & Kalisch, 1987, p. 20). Well over
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100 years later, the amount of scholarship on
Nightingale provides a more realistic portrait
of a complex and brilliant woman. To quote
Auerbach (1982) and Strachey (1918), she was
“a demon, a rebel.”
Florence Nightingale’s legacy of caring and
the activism it implies is carried on in nursing
today. There is a resurgence and inclusion of
concepts of spirituality in current nursing
practice and a delineation of nursing’s caring
base that in essence began with the nursing
life of Florence Nightingale. Nightingale’s
caring, as demonstrated in this chapter, ex-
tended beyond the individual patient, beyond
the individual person. She herself said that the
specific business of nursing was the least im-
portant of the functions into which she had
been forced in the Crimea. Her caring encom-
passed a broadened sphere—that of the
British Army and, indeed, the entire British
Themes in contemporary nursing practice
focusing on evidence-based practice and cur-
ricula championing cultures of safety and qual-
ity are all found in the life and works of
Florence Nightingale. I would venture to say
that almost all contemporary nursing practice
settings echo some aspect of the ideas—and
ideals—of Nightingale. Themes of Nightin-
gale, the environmentalist, are critical to nurs-
ing practice for the individual, the community,
and global health. An exemplar of practice
personifying Nightingale’s approach and prac-
tice would be a larger-than-life nurse hero or
heroine championing current health-care re-
form by designing health-care systems that are
truly responsive to the needs of the populace
and that extend cross-culturally and globally.
CHAPTER 4 • Florence Nightingale’s Legacy of Caring and Its Applications 53
■ Summary
The unique aspects of Florence Nightingale’s
personality and social position, combined with
historical circumstances, laid the groundwork
for the evolution of the modern discipline of
nursing. Are the challenges and obstacles that
we face today any more daunting than what
confronted Nightingale when she arrived in
the Crimea in 1854? Nursing for Florence
Nightingale was what we might call today her
“centering force.” It allowed her to express her
spiritual values as well as enabled her to fulfill
her needs for leadership and authority. As his-
torian Susan Reverby noted, today we are chal-
lenged with the dilemma of how to practice our
integral values of caring in an unjust health-care
system that does not value caring. Let us look
again to Florence Nightingale for inspiration,
for she remains a role model par excellence on
the transformation of values of caring into an
activism that could potentially transform our
current health-care system into a more human-
istic and just one. Her activism situates her in
the context of justice making. Justice making is
understood as a manifestation of compassion
and caring, for it is actions that bring about jus-
tice (Boykin & Dunphy, 2002, p. 16). Florence
Nightingale’s legacy of connecting caring with
activism can then truly be said to continue.
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Virginia Henderson
Chapter 5Early Conceptualizations
About Nursing
Ernestine Wiedenbach, Virginia
Henderson, and Lydia Hall
Introducing the Theorists
Overview of Wiedenbach, Henderson,
and Hall’s Conceptualizations of Nursing
Practice Applications
Practice Exemplars
Ernestine Wiedenbach
Introducing the Theorists
Ernestine Wiedenbach, Virginia Henderson,
and Lydia Hall are three of the most important
influences on nursing theory development of
the 20th century. Indeed, their work continues
to ground nursing thought in the new century.
The work of each of these nurse scholars was
based on nursing practice, and today some of
this work might be referred to as practice theo-
ries. Concepts and terms they first used are
heard today around the globe.
This chapter provides a brief introduction to
Wiedenbach, Henderson, and Hall; an overview
of their nursing conceptualizations; and sections
on practice applications and practice exemplars
based on their published works. The content of
this chapter is partially based on work from
scholars who have studied or worked with these
theorists and who wrote chapters for the first,
second and/or third editions of Nursing Theories
and Nursing Practice (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
Ernestine was a child. She received a bachelor
of arts degree from Wellesley College in 1922
and graduated from Johns Hopkins School of
Nursing in 1925 (Nickel, Gesse, & MacLaren,
Lydia Hall
1For additional information please see the bonus chapter
content available at
3312_Ch05_055-066 26/12/14 2:41 PM Page 55

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 recruit-
ment of nursing students and military nurses
during World War II. At age 45, she began
her studies in nurse-midwifery. Wiedenbach’s
roles as practitioner, teacher, author, and the-
orist were consolidated as a member of the
Yale University School of Nursing, where Yale
colleagues William Dickoff and Patricia James
encouraged her development of prescriptive
theory (Dickoff, James, & Wiedenbach, 1968).
Even after her retirement in 1966, she and her
lifelong friend Caroline Falls offered informal
seminars in Miami, always reminding students
and faculty of the need for clarity of purpose,
based on reality. She even continued to use her
gift for writing to transcribe books for the
blind, including a Lamaze childbirth manual,
which she prepared on her Braille typewriter.
Ernestine Wiedenbach died in April 1998 at
age 98.
Virginia Henderson
Born in Kansas City, Missouri, in 1897, Virginia
Avenel Henderson was the fifth of eight chil-
dren. With two of her brothers serving in the
armed forces during World War I and in antic-
ipation of a critical shortage of nurses, Virginia
Henderson entered the Army School of Nursing
at Walter Reed Army Hospital. It was there
that she began to question the regimentation
of patient care and the concept of nursing as
ancillary to medicine (Henderson, 1991).
As a member of society during a war, Hen-
derson considered it a privilege to care for sick
and wounded soldiers (Henderson, 1960).
This wartime experience forever influenced
her ethical understanding of nursing and her
appreciation of the importance and complexity
of the nurse–patient relationship.
After a summer spent with the Henry Street
Visiting Nurse Agency in New York City,
Henderson began to appreciate the importance
of getting to know the patients and their envi-
ronments. She enjoyed the less formal visiting
nurse approach to patient care and became skep-
tical of the ability of hospital regimes to alter
patients’ unhealthy ways of living upon returning
home (Henderson, 1991). She entered Teachers
College at Columbia University, earning her
baccalaureate degree in 1932 and her master’s
degree in 1934. She continued at Teachers Col-
lege as an instructor and associate professor of
nursing for the next 20 years.
Virginia Henderson presented her definition
of the nature of nursing in an era when few
nurses had ventured into describing the complex
phenomena of modern nursing. Henderson
wrote about nursing the way she lived it: focus-
ing on what nurses do, how nurses function, and
nursing’s unique role in health care. Henderson
has been heralded as the greatest advocate for
nursing libraries worldwide. Of all her contribu-
tions to nursing, Virginia Henderson’s work
on the identification and control of nursing
literature is perhaps her greatest. In the 1950s,
there was an increasing interest on the part of
the profession to establish a research basis for
the nursing practice. After the completion of
her revised text in 1955, Henderson moved to
Yale University and began what would become
a distinguished career in library science research.
In 1990, the Sigma Theta Tau International
Library was named in her honor.
Lydia Hall
Lydia Hall, born in 1906, was a visionary, risk
taker, and consummate professional. She in-
spired commitment and dedication through
her unique conceptual framework.
A 1927 graduate of the York Hospital
School of Nursing in Pennsylvania, Hall held
various nursing positions during the early years
of her career. In the mid-1930s, she enrolled at
Teachers College, Columbia University, where
she earned a Bachelor of Science degree in
1937, and a Master of Arts degree in 1942. She
worked with the Visiting Nurse Service of New
York from 1941 to 1947 and was a member of
the nursing faculty at Fordham Hospital
School of Nursing from 1947 to 1950. Hall was
subsequently appointed to a faculty position at
Teachers College, where she developed and
implemented a program in nursing consulta-
tion and joined a community of nurse leaders.
At the same time, she was involved in research
activities for the U.S. Public Health Service
(Birnbach, 1988).
Hall’s most significant contribution to
nursing practice was the practice model she
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designed and put into place in the Loeb Center
for Nursing and Rehabilitation at Montefiore
Medical Center in Bronx, New York. The Loeb
Center, which opened in 1963, was the culmi-
nation of 5 years of planning and construction
under Hall’s direction in collaboration with
Dr. Martin Cherkasky.
As a visiting nurse, Hall had frequent
contact through the Montefiore home care
program. Hall and Cherkasky discovered
they shared similar philosophies regarding
health care and the delivery of quality service
(Birnbach, 1988). In 1950, Cherkasky was
appointed director of the Montefiore Medical
Center. Convalescent treatment was undergo-
ing rapid change owing largely to medical
advances, new pharmaceuticals, and techno-
logical developments. The emerging trends led
to the closing of the Solomon and Betty Loeb
Memorial Home in Westchester County, New
York, and Cherkasky and Hall convinced the
board to join with Montefiore in founding
the Loeb Center for Nursing and Rehabilita-
tion. A unique feature of the center was a
separate board of trustees that interrelated
with the Montefiore board. As a result, Hall
had considerable autonomy in developing the
center’s policies and procedures.
Hall increased the role of nurses in decision
making. For example, nurses selected patients
for the Loeb Center based on a nursing assess-
ment of an individual patient’s potential for
rehabilitation. In addition, qualified profes-
sional nurses provided direct care to patients
and coordinated needed services. Hall fre-
quently described the center as “a halfway house
on the road home” (Hall, 1963, p. 2), where
the nurse worked with the patients as active par-
ticipants in achieving desired outcomes that
were meaningful to the patients. Over time, the
effectiveness of Hall’s practice model was vali-
dated by the significant decline in the number
of readmissions among former Loeb patients
compared with those who received other types
of posthospital care (“Montefiore cuts,” 1966).
Hall died in 1969, and in 1984 she was
posthumously inducted into the American
Nurses’ Association Hall of Fame. Hall is
remembered by her colleagues as a force for
change; she successfully implemented a pro-
fessional patient-centered framework at a time
when task-oriented team nursing was the
preferred practice model in most institutions.
Overview of Wiedenbach,
Henderson, and Hall’s
Conceptualizations of Nursing
Virginia Henderson, sometimes known as the
modern-day Florence Nightingale, developed
the definition of nursing that is most well
known internationally. Ernestine Wiedenbach
gave us new ways to think about nursing prac-
tice and nursing scholarship, introducing us to
the ideas of (1) nursing as a professional prac-
tice discipline and (2) nursing practice theory.
Lydia Hall challenged us to think conceptually
about the key role of professional nursing.
Each of these nurse scholars helped us focus
on the patient, instead of on the tasks to be
done, and to plan care to meet needs of the
person. Each emphasized caring based on the
perspective of the individual being cared for—
through observing, communicating, designing,
and reporting. Each was concerned with the
unique aspects of nursing practice and schol-
arship and with the essential question of
“What is nursing?”
Wiedenbach’s Conceptualizations of
Initial work on Wiedenbach’s prescriptive theory
is presented in her article in the American Journal
of Nursing (1963) and her book Meeting the
Realities in Clinical Teaching (1969).
Her explanation of prescriptive theory is
that “Account must be taken of the motivating
factors that influence the nurse not only in
doing what she [sic] does, but also in doing
it the way she [sic] does it with the realities
that exist in the situation in which she [sic] is
functioning” (Wiedenbach, 1970, p. 2). Three
ingredients essential to the prescriptive theory
are as follows:
1. The nurse’s central purpose in nursing is
the nurse’s professional commitment. For
Wiedenbach, the central purpose in nursing is
to motivate the individual and/or facilitate
efforts to overcome the obstacles that may
interfere with the ability to respond capably
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to the demands made by the realities within
the situation (Wiedenbach, 1970, p. 4). She
emphasized that the nurse’s goals are grounded
in the nurse’s philosophy, “those beliefs and
values that shape her [sic] attitude toward
life, toward fellow human beings and toward
herself [sic].” The three concepts that epitomize
the essence of such a philosophy are (1) rever-
ence for the gift of life; (2) respect for the dig-
nity, autonomy, worth, and individuality of
each human being; and (3) resolution to act
dynamically in relation to one’s beliefs
(Wiedenbach, 1970, p. 4).
She recognized that nurses have different
values and various commitments to nurs-
ing and that to formulate one’s purpose in
nursing is a “soul-searching experience.”
She encouraged each nurse to undergo
this experience and be “willing and ready
to present your central purpose in nursing
for examination and discussion when ap-
propriate” (Wiedenbach, 1970, p. 5).
2. The prescription indicates the broad
general action that the nurse deems
appropriate to fulfillment of his or her
central purpose. The nurse will have thought
through the kind of results to be sought and
will take action to obtain these results, accept-
ing accountability for what he/she does and for
the outcomes of any action. Nursing action,
then, is deliberate action that is mutually
understood and agreed on and that is both
patient-directed and nurse-directed
(Wiedenbach, 1970, p. 5).
3. The realities are the aspects of the immediate
nursing situation that influence the results
the nurse achieves through what he or she
does (Wiedenbach, 1970, p. 3). These include
the physical, psychological, emotional, and
spiritual factors in which nursing action occurs.
Within the situation are these components:
• The agent, who is the nurse supplying the
nursing action
• The recipient, or the patient receiving
this action or on whose behalf the action
is taken
• The framework, comprising situational
factors that affect the nurse’s ability to
achieve nursing results
• The goal, or the end to be attained through
nursing activity on behalf of the patient
• The means, the actions and devices
through which the nurse is enabled to
reach the goal
Henderson’s Definition of Nursing and
Components of Basic Nursing Care
While working on the 1955 revision of the
Textbook of the Principles and Practice of Nursing,
Henderson focused on the need to be clear
about the function of nurses. She opened the
first chapter with the following questions:
What is nursing and what is the function of
the nurse? (Harmer & Henderson, 1955, p. 1).
Henderson believed these questions were fun-
damental to anyone choosing to pursue the
study and practice of nursing.
Definition of Nursing
Henderson’s often-quoted definition of nurs-
ing first appeared in the fifth edition of Text-
book of the Principles and Practice of Nursing
(Harmer & Henderson, 1955, p. 4):
Nursing is primarily assisting the individual (sick or
well) in the performance of those activities contributing
to health or its recovery (or to a peaceful death), that
he [sic] would perform unaided if he [sic] had the nec-
essary strength, will, or knowledge. It is likewise the
unique contribution of nursing to help people be in-
dependent of such assistance as soon as possible.
In presenting her definition of nursing,
Henderson hoped to encourage others to de-
velop their own working concept of nursing and
nursing’s unique function in society. She be-
lieved the definitions of the day were too general
and failed to differentiate nurses from other
members of the health team, which led to the
following questions: “What is nursing that is not
also medicine, physical therapy, social work,
etc.?” and “What is the unique function of the
nurse?” (Harmer & Henderson, 1955, p. 4).
Based on her definition and after coining
the term basic nursing care, Henderson identi-
fied 14 components of basic nursing care that
reflect needs pertaining to personal hygiene
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and healthful living, including helping the pa-
tient carry out the physician’s therapeutic plan
(Henderson, 1960; 1966, pp. 16–17):
1. Breathe normally.
2. Eat and drink adequately.
3. Eliminate bodily wastes.
4. Move and maintain desirable postures.
5. Sleep and rest.
6. Select suitable clothes—dress and undress.
7. Maintain body temperature within normal
range by adjusting clothing and modifying
the environment.
8. Keep the body clean and well groomed
and protect the integument.
9. Avoid dangers in the environment and
avoid injuring others.
10. Communicate with others in expressing
emotions, needs, fears, or opinions.
11. Worship according to one’s faith.
12. Work in such a way that there is a sense
of accomplishment.
13. Play or participate in various forms of
14. Learn, discover, or satisfy the curiosity that
leads to normal development and health
and use the available health facilities.
Hall’s Care, Cure, and Core Model
Hall enumerated three aspects of the person as
patient: the person, the body, and the disease
(Hall, 1965). She envisioned these aspects as
overlapping circles of care, core, and cure that
influence each other. It was her belief that
[e]veryone in the health professions either neglects
or takes into consideration any or all of these, but
each profession, to be a profession, must have an
exclusive area of expertness with which it practices,
creates new practices, new theories, and introduces
newcomers to its practice. (Hall, 1965, p. 4)
Hall believed that medicine’s exclusive area
of expertness was disease, which includes pathol-
ogy and treatment. The area of person, which,
according to Hall, had been sadly neglected,
belongs to a number of professions, including
psychiatry, social work, and the ministry, among
others. In contrast, she saw nursing’s expertise
as the area of the body. Hall clearly stated that
the focus of nursing is the provision of intimate
bodily care. She reflected that the public has
long recognized this as belonging exclusively to
nursing (Hall, 1958, 1964, 1965). In Hall’s
opinion, to be expert, the nurse must know how
to modify the care depending on the pathology
and treatment while considering the patient’s
unique needs and personality.
Based on her view of the person as patient,
Hall conceptualized nursing as having three
aspects, and she delineated the area that is the
specific domain of nursing and those areas that
are shared with other professions (Hall, 1955,
1958, 1964, 1965; Fig. 5-1). Hall believed that
this model reflected the nature of nursing as a
professional interpersonal process. She visual-
ized each of the three overlapping circles as an
“aspect of the nursing process related to the
patient, to the supporting sciences and to the
underlying philosophical dynamics” (Hall,
1958, p. 1). The circles overlap and change in
size as the patient progresses through a med-
ical crisis to the rehabilitative phase of the ill-
ness. In the acute care phase, the cure circle is
the largest. During the evaluation and follow-
up phase, the care circle is predominant. Hall’s
framework for nursing has been described as
the Care, Core, and Cure Model.
CHAPTER 5 • Early Conceptualizations About Nursing 59
The Person
Social sciences
Therapeutic use of self—
aspects of nursing
“The Core”
The Disease
Pathological and
therapeutic sciences
Seeing the patient and
family through the
medical care—
aspects of nursing
“The Cure”
The Body
Natural and biological
Intimate bodily care—
aspects of nursing
“The Care”
Fig 5 • 1 Care, core, and cure model. (From Hall, L.
[1964, February]. Nursing: What is it? The Canadian
Nurse, 60[2], 151. Reproduced with permission from
The Canadian Nurse.)
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Hall suggested that the part of nursing that is
concerned with intimate bodily care (e.g.,
bathing, feeding, toileting, positioning, moving,
dressing, undressing, and maintaining a health-
ful environment) belongs exclusively to nursing.
From her perspective, nursing is required when
people are not able to undertake bodily care
activities for themselves. Care provided the
opportunity for closeness and required seeing the
nursing process as an interpersonal relationship
(Hall, 1958). For Hall, the intent of bodily care
was to comfort the patient. Through comforting,
the patient as a person, as well as his or her body,
responds to the physical care. Hall cautioned
against viewing intimate bodily care as a task
that can be performed by anyone:
To make the distinction between a trade and a pro-
fession, let me say that the laying on of hands to wash
around a body is an activity, it is a trade; but if you
look behind the activity for the rationale and intent,
look beyond it for the opportunities that the activity
opens up for something more enriching in growth,
learning and healing production on the part of the pa-
tient—you have got a profession. Our intent when we
lay hands on the patient in bodily care is to comfort.
While the patient is being comforted, he [sic] feels
close to the comforting one. At this time, his [sic] per-
son talks out and acts out those things that concern
him [sic]—good, bad, and indifferent. If nothing more
is done with these, what the patient gets is ventilation
or catharsis, if you will. This may bring relief of anxiety
and tension but not necessarily learning. If the individ-
ual who is in the comforting role has in her [sic] prepa-
ration all of the sciences whose principles she [sic]
can offer a teaching-learning experience around his
[sic] concerns, the ones that are most effective in
teaching and learning, then the comforter proceeds
to something beyond—to what I call “nurturer”—
someone who fosters learning, someone who fosters
growing up emotionally, someone who even fosters
healing. (Hall, 1969, p. 86)
Hall (1958) viewed cure as being shared with
medicine and asserted that this aspect of nursing
may be viewed as the nurse assisting the doctor
by assuming medical tasks/functions or as the
nurse helping the patient through his or her
medical, surgical, and rehabilitative care in
the role of comforter and nurturer. Hall was
concerned that the nursing profession was
assuming more and more of the medical
aspects of care while at the same time relin-
quishing the nurturing process of nursing to
less well-prepared persons. She expressed this
concern by stating:
Interestingly enough, physicians do not have practical
doctors. They don’t need them . . . they have nurses.
Interesting, too, is the fact that most nurses show by
their delegation of nurturing to others, that they prefer
being second class doctors to being first class nurses.
This is the prerogative of any nurse. If she [sic] feels
better in this role, why not? One good reason why
not for more and more nurses is that with this increas-
ing trend, patients receive from professional nurses
second class doctoring; and from practical nurses,
second class nursing. Some nurses would like the
public to get first class nursing. Seeing the patient
through [his or her] medical care without giving up
the nurturing will keep the unique opportunity that per-
sonal closeness provides to further [the] patient’s
growth and rehabilitation. (Hall, 1958, p. 3)
The third area, which Hall believed nursing
shared with all of the helping professions, was
the core. Hall defined the core as using rela-
tionships for therapeutic effect. This area em-
phasized the social, emotional, spiritual, and
intellectual needs of the patient in relation to
family, institution, community, and the world
(Hall, 1955, 1958, 1965). Knowledge that is
foundational to the core is based on the social
sciences and on therapeutic use of self.
Through the closeness offered by the provision
of intimate bodily care, the patient will feel
comfortable enough to explore with the nurse
“who he [sic] is, where he [sic] is, where he [sic]
wants to go, and will take or refuse help in get-
ting there—the patient will make amazingly
more rapid progress toward recovery and reha-
bilitation” (Hall, 1958, p. 3). Hall believed that
60 SECTION II • Conceptual Influences on the Evolution of Nursing Theory
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through this process, the patient would emerge
as a whole person.
Knowledge and skills the nurse needs to use
self therapeutically include knowing self and
learning interpersonal skills. The goals of the
interpersonal process are to help patients to
understand themselves as they participate in
problem focusing and problem-solving. Hall
discussed the importance of nursing with the
patient as opposed to nursing at, to, or for the
patient. Hall reflected on the value of the ther-
apeutic use of self by the professional nurse
when she stated:
The nurse who knows self by the same token can
love and trust the patient enough to work with him
[sic] professionally, rather than for him technically,
or at him vocationally.
Her [sic] goals cease being tied up with “where can
I throw my nursing stuff around,” or “how can I explain
my nursing stuff to get the patient to do what we want
him to do,” or “how can I understand my patient so
that I can handle him better.” Instead her goals are
linked up with “what is the problem?” and “how can
I help the patient understand himself?” as he partici-
pates in problem facing and solving. In this way, the
nurse recognizes that the power to heal lies in the
patient and not in the nurse, unless she is healing
herself. She takes satisfaction and pride in her ability
to help the patient tap this source of power in his
continuous growth and development. She becomes
comfortable working cooperatively and consistently
with members of other professions, as she meshes her
contributions with theirs in a concerted program of
care and rehabilitation. (Hall, 1958, p. 5)
Hall believed that the role of professional
nursing was enacted through the provision of
care that facilitates the interpersonal process
and invites the patient to learn to reach the core
of his difficulties while seeing him through the
cure that is possible. Through the professional
nursing process, the patient has the opportu-
nity to see the illness as a learning experience
from which he or she may emerge even health-
ier than before the illness (Hall, 1965).
Practice Applications
The practice of clinical nursing is goal directed,
deliberately carried out, and patient centered.
—WIEDENBACH (1964, P. 23)
Figure 5-2 represents a spherical model that
depicts the “experiencing individual” as the
central focus (Wiedenbach, 1964). This model
and detailed charts were later edited and pub-
lished in Clinical Nursing: A Helping Art
(Wiedenbach, 1964).
In a paper titled “A Concept of Dynamic
Nursing,” Wiedenbach (1962, p. 7), described
the model as follows:
In its broadest sense, Practice of Dynamic Nursing
may be envisioned as a set of concentric circles,
with the experiencing individual in the circle at its
core. Direct service, with its three components,
identification of the individual’s experienced need
for help, ministration of help needed, and valida-
tion that the help provided fulfilled its purpose, fills
the circle adjacent to the core. The next circle holds
CHAPTER 5 • Early Conceptualizations About Nursing 61

t i
f i
t io
Exper iencing
indiv idua l
labora t ion
Nurs ing A
is t r a

Nursing Organiz
ced study

Fig 5 • 2 Professional nursing practice focus and
components. (Reprinted with permission from the
Wiedenbach Reading Room [1962], Yale University
School of Nursing.)
3312_Ch05_055-066 26/12/14 2:41 PM Page 61

the essential concomitants of direct service: coordi-
nation, i.e., charting, recording, reporting, and
conferring; consultation, i.e., conferencing, and
seeking help or advice; and collaboration, i.e., giv-
ing assistance or cooperation with members of
other professional or nonprofessional groups con-
cerned with the individual’s welfare. The content of
the fourth circle represents activities which are es-
sential to the ultimate well-being of the experiencing
individual, but only indirectly related to him [sic]:
nursing education, nursing administration, and nurs-
ing organizations. The outermost circle comprises
research in nursing, publication, and advanced
study, the key ways to progress in every area of
Application of Wiedenbach’s prescriptive
theory was evident in her practice examples and
often related to general basic nursing procedures
and to maternity nursing practice. The most
recent application of Wiedenbach’s theory in the
literature is a description by VandeVusse (1997)
of an educational project designed to guide
the nurse midwife in articulating a professional
philosophy of nursing.
Based on the assumption that nursing has a
unique function, Henderson believed that
nursing independently initiates and controls
activities related to basic nursing care. Relating
the conceptualization of basic care components
with the unique functions of nursing provided
the initial groundwork for introducing the
concept of independent nursing practice. In
her 1966 publication The Nature of Nursing,
Henderson stated:
It is my contention that the nurse is, and should be
legally, an independent practitioner and able to
make independent judgments as long as he, or she,
is not diagnosing, prescribing treatment for disease,
or making a prognosis, for these are the physician’s
functions. (Henderson, 1966, p. 22)
Furthermore, Henderson believed that func-
tions pertaining to patient care could be catego-
rized as nursing and nonnursing. She believed
that limiting nursing activities to “nursing care”
was a useful method of conserving professional
nurse power (Harmer & Henderson, 1955). She
defined nonnursing functions as those that are
not a service to the person (mind and body)
(Harmer & Henderson, 1955). For Henderson,
examples of nonnursing functions included
ordering supplies, cleaning and sterilizing equip-
ment, and serving food (Harmer & Henderson,
At the same time, Henderson was not in
favor of the practice of assigning patients to
lesser trained workers on the basis of complexity
level. For Henderson, “all ‘nursing care’ is essen-
tially complex because it involves constant adap-
tation of procedures to the needs of the
individual” (Harmer & Henderson, 1955, p. 9).
As the authority on basic nursing care,
Henderson believed that the nurse has the
responsibility to assess the needs of the indi-
vidual patient, help individuals meet their
health needs, and/or provide an environment
in which the individual can perform activities
unaided. It is the nurse’s role, according to
Henderson, “to ‘get inside the patient’s skin’
and supplement his [sic] strength, will or
knowledge according to his needs” (Harmer
& Henderson, 1955, p. 5). Conceptualizing
the nurse as a substitute for the patient’s lack
of necessary will, strength, or knowledge to
attain good health and to complete or make
the patient whole, highlights the complexity
and uniqueness of nursing.
Based on the success of Textbook of the Prin-
ciples and Practice of Nursing (fifth edition),
Henderson was asked by the International
Council of Nurses to prepare a short essay
that could be used as a guide for nursing in any
part of the world. Despite Henderson’s belief
that it was difficult to promote a universal defi-
nition of nursing, Basic Principles of Nursing
Care (Henderson, 1960) became an interna-
tional sensation. To date, it has been published
in 29 languages and is referred to as the 20th-
century equivalent of Florence Nightingale’s
Notes on Nursing. After visiting countries
worldwide, Henderson concluded that nursing
varied from country to country and that rigor-
ous attempts to define it have been unsuccess-
ful, leaving the “nature of nursing” largely an
unanswered question (Henderson, 1991).
Henderson’s definition of nursing has had a
lasting influence on the way nursing is practiced
around the globe. She was one of the first nurses
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to articulate that nursing had a unique function
yielding a valuable contribution to the health
care of individuals. In writing reflections on the
nature of nursing, Henderson (1966) stated that
her concept of nursing anticipates universally
available health care and a partnership among
doctors, nurses, and other health-care workers.
The sixth edition of Principles and Practice
of Nursing (Henderson & Nite, 1978) is
considered “the most important single profes-
sional document written in the 20th century”
(Halloran, 1996, p. 17). In this book, the syn-
thesis of nursing practice, education, theory, and
research clearly demonstrated the functions of
professional nursing practice.
Henderson was a lifelong supporter of
nursing research. In 1964, she published an
influential review of nursing research that high-
lighted the need to increase research studies
focusing on the effect of nursing practice on
patients (Simmons & Henderson, 1964). This
publication resulted in a renewed interest in
research studies that focused on the effects of
nursing on patient outcomes and the need for
research guided by nursing theory (Halloran,
1996). Most recently, Henderson’s theory has
been applied to the management of the care of
patients who donate organs after brain death and
their families (Nicely & Delario, 2011).
In 1963, Lydia Hall was able to actualize her
vision of nursing through the creation of the
Loeb Center for Nursing and Rehabilitation
at Montefiore Medical Center. The center’s
major orientation was rehabilitation and subse-
quent discharge to home or to a long-term care
institution if further care was needed. Doctors
referred patients to the center, and a professional
nurse made admission decisions. Criteria for
admission were based on the patient’s need for
rehabilitation nursing. What made the Loeb
Center unique was the model of professional
nursing that was implemented under Lydia
Hall’s guidance. The center’s guiding philosophy
was Hall’s belief that during the rehabilitation
phase of an illness experience, professional
nurses were the best prepared to foster the reha-
bilitation process, decrease complications and
recurrences, and promote health and prevent
new illnesses. Hall saw these outcomes being
accomplished by the special and unique way
nurses work with patients in a close interpersonal
process with the goal of fostering learning,
growth, and healing.
The focus of practice is the individual for whom
the nurse is caring and the way this person per-
ceives his or her condition or situation. Mrs. A
was experiencing a red vaginal discharge on her
first postpartum day. The doctor recognized it as
lochia, a normal concomitant of the phenome-
non of involution, and had left an order for her
to be up and move about. Instead of trying to get
up, Mrs. A remained immobile in her bed. The
nurse, who wanted to help her out of bed, ex-
pressed surprise at Mrs. A’s unwillingness to get
up. Mrs. A explained to the nurse that her sister
had had a red discharge the day after giving birth
2 years ago and had almost died of hemorrhage.
Therefore, to Mrs. A, a red discharge was evi-
dence of the onset of a potentially lethal hemor-
rhage. The nurse expressed her understanding of
the mother’s fear and encouraged her to compare
her current experience with that of her sister.
When the mother did this, she recognized gross
differences between her experience and that of
her sister and accepted the nurse’s explanation
that the discharge was normal. The mother
voiced her relief and validated it by getting
out of bed without further encouragement
(Wiedenbach, 1962, pp. 6–7). Wiedenbach
considered nursing a “practical phenomenon”
that involved action. She believed that this
was necessary to understand the theory that
underlies the “nurse’s way of nursing.” This
involved “knowing what the nurse wanted to ac-
complish, how she [sic] went about accomplish-
ing it, and in what context she did what she did”
(Wiedenbach, 1970, p. 1058).
Henderson’s definition of nursing and the
14 components of basic nursing care can be use-
ful in guiding the assessment and care of patients
preparing for surgical procedures. For example,
in assessing Mr. G’s preoperative vital signs,
CHAPTER 5 • Early Conceptualizations About Nursing 63
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the nurse noticed he seemed anxious. The nurse
encouraged Mr. G to express his concerns
about the surgery. Mr. G told the nurse that he
had a fear of not being able to control his body
and that he felt general anesthesia represented
the extreme limit of loss of bodily control. The
nurse recognized this concern as being directly
related to Henderson’s fourth component of
basic nursing care: Move and maintain desirable
postures. The nurse explained to Mr. G that her
role was to “perform those acts he would do for
himself if he was not under the influence of
anesthesia” (Gillette, 1996, p. 267) and that she
would be responsible for maintaining his body
in a comfortable and dignified position. She ex-
plained how he would need to be positioned dur-
ing the surgical procedure, what part of his body
would be exposed, and how long the procedure
was expected to take. Mr. G also told the nurse
about an experience he had after an earlier surgical
procedure in which he experienced pain in his
right shoulder. Mr. G expressed concern that
being in one position too long during the surgery
would damage his shoulder and result in waking
up with shoulder pain again. Together they dis-
cussed positions that would be most comfortable
for his shoulder during the upcoming procedure,
and she assured Mr. G that she would be assess-
ing his position throughout the procedure.
Hall envisioned that outcomes were accom-
plished by the special and unique way nurses
work with patients in a close interpersonal
process with the goal of fostering learning,
growth, and healing. Her work at the Loeb
Center serves as an administrative exemplar
of the application of her theory. At the Loeb
Center, nursing was the chief therapy, with
medicine and the other disciplines ancillary to
nursing. In this new model of organization of
nursing services, nursing was in charge of the
total health program for the patient and was
responsible for integrating all aspects of care.
Only registered professional nurses were hired.
The 80-bed unit was staffed with 44 professional
nurses employed around the clock. Professional
nurses gave direct patient care and teaching, and
each nurse was responsible for eight patients and
their families. Senior staff nurses were available
on each ward as resources and mentors for staff
nurses. For every two professional nurses, there
was one nonprofessional worker called a “mes-
senger-attendant.” The messenger-attendants
did not provide hands-on care to the patients.
Instead, they performed such tasks as getting
linen and supplies, thus freeing the nurse to
nurse the patient (Hall, 1964). In addition, there
were four ward secretaries. Morning and evening
shifts were staffed at the same ratio. Night-shift
staffing was less; however, Hall (1965) noted
that there were “enough nurses at night to make
rounds every hour and to nurse those patients
who are awake around the concerns that may be
keeping them awake” (p. 2). In most institutions
of that time, the number of nurses was decreased
during the evening and night shifts because it
was felt that larger numbers of nurses were
needed during the day to get the work done.
Hall took exception to the idea that nursing
service was organized around work to be done
rather than the needs of the patients.
The patient was the center of care at Loeb
and actively participated in all care decisions.
Families were free to visit at any hour of the day
or night. Rather than strict adherence to insti-
tutional routines and schedules, patients at the
Loeb Center were encouraged to maintain their
own usual patterns of daily activities, thus
promoting independence and an easier transi-
tion to home. There was no chart section labeled
“Doctor’s Orders.” Hall believed that to order a
patient to do something violated the right of
the patient to participate in his or her treatment
plan. Instead, nurses shared the treatment plan
with the patient and helped him or her to discuss
his or her concerns and become an active learner
in the rehabilitation process. In addition, there
were no doctor’s progress notes or nursing notes.
Instead, all charting was done on a form titled
“Patient’s Progress Notes.” These notes included
patients’ reaction to care, their concerns and
feelings, their understanding of the problems,
the goals they have identified, and how they see
their progress toward those goals. Patients were
also encouraged to keep their own notes to share
with their caregivers.
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Staff conferences were held at least twice
weekly as forums to discuss concerns, problems,
or questions. A collaborative practice model
between physicians and nurses evolved, and
the shared knowledge of the two professions
led to more effective team planning (Isler,
1964). The nursing stories published by nurses
who worked at Loeb describe nursing situa-
tions that demonstrate the effect of professional
nursing on patient outcomes. In addition,
they reflect the satisfaction derived from
practicing in a truly professional role (Alfano,
1971; Bowar, 1971; Bowar-Ferres, 1975;
Englert, 1971).
CHAPTER 5 • Early Conceptualizations About Nursing 65
■ Summary
Among other theorists featured in Section II of this book, Wiedenbach, Henderson, and Hall
introduced nursing theory to us in the mid-20th century. Each of the nurse theorists presented
in this chapter began by reflecting on her personal practice experience to explore the definition of
nursing and the importance of nurse–patient interactions. These nurse scholars challenged us to
think about nursing in new ways. Their contributions significantly influenced the way nursing was
practiced and researched, both in the United States and in other countries around the world. Perhaps
most important, each of these scholars stated and responded to the question, “What is nursing?”
Their responses helped all who followed to understand that the individual being nursed is a person,
not an object, and that the relationship of nurse and patient is valuable to all.
Alfano, G. (1971). Healing or caretaking—which will it
be? Nursing Clinics of North America, 6, 273–280.
Birnbach, N. (1988). Lydia Eloise Hall, 1906–1969. In:
V. L. Bullough, O. M. Church, & A. P. Stein
(Eds.), American nursing: A biographical dictionary
(pp. 161–163). New York: Garland.
Bowar, S. (1971). Enabling professional practice
through leadership skills. Nursing Clinics of North
America, 6, 293–301.
Bowar-Ferres, S. (1975). Loeb Center and its philosophy
of nursing. American Journal of Nursing, 75, 810–815.
Chinn, P. L., & Jacobs, M. K. (1987). Theory and nursing.
St. Louis, MO: C. V. Mosby.
Dickoff, J., James, P., & Wiedenbach, E. (1968). Theory
in a practice discipline. Nursing Research, 14(5),
Englert, B. (1971). How a staff nurse perceives her role
at Loeb Center. Nursing Clinics of North America,
6(2), 281–292.
Gesse, T., Dombro, M., Gordon, S. C. & Rittman, M.
R. (2006). Twentieth-Century nursing: Wieden-
bach, Henderson, and Orlando’s theories and their
applications. In: M. Parker (Ed.), Nursing theories
and nursing practice (2nd ed., pp. 70–78). Philadel-
phia: F. A. Davis.
Gillette, V. A. (1996). Applying nursing theory to peri-
operative nursing practice. AORN, 64(2), 261–270.
Gordon, S. C. (2001). Virginia Avenel Henderson
definition of nursing. In: M. Parker (Ed.), Nursing
theories and nursing practice (pp. 143–149). Philadel-
phia: F. A. Davis.
Hall, L. E. (1955). Quality of nursing care. Manuscript
of an address before a meeting of the Department
of Baccalaureate and Higher Degree Programs of the
New Jersey League for Nursing, February 7, 1955,
at Seton Hall University, Newark, New Jersey.
Montefiore Medical Center Archives, Bronx,
New York.
Hall, L. E. (1958). Nursing: What is it? Manuscript. Mon-
tefiore Medical Center Archives, Bronx, New York.
Hall, L. E. (1963, March). Summary of project report:
Loeb Center for Nursing and Rehabilitation. Unpub-
lished report. Montefiore Medical Center Archives,
Bronx, New York.
Hall, L. E. (1964). Nursing—what is it? Canadian
Nurse, 60, 150–154.
Hall, L. E. (1965). Another view of nursing care and quality.
Address delivered at Catholic University, Washington,
DC. Unpublished report. Montefiore Medical Center
Archives, Bronx, New York.
Halloran, E. J. (1996). Virgina Hendeson and her timeless
writings. Journal of Advanced Nursing, 23, 17–23.
Harmer, B., & Henderson, V. A. (1955). Textbook of the
principles and practice of nursing. New York: Macmillan.
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66 SECTION II • Conceptual Influences on the Evolution of Nursing Theory
Henderson, V. A. (1960). Basic principles of nursing care.
Geneva: International Council of Nurses.
Henderson, V. A. (1966). The nature of nursing. New
York: The National League for Nursing Press.
Henderson, V. A. (1991). The nature of nursing: Reflec-
tions after 25 years. New York: The National League
for Nursing Press.
Henderson, V. A., & Nite, G. (1978). Principles and prac-
tice of nursing (6th ed.). New York, NY: Macmillan.
Isler, C. (June, 1964). New concept in nursing therapy:
Care as the patient improves. RN, 58–70.
Montefiore cuts readmissions 80%. (1966, February 23).
The New York Times.
Nicely, B. & Delario, G. (2011). Virginia Henderson’s
principles and practice of nursing applied to organ
donation after brain death. Progress in Transplantation,
21, 72–77
Nickel, S., Gesse, T., & MacLaren, A. (1992). Her pro-
fessional legacy. Journal of Nurse Midwifery, 3, 161.
Simmons, L., & Henderson, V. (1964). Nursing research: A
survey and assessment. New York: Appleton-Century-
Touhy, T., & Birnbach, N. (2006). Lydia Hall: The
care, core, and cure model and its applications. In:
M. Parker (Ed.), Nursing theories and nursing practice
(2nd ed., pp. 113–124). Philadelphia: F. A. Davis.
VandeVusse, L. (1997). Education exchange. Sculpting
a nurse-midwifery philosophy: Ernestine Wieden-
back’s Influence. Journal of Nurse-Midwifery, 42(1),
Wiedenbach, E. (1962). A concept of dynamic nursing:
Philosophy, purpose, practice and process. Paper pre-
sented at the Conference on Maternal and Child
Nursing, Pittsburgh, PA. Archives, Yale University
School of Nursing, New Haven, CT.
Wiedenbach, E. (1963). The helping art of nursing.
American Journal of Nursing, 63(11), 54–57.
Wiedenbach, E. (1964). Clinical nursing: A helping art.
New York: Springer.
Wiedenbach, E. (1969). Meeting the realities in clinical
teaching. New York: Springer.
Wiedenbach, E. (1970). A systematic inquiry: Application
of theory to nursing practice. Paper presented at Duke
University, Durham, NC (author’s personal files).
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Chapter 6Nurse–Patient Relationship
Hildegard Peplau, Joyce Travelbee, and
Ida Jean Orlando
Part One Hildegard Peplau’s
Nurse–Patient Relationship
and Its Applications
Introducing the Theorist
Overview of Peplau’s Nurse–Patient
Relationship Theory
Practice Applications
Practice Exemplar
Part Two Joyce Travelbee’s
Human-to-Human Relationship
Model and Its Applications
Introducing the Theorist
Overview of Travelbee’s Human-to-
Human Relationship Model Theory
Practice Applications
Practice Exemplar
Part Three Ida Jean Orlando’s
Dynamic Nurse–Patient
Introducing the Theorist
Overview of Orlando’s Theory of the
Dynamic Nurse–Patient Relationship
Practice Applications
Practice Exemplar
Hildegard Peplau Joyce Travelbee
Ida Jean Orlando
3312_Ch06_067-086 26/12/14 11:18 AM Page 67

After graduating, Peplau remained at
Columbia to teach in their master’s program.
At that time, there was no direction for what
to include in graduate nursing programs.
Taking educational experiences from psychi-
atry and psychology, she adapted them to
her conceptualization of nursing. Peplau
described this as a time of “innovation or
Peplau arranged clinical experiences at
Brooklyn State Hospital so that her students
met twice weekly with the same patient for a
session lasting 1 hour. Using carbon paper, the
students took verbatim notes during the session.
Students then met individually with Peplau to
review the interaction in detail. Through this
process, both Peplau and her students began to
learn what was helpful and what was harmful in
the interaction.
In 1955, Peplau left Columbia for Rutgers,
where she began the clinical nurse specialist
program in psychiatric–mental health nursing.
Students were prepared as nurse psychothera-
pists, developing expertise in individual, group,
and family therapies. Peplau required her
students to examine their own verbal and non-
verbal communication and its effects on the
nurse–patient relationship.
In addition to being an educator, re-
searcher, and clinician, Peplau is the only per-
son to serve as both executive director and
president of the American Nurses Association.
Holding 11 honorary degrees, in 1994, she
was inducted into the American Academy of
Nursing’s (ANA) Living Legends Hall of
Fame. She was named one of the 50 great
Americans by Marquis Who’s Who in 1995. In
1997, Peplau received the Christiane Reiman
Prize. In 1998, she was inducted into the
ANA Hall of Fame. Hildegard Peplau died
in March 1999 at her home in Sherman
Oaks, California.
Overview of Peplau’s Nurse–
Patient Relationship Theory
Peplau (1952) defined nursing as a “signifi-
cant, therapeutic, interpersonal process” that
is an “educative instrument, a maturing
The nurse–patient relationship was a signif-
icant focus of early conceptualizations
of nursing. Hildegard Peplau, Joyce Travel-
bee, and Ida Jean Orlando were three early
nursing scholars who explicated the nature of
this relationship. Their work shifted the
focus of nursing from performance of tasks
to engagement in a therapeutic relationship
designed to facilitate health and healing.
Each of these conceptualizations will be de-
scribed in Parts One, Two, and Three of the
Part One Peplau’s Nurse–Patient Relationship
Introducing the Theorist
Hildegard Peplau (1909–1999) was an out-
standing leader and pioneer in psychiatric
nursing whose career spanned 7 decades. A
review of the events in her life also serves as
an introduction to the history of modern psy-
chiatric nursing. With the publication of In-
terpersonal Relations in Nursing in 1952,
Peplau provided a framework for the practice
of psychiatric nursing that would result in a
paradigm shift in this specialty. Before this,
patients were viewed as objects to be ob-
served. Peplau taught that psychiatric nurses
must participate with the patients, engaging
in the nurse–patient relationship. Although
Interpersonal Relations in Nursing was not
well received when first published, the book’s
influence later became widespread. It was
reprinted in 1988 and has been translated
into at least six languages.
During World War II, Peplau serving in the
Army Nurse Corps, was assigned to the School
of Military Neuropsychiatry in England. This
experience introduced her to the psychiatric
problems of soldiers at war. After the war,
Peplau attended Columbia University on the
GI Bill, earning her master’s degree in psychi-
atric–mental health nursing.
1The author would like to acknowledge the contributions
of Kennetha Curtis who assisted in updating the literature.
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force, that aims to promote forward move-
ment of personality in the direction of cre-
ative, constructive, productive, personal, and
community living” (p. 16). Peplau was the
first nursing theorist to identify the nurse–
patient relationship as being central to all
nursing care. In fact, nursing cannot occur
if there is no relationship, or connection,
between the patient and the nurse. Her
work, although written for all nursing spe-
cialties, provides specific guidelines for the
psychiatric nurse.
The nurse brings to the relationship pro-
fessional expertise, which includes clinical
knowledge. Peplau valued knowledge, believ-
ing that the psychiatric nurse must possess
extensive knowledge about the potential
problems that emerge during a nurse–patient
interaction. The nurse must understand
psychiatric illnesses and their treatments
(Peplau, 1987). The nurse interacts with the
patients as both a resource person and a
teacher (Peplau, 1952). Through education
and supervision, the nurse develops the
knowledge base required to select the most
appropriate nursing intervention. To engage
fully in the nurse–patient relationship, the
nurse must possess intellectual, interpersonal,
and social skills. These are the same skills
often diminished or lacking in psychiatric
patients. For nurses to promote growth in
patients, they must themselves use these
skills competently (Peplau, 1987).
There are four components of the nurse–
patient relationship: two individuals (nurse
and patient), professional expertise, and pa-
tient need (Peplau, 1992). The goal of the
nurse–patient relationship is to further the
personal development of the patient (Peplau,
1960). Nurse and patient meet as “strangers”
who interact differently than friends would.
The role of stranger implies respect and pos-
itive interest in the patient as an individual.
The nurse “accepts the patients as they are
and interacts with them as emotionally
able strangers and relating on this basis until
evidence shows otherwise” (Peplau, 1992,
p. 44). Peplau valued therapeutic communi-
cation as a key component of nurse–patient
interactions. She advised strongly against the
use of “social chit-chat.” In fact, she would
view this as wasting valuable time with your
patient. Every interaction must focus on
being therapeutic. Even something as simple
as sharing a meal with psychiatric patients
can be a therapeutic encounter.
The nurse–patient relationship, viewed as
growth-promoting with forward movement,
is enhanced when nurses are aware of how
their own behavior affects the patient. The
“behavior of the nurse-as-a-person interact-
ing with the patient-as-a person has signifi-
cant effect on the patient’s well-being and the
quality and outcome of nursing care” (Peplau,
1992, p. 14). An essential component of this
relationship is the continuing process of the
nurse becoming more self-aware. This occurs
via supervision.
Peplau (1989) recommended that nurses
participate in weekly supervision meetings with
an expert nurse clinician. The focus of the
supervisory meetings is on the nurses’ interac-
tions with patients. The primary purpose is to
review observations and interpersonal patterns
that the nurse has made or used. The goal
is always to develop the nurse’s skills as an ex-
pert in interpersonal relations. Peplau (1989)
emphasized “the slow but sure growth of
nurses” (p. 166) as they developed their com-
petencies in working with patients. Not only
are patient problems reviewed but treatment
options and the nurses’ own pattern of re-
sponding to the patient are explored. If an in-
teraction between a nurse and a patient has not
gone well, the nurse’s response is to examine
his or her own behaviors first. Asking questions
such as, “Did my own anxiety interfere with
this interaction?” or “Is there something in my
experiences that influenced how I interacted
with this patient?” leads to continual growth
and development as a skilled clinician. This
process also ensures the delivery of quality care
in psychiatric settings. Supervision continues to
be an important aspect in advanced practice
psychiatric nursing and is a requirement for
certification as a psychiatric clinical specialist or
nurse practitioner. Supervision is essential as
the nurse assumes the role of counselor. In this
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role, the nurse assists the patient in integrating
the thoughts and feelings associated with the
illness into the patient’s own life experiences
(Lakeman, 1999).
The nurse–patient relationship is objec-
tive, and its focus is on the needs of the
patient. To focus on the patient’s needs, the
nurse must be a skilled listener and able to
respond in ways that foster the patient’s
growth and return to health. Active listening
facilitates the nurse–patient relationship. As
Peplau wrote in 1960, nursing is an “oppor-
tunity to further the patient’s learning about
himself [sic], the focus in the nurse–patient
relationship will be upon the patient —his
[sic] needs, difficulties, lack in interpersonal
competence, interest in living” (p. 966).
Within the nurse–patient relationship, the
nurse works “to create a mood that encour-
ages clients to reflect, to restructure percep-
tions and views of situations as needed, to get
in touch with their feelings, and to connect
interpersonally with other people” (Peplau,
1988, p. 10). Although the nurse–patient re-
lationship is “time-limited in both duration
and frequency, the aim is to create an inter-
personally intimate encounter, however brief,
as if two whole persons are involved in a pur-
posive, enduring relationship; this requires
discipline and skill on the part of the nurse”
(p. 11). Peplau continued to emphasize that
nurses must possess “well-developed intellec-
tual competencies, and disciplined attention
to the work at hand” (p. 13).
Communication, both verbal and nonver-
bal, is an essential component of the nurse–
patient relationship. However, in Peplau’s
view, verbal communication is required for the
nurse–patient relationship to develop. She
wrote, “[A]nything clients act out with nurses
will most probably not be talked about, and
that which is not discussed cannot be under-
stood” (Peplau, 1989, p. 197). One objective
of the nurse–patient relationship is to talk
about the problem or need that has resulted in
the patient interacting with the nurse. Peplau
provided descriptions of phrases commonly
used by patients that require clarification on
the part of the nurse. These included referring
to “they,” using the phrase “you know,” and
overgeneralizing responses to situations. The
nurse clarifies who “they” are, responds that
she or he does not know and needs further in-
formation, and assists patients to be more spe-
cific as they describe their experiences
(Forchuk, 1993).
Phases of the Nurse–Patient
Peplau (1952) introduced the phases of the
nurse–patient relationship in her interpersonal
relations theory. This time-limited relationship
is interpersonal in nature and has a starting
point, proceeds through identifiable phases,
and ends. Initially, Peplau (1952) included
four phases in the relationship: orientation,
identification, exploitation, and resolution.
In 1991, Forchuk, a Canadian researcher who
has tested and refined some of Peplau’s work,
proposed three phases: orientation, working,
and resolution (Peplau, 1992). Forchuk’s rec-
ommendation of a three-phase nurse–patient
relationship resolves the lack of easy differen-
tiation between the identification and exploita-
tion stages. These two phases were collapsed
into the working phase. By renaming these
two phases the working phase, a more accurate
reflection of what actually occurs in this im-
portant aspect of the nurse–patient relation-
ship is provided. Although the nurse–patient
relationship is time limited in nature, much of
this relationship is spent “working.”
Orientation Phase
The relationship begins with the orientation
phase (Peplau, 1952). This phase is particularly
important because it sets the stage for the de-
velopment of the relationship. During the
orientation period, the nurse and patient’s re-
lationship is still new and unfamiliar. Nurse
and patient get to know each other as people;
their expectations and roles are understood.
During this first phase, the patient expresses a
“felt need” and seeks professional assistance
from the nurse. In reaction to this need, the
nurse helps the individual by recognizing and
assessing his or her situation. It is during the as-
sessment that the patient’s needs are evaluated
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by the patient and nurse working together as
a team. Through this process, trust develops
between the patient and the nurse. Also, the
parameters for the relationship are clarified.
Nursing diagnoses, goals, and outcomes for
the patient are created based on the assessment
information. Nursing interventions are imple-
mented, and the evaluations of the patient’s
goals are also incorporated (Peplau, 1992).
Working Phase
The working phase incorporates identification
and exploitation. The focus of the working
phase is twofold: first is the patient, who “ex-
ploits” resources to improve health; second is
the nurse, who enacts the roles of “resource
person, counselor, surrogate, and teacher in fa-
cilitating . . . development toward well-being”
(Fitzpatrick & Wallace, 2005, p. 460). This
phase of the relationship is meant to be flexible
so that the patient is able to function “depen-
dently, independently, or interdependently
with the nurse, based on . . . developmental
capacity, level of anxiety, self-awareness, and
needs” (Fitzpatrick & Wallace, 2005, p. 460).
A balance between independence and depend-
ence must exist here, and it is the nurse
who must aid the patient in its development
(Lakeman, 1999).
During the exploitation phase of the working
phase, the client assumes an active role on the
health team by taking advantage of available
services and determining the degree to which
they are used (Erci, 2008). Within this phase,
the client begins to develop responsibility and
independence, becoming better able to face new
challenges in the future (Erci, 2008). Peplau
(1992) wrote that “[e]xploiting what a situation
offers gives rise to new differentiations of the
problem and the development and improvement
of skill in interpersonal relations” (pp. 41–42).
Resolution Phase
The resolution phase is the last phase and in-
volves the patient’s continual movement from
dependence to independence, based on both a
distancing from the nurse and a strengthening
of individual’s ability to manage care (Peplau,
1952). According to Peplau, resolution can
take place only when the patient has gained
the ability to be free from nursing assistance
and act independently (Lloyd, Hancock, &
Campbell, 2007). At this point, old needs
are abandoned, and new goals are adopted
(Lakeman, 1999). The completion of the res-
olution phase results in the mutual termination
of the nurse–patient relationship and involves
planning for future sources of support (Peplau,
1952). Completion of this final phase “is one
measure of the success of . . . all the other
phases” (Lloyd et al., 2007, p. 50).
Applications of the Theory
Almost all of the research that has tested
Peplau’s nurse–patient relationship has been
conducted by Forchuk (1994, 1995) and col-
leagues (Forchuk & Brown, 1989; Forchuk
et al., 1998; Forchuk et al., 1998). Much of
Forchuk’s work has focused on the orientation
phase. Forchuk and Brown (1989) emphasized
the importance of being able to identify the
orientation phase and not rush movement
into the working phase. To assist in this, they
developed a one-page instrument, the Rela-
tionship Form, which they have used to deter-
mine the current phase of the relationship and
overall progression from phase to phase.2
Peplau first wrote about the nurse–patient
relationship in 1952. She hoped that through
this work, nurses would change how they inter-
acted with their patients. She wanted nurses to
“do with” clients rather than “do to” (Forschuk,
1993). The majority of the work that has tested
Peplau’s nurse–patient relationship has been
conducted with individuals with severe mental
illness, many of them in psychiatric hospitals.
In these studies, patients did move through the
phases of the nurse–patient relationship.
As psychiatric nurses have changed the
location of their practice from hospital to com-
munity, they have carried Peplau’s work to this
new arena. Unfortunately, there has been lim-
ited testing of the nurse–patient relationship
in community settings. Parrish, Peden, and
CHAPTER 6 • Nurse–Patient Relationship Theories 71
2For additional information, please visit DavisPlus at
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Staten (2008) explored strategies used by ad-
vanced practice psychiatric nurses treating in-
dividuals with depression. All the participants
in this study practiced in community settings.
When describing the strategies used, the
nurse–patient relationship was the primary ve-
hicle by which strategies were delivered. These
strategies included active listening, partnering
with the client, and a holistic view of the client.
This work supports the integration of Peplau’s
nurse–patient relationship into the work of the
psychiatric nurse.
Moving beyond application of Peplau’s
theory in psychiatric settings with psychiatric
patients, Merritt and Proctor (2010) used
Peplau’s four phases of the nurse–patient rela-
tionship to guide their practice as mental
health consultation liaison nurses. Working
with patients experiencing psychiatric symp-
toms but who did not have a psychiatric dis-
order, these practitioners were guided by
Peplau’s four phases of the nurse–patient
relationship. This clinical application led to
better engagement with patients, provided
patients with the tools needed to address life
changes that precipitated their illness, and fi-
nally resulted in movement toward health that
included meaningful, productive living. They
concluded that Peplau’s work provided a
model to ensure successful engagement with
patients requiring consultation liaison nursing
Peplau’s theoretical work on the nurse–
patient relationship continues to be essential
to nursing practice. To increase patient satis-
faction with care received in health-care set-
tings, relationship-based care has become an
important component in the delivery of nursing
care. Large institutions are educating their
workforce on the importance of having a rela-
tionship, a connection with those with whom
the nurse interacts and to whom he or she pro-
vides care. The premise is that by putting the
patient and his or her family at the center of
care, patient satisfaction and outcomes will im-
prove. In response to this and other changes in
health care, Jones (2012) wrote a thoughtful
editorial encouraging nurse leaders and educa-
tors to reclaim the structure of the nurse–
patient relationship as defined by Peplau. He
raised the question: Isn’t relationship-based care
what Peplau described as early as the 1950s?
One such institution, St. Mary’s located in
Evansville, Indiana, has developed a model of
relationship-based care. It is defined as “health-
care achieved through collaborative relation-
ships. Relationship-Based Care takes place in
a caring, competent and healing environment
organized around the needs and priorities of the
patients and their families who are at the center
of the care team” (
shipbasedcare; retrieved February 5, 2013).
Some of the principles of this type of care
include developing a therapeutic relationship,
being knowledgeable of self, experiencing
change that occurs over time, and believing that
everyone has a valuable contribution to make.
As literature describing relationship-based care
is reviewed (Campbell, 2009; Small & Small,
2011), citations of Peplau’s work are notably
lacking. Their absence may be attributed to how
thoroughly Peplau’s writings have become in-
tegral to nursing practice—as if they belong to
nursing, are a part of nursing’s language and
culture, and are no longer recognizable as being
separate from what is nursing.
Not only is nursing practice enhanced when
Peplau’s work is reviewed and applied, it also
may provide guidance in maintaining profes-
sional roles. In a more informal society with its
consequent easing of professional behaviors in
registered nurses, boundary violations reported
to boards of nursing are increasing (Jones,
Fitzpatrick, & Drake, 2008). A return to the
structure of the nurse–patient relationship and
revisiting the roles as defined by Peplau may
be needed (Jones, 2012). Peplau clearly artic-
ulated the roles of the nurse. At the time when
she was writing about this, nursing was moving
from hospital-based educational systems into
university settings. The focus of nursing was on
becoming a profession. With this movement,
more autonomy in nursing practice was needed.
To provide a framework for this, Peplau devel-
oped, primarily for psychiatric-mental health
nurses, six roles that were integral in the nurse–
patient relationship. These were described
earlier in this chapter.
The stranger role has particular relevance
to establishing professional boundaries. All
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nurse–patient relationships begin with meet-
ing the patient. The nurse enters into this
relationship as a nurse, not as a friend. The
nurse is respectful of the patient and values his
or her privacy. When a nurse moves from pro-
fessional to friend, boundary issues have been
violated. If this is not recognized or even raised
as a concern, nursing care deteriorates. If every
interaction is therapeutic, as described by
Peplau, then in the nurse–patient relationship
there is no time for social chit-chat or devel-
oping friendships. The work of nursing is to
engage the patient in therapeutic relationships
that move them toward greater health. This
was as vital to nursing in the 1950s as it
is today.
CHAPTER 6 • Nurse–Patient Relationship Theories 73
Practice Exemplar
Karen Thomas is a 49-year-old married woman
who has a scheduled appointment with an ad-
vanced practice psychiatric nurse (APPN). She
appears anxious and uncomfortable in the en-
counter with the APPN. In an effort to help
Ms. Thomas feel more comfortable, the APPN
offers her a glass of water or cup of coffee.
Ms. Thomas announces that she has not eaten
all day and would like something to drink. The
APPN provides a cup of water and several
crackers for Ms. Thomas to eat. Once they are
both seated, the APPN asks Ms. Thomas about
the reason for the appointment (what brought
her here today). Ms. Thomas replies that she
does not know; her husband made the appoint-
ment for her. To more fully understand the rea-
son for her husband making the appointment,
the APPN asks Ms. Thomas to tell her what
aspects of her behavior were viewed by her
husband as calling for attention. Once again,
Ms. Thomas shares that she does not know.
Continuing to focus on getting acquainted and
enhancing Ms. Thomas’s comfort in this begin-
ning relationship, the APPN asks Ms. Thomas
to tell her about herself. Ms. Thomas shares
that she has been depressed in the past and was
treated by a psychiatric nurse practitioner, who
prescribed an antidepressant medication. Be-
coming tearful, she also shares that she left her
husband several days ago and has moved in
with her oldest son, stating that she “just needs
some time to think.” For the next 15 minutes,
Ms. Thomas talks about her marriage, her love
for her husband, and her lack of trust in him.
She also shares symptoms of depression that are
present. Ms. Thomas speaks tangentially and
is a poor historian when recalling events in
the marriage that have caused her pain. Her
responses are guarded as she alludes to marital
infidelity on the part of her husband. Inter-
spersed throughout the conversation are state-
ments about her dislike of medications. The
APPN then begins to ask more pointed assess-
ment questions related to depressive symptoms.
Ms. Thomas shares that she has very poor sleep,
cannot concentrate, is isolating herself, has dif-
ficulties making decisions, and feels hopeless
about her future. At this point, Ms. Thomas
also shares that she had never taken the antide-
pressant prescribed for her. By sharing this,
Ms. Thomas indicates the beginning of a trust-
ing relationship with the APPN. Once the
initial assessment is complete, a preliminary di-
agnosis is determined, and client and nurse are
ready to move into the working phase.
The working phase is initiated with problem
identification. For Ms. Thomas, the primary
problem is major depression with a secondary
problem, partner-relational issues. The APPN,
acting as a resource person, provides education
about the illness, major depression. Included is
information about the biological causes of the
illness, genetic predisposition, and explanations
about the symptoms. A partnership is formed as
the APPN and Ms. Thomas discuss treatment
options. Although Ms. Thomas shares that she
does not like to take medications, she agrees to
an appointment with a psychiatric nurse practi-
tioner, who will conduct a medication evalua-
tion. That appointment is scheduled later in the
week. Ms. Thomas also shares that she really
wants to talk about her relationship with her
husband and come to some decision about the
future of their marriage. Marital counseling is
mentioned as a possible treatment option, but
the APPN suggests that this be delayed until
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74 SECTION II • Conceptual Influences on the Evolution of Nursing Theory
Practice Exemplar cont.
Ms. Thomas’s depressive symptoms have
decreased. The first session ends with both
client and nurse committed to working to de-
crease Ms. Thomas’s depressive symptoms.
Ms. Thomas is reminded about her appoint-
ment for a medication evaluation, and a second
therapy appointment is made with the APPN.
At the second visit, Ms. Thomas reports that
she has started taking an antidepressant but as
of yet has not seen any relief of her symptoms.
The APPN provides information about the
usual length of time required for results to
occur. Although Ms. Thomas does not see no-
ticeable results from the medication, the APPN
shares that Ms. Thomas looks more relaxed
and seems less anxious. Ms. Thomas states that
she would like to spend this session talking
about her relationship with her husband. She
describes what was once a very happy mar-
riage. The APPN listens, asks for clarification
when needed, and encourages Ms. Thomas to
share her perceptions of her marriage. The
APPN asks Ms. Thomas again to talk about
what might have caused her husband to call
and make the therapy appointment for her.
Ms. Thomas shares that her husband does not
want their marriage to end; however, she is not
sure yet about their future. Her perception is
that her husband thinks she is the one with the
problem and once she is “fixed” that their mar-
riage will return to its former state of happi-
ness. The session ends with the APPN asking
Ms. Thomas to focus on her own physical and
mental health. Possible interventions include
beginning an exercise program, practicing stress
reduction strategies, and reconnecting with in-
dividuals who have been supportive in the past.
At the next session, Ms. Thomas is notice-
ably improved. She states that she is sleeping,
not crying as much, concentrating better, and
feeling more hopeful about her marriage. She
also shares that she and her husband have met
for dinner several times and that he is willing to
come with her for marital counseling. However,
she shares that she is not yet ready for this,
preferring to spend time focusing on her own
mental health. Over the course of several
months, Ms. Thomas and the APPN meet. In
these sessions, Ms. Thomas explores her child-
hood, talks about the recent death of her
mother, decides to begin a new exercise pro-
gram, and reconnects with childhood friends.
Through this work, Ms. Thomas grows more
secure in who she is and in how she wants to
live. During this same time period, she contin-
ues to meet her husband regularly for dinner and
sometimes a movie.
At their final session, Ms. Thomas shares
that she is ready to go with her husband to
marital counseling. As a result of antidepres-
sant medication and therapy, the problem of
major depression has been resolved. However,
the focus of this last session returns to depres-
sion. This is done to help Ms. Thomas recog-
nize the early symptoms of depression to
prevent a relapse. Ms. Thomas shares that her
first symptoms were not sleeping well and
withdrawing from friends and family. The
APPN emphasizes the importance of monitor-
ing this and calling for an appointment if these
early symptoms occur. The focus now is on
the secondary problem of partner-relationship
issues. With this, the APPN makes a referral
to a marital and family therapist.
■ Summary
Peplau is considered the first modern-day
nurse theorist. Her clinical work provided di-
rection for the practice of psychiatric-mental
health nursing. This occurred at a time when
there were few innovations in the care of the
mentally ill. She valued education, believing
that attaining advanced degrees would move
the nursing profession forward. She also be-
lieved that nursing research should be
grounded in clinical problems. She worked
tirelessly to advance the profession of nursing,
as both an educator and a leader at the national
and international levels. Her contributions
continue to have an influence today.
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CHAPTER 6 • Nurse–Patient Relationship Theories 75
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Parrish, E., Peden, A. R., & Staten, R. R. (2008).
Strategies used by advanced practice psychiatric
nurses in treating adults with depression. Perspectives
in Psychiatric Care, 44, 232–240.
Peplau, H. E. (1952). Interpersonal relations in nursing.
New York: G. P. Putnam’s Sons. (English edition
reissued as a paperback in 1988 by Macmillan
Education, London.)
Peplau, H. E. (1960). Talking with patients. American
Journal of Nursing, 60, 964–967.
Peplau, H. E. (1962). The crux of psychiatric nursing.
American Journal of Nursing, 62, 50–54.
Peplau, H. E. (1987). Tomorrow’s world. Nursing
Times, 83, 29–33.
Peplau, H. E. (1988). The art and science of nursing:
Similarities, differences and relations. Nursing
Science Quarterly, 1, 8–15.
Peplau, H. E. (1989). Clinical supervision of staff
nurses. In A. O’Toole, & S. R. Welt (Eds.),
Interpersonal theory in nursing practice: Selected works
of Hildegard Peplau (pp. 164–167). New York:
Peplau, H. E. (1992). Interpersonal relations: A theoret-
ical framework for application in nursing practice.
Nursing Science Quarterly, 5(1), 13–18.
Peplau, H. E. (1998). Life of an angel: Interview with
Hildegard Peplau (1998). Hatherleigh Co. Audio-
tape available from the American Psychiatric Nurses
Small, D. C., & Small, R.M. (2011). Patients first!
Engaging the hearts and minds of nurses with a
patient-centered practice model. Online Journal of
Issues in Nursing, 16 (2), 1091–3734.
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Part Two Joyce Travelbee’s Human-to-Human
Relationship Model and Its Applications
Introducing the Theorist
Joyce Travelbee (1926–1973) practiced psychi-
atric/mental health nursing for more than
30 years in both the clinical setting and as a
nurse educator. She is best known for her
human-to-human relationship model, a mid-
dle-range theory that guides the nurse–patient
interaction with emphasis on helping the
patient find hope and meaning in the illness
experience (Travelbee, 1971). The human-to-
human relationship model provided an early
framework for delivering patient-centered
care, as promoted today by the Agency for
Healthcare Research and Quality with the
U.S. Department of Health and Human Serv-
ices and as noted in the Institute of Medicine’s
(2001) report, “Crossing the Quality Chasm:
A New Health System for the 21st Century.”
Travelbee graduated from the diploma nurs-
ing program at Charity Hospital School of
Nursing in New Orleans, Louisiana, in 1943.
Her early clinical practice at Charity Hospital,
combined with her faith, spirituality, and reli-
gious background, influenced her view on nurs-
ing and later the development of her theoretical
model. She received her bachelor of science de-
gree in nursing from Louisiana State University
in 1956 and later her master of science degree in
nursing with a focus on psychiatric/mental
health nursing in 1959 from Yale University.
Travelbee taught psychiatric and mental
health nursing at Louisiana State University,
New Orleans; the Department of Nursing Ed-
ucation at New York University; the University
of Mississippi School of Nursing in Jackson; and
at the Hotel Dieu School of Nursing in New
Orleans, Louisiana (Meleis, 1997; Travelbee,
1971). As a clinical instructor and later a profes-
sor of nursing, Travelbee (1972) incorporated
her philosophy of caring into her teaching meth-
ods, challenging students to learn not only from
their textbooks and nursing colleagues but rather
from the patients and their relatives themselves.
She later served as a nursing consultant for the
Veteran’s Administration Hospital in MS and
was enrolled in doctoral study at the time of her
death at age 47. Travelbee was Director of
Graduate Education at the Louisiana State
University School of Nursing when she died.
Travelbee’s first book, Interpersonal Aspects
of Nursing (1966), identified the purpose of
nursing and the roles of the nurse in achieving
this purpose. The delicate balance between
scientific knowledge and the ability to apply
evidence-based interventions with the thera-
peutic use of self in effecting change was de-
scribed and the ultimate goal of helping the
patient find hope and meaning in the illness
experience was identified. In Travelbee’s sec-
ond book, Intervention in Psychiatric Nursing:
Process in the One-to-One Relationship (1969),
the role of the psychiatric nurse in patient care
is described, the concept of communication
in the human-to-human relationship is exam-
ined, and the process of establishing, maintain-
ing, and terminating a relationship is described.
Overview of Travelbee’s
Travelbee’s human-to-human relationship
model was based on the work of nurse theorists
Hildegard Peplau and Ida Jean Orlando
(Tomey & Alligood, 2006). Viktor E. Frankl’s
logotherapy guided Travelbee’s (1971) concept
of nursing intervention and the role of the
nurse in helping patients and their families
find meaning in the illness experience.
Caring, in the human-to-human relation-
ship model, involves the dynamic, reciprocal,
interpersonal connection between the nurse
and patient, developed through communica-
tion and the mutual commitment to perceive
self and other as unique and valued. Through
the therapeutic use of self and the integration
of evidence-based knowledge, the nurse pro-
vides quality patient care that can foster the
patient’s trust and confidence in the nurse
(Travelbee, 1971). The meaning of the illness
experience becomes self-actualizing for the
patient as the nurse helps the patient find
meaning in the experience. The purpose of the
nurse is to “enable (the individual) to help
themselves . . . in prevention of illness and
promotion of health, and in assisting those
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who are incapable, or unable, to help them-
selves” (Travelbee, 1969, p. 7).
The human-to-human relationship “refers
to an experience or series of experiences be-
tween the human being who is nurse and an ill
person,” culminating in the nurse meeting the
ill person’s unique needs (Travelbee, 1971,
pp. 16–17). The term patient is not used
in Travelbee’s model, because patient refers to
a label or category of people, rather than a
unique individual in need of nursing care. The
purpose of nursing, according to Travelbee
(1971), is “to assist an individual, family or
community to prevent or cope with the expe-
rience of illness and suffering and, if necessary,
to find meaning in these experiences” (p. 16).
Simply caring about an individual is not suffi-
cient for providing quality care but rather the
integration of a broad knowledge base with the
therapeutic use of self is needed. To effect
change in the human relationship, the nurse
must transcend her sense of self to focus on the
recipient of care (Travelbee, 1969).
Transcendence of the traditional titles of
nurse and patient is necessary to prevent dehu-
manization of the ill person. With the rapid
expansion of health technology, combined with
financial constraints leading to restructuring of
nurse–patient ratios, competing demands are
placed on the nurse’s time and attention. An
emotional detachment between the nurse and
ill person is created when the nurse views the
ill person as simply “patient,” rather than as a
unique individual with his own understanding
of the illness experience. By performing nurs-
ing tasks without an emotional investment in
the nurse–patient relationship, the ill person’s
physical needs are met. However, the ill person
recognizes the lack of caring in the transaction
and is left alone to suffer with the symptoms of
illness. Dehumanization occurs when the ill
person is left alone to find meaning in his
illness experience.
Many ill persons and their family members
may ask questions such as “why me?” or “why
my loved one?” By inquiring into the individ-
ual’s perception of his illness and how he has
derived meaning from his illness experience,
the nurse can assess his coping ability and pro-
vide nursing interventions to prevent suffering
and despair. Hope and motivation are impor-
tant nursing tasks in caring for an ill person in
despair. However, the nurse “cannot ‘give’
hope to another person; she can, however,
strive to provide some ways and means for an
ill person to experience hope” (Travelbee,
1971, p. 83).
All human beings endure suffering, al-
though the experience of suffering differs from
one individual to another (Travelbee, 1971).
Suffering may be inevitable, but one’s attitude
toward it affects how an individual copes with
any illness. If the patient’s needs are not met
in his suffering, he may develop “despairful
not-caring,” in which he does not care if he
dies or recovers, or “apathetic indifference,” in
which he has “lost the will to live” (Travelbee,
1971, pp. 180–181). Hope helps the suffer-
ing person to cope, and it is an assumption
of Travelbee’s (1971) that “the role of the
nurse . . . [is] to assist the ill person [to] ex-
perience hope in order to cope with the stress
of illness and suffering” (p. 77).
To relieve the patient’s suffering and to
foster hope, the nurse provides care based on
the individual’s unique needs. Nursing care,
according to Travelbee (1971), is delivered
through five stages: observation, interpreta-
tion, decision making, action (or nursing
intervention), and appraisal (or evaluation).
The nursing intervention is designed to achieve
the purpose of nursing and is communicated
to the patient. The goals of communication in
the nursing process are “to know (the) person,
(to) ascertain and meet the nursing needs of ill
persons, and (to) fulfill the purpose of nursing”
(Travelbee, 1971, p. 96).
In the observation stage of nursing care, the
nurse “does not observe signs of illness” but
rather collects sensory data to identify a prob-
lem or need (Travelbee, 1971, p. 99). The
nurse validates her interpretation of the prob-
lem or need with the ill person and decides
whether or not to act upon her interpretation.
A nursing intervention is developed in align-
ment with the purpose of nursing, and requires
the nurse to “assist ill persons to find meaning
in the experience of illness, suffering, and pain”
(Travelbee, 1971, p. 158). However, the nurse
may not assume she understands the meaning
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of the illness experience to the ill person with-
out first inquiring into this meaning. To do so
would communicate to the ill person that his
or her experience is not of value to the nurse,
resulting in dehumanization. The nurse evalu-
ates the outcomes of her nursing intervention
based on objectives developed before the phase
of appraisal.
In meeting the ill person’s needs through
the human-to-human relationship, the nurse
employs a disciplined intellectual approach
or a logical approach consistent with nursing
standards and clinical practice guidelines to
identify, manage, and evaluate the ill person’s
problem (Travelbee, 1971). Each stage in the
nursing process may be employed without
the establishment of a human-to-human
relationship. An acute medical need may be
met, but the patient’s deeper spiritual and
emotional needs are neglected. These spiri-
tual and emotional needs are addressed in the
human-to-human relationship in the pro-
gression through five phases: the original
encounter, emerging identities, empathy,
sympathy, and rapport.
In the phase of the original encounter, the
nurse and ill person form judgments about
each other that will guide and shape future
nurse–person interactions. Past experiences,
the media, and stereotypes may influence one’s
perception of another, blocking the develop-
ment of a human-to-human relationship. In
the phase of emerging identities, a bond begins
to form between nurse and person as each
individual begins to “appreciate the uniqueness
of the other” (Travelbee, 1971, p. 132). The
bond is created and shaped through each
nurse–person interaction and is facilitated by
the therapeutic use of self, combined with
nursing knowledge. The nurse must recognize
how she perceives the person to create a foun-
dation of empathy.
In the phase of empathy, the nurse begins
to see the individual “beyond outward behavior
and sense accurately another’s inner experience
at a given point in time” (Travelbee, 1971,
p. 136). Empathy enables the nurse to pre-
dict what the person is experiencing and re-
quires acceptance because empathy involves
the “intellectual and . . . emotional comprehen-
sion of another person” (Travelbee, 1964).
Empathy is the precursor to sympathy, or the
“desire, almost an urge, to help or aid an individ-
ual in order to relieve his distress” (Travelbee,
1964). Sympathy is not pity, but rather a demon-
stration to the person that he is not carrying the
burden of illness alone. Trust develops between
the nurse and person in the phase of sympathy,
and the person’s distress is diminished.
Rapport is essential in the nurse–patient
relationship. Travelbee (1971) defined rapport
as “a process, a happening, and experience, or
series of experiences, undergone simultane-
ously by nurse and the recipient of her care”
(p. 150). Rapport “is composed of a cluster of
interrelated thoughts and feelings: interest in
and concern for, others; empathy, compassion,
and sympathy; a non-judgmental attitude, and
respect for each individual as a unique human
being” (Travelbee, 1963). Through the estab-
lishment of rapport, the nurse is able to foster
a meaningful relationship with the ill person
during multiple points of contact in the care
setting. Rapport is not established in every
nurse–person encounter; however, emotional
involvement is required from the nurse. To
establish this emotional bond with one’s pa-
tient, the nurse must first ensure her own emo-
tional needs are met.
In Travelbee’s second book, Intervention in
Psychiatric Nursing, implementation of the
human-to-human relationship model is ex-
plained through the stages of selecting and es-
tablishing a patient relationship, the process of
maintaining the relationship, and ultimate ter-
mination of the relationship. Patients in the
acute care facility are typically assigned to a
nurse based on acuity, skill level and experience
of the nurse. However, nurses can select a pa-
tient to develop a one-on-one relationship
with based on availability and willingness of
the nurse and patient.
During the preinteraction phase, the nurse
and patient relationship is chosen or assigned.
The nurse may have preconceived thoughts and
feelings toward the patient she is entering the
relationship with and must identify these preju-
dices before the next phase of their relationship.
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Goals and objectives for the interaction are es-
tablished before the first meeting and may
evolve over time (Travelbee, 1969, p. 143).
Once the nurse and patient are acquainted,
both the nurse and patient begin to assess each
other and make an assumption about the
other. The nurse should clarify to the patient
that she is not there simply to collect data but
rather to get to “know” the patient (p. 151).
Data should be collected in a manner that is
sensitive to the patient’s privacy and comfort
level. The nurse’s own thoughts and feelings of
the interaction must be considered following a
one-on-one interaction to determine whether
her own behavior may have affected the patient
interaction (Travelbee, 1969, p. 132). Like-
wise, the nurse must evaluate whether the in-
teraction met previously established objectives
and set goals for future interactions. The nurse
and patient affect each other’s thoughts and
feelings during each encounter, based on “the
nurse’s knowledge and her ability to use it, the
ill person’s willingness or capacity to respond
to the nurse’s effort, and the kind of problem
experienced by the ill person” (Travelbee,
1969, p. 139).
The phase of emerging identities occurs
when the nurse and the patient have overcome
their own anxieties about the interaction,
stereotypes, and past experiences. The nurse
and patient come to see each other as unique,
and the nurse works to transcend her view of
the situation. The nurse helps the patient to
identify problems and helps the patient change
his own behaviors. During this stage of devel-
opment, the nurse helps the patient find
meaning in the illness experience “whether this
suffering be predominately mental, physical, or
spiritual in origin” (Travelbee, 1969, p 157).
Eventually, the relationship is terminated, and
preparation for termination of the relationship
should begin early in the Phase of Emerging
Identities. Patients may feel abandoned or
angry regarding the termination if remaining
in the facility. In some cases, the nurse may be
able to elicit their thoughts and feelings. Those
to be discharged from the facility should be en-
couraged to express their fears and be assisted
in problem-solving solutions.
Practice Applications
Cook (1989) used Travelbee’s nursing con-
cepts to design a support group for nurses
facing organizational restructuring at a
New York hospital. The purpose of the sup-
port group was to help nurses develop more
meaningful perceptions of their roles during
a nursing shortage created during a financial
crisis that resulted in a restructuring of
patient care delivery and nurse/patient ratios.
Group morale was low in the beginning, and
nurses were frustrated with higher nurse/
patient ratios. The support group met over
2 weeks, and the group intervention was
designed by incorporating Hoff’s theory on
crisis intervention with Travelbee’s phases of
observation and communication. Travelbee’s
human-to-human relationship was used to
guide supportive discussions and problem-
solving as nurses struggled to regain a sense
of meaning and purpose related to their pro-
fessional identity.
Participants shared their perceptions of their
work environment during the initial encounter.
Support group members discussed the similar-
ities and differences in their work perceptions
during the phase of emerging identities. Empa-
thy and trust developed as nurses became more
accepting and nonjudgmental of each other’s
perceptions, culminating in the establishment
of rapport as group members were able to “re-
capture” the meaning of nursing (Cook, 1989).
Cook (1989) found that nurses who had
threatened to quit earlier had remained in the
system by the end of the support group. Nurse
productivity had increased over time, and the
number of sick days taken by the nurses had
diminished over the 6-month period after pro-
gram cessation. Nurses regained a sense of
meaning of their work and reported increased
job satisfaction after completion of the pro-
gram. Travelbee’s ideas hold potential as an ef-
fective nursing intervention for improving
nurse retention rates. However, further re-
search is necessary because the exact number
of nurses recruited into the support group and
the actual number of nurses who completed
the program are unknown.
CHAPTER 6 • Nurse–Patient Relationship Theories 79
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80 SECTION II • Conceptual Influences on the Evolution of Nursing Theory
Practice Exemplar
Luciana came into nurse practitioner Janice’s
office for her annual well-woman examina-
tion. A 53-year-old mother of three without
insurance, Luciana had delayed her visit for
several months due to lack of money. Despite
a nagging feeling that the pain in her breasts
might be serious, Luciana waited until she
could no longer tolerate the pain and the red-
ness and swelling of the breasts that had since
When Janice explained to Luciana that she
was a nurse practitioner and would be per-
forming her examination today and address-
ing any concerns she may have. Luciana sat
silently, looking slightly below Janice’s eyes as
she spoke. She avoided eye contact until asked
if something was wrong. Unable to wait for
Janice to complete the history, Luciana lifted
her shirt and showed the nurse practitioner
her erythematous, swollen breasts. The most
significant swelling noted was located in the
upper left quadrant, where Janice’s own
mother-in-law had experienced her most sig-
nificant swelling and lesions from her breast
cancer 5 years earlier—a cancer she hid from
her family until it was too late to intervene.
“What do you think this means?” Luciana
asked. Stunned by her bluntness, Janice took
a closer look at the swelling and warm, red
skin across Luciana’s chest. Dread filled
quickly inside Janice. “Do you think this is
cancer?” she asked. Trying to think back to
what she had been taught to say in her nursing
education, her mind drew a blank and honesty
was the only thought to come to mind. “Yes,”
Janice replied softly. “I do.” Tears began to fall
from Luciana’s calm face, as though she knew
she had breast cancer all along. Janice gave her
a big hug and whispered softly into her left ear,
“It will be alright. I am going to help you.” Lu-
ciana explained that she did not work
and did not have either health insurance or
Medicaid. Janice explained that programs
were available to help provide financial assis-
tance and that she would help her contact a
representative from a state-run breast cancer
program. Janice carefully finished performing
her physical examination, taking care to doc-
ument the extent of her swelling and the size,
shape, smoothness, mobility, and location of
any lumps palpated during the clinical breast
Once the examination was finished, Janice
excused herself and sought out the office man-
ager. She pulled Sophia aside in private and ex-
plained the situation. They contacted their local
representative from the health department in
charge of a grant that allocated money for
diagnostic mammography and arranged for the
patient to obtain the mammography through
the program. Janice returned to the examina-
tion room with the referral form, prescription
for the diagnostic imaging, and contact infor-
mation for the program representative. The
patient began to cry softly as she expressed
concern for her three children and wondered
who would take care of them? Janice hugged
Luciana as she cried and shared her story of
working as a stay-at-home mom while her
husband worked for low wages. She felt lonely
and missed her family who lived abroad. She
had not shared her breast pain with any one,
wanting to protect her family from worrying
about her. Tears began to fall from Janice’s
own eyes, as she remembered her mother-
in-law lying in a hospice bed when she finally
shared the gaping wounds where her own
breast cancer had eaten away at her skin. Dread
had filled inside Janice then, too, as she knew
she was powerless to help her. As Janice
hugged Luciana, a shimmer of hope radiated
from somewhere in that examination room as
she realized she could actually do something to
help Luciana. Even though she did not have a
background in oncology, Janice knew how to
connect her with providers that could further
evaluate and manage her breast cancer. Janice
showed Luciana the documents that she had
carried into the examination room and ex-
plained how she could obtain the mammogram
at no charge. Janice described the program
being offered through the health department
and gave her the name of the woman who
would now help facilitate the care she needed.
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CHAPTER 6 • Nurse–Patient Relationship Theories 81
Practice Exemplar cont.
Luciana looked her in the eyes, hopefully em-
powered by the information Janice had given
her, and said “thank you.”
Several days later, Janice received the radi-
ologist’s report from Luciana’s diagnostic
mammography. The report confirmed that
Luciana did indeed have breast cancer. Fortu-
nately, Sophia, the assistant office manager,
had spoken with Jan at the health department
and learned Luciana had received Medicaid
and was now under the care of an oncologist
with experience in treating breast cancer. Lu-
ciana returned to the clinic a couple weeks
later and expressed her gratitude for their help
in getting her the health care she needed. She
had started chemotherapy treatment and her
mother had come to stay with her to help take
care of her children.
Travelbee’s concepts are evident in this
exemplar. Janice, the nurse practitioner, col-
lected the preliminary patient history and ex-
amination findings needed to formulate a
diagnosis during the Stage of Observation.
However, Janice’s interpretation of nonspoken
cues and body language led her to the purpose
of Luciana’s visit and to identify Luciana’s
fear related to the breast cancer. By identi-
fying barriers to care and existing sources of
support for the patient (Concept of Decision-
Making), Janice developed a care plan that in-
volved a referral to the health department for
access to a state grant available to fund Lu-
ciana’s mammogram and to a representative
with the state Medicaid program for financial
assistance with breast cancer treatment (Con-
cept of Action, or Nursing Intervention). By
caring for her as a person, Luciana was able to
express her story freely and let go of her feel-
ings of powerlessness and fear that had built
up inside her since she first noticed her breast
pain. The barrier between Janice-as-clinician
and Luciana-as-patient blurred as they con-
nected in that examination room, their stories
intertwining as they came together as woman-
to-woman each affected by breast cancer dif-
ferently and yet somehow the same (concept
of appraisal).
■ Summary
Travelbee’s conceptualizations of the human-
to-human relationship guide the nurse–patient
interaction with an emphasis on helping the
patient find hope and meaning in the illness
experience. Scientific knowledge and clinical
competence are incorporated into Travelbee’s
concept of therapeutic use of self to effect
change in patient-centered care. Patients are
viewed as unique, and nursing care is delivered
over five stages: observation, interpretation,
decision making, action (or nursing interven-
tion), and appraisal (or evaluation).
Cook, L. (1989). Nurses in crisis: A support group based
on Travelbee’s nursing theory. Nursing and Health
Care, 10(4), 203–205.
Institute of Medicine. (2001). Crossing the quality
chasm: A new health system for the 21st Century.
Available at:
Meleis, A. I. (1997). Theoretical nursing: Development &
progress (3rd ed.). New York: Lippincott.
Tomey, A. M., & Alligood, M. R. (2006). Nursing theo-
rists and their work (6th ed.). St. Louis, MO: Mosby
Travelbee, J. (1963). What do we mean by rapport?
American Journal of Nursing, 63(2), 70–72.
Travelbee, J. (1964). What’s wrong with sympathy?
American Journal of Nursing, 64(1), 68–71.
Travelbee, J. (1966). Interpersonal aspects of nursing.
Philadelphia, PA: F. A. Davis.
Travelbee, J. (1969). Intervention in psychiatric nursing:
Process in the one-to-one relationship. Philadelphia:
F.A. Davis.
Travelbee, J. (1971). Interpersonal aspects of nursing
(2nd ed.). Philadelphia: F. A. Davis.
Travelbee, J. (1972). Speaking out: To find meaning in
illness. Nursing, 2(12), 6–8.
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Part Three Ida Jean Orlando’s Dynamic Nurse–
Patient Relationship
Introducing the Theorist
Ida Jean Orlando was born in 1926 in
New York. Her nursing education began at
New York Medical College School of Nursing
where she received a diploma in nursing. In
1951, she received a bachelor of science degree
in public health nursing from St. John’s
University in Brooklyn, New York, and in
1954, she completed a master’s degree in nurs-
ing from Columbia University. Orlando’s early
nursing practice experience included obstetrics,
medicine, and emergency room nursing.
Her first book, The Dynamic Nurse–Patient
Relationship: Function, Process and Principles
(1961/1990), was based on her research and
blended nursing practice, psychiatric–mental
health nursing, and nursing education. It was
published when she was director of the gradu-
ate program in mental health and psychiatric
nursing at Yale University School of Nursing.
Ida Jean Orlando passed away November 28,
Orlando’s theoretical work is both practice
and research based. She received funding from
the National Institute of Mental Health to
improve education of nurses about interper-
sonal relationships. As a consultant at McLean
Hospital in Belmont, Massachusetts, Orlando
continued to study nursing practice and devel-
oped an educational program and nursing serv-
ice department based on her theory. From
evaluation of this program, she published her
second book, The Discipline and Teaching of
Nursing Process (Orlando, 1972; Rittman,
Overview of Orlando’s Theory
of the Dynamic Nurse–Patient
Nursing is responsive to individuals who suffer
or anticipate a sense of helplessness; it is fo-
cused on the process of care in an immediate
experience; it is concerned with providing
direct assistance to individuals in whatever set-
ting they are found for the purpose of avoid-
ing, relieving, diminishing or curing the
individual’s sense of helplessness (Orlando,
The essence of Orlando’s theory, the dy-
namic nurse–patient relationship, reflects her
beliefs that practice should be based on needs
of the patient and that communication with
the patient is essential to understanding needs
and providing effective nursing care. Following
is an overview of the major components of
Orlando’s work:
1. The nursing process includes identifying the
needs of patients, responses of the nurse,
and nursing action. The nursing process,
as envisioned and practiced by Orlando, is
not the linear model often taught today
but is more reflexive and circular and
occurs during encounters with patients.
2. Understanding the meaning of patient be-
havior is influenced by the nurse’s percep-
tions, thoughts, and feelings. It may be
validated through communication between
the nurse and the patient. Patients experi-
ence distress when they cannot cope with
unmet needs. Nurses use direct and indi-
rect observations of patient behavior to
discover distress and meaning.
3. Nurse–patient interactions are unique, com-
plex, and dynamic processes. Nurses help
patients express and understand the mean-
ing of behavior. The basis for nursing
action is the distress experienced and
expressed by the patient.
4. Professional nurses function in an independ-
ent role from physicians and other health-
care providers.
Practice Applications
Orlando’s theoretical work was based on
analysis of thousands of nurse–patient interac-
tions to describe major attributes of the rela-
tionship. Based on this work, her later book
provided direction for understanding and
using the nursing process (Orlando, 1972).
This has been known as the first theory of
nursing process and has been widely used in
82 SECTION II • Conceptual Influences on the Evolution of Nursing Theory
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nursing education and practice in the United
States and across the globe. Orlando consid-
ered her overall work to be a theoretical frame-
work for the practice of professional nursing,
emphasizing the essentiality of the nurse–
patient relationship. Orlando’s theoretical
work reveals and bears witness to the essence
of nursing as a practice discipline.
Orlando’s work has been used as a founda-
tion for master’s theses (Grove, 2008; Hendren,
2012). Reinforcing Orlando’s theory as a prac-
tice and conceptual framework continues to be
relevant and applicable to nursing situations in
today’s healthcare environment.
Laurent (2000) proposed a dynamic leader–
follower relationship model using Orlando’s
dynamic nurse–patient relationship. The dy-
namic leader-follower relationship model re-
focuses the nature of “control” through shared
responsibility and meaning making, thereby
granting the employee or patient the ability
to actively engage in resolving the issue or
problem at hand. The emphasis is on recog-
nizing in both patient care and management
that the person who knows most about the
situation is the person himself or herself. To
be truly effective in resolving a problem or
situation involves engaging in a dynamic re-
lationship of shared responsibility and active
participation on the part of both parties
(i.e., nurse–patient/nurse manager–employee)
without which the true nature of the issue at
hand may go unresolved. Laurant (2000) sug-
gested that engaging in a dynamic relation-
ship with the other provides a means by
which management of care and/or employees
becomes a process of providing direction
rather than control, thereby generating nurs-
ing leaders in roles of authority rather than
just nurse managers of care.
Aponte (2009) employed Orlando’s
Dynamic Nurse–Patient Relationship as a
conceptual framework for the Influenza Initia-
tive in New York City to address the linguistic
disparities within communities. A needs survey
identified unmet linguistic needs and gaps ex-
isting within the city; nursing students, many
of whom were bilingual, served as translators
for non-English speaking Spanish, Chinese,
Russian, and Ukraine residents. Orlando’s
theoretical framework was used to describe the
communication among the nursing students,
homecare nurses, and city residents (Aponte,
2009, p. 326). Dufault et al. (2010) developed
a cost-effective, easy-to-use, best practice
protocol for nurse-to-nurse shift handoffs at
Newport Hospital, using specific components
of Orlando’s theory of deliberative nursing
process. Abraham (2011) proposed addressing
fall risk in hospitals using Orlando’s concep-
tualizations. The author asserts that three
elements (patient’s behavior, nurse’s reaction,
and anything the nurse does to alleviate the
distress) can effectively act as a roadmap for
decreasing fall risk.
The New Hampshire Hospital, a university-
affiliated psychiatric facility, adopted Orlando’s
framework for nursing practice (Potter, Vitale-
Nolen, & Dawson, 2005; Potter, Williams, &
Constanzo, 2004). Two nursing interventions
stemmed directly from the adoption of Or-
lando’s ideas. Potter, Williams, and Constanzo
(2004) developed a structured group curriculum
for nurse-led psychoeducational groups in an
inpatient setting. Both nurses and patients
demonstrated improved comfort, active involve-
ment and learning from combining Orlando’s
dynamic nurse–patient relationship and a psy-
choeducational curriculum with training in
group leadership.
Potter, Vitale-Nolen, and Dawson (2005)
conducted a quasi-experimental study to
determine the effectiveness of implementing
a safety agreement tool among patients who
threaten self-harm. Orlando’s concepts were
used to guide the creation of the safety agree-
ment. Results demonstrated that RNs per-
ceived the safety agreements as promoting
a more positive and effective nurse–patient
relationship related to the risk of self-harm
and believed the safety agreements increased
their comfort in helping patients at risk for
self-harm. The nurses were divided, however,
about whether the safety agreements en-
hanced their relationships with patients, and
the majority did not feel the safety agreements
decreased self-harming incidents. The rate of
self-harm incidents was not statistically sig-
nificant but the authors report the findings as
clinically significant citing no increase in
CHAPTER 6 • Nurse–Patient Relationship Theories 83
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self-harming rates despite higher acuity levels
and shorter hospital stays during post imple-
mentation stages.
Sheldon and Ellington (2008) conducted a
pilot study to expand Orlando’s process into se-
quential steps that further define the deliberative
nursing process. The authors used cognitive in-
terviews with a convenience sample of five ex-
perienced nurses to gain insight into the process
of nurse communication with patients and the
strategies nurses use when responding to patient
84 SECTION II • Conceptual Influences on the Evolution of Nursing Theory
Practice Exemplar
Krystal, a 23-year-old woman with a history
of asthma, presents to the emergency depart-
ment with her boyfriend. She states, “I just
can’t seem to catch my breath, I just can’t seem
to relax”; appearing extremely agitated. Avoid-
ing eye contact, Krystal fearfully explains to
the nurse that she has not been able to obtain
any of her regular medications for approxi-
mately 4 months. The nurse obtains vital signs
including a blood pressure of 113/68; pulse of
98; respiratory rate of 22; an oral temperature
of 37.0 degrees Celsius; and an oxygen satu-
ration of 95% on room air. Assessment reveals
no increased work of breathing with slight, bi-
lateral, expiratory wheezing. The nurse, em-
ploying standing orders, places the patient on
2L of oxygen per nasal cannula and initiates a
respiratory treatment.
Seeking privacy with the patient, the nurse
kindly asks the boyfriend to wait in the patient
lounge. He becomes argumentative and reluc-
tant to leave, the nurse calmly states that she
simply needs to complete her assessment with
the patient and again asks again for him to
wait in the lounge; this time he complies. Fur-
ther investigation by the nurse reveals that
Krystal normally uses albuterol and Advair to
control her asthma, but she has been unable to
obtain her medications over the past 4 months
because of “personal problems.”
In this example, the nurse formulates an
immediate hypothesis based on direct and in-
direct observations and attempts to validate
this hypothesis by collecting additional data
(questioning the patient about her normal
medications, observing the boyfriend’s reluc-
tance to leave the room, assessing the patient’s
agitated state and refusal to make eye contact,
and obtaining vital signs). From the patient
data, the nurse formulates several additional
hypotheses about the patient. The nurse may
hypothesize that Krystal needs financial assis-
tance in obtaining her medications and addi-
tional education about asthma and the role of
medications in managing the disease. A nurse
not using Orlando’s theory might administer
the necessary asthma medications; provide
asthma education and resources for obtaining
free or low cost medications. A nurse using
Orlando’s theoretical framework, however,
understands that no nursing action should be
taken without first validating each hypothesis
with the patient as a means of determining the
patient’s immediate needs. The nurse in this
situation validates with the patient the source
of her anxiety and inability to catch her breath.
In doing so, the nurse learns that the patient’s
concern now is not with her wheezing or ob-
taining her asthma medication but rather with
her boyfriend.
The nurse hypothesizes that Krystal is a vic-
tim of intimate partner violence. Again, the
nurse seeks to validate this with the patient,
asking Krystal if her boyfriend is physically or
emotionally harming her. Krystal continues to
look fearfully at the door and states, “He is
going to kill me if I tell you anything.” The
nurse assures Krystal that she is in a safe place
right now, that she is not alone and that there
are safety measures that can be taken to re-
move the boyfriend from the premises if that
would make Krystal feel safer. Krystal requests
the nurse to do this and begins crying, telling
the nurse she had a fight with her boyfriend
today and he hit her. “He always makes sure
to hit me where people can’t see, and he is al-
ways sorry.” The nurse asks if Krystal is injured
in any way right now. Krystal pulls up her shirt
to reveal extensive bruising at various stages of
healing to her torso and what looks like several
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CHAPTER 6 • Nurse–Patient Relationship Theories 85
Practice Exemplar cont.
fresh cigarette burns to both her breasts. The
nurse asks Krystal if it would be okay to per-
form some additional assessmentsto ensure no
further internal injury has occurred. Krystal
nods her head yes, and the nurse asks if this
has happened before. Krystal tells the nurse
that these days it happens almost daily but that
she deserves it because she doesn’t have a job
and he is the only one who loves her. “I want
to leave. I really do, but I am afraid he will kill
me, and I don’t have anywhere else to go.” The
nurse acknowledges Krystal’s distress, clarify-
ing that Krystal does not deserve this type of
treatment and that she fears for her safety,
emphasizing abuse is a crime and only worsens
over time.
At this point, the nurse discusses how the
patient wishes to address this concern ensuring
there is a dynamic interaction occurring be-
tween the patient and the nurse. Offering the
patient the resources and opportunity to ex-
press and understand the meaning of her own
behavior inspires Krystal to find meaning in
the experience and ownership in the choices
needed to address these concerns. Using her
nursing knowledge of domestic abuse, the
nurse engages Krystal in a conversation about
the cycle of violence and empowers Krystal by
providing her with choices and resources to
address her current situation. After the nurse–
patient interaction, Krystal decides to go to a
local domestic abuse shelter for women (the
nurse makes arrangements by calling the shel-
ter and providing transportation), to file a po-
lice report (the nurse arranges for an officer to
come to the hospital), and allow for photos
and documentation of her injuries to be
charted (documentation follows the guidelines
needed to be admissible in a court of law if
necessary). The nurse also provides Krystal
with the number for the National Resource
Center on Domestic Violence, and with two
websites one for Violence Against Women
Network ( and the Florida
Coalition Against Domestic Violence
( The nurse calls the shelter a
few days later to check that Krystal is safe and
learns that Krystal will be remaining at the
shelter and has not had any further correspon-
dence with her boyfriend.
Through mutual engagement, the patient
and nurse were able to create a dynamic envi-
ronment that fostered effective communica-
tion and the ability to address the immediate
needs of the patient. Providing asthma educa-
tion and financial resources would not have
addressed Krystal’s need for physical safety re-
lated to domestic abuse because the plan
would have been based on an invalid hypoth-
esis. The nurse in this situation used her
perception and knowledge of the nursing
situation to explore the meaning of Krystal’s
behavior. Through communication and vali-
dation with the patient of the nurses’ hypothe-
ses, perceptions and supporting data, the nurse
was able to elicit the nature of the patient’s
problem and mutually engage the patient in
identifying what help was needed. After mutual
decision making, the nurse took deliberative
nursing actions to meet Krystal’s immediate
needs including initiating safety protocols, pro-
viding resources, gathering additional data, and
creating a supportive and encouraging environ-
ment for the patient.
■ Summary
The most important contribution of Orlando’s
theoretical work is the primacy of the nurse–
client relationship. Inherent in this theory is a
strong statement: What transpires between the
patient and the nurse is of the highest value.
The true worth of her ideas is that it clearly
states what nursing is or should be today.
Regardless of the changes in the health-care
system, the human transaction between the
nurse and the patient in any setting holds the
greatest value —not only for nursing, but also
for society at large. Orlando’s writings can
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86 SECTION II • Conceptual Influences on the Evolution of Nursing Theory
serve as a philosophy as well as a theory,
because it is the foundation on which our pro-
fession has been built. With all of the benefits
that modern technology and modern health
care bring—and there are many—we need to
pause and ask the question, What is at risk in
health care today? The answer to that question
may lead to reconsideration of the value of
Orlando’s theory as perhaps the critical link for
enhancing relationships between nursing and
patient today (Rittman, 1991).
Abraham, S. (2011). Fall prevention conceptual frame-
work. The Health Care Manager, 30(2), 179–184. doi:
Aponte, J. (2009). Meeting the linguistic needs of urban
communities. Home Health Nurse, 27(5), 324–329.
Dufault, M., Duquette, C. E., Ehmann, J., Hehl, R.,
Lavin, M., Martin, V., Moore, M. A., Sargent, S.,
Stout, P., Willey, C. (2010). Translating an evi-
dence-based protocol for nurse-to-nurse shift hand-
offs. Worldviews on Evidence-Based Nursing, 7(2),
Grove, C. (2008). Staff intervention to improve patient
satisfaction (master’s thesis). Retrieved from Pro-
Quest Dissertations and Theses database. (UMI
Hendren, D. W. (2012). Emergency departments and
STEMI care, are the guidelines being followed? (mas-
ter’s thesis). Retrieved from ProQuest Dissertations
and Theses database. (UMI 1520156)
Laurent, C. L. (2000). A nursing theory of nursing lead-
ership. Journal of Nursing Management, 8, 83–87.
Orlando, I. J. (1990). The dynamic nurse–patient relation-
ship: Function, process and principles. New York: Na-
tional League for Nursing New York: G. P.
Putnam’s Sons. (Original work published 1961)
Orlando, I. J. (1972). The discipline and teaching of nurs-
ing process: An evaluative study. New York: G. P.
Putnam’s Sons.
Potter, M. L., Vitale-Nolen, R., & Dawson, A. M.
(2005). Implementation of safety agreements in an
acute psychiatric facility. Journal of the American
Psychiatric Nurses Association, 11(3), 144–155. doi:
Potter, M. L., Williams, R. B. & Costanzo, R. (2004).
Using nursing theory and structured psychoeduca-
tional curriculum with inpatient groups. Journal of
the American Psychiatric Nurses Association, 10(3),
122–128. doi: 10.1177/1078390304265212
Rittman, M. R. (1991). Ida Jean Orlando (Pelletier)—
the dynamic nurse–patient relationship. In: M.
Parker (Ed.), Nursing theories and nursing practice
(pp. 125–130). Philadelphia: F. A. Davis.
Sheldon, L. K., & Ellington, L. (2008). Application
of a model of social information processing to nurs-
ing theory: How nurses respond to patients. Journal
of Advanced Nursing 64(4), 388–398. doi:
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Section III
Conceptual Models/Grand
Theories in the Integrative-
Interactive Paradigm
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Section III includes seven chapters on the conceptual models or grand theories
situated 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. The-
ories in the integrative-interactive paradigm view persons1 as integrated
wholes or integrated systems interacting with the larger environmental system.
The integrated dimensions of the person are influenced by environmental fac-
tors leading to some change that impacts health or well-being. The subjectivity
of the person and the multidimensional nature of any outcome are considered.
Most of the theories are based explicitly on a systems perspective.
In Chapter 7, Johnson’s behavioral systems model is described. It includes
principles of wholeness and order, stabilization, reorganization, hierarchic in-
teraction, 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, a conceptual model
with four interrelated theories associated with it: theory of nursing systems, theory of
self-care deficit, and the theory of self-care and theory of dependent care. According
to Orem, when requirements for self-care exceed capacity for self-care, self-care
deficits occur. Nursing systems are designed to address these self-care deficits.
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 accom-
plished through a transaction,setting a mutually agreed-upon goal with the patient.
In Chapter 10, Pamela Senesac and Sr. Callista Roy describe the Roy adap-
tation 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.
Lois White Lowry and Patricia Deal Aylward authored Chapter 12 on Neuman’s
systems model. The model includes the client–client system with a basic structure
protected from stressors by lines of defense and resistance. The concern of nursing
is to keep the client stable by assessing the actual or potential effects of stressors
and assisting client adjustments for optimal wellness.
In Chapter 13, Erickson, Tomlin, and Swain’s modeling and role modeling
theory is presented by Helen 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 adap-
tation, 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 connect-
edness. 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.
1 Person refers to individuals, families, groups or communities.
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Chapter 7Dorothy Johnson’s Behavioral
System Model and Its
Introducing the Theorist
Overview of Johnson’s Behavioral
System Model
Applications of the Model
Practice Exemplar by Kelly White
Dorothy Johnson
Introducing the Theorist
Dorothy Johnson’s earliest publications per-
tained to the knowledge base nurses needed for
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 me-
diated 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 career at
Vanderbilt University School of Nursing. A
call from Lulu Hassenplug, Dean of the
School of Nursing, enticed her to the Univer-
sity of California at Los Angeles in 1949. She
served there as an assistant, associate, and pro-
fessor of pediatric nursing until her retirement
in 1978. Johnson is recognized as one of the
founders of modern systems-based nursing
theory (Glennister, 2011; Meleis, 2011).
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During her academic career, Dorothy Johnson
addressed issues related to nursing practice, ed-
ucation, and science. While she was a pediatric
nursing advisor at the Christian Medical College
School of Nursing in Vellare, South India, she
wrote a series of clinical articles for the Nursing
Journal of India (Johnson, 1956, 1957). She
worked with the California Nurses’ Association,
the National League for Nursing, and the
American Nurses’ Association to examine the
role of the clinical nurse specialist, the scope of
nursing practice, and the need for nursing re-
search. She also completed a Public Health
Service–funded research project (“Crying as a
Physiologic State in the Newborn Infant”) in
1963 (Johnson & Smith, 1963). The founda-
tions of her model and her beliefs about nursing
are clearly evident in these early publications.
Overview of Johnson’s
Behavioral System Model
Johnson noted that her theory, the Johnson be-
havioral system model (JBSM), evolved from
philosophical ideas, theory, and research; her
clinical background; and many years of thought,
discussions, and writing (Johnson, 1968). She
cited a number of sources for her theory. From
Florence Nightingale came the belief that nurs-
ing’s concern is a focus on the person rather than
the disease. Systems theorists (Buckley, 1968;
Chin, 1961; Parsons & Shils, 1951; Rapoport,
1968; Von Bertalanffy, 1968) were all sources for
her model. Johnson’s background as a pediatric
nurse is also evident in the development of her
model. In her papers, Johnson cited developmen-
tal literature to support the validity of a behavioral
system model (Ainsworth, 1964; Crandal, 1963;
Gerwitz, 1972; Kagan, 1964; Sears, Maccoby, &
Levin, 1954). Johnson also noted that a number
of her subsystems had biological underpinnings.
Johnson’s theory and her related writings
reflect her knowledge about both development
and general systems theories. The combination
of nursing, development, and general systems
introduces some of the specifics into the rhet-
oric about nursing theory development that
make it possible to test hypotheses and con-
duct critical experiments.
Five Core Principles
Johnson’s model incorporates five core principles
of system thinking: wholeness and order, stabi-
lization, reorganization, hierarchic interaction,
and dialectical contradiction. Each of these gen-
eral systems principles has analogs in develop-
mental theories that Johnson used to verify the
validity of her model (Johnson, 1980, 1990).
Wholeness and order provide the basis for con-
tinuity and identity, stabilization for develop-
ment, reorganization for growth and/or change,
hierarchic interaction for discontinuity, and di-
alectical contradiction for motivation. Johnson
conceptualized a person as an open system with
organized, interrelated, and interdependent sub-
systems. By virtue of subsystem interaction and
independence, the whole of the human organism
(system) is greater than the sum of its parts (sub-
systems). Wholes and their parts create a system
with dual constraints: Neither has continuity and
identity without the other.
The overall representation of the model can
also be viewed as a behavioral system within an
environment. The behavioral system and the
environment are linked by interactions and
transactions. We define the person (behavioral
system) as comprising subsystems and the en-
vironment as comprising physical, interpersonal
(e.g., father, friend, mother, sibling), and soci-
ocultural (e.g., rules and mores of home, school,
country, and other cultural contexts) compo-
nents that supply the sustenal imperatives
(Grubbs, 1980; Holaday, 1997; Johnson, 1990;
Meleis, 2011). Sustenal imperatives are the nec-
essary prerequisites for the optimal functioning
of the behavioral system. The environment must
supply the sustenal imperatives of protection,
nurturance, and stimulation to all subsystems to
allow them to develop and to maintain stability.
Some examples of conditions that protect, stim-
ulate, and nurture related to achievement would
include encouragement from parents and peers;
enriched, stimulating environments, awards
and recognition; and increased autonomy and
Wholeness and Order
The developmental analogy of wholeness and
order is continuity and identity. Given the
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behavioral system’s potential for plasticity, a
basic feature of the system is that both conti-
nuity and change can exist across the life span.
The presence of or potentiality for at least some
plasticity means that the key way of casting the
issue of continuity is not a matter of deciding
what exists for a given process or function of a
subsystem. Instead, the issue should be cast in
terms of determining patterns of interactions
among levels of the behavioral system that may
promote continuity for a particular subsystem
at a given point in time. Johnson’s work im-
plies that continuity is in the relationship of
the parts rather than in their individuality.
Johnson (1990) noted that at the psychological
level, attachment (affiliation) and dependency
are examples of important specific behaviors
that change over time, although the represen-
tation (meaning) may remain the same. Johnson
stated: “[D]evelopmentally, dependence be-
havior in the socially optimum case evolves
from almost total dependence on others to a
greater degree of dependence on self, with a
certain amount of interdependence essential to
the survival of social groups” (1990, p. 28). In
terms of behavioral system balance, this pat-
tern of dependence to independence may be
repeated as the behavioral system engages in
new situations during the course of a lifetime.
Stabilization or behavioral system balance is
another core principle of the JBSM. Dynamic
systems respond to contextual changes by ei-
ther a homeostatic or homeorhetic process.
Systems have a set point (like a thermostat)
that they try to maintain by altering internal
conditions to compensate for changes in exter-
nal conditions. Human thermoregulation is an
example of a homeostatic process that is pri-
marily biological but is also behavioral (turning
on the heater). The use of attribution of ability
or effort is a behavioral homeostatic process we
use to interpret activities so that they are con-
sistent with our mental organization.
From a behavioral system perspective,
homeorrhesis is a more important stabilizing
process than is homeostasis. In homeorrhesis,
the system stabilizes around a trajectory rather
than a set point. A toddler placed in a body
cast may show motor lags when the cast is re-
moved but soon show age-appropriate motor
skills. An adult newly diagnosed with asthma
who does not receive proper education until a
year after diagnosis can successfully incorpo-
rate the material into her daily activities. These
are examples of homeorhetic processes or self-
righting tendencies that can occur over time.
What nurses observe as development or
adaptation of the behavioral system is a product
of stabilization. When a person is ill or threat-
ened with illness, he or she is subject to biopsy-
chosocial perturbations. The nurse, according
to Johnson (1980, 1990), acts as the external
regulator and monitors patient response, look-
ing for successful adaptation to occur. If behav-
ioral system balance returns, there is no need
for intervention. If not, the nurse intervenes to
help the patient restore behavioral system bal-
ance. It is hoped that the patient matures and
with additional hospitalizations, the previous
patterns of response have been assimilated, and
there are few disturbances.
Adaptive reorganization occurs when the behav-
ioral system encounters new experiences in the
environment that cannot be balanced by existing
system mechanisms. Adaptation is defined as
change that permits the behavioral system to
maintain its set points best in new situations. To
the extent that the behavioral system cannot as-
similate the new conditions with existing regu-
latory mechanisms, accommodation must occur
either as a new relationship between subsystems
or by the establishment of a higher order or dif-
ferent cognitive schema (set, choice). The nurse
acts to provide conditions or resources essential
to help the accommodation process, may impose
regulatory or control mechanisms to stimulate
or reinforce certain behaviors, or may attempt to
repair structural components (Johnson, 1980). If
the focus is on a structural part of the subsystem,
then the nurse will focus on the goal, set, choice,
or action of a specific subsystem. The nurse
might provide an educational intervention to
alter the client’s set and broaden the range of
choices available.
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The difference between stabilization and re-
organization is that the latter involves change
or evolution. A behavioral system is embedded
in an environment, but it is capable of oper-
ating independently of environmental con-
straints through the process of adaptation. The
diagnosis of a chronic illness, the birth of a
child, or the development of a healthy lifestyle
regimen to prevent problems in later years are
all examples in which accommodation not only
promotes behavioral system balance but also
involves a developmental process that results
in the establishment of a higher order or more
complex behavioral system.
Hierarchic Interaction
Each behavioral system exists in a context of
hierarchical relationships and environmental
relationships. From the perspective of general
systems theory, a behavioral system that has
the properties of wholeness and order, stabi-
lization, and reorganization will also demon-
strate a hierarchic structure (Buckley, 1968).
Hierarchies, or a pattern of relying on particular
subsystems, lead to a degree of stability. A dis-
ruption or failure will not destroy the whole
system but instead will lead to decomposition
to the next level of stability.
The judgment that a discontinuity has oc-
curred is typically based on a lack of correlation
between assessments at two points of time. For
example, one’s lifestyle before surgery is not a
good fit postoperatively. These discontinuities
can provide opportunities for reorganization
and development.
Dialectical Contradiction
The last core principle is the motivational force
for behavioral change. Johnson (1980) de-
scribed these as drives and noted that these re-
sponses are developed and modified over time
through maturation, experience, and learning.
A person’s activities in the environment lead to
knowledge and development. However, by act-
ing on the world, each person is constantly
changing it and his or her goals, and therefore
changing what he or she needs to know. The
number of environmental domains that the
person is responding to includes the biological,
psychological, cultural, familial, social, and
physical setting. The person needs to resolve
(maintain behavioral system balance of) a cas-
cade of contradictions between goals related to
physical status, social roles, and cognitive status
when faced with illness or the threat of illness.
Nurses’ interventions during these periods can
make a significant difference in the lives of the
persons involved because the nurse can help
clients compare opposing propositions and
make decisions. Dealing with these contradic-
tions can be viewed as the “driving force” of de-
velopment as resolution brings about a higher
level of understanding of the issue at hand. This
may also alter the persons set, choice and ac-
tion. Behavioral system balance is restored and
a new level of development is attained.
Johnson’s model is unique in part because it
takes from both general systems and develop-
mental theories. One may analyze the patient’s
response in terms of behavioral system balance
and, from a developmental perspective, ask,
“Where did this come from, and where is it
going?” The developmental component neces-
sitates that we identify and understand the
processes of stabilization and sources of distur-
bances that lead to reorganization. These need
to be evaluated by age, gender, and culture. The
combination of systems theory and develop-
ment identifies “nursing’s unique social mission
and our special realm of original responsibility
in patient care” (Johnson, 1990, p. 32).
Major Concepts of the Model
Next, we review the model as a behavioral sys-
tem within an environment.
Johnson conceptualized a nursing client as a
behavioral system. The behavioral system is or-
derly, repetitive, and organized with interre-
lated and interdependent biological and
behavioral subsystems. The client is seen as a
collection of behavioral subsystems that inter-
relate to form the behavioral system. The sys-
tem may be defined as “those complex, overt
actions or responses to a variety of stimuli pres-
ent in the surrounding environment that are
purposeful and functional” (Auger, 1976, p. 22).
These ways of behaving form an organized
and integrated functional unit that determines
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CHAPTER 7 • Dorothy Johnson’s Behavioral System Model and Its Applications 93
Achievement Subsystem
Affiliative Subsystem
Aggressive/Protective Subsystem
Dependency Subsystem
Eliminative Subsystem
Table 7 • 1 The Subsystems of Behavior
Mastery or control of self or the environment
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
To relate or belong to someone or something other than oneself; to
achieve intimacy and inclusion
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
To protect self or others from real or imagined threatening objects, per-
sons, or ideas; to achieve self-protection and self-assertion
To recognize biological, environmental, or health systems that are po-
tential threats to self or others
To mobilize resources to respond to challenges identified as threats
To use resources or feedback mechanisms to alter biological, environ-
mental, or health input or human responses in order 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
To obtain focused attention, approval, nurturance, and physical assis-
tance; to maintain the environmental resources needed for assistance; to
gain trust and reliance
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 in-
creased 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
To expel biological wastes; to externalize the internal biological
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 excre-
tion 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
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94 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm
Ingestive Subsystem
Restorative Subsystem
Sexual Subsystem
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. Unpub-
lished paper, University of California, San Francisco; and B. Holaday (1972). Operationalization of the JBSM. Unpub-
lished paper, University of California, Los Angeles.
Table 7 • 1 The Subsystems of Behavior—cont’d
To take in needed resources from the environment to maintain the in-
tegrity of the organism or to achieve a state of pleasure; to internalize
the external environment
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
To relieve fatigue and/or achieve a state of equilibrium by reestablish-
ing or replenishing the energy distribution among the other subsystems;
to redistribute energy
To maintain and/or return to physiological homeostasis
To produce relaxation of the self system
To procreate, to gratify or attract; to fulfill expectations associated with
one’s gender; to care for others and to be cared about by them
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 grat-
ification and/or procreation
To establish meaningful relationships in which sexual gratification
and/or procreation may be obtained
and limits the interaction between the person
and environment and establishes the relation-
ship of the person to the objects, events, and
situations in the environment. Johnson (1980,
p. 209) considered such “behavior to be or-
derly, purposeful and predictable; that is, it is
functionally efficient and effective most of the
time, and is sufficiently stable and recurrent to
be amenable to description and exploration.”
The parts of the behavioral system are called
subsystems. They carry out specialized tasks or
functions needed to maintain the integrity of
the whole behavioral system and manage its re-
lationship to the environment. Each of these
subsystems has a set of behavioral responses that
is developed and modified through motivation,
experience, and learning.
Johnson identified seven subsystems. How-
ever, in this author’s operationalization of the
model, as in Grubbs (1980), I have included
eight subsystems. These eight subsystems and their
goals and functions are described in Table 7-1.
Johnson noted that these subsystems are found
cross-culturally and across a broad range of the
phylogenetic scale. She also noted the signifi-
cance of social and cultural factors involved in
the development of the subsystems. She did
not consider the seven subsystems as complete,
because “the ultimate group of response systems
to be identified in the behavioral system will
undoubtedly change as research reveals new
subsystems or indicated changes in the struc-
ture, functions, or behavioral groupings in the
original set” (Johnson, 1980, p. 214).
Each subsystem has functions that serve to
meet the conceptual goal. Functional behaviors
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are the activities carried out to meet these
goals. These behaviors may vary with each in-
dividual, depending on the person’s age, sex,
motives, cultural values, social norms, and
self-concepts. For the subsystem goals to be
accomplished, behavioral system structural
components must meet functional require-
ments of the behavioral system.
Each subsystem is composed of at least four
structural components that interact in a spe-
cific pattern: goal, set, choice, and action. The
goal of a subsystem is defined as the desired
result or consequence of the behavior. The
basis for the goal is a universal drive that can
be shown to exist through scientific research.
In general, the drive of each subsystem is the
same for all people, but there are variations
among individuals (and within individuals over
time) in the specific objects or events that are
drive-fulfilling, in the value placed on goal at-
tainment, and in drive strength. With drives
as the impetus for the behavior, goals can be
identified and are considered universal.
The behavioral set is a predisposition to act
in a certain way in a given situation. The be-
havioral set represents a relatively stable and
habitual behavioral pattern of responses to par-
ticular drives or stimuli. It is learned behavior
and is influenced by knowledge, attitudes, and
beliefs. The set contains two components: per-
severation and preparation. The perseveratory
set refers to a consistent tendency to react to
certain stimuli with the same pattern of behav-
ior. The preparatory set is contingent on the
function of the perseveratory set. The prepara-
tory set functions to establish priorities for
attending or not attending to various stimuli.
The conceptual set is an additional com-
ponent to the model (Holaday, 1982). It is a
process of ordering that serves as the mediat-
ing link between stimuli from the preparatory
and perseveratory sets. Here attitudes, beliefs,
information, and knowledge are examined
before a choice is made. There are three levels
of processing—an inadequate conceptual set,
a developing conceptual set, and a sophisti-
cated conceptual set.
The third and fourth components of each
subsystem are choice and action. Choice refers
to the individual’s repertoire of alternative
behaviors in a situation that will best meet the
goal and attain the desired outcome. The larger
the behavioral repertoire of alternative behav-
iors in a situation, the more adaptable is the
individual. The fourth structural component of
each subsystem is the observable action of the
individual. The concern is with the efficiency
and effectiveness of the behavior in goal attain-
ment. Actions are any observable responses
to stimuli.
For the eight subsystems to develop and
maintain stability, each must have a constant
supply of functional requirements (sustenal
imperatives). The concept of functional re-
quirements tends to be confined to conditions
of the system’s survival, and it includes biolog-
ical as well as psychosocial needs. The prob-
lems are related to establishing the types of
functional requirements (universal vs. highly
specific) and finding procedures for validating
the assumptions of these requirements. It also
suggests a classification of the various states or
processes on the basis of some principle and
perhaps the establishment of a hierarchy
among them. The Johnson model proposes
that for the behavior to be maintained, it must
be protected, nurtured, and stimulated: It re-
quires protection from noxious stimuli that
threaten the survival of the behavioral system;
nurturance, which provides adequate input to
sustain behavior; and stimulation, which con-
tributes to continued growth of the behavior
and counteracts stagnation. A deficiency in any
or all of these functional requirements threat-
ens the behavioral system as a whole, or the ef-
fective functioning of the particular subsystem
with which it is directly involved.
In systems theory, the term environment is de-
fined as the set of all objects for which a change
in attributes will affect the system as well as
those objects whose attributes are changed by
the behavior of the system (von Bertalanffy,
1968). Johnson referred to the internal and
external environment of the system. She also
referred to the interaction between the person
and the environment and to the objects, events,
and situations in the environment. She further
noted that there are forces in the environment
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that impinge on the person and to which the
person adjusts. Thus, the JBSM environment
consists of all elements that are not a part of the
individual’s behavioral system but that influ-
ence the system and can also serve as a source
of sustenal imperatives. Some of these elements
can be manipulated by the nurse to achieve
health (behavioral system balance or stability)
for the patient. Johnson provided no other spe-
cific definition of the environment, nor did she
identify what she considered internal versus ex-
ternal environment. But much can be inferred
from her writings, and system theory also pro-
vides additional insights into the environment
component of the model.
The external environment may include peo-
ple, objects, and phenomena that can poten-
tially permeate the boundary of the behavioral
system. This external stimulus forms an organ-
ized or meaningful pattern that elicits a re-
sponse from the individual. The behavioral
system attempts to maintain equilibrium in re-
sponse to environmental factors by assimilating
and accommodating to the forces that impinge
on it. Areas of external environment of interest
to nurses include the physical settings, people,
objects, phenomena, and psychosocial–cultural
attributes of an environment.
Johnson provided detailed information
about the internal structure and how it func-
tions. She also noted that “[i]llness or other
sudden internal or external environmental
change is most frequently responsible for sys-
tem malfunction” (Johnson, 1980, p. 212).
Such factors as physiology; temperament; ego;
age; and related developmental capacities, at-
titudes, and self-concept are general regulators
that may be viewed as a class of internalized
intervening variables that influence set, choice,
and action. They are key areas for nursing as-
sessment. For example, a nurse attempting to
respond to the needs of an acutely ill hospital-
ized 6-year-old would need to know some-
thing about the developmental capacities of a
6-year-old and about self-concept and ego de-
velopment to understand the child’s behavior.
Johnson viewed health as efficient and effective
functioning of the system and as behavioral
system balance and stability. Behavioral system
balance and stability are demonstrated by ob-
served behavior that is purposeful, orderly, and
predictable. Such behavior is maintained when
it is efficient and effective in managing the
person’s relationship to the environment.
Behavior changes when efficiency and ef-
fectiveness are no longer evident or when a
more optimal level of functioning is per-
ceived. Individuals are said to achieve effi-
cient and effective behavioral functioning
when their behavior is commensurate with
social demands, when they are able to modify
their behavior in ways that support biological
imperatives, when they are able to benefit to
the fullest extent during illness from the
physician’s knowledge and skill, and when
their behavior does not reveal unnecessary
trauma as a consequence of illness (Johnson,
1980, p. 207).
Behavior system imbalance and instability
are not described explicitly but can be inferred
from the following statement to be a malfunc-
tion of the behavioral system:
The subsystems and the system as a
whole tend to be self-maintaining and
self-perpetuating so long as conditions
in the internal and external environment
of the system remain orderly and pre-
dictable, the conditions and resources nec-
essary to their functional requirements are
met, and the interrelationships among the
subsystems are harmonious. If these con-
ditions are not met, malfunction becomes
apparent in behavior that is in part disor-
ganized, erratic, and dysfunctional. Illness
or other sudden internal or external envi-
ronmental change is most frequently re-
sponsible for such malfunctions. (Johnson,
1980, p. 212)
Thus, Johnson equated behavioral system
imbalance and instability with illness. How-
ever, as Meleis (2011) has pointed out, we
must consider that illness may be separate
from behavioral system functioning. Johnson
also referred to physical and social health but
did not specifically define wellness. Just as the
inference about illness may be made, it may
be inferred that wellness is behavioral system
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balance and stability, as well as efficient and
effective behavioral functioning.
Nursing and Nursing Therapeutics
Nursing is viewed as “a service that is com-
plementary to that of medicine and other
health professions, but which makes its own
distinctive contribution to the health and
well-being of people” (Johnson, 1980, p. 207).
She distinguished nursing from medicine by
noting that nursing views the patient as a
behavioral system, and medicine views the
patient as a biological system. In her view,
the specific goal of nursing action is “to re-
store, maintain, or attain behavioral system
balance and stability at the highest possible
level for the individual” (Johnson, 1980,
p. 214). This goal may be expanded to in-
clude helping the person achieve an optimal
level of balance and functioning when this is
possible and desired.
The goal of the system’s action is behavioral
system balance. For the nurse, the area of con-
cern is a behavioral system threatened by the
loss of order and predictability through illness
or the threat of illness. The goal of a nurse’s ac-
tion is to maintain or restore the individual’s
behavioral system balance and stability or to
help the individual achieve a more optimal
level of balance and functioning.
Johnson did not specify the steps of the
nursing process but clearly identified the role
of the nurse as an external regulatory force. She
also identified questions to be asked when an-
alyzing system functioning, and she provided
diagnostic classifications to delineate distur-
bances and guidelines for interventions.
Johnson (1980) expected the nurse to base
judgments about behavioral system balance
and stability on knowledge and an explicit
value system. One important point she made
about the value system is that
given that the person has been provided with
an adequate understanding of the potential
for and means to obtain a more optimal level
of behavioral functioning than is evident at
the present time, the final judgment of the
desired level of functioning is the right of the
individual. (Johnson, 1980, p. 215)
The source of difficulty arises from structural
and functional stresses. Structural and func-
tional problems develop when the system is un-
able to meet its own functional requirements.
As a result of the inability to meet functional
requirements, structural impairments may take
place. In addition, functional stress may be
found as a result of structural damage or from
the dysfunctional consequences of the behavior.
Other problems develop when the system’s
control and regulatory mechanisms fail to
develop or become defective.
Four diagnostic classifications to delineate
these disturbances are differentiated in the
model. A disorder originating within any one
subsystem is classified as either an insuffi-
ciency, which exists when a subsystem is not
functioning or developed to its fullest capacity
due to inadequacy of functional requirements,
or as a discrepancy, which exists when a be-
havior does not meet the intended conceptual
goal. Disorders found between more than one
subsystem are classified either as an incompat-
ibility, which exists when the behaviors of two
or more subsystems in the same situation con-
flict with each other to the detriment of the in-
dividual, or as dominance, which exists when
the behavior of one subsystem is used more
than any other, regardless of the situation or
to the detriment of the other subsystems. This
is also an area where Johnson believed addi-
tional diagnostic classifications would be de-
veloped. Nursing therapeutics address these
three areas.
The next critical element is the nature of the
interventions the nurse would use to respond
to the behavioral system imbalance. The first
step is a thorough assessment to find the source
of the difficulty or the origin of the problem.
There are at least three types of interventions
that the nurse can use to bring about change.
The nurse may attempt to repair damaged
structural units by altering the individual’s set
and choice. The second would be for the nurse
to impose regulatory and control measures. The
nurse acts outside the patient environment to
provide the conditions, resources, and controls
necessary to restore behavioral system balance.
The nurse also acts within and upon the exter-
nal environment and the internal interactions
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of the subsystem to create change and restore
stability. The third, and most common, treat-
ment modality is to supply or to help the client
find his or her own supplies of essential func-
tional requirements. The nurse may provide
nurturance (resources and conditions necessary
for survival and growth; the nurse may train the
client to cope with new stimuli and encourage
effective behaviors), stimulation (provision of
stimuli that brings forth new behaviors or in-
creases behaviors, provides motivation for a
particular behavior, and provides opportunities
for appropriate behaviors), and protection
(safeguarding from noxious stimuli, defending
from unnecessary threats, and coping with a
threat on the individual’s behalf). The nurse
and the client negotiate the treatment plan.
Applications of the Model
Fundamental to any professional discipline is
the development of a scientific body of knowl-
edge that can be used to guide its practice.
JBSM has served as a means for identifying,
labeling, and classifying phenomena important
to the nursing discipline. Nurses have used the
JBSM model since the early 1970s, and the
model has demonstrated its ability to provide
a medium for theoretical growth; organization
for nurses’ thinking, observations, and inter-
pretations of what was observed; a systematic
structure and rationale for activities; direction
to the search for relevant research questions;
solutions for patient care problems; and, fi-
nally, criteria to determine whether a problem
has been solved.
Practice-Focused Research
Stevenson and Woods (1986) stated: “Nursing
science is the domain of knowledge concerned
with the adaptation of individuals and groups
to actual or potential health problems, the en-
vironments that influence health in humans
and the therapeutic interventions that promote
health and affect the consequences of illness”
(1986, p. 6). This position focuses efforts in
nursing science on the expansion of knowledge
about clients’ health problems and nursing
therapeutics. Nurse researchers have demon-
strated the usefulness of Johnson’s model in a
clinical practice in a variety of ways. The ma-
jority of the research focuses on clients’ func-
tioning in terms of maintaining or restoring
behavioral system balance, understanding the
system and/or subsystems by focusing on the
basic sciences, or focusing on the nurse as an
agent of action who uses the JBSM to gather
diagnostic data or to provide care that influ-
ences behavioral system balance.
Derdiarian (1990, 1991) examined the
nurse as an action agent within the practice
domain. She focused on the nurses’ assess-
ment of the patient using the JBSM and the
effect of using this instrument on the quality
of care (Derdiarian, 1990, 1991). This ap-
proach expanded the view of nursing knowl-
edge from exclusively client-based to knowledge
about the context and practice of nursing that
is model-based. The results of these studies
found a significant increase in patient and
nurse satisfaction when the JBSM was used.
Derdiarian (1983, 1988; Derdiarian & Forsythe,
1983) also found that a model-based, valid,
and reliable instrument could improve the
comprehensiveness and the quality of assess-
ment data; the method of assessment; and the
quality of nursing diagnosis, interventions,
and outcome. Derdiarian’s body of work re-
flects the complexity of nursing’s knowledge
as well as the strategic problem-solving capa-
bilities of the JBSM. Her 1991 article in Nurs-
ing Administration Quarterly demonstrated the
clear relationship between Johnson’s theory
and nursing practice.
Others have demonstrated the utility of
Johnson’s model for clinical practice. Tamilarasi
and Kanimozhi (2009) used the JBSM to de-
velop interventions to improve the quality of
life of breast cancer survivors. Oyedele (2010)
used the JBSM to develop and test nursing in-
terventions to prevent teen pregnancy in South
African teens. Box 7-1 highlights other JBSM
research. Talerico (1999) found that the JBSM
demonstrated utility in accounting for differ-
ences in the expression of aggressive behavioral
actions in elders with dementia in a way that
the biomedical model has proved unable.
Wang and Palmer (2010) used the JBSM to
gain a better understanding of women’s toilet-
ing behavior, and Colling, Owen, McCreedy,
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and Newman (2003) used it to study the effec-
tiveness of a continence program for frail eld-
ers. Poster, Dee, and Randell (1997) found the
JBSM was an effective framework to evaluate
patient outcomes.
Johnson’s model was used as the basis for un-
dergraduate education at the UCLA School of
Nursing. The curriculum was developed by the
faculty; however, no published material is
available that describes this process. Texts by Wu
(1973) and Auger (1976) extended Johnson’s
model and provided some idea of the content
of that curriculum. Later, in the 1980s, Harris
(1986) described the use of Johnson’s theory
as a framework for UCLA’s curriculum. The
Universities of Hawaii, Alaska, and Colorado
also used the JBSM as a basis for their under-
graduate curricula.
Loveland-Cherry and Wilkerson (1983)
analyzed Johnson’s model and concluded that
the model could be used to develop a curricu-
lum. The primary focus of the program would
be the study of the person as a behavioral sys-
tem. The student would need a background in
systems theory and in the biological, psycho-
logical, sociological sciences, and genetics. The
mapping of the human genome and clinical
exome and genome sequencing has provided
evidence that genes serve as general regulators
of behavioral system activity.
Nursing Practice and Administration
Johnson has influenced nursing practice be-
cause she enabled nurses to make statements
about the links between nursing input and
health outcomes for clients. The model has
been useful in practice because it identifies an
end product (behavioral system balance),
which is nursing’s goal. Nursing’s specific ob-
jective is to maintain or restore the person’s
behavioral system balance and stability, or to
help the person achieve a more optimum level
of functioning. The model provides a means
for identifying the source of the problem in
the system. Nursing is seen as the external
regulatory force that acts to restore balance
(Johnson, 1980).
One of the best examples of the model’s
use in practice has been at the University of
California, Los Angeles, Neuropsychiatric
Institute. Auger and Dee (1983) designed a
patient classification system using the JBSM.
Each subsystem of behavior was operational-
ized in terms of critical adaptive and maladap-
tive behaviors. The behavioral statements were
designed to be measurable, relevant to the
clinical setting, observable, and specific to the
subsystem. The use of the model has had a
major effect on all phases of the nursing
process, including a more systematic assess-
ment process, identification of patient strengths
and problem areas, and an objective means for
evaluating the quality of nursing care (Dee &
Auger, 1983).
The early works of Dee and Auger led to
further refinement in the patient classification
system. Behavioral indices for each subsystem
have been further operationalized in terms of
critical adaptive and maladaptive behaviors.
Behavioral data is gathered to determine the
effectiveness of each subsystem (Dee, 1990;
Dee & Randell, 1989).
The scores serve as an acuity rating system
and provide a basis for allocating resources.
These resources are allocated based on the as-
signed levels of nursing intervention, and re-
source needs are calculated based on the total
number of patients assigned according to levels
of nursing interventions and the hours of nurs-
ing care associated with each of the levels (Dee
& Randell, 1989). The development of this
system has provided nursing administration
with the ability to identify the levels of staff
needed to provide care (licensed vocational
CHAPTER 7 • Dorothy Johnson’s Behavioral System Model and Its Applications 99
Box 7-1 Bonnie Holaday’s Research Highlighted
My program of research has examined nor-
mal and atypical patterns of behavior of chil-
dren with a chronic illness and the behavior
of their parents and the interrelationship be-
tween the children and the environment. My
goal was to determine the causes of instability
within and between subsystems (e.g., break-
down in internal regulatory or control mecha-
nisms) and to identify the source of problems
in behavioral system balance.
3312_Ch07_087-104 26/12/14 2:43 PM Page 99

nurse vs. registered nurse), bill patients for ac-
tual nursing care services, and identify nursing
services that are absolutely necessary in times
of budgetary restraint. Recent research has
demonstrated the importance of a model-
based nursing database in medical records
(Poster et al., 1997) and the effectiveness of
using a model to identify the characteristics of
a large hospital’s managed behavioral health
population in relation to observed nursing care
needs, level of patient functioning on admis-
sion and discharge, and length of stay (Dee,
Van Servellen, & Brecht, 1998).1
The work of Vivien Dee and her colleagues
has demonstrated the validity and usefulness
of the JBSM as a basis for clinical practice
within a health care setting. From the findings
of their work, it is clear that the JBSM estab-
lished a systematic framework for patient as-
sessment and nursing interventions, provided
a common frame of reference for all practition-
ers in the clinical setting, provided a frame-
work for the integration of staff knowledge
about the clients, and promoted continuity in
the delivery of care. These findings should be
generalizable to a variety of clinical settings.
100 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm
1 For additional information please see the bonus chap-
ter content available at
Practice Exemplar
Provided by Kelly White
During the change-of-shift report that morn-
ing, I was told that a new patient had just been
wheeled onto the floor at 7:00 a.m. As a result,
it was my responsibility to complete the ad-
mission paperwork and organize the patient’s
day. He was a 49-year-old man who was ad-
mitted through the emergency department to
our oncology floor for fever and neutropenia
secondary to recent chemotherapy for lung
Immediately after my initial rounds, to en-
sure all my patients were stable and comfort-
able, I rolled the computer on wheels into his
room to begin the nursing admission process.
Jim explained to me that he was diagnosed
with small cell lung carcinoma 2 months ear-
lier after he was admitted to another hospital
for coughing, chest pain, and shortness of
breath. He went on to explain that a recent
magnetic resonance imaging scan showed
metastasis to the liver and brain.
His past health history revealed that he ir-
regularly visited his primary health care
provider. He is 6 feet 3 inches tall and weighs
168 pounds (76.4 kg). He states that he has
lost 67 pounds in the past 6 months. His ap-
petite has significantly diminished because
“everything tastes like metal.” He has a history
of smoking three packs per day of cigarettes
for 30 years. He states he quit when he began
his chemotherapy.
Jim, a high school graduate, is married to
his high school sweetheart, Ellen. He lives
with his wife and three children in their
home. He and his wife are currently unem-
ployed secondary to recent layoffs at the fac-
tory where they both worked. He explained
that Ellen has been emotionally pushing him
away and occasionally disappears from the
home for hours at a time without explaining
her whereabouts. He informs me that before
his diagnosis, they were the best of friends
and inseparable.
He has tolerated his treatments well until
now, except for having frequent, burning, un-
controlled diarrhea for days at a time after
his chemotherapy treatments. These episodes
have caused raw, tender patches of skin
around his rectal area that become increas-
ingly more painful and irritated with each
bowel movement.
Jim is exceptionally tearful this morning as
he expresses concerns about his own future
and the future of his family. He informs me
that Ellen’s mother is flying in from out
of state to care for the children while he is
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CHAPTER 7 • Dorothy Johnson’s Behavioral System Model and Its Applications 101
Practice Exemplar cont.
Johnson’s behavioral systems model guided
the assessment process. The significant behav-
ioral data are as follows:
Achievement subsystem
Jim is losing control of his life and of the re-
lationships that matter most to him as a
person—his family.
He is a high school graduate.
Affiliative protective subsystem
Jim is married but states that his wife is dis-
tancing herself from him. He feels he is
losing his “best friend” at a time when he
really needs this support.
Aggressive protective subsystem
Jim is protective of his health now (he quit
smoking when he began chemotherapy)
but has a long history of neglecting it
(smoking for 30 years, unexplained weight
loss for 4 months, irregular visits to his
primary health-care provider).
Dependency subsystem
Jim is realizing his ability to care for self and
family is diminishing and will continue to
diminish as his health deteriorates. He
questions who he can depend on because
his wife is not emotionally available to him.
Eliminative subsystem
Jim is experiencing frequent, burning, un-
controlled diarrhea for days at a time
after his chemotherapy treatments. These
episodes have caused raw, tender patches
of skin around his rectal area that become
increasingly more painful and irritated
with each bowel movement.
Ingestive subsystem
Jim has lost 67 pounds in 6 months and
has decreased appetite secondary to the
chemotherapy side effects.
Restorative subsystem
Jim currently experiences shortness of breath,
pain, and fatigue.
Sexual subsystem
Jim has shortness of breath and possible pain
on exertion, which may be leading to con-
cerns about his sexual abilities.
Jim’s wife, Ellen, is distant these days,
which would have an effect on the
couple’s intimacy.
The environmental assessment is as follows:
After the admission process was completed, I
had several concerns for my new patient. I
recognized that Jim was a middle-aged man
whose developmental stage was compro-
mised regarding his productivity with fam-
ily and career due to his illness. Mental and
physical abilities could be impaired as this
disease process advances. In addition, this
may create further strain on his relationship
with his wife, as she attempts to deal with
her own feelings about his diagnosis. Fam-
ily support would be essential as Jim’s jour-
ney continued. Lastly, Jim needed to be
educated on the expectations of his diagno-
sis, participate in a plan for treatment dur-
ing his hospital stay, and assist in the
development of goals for his future.
Diagnostic Analysis
Jim is likely uncertain about his future as a hus-
band, father, employee, and friend. Realizing
this, I encouraged Jim to verbalize his concerns
regarding these four areas of his life while I
completed my physical assessment and assisted
him in settling into his new environment. At
first he was hesitant to speak about his family
concerns but soon opened up to me after I sat
down in a chair at his bedside and simply made
him my complete focus for 5 minutes. As a re-
sult of this brief interaction, together we were
able to develop short-term goals related to his
hospitalization and home life throughout the
rest of my shift with him that day. In addition,
he acquiesced and allowed me to order a social
work consult, recognizing that he would no
longer be able to adequately meet his family’s
needs independently at this time.
We also addressed the skin impairment is-
sues in his rectal area. I was able to offer him
ideas on how to keep the area from experiencing
further breakdown. Lastly, the wound care nurse
was consulted.
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102 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm
Practice Exemplar cont.
During his 10-day hospitalization, Jim and
his wife agreed to speak to a counselor regard-
ing their thoughts on Jim’s diagnosis and
prognosis upon his discharge. Jim’s rectal
area healed because he did not receive any
chemotherapy/radiation during his stay. He
received tips on how to prevent breakdown in
that area from the wound care nurse who took
care of him on a daily basis. Jim gained 3
pounds during his stay and maintained that he
would continue drinking nutrition supple-
ments daily, regardless of his appetite changes
during his cancer treatment. Jim’s stamina and
thirst for life grew stronger as his body grew
physically stronger. As he was being dis-
charged, he whispered to me that he was
thankful for the care he had received while on
our floor, and he believed that the nurses had
brought him and his wife closer than they had
been in months. He stated that they were talk-
ing about the future and that Ellen had ac-
knowledged her fears to him the previous
evening. Jim was wheeled out of the hospital
because he continued to have shortness of
breath on extended exertion. As his wife drove
away from the hospital, Jim waved to me with
a genuine smile and a sparkle in his eye.
Jim passed away peacefully 3 months later at
home, with his wife and children at his side.
His wife contacted me soon afterward to let
me know that the nursing care Jim received
during his first stay on our unit opened the
doors to allow them both to recognize that
they needed to modify their approach to the
course of his disease. In the end, they flour-
ished as a couple and a family, creating a sup-
portive transition for Jim and the entire family.
■ Summary
The Johnson Behavioral System Model cap-
tures the richness and complexity of nursing.
It also addresses the interdependent functional
biological, psychological, and sociological
components within the behavioral system and
locates this within a larger social system. The
JBSM focuses on the person as a whole, as well
as on the complex interrelationships among its
constituent parts. Once the diagnosis has been
made, the nurse can proceed inward to the
subsystem and outward to the environment. It
also asks nurses to be systems thinkers as they
formulate their assessment plan, make their di-
agnosis of the problem, and plan interventions.
The JBSM provides nurses with a clear con-
ception of their goal and of their mission as an
integral part of the health-care team.
Johnson expected the theory’s further devel-
opment in the future and that it would uncover
and shape significant research problems that
have both theoretical and practical value to the
discipline. Some examples include examining
the levels of integration (biological, psycholog-
ical, and sociocultural) within and between the
subsystems. For example, a study could examine
the way a person deals with the transition from
health to illness with the onset of asthma. There
is concern with the relations between one’s bi-
ological system (e.g., unstable, problems breath-
ing), one’s psychological self (e.g., achievement
goals, need for assistance, self-concept), self in
relation to the physical environment (e.g., aller-
gens, being away from home), and transactions
related to the sociocultural context (e.g., attitudes
and values about the sick). The study of transi-
tions (e.g., the onset of puberty, menopause,
death of a spouse, onset of acute illness) also rep-
resents a treasury of open problems for research
with the JBSM. Findings obtained from these
studies will provide not only an opportunity to
revise and advance the theoretical conceptual-
ization of the JBSM, but also information about
nursing interventions. The JBSM approach
leads us to seek common organizational param-
eters in every scientific explanation and does
so using a shared language about nursing and
nursing care.
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Chapter 8Dorothea Orem’s Self-Care
Deficit Nursing Theory
Introducing the Theorist
Overview of the Theory
Applications of the Theory
Practice Applications
Practice Exemplar by Laureen Fleck
Introducing the Theorist
Dorothea E. Orem (1914–2007) dedicated her
life to creating and developing a theoretical
structure to improve nursing practice. As a
voracious reader and extraordinary thinker, she
framed her ideas in both theoretical and the
practical terms. She viewed nursing knowledge
as theoretical, with conceptual structure and
elements 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 her reading of
philosophers such as Aristotle, Aquinas, Harre
(1970), and Wallace (1983) directed her think-
ing (Orem, 2006). She sought to understand
the phenomena she observed, creating concep-
tualizations of nursing education, disciplinary
knowledge, and finally, a general theory of
nursing or SCDNT.
Orem worked independently and then col-
laboratively until her death at age 93. For a
lifetime of contributions to nursing science and
practice, Orem received honors from organiza-
tions such as Sigma Theta Tau, 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. After her 1934 gradua-
tion, Orem quickly moved into hospital staff/
supervisory positions in operating and emer-
gency areas. Her BSN Ed from Catholic
University of America (1939) led to a faculty
position there. After completing her MSN Ed
at Catholic University (1946), Orem became
Dorothea E. Orem
3312_Ch08_105-132 26/12/14 5:50 PM Page 105

Director of Nursing Service and Education
at Provident Hospital School of Nursing in
Detroit (Taylor, 2007).
Orem’s early formulations on the nature of
nursing occurred while she was working for
the Indiana State Board of Health between
1949 and 1957 (Hartweg, 1991). She became
aware of nurses’ ability to “do nursing,” but
their inability to “describe nursing.” Without
this understanding, Orem believed nurses
could not improve practice. She made an ini-
tial effort to define nursing in a report titled
“The Art of Nursing in Hospital Service: An
Analysis” (Orem, 1956). The language of the
patient doing-for-self or the nurse helping to-
do-for-self appears in the report as antecedent
language for the concept of self-care.
During her tenure at the Office of Educa-
tion, Vocational Section in Washington, DC,
Orem generated a simple yet important ques-
tion: Why do people need nursing? In Guides
for Developing Curriculum for the Education of
Practical Nurses (Orem, 1959), she expanded
the question to what she termed “the proper
object of nursing”: “What condition exists in a
person when judgments are made that a
nurse(s) should be brought into the situation?”
(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
because of situations of personal health.
Although Orem worked independently,
two groups contributed to the theory’s early
development (Taylor, 2007). The first group
was the Nursing Model Committee at
Catholic University of America. In 1968, the
Nursing Development Conference Group
(NDCG) was formed and continued the work
of the Nursing Model committee. The collab-
orative process and outcomes were published
in Concept Formalization: Process and Product
(NDCG, 1973, 1979), edited by Orem. Con-
current with group work, Orem published the
first of six editions of Nursing: Concepts of
Practice (1971), which has been translated into
many languages.
By 1989, the global impact of Orem’s work
was evident when the First International self-
care deficit nursing theory Conference was
held in Kansas City (Hartweg, 1991). These
conferences encouraged international collabo-
ration among institutions.
In 1991, the International Orem Society
(IOS) for Nursing Science and Scholarship was
founded by a group of international scholars.
The IOS’s mission is “To disseminate informa-
tion related to development of nursing science
and its articulation with the science of self-care”
( This mission has been real-
ized through the publication of newsletters
(1993–2001) and a peer-reviewed journal,
Self-Care, Dependent Care & Nursing begun in
2002 ( Twelve
biennial Orem congresses have been held
throughout the world (Berbiglia, Hohmann, &
Bekel, 2012;
In 1995, Orem convened the Orem Study
Group. This international group of scholars met
regularly at her home in Savannah, GA, for im-
mersion in areas of SCDNT needing further
development. Several publications resulted from
this group work (Denyes, Orem, & Bekel,
2001; Taylor, Renpenning, Geden, Neuman, &
Hart, 2001). Work groups continue today to re-
fine or develop concepts such as the universal
requisite of normalcy (personal communication,
Taylor & Renpenning, January, 20, 2014).
Many of Orem’s original papers are pub-
lished in Self-Care Theory in Nursing: Selected
Papers of Dorothea Orem (Renpenning &
Taylor, 2003) and are also available in the
Mason Chesney Archives of the Johns
Hopkins Medical Institutions for the Orem
Collection (
papers/orem.html) and in the archives of the
IOS website. Audios and videos of the theo-
rist’s lectures are available through the Helene
Fuld Health Trust (1988) and the National
League for Nursing (1987). Self-Care Science,
Nursing Theory, and Evidence-based Practice
(Taylor & Renpenning, 2011) is the most
recent theory development and practice publi-
cation. Orem’s 50-year influence on nursing
science and practice is also summarized in
recent works by Clarke, Allison, Berbiglia, and
Taylor (2009) and by Taylor (2011).1
106 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm
1For additional information please see the bonus chapter
content available at
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Overview of the Theory
As noted earlier, Orem’s general theory of
nursing is correctly referred to as self-care
deficit nursing theory. Orem believed a general
model or theory created for a practical science
such as nursing encompasses not only the
What and Why, but also the Who and How
(Orem, 2006). This action theory therefore in-
cludes clear specifications for nurse and patient
roles. The grand theory originally comprised
three interrelated theories: the theory of self-
care, the theory of self-care deficit, and the
theory of nursing systems. A fourth, the theory
of dependent care, emerged over time to ad-
dress the complexity not only of the individual
in need of care but also of the caregivers whose
requisites and capabilities influence the design
of the nursing system (Taylor & Renpenning,
2011). The building blocks of these theories
are six major concepts, with parallel concepts
from the theory of dependent care, and one
peripheral concept. The following is a brief
overview of each theory and concept. Readers
are encouraged to study relevant sections in
Orem’s Concepts of Practice (2001) or other
citations to enhance understanding.
Foundational to learning any theory is explo-
ration of its underlying assumptions, the key to
conceptual understanding. Many principles
emerged from Orem’s independent work as well
as from discussions within the Nursing Develop-
ment Conference Group and the Nursing Study
Group. Five general assumptions/principles
about humans provided guidance to Orem’s
conceptualizations (Orem, 2001, p. 140). When
thinking about humans within the context of the
theory, Orem viewed two types: those who need
nursing care and those who produce it (Orem,
2006). In the simplest terms, this is the patient
and the nurse, respectively. These assumptions
also reveal human powers and properties neces-
sary for self-care. Consistent with most Orem
writings, the term patient is used to refer to the
recipient of care.
Four Constituent Theories Within
Self-Care Deficit Nursing Theory
Each theory includes a central idea, presuppo-
sitions, and propositions. The central idea
presents the general focus of the theory, the
presuppositions are assumptions specific to this
theory, and the propositions are statements
about the concepts and their interrelationships.
The propositions have changed over time with
SCDNT refinement. These occurred in part
through theory testing that validated or inval-
idated hypotheses generated from the relation-
ships. As Orem used terminology at various
levels of abstraction within constituent theo-
ries, the reader is advised to thoroughly study
SCDNT concepts, including the synonyms.
For example, agency is also called capability,
ability and/or power.
1. Theory of Self-Care (TSC)
The central idea describes self-care in contrast
to other forms of care. Self-care, or care for
oneself, must be learned and be deliberately
performed for life, human functioning, and
well-being. Six presuppositions articulate
Orem’s notions about necessary resources, ca-
pabilities for learning, and motivation for self-
care. However, there are situational variations
that affect self-care such as culture.
Orem (2001) expanded two sets of propo-
sitions from previous writings. She introduced
requirements necessary for life, health, and
well-being and explained the complexity of a
self-care system. A person performing self-care
must first estimate or investigate what can and
should be done. This is a complex action of
knowing and seeking information on specific
care measures. The self-care sequence contin-
ues by deciding what can be done and finally pro-
ducing the care (see Orem, 2001, pp. 143–145).
2. Theory of Dependent Care
Taylor and others (2001) formalized the the-
ory of dependent care as a corollary theory to
the theory of self-care. Concepts within the
theory of dependent care (TDC) parallel those
in the theory of self-care. Assumptions relate
to the nature of interpersonal action systems
and social dependency. Within a particular so-
cial unit such as a family, the self-care agent
(the patient) is in a socially dependent rela-
tionship with the person or persons providing
care, such as a parent (the dependent-care
agent). The presence of a self-care deficit of
CHAPTER 8 • Dorothea Orem’s Self-Care Deficit Nursing Theory 107
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the dependent also gives rise to the need for
nursing (Taylor & Renpenning, 2011; Taylor,
Renpenning, Geden, Neuman, & Hart, 2001).
3. Theory of Self-Care Deficit
The central idea describes why people need nurs-
ing (Orem, 2001, pp. 146–147). Requirements
for nursing are health-related limitations for
knowing, deciding, and producing care to self.
Orem presents two sets of presuppositions that
articulate this theory with the theory of self-
care and what she calls the idea of social de-
pendency. To engage in self-care, persons must
have values and capabilities to learn (to know),
to decide, and to manage self (to produce and
regulate care). The second set presents the con-
text of nursing as a health service when people
are in a state of social dependency.
The theory of self-care deficit (TSCD) in-
cludes nine propositions called principles or
guides for future development and theory test-
ing. These statements are essential ideas of the
larger, SCDNT. Orem describes the situations
that affect legitimate nursing. Nursing is legit-
imate or needed when the individual’s self-care
capabilities and care demands are equal to, less
than, or more than at a point in time. With the
existence of this inequity, a self-care deficit ex-
ists, and nursing is needed. In a dependent-
care system, a self-care deficit exists in the
patient as well as a dependent-care deficit in a
caregiver. The latter is an inequity between the
dependent-care demand and agency (abilities)
to care for the person in need of health care.
Legitimate nursing also occurs when a future
deficit relationship is predicted such as an up-
coming surgery.
4. Theory of Nursing Systems
The fourth theory, the theory of nursing sys-
tems (TNS), encompasses the three others.
The central focus is the product of nursing,
establishing both structure and content for
nursing practice as well as the nursing role (see
Orem, 2001, pp. 111, 147–149). The four pre-
suppositions direct the nurse to major com-
plexities of nursing practice. For example,
Orem stated that “Nursing has results-achieving
operations that must be articulated with the in-
terpersonal and societal features of nursing”
(Orem, 2001, p. 147). Although much of the
theory relates to diagnosis, actions, and out-
comes based on a deficit relationship between
self-care capabilities and self-care demand,
Orem also presents theoretical work related to
the interpersonal relationship between nurse
and person(s) receiving nursing and a social
contract between the nurse and patient(s)
(Orem, 2001, pp. 314–317). These compo-
nents are often overlooked when studying the
SCDNT and are important antecedents and
concurrent actions in the process of nursing.
The theory of nursing systems includes
seven propositions related to most SCDNT
concepts but adds nursing agency (capabilities
of the nurse) and nursing systems (complex ac-
tions). Nursing agency and nursing systems are
linked to the concepts of the person receiving
care or dependent care, such as self-care capa-
bilities (agency), self-care demands (therapeu-
tic self-care demand), and limitations (deficits)
for self-care. Through this, the general theory
or SCDNT becomes concrete to the practicing
nurse. Although the language is implicit,
Orem proposes that nursing systems are deter-
mined by the person’s (or dependent-care
agent’s) self-care limitations (capabilities in
relationship to health-related self-care or
dependent-care demand). Nursing systems
therefore vary by the amount of care the nurse
must provide, such as a total care system, or
wholly compensatory system (e.g., unconscious
critical care patient); partial care, or partially
compensatory system (e.g., patient in rehabil-
itation); or supportive-educative system (e.g.,
patient needing teaching).
Theoretical development by Orem scholars
and others continues as nursing practice
evolves. The addition of the theory of depend-
ent care is a major example and extends basic
concepts, such as adding “dependent-care sys-
tem” (Taylor & Renpenning, 2011). Other
concepts such as self-care and self-care requi-
sites, their processes and core operations, con-
tinue to be explicated (Denyes, Orem & Bekel,
2001). Some researchers or theorists develop
the subconcepts of basic concepts such as self-
care agency through exploration of congruent
theories. For example, Pickens (2012) proposed
exploration of motivation, a foundational
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capability and power component of self-care
agency, through examination of several theories
including self-determination theory (Ryan,
Patrick, Deci, & Williams, 2008). Others cre-
ate new concepts, such as spiritual self-care
(White, Peters, & Schim, 2011) or extend gen-
eral concepts such as environment (Banfield,
SCDNT is constructed from six basic con-
cepts and a peripheral concept. Four concepts
are patient related: self-care/dependent care,
self-care agency/dependent-care agency, ther-
apeutic self-care demand/dependent-care de-
mand, and self-care deficit/dependent-care
deficit. Two concepts relate to the nurse:
nursing agency and nursing system. Basic
conditioning factors, the peripheral concept,
is related to both the self-care agent (person
receiving care)/dependent-care agent (family
member/friend providing care) and also to
the nurse (nurse agent). Orem defines agent
as the person who engages in a course of action
or has the power to do so (Orem, 2001,
p. 514). Hence there is a self-care agent, a
dependent-care agent, and a nurse agent.
The unit of service is a person(s), whether
that is the individual (self-care agent) or
another on whom the person is socially de-
pendent (dependent-care agent). Orem also
addresses multiperson situations and multi-
person units such as entire families, groups,
or communities.
Each concept is defined and presented with
levels of abstraction. Varied constructs within
each concept allow theoretical testing at the
level of middle-range theory or at the practice
application level whether with the individual
or multiperson situations. All constructs and
concepts build on decades of Orem’s inde-
pendent and collaborative work. A “kite-like”
model provides a visual guide for the six con-
cepts and their interrelationships (Fig. 8-1).
For a model of concepts and relationships of
dependent care, the reader is referred to Taylor
and Renpenning (2011, p. 112). For a model
of multiperson structure, the reader is referred
to Taylor and Renpenning (2001).
Basic Conditioning Factors
A peripheral concept, basic conditioning factors
(BCFs), is related to three major concepts. For
simplicity, only the patient component is pre-
sented rather than the parallel dependent-care
components. In general, basic conditioning fac-
tors relate to the patient concepts (self-care
agency and therapeutic self-care demand) and
CHAPTER 8 • Dorothea Orem’s Self-Care Deficit Nursing Theory 109
Fig 8 • 1 Structure of SCDNT.
3312_Ch08_105-132 26/12/14 5:50 PM Page 109

one nurse concept (nursing agency). These
conditioning factors are values that affect the
constructs: age, gender, developmental state,
health state, sociocultural orientation, health-
care system factors, family system factors, pat-
tern of living, environmental factors, and
resource availability and adequacy (Orem, 2001,
p. 245). For example, the family system factor
such as living alone or with others may affect
the person’s ability (self-care agency) to care
for self after hospital discharge. The self-care
demand (care requirements) of a person taking
insulin for type 2 diabetes will vary based
on availability of resources and health system
services (e.g., access to medications and care
services). These same BCFs apply to nursing
agency, such as health state. A nurse with recent
back surgery may have limitations in nursing
capabilities (nurse agency) in relationship to
specific care demands of the patient.
These BCF categories have many subfactors
that have not been explicitly defined and con-
tinue in development. For example, sociocul-
tural orientation refers to culture with its
various components such as values and prac-
tices. Sociocultural includes economic condi-
tions as well as others. The BCFs related to
nursing agency include those such as age but
expand to include nursing experience and ed-
ucation. A clinical specialist in diabetes usually
has more capabilities in caring for the self-care
agent with type 2 diabetes than one without
such credentials. All these affect the parame-
ters of the nurse’s capability to provide care.
Self-Care (Dependent Care)
Orem (2001) defined self-care as the practice of
activities that individuals initiate and perform on
their own behalf in maintaining life, health, and
well-being (p. 43). Self-care is purposeful ac-
tion performed in sequence and with a pattern.
Although engagement in purposeful self-care
may not improve health or well-being, a posi-
tive outcome is assumed. Dependent care is
performed by mature, responsible persons on
behalf of socially dependent individuals or self-
care agents such as an infant, child, or cognitively
impaired person. The purpose is to meet the
person’s health-related demands (dependent-
care demand) and/or to develop their self-care
capabilities (self-care agency; Taylor et al.,
2001; Taylor & Renpenning, 2011).
Although the practice of maintaining life is
self-explanatory, Orem (2001) viewed outcomes
of health and well-being as related but different.
Health is a state of physical–psychological,
structural–functional soundness and wholeness.
In contrast, well-being is conceived as experi-
ences of contentment, pleasure, and kinds of happi-
ness; by spiritual experiences; by movement toward
fulfilment of one’s self-ideal; and by continuing
personalization (Orem, 2001, p. 186). Self-care
performed deliberately for well-being versus
structural–functional health was conceptualized
and developed as health promotion self-care by
Hartweg (1990, 1993) and Hartweg and
Berbiglia (1996). Exploration of the relation-
ship between self-care and well-being was later
conducted by Matchim, Armer, and Stewart
Key to understanding self-care and depend-
ent care is the concept of deliberate action, a
voluntary behavior to achieve a goal. Deliberate
action is preceded by investigating and deciding
what choice to make (Orem, 2001). In practice,
the nurse’s understanding of each of these
phases of investigating, deciding, and produc-
ing self-care is essential for positive health
outcomes. Take two situations: A pregnant
woman avoids alcohol for her fetus’s health
and a woman with breast cancer requires
chemotherapy for life and health. Each woman
must first know and understand the relation-
ship of self-care to life, health, and well-being.
Decision making follows, such as deciding to
avoid alcohol or choosing to engage in
chemotherapy. Finally, the individual must
take action, such as not drinking when offered
alcohol or accepting chemotherapy treatment.
Without each phase, self-care does not occur.
The pregnant woman may know the dangers to
her fetus and decide not to drink but engage in
drinking when pressured to do so. The woman
with cancer may understand the health out-
come without treatment, decide to have
treatment, then not follow through because
transportation to chemotherapy sessions dis-
rupts her husband’s employment. Because each
phase of the action sequence has many compo-
nents, nurses often provide partial support to
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patients and self-care action does not occur. If
skills related to the operation to avoid alcohol
when pressured or the operations necessary for
transportation to a cancer center are not antic-
ipated by the nurse for these patients, the self-
care action sequences may not be completed.
Then outcomes related to life, health, and well-
being are affected.
Self-Care Agency (Dependent
Care Agency)
Orem (2001) defined self-care agency (SCA)
as complex acquired capability to meet one’s con-
tinuing requirements for care of self that regulates
life processes, maintains or promotes integrity of
human structure and functioning [health] and
human development, and promotes well-being
(p. 254). Capability, ability, and power are all
terms used to express agency. Self-care agency
is therefore the mature or maturing individ-
ual’s capability for deliberate action to care for
self. Dependent care agency is a complex ac-
quired ability of mature or maturing persons to
know and meet some or all of the self-care requi-
sites of persons who have health-derived or health
associated limitations of self-care agency, which
places them in socially dependent relationships for
care (Taylor & Renpenning, 2011, p. 108).
Viewed as the summation of all human capabil-
ities needed for performing self-care, these range
from a very basic ability, such as memory, to
capability for a specific action in a sequence to
meet a specific self-care demand or require-
ment. At this concrete level, the capabilities of
knowing, deciding, and acting or producing
self-care are necessary. If these capabilities do
not exist, then the abilities of others are nec-
essary, such as the family member or the nurse.
A three-part, hierarchical model of self-care
agency provides a visualization of this structure
(Fig. 8-2). Understanding these elements is
necessary to determine the self-care agent role,
dependent-care agent role, and the nurse role.
Foundational Capabilities
and Dispositions
Foundational capabilities and dispositions are
at the most basic level (Orem, 2001, pp. 262–
263). These are capabilities for all types of
deliberate action, not just self-care. Included
are abilities related to perception, memory,
and orientation. One example is the deliberate
act of repairing a car. One must have perception
of the concept of the car and its parts, memory
of methods of repair, and orientation of self to
the equipment and vehicle. If these founda-
tional abilities are not present, then actions
cannot occur.
Power Components
At the midlevel of the hierarchy are the power
components, or 10 powers or types of abilities
necessary for self-care. Examples are the valu-
ing of health, ability to acquire knowledge
about self-care resources, and physical energy
for self-care. At a very general level, these ca-
pabilities relate to knowledge, motivation, and
skills to produce self-care. If a mature person
becomes comatose, the abilities to maintain at-
tention, to reason, to make decisions, to phys-
ically carry out the actions are not functioning.
The self-care actions necessary for life, health,
and well-being must then be performed by the
dependent-care agent or the nurse agent.
Capabilities for Estimative,
Transitional, and Productive
The most concrete level of self-care agency is
one specific to the individual’s detailed com-
ponents of self-care demand or requirements.
Capabilities related to estimative operations
are those necessary to determine what self-care
CHAPTER 8 • Dorothea Orem’s Self-Care Deficit Nursing Theory 111
for self-care
Power components
(enabling capabilities
for self-care)
Foundational capabilities
and disposition
Fig 8 • 2 Structure of self-care agency.
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actions are needed in a specific nursing situa-
tion at one point in time—in other words, ca-
pabilities of investigating and estimating what
needs to be done. This includes capabilities of
learning in situations related to health and
well-being. For example, does the person
newly diagnosed with asthma have the capa-
bility to learn about regular exercise activities
and rescue medication? Does the person know
how to obtain the necessary resources? Tran-
sitional operations relate to abilities necessary
for decision making, such as reflecting on the
course of action and making an appropriate
decision. The patient may have the capabilities
to learn and obtain resources but not the ability
to make the decision. The asthma patient has
the capability to learn about exercise and med-
ication but not the capability to make the
decision to follow through on directions.
Capabilities for productive operations are
those necessary for preparing the self for the
action, carrying out the action, monitoring the
effects, and evaluating the action’s effective-
ness. If the person decides to use the inhaler,
does the person have the ability to take time to
engage in the necessary self-care, to physically
push the device, to monitor the changes, and
determine the effectiveness of the action? Just
as the action sequence is important in the self-
care concept, these types of capabilities reveal
the complexity of human capability.
At the concrete practice level, self-care
agency also varies by development and oper-
ability. For example, the nurse must determine
whether capabilities for learning are fully de-
veloped at the level necessary to understand
and retain information about the required ac-
tions. For example, a mature adult with late
stage Alzheimer’s disease is not able to retain
new information. The self-care agency is there-
fore developed but declining, creating the possi-
ble need for dependent-care agency or nursing
agency. A second determination is the oper-
ability of agency. Is agency not operative, par-
tially operative, or fully operative? A comatose
patient may have fully developed capabilities
before a motor vehicle accident, but the trauma
results in inoperable cognitive functioning.
SCA is therefore developed, but not operative at
that moment in time. In this situation, the
nurse agent must provide care. Similar varia-
tions of development and operability occur
with dependent-care agency and must be con-
sidered by the nurse when developing the self-
care or dependent-care system.
Therapeutic Self-Care Demand
(Dependent-Care Demand)
Therapeutic self-care demand (TSCD) is a
complex theoretical concept that summarizes
all actions that should be performed over time
for life, health, and well-being. When first de-
veloped, the concept was referred to as action
demand or self-care demand (Orem, 2001).
Readers will therefore see these terms used in
Orem’s writings and in the literature. Dependent
care demand is the summation of all care actions
for meeting the dependent caregiver’s therapeutic
self-care demand when his or her agency is not ade-
quate or operational (Taylor & Renpenning,
2011, p. 108).
The word therapeutic is essential to one’s un-
derstanding of the concept. Consideration is
always on a therapeutic outcome of life, health,
and well-being. A Haitian mother in a remote
village may expect to apply horse or cow dung
to the severed umbilical cord to facilitate dry-
ing, a culturally adjusted self-care measure for
a newborn. With horse/cow dung as the major
carrier of Clostridium tetanus, this dependent-
care action may lead to disease and infant
death, not a therapeutic outcome.
Constructing or calculating a TSCD re-
quires extensive nursing knowledge of evi-
denced-based practice, communication, and
interpersonal skills. Both scientific nursing
knowledge and knowledge of the person and
environment are merged to formulate what
needs to be done in a particular nursing situation
(NDCG, 1979). The process of calculating the
TSCD includes adjusting values by the basic
conditioning factors. For example, a mental
health patient will have different needs based
on the type of mental health condition (health
state), family system factors, and health-care
Self-Care Requisites
To provide the framework for determining the
TSCD, Orem developed three types of self-care
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requisites (or requirements): universal, develop-
mental, and health deviation. These are the pur-
poses or goals for which actions are performed for
life, health, and well-being. The individual
sleeps once each day and engages in daily activ-
ities to meet the requisite or goal of maintaining
a balance of activity and rest. Without rest, a
human cannot survive. Therefore, these are gen-
eral statements within a three-part framework
that provide a level of abstraction similar to the
power components of self-care agency. Denyes
et al. (2001) explicated the self-care requisite to
maintain an adequate intake of water. Their work
demonstrates the complexity of actions neces-
sary to meet a basic human need. Without con-
sideration of this complexity, analysis and
diagnosis of patient requirements is not com-
plete. This scholarly contribution by Denyes and
others (2001) can serve as a model for structur-
ing information regarding all other requisites
(personal communication, Dr. Susan G. Taylor,
March 12, 2013).
Universal Self-Care Requisites
The eight universal self-care requisites (USCR)
are necessary for all human beings of all ages
and in all conditions, such as air, food, activity
and rest, solitude, and social interaction. The
BCFs influence the quality and quantity of the
action necessary to achieve the purpose. Ac-
tions to be performed over time that meet the
requisite, prevention of hazards to human life,
human functioning, and human well-being (the
purpose), will vary for an infant (e.g., keeping
crib rails up) versus an adult (e.g., ambulation
safety). Some requisites are very general yet
provide important concepts necessary for all
humans. One example is the concept of nor-
malcy, the eighth USCR. The goal is promotion
of human functioning and development within
social groups in accord with human potential,
human limitations, and the human desire to be
normal (Orem, 2001, p. 225). Practice exam-
ples in the literature have emerged, such as the
importance of normalcy to individuals with
learning disabilities (Horan, 2004). These two
requisites, prevention of hazards and promo-
tion of normalcy, also relate to the other six
USCRs. For example, when maintaining a
sufficient intake of food, one must consider
hazards to ingestion of food such as avoiding
Developmental Self-Care Requisites
Orem (2001) identified three types of devel-
opmental self-care requisites (DSCRs). The
first refers to actions necessary for general
human developmental processes throughout
the life span. These requisites are often met by
dependent-care agents when caring for devel-
oping infants and children or when disaster and
serious physical or mental illness affects adults.
Engagement in self-development, the second
DSCR, refers to demands for action by indi-
viduals in positive roles and in positive mental
health. Examples include self-reflection,
goal-setting, and responsibility in one’s roles.
The third DSCR, interferences with develop-
ment, expresses goals achieved by actions that
are necessary in situational crises such as loss
of friends and relatives, loss of job, or terminal
illness. Originally subsumed under USCRs,
Orem created the developmental self-care
requisite category to indicate the importance
of human development to life, health, and
Health Deviation Self-Care Requisites
Health deviation self-care requisites (HDSCR)
are situation-specific requisites or goals when
people have disease, injuries, or are under pro-
fessional medical care. These six requisites
guide actions when pathology exists or when
medical interventions are prescribed. The first
HDSCR refers in part to a patient purpose: to
seek and secure appropriate medical assistance for
genetic, physiological, or psychological conditions
known to produce or be associated with human
pathology (Orem, 2001, p. 235). For a person
with history of breast cancer, seeking regular
diagnostic tests is a goal to preserve life, health,
and well-being. A teenager in treatment for se-
vere acne takes action to meet HDSCR 5: to
modify the self-concept (and self-image) in ac-
cepting oneself as being in a particular state of
health and in need of a specific form of health care
(Orem, p. 235).
Each TSCD, through the three types of
self-care requisites, is individualized and ad-
justed by the basic conditioning factors (BCFs)
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such as age, health state, and sociocultural ori-
entation. Once adjusted to the specific patient
in a unique situation, the purposes are specific
for the patient or type of patient. These are
called “particularized self-care requisites.”
Dennis and Jesek-Hale (2003) proposed a list
of particularized self-care requisites for a nurs-
ing population of newborns. Although created
for nursery newborns, a group particularized
by age, the individual patient adjustments are
then made. For example, a newborn’s sucking
needs may vary, necessitating variation in feed-
ing methods. More recent nursing literature
continues to expand the types of requisites var-
ied by specific diseases or illnesses that provide
a basis for application to specific patients and
Self-Care Deficit (Dependent-Care
As a theoretical concept, self-care deficit ex-
presses the value of the relationship between
two other concepts: self-care agency and ther-
apeutic self-care demand (Orem, 2001). When
the person’s self-care agency is not adequate to
meet all self-care requisites (TSCD), a self-
care deficit exists. This qualitative and quanti-
tative relationship at the conceptual level of
abstraction is expressed as “equal to,” “more
than,” or “less than” (see Fig. 8-1). A deficit
relationship is also described as complete or
partial; a complete deficit suggests no capabil-
ity to engage in self-care or dependent care.
An example of a complete deficit may exist in
a premature infant in a neonatal intensive care
unit. A partial self-care deficit may exist in a
patient recovering from a routine bowel resec-
tion 1 day after surgery. This person is able to
provide some self-care.
Understanding self-care deficit is necessary
to appreciate Orem’s concept of legitimate nurs-
ing. If a nurse determines a patient has self-care
agency (estimative, transitional, and productive
capabilities) to carry out a sequence of actions
to meet the self-care requisites, then nursing is
not necessary. A self-care deficit or anticipated
self-care deficit must exist before a nursing sys-
tem is designed and implemented. The nurse
reflects with the patient: Is self-care agency
(and/or dependent-care agency) adequate to
meet the therapeutic self-care demand? If ade-
quate, there is no need for nursing.
A dependent-care deficit is a statement of
the relationship between the dependent-care
demand and the powers and capabilities of the
dependent-care agent to meet the self-care
deficit of the socially dependent person, the
self-care agent (Taylor & Renpenning, 2011).
When this deficit occurs, then a need for nurs-
ing exists. When a parent has the capabilities
to meet all health-related self-care requisites
of an ill child, then no nursing is needed.
When an existing or potential self-care deficit
is identified and legitimate nursing is needed, an
analysis by the nurse/patient/dependent-care
agents results in identification of types of limi-
tations in relationship to the particularized self-
care requisites. These are generally described as
limitations of knowing, limitations or restric-
tions of decision-making, and limitations in
ability to engage in result-achieving courses of
action. Orem classified these into sets of limi-
tations (Orem, 2001, pp. 279–282).
Nursing System (Dependent-Care
Orem describes a nursing system as an “action
system,” an action or a sequence of actions per-
formed for a purpose. This is a composite of all
the nurse’s concrete actions completed or to be
completed for or with a self-care agent to pro-
mote life, health, and well-being. The compos-
ite of actions and their sequence produced by
the dependent-care agent to meet the thera-
peutic dependent self-care demand is termed
a dependent-care system (Taylor et al., 2001).
These actions relate to three types of subsys-
tems: interpersonal, social/contractual, and
The interpersonal subsystem includes all
necessary actions or operations such as enter-
ing into and maintaining effective relation-
ships with the patient and/or family or others
involved in care. The social/contractual subsys-
tem relates to all nursing actions/operations to
reach agreements with the patient and others
related to information necessary to determine
the therapeutic self-care demand and self-care
agency of an individual and caregivers. Within
this subsystem, the nurse, in collaboration with
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the patient or dependent-caregiver, determines
roles for all care participants (Orem, 2001).
These are based on social norms and other
variables such as basic conditioning factors.
Although other nursing theories emphasize in-
terpersonal interactions, Orem’s general theory
clearly specifies details of interpersonal and
contractual operations as necessary antecedents
and concurrent components of care. This ele-
ment of Orem’s model is often overlooked and
clarifies the decision-making process and col-
laborative relationship within the nurse–
patient–family/multiperson roles.
The professional–technological subsystem
comprises actions/operations that are diagnostic,
prescriptive, regulatory, evaluative, and case
management. The latter involves placing all
operations within a system that uses resources
effectively and efficiently with a positive pa-
tient outcome. Orem views the professional–
technological subsystem as the process of
nursing, a nonlinear one that integrates all
operations of this subsystem with those of the
interpersonal and the social–contractual. This
involves collecting data to determine existing
and projected universal, developmental, and
health-deviation self-care requisites, and meth-
ods to meet these requisites as adjusted by the
basic conditioning factors. Using the interper-
sonal and social–contractual subsystems, the
nurse incorporates modifications of her or his
diagnosis and prescriptions in collaboration with
the patient and family on what is possible. The
nurse also identifies the patient’s usual self-care
practices and assesses the person’s estimative,
transitional, and productive capabilities for
knowledge, skills, and motivation in relationship
to the known self-care requisites. That is, are the
capabilities (self-care agency/dependent-care
agency) needed to meet the self-care requisites
developed, operable, and adequate? Are there
limitations in knowing, deciding, or producing
self-care? If no limitations exist, then there is no
need for nursing and no nursing system is devel-
oped. If there is a self-care deficit or dependent-
care deficit, then the nurse and patient or
caregivers reach agreement about the patient’s
role, the family’s role, and/or the nurse’s role.
Orem (2001) charted the progression of these
steps by subsystems (pp. 311, 314–317).
With determination of a real or potential
self-care deficit or dependent-care deficit, the
nurse develops one of three types of nursing
systems: wholly compensatory, partly compen-
satory, or supportive-educative (developmen-
tal). The nurse then continues the query: Who
can or should perform actions that require move-
ment in space and controlled manipulation?
(Orem, 2001, p. 350). If the answer is only the
nurse, then a wholly compensatory system is
designed. If the patient has some capabilities
to perform operations or actions, then the
nurse and patient share responsibilities. If the
patient can perform all actions that control
movement in space and controlled manipula-
tion, but nurse actions are required for support
(physical or psychological), then the system is
supportive–educative. Note, in all systems, the
self-care deficit is the necessary element that
leads to the design of a nursing system. Using
the interpersonal and social–contractual oper-
ations, the nurse first enters into an interper-
sonal relationship and an agreement to
determine a real or potential self-care deficit,
prescribe roles, and implement productive
operations of self-care and/or dependent
care. Regulation or treatment operations are
designed or planned and then produced or
performed. Control operations are used to
appraise and evaluate the effectiveness of
nursing actions and to determine whether
adjustments should be made. These ap-
praisals emphasize validity of operations or
actions in relationship to standards. Selecting
valid operations in the plan and in evaluation
incorporate evidence-based practices. These
processes, including diagnosis, prescription,
designing, planning, regulating, and control-
ling, can be viewed as elements of Orem’s
steps in the process of nursing (Fig. 8-3).
Orem’s language of the nursing process
varies from the standard language of assess-
ment, diagnosis, planning, implementation,
and evaluation. The interaction of the three
aforementioned subsystems creates a model for
true collaboration with the recipient of care or
the caregiver.
The three steps of Orem’s process of nurs-
ing are as follows: (1) diagnosis and prescrip-
tion, (2) design and plan, and (3) produce and
CHAPTER 8 • Dorothea Orem’s Self-Care Deficit Nursing Theory 115
3312_Ch08_105-132 26/12/14 5:50 PM Page 115

control. For example, Orem considers the term
“assessment” too limiting. Within Orem’s
process, assessments are made throughout the
iterative social–contractual and professional-
technological operations. During the first step
of diagnosis, data are collected on the basic
conditioning factors and a determination is
made about their relationship to the self-care
requisites and to self-care agency. How does
health state (e.g., type 2 diabetes) affect the
individual’s universal, developmental, and
health-deviation self-care requirements? How
does the basic conditioning factor, or health
state, affect the individual’s self-care agency
(capabilities)? What, if any, are limitations
for deliberate action related to the estimative
(investigative–knowing), transitional (decision
making), and productive (performing) phases
of self-care? (Orem, 2001, p. 312). The nurse
collects information, analyses it, and makes
judgments about the information within the
limits of nursing agency (capabilities of the
nurse, such as expertise).
Orem describes nursing as a specialized
helping service and identifies five helping
methods to overcome self-care limitations or
regulate functioning and development of pa-
tients or their dependents. Nurses employ one
or more of these methods throughout the
process of nursing, including acting for or
doing for another, guiding another, supporting
another, providing for a developmental envi-
ronment, and teaching another (Orem, 2001,
pp. 56–60). Acting for or doing for another in-
cludes physical assistance such as positioning
the patient. Assuming self-care agency that is
developed and operable, the nurse replaces this
method with others that focus on cognitive de-
velopment, such as guiding and teaching.
These methods are not unique to nursing, but
are used by most health professionals. Through
their unique role functions, nurses perform a
specific sequence of actions in relationship to
the identified patient and/or dependent-care
agent’s self-care limitations in combination
with other health professionals to meet the
self-care requirements.
Although comparisons are made between
these steps and those of the general nursing
process, Orem’s complexity is unique in ad-
dressing an integration of interpersonal, social–
contractual, and professional–technological
subsystems. The intricacy of her steps is also ev-
ident in the complexity of the diagnostic and
prescriptive components. The practice exemplar
in this chapter provides one simplified example
of this process.
Nursing Agency
Nursing agency is the power or ability to nurse.
The agency or capabilities are necessary to know
and meet patients’ therapeutic self-care demands
and to protect and to regulate the exercise of devel-
opment of patient’s self-care agency (Orem, 2001,
116 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm
Accomplishes patient’s
therapeutic self-care
Accomplishes self-care
Regulates the exercise
and development of
self-care agency
Compensates for patient’s
inability to engage in
Supports and protects
Performs some self-care
measures for patient
Compensates for self-care
limitations of patient
Assists patient as required
Performs some self-care
Regulated self-care
Accepts care and
assistance from nurse
Wholly compensatory system
Partly compensatory system
Supportive-educative system
Fig 8 • 3 Basic nursing system.
3312_Ch08_105-132 26/12/14 5:50 PM Page 116

p. 290). Nursing agency is analogous to self-
care agency but with capabilities performed on
behalf of “legitimate patients.” Similar to self-
care agency, nursing agency is affected by basic
conditioning factors. The nurse’s family system,
as well as nursing education and experience,
may affect his or her ability to nurse.
Orem categorizes nursing capabilities
(agency) as interpersonal, social–contractual,
and professional-technological. That is, the
nurse must have capabilities within each of the
subsystems described in the nursing system.
Capabilities that result in desirable interper-
sonal nurse characteristics include effective
communication skills and ability to form rela-
tionships with patients and significant others.
Social–contractual characteristics require
the ability to apply knowledge of variations in
patients to nursing situations and to form con-
tracts with patients and others for clear
role boundaries. Desirable professional–
technologic characteristics require the ability
to perform techniques related to the process of
nursing: diagnosis of therapeutic self-care de-
mand of an assigned patient with considera-
tion of all self-care requisites (universal,
developmental, and health deviation) and a
concomitant diagnosis of a patient’s self-care
agency. Other desired nurse characteristics in-
clude the ability to prescribe roles: Assuming
a self-care deficit (and therefore a legitimate
patient), what are the roles and related respon-
sibilities of the nurse, the patient, the aide, and
the family? Nurses must also have the ability
to know and apply care measures such as gen-
eral helping techniques (teaching, guiding) and
specialized interventions and technologies
such as those identified with evidence-based
practice. These necessary nursing capabilities
also have implications for nursing education
and nursing administration. Knowledge of all
components of nursing agency will direct nurs-
ing curricula for successful development of
nursing abilities. Likewise, knowledge related
to nursing administration is critical to oper-
ability of nursing agency (Banfield, 2011).
Multiperson Situations and Units
Taylor and Renpenning (2001) extended ap-
plication of Orem’s concepts to families,
groups, and communities, where the recipient
of nursing care is more than a single individual
with a self-care deficit. They distinguished
among types of multiperson units, such as
community groups and family or residential
group units. These authors present categories
of multiperson care systems, create family and
community as basic conditioning factors, and
present a model of community as aggregate.
This model appropriately incorporates addi-
tional basic conditioning factors such as public
policy, health-care system changes, and com-
munity development. Other frameworks such
as a community participation model have been
developed (Isaramalai, 2002).
Community groups have a selected number
of common self-care requisites and/or limita-
tions of knowledge, decision making, and pro-
ducing care. These can be based on requirements
of entire communities, groups within the com-
munities, or to other situations when groups
have common needs. For example, the focus of
a student health nurse at a university may be a
group of first-year students and the self-care req-
uisite, prevention of the hazards of alcohol poi-
soning. The self-care limitations of the group
may be knowledge of binge drinking outcomes
and the skills to resist peer pressure at parties.
This environment and situation, the college mi-
lieu and new independence, creates the common
set of self-care requisites. The action system de-
signed by the college health nurse is to develop
the knowledge, decision-making, and result-
producing skills of new students collectively so
life, health, and well-being are enhanced for the
group, as well as the college community.
Family or others in a communal living
arrangement are another type of multiperson
unit of service. Because of the interrelationship
of the individuals in the living unit, the purpose
of nursing varies from that for a community
group. In this situation, the focus is often an
individual, as well as the family as a unit. The
health-related requirements of one individual
trigger the need for nursing but also affect the
unit as a whole. In one situation, an elderly par-
ent moves into the family home. Not only is
the therapeutic self-care demand of the parent
involved, but also the needs of family members
as it affects their self-care requisites. The health
CHAPTER 8 • Dorothea Orem’s Self-Care Deficit Nursing Theory 117
3312_Ch08_105-132 26/12/14 5:50 PM Page 117

of the unit is therefore established and main-
tained by meeting the therapeutic self-care de-
mands of all members and facilitating the
development and exercise of self-care agency
for each group member (Taylor & Renpen-
ning, 2011).
Applications of the Theory
Nursing Education Applications
Many educational programs used Orem’s con-
ceptualizations to frame the curriculum and to
guide nursing practice (Hartweg, 2001; Ransom,
2008). Taylor and Hartweg (2002) found
Orem’s conceptualization was the most fre-
quently used nursing theory in U.S. programs.
Examples of Orem-based schools included
Morris Harvey College in Charleston, West
Virginia, Georgetown University, the University
of Missouri—Columbia, and Illinois Wesleyan
University (Taylor, 2007). Current application
of Orem’s theory in nursing education ranges
from application to pedagogy in a hybrid
RN-BSN course in the United States (Davidson,
2012) to use as a general framework for nursing
education in Germany (Hintze, 2011).
Research Applications
The use of SCDNT as a framework for re-
search continues to increase with application
to specific populations and conditions. Studies
range from those with general reference to
Orem’s theory to more sophisticated explo-
ration of concepts and their relationships.
Early Orem studies concentrated on theory
development and testing, including creation of
theory-derived research instruments (Gast et al.,
1989), a necessary process in theory building.
Examples of widely used concept-based instru-
ments include those by Denyes (1981, 1988)
on self-care practices and self-care agency. The
Appraisal of Self-care Agency (ASA scale) was
an early tool used in international research (van
Achterberg et al., 1991) and later modified for
specific populations (West & Isenberg, 1997).
More recent instruments derive from structural
components of SCDNT but are applicable in
more specific situations: Self-Care for Adults
on Dialysis Tool (Costantini, Beanlands, &
Horsburgh, 2011); Spanish Version of the
Child and Adolescent Self-Care Performance
Questionnaire (Jaimovich, Campos, Campos
& Moore, 2009); The Nutrition Self-Care
Inventory (Fleck, 2012); and Self-Care
Outcomes (Valente, Saunders, & Uman,
A few Orem scholars continue with devel-
opment of theoretical elements through well-
designed programs of research with specific
populations. For example, Armer et al. (2009)
studied select power components (elements
of self-care agency) to describe those important
in developing supportive-educative nursing
systems with postmastectomy breast cancer
patients. A secondary analysis of this study
contributed to identification of the types of
self-care limitations experienced by this popula-
tion. The results have potential to promote effec-
tive nursing interventions (Armer, Brooks, &
Steward, 2011). Research is needed on actions
and methods to meet health deviation self-care
requisites in a variety of specific health situations
(Casida, Peters, Peters, & Magnan, 2009).
Many studies use SCDNT as a framework
for research and reference select concepts but
with limited application (Lundberg & Thrakul,
2011). For example, Carthron and others
(2010) used Orem’s SCDNT to guide research
related to specific concepts such as therapeutic
self-care demand and self-care agency. How-
ever, a family system factor (the primary care
role of grand-mothering) on type 2 diabetes
self-management was the primary emphasis
within the study. Other studies combine ele-
ments from SCDNT with other theories with-
out consideration of the congruence of
underlying assumptions. For example, Single-
ton, Bienemy, Hutchinson, Dellinger, and
Rami (2011) framed their study in part within
Orem’s theory of self-care as well as in the
health belief model and the concept of self-
efficacy. This combination of concepts and
theories in research studies is common. Fur-
ther, Klainin and Ounnapiruk (2010) summa-
rized research findings from 20 studies of
Thai elderly guided by Orem’s SCDNT. Al-
though their analysis revealed two of six major
concepts and one peripheral concept were
evident in the research, many studies explored
other non–SCDNT-specific concepts such as
118 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm
3312_Ch08_105-132 26/12/14 5:50 PM Page 118

self-concept, self-efficacy, and locus of control.
The authors suggest that SCDNT should be
revisited to include additional concepts to
strengthen the theory.
Table 8-1 provides examples of domestic
and international theory development and
practice-related research conducted in the past
5 years at the time of this writing.
CHAPTER 8 • Dorothea Orem’s Self-Care Deficit Nursing Theory 119
Author (Year), Population/ SCDNT
Country Purpose Settings Concept(s) Methods Results
Table 8 • 1 Examples of Research Applications
Identified types
of self-care limi-
tations in rela-
tionship to sets
of limitations,
e.g., “know-
ing.” Most limi-
tations were not
related to lack
of knowledge
but to energy,
patterns of liv-
ing, etc. Em-
phasized the
element in this
nursing system.
Perspectives re-
vealed that SC
requires dia-
logues with the
body and envi-
ronment, power
struggles with
the disease,
and making
choices to fight
the disease. SC
was viewed as
a way of life.
SCA predicted
SC. Education,
and health sta-
tus facilitated
SC practices;
smoking and
chronic condi-
tions were
Before and
after beginning
GMs were sta-
tistically differ-
ent with fewer
days of eating
Armer, Brooks, &
Steward (2011),
Fridlund, & Tops
(2011), Sweden
Burdette (2012),
Johnson, Hubbart,
Strickland, &
Nance (2010),
To examine
patient per-
ceptions of
SC limitations
to meet TSCD
to reduce
To describe
the meaning
of health-
SC in pa-
tients with
To examine
among SCA,
SC, and
To compare
diabetes self-
activities of
primary care-
giving grand-
mothers (GM)
Breast cancer
(N = 14)
(N = 12)
Rural midlife
(N = 224)
GMs with
type 2
(N = 68, 34
per group)
tional, and
phases of
to de-
risk of lym-
SCA, and
SC prac-
tices; com-
with rural
BCF (fam-
ily system
factor of
patterns of
analysis of
data from
pilot study
et al.,
was used.
tive design
3312_Ch08_105-132 26/12/14 5:50 PM Page 119

120 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm
a healthy diet
and fewer per-
formed self-
blood glucose
tests. Fewer self-
blood glucose
tests and fewer
eye examina-
tions were per-
formed by GMs
providing pri-
mary care to
Significant dif-
ference was
found between
agency and
quality of life in
group vs con-
trol group at
8 weeks after
Four themes
emerged on self-
daily life prac-
tices (dietary, ex-
ercise, medicine,
doctor follow-up,
blood sugar
use of herbal
remedies), af-
fect of illness,
family support
and need for
everyday life
as before
diagnosis (e.g.,
religious prac-
tices during
For patients
with RA, pa-
tients with
higher disabil-
ity and pain
had lower self-
care agency.
The potential for
development of
Kim (2011),
Lundberg &
Thrakul (2011),
Sweden &
Ovayolu, &
Karadag (2011),
before and
after begin-
ning caregiv-
ing activities;
to compare
these GMs’
ment activi-
ties with
those of GMs
not providing
primary care
To determine
of a program
to develop
SCA based
on SC needs
specific to
To explore
Thai Muslim
women’s self-
of type 2
To explore re-
among SCA,
disability lev-
els, and other
Prostate can-
cer patients
(N = 69)
Thai Muslim
women living
in Bangkok
(N = 29)
Turkish pa-
tients with
arthritis (RA)
(N = 467)
of life
was used
as frame-
Factors re-
lated to
care, such
as pain
and dis-
tal; non-
group using
test design
study using
Table 8 • 1 Examples of Research Applications—cont’d
Author (Year), Population/ SCDNT
Country Purpose Settings Concept(s) Methods Results
3312_Ch08_105-132 26/12/14 5:50 PM Page 120

CHAPTER 8 • Dorothea Orem’s Self-Care Deficit Nursing Theory 121
skills, and re-
sources neces-
sary for SC
were identified.
Patients in treat-
ment group
had higher
knowledge of
self-care de-
mands and self-
care ability
regarding med-
ication, dietary,
physical activity,
Both systolic
and diastolic
readings of
treatment group
were lower
than control
improvement in
health indica-
tors after design
of a nursing sys-
tem directed at
deficits in SCA
related to
51% of patients
had the re-
quired hepatitis
B SC knowl-
edge, espe-
cially need for
exercise, rest,
and methods of
prevention of
through sexual
activity. There
was a knowl-
edge deficit re-
lated to diet and
monitoring of
Level of educa-
tion, type of
previous health
education, and
Malathum, &
Tanomsup (2011),
Surucu & Kizilci
(2012), Turkey
Thi (2012), South
To examine
of a SC man-
To explore
the use of
SCDNT in di-
abetes self-
To describe
levels of SC
knowledge in
Thais with
(N = 96)
Type 2 dia-
betes patients
Hepatitis B in-
patients and
(N = 230)
SC de-
case study
Table 8 • 1 Examples of Research Applications—cont’d
Author (Year), Population/ SCDNT
Country Purpose Settings Concept(s) Methods Results
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122 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm
health-care set-
ting affected
levels of SC
about radiation
side effect man-
agement var-
ied by literacy
level despite
low literacy
level of pam-
phlets. Sup-
ported premise
that founda-
tional capaci-
ties for self-care
include skills
for reading,
writing, com-
munication per-
ception and
(2012), USA
To determine
reading low
literacy pam-
phlets on
side effects
affect patient
Urban radia-
tion oncology
clinic pa-
(N = 47)
of radia-
tion side
Note. BCF = basic conditioning factors; HDSCR = health deviation self-care requisites; SC = self-care or self-care practices;
SCA = self-care agency; SCDNT = self-care deficit nursing theory; SCR = self-care requisites; TSCD = therapeutic self-care demand.
Practice Applications
Nursing practice has informed development
of SCDNT as SCDNT has guided nursing
practice and research. Biggs (2008) con-
ducted a review of nursing literature from
1999 to 2007. The results revealed more
than 400 articles, including those in Inter-
national Orem Society Newsletters and Self-
Care, Dependent-Care, and Nursing, the
official journal of the International Orem
Society. Although Biggs noted a tremendous
increase in publications during that period,
the author observed that SCDNT research
has not always contributed to theory progres-
sion and development or to nursing practice.
She identified deficient areas such as those
related to concepts such as therapeutic self-
care demand, self-care deficit, nursing sys-
tems, and the methods of helping or
assisting. Recent publications on Orem based
practice address areas identified by Biggs.
Table 8-2 provides examples of specific prac-
tice applications in the past 5 years at the
time of this writing.
One theoretical application to nursing prac-
tice exemplifies the continued scholarly work
necessary for practice models and addresses
one deficit area noted by Biggs (2008). Casida
and colleagues (2009) applied Orem’s general
theoretical framework to formulate and de-
velop the health-deviation self-care requisites
of patients with left ventricular assist devices.
This article specifies not only the self-care
requisites for this population but also the nec-
essary subsystems unique to practice applica-
tions. This work illustrates the complexity of
SCDNT and also the utility of SCDNT for
patients with all types of technology assisted
One change in the past few years has been
an emphasis on self-management rather than or
in conjunction with self-care (Ryan, Aloe, &
Table 8 • 1 Examples of Research Applications—cont’d
Author (Year), Population/ SCDNT
Country Purpose Settings Concept(s) Methods Results
3312_Ch08_105-132 26/12/14 5:50 PM Page 122

CHAPTER 8 • Dorothea Orem’s Self-Care Deficit Nursing Theory 123
use of theoreti-
cal framework
to design a
brief checklist
An exemplar
for the six HD-
SCRs specific
health situation
and model for
other condi-
tions using
An example of
types of nurs-
ing systems
One hospital’s
goal to im-
prove quality
care and de-
crease length
of stay by mov-
ing to theory
based practice
An example of
application or
SCDNT to ar-
fistula SC
(2011), USA
Peters, Peters,
& Magnan
(2009), USA
(2012), USA
Hudson &
heart failure
in elderly
assist devices
Children with
special needs
Adults with
fistula self-
Critical care
Acute care
School setting
Acute care
dialysis unit
HDSCR, in-
cluding SC
all concepts
including NA
of checklist
tool to meas-
ure SC at
home after
critical care
common to
patients with
LVAD using
five guidelines
described by
Orem (2001)
to validate
form and
of utility of
through two
case studies:
wholly com-
pensatory sys-
tem for child
with cerebral
palsy; partly
for child with
asthma; and
educative sys-
tem for diabetic.
change of
focus to
of SCDNT as
guide to de-
velop and
update patient-
teaching re-
sources in
preparation for
home care; as-
sisted nurses
with role
Table 8 • 2 Examples of Practice Applications
Patient or Practice
Author (Year), Health or SCDNT Focus (Selected
Country Illness Focus Settings Concept(s) Examples) Other
3312_Ch08_105-132 26/12/14 5:50 PM Page 123

124 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm
paper incorpo-
rating elements
of other theo-
ries to expand
technologies in
patients with
serious mental
use of SCDNT
toward partner-
based relation-
ships for
recovery from
mental illness
This case study
provides an ex-
emplar for self-
management of
type 2 diabetes
component of
health system
practice model
(2012), USA
Seed &
(2012), USA
Surucu &
Swanson &
(2011), USA
Armer, &
(2010), USA,
Adults with
Acute psychi-
atric care
Use of
type 2 dia-
betes self-
model of
shared gover-
nance using
magnet com-
ponents to
promote pa-
tient safety
Breast cancer
nursing care
University set-
ting; diabetes
Orem’s self-
care deficit
theory as
general prac-
tice frame-
based on
review of 11
studies from
SCDNT con-
cepts in align-
ment with
recovery can
be used to
structure inter-
ventions and
research in
acute psychi-
atric settings
with empha-
sis on HDSCR
Explored vari-
ous theories
of motivation
to develop
and power
component of
SCDNT pro-
vided a com-
for delivering
that empower
individuals to
make choices
in care and
through part-
nerships and
steps of gen-
eral nursing
process using
of SCDNT as
the theoreti-
cal guide to
practice at
one institution
and its com-
shared gover-
nance to en-
hance patient
SC agency
through use
of comple-
mentary or
therapies to
meet HDSCR,
specifically to
Table 8 • 2 Examples of Practice Applications—cont’d
Patient or Practice
Author (Year), Health or SCDNT Focus (Selected
Country Illness Focus Settings Concept(s) Examples) Other
3312_Ch08_105-132 26/12/14 5:50 PM Page 124

CHAPTER 8 • Dorothea Orem’s Self-Care Deficit Nursing Theory 125
physical and
and to man-
age side ef-
fects of
BCFs = basic conditioning factors; DCA = dependent-care agency; HDSCR = health deviation self-care requisites; NA =
nursing agency; SC = self-care; SCA = self-care agency; SCD = self-care deficit; SCR = self-care requisites; SCS = self-care
systems; TSCD = therapeutic self-care demand.
Mason-Johnson, 2009; Sürücu & Kizilci,
2012; Swanlund, Scherck, Metcalfe, & Jesek-
Hale, 2008; Wilson, Mood, & Nordstrom,
2012). Orem (2001) introduced the term
self-management in her final book, defining the
concept as the ability to manage self in stable or
changing environments and ability to manage one’s
personal affairs (p. 111). This definition relates
to continuity of contacts and interactions one
would expect over time with nursing, especially
when caring for people with chronic conditions
such as diabetes. By nature, chronic disease vari-
ations over time are collaboratively managed
by the self-care agent, dependent-care agent,
the nurse agent, and others. The dependent-
care theory enhances the self-management
component, a uniqueness of SCDNT (Casida
et al., 2009). With increases in chronic illness
and treatment, especially in relationship to
allocation of health-care dollars, countries such
as Thailand now emphasize self-management
versus self-care in health policy decisions
(personal communication, Prof. Dr. Somchit
Hanucharurnkul, January 15, 2013). Taylor and
Renpenning (2011) presented diverse perspec-
tives on self-management, describing it first
as a subset of self-care with emphasis on creat-
ing a sense of order in life using all available
resources, social and other. Another perspective
relates to controlling and directing actions in
a particular situation at a particular time. This
includes incorporating standardized models for
self-management in specific health situations
such as diabetes.
In addition to creating models for specific
health-care conditions, Orem’s SCDNT is
also used as a general framework for nursing
practice in health care institutions. For ex-
ample, Cedars Sinai Medical Center in Los
Angeles, California, integrates SCDNT with
its shared governance model to promote pa-
tient safety (Swanson & Tidwell, 2011).
However, most practice applications use the
general theory or elements of the theory with
specific populations. Table 8-2 includes di-
verse examples from English publications.
However, the reader is also directed to non-
English publications including examples
from practitioners or researchers in Brazil
(Herculano, De Souse, Galvão, Caetano, &
Damasceno, 2011) and China (Su & Jueng,
To further develop the sciences of self-
care related to specific self-care systems and
to nursing systems for diverse populations
around the globe, collaboration will be nec-
essary between reflective practitioners and
scholars (Taylor & Renpenning, 2011).
Orem’s wise approach to theory develop-
ment, combining independent work with
formal collaboration among practitioners,
administrators, educators, and researchers
will determine the future of self-care deficit
nursing theory. The International Orem So-
ciety for Nursing Science and Scholarship
continues as an important avenue for collab-
orative work among expert and novice
SCDNT scholars around the globe.
Table 8 • 2 Examples of Practice Applications—cont’d
Patient or Practice
Author (Year), Health or SCDNT Focus (Selected
Country Illness Focus Settings Concept(s) Examples) Other
3312_Ch08_105-132 26/12/14 5:50 PM Page 125

126 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm
Practice Exemplar
Provided by Laureen M. Fleck, PhD,
Marion W. presents to a primary care office
seeking care for recent fatigue. She is assigned
to the nurse practitioner. The nurse explains
the need for information to determine what
needs to be done and by whom to promote
Marion’s life, health, and well-being. Infor-
mation regarding Marion is gathered in part
using Orem’s conceptualizations as a guide.
First, the nurse introduces herself and then de-
scribes the information she will seek to help
her with the health situation. Marion agrees
to provide information to the best of her
knowledge. As the nurse and Marion have en-
tered into a professional relationship and
agreed to the roles of nurse and patient, the
nurse initiates the three steps of Orem’s
process of nursing:
Step 1: Diagnosis and Prescription
I. Basic Conditioning Factors
As basic conditioning factors affect the value
of therapeutic self-care demand and self-care
agency, the nurse seeks information regarding
the following: age, gender, developmental
state, patterns of living, family system factors,
sociocultural factors, health state, health-care
system factors, availability and adequacy of re-
sources, and external environmental factors
such as the physical or biological.
Marion is 42, female, in a developmental
stage of adulthood where she carries out tasks
of family and work responsibilities as a produc-
tive member of society. The history related to
patterns of living and family system reveals em-
ployment as a school crossing guard, a role that
allows time after school with her children, ages
5, 7, and 9. Her husband works for “the city”
but recently had hours cut to 4 days per week.
Therefore, money is tight. They pay bills on
time, but no money remains at the end of the
month. She has learned to stretch their money
by shopping at the local discount store for
clothes and food and cooking “one-pot meals”
so that they have leftovers to stretch through-
out the week. As an African American, she
worships in a community-based black church,
a source of spiritual strength and social support.
Marion has a high school education.
Questions about health state and health
system reveal Marion has type 2 diabetes that
was diagnosed more than 5 years ago. Except
for periodic fatigue, she believes she has man-
aged this chronic condition by following the
treatment plan, faithfully taking oral medica-
tion, and checking blood sugar once per day.
The morning reading was 230 mg/dL. Al-
though the family has no health insurance,
Marion has access to the community health
care clinic and free oral medications. There is
a small co-pay for her blood glucose testing
strips, which is now a concern. The children
receive health care through the State Chil-
dren’s Health Insurance Program. The neigh-
borhood Marion lives in has a safe, outdoor
environment. The latter has been a comfort
because she works as a crossing guard and
walks her children to school. Although she en-
joys this exercise, her increasing fatigue dis-
courages additional exercise.
When asked about her perception of her
current condition, Marion expressed concern
for her weight and considers this a partial ex-
planation for the fatigue. She desires to lose
weight but admits she has no willpower,
snacks late at night, and finds “healthy foods”
too expensive. At 205 lbs (93 kg) and 5 feet
3 inches (1.6 m), Marion is classified as obese
with a body mass index of 38 kg/m2.
II. Calculating the Therapeutic Self-Care Demand
With Marion, the nurse identifies many ac-
tions that should be performed to meet the
universal, developmental, and health devia-
tion self-care requisites. Her health state and
health system factors (including previous
treatment modalities) are major conditioners
of two universal self-care requisites: maintain
a sufficient intake of food and maintain a
balance between activity and rest. Throughout
the interview, the nurse determines that
Marion is clear about her chronic condition
and has accepted herself in need of continued
monitoring and care, including quarterly
3312_Ch08_105-132 26/12/14 5:50 PM Page 126

CHAPTER 8 • Dorothea Orem’s Self-Care Deficit Nursing Theory 127
Practice Exemplar cont.
hemoglobin A1C and lipid blood tests
(American Diabetes Association [ADA],
Two health deviation self-care requisites also
emerge as the primary focus for seeking helping
services: being aware and attending to effects
and results of pathological conditions; and
effectively carrying out medically prescribed
diagnostic and therapeutic measures. Without
additional self-care actions beyond the pre-
scribed medication, short walks, and daily blood
glucose testing, the risks of uncontrolled dia-
betes may lead to diabetic retinopathy,
nephropathy, neuropathy, and cardiovascular
disease (ADA, 2013).
One particularized self-care requisite
(PSCRs) is presented as an example, with
the related actions Marion should perform to
improve her health and well-being. Once the
actions to be performed and concomitant meth-
ods are identified, then the nurse determines
Marion’s self-care agency: the capabilities of
knowing (estimative operations), deciding
(transitional operations), and performing these
actions (productive operations).
PSCR: Reduce and maintain blood glucose
level within normal parameters through in-
creased blood glucose monitoring, appropriate
healthy food choices, and increased activity. If
this PSCR is achieved, Marion’s weight will be
decreased, a related purpose that provides mo-
tivation to engage in self-care. The methods to
achieve the PSCR include detailed actions:
A. Increase blood glucose monitoring to twice
per day; set goals for 100–110 mg/dL fasting
and <140 mg/dL at 2 hours after a main meal. 1. Obtain discounted glucose monitoring strips from ABC drug company. 2. Obtain assistance from community clinic for monthly replacement request to ABC drug company. 3. Monitor glucose level through testing two times per day, with one test before break- fast and one test 2 hours after a main meal. Add more testing when needed for symp- toms of high or low blood sugar (ADA, 2013). 4. Seek assistance from health professional when levels are below 60 mg/dL and not responsive to sugar intake or higher than 300 mg/dL with feelings of fatigue, thirst, or visual disturbances. 5. Adjust activity and meal planning/portion sizes when levels are not within parameters. B. Make healthy food choices. 6. Seek knowledge of healthy food choices for family meal planning from dietitian at clinic. 7. Review family expenses with health pro- fessional to adjust grocery budget to pur- chase affordable but healthy foods. 8. Eat three balanced meals per day including midmorning, afternoon, and evening snack as desired. These meals and snacks will have portion sizes established between Marion and the nurse. 9. All meals will have a selection of protein, fats, and carbohydrates, and the snacks will be limited to 15 grams of carbohy- drate or less (ADA, 2013). C. Increase physical activity to 150 minutes/ week of moderate intensity exercise (ADA, 2013). 10. Gain knowledge regarding step-walking program to increase activity. Discuss community options for safe walking areas. 11. Explore budget to include properly fitting footwear. Tennis shoes with socks are to be worn for each walk. Obtain free pe- dometer from clinic to measure perform- ance of steps and walking. 12. Review pedometer measures three times a week. Increase steps by 10% each week if natural increase in steps has not occurred. For example, if walking 2000 steps/walk increase next walk by 200 steps as a goal. Maintain goals until 10,000 step/day is achieved (ADA, 2013). III. Determining Self-Care Agency The nurse and Marion then seek information about self-care agency or the capabilities related to knowledge, decision making, and Continued 3312_Ch08_105-132 26/12/14 5:50 PM Page 127 128 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm Practice Exemplar cont. performance necessary to meet this PSCR. This includes the ability to seek and obtain re- quired resources important to each action. What capabilities are necessary to increase blood glucose testing? Does Marion have the knowledge about access to drug company re- sources (testing strips) available to persons with their income level? Does she have the communication skills to seek resources from the community center? Does she have the knowledge regarding blood glucose parame- ters and methods to adjust exercise and diet to maintain the levels? The nurse and Marion to- gether determine capabilities for each of these components of each action necessary to meet her particularized self-care requisite. After collecting and analyzing data about her abilities in relationship to the required actions, the nurse determines the absence or existence of a self-care deficit—that is, is self- agency adequate to meet the therapeutic self- care demand? The nurse quickly determines throughout the data collection period that Marion’s foundational and disposition capa- bilities (necessary for any deliberate action) and the power components (necessary for self- care) are developed and operable. The question is the adequacy of self-care agency in relation- ship to this PSCR. 1. Blood glucose monitoring: The nurse learns that Marion possesses necessary ca- pabilities of knowing, deciding, and per- forming to obtain additional testing strips from ABC drug company and to increase her blood glucose testing to two times per day. After questioning, the nurse deter- mines Marion is aware of norms and in general the effect of food and exercise. In addition to verbalizing available time for testing, Marion also recalls that the school nurse where she works agreed to be a re- source if blood glucose readings are not within the required range. She agreed to seek out this resource if adjustment in ex- ercise or food intake is needed. The nurse practitioner concludes Marion’s self-care capabilities of knowing, deciding, and performing the necessary actions is intact to meet the particularized self-care requi- site, maintain blood glucose level at 100– 110 mg/dL fasting and <140 mg/dL at 2 hours after a main meal. 2. Dietary practices: The nurse seeks infor- mation from Marion on her knowledge of effective dietary practices and healthy foods, including flexibility in the family budget, shopping practices, and family cultural practices that may influence her food purchases. The nurse learns Marion has misinformation about her selected foods and is aware of resources, such as the local health department that offers free classes by a registered dietitian. However, transportation to dietary classes is not pos- sible because her husband uses the only car to drive to work. Although Marion under- stands the relationship of her high blood glucose levels to the resulting fatigue, she seems to focus on losing weight, a possible motivational asset. Marion maintains the ability to shop, cook, use the stove safely, and ingest all food types. 3. The nurse assesses that Marion enjoys walking and generally feels safe in the sur- rounding environment. She also has time while the children are at school to take walks. The nurse discovers that Marion is not aware of proper foot care or the step program for increasing exercise. Marion does not believe the family budget can manage both changes in food purchases as well as the purchase of good walking shoes. IV. Self-Care Limitations Marion has self-care limitations in the area of knowledge and decision making about re- quired dietary actions. The limitations of knowing are related to healthy dietary prac- tices. This includes the use of carbohydrate counting. She lacks knowledge about purchas- ing options for healthier foods and methods to incorporate these into her meal effort. Al- though interested, she is unable to enroll in di- etary classes at the health department due to transportation issues. Marion has knowledge 3312_Ch08_105-132 26/12/14 5:50 PM Page 128 CHAPTER 8 • Dorothea Orem’s Self-Care Deficit Nursing Theory 129 Practice Exemplar cont. and decision-making authority for managing the family budget but has no experience incor- porating healthier foods into the planning. Marion also has self-care limitations in rela- tionship to knowledge of the step program, proper footwear, and related foot care. No re- sources exist to purchase the necessary walking shoes. Major capabilities include Marion’s ability to learn, availability of time, and her motivation to lose weight, and hence have less fatigue. If Marion decides to make healthier food choices that are affordable and also in- crease her general activity, she will need mon- itoring, counseling, and support from a health professional related to the blood glucose levels, access to resources for classes, budgeting, and purchase of equipment. With analysis of self-care agency in rela- tionship to the particularized self-care requi- site, the nurse and patient establish the presence of a self-care deficit. Now that legit- imate nursing has been established, a nursing system is designed. Step 2: Design and Plan of Nursing System Now that the self-care limitations of knowing are identified, the nurse will use helping methods of guiding and supporting by de- signing a supportive-educative nursing sys- tem. The design involves planning Marion’s activities to meet the particularized self-care requisite with nurse guidance and monitoring and also to establishing the nurse’s role. Together they agree on communication methods to work together to monitor progress as Marion attends classes to learn healthy dietary practices and increase activity. Marion agrees to share information related to blood glucose testing with the school nurse and the pharmacist at the community clinic when refilling medication and supplies. The nurse agrees to seek out resources for transportation to the health department for dietary classes, purchase of footwear, assis- tance to fill out forms, and also to meet with Marion every 2 weeks to review food con- sumption and activity records. Although the goal is to maintain blood glucose levels at 100–110 mg/dL fasting and <140 mg/dL at 2 hours after a main meal, the priority actions relate to dietary changes, followed by slow, incremental changes in activity. The nurse expects it will take 1 month to obtain the necessary footwear. Objectives will be re- viewed at 1 month. Marion knows that weight loss is her objective, but she must start changes in dietary practices. The goal for weight loss will be set at the first month’s meeting after attendance at the di- etary sessions and initial experience with changing the family’s food purchases and meal planning. Marion and the nurse prac- titioner begin implementing their roles as prescribed. Step 3: Treatment, Regulation, Case Management, Control/Evaluation Marion and the nurse begin implementing their agreed-on actions as they collaborate within the nursing system. The nurse practi- tioner maintains contact via phone with Marion as she completes actions, such as seeking resources for the dietary classes and footwear. Marion contacts the school nurse where she works to see if she will be a resource for weekly reports on blood glucose levels. She also seeks out additional testing strips and calls the clinic to obtain the routine forms for monthly renewal requests. They proceed through each of these actions as agreed on as social–contractual operations. Throughout this step, the interpersonal operations are essential as the nurse evaluates Marion’s progress and new roles are determined and agreed on. This continues over time, with continued review of the design, the role pre- scriptions, until Marion’s therapeutic self- care demand is decreased or self-care agency is developed so no self-care deficit exists, and nursing is no longer required. Throughout the process, nursing agency was evident. The capabilities related to inter- personal, social–contractual, and professional– technological operations were evident. 3312_Ch08_105-132 26/12/14 5:50 PM Page 129 130 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm ■ Summary This chapter provided an overview of Orem’s self-care deficit nursing theory. Orem created this general theory of nursing to address the proper objective of nursing through the ques- tion, What condition exists in a person when judgments are made that a nurse(s) should be brought into the situation (i.e., that a person should be under nursing care; Orem, 2001, p. 20)? The grand theory comprises four inter- related theories: the theory of self-care, theory of dependent care, theory of self-care deficit, and theory of nursing systems. The building blocks of these theories are six major concepts and one peripheral concept. Orem’s SCDNT has been applied extensively in nursing practice throughout the United States and internation- ally in diverse settings and with diverse popu- lations. SCDNT continues to be used as a framework for research with specific patient populations throughout the world. Collabora- tion among scholars, researchers, and practi- tioners is necessary to provide the science of self-care useful to improve nursing practice into the future (Taylor & Renpenning, 2011). References Alspach, J. (2011). Editorial: The patient’s capacity for self-care: Advocating for pre-discharge assessment. Critical Care Nurse, 31(2), 10–14. doi:10.4037/ ccn2011419 American Diabetes Association. (2013). Clinical prac- tice recommendations 2013. Diabetes Care 36(1), s12–s66. Armer, J. M., Brooks, C. W., & Stewart, B. R. (2011). Limitations of self-care in reducing the risk of lym- phedema: Supportive–educative systems. Nursing Science Quarterly, 24(1), 57–63. Armer, J. M., Shook, R. P., Schneider, M. 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White, M. L. Peters, R., & Schim, S. M. (2011). Spiri- tuality and spiritual self-care: Expanding self-care deficit nursing theory. Nursing Science Quarterly, 24(1), 48–56. Wilson, F. L., Mood, D., & Nordstrom, C. K. (2010). The influence of easy-to read pamphlets about self- care management of radiation side effects on pa- tients’ knowledge. Oncology Nursing Forum, 37(6), 774–781. 132 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm 3312_Ch08_105-132 26/12/14 5:50 PM Page 132 Chapter 9Imogene King’s Theory of Goal Attainment CHRISTINA L. SIELOFF AND MAUREEN A. FREY Introducing the Theorist Overview of the Conceptual System (King’s Conceptual System and Theory of Goal Attainment) Applications of the Theory In Practice Practice Exemplar by Mary B. Killeen Summary References 133 Introducing the Theorist Imogene M. King was born on January 30, 1923, in West Point, Iowa. She received a diploma in nursing from St. John’s Hospital School of Nursing, St. Louis, Missouri (1945); a bachelor of science in nursing education (1948); a master of science in nursing from St. Louis University (1957); and a doctor of education (EdD) 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 Nurs- ing” (1968), Towards a Theory for Nursing: General Concepts of Human Behaviour (1971), and A Theory for Nursing: Systems, Concepts, Process (1981). Since 1981, King has clarified and expanded 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 prac- tice. King received recognition and numerous Imogene M. King 3312_Ch09_133-152 26/12/14 2:50 PM Page 133 awards for her distinguished career in nursing from the American Nurses Association, the Florida Nurses Association, the American Academy of Nursing, and Sigma Theta Tau International. King died in December 2007. Her theoretical formulations for nursing con- tinue to be taught at all levels of nursing edu- cation and applied and extended by national and international scholars.1 Overview of the Conceptual System (King’s Conceptual System and Theory of Goal Attainment) Theoretical Evolution in King’s Own Words My first theory publication pronounced the problems and prospect of knowledge devel- opment in nursing (King, 1964). More than 30 years ago, the problems were identified as (1) lack of a professional nursing language, (2) a theoretical nursing phenomena, and (3) limited concept development. Today, the- ories and conceptual frameworks have iden- tified theoretical approaches to knowledge development and utilization of knowledge in practice. Concept development is a continu- ous process in the nursing science movement (King, 1988). My rationale for developing a schematic representation of nursing phenomena was in- fluenced by the Howland systems model (Howland, 1976) and the Howland and McDowell conceptual framework (Howland & McDowell, 1964). The levels of interaction in those works influenced my ideas relative to organizing a conceptual frame of reference for nursing. Because concepts offer one approach to structure knowledge for nursing, a thorough review of nursing literature provided me with ideas to identify five comprehensive concepts as a basis for a conceptual system for nursing. The overall concept is a human being, com- monly referred to as an “individual” or a “per- son.” Initially, I selected abstract concepts of perception, communication, interpersonal re- lations, health, and social institutions (King, 1968). These ideas forced me to review my knowledge of philosophy relative to the nature of human beings (ontology) and to the nature of knowledge (epistemology). Philosophical Foundation In the late 1960s, while auditing a series of courses in systems research, I was introduced to a philosophy of science called general system theory (von Bertalanffy, 1968). This philoso- phy of science gained momentum in the 1950s, although its roots date to an earlier pe- riod. This philosophy refuted logical positivism and reductionism and proposed the idea of iso- morphism and perspectivism in knowledge development. Von Bertalanffy, credited with originating the idea of general system theory, defined this philosophy of science movement as a “general science of wholeness: systems of elements in mutual interaction” (von Bertalanffy, 1968, p. 37). My philosophical position is rooted in gen- eral system theory, which guides the study of organized complexity as whole systems. This philosophy gave me the impetus to focus on knowledge development as an information- processing, goal-seeking, and decision-making system. General system theory provides a ho- listic approach to study nursing phenomena as an open system and frees one’s thinking from the parts-versus-whole dilemma. In any dis- cussion of the nature of nursing, the central ideas revolve around the nature of human be- ings and their interaction with internal and ex- ternal environments. During this journey, I began to conceptualize a theory for nursing. However, because a manuscript was due in the publisher’s office, I organized my ideas into a conceptual system (formerly called a “concep- tual framework”), and the result was the pub- lication of a book titled Toward a Theory of Nursing (King, 1971). 134 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm For additional information about the theorist, publica- tions and research using King’s conceptual model and the theory of goal attainment (Tables 9-1 to 9-15), please go to bonus chapter content available at Some tables are specifically referenced throughout the text to further guide the reader. 3312_Ch09_133-152 26/12/14 2:50 PM Page 134 Design of a Conceptual System A conceptual system provides structure for or- ganizing multiple ideas into meaningful wholes. From my initial set of ideas in 1968 and 1971, my conceptual framework was refined to show some unity and relationships among the con- cepts. The conceptual system consists of indi- vidual systems, interpersonal systems, and social systems and concepts that are important for un- derstanding the interactions within and be- tween the systems (Fig. 9-1). The next step in this process was to review the research literature in the discipline in which the concepts had been studied. For ex- ample, the concept of perception has been studied in psychology for many years. The lit- erature indicated that most of the early studies dealt with sensory perception. Around the 1950s, psychologists began to study interper- sonal perception, which related to my ideas about interactions. From this research literature, I identified the characteristics of perception and defined the concept for my framework. I con- tinued searching literature for knowledge of each of the concepts in my framework. An up- date on my conceptual system was published in 1995 (King, 1995). Process for Development of Concepts “Searching for scientific knowledge in nursing is an ongoing dynamic process of continuous identification, development, and validation of relevant concepts” (King, 1975, p. 25). What is a concept? A concept is an organization of reference points. Words are the verbal symbols used to explain events and things in our envi- ronment and relationships to past experiences. Northrop (1969) noted: “[C]oncepts fall into different types according to the different sources of their meaning. . . . A concept is a term to which meaning has been assigned.” Concepts are the categories in a theory. The concept development and validation process is as follows: 1. Review, analyze, and synthesize research literature related to the concept. 2. From the review, identify the characteris- tics (attributes) of the concept. 3. From the characteristics, write a concep- tual definition. 4. Review literature to select an instrument or develop an instrument. 5. Design a study to measure the character- istics of the concept. 6. Select the population to be sampled. 7. Collect data. 8. Analyze and interpret data. 9. Write results of findings and conclusions. 10. State implications for adding to nursing knowledge. Concepts that represent phenomena in nursing are structured within a framework and theory to show relationships. Multiple concepts were identified from my analysis of nursing literature (King, 1981). The concepts that provided substantive knowledge about human beings (self, body image, percep- tion, growth and development, learning, time, and personal space) were placed within the personal system, those related to small groups (interaction, communication, role, transac- tions, and stress) were placed within the inter- personal system, and those related to large groups that make up a society (decision mak- ing, organization, power, status, and authority) were placed within the social system (King, 1995). However, knowledge from all of the CHAPTER 9 • Imogene King’s Theory of Goal Attainment 135 Social systems (society) Interpersonal systems (group) Personal systems (individuals) Fig 9 • 1 King’s conceptual system. 3312_Ch09_133-152 26/12/14 2:50 PM Page 135 concepts is used in nurses’ interactions with in- dividuals and groups within social organiza- tions, such as the family, the educational system, and the political system. Knowledge of these concepts came from my synthesis of re- search in many disciplines. Concepts, when defined from research 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, education, or ad- ministration. 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 to the question: What is the nature of human beings? A vicious circle? Not really! Because nurses are first and foremost human beings 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 recently, others have derived theories from my conceptual system (Frey & Sieloff, 1995). Theory of Goal Attainment Generally speaking, nursing care’s goal is to help individuals maintain health or regain health (King, 1990). Concepts are essential elements in theories. When a theory is derived from a conceptual system, concepts are se- lected from that system. Remember my ques- tion: What is the essence of nursing? The concepts of self, perception, communication, interaction, transaction, role, growth and de- velopment, stress, time, and personal space were selected for the theory of goal attainment. Transaction Process Model A transaction model, shown in Figure 9-2, was developed that represented the process in which individuals interact to set goals that re- sult in goal attainment (King, 1981, 1995). The model is a human process that can be observed in many situations when two or more people interact, such as in the family and in 136 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm Feedback REACTION INTERACTION TRANSACTION PERCEPTION JUDGMENT ACTION NURSE PATIENT ACTION JUDGMENT 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.) 3312_Ch09_133-152 26/12/14 2:50 PM Page 136 social events (King, 1996). As nurses, we bring knowledge and skills that influence our percep- tions, communications, and interactions in per- forming the functions of the role. In your role as a nurse, after interacting with a patient, sit down and write a description of your behavior and that of the patient. It is my belief that you can identify your perceptions, mental judg- ments, mental action, and reaction (negative or positive). Did you make a transaction? That is, did you exchange information and set a goal with the patient? Did you explore the means for the patient to use to achieve the goal? Was the goal achieved? If not, why? It is my opinion that most nurses use this process but are not aware that it is based in a nursing theory. With knowledge of the concepts and of the process, nurses have a scientific base for practice that can be clearly articulated and documented to show quality care. How can a nurse document this transaction model in practice? Documentation System A documentation system was designed to im- plement the transaction process that leads to goal attainment (King, 1984). Most nurses use the nursing process to assess, diagnose, plan, implement, and evaluate, which I call a method. My transaction process provides the theoretical knowledge base to implement this method. For example, as one assesses the patient and the environment and makes a nursing diagnosis, the concepts of perception, communication, and interaction represent knowledge the nurse uses to gather informa- tion and make a judgment. A transaction is made when the nurse and patient decide mu- tually on the goals to be attained, agree on the means to attain goals that represent the plan of care, and then implement the plan. Evalua- tion determines whether or not goals were attained. If not, you ask why, and the process begins again. The documentation is recorded directly in the patient’s chart. The patient’s record indicates the process used to achieve goals. On discharge, the summary indicates goals set and goals achieved. One does not need multiple forms when this documentation system is in place, and the quality of nursing care is recorded. Why do nurses insist on designing critical paths, various care plans, and other types of forms when, with knowledge of this system, the nurse documents nursing care directly on the patient’s chart? Why do we use multiple forms to complicate a process that is knowledge-based and also provides essential data to demonstrate outcomes and to evaluate quality nursing care? Federal laws have been passed that indicate that patients must be involved in decisions about their care and about dying. This trans- action process provides a scientifically based process to help nurses implement federal laws such as the Patient Self-Determination Act (Federal Register, 1995). Goal Attainment Scale Analysis of nursing research literature in the 1970s revealed that few instruments were de- signed for nursing research. In the late 1980s, the faculty at the University of Maryland, ex- perts in measurement and evaluation, applied for and received a grant to conduct conferences to teach nurses to design reliable and valid in- struments. I had the privilege of participating in this 2-year continuing education confer- ence, where I developed a Goal Attainment Scale (King, 1989b). This instrument may be used to measure goal attainment. It may also be used as an assessment tool to provide pa- tient data to plan and implement nursing care. Vision for the Future My vision for the future of nursing is that nursing will provide access to health care for all citizens. The United States’ health-care sys- tem will be structured using my conceptual system. Entry into the system will be via nurses’ assessment so that individuals are di- rected to the right place in the system for nursing care, medical care, social services in- formation, health teaching, or rehabilitation. My transaction process will be used by every practicing nurse so that goals can be achieved to demonstrate quality care that is cost-effective. My conceptual system, theory of goal attain- ment, and transaction process model will con- tinue to serve a useful purpose in delivering professional nursing care. The relevance of evidence-based practice, using my theory, joins CHAPTER 9 • Imogene King’s Theory of Goal Attainment 137 3312_Ch09_133-152 26/12/14 2:50 PM Page 137 the art of nursing of the 20th century to the science of nursing in the 21st century. Concepts and Middle-Range Theory Development Within King’s Conceptual System or the Theory of Goal Attainment Concept development within a conceptual framework is particularly valuable, as it often explicates concepts more clearly than a theorist may have done in his or her origi- nal work. Concept development may also demonstrate how other concepts of interest to nursing can be examined through a nurs- ing lens. Such explication further assists the development of nursing knowledge by enabling the nurse to better understand the application of the concept within specific practice situations. Examples of concepts developed from within King’s work include the following: collaborative alliance relation- ship (Hernandez, 2007); decision making (Ehrenberger, Alligood, Thomas, Wallace, & Licavoli, 2007), empathy (May, 2007), holis- tic nursing (Li, Li, & Xu, 2010), managerial coaching (Batson & Yoder, 2012), patient satisfaction with nursing care (Killeen, 2007), sibling closeness (Lehna, 2009), and whole person care (Joseph, Laughon, & Bogue, 2011).2 Applications of the Theory in Practice Since the first publication of King’s work (1971), nursing’s interest in the application of her work to practice has grown. The fact that she was one of the few theorists who generated both a framework and a middle range theory further expanded her work. Today, new pub- lications related to King’s work are a frequent occurrence. Additional middle-range theories have been generated and tested, and applica- tions to practice have expanded. After her re- tirement, King continued to publish and examine new applications of the theory. The purpose of this part of the chapter is to provide an updated review of the state of the art in terms of the application of King’s conceptual system (KCS) and middle-range theory in a variety of areas: practice, administration, edu- cation, and research. Publications, identified from a review of the literature, are summarized and briefly discussed. Finally, recommenda- tions are made for future knowledge develop- ment in relation to KCS and middle-range theory, particularly in relation to the impor- tance of their application within an evidence- based practice environment. In conducting the literature review, the authors began with the broadest category of application—application within KCS to nursing care situations. Because a conceptual framework is, by nature, very broad and abstract, it can serve only to guide, rather than to prescriptively direct, nursing practice. Development of middle-range theories is a natural extension of a conceptual framework. Middle-range theories, clearly developed from within a conceptual framework, accomplish two goals: (1) Such theories can be directly applied to nursing situations, whereas a conceptual framework is usually too abstract for such direct application, and (2) validation of middle-range theories, clearly developed within a particular conceptual framework, lends validation to the conceptual framework itself. King (1981) stated that individuals act to maintain their own health. Although not explicitly stated, the converse is probably true as well: Individuals often do things that are not good for their health. Accordingly, it is not surprising that the KCS and related middle-range theory are often directed toward patient and group behaviors that influence health. In addition to the middle-range theory of goal attainment (King, 1981), several other mid- dle-range theories have been developed from within King’s interacting systems framework. In terms of the personal system, Brooks and Thomas (1997) used King’s framework to derive a theory of perceptual awareness. The focus was to develop the concepts of judgment and action as core concepts in the personal system. Other concepts in the theory included communication, perception, and decision making. 138 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm 2See Table 9-2 in the bonus chapter content available at 3312_Ch09_133-152 26/12/14 2:50 PM Page 138 In relation to the interpersonal system, several middle-range theories have been developed regarding families. Doornbos (2007), using her family health theory, ad- dressed family health in terms of families of adults with persistent mental illness. Thoma- son and Lagowski (2008) used concepts from King along with other nursing theorists to develop a model for collaboration through reciprocation in health-care organizations. In relation to social systems, Sieloff and Bularzik (2011) revised the “theory of group power within organizations” to the “theory of group empowerment within organiza- tions” to assist in explaining the ability of groups to empower themselves within organizations.3 Review of the literature identified instru- ments specifically designed within King’s framework. King (1988) developed the Health Goal Attainment instrument, designed to de- tail the level of attainment of health goals by individual clients. The Nurse Performance Goal Attainment (NPGA) was developed by Kameoka, Funashima, and Sugimori (2007). Applications in Nursing Practice There have been many applications of King’s middle-range theory to nursing practice be- cause the theory focuses on concepts relevant to all nursing situations—the attainment of client goals. The application of the middle- range theory of goal attainment (King, 1981) is documented in several categories: (1) general application of the theory, (2) exploring a par- ticular concept within the context of the theory of goal attainment, (3) exploring a particular concept related to the theory of goal attain- ment, and (4) application of the theory in non- clinical nursing situations. For example, King (1997) described the use of the theory of goal attainment in nursing practice. Short-term group psychotherapy was the focus of theory application for Laben, Sneed, and Seidel (1995). D’Souza, Somayaji, and Subrahmanya (2011) used the theory to “examine determinants of reproductive health and related quality of life among Indian women in mining communities” (p. 1963). Nursing Process and Nursing Terminologies, Including Standardized Nursing Languages Within the nursing profession, the nursing process has consistently been used as the basis for nursing practice. King’s framework and middle-range theory of goal attainment (1981) have been clearly linked to the process of nurs- ing. Although many published applications have broad reference to the nursing process, several deserve special recognition. First, King herself (1981) clearly linked the theory of goal attainment to nursing process as theory and to nursing process as method. Application of King’s work to nursing curricula further strengthened this link. In addition, the steps of the nursing process have long been integrated within the KCS and the middle-range theory of goal attain- ment (Daubenmire & King, 1973; D’Souza, Somayaji, & Suybrahmanya, 2011; Woods, 1994). In these process applications, assess- ment, diagnosis, and goal-setting occur, fol- lowed by actions based on the nurse–client goals. The evaluation component of the nurs- ing process consistently refers back to the orig- inal goal statement(s). In related research, Frey and Norris (1997) also drew parallels between the processes of critical thinking, nursing, and transaction. Over time, nursing has developed nursing terminologies that are used to assist the pro- fession to improve communication both within, and external to, the profession. These terminologies include the nursing diagnoses, nursing interventions, and nursing outcomes. With the use of these standardized nursing languages (SNLs), the nursing process is fur- ther refined. Standardized terms for diagnoses, interventions, and outcomes also potentially improve communication among nurses. Using SNLs also enables the development of middle-range theory by building on con- cepts unique to nursing, such as those concepts of King that can be directly applied to the nursing process: action, reaction, interaction, CHAPTER 9 • Imogene King’s Theory of Goal Attainment 139 See Table 9-5 in the bonus chapter content available at 3312_Ch09_133-152 26/12/14 2:50 PM Page 139 transaction, goal setting, and goal attainment. Biegen and Tripp-Reimer (1997) suggested middle-range theories be constructed from the concepts in the taxonomies of the nursing lan- guages focusing on outcomes. Alternatively, King’s framework and theory may be used as a theoretical basis for these phenomena and may assist in knowledge development in nursing in the future. With the advent of SNLs, “outcome identification” is identified as a step in the nursing process after assessment and diagnosis (McFarland & McFarland, 1997, p. 3). King’s (1981) concept of mutual goal setting is anal- ogous to the outcomes identification step, because King’s concept of goal attainment is congruent with the evaluation of client outcomes. In addition, King’s concept of perception (1981) lends itself well to the definition of client outcomes. Moorhead, Johnson, and Maas (2013) define a nursing-sensitive patient outcome as “an individual, family or commu- nity state, behaviour or perception that is measured along a continuum in response to nursing intervention(s)” (p. 2). This is fortu- itous because the development of nursing knowledge requires the use of client outcome measurement. The use of standardized client outcomes as study variables increases the ease with which research findings can be compared across settings and contributes to knowledge development. Therefore, King’s concept of mutually set goals may be studied as “expected outcomes.” Also, by using SNLs, King’s (1981) middle-range theory of goal attainment can be conceptualized as the “attainment of ex- pected outcomes” as the evaluation step in the application of the nursing process. In summary, although these terminologies, including SNLs, were developed after many of the original nursing theorists had completed their works, nursing frameworks such as the KCS (1981) can still find application and use within the terminologies. In addition, it is this type of application that further demonstrates the framework’s utility across time. For exam- ple, Chaves and Araujo (2006), Ferreira De Sourza, Figueiredo De Martino, and Daena De Morais Lopes (2006), Goyatá, Rossi, and Dalri (2006), and Palmer (2006) implemented nursing diagnoses within the context of King’s framework.4 Applications in Client Systems KCS and middle-range theory of goal attain- ment have a long history of application with large groups or social systems (organizations, communities). The earliest applications in- volved the use of the framework and theory to guide continuing education (Brown & Lee, 1980) and nursing curricula (Daubenmire, 1989; Gulitz & King, 1988). More contempo- rary applications address a variety of organiza- tional settings. For example, the framework served as the basis for the development of a middle-range theory relating to practice in a nursing home (Zurakowski, 2007). Nwinee (2011) used King’s work, along with Peplau’s, to develop the sociobehavioral self-care man- agement nursing model (p. 91). In addition, the theory of goal attainment has been pro- posed as the practice model for case manage- ment (Hampton, 1994; Tritsch, 1996). These latter applications are especially important be- cause they may be the first use of the frame- work by other disciplines. Applicable to administration and manage- ment in a variety of settings, a middle-range theory of group power within organizations has been developed and revised to the theory of group empowerment within organizations (Sieloff, 1995, 2003, 2007; Sieloff & Dunn, 2008; Sieloff & Bularzik, 2011). Educational settings, also considered as social systems, have been the focus of application of King’s work (George, Roach, & Andfrade, 2011; Greef, Strydom, Wessels, & Schutte, 2009; Ritter, 2008).5 Multidisciplinary Applications Because of King’s emphasis on the attainment of goals and the relevancy of goal attainment to many disciplines, both within and external to health care, it is reasonable to expect that 140 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm 4See Table 9-4 in the bonus chapter content available at 5See Table 9-8 in the bonus chapter content available at 3312_Ch09_133-152 26/12/14 2:50 PM Page 140 King’s work can find application beyond nursing-specific situations. Two specific ex- amples of this include the application of King’s work to case management (Hampton, 1994; Sowell & Lowenstein, 1994) and to managed care (Hampton, 1994). Both case management and managed care incorporate multiple disciplines as they work to improve the overall quality and cost-efficiency of the health care provided. These applications also address the continuum of care, a priority in today’s health-care environment. Specific re- searchers (Fewster-Thuente & Velsor- Friedrich, 2008; Khowaja, 2006) detailed their research related to multidisciplinary ac- tivities and interdisciplinary collaborations, respectively.6 Multicultural Applications Multicultural applications of KCS and re- lated theories are many. Such applications are particularly critical because many theo- retical formulations are limited by their culture-bound nature. Several authors specif- ically addressed the utility of King’s frame- work and theory for transcultural nursing. Spratlen (1976) drew heavily from King’s framework and theory to integrate ethnic cultural factors into nursing curricula and to develop a culturally oriented model for mental health care. Key elements derived from King’s work were the focus on percep- tions and communication patterns that mo- tivate action, reaction, interaction, and transaction. Rooda (1992) derived proposi- tions from the midrange theory of goal attainment as the framework for a conceptual model for multicultural nursing. Cultural relevance has also been demon- strated in reviews by Frey, Rooke, Sieloff, Messmer, and Kameoka (1995) and Husting (1997). Although Husting identified that cul- tural issues were implicit variables throughout King’s framework, particular attention was given to the concept of health, which, accord- ing to King (1990), acquires meaning from cultural values and social norms. Undoubtedly, the strongest evidence for the cultural utility of King’s conceptual framework and midrange theory of goal attainment (1981) is the extent of work that has been done in other cultures. Applications of the framework and related theories have been documented in the following countries beyond the United States: Brazil (Firmino, Cavalcante, & Celia, 2010), Canada (Plummer & Molzahn, 2009), China (Li, Li, & Xu, 2010), India (D’Souza, Somayaji, & Subrahmanya, 2011; George et al., 2011), Japan (Kameoka et al., 2007), Portugal (Chaves & Araujo, 2006; Goyatá et al., 2006; Pelloso & Tavares, 2006), Slovenia (Harih & Pajnkihar, 2009), Sweden (Rooke, 1995a, 1995b), and West Africa (Nwinee, 2011). In Japan, a culture very different from the United States with regard to communica- tion style, Kameoka (1995) used the classifica- tion system of nurse–patient interactions identified within the theory of goal attainment (King, 1981) to analyze nurse–patient interac- tions. In addition to research and publications regarding the application of King’s work to nursing practice internationally, publications by and about King have been translated into other languages, including Japanese (King, 1976, 1985; Kobayashi, 1970). Therefore, perception and the influence of culture on perception were identified as strengths of King’s theory. Research Applications in Varied Settings and Populations KCS has been used to guide nursing practice and research in multiple settings and with multiple populations. For example, Harih and Pajnkihar (2009) applied King’s model in treating elderly diabetes patients. Joseph et al. (2011) examined the implementation of whole-person care.7 As stated previously, dis- eases or diagnoses are often identified as the focus for the application of nursing knowledge. Maloni (2007) and Nwinee (2011) conducted research with patients with diabetes, and women with breast cancer were the focus of the work of Funghetto, Terra, and Wolff (2003). In addition, clients with chronic CHAPTER 9 • Imogene King’s Theory of Goal Attainment 141 6See Table 9-14 in the bonus chapter content available at 7See Table 9-11 in the bonus chapter content available at 3312_Ch09_133-152 26/12/14 2:50 PM Page 141 obstructive pulmonary disease were involved in research by Wicks, Rice, and Talley (2007). Clients experiencing a variety of psychiatric concerns have also been the focus of work, using King’s conceptualizations (Murray & Baier, 1996; Schreiber, 1991). Clients’ con- cerns ranged from psychotic symptoms (Kemppainen, 1990) to families experiencing chronic mental illness (Doornbos, 2007), to clients in short-term group psychotherapy (Laben, Sneed, & Seidel, 1995).8 The theory has also been applied in nonclinical nursing situations. Secrest, Iorio, and Martz (2005) used the theory in examining the empower- ment of nursing assistants. Li et al. (2010) ex- plored the “development of the concept of holistic nursing” (p. 33).9 Research Applications with Clients Across the Life Span Additional evidence of the scope and usefulness of King’s framework and theory is its use with clients across the life span. Several applications have targeted high-risk infants (Frey & Norris, 1997; Syzmanski, 1991). Frey (1993, 1995, 1996) developed and tested relationships among multiple systems with children, youth, and young adults. Lehna (2009) explicated the con- cept of sibling closeness in a study of siblings experiencing a major burn trauma. Interestingly, these studies considered personal systems (in- fants), interpersonal systems (parents, families), and social systems (the nursing staff and hospi- tal environment). Clearly, a strength of King’s framework and theory is its utility in encom- passing complex settings and situations. KCS and the midrange theory of goal at- tainment have also been used to guide practice with adults (young adults, adults, mature adults) with a broad range of concerns. Goyatá et al. (2006) used King’s work in their study of adults experiencing burns. Additional exam- ples of applications focusing on adults include individuals with hypertension (Firmino et al., 2010) and perceptions of students toward obesity (Ongoco, 2012). Gender-specific work included Sharts-Hopko’s (2007) use of a middle- range theory of health perception to study the health status of women during menopause transition and Martin’s (1990) application of the framework toward cancer awareness among males. Several of the applications with adults have targeted the mature adult, thus demonstrating contributions to the nursing specialty of geron- tology. Reed (2007) used a middle-range the- ory to examine the relationship of social support and health in older adults. Harih and Pajnkihar (2009) applied “King’s model in the treatment of elderly diabetes patients” (p. 201). Clearly, these applications, and others, show how the complexity of King’s framework and midrange theory increases its usefulness for nursing.10 Research Applications to Client Systems In addition to discussing client populations across the life span, client populations can be identified by focus of care (client system) and/or focus of health problem (phenomenon of concern). The focus of care, or interest, can be an individual (personal system) or group (interpersonal or social system). Thus, applica- tion of King’s work, across client systems, can be divided into the three systems identified within the KCS (1981): personal (the individ- ual), interpersonal (small groups), and social (large groups/society). Use with personal systems has included both patients and nurses. LaMar (2008) exam- ined nurses in a tertiary acute care organization as the personal system of interest. Nursing stu- dents as personal systems were the focus of Lockhart and Goodfellow’s research (2009). When the focus of interest moves from an in- dividual to include interaction between two people, the interpersonal system is involved. Interpersonal systems often include clients and nurses. An example of an application to a nurse–client dyad is Langford’s (2008) study of the perceptions of transactions with nurse practitioners and obese adolescents. In relation 142 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm 8See Table 9-8 and 9-11 in the bonus chapter content available at 9See Table 9-3 in the bonus chapter content available at 10 See Table 9-7 in the bonus chapter content available at 3312_Ch09_133-152 26/12/14 2:50 PM Page 142 to interpersonal systems, or small groups, many publications focus on the family. Frey and Norris (1997) used both KCS and the the- ory of goal attainment in planning care with families of premature infants. Alligood (2010) described “family health care with King’s the- ory of goal attainment” (p. 99). Research Applications Focusing on Phenomena of Concern to Clients Within King’s work, it is critically important for the nurse to focus on, and address, the phenomenon of concern to the client. With- out this emphasis on the client’s perspective, mutual goal setting cannot occur. Hence, a client’s phenomenon of concern was selected as neutral terminology that clearly demon- strated the broad application of King’s work to a wide variety of practice situations. A topic that frequently divides nurses is their area of specialty. However, by using a consistent framework across specialties, nurses may be able to focus more clearly on their common- alities, rather than highlighting their differ- ences.11 A review of the literature clearly demonstrates that King’s framework and re- lated theories have application within a variety of nursing specialties.12 This application is ev- ident whether one is reviewing a “traditional” specialty, such as surgical nursing (Bruns, Norwood, Bosworth, & Gill, 2009; Lockhart & Goodfellow, 2009; Sivaramalingam, 2008), or the nontraditional specialties of forensic nursing (Laben et al., 1991) and/or nursing administration (Gianfermi & Buchholz, 2011; Joseph et al., 2011). Health is one area that certainly binds clients and nurses. Improved health is clearly the desired end point, or outcome, of nursing care and something to which clients aspire. Review of the outcome of nursing care, as addressed in published applications, tends to support the goal of improved health directly and/or indirectly, as the result of the applica- tion of King’s work. Health status is explicitly the outcome of concern in practice applications by Smith (1988). Several applications used health-related terms. For example, DeHowitt (1992) studied well-being, and D’Souza et al. (2011) examined the determinants of health. Health promotion has also been an em- phasis for the application of King’s ideas. Sexual counseling was the focus of work by Villeneuve and Ozolins (1991). Health be- haviors were Hanna’s (1995) focus of study, and Plummer and Molzahn (2009) explored the “quality of life in contemporary nursing theory” (p. 134). Frey (1996, 1997) examined both health behaviors and illness manage- ment behaviors in several groups of children with chronic conditions as well as risky behaviors (1996). Recently, researchers have explored weight loss and obesity (Langford, 2008; Ongoco, 2012). Research Applications in Varied Work Settings An additional potential source of division within the nursing profession is the work sites where nursing is practiced and care is deliv- ered. As the delivery of health care moves from the acute care hospital to community-based agencies and clients’ homes, it is important to highlight commonalities across these settings, and it is important to identify that King’s framework and middle-range theory of goal attainment continue to be applicable. Al- though many applications tend to be with nurses and clients in traditional settings, suc- cessful applications have been shown across other, including newer and nontraditional set- tings. From hospitals (Bogue, Jospeh, & Sieloff, 2009; Firmino et al., 2010; Kameoka et al., 2007) to nursing homes (Zurakowski, 2007), King’s framework and related theories provide a foundation on which nurses can build their practice interventions. In addition, the use of the KCS and related theories are ev- ident within quality improvement projects (Anderson & Mangino, 2006; Durston, 2006; Khowaja, 2006).13 Nurses also use the theory CHAPTER 9 • Imogene King’s Theory of Goal Attainment 143 11See Table 9-9 in the bonus chapter content available at 12See Table 9-10 in the bonus chapter content available at 13See Table 9-11 in the bonus chapter content available at 3312_Ch09_133-152 26/12/14 2:50 PM Page 143 of goal attainment (King, 1981) to examine concepts related to the theory. This application was demonstrated by Smith (2003), by Jones and Bugge (2006), by Sivaramalingam (2008) in a study of patients’ perceptions of nurses’ roles and responsibilities, and by Mardis (2012) in a study of patients’ perceptions of minimal lift equipment. Relationship to Evidence-Based Practice From an evidence-based practice and King perspective, the profession must implement three strategies to apply theory-based research findings effectively. First, nursing as a disci- pline must agree on rules of evidence in evalu- ation of quality research that reflect the unique contribution of nursing to health care. Second, the nursing rules of evidence must include heavier weight for research that is derived from, or adds to, nursing theory. Third, the nursing rules of evidence must reflect higher scores when nursing’s central beliefs are af- firmed in the choice of variables. This third strategy, for the use of concepts central to nursing, has clear relevance for evidence-based practice when using King’s (1981) concepts as reformulated within interventions or out- comes. Outcomes, as in King’s concept of goal attainment, provide data for evidence-based practice. Currently, safety and quality initiatives in organizations, with evidence-based practice as the innovation, use many concepts initially defined by King and found in middle-range theories (Sieloff & Frey, 2007). King’s (1981) work on the concepts of client and nurse perceptions, and the achievement of mutual goals has been assimilated and ac- cepted as core beliefs of the discipline of nursing. Research conducted with a King theoretical base is well positioned for appli- cation by nurse caregivers (Bruns et al., 2009; Gemmill et al., 2011; Mardis, 2011), nurse administrators (Sieloff & Bularzik, 2011), and client-consumers (Killeen, 2007) as part of evolving evidence-based nursing practice.14 Recommendations for Future Applications Related to King’s Framework and Theory Obviously, new nursing knowledge has resulted from applications of King’s framework and the- ory. However, nursing is evolving as a science. Additional work continues to be needed. On the basis of a review of the applications previ- ously discussed, recommendations for future applications continue to focus on (1) the need for evidence-based nursing practice that is the- oretically derived; (2) the integration of King’s work in evidence-based nursing practice; (3) the integration of King’s concepts within SNLs; (4) analysis of the future effect of managed care, continuous quality improvement, and technol- ogy on King’s concepts; (5) identification, or de- velopment and implementation, of additional relevant instruments; and (6) clarification of ef- fective nursing interventions, including identi- fication of relevant Nursing Interventions Classifications, based on King’s work. As part of its mission, the King International Nursing Group (KING) (www.kingnursing .org) continuously monitors the latest publica- tions and research based on King’s work and related theories, providing updates to mem- bers. To further assist in the dissemination of such research, KING also conducts a biannual research conference. The following Exemplar illustrates the application of the theory of goal attainment to an interdisciplinary team, quality improvement, and evidence-based practice. 144 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm 14See Table 9-12 in the bonus chapter content available at 3312_Ch09_133-152 26/12/14 2:50 PM Page 144 CHAPTER 9 • Imogene King’s Theory of Goal Attainment 145 Practice Exemplar Provided by Mary B. Killeen, PhD, RN, NEA-BC Claire Smith, RN, BSN, is a recent nursing graduate in her first position on a medical in- tensive care unit in a suburban community hospital. Claire’s manager suggests that she should join the unit’s interdisciplinary quality improvement committee to develop her lead- ership skills. The goal of the committee is to improve patient care by using the best avail- able evidence to develop and implement prac- tice protocols. At the first meeting, Claire was asked if she had any burning clinical questions as a new graduate. She stated that she was taught to avoid use of normal saline for tracheal suc- tioning. However, she noticed many respira- tory therapists and some nurses routinely using normal saline with suctioning. When asked about this practice, she was told that normal saline was useful to break up se- cretions and aid in their removal. The com- mittee affirmed Claire’s observation of contradictory practices between what is taught and what is done in practice. After discussion, the group formulated the follow- ing clinical question: Does instilling normal saline decrease favorable patient outcomes among patients with endotracheal tubes or tracheostomies? Claire suggests to the committee that King’s theory of goal attainment might be useful as a theoretical guide for this project because the question is focused on patient outcomes, or according to King’s theory, goals. The nursing members are familiar with King’s theory, and all members value using theory to guide practice. Claire’s pro- posal is accepted. Claire experienced work- ing on EBP group projects as a student, so she feels comfortable volunteering to develop a draft of the theoretical foundation for the project. Two other committee members agree to work on the plan and present it at the next meeting. The following are the questions and the conclusions that Claire and her colleagues discussed: 1. How does King’s theory of goal attainment help the unit’s quality improvement (QI) committee? Goal attainment theory is derived from KCS, which includes personal, interpersonal, and social systems. The QI committee is a type of interpersonal system. An interpersonal system encompasses individuals in groups in- teracting to achieve goals. The QI committee is engaged in the committee’s goal attainment for the benefit of patients. “Role expectations and role performance of nurses and clients in- fluence transactions” (King, 1981, p. 147). When used in interdisciplinary teams, the transaction process in King’s theory facilitates mutual goal setting with nurses, and ulti- mately patients, based on each member of the team’s specific knowledge and functions. Multidisciplinary care conferences, an ex- ample of a situation where goal-setting among professionals occurs, is a label for an indirect nursing intervention within the Nursing Interventions Classification (NIC; Bulechek, Butcher, & Dochterman, 2008). Some of the activities listed under this NIC reflect King’s (1981) concepts: “establish mu- tually agreeable goals; solicit input for patient care planning; revise patient care plan, as necessary; discuss progress toward goals; and provide data to facilitate evaluation of patient care plan” (p. 501). 2. How does King define goals and goal attain- ment and how are these related to quality patient outcomes? According to King’s theory of goal at- tainment (1981), goals are mutually agreed upon, and through a transaction process, are attained. Goals are similar to outcomes that are achieved after agreement on the definitions and measurement of the out- comes. Quality improvement has shown agreement that evaluation of care must in- clude process and outcomes. Outcomes are Continued 3312_Ch09_133-152 26/12/14 2:50 PM Page 145 146 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm Practice Exemplar cont. the results of interventions or processes. The term “outcome” assumes that a process is central to effective care. An outcome is de- fined as a change in a patient’s health status. Effectiveness of care can be measured by whether the patient goals (i.e., outcomes) have been attained. The QI Committee en- gages in goal attainment through communi- cation by setting goals, exploring means, and agreeing on means to achieve goals. In this example, members will gather information, examine data and evidence, interpret the in- formation, and participate in developing a protocol for patients to achieve quality patient outcomes, that is, goals. 3. How does King’s theory of goal attainment provide a theoretical foundation for the clini- cal problem of using normal saline with suctioning? First, the use of King’s theory will help guide the literature search to include studies that address interventions or processes that lead to favorable patient outcomes or goals among patients similar to the population on the unit. Claire’s subgroup enlisted the help of the hospital librarian in searching the literature using the elements of the clinical question and the theoretical concepts as key words. Second, the theoretical formulation of the study helps organize the implementation and evaluation plans so they are attainable. 4. What key words would you use for the search con- sidering the clinical question and King’s theory? Key words used are endotracheal tubes, tracheostomies, normal saline, suctioning, out- comes, King’s theory of goal attainment, and goal attainment. 5. How does a theoretical foundation, such as King’s theory of goal attainment, apply to a quality improvement or EBP project? Claire used these criteria from her nurs- ing program to develop a theoretical foun- dation for the project. The theoretical foundation for the proj- ect was presented to the committee and accepted (Fig. 9–3). 6. What were the results of the committee’s work? The search strategy included MEDLINE, CINAHL, Cochrane Library, Joanna Briggs Institute, and TRIP databases. All types of evidence (nonexperimental, experimental, qualitative studies, systematic reviews) were Clinical Problem Elements King’s Concepts Application to the Project Members of the Interdisciplinary Committee Clinical problem formulated and relevance to unit discussed. Evidence sought and examined to select measurable goals/ outcomes. Implementation plan devised. Implementation plan accepted by members. Intervention: normal saline with suctioning Outcomes Outcomes Outcomes Population: patients with endotracheal tubes or tracheostomies Clients and nurses Transaction process: Disturbance Goals explored Explore means to achieve goals Agree on means to achieve goals 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). 3312_Ch09_133-152 26/12/14 2:50 PM Page 146 CHAPTER 9 • Imogene King’s Theory of Goal Attainment 147 Practice Exemplar cont. included. The evidence was evaluated by the QI committee and included physiological and psychological effects of instillation of normal saline. The collective evidence, rele- vant to their unit’s practice problem, did not support the routine use of normal saline with suctioning (similar to Halm & Kriski- Hagel, 2008). From the evidence, the com- mittee selected the specific outcomes to track for the project: sputum recovery, oxygena- tion, and subjective symptoms of pain, anx- iety, and dyspnea. Owing to anticipated small samples, hemodynamic alterations and infections were not selected as outcomes. The committee devised a theory-based im- plementation plan to discontinue normal saline for suctioning using the five Ws (who, what, where, when, why) and how as the outline for the plan. Change processes were employed in the plan. Evaluation of the at- tainment of outcomes will address the effec- tiveness of the plan using the measurable outcomes and the degree to which they were attained. ■ Summary An essential component in the analysis of con- ceptual frameworks and theories is the consid- eration of their adequacy (Ellis, 1968). Adequacy depends on the three interrelated characteristics of scope, usefulness, and com- plexity. Conceptual frameworks are broad in scope and sufficiently complex to be useful for many situations. Theories, on the other hand, are narrower in scope, usually addressing less abstract concepts, and are more specific in terms of the nature and direction of relation- ships and focus. King fully intended her conceptual system for nursing to be useful in all nursing situa- tions. Likewise, the middle-range theory of goal attainment (King, 1981) has broad scope because interaction is a part of every nursing encounter. Although previous evaluations of the scope of King’s framework and middle- range theory have resulted in mixed reviews (Austin & Champion, 1983; Carter & Dufour, 1994; Frey, 1996; Jonas, 1987; Meleis, 2012), the nursing profession has clearly recognized their scope and usefulness. In addition, the variety of practice applications evident in the literature clearly attests to the complexity of King’s work. 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CHAPTER 9 • Imogene King’s Theory of Goal Attainment 151 3312_Ch09_133-152 26/12/14 2:50 PM Page 151 3312_Ch09_133-152 26/12/14 2:50 PM Page 152 Chapter 10Sister Callista Roy’s Adaptation Model PAMELA SENESAC AND SISTER CALLISTA ROY Introducing the Theorist Overview of the Roy Adaptation Model Applications of the Theory Practice Exemplar Summary References 153 Introducing the Theorist Sister Callista Roy is a highly respected nurse theorist, writer, lecturer, researcher, and teacher. She is currently Professor and Nurse Theorist at the Connell School of Nursing at Boston College. Roy holds concurrent ap- pointments as Research Professor in Nursing at her alma mater, Mt. Saint Mary’s College, Los Angeles, CA, and as Faculty Senior Sci- entist, Yvonne L. Munn Center for Nursing Research, Massachusetts General Hospital, Boston, MA. Roy has been a member of the Sisters of St. Joseph of Carondolet for more than 50 years. Roy is recognized worldwide in the field of nursing and considered to be among nursing’s great living thinkers. 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 nurs- ing practice for individuals and for groups. In the first decade of the 21st century, Roy provided an expanded, values-based concept of adaptation based on insights related to the place of the person in the universe and in so- ciety. A prolific thinker, educator, and writer, she has welcomed the contributions of others in the development of the work; she 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, in 1939, 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 Sister Callista Roy 3312_Ch10_153-164 26/12/14 2:53 PM Page 153 service to others was central in the family. Her mother was a licensed vocational nurse and in- stilled the values of always seeking to know more about people and their care and of selfless giving as a nurse. Roy was awarded a bachelor of arts degree with a major in nursing from Mount St. Mary’s College, Los Angeles; a master’s degree in pe- diatric nursing and a master’s degree and a PhD in sociology from the University of California, Los Angeles. Roy completed a 2-year postdoc- toral program as a clinical nurse scholar in neu- roscience nursing at the University of California, San Francisco. She was a Senior Fulbright Scholar in Australia. Important mentors in her life have included Dorothy E. Johnson, Ruth Wu, Connie Robinson, and Barbara Smith Moran. Roy is best known for developing and con- tinually updating the Roy adaptation model as a framework for theory, practice, and research in nursing. Books on the model have been translated into many languages, including French, Italian, Spanish, Finnish, Chinese, Korean, and Japanese. Two publications that Roy considers significant are The Roy Adapta- tion Model (Roy, 2009) and Nursing Knowledge Development and Clinical Practice (Roy & Jones, 2007). Another important work is a two-part project analyzing research based on the Roy adaptation model and using the find- ings for knowledge development. The first was a critical analysis of 25 years of model-based literature, which included 163 studies pub- lished in 46 English-speaking journals, as well as dissertations and theses. It was published as a research monograph by Sigma Theta Tau In- ternational and entitled The Roy Adaptation Model-based Research: Twenty-five Years of Con- tributions to Nursing Science (Boston-Based Adaptation Research in Nursing Society, 1999). The research literature of the next 15 years was analyzed and used to create middle range theo- ries as evidence for practice. Including 172 stud- ies and currently in press, this work is entitled Generating Middle Range Theory: Evidence for Practice (Buckner & Hayden, in press). Roy was honored as a Living Legend by the American Academy of Nursing and the Mas- sachusetts Association of Registered Nurses. She has received many other awards, including the National League for Nursing Martha Rogers Award for advancing nursing science; the Sigma Theta Tau International Founders Award for contributions to professional prac- tice; and four honorary doctorates. Sigma Theta Tau International, Honor Society of Nursing included Roy as an inaugural inductee to the Nurse Researcher Hall of Fame.1 Overview of the Roy Adaption Model The Roy adaptation model (Roy, 1970, 1984, 1988a, 1988b, 2009, 2011a, 2011b, 2014; Roy & Andrews, 1991, 1999; Roy & Roberts, 1981; Roy, Whetzell & Fredrickson, 2009) has been in use for more than 40 years, providing direction for nursing practice, education, and research. Extensive implementation efforts around the world and continuing philosophical and scientific developments by the theorist have contributed to model-based knowledge for nursing practice. The purpose of this chap- ter is to describe the model as the foundation for knowledge-based practice. The develop- ments of the model, including assumptions and major concepts are described. The reader is introduced to the knowledge that the model provides as the basis for planning nursing care along with applications in practice and three practice exemplars. Historical Development Under the mentorship of Dorothy E. Johnson, Roy first developed a description of the adap- tation model while a master’s student at the University of California at Los Angeles. The first publication on the model appeared in 1970 (Roy, 1970) while Roy was on the faculty of the baccalaureate nursing program of a small liberal arts college. There, she had the opportunity to lead the implementation of this model of nurs- ing as the basis of the nursing curriculum. Dur- ing the next decade, more than 1500 faculty and students at Mount St. Mary’s College 154 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm 1For additional information please see the bonus chapter content available at 3312_Ch10_153-164 26/12/14 2:53 PM Page 154 helped to clarify, refine, and develop this ap- proach to nursing. The constant influence of practice was important during this develop- ment. One example of data from practice used in model development was the derivation of four adaptive modes from 500 samples of pa- tient behaviors described by nursing students. The mid-1970s to the mid-1980s saw the expansion of the use of the model in nursing education. Roy and the faculty at her home institution consulted on curriculum in more than 30 schools across the United States and Canada. By 1987, it was estimated that more than 100,000 students had graduated from curricula based on the Roy model. Theory de- velopment was also a focus during this time, and 91 propositions based on the model were identified. These described relationships be- tween and among concepts of the regulator and the cognator and the four adaptive modes (Roy & Roberts, 1981). In the 1980s, Roy also was influenced by postdoctoral work in neu- roscience nursing and an increasing number of commitments in other countries. Roy fo- cused on contemporary movements in nursing knowledge and the continued integration of spirituality with an understanding of nursing’s role in promoting adaptation. The first decade of the 21st century included a greater focus on philosophy, knowledge for practice, and global concerns. Philosophical, Scientific, and Cultural Assumptions Assumptions provide the beliefs, values, and accepted knowledge that form the basis for the work. For the Roy adaptation model, the con- cept of adaptation rests on scientific and philo- sophic assumptions that Roy has developed over time. The scientific assumptions initially reflected von Bertalanffy’s (1968) general sys- tems theory and Helson’s (1964) adaptation- level theory. Later beliefs about the unity and meaningfulness of the created universe were in- cluded (Young, 1986). Early identification of the philosophic assumptions for the model named humanism and veritivity. In 1988, Roy introduced the concept of veritivity as an option to total relativity. Veritivity was a term coined by Roy, based on the Latin word veritas. For Roy, the word offered the notion of the root- edness of all knowledge being one. Veritivity is the principle within the Roy Adaptation Model of human nature that affirms a common pur- posefulness of human existence. Veritivity is the affirmation that human beings are viewed in the context of the purposefulness of their ex- istence, unity of purpose of humankind, activity and creativity for the common good, and the value and meaning of life. Currently, Roy views the 21st century as a time of transition, transformation, and need for spiritual vision. The further development of the philosophic assumptions focuses on people’s mutuality with others, the world, and a God-figure. The development and expansion of the major concepts of the model show the influence of the theorist’s scientific and philo- sophic background and global experiences. For nursing in the 21st century, Roy (1997) provided a redefinition of adaptation and a re- statement of the assumptions that are founda- tional to the model, which led to expanded philosophical and scientific assumptions in contemporary society and to adding cultural assumptions. These assumptions are listed in Table 10-1 and further described in the basic work on the model (Roy, 2009). Roy also uses the idea of cosmic unity that stresses her vision for the future and emphasizes the principle that people and Earth have common patterns and integral relationships. Rather than the sys- tem acting to maintain itself, the emphasis shifts to the purposefulness of human existence in a creative universe. Model Concepts The underlying assumptions of the Roy adap- tation model are the basis for and are evident in the specific description of the major con- cepts of the model. The major concepts include people as adaptive systems (both individuals and groups), the environment, health, and the goal of nursing. People as Adaptive Systems Roy describes people, both individually and in groups, as holistic adaptive systems, complete with coping processes acting to maintain adap- tation and to promote person and environment CHAPTER 10 • Sister Callista Roy’s Adaptation Model 155 3312_Ch10_153-164 26/12/14 2:53 PM Page 155 156 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm Philosophic Assumptions Persons have mutual relationships with the world and the God-figure. Human meaning is rooted in an omega point convergence of the universe. God is intimately revealed in the diversity of creation and is the common destiny of creation. Persons use human creative abilities of awareness, enlightenment, and faith. Persons are accountable for entering the process of deriving, sustaining, and transforming the universe. Scientific Assumptions Systems of matter and energy progress to higher levels of complex self-organization. Consciousness and meaning are consistent of person and environment integration. Awareness of self and environment is rooted in thinking and feeling. Human decisions are accountable for the integration of creative processes. Thinking and feeling mediate human action. System relationships include acceptance, protection, and fostering interdependence. Persons and the Earth have common patterns and integral relations. Person and environment transformations created human consciousness. Integration of human and environment meanings result in adaptation. Cultural Assumptions Experiences within a specific culture will influence how each element of the Roy adaptation model is expressed. Within a culture, there may be a concept that is central to the culture and will influence some or all of the elements of the Roy adaptation model to a greater or lesser extent. Cultural expressions of the elements of the Roy adaptation model may lead to changes in prac- tice activities such as nursing assessment. As Roy adaptation model elements evolve within a cultural perspective, implications for educa- tion and research may differ from experience in the original culture. Table 10 • 1 Assumptions of the Roy Adaptation Model for the 21st Century transformations. As with any type of system, people have internal processes that act to maintain the integrity of the individual or group. These processes have been broadly cat- egorized as a regulator subsystem and a cognator subsystem for the person related to a stabilizer subsystem and an innovator subsystem for the group. The regulator uses physiological processes such as chemical, neurological, and endocrine responses to cope with the changing environment. For example, when an individual sees a sudden threat, such as an oncoming car approaching when stepping off the curb, an in- crease of adrenal hormones provides immedi- ate energy enabling him or her to escape harm. The cognator subsystem involves the cognitive and emotional processes that interact with the environment. In the example of the individual who escapes from an oncoming car, the cogna- tor acts to process the emotion of fear. The per- son also processes perceptions of the situation and comes to a new decision about where and how to cross the street safely. The coping processes for the group relate to stability and change. The stabilizer subsystem has structures, values, and daily activities to accomplish the primary purpose of the group. Thus a family group is structured to earn a living and to provide for the nurturance and ed- ucation of children. Family values also influence how the members respond to the environment to fulfill their responsibilities to maintain the family. Groups also have processes to respond to the environment with innovation and change by way of the innovator subsystem. For exam- ple, organizations use strategic planning activi- ties and team-building sessions. When the innovator is functioning well, the group creates new goals and growth, achieving new mastery and transformation. Nurses can use innovator subsystems to create organizational change in practice. 3312_Ch10_153-164 26/12/14 2:53 PM Page 156 Both the cognator-regulator and stabilizer- innovator coping processes are manifested in four particular ways of adapting in each indi- vidual and in groups of people. These four ways of categorizing the effects of coping activity are called adaptive modes. These four modes, initially developed for human systems as individuals, were expanded to encompass groups. These are termed the physiological– physical, self-concept–group identity, role func- tion, and interdependence modes. These four major categories describe responses to and interaction with the environment and are how adaptation can be observed. For individuals, the physiological mode in the Roy adaptation model is associated with the way people as individuals interact as physical beings with the environment. Behavior in this mode is the manifestation of the physiological activities of all the cells, tissues, organs, and systems comprising the human body. The physiological mode has nine components: the five basic needs of oxygenation, nutrition, elimination, activity and rest, and protection and four complex processes that are involved in physiological adaptation, including the senses; fluid, electrolyte, and acid–base bal- ance; neurological function; and endocrine function. The underlying need for the physio- logical mode is physiological integrity. The category of behavior related to the personal aspects of individuals is termed the self-concept. The basic need underlying the self- concept mode has been identified as psychic and spiritual integrity; one needs to know who one is to be or exist with a sense of unity. Self- concept is defined as the composite of beliefs and feelings that a person holds about him- or herself at a given time. Formed from internal perceptions and perceptions of others, self- concept directs one’s behavior. Components of the self-concept mode are the physical self, in- cluding body sensation and body image; and the personal self, including self-consistency, self-ideal, and moral–ethical–spiritual self. Processes in the mode are the developing self, perceiving self, and focusing self. Behavior relating to positions in society is termed the role function mode for both the in- dividual and the group. From the perspective of the individual, the role function mode focuses on the roles that the individual occupies in so- ciety. A role, as the functioning unit of society, is defined as a set of expectations about how a person occupying one position behaves toward a person occupying another position. The basic need underlying the role function mode for the individual has been identified as social in- tegrity, the need to know who one is in rela- tion to others in order to act. The underlying processes include developing roles and role taking. Behavior related to interdependent rela- tionships of individuals and groups is the interdependence mode, the final adaptive mode Roy describes. For the individual, the mode focuses on interactions related to the giving and receiving of love, respect, and value. The basic need of this mode is termed relational integrity, the feeling of security in nurturing re- lationships. Two specific relationships are the focus within the interdependence mode for the individual: significant others, persons who are the most important to the individual, and support systems, others contributing to meet- ing interdependence needs. Interdependence processes include affectional adequacy and de- velopmental adequacy. For people in groups it is more appropriate to use the term physical in referring to the first adaptive mode. At the group level, this mode relates to the manner in which the human adaptive system of the group manifests adap- tation relative to basic operating resources, that is, participants, physical facilities, and fiscal re- sources. The basic need associated with the physical mode for the group is resource ade- quacy, or wholeness achieved by adapting to change in physical resource needs. Processes in this mode for groups include resource manage- ment and strategic planning. Group identity is the relevant term used for the second mode related to groups. Identity in- tegrity is the need underlying this group adap- tive mode. The mode comprises interpersonal relationships, group self-image, social milieu, and culture. A nurse can have a self-concept of seeing self as physically capable of the work involved. In addition, the nurse feels comfortable meeting CHAPTER 10 • Sister Callista Roy’s Adaptation Model 157 3312_Ch10_153-164 26/12/14 2:53 PM Page 157 self-expectations of being a caring professional. In a social system, such as a nursing care unit, an associated culture can be described. There is a social environment experienced by the nurses, administrators, and other staff that is reflected by those who are part of the nursing care group. The group feels shared values and counts on each other. As such, the self-concept–group iden- tity mode can reflect adaptive or ineffective be- haviors associated with an individual nurse or the nursing care unit as an adaptive system. As we note later in the chapter, two processes iden- tified in this mode are group shared identity and family coherence. Roles within a group are the vehicles through which the goals of the social system are actually accomplished. They are the action components associated with group infrastruc- ture. Roles are designed to contribute to the accomplishment of the group’s mission, or the tasks or functions associated with the group. The role function mode includes the functions of administrators and staff, the management of information, and systems for decision mak- ing and maintaining order. The basic need as- sociated with the group role function mode is termed role clarity, the need to understand and commit to fulfil expected tasks, to achieve common goals. Processes involve socializing for role expectations, reciprocating roles, and integrating roles. For groups, the interdependence mode per- tains to the social context in which the group operates. It involves private and public contacts both within the group and with those outside the group. The components of group interde- pendence include context, infrastructure, and resources. The processes for group interde- pendence include relational integrity, develop- mental adequacy, and resource adequacy. The four adaptive modes are interrelated, which can be illustrated by drawing the modes as overlapping circles. The physiological–physical mode is intersected by each of the other three modes. Behavior in the physiological–physical mode can have an effect on or act as a stimulus for one or all of the other modes. In addition, a given stimulus can affect more than one mode, or a particular behavior can be indicative of adaptation in more than one mode. Such complex relationships among modes further demonstrate the holistic nature of humans as adaptive systems. The adaptive modes and coping processes for individuals and groups of individuals are described by the Roy adapta- tion model (Roy, 2009). Environment The Roy adaptation model defines environ- ment as all the conditions, circumstances, and influences surrounding and affecting the de- velopment and behavior of individuals and groups. Given the model’s view of the place of the person in the evolving universe, environ- ment is a biophysical community of beings with complex patterns of interaction, feedback, growth, and decline, constituting periodic and long-term rhythms. Individual and environ- mental interactions are input for the individual or group as adaptive systems. This input in- volves both internal and external factors. Roy used the work of Helson (1964), a physiolog- ical psychologist, to categorize these factors as focal, contextual, and residual stimuli. The focal is the stimulus most immediately confronting the individual and holding the focus of attention; contextual stimuli are those factors also acting in the situation; and resid- ual are possible factors that as yet have an unknown affect. A specific internal input stimulus is an adaptation level that represents the individual’s or group’s coping capacities. This changing level of ability has an internal effect on adaptive behaviors. Roy defined three levels of adaptation: integrated, com- pensatory, and compromised. Integrated adap- tation occurs when the structures and functions of the adaptive modes are working as a whole to meet human needs. The compensatory adap- tation level occurs when the cognator and regulator or stabilizer and innovator are acti- vated by a challenge. Compromised adaptation occurs when integrated and compensatory processes are inadequate, creating an adapta- tion problem. Health Roy’s concept of health is related to the con- cept of adaptation and the idea that adaptive responses promote integrity. Individuals and 158 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm 3312_Ch10_153-164 26/12/14 2:53 PM Page 158 groups are viewed as adaptive systems that interact with the environment and grow, change, develop, and flourish. Health is the re- flection of personal and environmental inter- actions that are adaptive. According to the Roy adaptation model, health is defined as (1) a process, (2) a state of being, and (3) becoming whole and integrated in a way that reflects in- dividual and environment mutuality. Goal of Nursing When Roy began her theoretical work, the goal of nursing was the first major concept of her nursing model to be described. She began by attempting to identify the unique function of nursing in promoting health. As a number of health-care workers have the goal of pro- moting health, it seemed important to iden- tify a unique goal for nursing. While she was working as a staff nurse in pediatric settings, Roy noted the great resiliency of children in responding to major physiological and psy- chological changes. Yet nursing intervention was needed to support and promote this pos- itive coping. It seemed, then, that the con- cept of adaptation, or positive coping, might be used to describe the goal or function of nursing. From this initial notion, Roy devel- oped a description of the goal of nursing: the promotion of adaptation for individuals and groups in each of the four adaptive modes, thus contributing to health, quality of life, and dying with dignity. Basis for Practice—Theory and Process The assumptions and concepts of the model provide the basis for theory building for nursing practice, as well as a specific ap- proach to the nursing process. As early as the 1970s, human life processes and patterns were identified as the common focus of nursing knowledge (Donaldson & Crowley, 1978). In a more recent article, a central uni- fying focus of nursing has extended this view to include nursing concepts categorized as fa- cilitating humanization, meaning, choice, quality of life, and healing, living, and dying (Willis, Grace, & Roy, 2008). Adaptation is a significant life process that leads to these ideals. Theory Development for Practice To lead to middle-range theories within the model, Roy identified the major life processes within each adaptive mode. For example, in the physiological mode, there are processes and patterns for the need for oxygenation that include ventilation, patterns of gas exchange, transport of gases, and compensation for inad- equate oxygenation. Similarly, the self-concept mode has three processes identified to meet the person’s need for psychic and spiritual in- tegrity: the developing self, the perceiving self, and the focusing self. On the group level, two examples of processes identified to meet the need for a shared self-image are group shared identity and family coherence. The group iden- tity mode reflects how people in groups perceive themselves based on environmental feedback about the group. Persons in a group have per- ceptions about their shared relations, goals, and values. The social milieu and the culture provide feedback for the group. The social mi- lieu refers to the human-made environment in which the group is embedded, including eco- nomic, political, religious, and family struc- tures. Ethnicity and socioeconomic status in particular make up the social culture, a specific part of the milieu or environment of the group. The belief systems of the milieu and social culture act as stimuli for the group and also affect other groups with which the group interacts. The family is most often the first group with which a person identifies. The group self-image and shared responsibility for goal achievement is central to group identity. Identity integrity is the basic need underlying the group identity mode. Nursing care uses the understanding of these processes to evaluate the adaptation level and to provide care to promote integrated processes at the highest level of adaptation possible. To develop knowledge for practice from the grand theory, Roy described a five-step process for developing middle or practice level theory and nursing knowledge: 1. Select a life process. 2. Study the life process in the literature and in people. 3. Develop an intervention strategy to en- hance the life process. CHAPTER 10 • Sister Callista Roy’s Adaptation Model 159 3312_Ch10_153-164 26/12/14 2:53 PM Page 159 4. Derive a proposition for practice. 5. Test the proposition in research. Processes can also be identified by using qualitative research to identify and describe human experiences. Nursing Process for Care The nursing process based on the model stems from the assumptions and concepts of the model. First-level assessment of behavior in- volves gathering data about the behavior of the person or group as an adaptive system in each of the adaptive modes. Second-level assess- ment is the assessment of stimuli, that is, the identification of internal and external stimuli that influence the adaptive behaviors. Stimuli are classified as focal, contextual, and residual. The nurse uses the first- and second-level as- sessment to make a nursing judgment called a nursing diagnosis. In collaboration with the person or group, the data are interpreted in statements about the adaptation status of the person, including behavior and most relevant stimuli. The adaptation level is then classified as integrated, compensatory, or compromised. Also, in collaboration with the person or group, the nurse sets goals, establishing clear statements of the behavioral outcomes for nurs- ing care. Interventions then involve the deter- mination of how best to assist the person in attaining the established goals. These may in- volve changing stimuli or strengthening coping ability. The aim is to promote an integrated adaptation level. Evaluation involves judging the effectiveness of the nursing intervention in rela- tion to the resulting behavior in comparison with the goal established. The steps of the nursing process have been given in sequential order; however, the process is ongoing and the steps can be simultaneous. For example, the nurse may be intervening in one adaptive mode and assessing in another at the same time. Applications of the Theory Senesac (2003) reviewed published projects that have implemented the Roy adaptation model in institutional practice settings and identified seven distinct projects ranging from an ideology basis for a single unit to hospital- wide projects. In some cases the published proj- ect developed from a unit implementation to a full agency implementation, as in one of the early projects reported by Mastal et al. (1982). Gray (1991) discussed involvement in five proj- ects. She reported that not all implementation projects were completed due to changes in hos- pital management, philosophy, or direction. Gray’s initial work was at a 132-bed acute care, not-for-profit children’s hospital. Other projects varied from a 100-bed proprietary hos- pital to a 248-bed nonprofit, community-owned hospital. The main focus of the implementation projects was to improve patient care through quality nursing care plans and in some cases to develop performance standards. Two implemen- tation projects in Colombia were reported on by Moreno-Ferguson and Alvarado-Garcia (2009). One project was in an ambulatory rehabilitation service (Moreno-Ferguson, 2001) and the other a pediatric intensive care unit of a cardiology in- stitute (Monroy, 2003). As hospitals in the United States work toward certification of Mag- net Status, more nursing groups are requesting information about application of the Roy adap- tation model in institutional health-care settings. 160 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm Practice Exemplar Family coherence is an indicator of positive adaptation and refers to a state of unity or a consistent sequence of thought that connects family members who share group identity, goals, and values (Roy, 2009). When interact- ing with families of other cultures, health-care providers need to assess cultural norms and be- liefs that determine patterns of interaction with the health and social services system, health- care decision making, the availability of social support for caregivers, and may have implica- tions for the psychosocial experience of family caregivers and the clients. Roy’s group identity mode provides a useful conceptual framework that guides health-care providers working with families of diverse ethnic backgrounds. 3312_Ch10_153-164 26/12/14 2:53 PM Page 160 CHAPTER 10 • Sister Callista Roy’s Adaptation Model 161 Practice Exemplar cont. Introduction to the Practice Exemplar—the Wang Family The Wang family includes David Wang; his wife, Teresa Wang; their 7-year old daughter, Vivian Wang; and extended family including David’s mother, Uncle Frank Wang; his daughter Lisa Wang, 32; and her husband and their 5-year-old son (Zhan, 2003). David’s parents immigrated to the United States when he was ten years old. The Wang family opened a small Chinese restaurant, which David has managed since his father’s retirement. David’s parents participate regu- larly in activities organized by Chinatown’s Council on Aging. David and his parents have a shared self- image as Chinese immigrants and a shared group identity as the Wang family. The Wang family shares a strong cultural commitment to the value of filial piety. To family members, this means to be good to one’s parents and take care of them; to engage in good conduct and bring a good name to parents and ances- tors; to perform one’s job well to support par- ents and carry out sacrifices to the ancestors; and to show love, respect, and support. The term filial denotes the respect and obedience that a child, primarily a son, should show to his parents, especially to his father. David’s father suffered a stroke and died at the age of 78. His mother began to show de- cline in memory, experiencing difficulty find- ing her way in familiar places, misplacing objects, becoming disoriented and easily irri- tated. David took his mother for a physical examination; she was diagnosed as having dementia and referred to a specialist. Recog- nizing that his mother was unable to live independently, David arranged for her to live with his family. David and his wife took on the family caregiver role while trying to keep their respective jobs. David’s cousin visited them regularly and helped with household chores. David was glad that he was able to keep the family together despite the passing of his father and the cognitive impairment of his mother. David provides primary financial support for his family. As his mother’s cognitive func- tion deteriorated, David became overwhelmed by caring for his mother while being respon- sible for managing the restaurant. His wife quit her job to attend to her mother-in-law’s care. When David and his wife tried to find someone in the Chinese community to pro- vide respite care for their mother, they heard some strong negative reactions. Some consid- ered his mother’s dementia as “insanity” or “a mental disorder.” Some talked about dementia as contagious or believed his mother’s demen- tia was being caused by bad Feng Shui, an an- cient Chinese belief in which Feng (the force of wind) and Shui (the flow of water) are viewed as living energies that flow around one’s home and affect one’s life and well- being. If Feng Shui flows gently and peacefully, it brings happiness and health to one’s family. If Feng Shui stagnates, one can be ill, poor, and unfortunate (Beattie, 2000). The perception of dementia triggered a strong negative re- sponse from the Chinese community, and his mother’s friends stopped visiting her. David’s daughter began to miss school, and her grades were declining. Both David and his wife were feeling overwhelmed and depressed. Analysis of the Practice Exemplar In the case of the Wang family, the focus of nursing practice is on the relational system of the family. To begin planning nursing care, the family is addressed as an adaptive system. Assessment of behaviors The nurse met with David and Teresa to assess family structure, function, relationships, and consistency, and their employment status, liv- ing arrangements, and the division of family caregiving responsibilities. The nurse assessed how decisions are made in the family, from small daily decisions to larger, health-care- related decisions. The nurse observed that David and his wife show love, respect, and loyalty to David’s mother and to each other. Although the mother’s needs for care are met, individual needs of both David and his wife, Continued 3312_Ch10_153-164 26/12/14 2:53 PM Page 161 162 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm Practice Exemplar cont. Teresa are unmet. Alternating care for David’s mother, maintaining their jobs, and attending to Vivian’s schoolwork and growth needs is challenging. The nurse finds out that the Wang family holds a strong Chinese tradition of filial piety and that they feel a moral obliga- tion to take care of their mother. The strong stigma attached to dementia in the Chinese community takes an emotional toll on them. Assessment of stimuli The nurse conducts a second level of assess- ment by meeting with the extended Wang family to identify influencing factors, or stim- uli, related to group identity and family coher- ence. The major stimuli are the demands they face and the problems posed for them to solve. David’s mother requires medical and personal care. David needs to work to ensure health in- surance for his family and to secure income to pay for the cost of personal care. Finding Chinese-speaking home health aides is chal- lenging. The social stigma toward dementia is strong in the Chinese community, bringing shame to the Wang family and isolating David’s mother from her ethnic community. The Wang family agrees that the stigma and reaction from the external social environment have become stressors to family caregiving. Nursing diagnosis The nurse identifies three tentative diagnoses. First, the Wang family has a strong ethnic her- itage related to the group’s responsibility to maintain values and goals. Second, family con- flict exists as the demands of family caregiving for the mother increase. Third, strong stigma attached to dementia in the Chinese commu- nity creates prejudice against the Wang family and causes some family members to feel dis- tressed and ambivalent. The nurse continues to assess behaviors of shared identity and cohesion in the Wang family, looking for common perceptions, feel- ings, and experiences of caregiving for the loved one with dementia. The nurse learns that David, as the only son, has a moral responsi- bility to care for his mother and considers himself solely responsible. The nurse asks each member of the Wang family to find common orientations by sharing their thinking and feel- ings. David and his wife openly share their feelings and frustrations. Lisa and her father express their willingness to share responsibility and help out. Goal setting At the next meeting, the nurse helps the Wang family set up attainable short-term goals based on shared cognitive and emotional orientations and common values. Attaining goals requires shared responsibilities and some division of labor. Their goals include (1) work- ing together with home health aides; (2) sup- porting each other through shared feelings and thoughts and the shared responsibilities of caregiving based on each individual’s desire, skill, and availability; and (3) communicating with the Chinese community about the stigma toward dementia and finding ways to demys- tify dementia. The Wang family decides to have Lisa Chang, a social worker in a community hospi- tal, lead the search for home health aides. David Wang convenes family meetings as needed, and Frank Wang leads the talk with key players in the Chinese community. Despite the stressors they have encountered, family members feel a sense of unity through com- pensatory adaptation process. Intervention Nursing intervention involves focusing on the stimuli affecting the behavior and managing the stimuli by altering, increasing, or decreas- ing, removing, or maintaining stimuli. The nurse (1) assesses the Wang family with re- spect to shared values, shared goals, shared re- lations, group identify, and social environment and stimuli; (2) works with the Wang family to write down shared goals, values, and expec- tations; and (3) encourages the family to ex- plore additional resources. The nurse also helps the Wang family to use effective coping strate- gies to strengthen compensatory processes by acknowledging that the family is transcending the crisis, identifying additional resources in support of family caregiving, and by reinforc- ing their shared goals, values, relations, and group identity. 3312_Ch10_153-164 26/12/14 2:53 PM Page 162 CHAPTER 10 • Sister Callista Roy’s Adaptation Model 163 Practice Exemplar cont. Evaluation The nurse evaluates the effectiveness of the nursing intervention. Lisa Chang called her social work network and found appropriate home health aides to provide personal care to David’s mother. This allows David to attend to his work and allows his wife to spend more time with their daughter, attending to her schoolwork and personal needs. Vivian has not been absent from school again. David Wang hired a manager to help op- erate the restaurant so that he has time to take his mother to appointments and to maintain a stable income. David’s mother’s old friend visited her briefly. Frank Wang, an activist in the Chinese community, began to talk with other Chinese about dementia. The strong stigma attached to dementia in the Chinese community influenced the adaptation problem experienced by the Wang family. Social stigma can be pervasive, distorting the perceptions of individuals, affecting the perception of a disease and how a dementia diagnosis and services are sought, and how caregiving is supported. To reduce stigma in promotion of effective adaptation of family caregivers and health-care providers, families and the community need to work together toward better understanding of dementia, its diagnosis, treatment, and care options. Educational and service outreach is the first step to reduce the stigma in the Chinese community. Educational materials and service need to be linguistically appropri- ate and adaptable to Chinese patients and their families. Elderly Chinese immigrants often read Chinese newspapers to connect themselves to their culture and people. Pub- lishing dementia information and related educational articles in widely circulated Chinese newspapers is a way to reach out to Chinese families. Bilingual professional staff and linguistically appropriate oral and written instructions on dementia are helpful (Valle, 1998). Reprinted from: Roy, C. & Zhan, l. (2010). Sister Callista Roy’s Adaptation Model. In Nurs- ing Theories and Nursing Practice (3rd. Ed.). ■ Summary This chapter focused on the Roy adaptation model as a foundation for knowledge-based practice. The background of the theorist and the historical development of the model were presented briefly. Roy’s most recent theoretical developments were the main focus of the de- scription of the model assumptions and major concepts (. The process for theory becoming the basis for developing knowledge for practice was introduced by outlining how to develop middle- and practice-level theory that is tested in research. In particular, the effects of the Roy adaptation model on practice were articulated from a general summary of major practice projects and through a practice exemplar. The exemplar illustrates the use of the self-identity adaptive mode as an example of using theory- based knowledge to provide care for a Chinese family dealing with a parent diagnosed with dementia. References Beattie, A. (2000). Using Feng Shui. Vancouver: Raincoast Books. Boston-Based Adaptation Research in Nursing Society. (1999). Roy adaptation model-based research: 25 years of contributions to nursing science. Indianapolis, IN: Centre Nursing Press. Buckner, E. B., & Hayden, S. (2014). Synthesis of middle range theory of adapting in chronic health conditions. In C. Roy with the Roy Adaptation Association, Generating middle range theory: Evidence for practice (pp. 277–308). New York, NY: Springer Publishing Company. 3312_Ch10_153-164 26/12/14 2:53 PM Page 163 Donaldson, S. K., & Crowley, D. (1978). The discipline of nursing. Nursing Outlook, 26, 113–120. Gray, J. (1991). The Roy adaptation model in nursing practice. In C. Roy & H. A. Andrews (Eds.), The Roy adaptation model: The definitive statement (pp. 429–443). Norwalk, CT: Appleton & Lange. Helson, H. (1964). Adaptation level theory. New York: Harper & Row. Mastal, M. F., Hammond, H., & Roberts, M. P. (1982). Theory into hospital practice: A pilot imple- mentation. The Journal of Nursing Administration, 12, 9–15. Monroy, P. (2003). Aproximación a la experiencia de aplicación del Modelo de Callista Roy en la Unidad de cuidado intensivo pediátrico. Enfermería Hoy, 1(1), 17–20. Moreno-Ferguson, M. E. (2001). Aplicacion del modelo de adaptacion en un servicio de rehabilitacion ambu- latoria, Aquichan, 1(1), 14–17. Moreno-Ferguson, M. E., & Alvardo-Garcia, A. M. (2009). Aplicacion del modelo de adaptacion de Callista Roy en Latinoamerica: Revision de la literatura. Aquichan, 9(1), 62–72. Roy, C. (1970). Adaptation: A conceptual framework for nursing. Nursing Outlook, 18, 42–45. Roy, C. (1984). Introduction to nursing: An adaptation model (2nd ed.). Englewood Cliffs, NJ: Prentice- Hall. Roy, C. (1988a). Altered cognition: An information processing approach. In P. H. Mitchell, L. C. Hodges, M. Muwaswes, & C. A. Walleck (Eds.), AANN’s neuroscience nursing, phenomenon and practice: Human responses to neurological health problems (pp. 185–211). Norwalk, CT: Appleton & Lange. Roy, C. (1988b). Human information processing. In J. J. Fitzpatrick, R. L. Taunton, & J. Q. Benoliel (Eds.), Annual review of nursing research (pp. 237–261). New York: Springer. Roy, C. (1997). Knowledge as universal cosmic imperative. Proceedings of nursing knowledge impact conference 1996 (pp. 95–118). Chestnut Hill, MA: Boston College Press. Roy, C. (2009). The Roy adaptation model (3rd ed.). Upper Saddle River, NJ: Prentice-Hall Health. Roy, S. C. (2011a). Extending the Roy adaptation model to meet changing global needs. Nursing Science Quarterly, 24(4), 345–351. Roy, S. C. (2011b). Research based on the Roy adapta- tion model: Last 25 years. Nursing Science Quarterly, 24(4), 312–320. Roy, C.with the RAA. (Ed.). (2014). Generating middle range theory: Evidence for practice. New York, NY: Springer Publishing Company. Roy, C., & Andrews, H. A. (1991). The Roy adaptation model: The definitive statement. East Norwalk, CT: Appleton & Lange. Roy, C., & Andrews, H. A. (1999). The Roy adaptation model (2nd ed.). Stamford, CT: Appleton & Lange. Roy, C., & Jones, D. (Eds.). (2007). Nursing knowledge development and clinical practice. New York: Springer. Roy, C., & Roberts, S. (1981). Theory construction in nursing: An adaptation model. Englewood Cliffs, NJ: Prentice-Hall. Roy, C., Whetsell, M.V., & Frederickson, K. (2009).The Roy adaptation model and research: Global Perspec- tive Nursing Science Quarterly, 22(3), 209–211. Senesac, P. (2003). Implementing the Roy adaptation model: From theory to practice. Roy Adaptation Association Review, 4(2), 5. Valle, R. (1998). Caregiving across cultures: Working with dementing illness and ethnically diverse populations. Boca Raton, FL: Taylor & Francis. von Bertalanffy, L. (1968). General system theory: Foun- dations, development, applications. New York: George Braziller. Willis, D., Grace, P., & Roy, C. (2008). A central uni- fying focus for the discipline: Facilitating humaniza- tion, meaning, choice, quality of life and healing in living and dying. Advances in Nursing Science, 31(1), E28–40. Retrieved from www.advancesinnursing- Young, L. B. (1986). The unfinished universe. New York: Simon & Schuster. Zhan, L. (2003). Asian Americans: Vulnerable population, model intervention, and clarifying agendas. Sudbury, MA: Jones and Bartlett. 164 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm 3312_Ch10_153-164 26/12/14 2:53 PM Page 164 Chapter 11Betty Neuman’s Systems Model LOIS WHITE LOWRY AND PATRICIA DEAL AYLWARD Introducing the Theorist Overview of the Neuman Systems Model Applications of the Theory Practice Exemplar Summary References 165 Introducing the Theorist Betty Neuman developed the Neuman systems model (NSM) in 1970 to “provide unity, or a focal point, for student learning” (Neuman, 2002b, p. 327) at the School of Nursing, Uni- versity of California at Los Angeles (UCLA). Neuman recognized the need for educators and practitioners to have a framework to view nursing comprehensively within various con- texts. Although she developed the model strictly as a teaching aid, it is now used globally as a nursing conceptual model to guide cur- riculum development, research studies, and clinical practice in the full array of health-care disciplines. Neuman’s autobiography, touched on briefly here, is presented more fully in the lat- est edition of her book focusing on the model (Neuman & Fawcett, 2011). Neuman was born in southeastern Ohio on a 100-acre fam- ily farm on September 11, 1924. Her father died at age 37 when she was 11, and she, her mother, and two brothers worked hard to keep the farm. Neuman idealized nursing because her fa- ther had praised nurses during his 6 years of intermittent hospitalizations. In gratitude, she developed a strong commitment to become an excellent bedside nurse. She also attributed her decisions about her life’s work to the important influence of her mother’s charity experiences as a self-taught rural midwife. Betty Neuman graduated from high school soon after the onset of World War II. Al- though she had dreamed of attending nearby Marietta College, she lacked the financial means and instead became an aircraft instru- ment repair technician. After the Cadet Nurse Betty Neuman 3312_Ch11_165-184 26/12/14 2:57 PM Page 165 Corps Program became available, she entered the 3-year diploma nurse program at People Hospital, Akron, Ohio (currently General Hospital Medical Center). She completed her baccalaureate degree in nursing and earned a master’s degree, with a major in public health nursing, from UCLA. During her master’s program, she worked on special projects, as a relief psychiatric head nurse and as a volunteer crisis counselor. Be- cause of these experiences, Neuman became one of the first California Nurse Licensed Clinical Fellows of the American Association of Marriage and Family Therapy. In 1967, Neuman became a faculty member at UCLA and assumed the role of chair of the program from which she had graduated. She expanded the master’s program, focusing on interdisciplinary practice in community mental health. In 1970, she developed the NSM as a guide for graduate nursing students. The model was first published in the May–June 1972 issue of Nursing Research. Since 1980, several impor- tant changes have enhanced the model. A nursing process format was designed, and in 1989, Neuman introduced the concepts of the created environment and the spiritual variable. In collaboration with Dr. Audrey Koertve- lyessy, Neuman developed a theory of client system stability. Along with the Neuman Sys- tems Trustees Group, she continues to clarify concepts and components of the model. Neuman completed a doctoral degree in clin- ical psychology in 1985 from Pacific Western University. She received honorary doctorates from Neumann College in Aston, Pennsylvania, and Grand Valley State University in Allendale, Michigan. She is an honorary fellow in the American Academy of Nursing. Overview of the Neuman Systems Model The philosophic base of the Neuman Systems Model encompasses wholism, a wellness orienta- tion, client perception and motivation, and a dy- namic systems perspective of energy and variable interaction with the environment to mitigate possible harm from internal and external stres- sors, while caregivers and clients form a partner- ship relationship to negotiated desired outcome goals for optimal health retention, restoration, and maintenance. This philosophic base pervades all aspects of the model. —BETTY NEUMAN (2002c, p. 12) As its name suggests, the Neuman systems model is classified as a systems model or a sys- tems category of knowledge. Neuman (1995) defined system as a pervasive order that holds together its parts. With this definition in mind, she writes that nursing can be readily conceptualized as a complete whole, with identifiable smaller wholes or parts. The com- plete whole structure is maintained by interre- lationships among identifiable smaller wholes or parts through regulations that evolve out of the dynamics of the open system. In the system there is dynamic energy exchange, moving ei- ther toward or away from stability. Energy moves toward negentropy, or evolution, as a system absorbs energy to increase its organiza- tion, complexity, and development when it moves toward a steady or wellness state. An open system of energy exchange is never at rest. The open system tends to move cyclically toward differentiation and elaboration for fur- ther growth and survival of the organism. With the dynamic energy exchange, the sys- tem can also move away from stability. Energy can move toward extinction (entropy) by grad- ual disorganization, increasing randomness, and energy dissipation. The NSM illustrates a client–client system and presents nursing as a discipline concerned primarily with defining appropriate nursing actions in stressor-related situations or in pos- sible reactions of the client–client system. The client and environment may be positively or negatively affected by each other. There is a tendency within any system to maintain a steady state or balance among the various dis- ruptive forces operating within or upon it. Neuman has identified these forces as stressors and suggests that possible reactions and actual reactions with identifiable signs or symptoms may be mitigated through appropriate early in- terventions (Neuman, 1995). 166 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm 3312_Ch11_165-184 26/12/14 2:57 PM Page 166 Unique Perspectives of the Neuman Systems Model Neuman (2002c, p. 14; 2011a, p. 14) has iden- tified 10 unique perspectives inherent within her model. They describe, define, and connect concepts essential to understanding the con- ceptual model that is presented in the next sec- tion of this chapter. 1. Each individual client or group as a client system is unique; each system is a compos- ite of common known factors or innate characteristics within a normal, given range of response contained within a basic structure. 2. The client as a system is in a dynamic, con- stant energy exchange with the environment. 3. Many known, unknown, and universal en- vironmental stressors exist. Each differs in its potential for disturbing a client’s usual stability level, or normal line of defense. The particular interrelationships of client variables—physiological, psychological, so- ciocultural, developmental, and spiritual— at any point in time can affect the degree to which a client is protected by the flexi- ble line of defense against possible reaction to a single stressor or a combination of stressors. 4. Each individual client–client system has evolved a normal range of response to the environment that is referred to as a normal line of defense, or usual wellness/stability state. It represents change over time through coping with diverse stress encounters. The normal line of defense can be used as a standard from which to measure health deviation. 5. When the cushioning, accordion-like ef- fect of the flexible line of defense is no longer capable of protecting the client– client system against an environmental stressor, the stressor breaks through the normal line of defense. The interrelation- ships of variables—physiological, psycho- logical, sociocultural, developmental, and spiritual—determine the nature and degree of system reaction or possible reaction to the stressor. 6. The client, whether in a state of wellness or illness, is a dynamic composite of the inter- relationships of variables—physiological, psychological, sociocultural, developmental, and spiritual. Wellness is on a continuum of available energy to support the system in an optimal state of system stability. 7. Implicit within each client system are in- ternal resistance factors known as lines of resistance, which function to stabilize and return the client to the usual wellness state (normal line of defense) or possibly to a higher level of stability after an envi- ronmental stressor reaction. 8. Primary prevention relates to general knowledge that is applied in client assess- ment and intervention in identification and reduction or mitigation of possible or actual risk factors associated with envi- ronmental stressors to prevent possible reaction. The goal of health promotion is included in primary prevention. 9. Secondary prevention relates to sympto- matology after a reaction to stressors, appropriate ranking of intervention priorities, and treatment to reduce their noxious effects. 10. Tertiary prevention relates to the adaptive processes taking place as reconstitution begins and maintenance factors move the client back in a circular manner toward primary prevention. The Conceptual Model Neuman’s original diagram of her model is illus- trated in Figure 11-1. The conceptual model was developed to explain the client–client system as an individual person for the discipline of nursing. Neuman chose the term client to show respect for collaborative relationships that exist between the client and the caregiver in Neuman’s model, as well as the wellness perspective of the model. The model can be applied to an individual, a group, a community, or a social issue and is appropri- ate for nursing and other health disciplines (Neuman, 1995, 2002c, 2011a, p.15). The NSM provides a way of looking at the domain of nursing: humans, environment, health, and nursing. CHAPTER 11 • Betty Neuman’s Systems Model 167 3312_Ch11_165-184 26/12/14 2:58 PM Page 167 168 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm Stressors Identified Classified as knowns or possibilities, i.e., Loss Pain Sensory deprivation Cultural change Inter Intra Extra Personal factors Stressors More than one stressor could occur simultaneously* Same stressors could vary as to impact or reaction Normal defense line varies with age and development Basic structure Basic factors common to all organisms, i.e.: Normal temperature range Genetic structure Response pattern Organ strength or weakness Ego structure Knowns or commonalities StressorStressor Reaction BASIC STRUCTURE ENERGY RESOURCES Reconstitution Could begin at any degree or level of reaction Range of possibility may extend beyond normal line of defense Primary prevention Reduce possibility of encounter with stressors Strengthen flexible line of defense Inter Intra Extra Personal factors Inter Intra Extra Personal factors Secondary prevention Early case-finding and Treatment of symptoms Tertiary prevention Readaptation Reeducation to prevent future occurrences Maintenance of stability Reaction Individual intervening variables, i.e.: Basic structure idiosyncrasies Natural and learned resistance Time of encounter with stressor *Physiological, psychological, sociocultural, developmental, and spiritual variables are considered simultaneously in each client concentric circle. NOTE: Interventions Can occur before or after resistance lines are penetrated in both reaction and reconstitution phases Interventions are based on: Degree of reaction Resources Goals Anticipated outcome Fle xible Line of Defense No rmal Line of Defense Li nes of Resistance Degree of Reaction R econstitution 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, 1995, p. 17, with permission.) 3312_Ch11_165-184 26/12/14 2:58 PM Page 168 Client–Client System The client–client system (see Fig. 11-1) con- sists of the flexible line of defense, the nor- mal line of defense, lines of resistance, and the basic structure energy resources (shown at the core of the concentric circles in Fig. 11-2). Five client variables—physiological, psychological, sociocultural, developmental, and spiritual—occur and are considered simulta- neously in each concentric circle that makes up the client–client system (Neuman, 1995, 2002c, 2011a). Flexible Line of Defense Stressors must penetrate the flexible line of de- fense before they are capable of penetrating the rest of the client system. Neuman described this line of defense as accordion-like in func- tion. The flexible line of defense acts like a pro- tective buffer system to help prevent stressor invasion of the client system and protects the normal line of defense. The client has more protection from stressors when the flexible line expands away from the normal line of defense. The opposite is true when the flexible line moves closer to the normal line of defense. The effectiveness of the buffer system can be re- duced by single or multiple stressors. The flex- ible line of defense can be rapidly altered over a relatively short time period by states of emer- gency, or short-term conditions, such as loss of sleep, poor nutrition, or dehydration (Neuman, 1995, 2002c; 2011a, p. 17). Consider the latter examples. What are the effects of short-term loss of sleep, poor nutrition, or dehydration on a client’s normal state of wellness? Will these situations increase the possibility for stressor penetration? The answer is that the possibility for stressor penetration may be increased. The actual response depends on the accordion-like function previously described, along with the other components of the client system. Normal Line of Defense The normal line of defense represents what the client has become over time, or the usual state of wellness. The nurse should determine the client’s usual level of wellness to recognize a change. The normal line of defense is consid- ered dynamic because it can expand or contract over time. The usual wellness level or system stability can decrease, remain the same, or im- prove after treatment of a stressor reaction. The normal line of defense is dynamic because of its ability to become and remain stabilized with life stressors over time, protecting the basic structure and system integrity (Neuman, 1995, 2002c, 2011, p. 18). Lines of Resistance Neuman identified the series of concentric broken circles that surround the basic structure CHAPTER 11 • Betty Neuman’s Systems Model 169 Line s of Resistance Nor mal Line of Defense Flex ible Line of Defense Basic structure Basic factors common to all organisms, i.e.: Normal temperature range Genetic structure Response pattern Organ strength or weakness Ego structure Knowns or commonalities Physiological, psychological, sociocultural, developmental, and spiritual variables occur and are considered simultaneously in each client concentric circle. NOTE: BASIC STRUCTURE ENERGY RESOURCES Fig 11 • 2 Client–client system. The structure of the client-client system, including the five vari- ables that are occurring simultaneously in each client concentric circle. (From Neuman, 1995, p. 26, with permission.) 3312_Ch11_165-184 26/12/14 2:58 PM Page 169 as lines of resistance for the client. When the normal line of defense is penetrated by environ- mental stressors, a degree of reaction, or signs and/or symptoms, will occur. Each line of re- sistance contains known and unknown internal and external resource factors. These factors sup- port the client’s basic structure and the normal line of defense, resulting in protection of system integrity. Examples of the factors that support the basic structure and normal line of defense include the body’s mobilization of white blood cells and activation of the immune system mechanisms. There is a decrease in the signs or symptoms, or a reversal of the reaction to stres- sors, when the lines of resistance are effective. The system reconstitutes itself, and system sta- bility is returned. The level of wellness may be higher or lower than it was before the stressor penetration. When the lines of resistance are in- effective, energy depletion and death may occur (Neuman, 1995, 2002c, 2011a, p. 18). Basic Structure The basic structure or central core consists of factors that are common to the human species. Neuman offered the following exam- ples of basic survival factors: temperature range, genetic structure, response pattern, organ strength or weakness, ego structure, and knowns or commonalities (Neuman, 1995, 2002c, 2011a, p. 16). Five Client Variables Neuman (1995, p. 28; 2002c, p. 17; 2011a, p. 16) identified five variables that are con- tained in all client systems: physiological, psy- chological, sociocultural, developmental, and spiritual. These variables are considered simul- taneously in each client concentric circle. They are present in varying degrees of development and in a wide range of interactive styles and po- tential. Neuman offers the following definitions for each variable: Physiological: Refers to bodily structure and function Psychological: Refers to mental processes and relationships Sociocultural: Refers to combined social and cultural functions Developmental: Refers to life-developmental processes Spiritual: Refers to spiritual beliefs and influence Neuman elaborated that the spiritual vari- able is an innate component of the basic structure. Although it may or may not be ac- knowledged or developed by the client or client system, Neuman views the spiritual variable as being on a continuum of development that penetrates all other client system variables and supports the client’s optimal wellness. The client–client system can have a complete lack of awareness of the spiritual variable’s presence and potential, deny its presence, or have a conscious and highly developed spiritual understanding that supports the client’s optimal wellness. Neuman explained that the spirit controls the mind, and the mind consciously or uncon- sciously controls the body. She used an analogy of a seed to clarify this idea. It is assumed that each person is born with a spiritual energy force, or “seed,” within the spiritual variable, as identified in the basic struc- ture of the client system. The seed or human spirit with its enormous energy potential lies on a continuum of dormant, unacceptable, or un- developed to recognition, development, and positive system influence. Traditionally, a seed must have environmental catalysts, such as tim- ing, warmth, moisture, and nutrients, to burst forth with the energy that transforms into a liv- ing form that then, in turn, as it becomes fur- ther nourished and develops, offers itself as sustenance, generating power as long as its own source of nurture exists (Neuman, 2002c, p. 16; 2011, Box 1-1, p. 17). The spiritual variable affects or is affected by a condition and interacts with other vari- ables in a positive or negative way. Neuman gave the example of grief or loss (psychologi- cal state), which may inactivate, decrease, initiate, or increase spirituality. There can be movement in either direction of a contin- uum (Neuman, 1995, 2002c, 2011a, p. 17). Neuman believes that spiritual variable con- siderations are necessary for a truly holistic perspective and for a truly caring concern for the client–client system. 170 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm 3312_Ch11_165-184 26/12/14 2:58 PM Page 170 Fulton (1995) has studied the spiritual vari- able in depth. She elaborated on research studies that extend our understanding of the following aspects of spirituality: spiritual well-being, spir- itual needs, spiritual distress, and spiritual care. She suggested that spiritual needs include (1) the need for meaning and purpose in life, (2) the need to receive love and give love, (3) the need for hope and creativity, and (4) the need for for- giving, trusting relationships with self, others, and God or a deity or a guiding philosophy. Environment A second concept identified by Neuman is the environment, as illustrated in Figure 11-3. She defined environment broadly as “all internal and external factors or influences surrounding the identified client or client system” (Neu- man, 1995, p. 30; 2002c, p. 18; 2011, pp. 20–21), including: • Internal environment: intrapersonal factors • External environment: Inter- and extraper- sonal factors • Created environment: Intra-, inter-, and extrapersonal factors (Neuman, 1995, p. 31; 2002c, pp. 18–19; 2011a, pp. 20–21) The internal environment consists of all forces or interactive influences contained within the boundaries of the client–client system. Examples of intrapersonal forces are presented for each variable. • Physiological variable: autoimmune re- sponse, degree of mobility, range of body function • Psychological and sociocultural variables: attitudes, values, expectations, behavior pat- terns, coping patterns, conditioned responses • Developmental variable: age, degree of nor- malcy, factors related to the present situation • Spiritual variable: hope, sustaining forces (Neuman, 1995; 2002c; 2011, p. 17) The external environment consists of all forces or interactive influences existing out- side the client–client system. Interpersonal factors in the environment are forces between CHAPTER 11 • Betty Neuman’s Systems Model 171 No rmal L ine of Defense Stressors Identified Classified as knowns or possibilities, i.e.: Loss Pain Sensory deprivation Cultural change Inter Intra Extra Personal factors Stressor Stressor Lin es of Resistance Fle xible Line of Defense Basic structure Basic factors common to all organisms, i.e.: Normal temperature range Genetic structure Response pattern Organ strength or weakness Ego structure Knowns or commonalities Stressors More than one stressor could occur simultaneously Same stressors could vary as to impact or reaction Normal defense line varies with age and development BASIC STRUCTURE ENERGY RESOURCES Fig 11 • 3 Environment. Internal and external factors surrounding the client–client system. (From Neuman, 1995, p. 27, with permission.) 3312_Ch11_165-184 26/12/14 2:58 PM Page 171 people or client systems. These factors include the relationships and resources of family, friends, or caregivers. Extrapersonal factors include education, finances, employ- ment, and other resources (Neuman, 1995, 2002c). Neuman (1995, 2002c, 2011a, pp. 20–21) identified a third environment as the “created environment.” The client unconsciously mo- bilizes all system variables, including the basic structure of energy factors, toward sys- tem integration, stability, and integrity to create a safe environment. This safe, created environment offers a protective perceptive coping shield that helps the client to func- tion. A major objective of this environment is to stimulate the client’s health. Neuman pointed out that what was originally created to safeguard the health of the system may have a negative effect because of the binding of available energy. This environment repre- sents an open system that exchanges energy with the internal and external environments. The created environment supersedes or goes beyond the internal and external environ- ments while encompassing both; it provides an insulating effect to change the response or possible response of the client to environ- mental stressors. Neuman (1995, 2002c, 2011) gave the following examples of re- sponses: use of denial or envy (psychological), physical rigidity or muscle constraint (physi- ological), life-cycle continuation of survival patterns (developmental), required social space range (sociocultural), and sustaining hope (spiritual). Neuman believes the caregiver, through as- sessment, will need to determine (1) what has been created (nature of the created environ- ment), (2) the outcome of the created environ- ment (extent of its use and client value), and (3) the ideal that has yet to be created (the pro- tection that is needed or possible, to a lesser or greater degree). This assessment is necessary to best understand and support the client’s created environment (Neuman, 1995, 2002c, 2011a). Neuman suggested that further research is needed to understand the client’s awareness of the created environment and its relationship to health. She believes that as the caregiver recognizes the value of the client-created environment and purposefully intervenes, the interpersonal relationship can become one of important mutual exchange (Neuman, 1995, 2002c, 2011a). de Kuiper (2011) added her perspective of the created environment and guidelines for nursing practice. Health Health is a third concept in Neuman’s model. She believes that health (or wellness) and ill- ness are on opposite ends of the continuum. Health is equated with optimal system stability (the best possible wellness state at any given time). Client movement toward wellness exists when more energy is built and stored than ex- pended. Client movement toward illness and death exists when more energy is needed than is available to support life. The degree of well- ness depends on the amount of energy required to return to and maintain system stability. The system is stable when more energy is available than is being used. Health is seen as varying levels within a normal range, rising and falling throughout the life span. These changes are in response to basic structure factors and reflect satisfactory or unsatisfactory adjustment by the client system to environmental stressors (Neuman, 1995, 2002c, 2011a, p. 23). Nursing Nursing is a fourth concept in Neuman’s model and is depicted in Figure 11-4. Nursing’s major concern is to keep the client system stable by (1) accurately assessing the effects and possible effects of environmental stressors and (2) as- sisting client adjustments required for optimal wellness. Nursing actions, which are called pre- vention as intervention, are initiated to keep the system stable. Neuman created a typology for her prevention as intervention nursing actions that includes primary prevention as interven- tion, secondary prevention as intervention, and tertiary prevention as intervention. All of these actions are initiated to best retain, attain, and maintain optimal client health or wellness. Neuman (1995, 2002c) believes the nurse cre- ates a linkage among the client, the environ- ment, health, and nursing in the process of keeping the system stable. 172 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm 3312_Ch11_165-184 26/12/14 2:58 PM Page 172 Prevention as Intervention The nurse collaborates with the client to estab- lish relevant goals. These goals are derived only after validating with the client and synthesiz- ing comprehensive client data and relevant theory to determine an appropriate nursing di- agnostic statement. With the nursing diagnos- tic statement and goals in mind, appropriate interventions can be planned and implemented (Neuman, 1995, 2002c, 2011a, pp. 25–29). Primary prevention as intervention involves the nurse’s actions that promote client wellness by stress prevention and reduction of risk fac- tors. These interventions can begin at any point a stressor is suspected or identified, before a re- action has occurred. They protect the normal line of defense by reducing the possibility of an encounter with a stressor and strengthening the flexible lines of defense. Health promotion is a significant intervention. The goal of pri- mary prevention as intervention is to retain op- timal stability or wellness. Ideally, the nurse should consider primary prevention along with secondary and tertiary preventions as interven- tions when actual client problems exist. Once a reaction from a stressor occurs, the nurse can use secondary prevention as inter- vention to treat the symptoms within the nurse’s scope of practice, reduce the degree of reaction to the stressors, and protect the basic structure by strengthening the lines of resist- ance. The goal of secondary prevention as in- tervention is to attain optimal client system stability or wellness and energy conservation. The nurse uses as much of the client’s existing internal and external resources (lines of resist- ance) as possible to stabilize the system. Reconstitution represents the return and maintenance of system stability after nursing intervention for stressor reaction. The state of wellness may be higher, the same, or lower than the state of wellness before the system was stabilized. Death occurs when secondary prevention as intervention fails to protect the basic structure and thus fails to reconstitute the client (Neuman, 1995, 2002c). Tertiary prevention as intervention can begin at any point in the client’s reconstitu- tion. This includes interventions that pro- mote (1) readaptation, (2) reeducation to CHAPTER 11 • Betty Neuman’s Systems Model 173 Inter Intra Extra Personal factors Primary prevention Reduce possibility of encounter with stressors Strengthen flexible line of defense Secondary prevention Early case-finding and Treatment of symptoms Tertiary prevention Readaptation Reeducation to prevent future occurrences Maintenance of stability Interventions Can occur before or after resistance lines are penetrated in both reaction and reconstitution phases Interventions are based on: Degree of reaction Resources Goals Anticipated outcome Fig 11 • 4 Nursing. Accurately assessing the effects and possible effects of environmental stressors (inter-, intra-, and extrapersonal factors) and using appropriate prevention by interventions to assist with client adjustments for an optimal level of wellness. (From Neuman, 1995, p. 29, with permission.) 3312_Ch11_165-184 26/12/14 2:58 PM Page 173 prevent further occurrences, and (3) mainte- nance of stability. These actions are designed to maintain an optimal wellness level by sup- porting existing strengths and conserving client system energy. Tertiary prevention tends to lead back toward primary prevention in a circular fashion. Neuman pointed out that one or all three of these prevention modalities give direction to, or may be used simultaneously for, nursing actions with pos- sible synergistic benefits (Neuman, 1995, 2002, 2011, pp. 28–29). Nursing Tools for Model Implementation Neuman designed the NSM nursing process format and the NSM Assessment and Inter- vention Tool: Client Assessment and Nursing Diagnosis to facilitate implementation of the Neuman model. These tools are presented in all the editions of The Neuman Systems Model (Neuman, 1982, 1989, 1995, 2002c; 2011a; Neuman & Lowry, 2011). The NSM nursing process format reflects a process that guides information processing and goal-directed activities. Neuman uses the nurs- ing process within three categories: nursing di- agnosis, nursing goals, and nursing outcomes. In 1982, doctoral students validated the Neuman nursing process format. The format’s validity and social utility have been supported in a wide variety of nursing education and practice areas. The Neuman Systems Model Assessment and Intervention Tool The Client Assessment and Nursing Diagnosis tool is used to guide the nursing process. The nurse collects holistic, comprehensive data to determine the effect or possible effect of envi- ronmental stressors on the client system then validates the data with the client before formu- lating a nursing diagnosis. Selected nursing diagnoses are prioritized and related to rele- vant knowledge. Nursing goals are determined mutually with the caregiver–client–client sys- tem, along with mutually agreed on prevention as intervention strategies. Mutually agreed on goals and interventions are consistent with cur- rent mandates within the health-care system for client rights related to health-care issues. The Client Assessment and Nursing Diag- nosis tool with primary, secondary, and tertiary prevention as intervention was developed to convey appropriate nursing actions with each typology of prevention. There are clear instruc- tions for writing appropriate nursing actions (Neuman, 2002a, p. 354; 2011b, pp. 343–350), which students are encouraged to review before writing these nursing actions. Keep in mind that the nature of stressors and their threat to the client–client system are first de- termined for each type of prevention before any other nursing actions are initiated. The same stressors could produce variable effects or reactions. Nursing outcomes are determined by the accomplishment of the interventions and evaluation of goals after intervention. Applications of the Theory Because the model is flexible and adaptable to a wide range of groups and situations, people have used it globally for more than three decades. Neuman’s first book, The Neuman Systems Model: Application to Nursing Education and Practice, was published in 1982 as a response to requests for data and support in applying the model in practice settings and as a guide for entire nursing curricula. The second and third editions (1989, 1995) present examples of the use of the model in practice and education, pri- marily. The fourth edition (2002c) includes integrative reviews of practice, educational, and research literature and discussions of prac- tice and educational tools. The fifth edition (Neuman & Fawcett, 2011) continues the tra- dition of including contributions that reflect the broad applicability of the model. Guidelines and available tools for NSM-based practice, educa- tional programs, and research are summarized. Application of the Neuman Systems Model to Nursing Practice “The function of a conceptual model in nursing practice is to provide a distinctive frame of ref- erence that guides approaches to patient care” (Amaya, 2002, p. 43). There is a critical need for meaningful definitions and conceptual frames of reference for nursing practice if the profession is to be established as a science (Neuman, 2002c). 174 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm 3312_Ch11_165-184 26/12/14 2:58 PM Page 174 The NSM is being used in diverse practice settings globally such as critical care nursing, psychiatric mental health nursing, gerontolog- ical nursing, perinatal nursing, community nursing, occupational health nursing, rehabil- itation, and advanced nursing practice (Amaya, 2002; Bueno & Sengin, 1995; Chiverton & Flannery, 1995; McGee, 1995; Peirce & Fulmer, 1995; Groesbeck, 2011; Merks, van Tilburg, & Lowry, 2011; Russell, Hileman, & Grant, 1995; Stuart & Wright, 1995; Trepanier, Dunn, & Sprague, 1995; Ware & Shannahan, 1995). The model is used to guide practice in clients with acute and chronic health-care problems (e.g., hypertension, chronic obstructive pul- monary disease, renal disease, cardiac surgery, cognitive impairment, mental illness, multiple sclerosis, pain, grief, pediatric cancers, perinatal stressors); to meet family needs of clients in crit- ical care; to provide stable support groups for parents with infants in neonatal intensive care units; and to meet the needs of home caregivers, with emphasis on clients with cancer, HIV/ AIDS, and head trauma (Beddome, 1995; Beynon, 1995; Craig, 1995; Damant, 1995; Davies & Proctor, 1995; Engberg, Bjalming, & Bertilson, 1995; Felix, Hinds, Wolfe, & Martin, 1995; Vaughan & Gough, 1995; Verberk, 1995). An excellent example of how the com- prehensive NSM can be used to gather and analyze individual client system data is found in Tarko and Helewka (2011, pp. 37–69). Ume-Nwangbo, DeWan, and Lowry (2006) provided two examples of using the model to provide care: first, for an individual client; sec- ond, for a family client. “Nurses who conduct their practice from a nursing theory base, while assisting individuals and families to meet their health needs, are more likely to provide com- prehensive, individualized care that exemplifies best practices” (p. 31). Application of the Neuman Systems Model to Nursing Education Neuman originally designed the model “as a focal point for student learning” (2011, p. 332) because it considered four variables of human experience: physiological, psychologi- cal, sociocultural and developmental. Before long, the potential of using the model for cur- riculum development was recognized at all levels of nursing education in the United States, Canada, and globally. The NSM was selected because it is a systems approach, com- prehensive, and holistic and focuses on health and prevention. Programs adopting the model in the 1980s used it in its entirety. Through the years, some programs moved to a more eclectic approach that combines the model concepts of stress, systems, and primary pre- vention with concepts from other models. Appendix F in Neuman and Fawcett (2011) summarizes 28 programs currently using the NSM at the time of publication. Two bac- calaureate programs at Newberry College, Newberry, SC, and Cedar Crest College, Allentown, PA, adopted the model in 2007 and 2009, respectively. The department of Psychiatric Nursing at Douglas College, British Columbia, Canada, follows a Neuman- based curriculum for advanced practice psychi- atric nurses (Tarko & Helewka, pp. 216–220). MacEwan University in Edmonton, Alberta, Canada, is planning for the adoption of the model for their curriculum in fall of 2011 (personal communication, Betty Neuman, January, 2013). Educators have developed tools with NSM terminology to guide student learning and examine student progress in courses within Neuman-based nursing programs (Newman et al., 2011). The Lowry-Jopp Neuman Model Evaluation Instrument (LJNMEI) has been used by two associate-degree nursing programs, one at Cecil Community College and the other at Indiana University—Ft. Wayne. The objec- tive of the evaluation instrument is to assess the efficacy of being educated within a Neuman- based curriculum. Participants were assessed at graduation and 7 months after graduation. Findings indicate that graduates internalized the Neuman concepts well and continued to practice from the model perspective if they were encouraged by their colleagues. Graduates who were employed in institutions that did not encourage use of the model for assessments often did not continue to use it (Beckman, Boxley-Harges, Bruick-Sorge, & Eichenauer, 1998; Lowry, 1998). CHAPTER 11 • Betty Neuman’s Systems Model 175 3312_Ch11_165-184 26/12/14 2:58 PM Page 175 The LJNMEI instrument was adapted for use by the practicing nurses at the Emergis Psychiatric Institute in Zeeland, Holland, in 2002. Data have been collected for a decade to track the efficacy of using the NSM for de- livering quality patient care within this psychi- atric health-care system. Other disciplines in the institution became interested in using the model as well with no significant difference for knowledge of the NSM among nurses, psychi- atrists, and psychologists. Having all disciplines practicing from one theoretical perspective en- ables an integrated approach to motivate and stimulate clients to reach their levels of opti- mum stability (Merks et al., 2011). Application of the Neuman Systems Model to Nursing Administration and Management Although there is less evidence of the use of the NSM in administration compared with prac- tice and education, the available literature is in- creasing and emphasizes how complex systems are greatly benefitted by using a systems ap- proach as a guide to management (Pew Health Professions Commission, 1995; Sanders & Kelley, 2002). For example, the purpose of the Magnet recognition program is to promote quality patient care within a culture that sup- ports professional nursing practice (McClure, 2005). This is the gold standard for work envi- ronments in health care. One of the attributes of Magnet status is practicing from a profes- sional model of care. Nurses and administrators with knowledge of the NSM are poised to as- sume leadership roles within these hospital sys- tems. The model emphasizes comprehensive patient care to facilitate the delivery of primary, secondary and tertiary interventions, within a culture supporting professional nursing prac- tice. Some examples of magnet hospitals using the NSM are Allegiance Health, Michigan (Burnett & Johnson-Crisanti, 2011); Riverside Methodist Hospital, Ohio (Kinder, Napier, Rupertino, Surace, & Burkholder, 2011); Abingdon Memorial Hospital, Philadelphia (Breckenridge, 2011); and the South Jersey Healthcare System (Boxer, 2008). These exem- plars describe how nurses combine their pro- fessional model of care (the NSM) with the other Magnet criteria to achieve quality health care and national recognition. Nursing research in these institutions is reported in publications and at the Biennial International Neuman Systems Model Symposia. Application of the Neuman Systems Model to Nursing Research Each edition of The Neuman Systems Model from the second to the fifth (1989–2011) pro- vides a chapter that summarizes the research based on the model completed in the years be- tween the editions. Through the years, the growth of Neuman-based research is evident. In the early years, most of the research was de- scriptive, focusing on one concept from the model, such as stressor reactions or primary prevention interventions. Many of the early studies were completed by master’s and doc- toral students as fulfillment of their advanced degrees (Fawcett, 2011, pp. 393–404). To date there are 132 master’s theses, 110 doctoral dis- sertations, and 109 Neuman-based studies completed by researchers. Neuman-based research has progressed developmentally through the decades as re- searchers become more sophisticated and in- formed about processes that lead to sound conceptual model-based studies. Conceptual models provide the broad framework for or- ganizing the phenomena to be studied through research and are critical because they are pre- cursors for theory development. The models provide the concepts and propositions (con- necting statements) that explain the model. For example, the NSM provides the context and structure for research. Because the con- cepts are abstract, the model cannot be tested in a single research study. Thus, midrange the- ories must be derived from the NSM concepts, and these theories can then be tested in indi- vidual studies. Fawcett (1989) developed a structure that is used by researchers when developing a research study from a conceptual model. This conceptual- theoretical-empirical (CTE) framework pres- ents the model concepts to be studied at the upper level, then the more observable concepts being studied at the second level, and the in- struments that will be used to collect data 176 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm 3312_Ch11_165-184 26/12/14 2:58 PM Page 176 about the second level concepts at the third level. This CTE diagram shows explicit vertical linkages. Then a narrative explanation is neces- sary to clarify the concepts and propositions dis- played in the CTE diagram. Examples of studies developed from CTE frameworks can be found in research chapters in two editions of Neuman and Fawcett (2002, 2011). A second major contribution of Fawcett to model-based research is the publishing of guidelines for the development of research stud- ies (Fawcett, 1995, table 32-1). These rules are applicable to any health-care discipline and have been refined over the years. The latest rendition is given in Neuman and Fawcett (2011, p. 162, table 10-1). These rules can apply to both quan- titative and qualitative studies. An excellent example of a CTE structure for a quantitative study of multiple role stress in mothers at- tending college (Gigliotti, 1997, 1999) is dis- played in Neuman and Fawcett (2002, p. 290, Figure 21-1). Note that the midrange theory concepts are specific attributes of the NSM concepts but do not include all model concepts. An excellent example of a CTE for a qualitative study is found in Neuman and Fawcett (2002, p. 179, Figure 10-3). Note that this diagram moves from the Neuman model concepts (Level 1) to empirical research methods (Level 3), from which Level 2 midrange theory concepts have been derived from patient interviews. If the guidelines for conducting model-based research are followed, resulting studies will be logically consistent and will advance nursing knowledge by helping to explain the effects of using the NSM (Louis, Gigliotti, Neuman, & Fawcett, 2011; Gigliotti). The ultimate goal of all re- search is to develop conceptual model-based middle-range theories (Fawcett & Garrity, 2009; Gigliotti, 2012). The fourth step of the research guidelines is research methodology. Appropriate re- search instruments for data collection must be selected. This means that the items in each instrument are either derived from the NSM or are compatible with concepts within the NSM. For example, Loescher, Clark, Atwood, Leigh, and Lamb (1990) created the Cancer Survivors Questionnaire, which collects data on the client’s perception of physiological, psychological, and sociocultu- ral stressors. Each item in each of these cat- egories is a descriptor of something physical, psychological, and sociocultural. A second example is the “Client System Perception Guides” for structured interviews. The items listed in the guide were developed from the NSM for measuring spirituality (Clark, Cross, Deane, & Lowry, 1991), dialysis treatment (Breckenridge, 1997), and elder abuse (Kottwitz & Bowling, 2003). To date, 25 instruments have been directly derived from the NSM and can measure stressors, client systems percep- tions, client system needs, the five system vari- ables, coping strategies, the lines of defense and resistance, and client system responses. Four reviews of NSM-based studies from the 1980s and 1990s focused on how the stud- ies reflected the research rules. Gigliotti (2001) presented an integrative review of 10 studies to determine the extent of support for Neuman propositions that link various concepts of the model. Gigliotti reported her difficulty inter- preting the results due to investigators’ failures to link the research concepts to the NSM in their designs. Fawcett and Giangrande (2002) presented a full integrative-review project that linked all the available NSM-based research. The authors found that about one-half of pub- lished research journal articles and book chap- ters included conceptual linkages between NSM propositions and the study variables. Master’s theses and doctoral dissertations (about two-thirds) did not make the concep- tual linkages. Researchers are reminded to pay more attention to conceptual aspects of their studies and make explicit references to these so that nursing theoretical knowledge is ad- vanced. Throughout this chapter, one can find the network of researchers who have con- ducted model-based studies. Fawcett and Giangrande (2002) presented a literature review of 212 studies and identified the instruments used for data collection that are compatible with the NSM concepts and propo- sitions as well as the middle-range theory meas- ured by each instrument. Compatible with the NSM concepts are 75 instruments, such as the State-Trait Anxiety Inventory, used to measure anxiety; the Beck Depression Inventory, used to CHAPTER 11 • Betty Neuman’s Systems Model 177 3312_Ch11_165-184 26/12/14 2:58 PM Page 177 measure depression; and the Norbeck Social Support Questionnaire, used to measure client’s perception of social support in their lives. When using an instrument not deducted directly from the model, researchers must describe the link- ages between the concepts in the instruments and those from the NSM to demonstrate logical congruence between the NSM and the instru- ment. The evidence of validity and reliability of the instruments selected must be provided in the study. The ultimate goal is to accumulate a group of instruments that measure the complete spec- trum of NSM concepts, such as the five vari- ables; the central core; the four environments; client system stability; reconstitution; variances from wellness; primary, secondary, and tertiary prevention interventions; and client perceptions. Finally, Gigliotti and Manister (2012) presented an article to guide novice researchers through the writing of the conceptual model-based the- oretical rationale. This is a must-read for every beginning researcher. Focus of Current Research Neuman concepts of stressors, and the three pre- ventions as intervention have been the foci most frequently studied by descriptive methodology. Gigliotti (1999, 2004, 2007) has a program of research on the subject of women’s maternal- student role stress in which she tests the NSM flexible line of defense. Spirituality is the vari- able that has been researched most recently. Neuman (1989) claimed that spirituality is the unifying variable of all personal systems. She states that the “spirit controls the mind, and the mind controls the body” (pp. 29–30). A spiritual encounter occurs between clients and caregivers, thus, nurses must assess spirituality as part of their data collection. These beliefs have influ- enced the development of spirituality studies. Some of the studies focus on the development of spirituality in students, and others aim to un- derstand the concept of spirituality. Because student nurses must learn to assess the spiritual variable, it is imperative that they develop spir- itually. A team of faculty from Indiana Purdue– Ft. Wayne are studying the evolution of student nurses’ awareness of the concept of spirituality (Beckman, Boxley-Harges, Bruick-Sorge, & Salmon, 2007; Beckman, Boxley-Harges, & Kaskel, 2012; Bruick-Sorge, Beckman, Boxley- Harges, & Salmon, 2010). If the NSM is to be used for assessment of the spiritual variable, then caregivers must be confident that the Neu- man definition is congruent with client beliefs (Lowry, 2012). Several studies have addressed the importance of spirituality to quality care (Clark, Cross, Deane & Lowry, 1991), to aging persons (Lowry, 2002, 2012), and to adults liv- ing with HIV (Cobb, 2012). Finally, Burkhart, Schmidt, and Hogan (2012) published a new spiritual care inventory instrument within the context of the NSM to measure spiritual in- terventions that facilitate health and wellness. The Neuman Systems Model Research Institute At the 2003 Biennial International Neuman Systems Model Symposium in Philadelphia, PA, the NSM Trustees formally approved the formation of a Research Institute to test and generate midrange theories derived from the NSM (Gigliotti & Fawcett, 2011). Activities of this institute include the funding of two dis- tinct types of fellowships for novice researchers: the John Crawford Awards (up to 10 per bien- nium) and the Patricia Chadwick Research Grant (one per biennium). For more informa- tion, see http://www.neumansystemsmodel .org/NSMdocs/research_institute.htm. Each biennium, the Neuman Systems Model Trustees Group conducts an international sym- posium where the recipients of the fellowships can join other scholars and present their find- ings. All researchers, educators, and nurses who practice from the NSM perspective are welcome to attend these events to share new insights and to advance understanding of various model concepts. The networking among these scholars helps to integrate the growing body of knowl- edge about the use of the model in education, research, practice, and administration of nursing services. Value of the Neuman Systems Model for the Future Theory development is the hallmark of any pro- fession. The NSM continues to be researched and validated through studies; thus, it becomes more valuable as the basis for quality patient care 178 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm 3312_Ch11_165-184 26/12/14 2:58 PM Page 178 and for the advancement of the nursing profes- sion. The addition of the spiritual variable to the client system in 1989 accentuated the impor- tance of this dimension. The plethora of research on spirituality and the recognition of the impor- tance of the concept are increasingly being recognized by the health-care community. The development of middle-range theories from the NSM is imperative because it is the integration of theories from other disciplines that are com- patible with Neuman concepts. The concepts of holism, wellness, and prevention interventions used to attain, retain, and maintain client system stability are as viable today in our complex health-care system as they were in 1970. Our global colleagues find that these philosophical beliefs are congruent with beliefs in their own health-care systems. More than 12 countries have been introduced to the model over two decades, with Belgium being the most recent in 2012. Holland has adopted the model most widely due to its translation into Dutch and hosts the annual International Neuman Systems Model Association symposium (Merks, Verberk, de Kuiper, & Lowry, 2012). Networking to Enhance Applications of the Model There are opportunities to network with others using the model in a variety of applications and settings. One way is to attend the Neuman Systems Model International Symposium, which is held every 2 years, in the odd year. International scholars gather to share ideas, insights, innovations, practice, and research from the model. The Neuman Systems Model website provides the latest information: www The Neuman Archives were established to preserve and protect the work of Betty Neuman and others working with the model. The archives, previously located at Newmann University in Aston, PA, are now housed in the Barbara Bates Center for the Study of the History of Nursing at the University of Pennsylvania (http://www.nursing.upenn .edu/history/Pages/default.aspx). Contact Gail Farr, MA, CA, for information and an appointment to access the collection ( CHAPTER 11 • Betty Neuman’s Systems Model 179 Practice Exemplar A nurse guided by the Neuman systems model met Gloria Washington while providing care for her mother in Gloria’s home. Gloria’s 74-year-old mother has Alzheimer’s disease, and Gloria has been her caregiver for 4 years. The nurse was aware that, according to Neu- man, the family client system includes Gloria and her mother. This nurse uses practice-based research to guide her work (best practice). She recently read Jones-Cannon and Davis’s (2005) research study that examined the cop- ing strategies of African American daughters who have functioned as caregivers. In their study, African American caregivers of a family member with dementia or a stroke believed that attending support groups and knowing that their parent needed them influenced their caregiving experience positively. Most care- givers identified that religion gave them a strong tolerance for the caregiving situation and served to mediate strain. Caregivers who voiced a lack of support from family, especially siblings, had much anger and resentment. The nurse used this new knowledge to en- hance the nursing process with Gloria. By using the Neuman systems model Assessment and Intervention Tool, she learned that Gloria is a 52-year-old divorced African American woman who is employed full-time by a com- pany for which she enjoys working. She also has a teenage daughter who lives with her and a grown son who lives away from home. Glo- ria attends the Baptist church in her neighbor- hood 2 or 3 times a week and attributes this experience to her ability to care for her mother. The nurse assessed for stressors as they were perceived by Gloria and by herself. The nurse assessed for discrepancies between their Continued 3312_Ch11_165-184 26/12/14 2:58 PM Page 179 180 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm Practice Exemplar cont. perceptions and found none. She identified the intrapersonal, interpersonal, and extraper- sonal factors that made up Gloria’s environ- ment. To ensure the assessment was holistic and comprehensive, she identified the physi- ological, psychological, sociocultural, develop- mental, and spiritual variables for each of these factors. Gloria identified caring for her mother with Alzheimer’s disease as her major stressor. Assessment The nurse’s assessment of Gloria’s environ- mental factors is identified below. Examples of assessment data for each variable are included. Intrapersonal factors Physiological: Gloria experiences occasional signs and symptoms of increased anxiety such as rapid heart rate and increased blood pressure. Psychological: Gloria occasionally worries about the future, but she tries to focus on the present and prides herself on her sense of humor. Sociocultural: Gloria values her belief that African American families take care of their elderly. Developmental: Gloria is in Erickson’s (1959) developmental stage of middle adulthood with its crisis of generativity versus stagnation. She strives to look out- side of herself to care for others. Spiritual: Gloria reports that religion, faith, and prayer help her cope with caregiving demands. Interpersonal factors Physiological: Gloria occasionally has inter- rupted sleep when her mother awakens and wanders during the night. Psychological: Gloria reminds herself when physically caring for her mother that this is an expected part of her mother’s aging. Sociocultural: Gloria is the full-time care- giver of her mother, who has Alzheimer’s disease. She works full-time with sup- portive people but does not attend an Alzheimer’s support group because she didn’t know anything about them. Developmental: Gloria has significant rela- tionships with her co-workers. Spiritual: Gloria is supported by her pastor and friends at church. Extrapersonal factors Physiological: From a co-worker, Gloria re- ceived the gift of a comfortable bed mat- tress that promotes her sleep. Psychological: Gloria shared that reading her Bible helps her think positive thoughts. Sociocultural: Gloria earns $35,000 per year. Developmental: Gloria can feel “in charge of the situation” with a comfortable house for her mom. Spiritual: Gloria attends church services in her neighborhood 2 or 3 times a week. The nurse applied the NSM nursing process format (Neuman & Fawcett, 2011, p. 338) fo- cusing on the following: (1) nursing diagnosis (based on valid database), (2) nursing goals negotiated with the client including appropri- ate levels of prevention as interventions, and (3) nursing outcomes. The nurse prepared a comprehensive list of nursing diagnoses based on her holistic and comprehensive assessment and then priori- tized the list. She validated her findings with Gloria to ensure that their perceptions were in agreement. The nurse and Gloria identified Gloria’s full-time role as a caregiver for her mother with Alzheimer’s disease as a significant stressor. The nurse considered the research study by Jones-Cannon and Davis (2005), which reported that caregivers of a family member with dementia believed attendance at a support group influenced their caregiving in a positive way. One of the nursing diag- noses they determined was “risk for caregiver role strain.” Although this was identified as a risk, they both agreed there was not a sup- porting sign or symptom to validate the exis- tence of caregiver role strain at this time. However, it was important to prevent this strain in the future. The nurse recognized that their observa- tions provided a glimpse of Gloria’s normal line of defense; then they identified an 3312_Ch11_165-184 26/12/14 2:58 PM Page 180 CHAPTER 11 • Betty Neuman’s Systems Model 181 Practice Exemplar cont. immediate goal to strengthen her flexible line of defense. The goal is that Gloria will report that she has participated in a monthly Alzheimer sup- port group session by (date). They could have identified intermediate and future goals at that time. Together they planned nursing actions for primary prevention as intervention. The nurse also used the tool and nursing process to provide holistic comprehensive care for Gloria’s mother, and the family client system was strengthened. By strengthening Gloria’s lines of defense, the nurse helped strengthen Gloria’s mother’s lines of defense. The model is dynamic as the individual and family client systems are assessed continu- ously, leading to new diagnoses, goals, and in- terventions that promote optimal holistic comprehensive nursing care. The desired out- come goal for Gloria in the case example was optimal health retention. If this had been an actual problem of care- giver role strain, they would have identified secondary prevention as interventions and tertiary prevention as interventions that would activate resource factors (lines of resistance) to protect Gloria’s basic structure (organ strength or ability to cope). An example of each follows. Secondary prevention as intervention: Assist Gloria to schedule respite care for a deter- mined period of time. Tertiary prevention as intervention: Provide ongoing education at each visit about practical resources that will provide care- giver support. The nurse would have continued to use the nursing process by implementing and evaluating their plan; reassessing, as part of evaluation, for a reduction or elimination of caregiver role strain; and maintenance of system stability. Neuman refers to this as reconstitution. Reconstitution represents the return and maintenance of system stability after treatment of a stressor reaction, which may result in a higher or lower level of wellness than previously. It represents successful mobilization of energy resources (Neuman, 2002c, p. 324). The desired outcome goals are for optimal health retention, restoration, and mainte- nance. In Neuman’s model, high importance is placed on validating nurse and client per- ceptions and validating data. ■ Summary “The Neuman Systems Model is well positioned as a contemporary and future guide for health care practice, research, education and adminis- tration far into the 21st century. The concepts and processes of the model are so universal and timeless that they are easily understood by all members of the health care teams worldwide” (Neuman and Fawcett, 2011, p. 317). The NSM has been used for more than three decades, first as a teaching tool and later as a conceptual model to observe and interpret the phenomena of nursing and health care globally. The model is well accepted by the nursing profession and is guided by the Neuman Systems Model Trustees, Inc. 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Norwalk, CT: Appleton & Lange. 184 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm 3312_Ch11_165-184 26/12/14 2:58 PM Page 184 Chapter 12Helen Erickson, Evelyn Tomlin, and Mary Ann Swain’s Theory of Modeling and Role Modeling HELEN L. ERICKSON Introducing the Theorist Overview of Modeling and Role-Modeling Theory Practice Applications Practice Exemplar Summary References 185 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, 2006a). My Self is reflected in my values and beliefs; my Reason for Being is to learn that 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 highway 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 environment, 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, Mary Ann SwainHelen L. Erickson 3312_Ch12_185-206 26/12/14 2:59 PM Page 185 well known for his work with mind–body heal- ing, taught me that people know more about themselves than health-care providers do, that their inner-knowing is essential to healing, and that we can help them by attending to their worldview. I committed to married life, moved to Texas, and accepted the position of head nurse in the emergency room of the Midland Memorial Hospital. Between 1959 and 1967, I worked in a va- riety of settings in Texas, Michigan, and Puerto Rico and welcomed four children into our fam- ily. I learned valuable lessons about blind prej- udice, discrimination, and staying true to self; about how personal stories provide insight into client needs; and about the uniqueness of peo- ple and how limiting labels did not capture their wholeness. I had opportunities to develop a professional practice model. In 1974, I completed my RN-BSN pro- gram at the University of Michigan and was recruited as a faculty member and consultant at the University Hospital. I enrolled in the master’s program in medical–surgical and psychiatric nursing and graduated in 1976. During this time, Evelyn Tomlin and I talked freely about the nursing model I had derived from practice. I labeled and developed the adaptive potential assess- ment model and worked with Mary Ann Swain to test some of my hypotheses (H. Er- ickson & Swain, 1982). I continued in my fac- ulty position and advanced to chairman of the undergraduate program and assistant dean. Over the next 10 years, my model of nursing acquired a life of its own. By the early 1980s, I had speaking invitations but little had been written (H. Erickson, 1976; H. Erickson & Swain, 1982). Together Evelyn, Mary Ann, and I further elaborated some of the concepts. The term modeling and role-modeling (MRM), first coined by Milton Erickson, was selected as the best descriptor of this work. The original edition was printed in November 1982 (H. Erickson, Tomlin, & Swain, 2009), has had eight reprints, and is now considered a classic by the Society for the Advancement of Modeling and Role- Modeling (SAMRM). I completed my PhD in 1984, left Michigan in 1986, spent 2 years at the University of South Carolina School of Nursing as associate dean of academic affairs and then moved to the University of Texas, where I as- sumed the role of professor and chair of adult health nursing. When I retired in 1997, the Helen L. Erickson Endowed Lectureship on Holistic Nursing was established at the University of Texas in Austin. I have authored or coauthored chapters on MRM and/or holistic nursing (Clayton, Erickson, & Rogers, 2006; H. Erickson, 1996, 2002, 2006b, 2006c, 2006d, 2006e, 2007, 2008; M. Erickson, Erickson, & Jensen, 2006; Walker & Erickson, 2006), some of which are included in the second book on MRM, and more recently, a book on the relationship be- tween the philosophy and discipline of holistic nursing. I know now that advancing holistic health care is my mission, my life work; MRM is a vehicle for that purpose.1 Overview of Modeling and Role-Modeling Theory MRM is based in several nursing principles that guide the assessment, intervention, and evaluation aspects of practice. These principles, reflected in the data collection categories (H. Erickson et al., 2009, pp. 148–168), are linked to intervention aims and goals (H. Erickson et al., 2009, pp. 168–201). Although both in- tervention aims and goals involve nursing actions, they differ in their purpose. Nursing interventions should have intent; nurses should aim to make something happen that facilitates health and healing when they interact with clients. There should also be markers that help us evaluate the efficacy of our activities— intervention goals. Table 12-1 shows the rela- tions among MRM principles of nursing, data needed to practice this model, the aims of nursing actions, and specific goals. Modeling The modeling process involves assessment of a client’s situation. It starts when we initiate an in- teraction with an individual and concludes with 186 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm 1For additional information, please see the bonus chapter content available at 3312_Ch12_185-206 26/12/14 2:59 PM Page 186 CHAPTER 12 • Helen Erickson, Evelyn Tomlin, and Mary Ann Swain’s Theory of Modeling 187 Principles Categories of Data Goals Aims The nursing process requires that a trusting and functional relation- ship exist between nurse and client. Affiliated-individuation is contingent on the individual’s perceiving that he or she is an ac- ceptable, respectable, and worthwhile human being. Human development is dependent on the indi- vidual’s perceiving that he or she has some control over life while concurrently sensing a state of affiliation. There is an innate drive toward holistic health that is facilitated by consistent and system- atic nurturance. Human growth is de- pendent on satisfaction of basic needs and is fa- cilitated by growth-need satisfaction. Adapted with permission from Erickson, H., Tomlin, E., & Swain, M. A. (Eds.). (2009). Modeling and role-modeling: A the- ory and paradigm for nursing (p. 171). Cedar Park, TX: EST. Table 12 • 1 Relations Among Principles, Data Categories, Intervention Goals, and Aims Description of the situation Expectation (External) Resource potential (Internal) Resource potential (Internal) Resource potential Goal and life tasks Develop a trusting and functional rela- tionship between self and your client. Facilitate a self- projection that is futuristic and positive. Promote affiliated- individuation with the minimum degree of ambivalence possible. Promote a dynamic, adaptive, and holistic state of health. Promote (and nurture) coping mechanisms that satisfy basic needs and permit growth- need satisfaction. Facilitate congruent actual and chrono- logical development stages. Build trust. Promote client’s positive orientation. Promote client’s control. Affirm and promote client’s strengths. Set mutual goals that are health directed. an understanding of that person’s perspective of their circumstances. We aim to learn how that in- dividual describes the situation, what he or she expects will happen, and his or her perceived re- sources and life goals. As we listen and observe, we interpret the information using the constructs embedded in the theory. Stated simplistically, modeling is the process we use to build a mirror image of an individual’s worldview. This worldview helps us understand what that person perceives to be im- portant, what has caused his or her problems, what will help, and how he or she wants to relate to others. Table 12-2 shows the categories of data and the type of information needed in the model- ing process. Table 12-3 shows the priority given to the information we collect. Primary data are ac- quired from the client; secondary data include the nurse’s observations and information from the family. Tertiary data include information from medical records and other sources. Pri- mary and secondary data are essential for pro- fessional practice, whereas tertiary data are added as needed. Role-Modeling The role-modeling process requires both objec- tive and artistic actions. First, we analyze the data using theoretical propositions in the MRM model (Table 12-4; H. Erickson et al., 2009, 3312_Ch12_185-206 26/12/14 2:59 PM Page 187 188 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm Categories of Data Collection Purpose of Data Is to Obtain Description of the Situation Expectations Resource Potential Goal and Life Tasks Adapted with permission from Erickson, H., Tomlin, E., & Swain, M. A. (Eds.). (2009). Modeling and role-modeling: A the- ory and paradigm for nursing (p. 119). Cedar Park, TX: EST. Table 12 • 2 Categories of Data and Purpose for Obtaining Data 1. An overview of client’s perception of the problem 2. The etiology of the problem including stressors and distressors 3. Client’s perceived therapeutic needs 1. Immediate expectations 2. Long-term expectations 1. External: Social network, support system, and health-care system 2. Internal: Self-strengths, adaptive potential, feeling states, physiological states 1. Current goals 2. Plans for future Primary Source Client’s self-care knowledge Secondary Source Tertiary Source Table 12 • 3 Sources of Information Information from family and nurses’ observations Medical records and other information related to client’s case 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. Table 12 • 4 Selected Theoretical Propositions in MRM Theory pp. 148–167). We interpret the meaning of what has been provided and search for linkages among the data that will help us understand the client’s worldview. As we analyze the data, implications for nursing actions emerge (H. Erickson et al., 2009, pp. 168–220). Nursing ac- tions are then artistically designed with intent (i.e., the aims of interventions) and specific out- comes (i.e., intervention goals). Our overall ob- jectives are to help people grow and heal and to find meaning in their experiences. The following sections elaborate each of these objectives. The first section addresses the philosophical assump- tions that underlie this model; theoretical under- pinnings follow with implications for practice. Finally, the global applications of MRM are presented. Philosophical Assumptions Nursing has a metaparadigm that includes four extant constructs: person, environment, health, and nursing; sometimes social justice is added 3312_Ch12_185-206 26/12/14 2:59 PM Page 188 as a fifth construct (Schim, Benkert, Bell, Walker, & Danford, 2007). The operational definitions of these constructs provide the con- text necessary to clarify how an individual’s actions are unique to nursing as opposed to the actions of another profession. Although all nursing theories are developed and articulated within this context, our personal philosophy affects how we define and operationalize the constructs of nursing and therefore how we ar- ticulate our models (H. Erickson, 2010). For this reason, it is important to be clear about our own philosophical beliefs and how they affect our conceptual definitions and our the- oretical models. Nurses can use clear philo- sophical statements to determine whether the underpinnings of a theoretical model are consistent with their own belief systems (H. Erickson, 2010). When they are not, dis- crepancies among nursing’s philosophical be- liefs, the nurse’s personal belief system, and the theoretical propositions often create disso- nance that impedes the nurses’ ability to use the model (H. Erickson et al., 2009). The philosophical assumptions underlying the MRM theory and paradigm are described in the text that follows. The first section presents MRM’s orientation toward two of nursing’s metaparadigm constructs: person and environ- ment. Health, nursing, and social justice are described in the following sections. Person and Environment Humans are inherently holistic. This means that all aspects of the human are intercon- nected and dynamically interactive; what af- fects one part affects another. This is different from the wholistic person, wherein the parts are associated but not necessarily intercon- nected or interactive (Fig. 12-1). When we ap- proach people from a wholistic perspective, we can break them down into systems, organs, and other parts. When we view them as holis- tic, we understand that all the dimensions of the human being are interconnected; what af- fects one part has the potential to affect other parts. Our holistic nature is manifested through our innate instincts and drives: in- stincts and drives necessary for humans to maneuver 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 some have an innate ability to receive and in- terpret stimuli, most would agree that not all animals have an innate drive to receive stimuli in a cognitive form, to acquire skills necessary to perceive and understand stimuli, to give and receive feedback, the freedom to speak, or the CHAPTER 12 • Helen Erickson, Evelyn Tomlin, and Mary Ann Swain’s Theory of Modeling 189 Cognitive Psychological Social The Holistic model Biophysical G en et ic b as e an d sp iri tu al D .G .P .I. CognitivePsychological Social The Wholistic model Biophysical Fig 12 • 1 Holism versus wholism. A B 3312_Ch12_185-206 26/12/14 2:59 PM Page 189 190 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm Instincts Inherent in Human Nature Drives That Motivate Our Behavior Table 12 • 5 Selected List of Human Instincts and Drives To receive and interpret stimuli To cope and adapt to stressors To experience mind–body–spirit intraconnectedness, or holistic well-being 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 freedom to choose. These latter characteristics are unique to the human species, are innate, and often motivate our behavior (Maslow, 1968, 1982). I have added one instinct—an inherent instinct for holistic well-being—and two human drives: the drive for healthy affiliated-individuation and the drive for self- actualization. These instincts and drives affect how we function as holistic beings. The holistic person is one in whom the whole is greater than the sum of the parts, whereas a wholistic person is one in whom the whole is equal to the sum of the parts (H. Erickson et al., 2009, pp. 45–46). As holistic beings, our mind, body, and spirit are inextricably interrelated with continuous feedback loops. Cells in each dimension can produce stimuli affecting responses in cells of other dimensions. Cellular responses have the potential to become new stimuli, moving the chain reaction around and among the dimen- sions of the human being. These interactions are dynamic and ongoing. Because we have an internal environment (i.e., within the confines of our physical being) and an external environ- ment (i.e., outside the confines of the biopsy- chosocial being), external stimuli have the potential to create multiple internal responses, and vice versa. To agree that we are holistic is to believe that we are human beings, living in a context that includes all that is within us and within our external environment—holistic be- ings, constantly in process both internally and externally. These dynamically interactive di- mensions cannot be separated without a loss of information about the person, a loss that diminishes our ability to fully understand the person’s situation. Humans are inherently intuitive. We know (at some level) what we need. We know what has made us sick and what will help us get well, grow, develop, and heal. We have instinctual information about our own personhood and our mind–body–spirit linkages. This informa- tion is called self-care knowledge. Our percep- tions of what we have available to help us are called self-care resources. Self-care resources are both internal and external. We have resources within ourselves as well as resources within our external environment. Our actions, thoughts, biophysical responses, and behavior that help us get our needs met are our self-care actions. We are inherently social beings with an innate drive to grow and develop, to become the most that we can be, find meaning in our lives, fulfill our potential, and self-actualize. However, we are vulnerable. Our ability to grow and de- velop is dependent on repeated satisfaction of our needs. We want and need to be connected or affiliated to others in some way. Simulta- neously, we also need to perceive ourselves as unique and individuated from these same people. We call this affiliated-individuation (Acton, 1992; H. Erickson et al., 2009, p. 47; M. Erickson et al., 2006, pp. 182–207). Our drive to be both affiliated and individuated at the same time mandates a balance between being connected while perceiving a sense of one’s self as a unique human being, separate from others. We achieve our drive for a bal- anced affiliated-individuation through our in- teractions with others. How well we achieve 3312_Ch12_185-206 26/12/14 2:59 PM Page 190 this balance at any point in our life will deter- mine how we relate to others in the following years. Although we are social beings with a drive for affiliated-individuation with others, we are also spiritual beings with an inherent drive to be connected with our soul (H. Erickson et al., 2009, 2006). More specifically, our drive for individuation is to fulfill our psychosocial needs while doing soul-work unique to our life journey. Health Health is a matter of perception. It is a state of well-being in the whole person, not just a part of the person. It is not the presence, ab- sence, or control of disease; one’s ability to adapt; or one’s ability to perform social roles. Instead, it is a eudemonistic health that incor- porates all of these and more. It is a sense of well-being in the holistic, social being. It in- cludes one’s perceptions of her life quality, her ability to find meaning in her existence, and a capacity to enjoy a positive orientation toward the future. As a result, personal per- ceptions of health may differ from those of others. It is possible for persons with no ob- vious physical problem to perceive a low level of health, while at the same time others, tak- ing their last mortal breath, may perceive themselves as very healthy. The perception of health status is always related to perceived balance of affiliated-individuation. Nursing Nursing is the unconditional acceptance of the inherent worth of another human being. When we have unconditional acceptance for another person, we recognize that all humans have an innate need to be loved, to belong, to be respected, and to feel worthy. Uncondi- tional acceptance of a person as a worthwhile being is not the same as accepting all behaviors without conditions. It does mean, however, that we recognize that behaviors are motivated by unmet needs. Our work, then, is to help people find ways to get their needs met with- out harming themselves or others. We do this through nurturance and facili- tation of the holistic person. Our goal is to help people grow, develop, and, when necessary, to heal. We use all of our skills acquired through formal education as well as our own innate abil- ity to connect with others to help them recover from illnesses and to live meaningful lives. We do this from the beginning of physical life to the end, even as people are taking their last breath. Within this context, our intent, or what we aim to facilitate when we interact with an- other human being, is important. Social Justice As professional nurses, we are committed to live by the ethics of our profession, serve as ad- vocates for our clients, and serve the public as defined by our professional standards. For nurses who use the MRM theory, this means that we are committed to recognize the indi- vidual’s worldview as valid information, to act on that information with the intent of nurtur- ing and facilitating growth and well-being in our clients, and to practice within the context of the Standards of Holistic Nursing as defined by the American Holistic Nurses Association (AHNA, 2013) and recognized by the American Nurses Association (ANA, 2008). Theoretical Constructs People have an innate instinct to cope and adapt to stressors and related stress responses that confront us constantly. We adapt as much as we are able to, given our life situa- tion. We need oxygen, glucose, and protein to maintain our physical systems; we also need to feel safe and to be loved. When these needs are perceived to be unmet, they create stres- sors; stressors produce the stress response. Stress responses can become new stressors mandating still more responses, and so on (Benson, 2006, pp. 240–266; H. Erickson, 1976; H. Erickson et al., 2009). Many of our stress responses are instinctual, a part of our human makeup; however, some have to be learned and developed. As our needs are met, the stressors decrease; and we are able to work through the stress response. Adaptive Potential Our ability to mobilize resources at any mo- ment in time can be identified as our Adaptive CHAPTER 12 • Helen Erickson, Evelyn Tomlin, and Mary Ann Swain’s Theory of Modeling 191 3312_Ch12_185-206 26/12/14 2:59 PM Page 191 Potential. The adaptive potential assessment model (APAM; Fig. 12-2), first labeled in 1976 (H. Erickson, 1976; H. Erickson & Swain, 1982; H. Erickson et al., 2009), was derived by synthesizing Selye’s (1974, 1976, 1980, 1985) work with that of George Engel (1964). Our adaptive potential has three states: equilibrium, arousal, and impoverishment. Equilibrium, a state of nonstress or eustress, represents maximum ability to mobilize re- sources. The individual in equilibrium is in a healthy balance between need demands and need resources. Arousal and impoverishment are both stress states; needs are unmet, creating stressors and the related stress responses. However, people in arousal are temporarily able to mobilize their resources, whereas those in impoverishment are not. Persons in the first group (arousal) need help solving their problem, finding alternatives. They tend to be tense and anxious but do not demonstrate depleted resources through the ex- pression of fatigue and sadness. On the other hand, impoverished people show the wear and tear of prolonged stress. They have diminished physical resources and are fatigued and sad. People in arousal are at risk for becoming impoverished, and impoverished people are at risk for depleting their resources, getting sick, developing complications, and even dying (Barnfather, 1987; Barnfather & Ronis, 2000; Benson, 2006, pp. 242–254; H. Erickson, 1976; H. Erickson et al., 2009, pp. 75–83; H. Erickson & Swain, 1982). As indicated, a person’s ability to cope is related to how well his or her needs are met at any given point in time. Human Needs Human needs, classified as basic, social, and growth needs, drive our behavior. They provide motivation for our self-care actions and emerge in a quasi-hierarchical order. Physiological needs must be met to some degree before social needs emerge. Growth or higher-level needs emerge after the basic and social needs have been met to some degree (for a more detailed taxonomy of human needs, see H. Erickson, 2006a, pp. 484–485). Basic needs are related to survival of the species. When they are unmet, tension rises, motivating behavioral response(s) necessary to decrease the tension. When self- care actions decrease the tension, the need dis- sipates. When the need is completely satisfied, the tension disappears. When needs are met repeatedly, need assets are built. Conversely, when the need is not met, the tension rises, and need deficits emerge. When the tension contin- ues, need deprivation exists. Need status can be classified on a 0 to 5 scale ranging from deprivation to asset status (Fig. 12-3). Growth needs are different. Because people have an in- nate drive for self-actualization, growth needs emerge when basic needs are met (to some de- gree). Unmet growth needs do not create ten- sion unless they are related to a basic need. Instead, satisfaction of growth needs creates ten- sion. The need increases in intensity. Until one feels satiated, the need to continue to behave in ways that will meet growth needs continues. Need Satisfaction and the Object Attachment Process Objects that repeatedly meet humans needs become attachment objects. These objects take on significance unique to the individual, are both human and nonhuman, have a physical form (so they stimulate one of the five senses) or are abstract (such as an idea), and are nec- essary throughout life. When a person per- ceives that the object is or will be lost, a grieving response occurs. Loss is a subjective 192 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm Equilibrium Stressor S tressorS tre ss or C op in g C oping Stress ImpoverishmentArousal Fig 12 • 2 The adaptive potential assessment model. Deprivation Deficit Unmet Met Satisfied Assets 0 1 2 3 4 5 Fig 12 • 3 The needs status scale, 0 to 5. 3312_Ch12_185-206 26/12/14 2:59 PM Page 192 experience known by the individual; it can be real, threatened, or perceived. Any loss pro- duces a grieving process. One’s difficulty in re- solving the loss depends on the significance of the lost object. The grieving response is nor- mal, occurs in a predetermined sequence, and is self-limited. Normal grieving processes take about 1 year (Fig. 12-4). Grief resolution oc- curs as the individual finds new ways to view the lost object or finds alternative objects that meet their needs. Commonly accepted processes of grief include sequential phases of shock/disbelief, anger, bargaining, sadness, and acceptance (Kübler-Ross, 1969). Other models (Engel, 1964; Bowlby, 1973) indicate slightly different phases (M. Erickson, 2006, p. 229). Table 12-6 compares three of these models. I believe that their differences are based in the nature of the lost object, its mean- ing to the individual, and the resources accrued CHAPTER 12 • Helen Erickson, Evelyn Tomlin, and Mary Ann Swain’s Theory of Modeling 193 Satisfied needs Basic needs Unmet needs Secure attachment to object meeting needs Positive developmental residual Health- promoting behaviors High-level wellness Negative developmental residual Health- impeding behaviors Physical and psychological problems Resolution of loss with reattachment and satisfied needs Nonresolution of loss with continued unmet needs Situational or developmental loss and grief Holistic well-being Insecure attachment with continued unmet needs and morbid grief before the experienced loss. Resources are based on one’s ability to work through the nor- mal developmental tasks encountered during the human journey. This issue is discussed fur- ther in the text that follows. Attachment to new objects is necessary for continued growth and grief resolution. The new object can be the same object, perceived in a new way, or a completely new object. Some- times transitional objects are used to facilitate this process. Transitional objects are those that symbolize the lost object and are never human, but are almost always concrete. For example, mothers attached to their children as preschoolers often experience a loss when their children start school and become increasingly independent. It is common to see these moth- ers attach to their child’s baby shoes, pictures, or some other symbol of who they were in their previous life stage. Fig 12 • 4 The needs–attachment–development–loss–reattachment model. 3312_Ch12_185-206 26/12/14 2:59 PM Page 193 194 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm Engel Kübler-Ross Bowlby Shock/disbelief Awareness Resolution Loss resolution Idealization 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. Table 12 • 6 Stages of Grief According to Contributing Authors Denial/shock Anger/hostility Bargaining Depression Acceptance Protest Despair Detachment Morbid grief emerges when the individual is unable to find alternative objects that will repeatedly meet their needs. Because we are holistic beings, morbid grief has the potential to result in physical symptoms, illness, and over the long period, disease. What happens in one part of the holistic person has the potential of creating disease in another part, disease that becomes distressful, mandates mobilization of resources often not available, and therefore producing alternative biophysi- cal responses, depleting psychoneuroimmuno- logical resources (Walker & Erickson, 2006 Behaviors that indicate emergence of mor- bid grief include an inability to move on and let go of the lost object, combined with vacil- lation between anger and sadness (M. Erickson, 2006, pp. 209–239; Lindeman, 1944, pp. 141– 148). Initially individuals are able to focus their anger and sadness, but with time, anger grows into hostility and sadness into depression. When this happens, people are less able to ar- ticulate the focus of their feelings or recognize the loss that produced the grieving response in the beginning. They often use language that describes giving up rather than letting go, and sometimes express nostalgia for the lost object. In contrast, those who have let go of the lost object, worked through the normal grief re- sponse, and reattached to a new object can usually describe the importance of moving on. Need Satisfaction and Life Orientation The degree to which a person’s needs are met repeatedly determines how he or she relates to others; it affects his or her life orientation. When needs are met repeatedly, people are able to grow and develop, to integrate mind– body–spirit, to perceive themselves as worthy human beings, and to experience a healthy balance of affiliated-individuation. When this happens, they are interested in others as indi- viduals who are unique and worthwhile. They enjoy both a sense of connectedness and a sense of individuation. Their life orientation is called a being orientation because they are in- terested in becoming all they can be and in participating in the same way with others. However, when needs are repeatedly unmet, growth is limited, and people have difficulty with their developmental processes. Their rela- tionships with others exist within a context of what can be obtained from the other. They are not interested in the well-being of the other, might be threatened by growth in significant others, and are intolerant of the uniqueness of others. More interested in what they can get from someone than what they can give, these people often view others as a source of getting their basic needs met. As a result, often unable to meet the needs of significant others, they are perceived as “needy people.” Their life orienta- tion is called a deficit orientation. Being and deficit orientations exist on a scale; most people have some of both. The balance between the two is what determines one’s overriding traits or personal attributes, one’s values and virtues, and one’s ways of interacting with others. Developmental Processes People have an inherent drive for self- actualization. This requires that they pass through predetermined chronological develop- mental stages—stages with tasks that mandate 3312_Ch12_185-206 26/12/14 2:59 PM Page 194 attention as they emerge. Our ability to work on these developmental tasks depends on our ability to mobilize resources. Resources are derived by getting our needs met at any given time as well as our past experiences. Because our experiences are always contextual, how we resolve our devel- opmental tasks will determine the resources we have to work on current tasks. As we work through a stage-related task, a developmental residual is produced. This residual includes positive and negative attributes, strengths, and virtues. In our original work, we followed Erik Erikson’s (1994) work to define eight stages, their tasks, and the associated residual. Our more recent work has expanded the stages to include one prebirth and another at the time of death because the work of the soul affects the devel- opmental processes during one’s physical life (M. Erickson, 2006, pp. 121–181; Table 12-7). Sequential Development Development occurs as a series of predeter- mined stages with specific tasks in each stage. It is also chronological: unique, sequential stages, and their related tasks emerge during a specific time frame in our lives. During that time, the task becomes predominate in our life journey, drawing resources, focusing attention, and motivating behaviors. Epigenesis Development is also epigenetic. Although we have specific tasks that focus our attention at spe- cific times in life, we also rework earlier life 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 stated, we re- peatedly work on all of the developmental tasks at every stage of life, although we have a key task that dominates at any given time. Our ability to manage multiple tasks is dependent on the resid- ual we have produced throughout the process and our current ability to have our needs met. Linkages Three key theoretical linkages exist in the MRM model. Relations exist between or among (1) adaptive potential and need status; CHAPTER 12 • Helen Erickson, Evelyn Tomlin, and Mary Ann Swain’s Theory of Modeling 195 Stages/Age Residual Virtue Strength(s) Integration of Spirit (pre–post birth) Building Trust (birth–15 months) Acquiring Autonomy (12–36 months) Taking Initiative (2–7 years) Developing Industry (5–13 years) Developing Identity (11–30 years) Building Intimacy (20–50 years) Developing Genera- tivity (midlife to 60s) Ego Integrity (60s to transformation) Transformation (end of physical life) 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. Table 12 • 7 Developmental Stages, Residual, Virtues, and Strengths Unity vs. duality Trust vs. mistrust Autonomy vs. introspection Initiative vs. responsibility Competency vs. inferiority Self-identity vs. role confusion Intimacy vs. isolation Generativity vs. stagnation Ego integrity vs. despair Reconnecting vs. disconnecting Groundedness Hope Willpower Purpose Competence Fidelity Love Caring Wisdom Oneness Awareness Drive toward future Self-control Drive Methodological problem-solving Devotion Affiliation with individuation Production Renunciation Peace, cosmic under- standing, compassion 3312_Ch12_185-206 26/12/14 2:59 PM Page 195 (2) need status, object attachment, loss, and new attachment status; and (3) developmental task resolution and need satisfaction. Selected theo- retical propositions, derived from these linkages, are shown in Table 12-4. Others exist, limited only by an understanding of MRM. MRM Practice Strategies Initiating the Relationship Three sequential strategies are important for those using the MRM model: (1) establishing a mindset, (2) creating a nurturing space, and (3) facilitating the story (H. Erickson, 2006b, pp. 309–317; Table 12-8). Each can be done in seconds once the essence of the strategy is understood. However, before you can start, it is necessary to reflect on your own beliefs about human nature and nursing and to con- sider how these affect your practice. This helps you clarify how to get your needs met—a prerequisite to meeting the needs of others. Unless we know how to initiate our own self- care, we have difficulty mobilizing the energy necessary to focus on the needs of our clients. Finally, we have to open ourselves to the worth of each individual, to unconditionally accept that each human has an inherent need to be valued, to be treated with respect, and to live with dignity. Establishing a Mindset Establishing a mindset involves three strate- gies: centering, focusing, and opening. Center- ing helps to organize our resources so that we can connect energetically with our client. It re- quires that we temporarily put aside other thoughts, worries, or concerns and believe that at some level we can discover what we need to know to help our clients; it requires us to focus on the other with the intent of nurturing their growth and facilitating their healing. When we focus on our client’s needs, we initiate an energetic connection, necessary for a caring– healing environment. Creating a Nurturing Space Creating a nurturing space follows naturally when we have established a mind-set. Our goal is to create a caring–healing environment. Although one cannot force growth in others, we can create environments that nurture growth. We do this by decreasing adverse stimuli while increasing positive ones. It is im- portant to remember that you are entering the client’s space and to respect it. Even though you may think it is important to close the door, turn on the radio, or fluff pillows, you will want to assess whether your actions serve to comfort the client. Each of these processes helps you connect with your client in such a 196 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm Establish a Mindset Create a Nurturing Space Facilitate the Client’s Story 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. Table 12 • 8 Three Strategies That Facilitate a Trusting–Functional Relationship Self-care preliminaries Moving forward Reduce distracting stimuli. Respect client’s space. Connect spirit to spirit. Tap self-care knowledge. Enhance sense-of-self. Center self. Focus intent. Open self to the essence of other. Attend to sounds, lights, smells, and other stimuli that are distracting and discomforting. Recognize and respect client’s physical/ energetic space. Use eye contact, soft tones, and gentle touch to connect with client. 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. 3312_Ch12_185-206 26/12/14 2:59 PM Page 196 way that you will initiate a trusting relationship and create a caring–healing environment. Any stimuli that affects the five senses has the pos- sibility of being comforting, uncomfortable, or discomforting. We can influence these by our actions in the milieu and by our interactions with our client. For example, a noisy hallway or bright lights shining in our eyes are stimuli that seem to drain energy from us, and no doubt our clients experience the same thing. Or consider a beautiful picture, the glimpse of a fully leafed tree swaying in a gentle breeze, soft music of our choice, clean sheets against our skin, or the gentle touch of a loving person. In thinking about how you respond to these stimuli, you will understand that these have the possibility of comforting another human being. You will also understand that how you touch, look, or speak to someone conveys a message about your intent to comfort or not to comfort. Of course, it is extremely important that we consider the individual’s cultural per- spectives and values as we consider how to cre- ate a nurturing space; what works for one person does not for another. The only way we can know is to ask our clients or, when they are unable to speak for themselves, to ask their significant others. Facilitating the Story Facilitating the story is the third strategy that MRM nurses use. Disclosure of our clients’ self-care knowledge provides basic information needed before we can decide what nursing ac- tions are required—information that provides insight into their worldview. We learn about their perceptions and beliefs, what they believe about their current situation, what they expect will happen, what resources they believe they have, and what they would like to do to alter the situation. It also allows them to “contextu- alize life experiences and present them in a way that softens associated feelings” (H. Erickson, 2006b, p. 315). Our clients’ self-care knowledge is best ob- tained by allowing them to tell their story in their own way. We use active listening to fa- cilitate our clients to tell their stories. This can be done very quickly by initiating the discus- sion with statements such as, “Tell me about your situation” followed by “Why do you think this has happened?” or “What do you think has caused it?” and “How do you feel about that?” and so forth (H. Erickson et al., 2009, pp. 153–167). The data are then organized into four distinct but interrelated categories: de- scription of the situation, expectations, resource potential, and goals (see Table 12-2). Informa- tion provided by our clients has to be inter- preted, aggregated, and analyzed before we can use it to plan interventions (H. Erickson et al., 2009, pp. 153–168). Phases of Understanding the Data There are three phases in understanding the in- formation gained in MRM practice model. In data interpretation, we use the philosophical and theoretical underpinnings discussed earlier as we attend to words, affects, and nonverbal cues, searching for evidence of coping potential (i.e., adaptive potential), needs status, and de- velopmental residual. Sometimes it is necessary to clarify what we observe to avoid superimpos- ing our own interpretations on these data. For example, clients might have a spouse or signifi- cant other but not perceive this individual as supportive. When this happens, they often describe them as “draining” rather than invig- orating. We cannot always make these dis- tinctions without asking the client how they perceive their relationship with their significant other (H. Erickson et al., 2009, pp. 160–163). A person’s story usually includes information about interactions among the dimensions of the holistic person, but nurses often have trou- ble understanding the significance of what they have heard. For example, when people say they are sick because they are too stressed, our first response might be to think about the cause and effect of disease—for example, bacteria (not stress) cause infections. However, the MRM model supports a holistic perspective; we know that mind and body are inextricably interactive. Therefore, we recognize that psychosocial stress stimulates the hypothalamic–pituitary–adrenal axis interactions, compromising the immune system. When this happens, we have more difficulty fighting bacterial invasions. As a re- sult, we know that psychosocial stress has the potential of causing signs and symptoms of physical illness and/or disease. CHAPTER 12 • Helen Erickson, Evelyn Tomlin, and Mary Ann Swain’s Theory of Modeling 197 3312_Ch12_185-206 26/12/14 2:59 PM Page 197 The second phase, data aggregation, some- times occurs as we interpret data derived from the primary source (i.e., the client), but not al- ways. To aggregate data accurately, we need to consider data derived from the secondary and tertiary sources as well as the data derived from the client. Although data can be aggregated with only the client’s story and the nurse’s clin- ical knowledge, it is also helpful to hear the family’s perspective. Sometimes it is important to include the information collected from ter- tiary sources as well. When aggregating data, we consider all the information and look for consistencies as well as inconsistencies across the sources of infor- mation. Additional information may be nec- essary to clarify perspectives. Usually, this phase helps determine what needs to be done when moving into the intervention phase of the nursing process. Data analysis is the next phase. Again, you may be doing all three—interpreting, aggre- gating, and analyzing—simultaneously. Dur- ing the analysis phase, you look for theoretical linkages among the data and make diagnoses. Proactive Nursing Care Often the process of assessing our clients’ worldview serves as a therapeutic intervention. People in arousal commonly state that they feel much better after talking. Some will ask for minimal help, but some require more sophis- ticated help. In any case, based on our diag- noses, nursing care is planned within the context of the MRM principles of care, aimed at facilitating well-being in our clients, and de- signed specifically to meet intervention goals. We do this as we manage technical care such as wound management, intravenous insertion, and so forth. We use nonjudgmental language, caring tones, and direct statements that relay information needed to feel safe and cared about. We also use Ericksonian hypnothera- peutic techniques to promote growth and facilitate healing (H. Erickson et al., 2009, pp. 84–85, 145–147; H. Erickson, 2006b, pp. 315–317; 372–374; Zeig, 1982). We can also do this without ever touching the person because we use ourselves as con- duits of healing energy. Sometimes knowing that someone cares about us will help us grow and heal. We project these messages through our actions when we unconditionally accept the worth of another human being and set intent to facilitate health and healing. Watzlawick (1967) stated that “we cannot not communicate.” Our attitudes, nonverbal behaviors, and touch are often more important than what we say when we convey our intent to help others heal and grow; words are not al- ways necessary. Our demeanor, the way we look at the person, what we focus on first, and how we touch our clients relays our intent. When we enter a relationship with the intent to comfort and nurture the other person, our energy field connects with his; we convey pres- ence and initiate a caring–healing environment (H. Erickson, 2006b, pp. 300–324). Practice Applications MRM, recognized by AHNA as one of the extant holistic nursing theories, is used in a va- riety of settings including educational institu- tions as a framework for entire programs or specific courses, hospitals to guide practice, and for independent practice (Table 12-9). The Society for the Advancement of Mod- eling and Role-Modeling (SAMRM; www, established in 1985, meets biennially with retreats in alternate years. Selected publications (Table 12-10) demonstrate how MRM has been applied across populations and settings from pediatrics to the elderly, chronically ill to the well, and intensive care to home care. Others (such as publications by Baas, Barnfather, Duke, Frisch, Hertz, Kelly, and Perese; see Table 12-10) describe MRM with those who have heart fail- ure, undereducated adult learners, and/or employed mothers with preschool children. For example, Baas (2004) has tested relations between self-care resources and activities and quality of life and developed protocol for nurs- ing practice. Baas, Past President of the Amer- ican Association of Heart Failure (AAFH) Nurses and Director of Nursing Research at the University of Cincinnati Medical Center (2009–2012), continues to be actively involved in setting practice protocol for nurses working 198 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm 3312_Ch12_185-206 26/12/14 2:59 PM Page 198 CHAPTER 12 • Helen Erickson, Evelyn Tomlin, and Mary Ann Swain’s Theory of Modeling 199 Harding University, School of Nursing, Searcy, Arkansas Metro State University, School of Nursing, St. Paul, Minnesota The College of St. Catherine’s, School of Nursing, St. Paul, Minnesota The University of Texas at Austin, School of Nursing Contemporary Health Care, Austin, Texas Table 12 • 9 Agencies Using or Teaching Modeling and Role-Modeling Theoretical foundation for pediatric clinical course Theoretical foundation, and student advising Theoretical foundation, ADN Program Theoretical foundation, the Alternate Entry Program Independent Nurse Practice Agency with people experiencing congestive heart fail- ure. Duke, Professor of Nursing and Associate Dean for Research, University of Texas at Tyler, previously interested in the experiences of single mothers (published in Weber, 1999), is currently studying attitudes about and pref- erences for end-of-life care in persons of Jewish, Hindu, Muslim, Buddhist, and Bhai’I faiths and living in Texas. Both Frisch & Frisch (2010) and Perese (2012) have pub- lished textbooks for mental health practition- ers; Frisch & Frisch’s book is used as a foundational book, whereas Perese’s was writ- ten specifically for advanced practice nurses. Hertz has developed and tested a midrange theory derived from MRM that measures per- ceived enactment of autonomy in the elderly. Hertz, Professor and Director of Graduate Studies, Northern Illinois University, is cur- rently involved with mentoring graduate students interested in advancing holistic care for the elderly. Case studies are reported by practitioners in each of the SAMRM newsletters; these and additional publications (Hertz, 2013; Hertz, Irving, & Bowman, 2010; Hertz, Koren, Rossetti, & Robertson, 2008; Jablonski & Duke, 2012; Mitty, Resnick, Allen, Bakerjian, Hertz, Gardner et al., 2010) can be found on the SAMRM website (www Author Tested Source Erickson, H. (1976) Erickson, H., & Swain, M. (1982) Erickson, H. (1984) Darling-Fisher, C., & Kline-Leidy, N. (1988) Walsh, K., Vanden Bosch, T., & Boehm, S. (1989) Barnfather, J., Swain, M. A. P., & Erickson, H. (1989). Erickson, H., & Swain, M. (1990) Table 12 • 10 Practice/Intervention Studies Related to Modeling and Role- Modeling (MRM) Theory and Paradigm Identification of states of coping MRM and well-being Exploration of self-care knowledge Measuring Eriksonian devel- opmental residual in the adult MRM applied to two clinical cases Construct validity the APAM MRM and hypertension reduction Unpublished master’s thesis, Univer- sity of Michigan, Ann Arbor Research in Nursing & Health, 5, 93–101 Dissertation Abstracts International, 45, 171. University Microfilms No. AAD84–12136 Psychological Reports, 62, 747–754 Journal of Advanced Nursing, 14(9), 755–761 Issues in Mental Health Nursing, 10, 23–40 Issues in Mental Health Nursing, 11(3), 217–235 Continued 3312_Ch12_185-206 26/12/14 2:59 PM Page 199 200 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm Author Tested Source Table 12 • 10 Practice/Intervention Studies Related to Modeling and Role- Modeling (MRM) Theory and Paradigm—cont’d Finch, D. (1990) Kline-Leidy, N. (1990) Erickson, H. (1990) Acton, G., Irvin, B., & Hopkins, B. (1991) Barnfather, J. (1993) Holl, R. (1993) Baas, L., Deges-Curl, E., Hertz, J., & Robinson, K. (1994) Webster, D., Vaughn, K., Webb, M., & Player, A. (1995) Kline-Leidy, N., & Travis, G. (1995) Hertz, J. (1996) Baldwin, C. (1996) Erickson, M. (1996) Sappington, J., & Kelly, J. (1996) Baas, L., Fontana, J., & Bhat, G. (1997) Raudonis, B., & Acton, G. (1997) Acton, G., Mayhew, P., Hopkins, B., & Yauk, S. (1999) Acton, G. (1997) Irvin, B., & Acton, G. (1997) Jensen, B. (1997) Baas, L., Berry, T., Fontana, J., & Wag- oner, L. (1999) Jensen, B. (1999) Scheela, R. (1999) Weber, G. (1999) MRM nursing assessment model Relations among stress, resources, and symptoms of chronic illness MRM with mind–body problems Theory testing research: Building the science Testing a theoretical proposition of MRM MRM vs. restricted visiting Innovative approaches to theory based measurement: MRM research MRM and brief solution- focused therapy Relations between psychophysiological factors and physical functioning Perceived enactment of autonomy (PEA) Perceptions of hope EMBAT and maternal well-being A case study Self-care resources and the quality of life Theory-based nursing practice Communicating with persons with dementia The mediating effect of affiliated-individuation Stress, hope and well-being Caring for the caregiver Developmental growth in adults with heart failure Caregiver responses to MRM Remodeling sex offenders The meaning of well-being (self-care knowledge) Modeling and Role-Modeling: Theory, Practice and Research, 1(1), 203–213 Nursing Research, 39, 230–236 In J.K. Zeig & Gilligan, S. (Eds.) Brief Therapy: Myths, Methods, and Metaphors. New York: Brunner/ Mazel, 473–491. Advances in Nursing Science, 14(1), 52–61. Issues in Mental Health Nursing, 14, 1–18. Critical Care Nursing Quarterly, 16(2), 70–82 Advances in Nursing Science Series: Advances in Methods of Inquiry, 5, 147–159. Issues in Mental Health Nursing, 16(6), 505–518 Research in Nursing & Health, 18, 535–546 Issues in Mental Health Nursing, 17, 261–273 The Journal of Multicultural Nursing & Health, 2(3), 41–45 Issues in Mental Health Nursing, 17, 185–200 Journal of Holistic Nursing, 14(2), 130–141 Progress in Cardiovascular Nursing, 12(1), 25–38 Journal of Advanced Nursing, 26(1), 138–145 Journal of Gerontological Nursing, 25(2), 6–13 Journal of Holistic Nursing, 15(4), 336–357 Holistic Nursing Practice, 11(2), 69–79 Home Care Provider, 2(6), 34–36 Journal of Holistic Nursing, 17(2), 117–138 Dissertation Abstracts International, B 56/06, 3127 Journal of Psychosocial Nursing and Mental Health Services, 37(9), 25–31 Western Journal of Nursing Research, 21(6), 785–795 3312_Ch12_185-206 26/12/14 2:59 PM Page 200 CHAPTER 12 • Helen Erickson, Evelyn Tomlin, and Mary Ann Swain’s Theory of Modeling 201 Author Tested Source Table 12 • 10 Practice/Intervention Studies Related to Modeling and Role- Modeling (MRM) Theory and Paradigm—cont’d Barnfather, J., & Ronis, D. (2000) Timmerman, G., & Acton, G. (2001) Mayhew, P., Acton, G., Yauk, S., & Hopkins, B. (2001) Berry, T., Baas, L., Fowler, C., & Allen, G. (2002) Perese, E. (2002) Hertz, J., Anschutz, C. (2002) Baas, L. (2004) Baas, L., Berry, T., Allen, G., Wizer, M., &Wagoner, L. (2004) Lombardo, S. L., & Roof, M. (2005) Berry, T., Baas, L., & Henthorn, C. (2007) Psychosocial resources, stress, and health Relations between needs and emotional eating Communication, dementia, and well-being Spirituality in persons with heart failure Integrating psychiatric nurs- ing into educational models Relationships among PEA, self-care, and holistic health Self-care resources, activities as predictors of quality of life Awareness in persons with heart failure or transplant Application MRM to person with morbid obesity Self-reported adjustment to implanted cardiac devices Research in nursing & health, 23, 55–66. Issues in Mental Health Nursing, 22(7), 691–701 Gerontological Nursing, 22, 106–110 Journal of Holistic Nursing, 20(1), pp. 5–30 Journal of American Association of Psychiatric Nurses, 8(5), 152–158 Journal of Holistic Nursing, 20, 166–186 Dimensions of Critical Care Nurs- ing, 23(3), 131–138 Journal of Cardiovascular Nursing, 19(1), 32–40 Home Healthcare Nurse, 23(7), 425–428. Journal of Cardiovascular Nursing, 22(6), 516–524 We cannot cure people, but we can help them heal and grow, even as they are taking their first or last breath. When people heal, they be- come more fully connected with the multiple di- mensions of their mind, body, and spirit, and as a result, they become more fully actualized. A caring–healing environment, created by the nurses’ intent, fosters growth and well-being in their clients. Because people have inherent in- stincts and drives to grow, develop, and heal, all nursing actions focus on facilitation and nurtu- rance of these innate abilities. We use ourselves to connect with our clients in such a way that we can create trusting functional relationships with them, relationships that have a purpose or are aimed at some outcome. In the MRM model, these relationships aim to affirm clients’ worth; to help them mobilize and build resources needed to cope with their stressors/stress; foster hope for the future; and promote a sense of affiliated-individuation. When people have these experiences, a sense of well-being follows. Although we use every professional skill we have acquired, these are secondary to using ourselves as healing agents. As nurses, we nurture and facilitate people to become the most that they can be. We help them actualize their life roles and find meaning in their existence. When this happens, it affects not only our clients but also those who are significant in their lives. As nurses, every interaction with our clients and their loved ones provides us with oppor - tunities to affect the future; I call this the “long- arm affect” (H. Erickson, 2006b, p. 390). How we perceive our roles as nurses will de- termine our intent. This in turn affects what we do, how we interact, the focus of our work, and the outcomes of our relationships. We cannot always change what will happen in our lives or those of others, but we can set the in- tent to help people grow, heal, and move on. J. M.’s letter (see Practice Exemplar 1) sug- gests that I not only helped his family deal with a life tragedy but also helped them dis- cover ways to find meaning in the experience. I helped them grow, heal, and move on. 3312_Ch12_185-206 26/12/14 2:59 PM Page 201 202 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm Practice Exemplar 1 A man who was the strong, dominant mem- ber of his family was lying in bed, inconti- nent, riddled with cancer, and feeling hopeless. When I learned that he no longer allowed his family to visit, I gently took his hand and told him I was happy to be his nurse that evening. He “looked at me with very sad eyes . . . [and said] that he didn’t want his family to see him in this condition. . . . [H]e had always taken care of his family, and now . . . he couldn’t take care of himself” (H. Erickson, 2006a, p. 325). I rephrased his words and then told him that although he had been the breadwinner in the past and his family members had enjoyed and appreciated that, all they wanted now was to be with him, to share his life, to show him that he was important because he loved them and they loved him. He agreed, and for the next few days his family members took turns just being with him. On the third day when he quietly passed, he and his family were able to grieve with dignity and peace. Eight years later, I received a letter from his son (only 16 at the time of his father’s death), notifying me that his mother had died. He knew I would want to know that because of what they had learned from me, she was able to pass at home with her family at her side, singing her favorite songs and strumming on the guitar. He went on to state: In the year my Dad was with you people in Ann Arbor, you were of incalculable aid and com- fort to both my parents—you gave them confidence in you and your staff, and the dignity and respect which makes life worth living; no one else could, or did, more genuinely have their gratitude and respect. When I would come down and all seemed to be lost, the one bright spot was that Mrs. Erickson would be coming on, and we could breathe a little more easily as Dad’s anxiety visibly receded. Your kindness and humanity made the world a better place at that time and without you the experience would have been more difficult than you probably believe. Thank you, J. M. Practice Exemplar 2 Most data are easy to understand although there are some that are symbolic of earlier losses. A middle-aged man I worked with a number of years ago had just been admitted to the hospital for a “workup.” Mr. S. had complained of chronic fatigue for the past 6 months. An hour or so before I saw him, he had learned that he had acute leukemia. When I asked him to tell me about his situ- ation, he told me about his leukemia and then launched into a story about his child- hood. He described a time when he was about 16 years old, had been told to watch his younger sister and had let her ride a horse without supervision. She fell off and was killed. He remembered his father telling him that he had not been responsible and that he needed to grow-up and be a man. Mr. S. looked surprised and said he didn’t know what had made him think of that event and hadn’t thought about it for years. When I asked him what he expected to happen to him, he said he guessed that he was going to die. He went on to say that he thought he had de- veloped leukemia because he hadn’t been re- sponsible, and when he wasn’t responsible; people died. As we explored his resources, he explained that he had been promoted about 9 months earlier and that his new job required skills he didn’t think he had. His conclusions were that he was sick because he had “worried himself to death.” He also stated that he didn’t want his wife to come see him, that he needed to decide what he wanted to do first, and how he could take care of her now that he was sick? When I asked if she or someone else could 3312_Ch12_185-206 26/12/14 2:59 PM Page 202 CHAPTER 12 • Helen Erickson, Evelyn Tomlin, and Mary Ann Swain’s Theory of Modeling 203 Practice Exemplar 2 cont. help him consider options, he said no, that it was his responsibility to take care of himself. To understand these data, I needed to recog- nize the following: • People who link new stressful experiences to past experiences are usually dealing with a loss related to the past experience. In his case, it was not only the loss of his sister but also the meaning of the loss. As a 16-year-old boy, he was learning about his ability to make sound decisions, to be inde- pendent, to determine who he was as a unique human being in society. He had learned that “when he wasn’t responsible, people died.” • Although he identified his wife as his sig- nificant other, he was overindividuated. He needed to decide how to “tell” his wife about his problem—his problem of not being responsible, not being a “man.” He did not perceive that it was appropriate to seek comfort from her or others. • Mr. S. is in arousal with unmet safety and belonging needs, unresolved loss with mor- bid grief, and both positive and negative residual from adolescence on. Strong posi- tive residual from early childhood provides some resources that could be mobilized with assistance. • Although Mr. S. is chronologically in the stage of Intimacy versus Isolation, his stres- sors are related to residuals from the stage of Competency versus Limitations. • Mr. S’s healthy affiliated–individuation has been threatened due to overindividuation. • Mr. S. wished to be “responsible” to “take care of his wife.” Specific interventions used in this case are as follows: • I centered myself and set intent to be ener- getically connected, using myself as a con- duit of healing energy from the universe. Setting an intent to connect and serve as a healing instrument is a prerequisite to facili- tating a client’s storytelling. It is also an im- portant strategy for helping people mobilize resources needed to help themselves heal. Centering, setting intent to connect, and to serve as an energetic conduit were strategies used throughout our time together, pur- posefully initiated with each visit. • When I asked him to tell me about his situation, I also stated that he could talk about anything that popped into his mind, even if it didn’t seem to be related to his current situation. This strategy is used because people have state-dependent memory, their current experiences are often related to losses incurred in the past. Al- though they are unaware of these relations, it may be important to help them “uncover” these experiences in their own time and their own way so that they can begin to heal—a prerequisite for mobilizing re- sources needed to contend with the current situation. • I used active listening skills as he told his story, using nonverbal communications to encourage him to open up, staying energet- ically connected, and remaining quiet when he paused, allowing him an opportunity to express his self-care knowledge. • My question: What do you expect will hap- pen? was used to assess self-care resources and to allow him to identify associated factors and express his worse fears. His re- sponse indicated that he was depleted of resources (i.e., impoverished), his definition of being responsible no longer worked for him, and he needed help reframing his be- haviors and identifying new resources. I further explored his resources with the follow-up questions. • Considering that the loss had occurred dur- ing the age of adolescence and the task of developing Identity and that healthy reso- lution of Identify is important for the devel- opment of healthy intimacy in the next stage of life, follow-up interventions in- cluded exploring alternative ways to think about “being responsible”—the role he had chosen for himself. Using open-ended questions, I helped him consider his rela- tionship with his family by thinking about how he was like the 16-year-old boy and how he was different; how he wanted to be Continued 3312_Ch12_185-206 26/12/14 2:59 PM Page 203 204 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm Practice Exemplar 2 cont. like that boy and how he wanted to be dif- ferent; and how he wanted to relate to his wife in the future and how he might start. Rhetorical questions, stated as curiosities rather than a demand for a response, were used to stimulate growth. Examples include statements such as I wonder how you are like that 16-year-old boy now, and how you are different? It might even be interesting to think about how you want to be like that boy—or different. • Biophysical care was also offered and pro- vided with consideration for his develop- mental resources. Adolescents with healthy developmental resources often vacillate in their need to be independent in their activi- ties of daily life and their needs to have care consistent with earlier stages provided. The only way to know is to offer care and follow the client’s responses. Thus, when asked to help with foot care, it was provided; when told that he could manage making his own outpatient appointments, he was given the information needed to make his appoint- ments and asked if he needed any other in- formation after the appointments were confirmed. • As he prepared for discharge to the outpa- tient clinic for chemotherapy, I explored his perceptions of the effects of chemotherapy. He stated that chemotherapy was a poison and would make him sick, that he didn’t look forward to that. I agreed that chemotherapy was a poison, but that there were several things he could do to help himself. Aiming to reframe the perception of chemotherapy outcomes, I suggested that chemotherapy was designed to fight with the bad cells, but he didn’t need to have the chemotherapy fight with his good cells, that he could protect them if he wanted. When he expressed curiosity about protecting his good cells, I helped him learn how to use guided imagery so that the chemotherapy would seek out bad cells and attach them, but leave the others alone. We then talked about ensuring that the chemotherapy had a good chance of doing its work by proactively getting sufficient sleep, drinking fluids, seeking nurturing re- lations, participating in activities that help him laugh, and other activities that made him feel loved, happy, and at peace. • Upon discharge, I offered him a business card as a transitional object. I explained that it contained my name and contact in- formation in the event that he wanted to talk with me at any time. I also stated that many people find they are able remember our time together—what they felt, heard, smelled, and saw—by holding the card and/or even just by thinking about it. I followed this gentleman for several weeks, visiting him occasionally in the outpatient clinic. He always had my business card with him and often commented that it was magic and that it helped him get through the bad days. Two years later I received a letter thank- ing me for helping him and stating that he was in remission. He and his wife were planning a trip to celebrate their anniversary. ■ Summary Nurses who use modeling and role-modeling believe the human is holistic with ongoing, dy- namic mind–body–spirit interactions; clients are the primary source of information; and nurses are instruments of healing. Modeling is the process used to gain an understanding of their clients’ perceptions and understandings of their conditions, health needs, and possible therapeutic interventions. During the model- ing process, nurses gain an understanding of their clients perceptions of what has caused their health problem, what impedes their heal- ing, and what will facilitate healing and growth. Modeling the client’s worldview also helps nurses to understand their clients’ rela- tionships and related roles, identify those that 3312_Ch12_185-206 26/12/14 2:59 PM Page 204 CHAPTER 12 • Helen Erickson, Evelyn Tomlin, and Mary Ann Swain’s Theory of Modeling 205 impede health and wellness and those that are meaningful and facilitate healing and growth. Role-modeling is helping clients find alter- native ways to fulfill their desired roles in life. This requires interventions including biophys- ical care as well as psychosocial strategies de- signed to help people articulate their self-care knowledge, mobilize resources, and participate in healthy self-care actions. Strategies are de- signed within the context of developmental residual and with consideration for losses and related attachment objects. Verbal and nonver- bal communication and basic biophysical nurs- ing skills are considered essential prerequisites in the use of MRM. References Acton, G. (1992). 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New York: Brunner/Mazel. 206 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm 3312_Ch12_185-206 26/12/14 2:59 PM Page 206 Chapter 13Barbara Dossey’s Theory of Integral Nursing BARBARA MONTGOMERY DOSSEY Introducing the Theorist Overview of the Theory Applications to Practice Practice Exemplar Summary References 207 Introducing the Theorist Barbara Montgomery Dossey, PhD, RN, AHN-BC, FAAN, HWNC-BC, is interna- tionally recognized as a pioneer in the holistic nursing movement and the integrative nurse coach movement as well as a Florence Nightingale scholar. She is Co-Director, In- ternational Nurse Coach Association (INCA), and Core Faculty, Integrative Nurse Coach Certificate Program (INCCP); International Co-Director, Nightingale Initiative for Global Health (NIGH); and Director, Holistic Nurs- ing Consultants. She is the author or coauthor of 25 books. Her most recent books include Nurse Coaching: Integrative Approaches for Health and Wellbeing (2015), Holistic Nursing: A Handbook for Practice (6th ed., 2013), The Art and Science of Nurse Coaching: The Provider’s Guide to Coaching Scope and Competencies (2013), Florence Nightingale: Mystic, Visionary, Healer (Commemorative Edition, 2010), and Florence Nightingale Today: Healing, Leadership, Global Action (2005). B. M. Dossey’s theory of integral nursing (2008, 2013) is considered a grand theory that presents the science and art of nursing. Her collaborative global nursing project, the Nightingale Initiative for Global Health (NIGH) and its initiative the Nightingale Declaration Campaign (NDC), recognizes the contributions of nurses worldwide as they engage in the promotion of global health, including the United Nations Millennium Development Goals and the Post-2015 Sus- tainable Development Goals. Dossey has re- ceived many awards and recognitions. She is a Fellow of the American Academy of Nursing, Board Certified by the American Holistic Nurses credentialing corporation as an advanced Barbara Montgomery Dossey 3312_Ch13_207-234 26/12/14 5:53 PM Page 207 holistic nurse (AHN-BC), and a health and wellness nurse coach (HWNC-BC). She is a ten-time recipient of the prestigious American Journal of Nursing Book of the Year Award. Dossey received the 2014 Lifetime Achieve- ment Award and was named the 1985 Holistic Nurse of the Year by the American Holistic Nurse’s Association. With her husband, Larry, she received the 2003 Archon Award from Sigma Theta Tau International, the Interna- tional Honor Society of Nursing, honoring the contribution that they have made to promote global health. In 2004, Barbara and Larry also received the Pioneer of Integrative Medicine Award from the Aspen Center for Integrative Medicine, Aspen, Colorado. Overview of the Theory As you begin to explore the theory of integral nursing, I invite you to reflect on the following questions: Why am I here? Are my personal and professional actions sourced from my soul’s purpose and wisdom? What is my call- ing, mission, and vision for my work in the world? How can I strengthen my passion in nursing and in my life? What am I currently doing to become more aware of my personal health and the health of my home and work- place? What am I doing locally that can affect the health and well-being of humanity and our Earth? How am I connected to my nursing colleagues and concerned citizens in my com- munity, in other cities, and nations? What is my calling? The theory of integral nursing is a grand theory that guides the science and art of inte- gral nursing practice, education, research, and health-care policy. It incorporates physical, mental, emotional, social, spiritual, cultural, and environmental dimensions and an expan- sive worldview. It invites nurses to think widely and deeply about personal health and client, patient, and family health, as well as that of the local community and the global vil- lage. This theory recognizes the philosophical foundation and legacy of Florence Nightin- gale (1820–1910; Dossey, 2010; Dossey, Selanders, Beck, & Attewell, 2005) healing and healing research, the metaparadigm of nursing (nurse, person[s], health, and envi- ronment [society]), six patterns of knowing (personal, empirics, aesthetics, ethics, not knowing, sociopolitical), integral theory, and theories outside of the discipline of nursing. It builds on the existing integral, integrative, and holistic ultidimensional theoretical nurs- ing foundations and has been informed by the work of other nurse theorists; it is not a free- standing theory. It incorporates concepts from various philosophies and fields that include holistic, multidimensionality, integral, chaos, spiral dynamics, complexity, systems, and many other paradigms. [Note: Concepts specific to the theory of integral nursing are in italics throughout this chapter. Please consider these words as a frame of reference and a way to ex- plain and explore what you have observed or ex- perienced with yourself and others.] Integral nursing is a comprehensive integral worldview and process that includes integrative and holistic theories and other paradigms; ho- listic nursing is included (embraced) and tran- scended (goes beyond); this integral process and integral worldview enlarges our holistic nursing knowledge and understanding of body–mind–spirit connections and our know- ing, doing, and being to more comprehensive and deeper levels. To delete the word “inte- gral” or to substitute the word “holistic” dimin- ishes the impact of the expansiveness of the integral process and integral worldview and its implications. The theory of integral nursing includes an integral process, integral worldview, and inte- gral dialogues that compose praxis—theory in action (B. M. Dossey, 2008; 2013). An inte- gral process is defined as a comprehensive way to organize multiple phenomena of human experience and reality from four perspectives: (1) the individual interior (personal/inten- tional), (2) individual exterior (physiology/ behavioral), (3) collective interior (shared/ cultural), and (4) collective exterior (systems/ structures). An integral worldview examines values, beliefs, assumptions, meaning, purpose, and judgments related to how individuals per- ceive reality and relationships from the four perspectives. Integral dialogues are transforma- tive and visionary explorations of ideas and 208 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm 3312_Ch13_207-234 26/12/14 5:53 PM Page 208 possibilities across disciplines, where these four perspectives are considered as equally impor- tant to all exchanges, endeavors, and out- comes. With an increased integral awareness and an integral worldview, we are more likely to raise our collective nursing voice and power to engage in social action in our role and work of service for society—local to global. As you read this chapter, 35 million nurses and midwives are engaged in nursing and health care around the world (World Health Organization [WHO], 2009). Together, we are collectively addressing human health—of individuals, of communities, of environments (interior and exterior) and the world as our first priority. We are educated and prepared— physically, emotionally, socially, mentally, and spiritually—to accomplish the required activi- ties effectively—on the ground—to create a healthy world. Nurses are key in mobilizing new approaches in health education and health-care delivery in all areas of the profes- sion and society as a whole. Theories, solu- tions, and evidence-based practice protocols can be shared and implemented around the world through dialogues, the Internet, and publications. We are challenged to “act locally and think globally” and to address ways to create healthy environments (B. M. Dossey, 2013; B. M. Dossey et al., 2005). For example, we can ad- dress global warming in our personal habits at home as well as in our workplace (using green products, turning off lights when not in the room, using water efficiently) and simultane- ously address our personal health and the health of the communities where we live (Na- tional Prevention Council, 2011). In 2000, the United Nations Millennium Goals were rec- ommended to articulate clearly how to achieve health and decrease health disparities (United Nations, 2000). As we expand our awareness of individual and collective states of healing consciousness and integral dialogues, we are able to explore integral ways of knowing, doing, and being. We can unite 35 million nurses and midwives and concerned citizens through the Internet to create a healthy world through many endeavors such as the Nightingale Declaration (B. M. Dossey et al., 2013; NIGH, 2013; WHO, 2009). You are invited to sign the Nightingale Declaration at www.nightin- Our Nightingale nursing legacy, as discussed in the next section, is foun- dational to the theory of integral nursing and to understanding our important roles as 21st-century nurses. Philosophical Foundation: Florence Nightingale’s Legacy Florence Nightingale, the philosophical founder of modern secular nursing and the first recognized nurse theorist, was an integralist. Her worldview focused on the individual and the collective, the inner and outer, and human and nonhuman concerns. She identified envi- ronmental determinants (clean air, water, food, houses, etc.) and social determinants (poverty, education, family relationships, employ- ment)—local to global. She also experienced and recorded her personal understanding of the connection with the Divine—that is, awareness that something greater than she, the Divine, was present in all aspects of her life. Nightingale’s work was social action that clearly articulated the science and art of an in- tegral worldview for nursing, health care, and humankind. Her social action was also sacred activism (Harvey, 2007), the fusion of the deepest spiritual knowledge with radical action in the world. Nightingale was ahead of her time; her dedicated and focused 50 years of work and service still inform and affect the nurs- ing profession and our global mission of health and healing. In the 1880s, Nightingale began to write in letters that it would take 100 to 150 years before sufficiently educated and ex- perienced nurses would arrive to change the health-care system. We are that generation of 21st-century Nightingales who can transform health care and carry forth her vision to create a healthy world (B. M. Dossey, 2013; B. M. Dossey, Luck, & Schaub, 2015; Beck, Dossey, & Rushton, 2011; McDonald, 2001–2012; Mittelman et al., 2010). Personal Journey Developing the Theory of Integral Nursing As a young nurse attending my first nursing theory conference in the late 1960s, I was CHAPTER 13 • Barbara Dossey’s Theory of Integral Nursing 209 3312_Ch13_207-234 26/12/14 5:53 PM Page 209 captivated by nursing theory and the eloquent visionary words of these theorists as they spoke about the science and art of nursing. This opened my heart and mind to explo- ration and to the necessity to understand and use nursing theory. Thus, I began my profes- sional commitment to address theory in all endeavors as well as to increase my knowl- edge of other disciplines that could inform a deeper understanding about the human expe- rience. I realized that nursing was not either “science” or “art,” but both. From the begin- ning of my critical care and cardiovascular nursing focus, I learned how to combine sci- ence and technology with the art of nursing. For example, for patients with severe pain after an acute myocardial infarction, I gave pain medication while simultaneously guid- ing them in a relaxation or imagery practice to enhance relaxation and release anxiety. I also experienced a difference in myself when I used this approach to combine the science and art of nursing. In the late 1960s, I began to study and attend workshops on holistic and mind– body-related ideas and to read in other disci- plines, such as systems theory, quantum physics, integral theory, Eastern and Western philoso- phy, and mysticism. I was reading theorists from nursing and other disciplines that in- formed my knowing, doing, and being in car- ing, healing, and holism. My husband, a physician of internal medicine who was caring for critically ill patients and their families, was with me at the beginning of this journey of dis- covery. As we cared for patients and families— some of our greatest teachers—we reflected on how to blend the art of caring–healing modal- ities with the science of technology and tradi- tional modalities. I discussed these ideas with a critical care and cardiovascular nursing soul- mate, Cathie Guzzetta. We began writing teaching protocols and presenting in critical care courses as well as writing textbooks and articles with other contributors. My husband and I both had health chal- lenges—mine was postcorneal transplant re- jection, and my husband’s challenge was blinding migraine headaches. We both began to take courses related to body–mind–spirit therapies (biofeedback, relaxation, imagery, music, meditation, and other reflective prac- tices and touch therapies) and began to in- corporate them into our daily lives. As we strengthened our capacities with self-care and self-regulation modalities, our personal and professional philosophies and clinical practices changed. As we integrated these modalities into our own lives, we began to introduce them into the traditional health-care setting that today is called integrative and integral health care. As a founding member in 1980 of the American Holistic Nurses Association (AHNA) and with my AHNA colleagues, our collective holistic nursing endeavors were recognized as the specialty of holistic nursing by the American Nurses Association (ANA) in November 2006 (AHNA & ANA, 2007, 2013). Holistic nurs- ing can now be expanded by using an integral lens. An integral perspective can also further our endeavors in national health-care reform and the implementation of Healthy People 2020 as a national strategy. The emerging movement for professional nurse coaching (Dossey, Luck, & Schaub, 2015; Hess et al., 2013) and strategies to increase patient engagement (Weil, 2013) can be strengthened when considered from an integral perspective. Beginning in 1992 in London, my Florence Nightingale primary, historical research of studying and synthesizing her original letters, army and public health documents, manu- scripts, and books, deepened my understanding of her relevance for nursing. My professional mission now is to articulate and use the inte- gral process and integral worldview in my nursing, integrative nurse coaching, and inter- professional endeavors, and to explore rituals of healing with many. My sustained nursing career focus with nursing colleagues on whole- ness, unity, and healing and my Florence Nightingale scholarship have resulted in numerous protocols and standards for practice, education, research, and health-care policy. My integral focus since 2000 and my many conversations with Ken Wilber and the inte- gral team and other interdisciplinary integral colleagues has led to my development of the theory of integral nursing. 210 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm 3312_Ch13_207-234 26/12/14 5:53 PM Page 210 Theory of Integral Nursing Developmental Process and Intentions The theory of integral nursing advances the evolutionary growth processes, stages, and lev- els of human development and consciousness toward a comprehensive integral philosophy and understanding. It can assist nurses to map human capacities that begin with healing and evolve to the transpersonal self in connection with the Divine, however defined or identified, in their endeavors to create a healthy world. The theory of integral nursing has three intentions: (1) to embrace the unitary whole person and the complexity of the nursing profession and health care; (2) to explore the direct application of an integral process and in- tegral worldview that includes four perspec- tives of realities—the individual interior and exterior and the collective interior and exterior; and (3) to expand nurses’ capacities as 21st- century Nightingales, health diplomats, and integral nurse coaches for integral health— local to global. Integral Foundation and the Integral Model The theory of integral nursing adapts the work of Ken Wilber, one of the most significant American new-paradigm philosophers, to strengthen the central concept of healing. His elegant, four-quadrant model was developed over 35 years. In the eight-volume The Collected Works of Ken Wilber (Wilber, 1999, 2000a), Wilber synthesizes the best known and most influential thinkers to show that no individual or discipline can determine reality or lay claim to all the answers. Many concepts within the integral nursing theory have been researched or are in formative stages of development within integral medicine, integral health-care administration, integral business, integral health-care education, and integral psy- chotherapy (Wilber, 2000a, 2000b, 2005a, 2005b, 2006). Within the nursing profession, other nurses are exploring integral and related theories and ideas. When nurses use an inte- gral lens, they are more likely to expand nurses’ roles in transdisciplinary dialogues and to ex- plore commonalities and differences across disciplines (J. Baye, personal communication, 2007; Clark, 2006; Fiandt et al., 2003; Frisch, 2013; Jarrin, 2007; Quinn, Smith, Ritten- baugh, Swanson, & Watson, 2003; Watson, 2005; Zahourek, 2013). Content, Context, and Process To present the theory of integral nursing, Bar- bara Barnum’s (2005) framework to critique a nursing theory—content, context, and process— provides an organizing structure that is most useful. The philosophical assumptions of the theory of integral nursing are as follows: 1. An integral understanding recognizes the individual as an energy field con- nected to the energy fields of others and the wholeness of humanity; the world is open, dynamic, interdependent, fluid, and continuously interacting with chang- ing variables that can lead to greater complexity and order. 2. An integral worldview is a comprehensive way to organize multiple phenomena of human experience from four perspectives of reality: (a) individual interior (subjective, personal); (b) individual exterior (objective, behavioral); (c) collective interior (interob- jective, cultural); and (d) collective exterior (interobjective, systems/structures). 3. Healing is a process inherent in all living things; it may occur with curing of symptoms, but it is not synonymous with curing. 4. Integral health is experienced by a per- son as wholeness with development toward personal growth and expanding states of consciousness to deeper levels of personal and collective understanding of one’s physical, mental, emotional, social, spiritual, cultural, environmental dimensions. 5. Integral nursing is founded on an integral worldview using integral language and knowledge that integrates integral life practices and skills each day. 6. Integral nursing is broadly defined to include knowledge development and all ways of knowing that also recognizes the emergent patterns of not knowing. CHAPTER 13 • Barbara Dossey’s Theory of Integral Nursing 211 3312_Ch13_207-234 26/12/14 5:53 PM Page 211 7. An integral nurse is an instrument in the healing process and facilitates healing through her or his knowing, doing, and being. 8. Integral nursing is applicable in practice, education, research, and health-care policy. Content Components Content of a nursing theory includes the subject matter and building blocks that give a theory its form. It comprises the stable elements that are acted on or that do the acting. In the theory of integral nursing, the subject matter and building blocks are (1) healing, (2) the meta- paradigm of nursing, (3) patterns of knowing, (4) the four quadrants that are adapted from Wilber’s (2000a) integral theory (individual in- terior [subjective, personal/intentional], indi- vidual exterior [objective, behavioral], collective interior [intersubjective, cultural], and collec- tive exterior [interobjective, systems/struc- tures]), and (5) Wilber’s “all quadrants, all levels, all lines” (Wilber, 2000a, 2006). Content Component 1: Healing. The first content component in a theory of integral nursing is healing, illustrated as a diamond shape in Figure 13-1A. The theory of integral nursing enfolds from the central core concept of healing. Healing includes knowing, doing, and being, and is a lifelong journey and process of bringing together aspects of oneself at deeper levels of harmony and inner knowing leading toward integration. This healing process places us in a space to face our fears, to seek and express self in its fullness where we can learn to trust life, creativity, passion, and love. Each aspect of healing has equal impor- tance and value that leads to more complex levels of understanding and meaning. Healing capacities are inherent in all living things. No one can take healing away from life; however, we often get “stuck” in our healing or forget that we possess it due to life’s contin- uing challenges and perceived barriers to wholeness. Healing can take place at all levels of human experience, but it may not occur si- multaneously in every realm. In truth, healing will most likely not occur simultaneously or even in all realms, and yet the person may still 212 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm Healing Fig 13 • 1 A, Healing. Source: Copyright © Barbara Dossey, 2007. have a perception of healing having occurred (B. M. Dossey, 2013; Gaydos, 2004, 2005). Healing embraces the individual as an en- ergy field that is connected with the energy fields of all humanity and the world. Healing is transformed when we consider four perspectives of reality in any moment: (1) the individual interior (personal/intentional), (2) individual exterior (physiology/behavioral), (3) collective interior (shared/cultural), and (4) collective ex- terior (systems/structures). Using our reflective integral lens of these four perspectives of reality assists us to more likely experience a unitary grasp within the complexity that emerges in healing. Healing is not predictable; it may occur with curing of symptoms, but it is not synonymous with curing. Curing may not always occur, but the potential for healing is always present even until one’s last breath. Intention and intention- ality are key factors in healing (Barnum, 2004; Engebretson, 1998; Zahourek, 2004; 2013). Intention is the conscious determination to do a specific thing or to act in a specific manner; it is the mental state of being committed to, plan- ning to, or trying to perform an action. Inten- tionality is the quality of an intentionally performed action. Content Component 2: Metaparadigm of Nursing. The second content component in the theory of integral nursing is the recognition of the metaparadigm in a nurse theory: nurse, person/s, health, and environment (society; Fig. 13-1B) (Fawcett, Watson, Neuman, Walker, & Fitzpatrick, 2001). Starting with healing at the center, a Venn diagram sur- rounds healing and implies the interrelation, interdependence, and effect of these domains as each informs and influences the others; a change in one will create a degree(s) of change in the other(s), thus affecting healing at many 3312_Ch13_207-234 26/12/14 5:53 PM Page 212 CHAPTER 13 • Barbara Dossey’s Theory of Integral Nursing 213 levels. These concepts are important to the the- ory of integral nursing because they are en- compassed within the quadrants of human experience as seen in Content Component 4. An integral nurse is defined as a 21st- century Nightingale. Using terms coined by Patricia Hinton Walker, PhD, RN, FAAN (personal communication, May 15, 2007), nurses’ endeavors of social action and sacred activism engage “nurses as health diplomats” and “integral nurse coaches” that are “coaching for integral health.” As nurses strive to be in- tegrally informed, they are more likely to move to a deeper experience of a connection with the Divine or Infinite, however defined or identi- fied. Integral nursing provides a comprehensive way to organize multiple phenomena of human experience in the four perspectives of reality as previously described. The nurse is an instrument in the healing process, bringing her or his whole self into relationship to the whole self of another or a group of significant others and thus reinforcing the meaning and experi- ence of oneness and unity. A person(s) is defined as an individual (patient/client, family members, significant others) who is engaged with a nurse who is re- spectful of this person’s subjective experiences about health, health beliefs, values, sexual orientation, and personal preferences. It also Environment (society) Person(s) HealthNurse Healing Fig 13 • 1 B, Healing and Meta-Paradigm of Nursing. Source: Copyright © Barbara Dossey, 2007. includes an individual nurse who interacts with a nursing colleague, other interprofessional health-care team members, or a group of com- munity members or other groups. Integral health is the process through which we reshape basic assumptions and worldviews about well-being and see death as a natural process of the cycle of life. Integral health may be symbolically seen as a jewel with many facets that is reflected as a “bright gem” or a “rough stone” depending on one’s situation and personal growth that influence states of health, health beliefs, and values (Gaydos, 2004). The jewel may also be seen as a spiral or as a symbol of transformation to higher states of consciousness to more fully under- stand the essential nature of our beingness as energy fields and expressions of wholeness (Newman, 2003). This includes evolving one’s state of consciousness to higher levels of per- sonal and collective understanding of one’s physical, mental, emotional, social, and spiri- tual dimensions. It acknowledges the individ- ual’s interior and exterior experiences and the shared collective interior and exterior experi- ences with others, where authentic power is recognized within each person. Disease and illness at the physical level may manifest for many reasons and variables. It is important not to equate physical health, mental health, and spiritual health, as they are not the same thing. They are facets of the whole jewel of integral health. An integral environment(s) has both interior and exterior aspects (Samueli Institute, 2013). The interior environment includes the individ- ual’s mental, emotional, and spiritual dimen- sions, including feelings and meanings as well as the brain and its components that constitute the internal aspect of the exterior self. It in- cludes patterns that may not be understood or may manifest related to various situations or relationships. These patterns may be related to living and nonliving people and things—for example, a deceased relative, a pet, lost pre- cious object(s) that surface through flashes of memories stimulated by a current situation (e.g., a touch may bring forth past memories of abuse, suffering). Insights gained through 3312_Ch13_207-234 26/12/14 5:53 PM Page 213 dreams and other reflective practices that re- veal symbols, images, and other connections also influence one’s internal environment. 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 levels that are ex- panded later in Content Component 4. Content Component 3: Patterns of Knowing. The third content component in a theory of in- tegral nursing is the recognition of the patterns of knowing in nursing (Fig. 13-1C). These six patterns of knowing are personal, empirics, aes- thetics, ethics, not knowing, and sociopolitical. As a way to organize nursing knowledge, Carper (1978) in her now-classic 1978 article identified the four fundamental patterns of knowing (personal, empirics, ethics, aesthetics) followed by the introduction of the pattern of not knowing by Munhall (1993) and the pat- tern of sociopolitical knowing by White (1995). All of these patterns continue to be refined and reframed with new applications and interpretations (Averill & Clements, 2007; Barnum, 2003; Burkhardt & Najai- Jacobson, 2013; Chinn & Kramer, 2010; Cowling, 2004; Fawcett et al., 2001; Halifax, Dossey, & Rushton, 2007; Koerner, 2011; McElligott, 2013; McKivergin, 2008; Meleis, 2012; Newman, 2003). These patterns of knowing assist nurses in bringing themselves into a full presence in the moment, integrating aesthetics with science, and developing the flow of ethical experience with thinking and acting. Personal knowing is the nurse’s dynamic process of being whole that focuses on the syn- thesis 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. Empirical knowing is 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 indi- cators are accessed through the known senses that are subject to direct observation, measure- ment, and verification. Aesthetic knowing is the art of nursing that focuses on how to explore experiences and meaning in life with self or another that in- cludes authentic presence, the nurse as a facil- itator of healing, and the artfulness of a healing environment. It calls forth resources and inner strengths from the nurse to be a facilitator in the healing process. It is the integration and 214 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm Not knowing Sociopolitical EmpiricsPersonal Aesthetics Ethics Healing Fig 13 • 1 C, Healing and patterns of knowing in nurs- ing. Source: Adapted from B. Carper (1978). Copyright © Barbara Dossey, 2007. 3312_Ch13_207-234 26/12/14 5:53 PM Page 214 expression of all the other patterns of knowing in nursing praxis. By combining knowledge, experience, instinct, and intuition, the nurse connects with a patient/client to explore the meaning of a situation about the human expe- riences of life, health, illness, and death. Ethical knowing is 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 in- tersecting with legally prescribed duties. It emphasizes respect for the person, the family, and the community that encourages connect- edness and relationships that enhance atten- tiveness, responsiveness, communication, and moral action. Not knowing is the capacity to use healing presence, to be open spontaneously to the mo- ment with no preconceived answers or goals to be obtained. It engages authenticity, mindful- ness, openness, receptivity, surprise, mystery, and discovery with self and others in the sub- jective space and the intersubjective space that allows for new solutions, possibilities, and insights to emerge. Sociopolitical knowing addresses the impor- tant contextual variables of social, economic, geographic, cultural, political, historical, and other key factors in theoretical, evidence-based practice and research. This pattern includes in- formed critique and social justice for the voices of the underserved in all areas of society along with protocols to reduce health disparities. [Note: Because all patterns of knowing in the theory of integral nursing are superimposed on Wilber’s four quadrants, these patterns will be primarily positioned as seen; however, they may also appear in one, several, or all quadrants and inform all other quadrants.] Content Component 4: Quadrants. The fourth content component in the theory of in- tegral nursing examines four perspectives for all known aspects of reality; expressed another way, it is how we look at and/or describe any- thing (Fig. 13-1D). Healing, the core concept in the theory of integral nursing, is trans- formed by adapting Ken Wilber’s (2000b) in- tegral model. Starting with healing at the center to represent our integral nursing philos- ophy, human capacities, and global mission, dotted horizontal and vertical lines illustrate that each quadrant can be understood as per- meable and porous, with each quadrant’s expe- rience(s) integrally informing and empowering all other quadrant experiences. Within each quadrant, we see “I,” “We,” “It,” and “Its” to represent four perspectives of realities that are already part of our everyday language and awareness. Virtually all human languages use first- person, second-person, and third-person pro- nouns to indicate three basic dimensions of reality (Wilber, 2000b). First-person is “the person who is speaking,” which includes pro- nouns like I, me, mine in the singular, and we, us, ours in the plural (Wilber, 2000b, 2005a). Second-person means “the person who is spo- ken to,” which includes pronouns like you and yours. Third-person is “the person or thing being spoken about,” such as she, her, he, him, or they, it, and its. For example, if I am speak- ing about my new car, “I” am first-person, and “you” are second-person, and the new car is third-person. If you and I are communicating, the word “we” is used to indicate that we un- derstand each other. “We” is technically first CHAPTER 13 • Barbara Dossey’s Theory of Integral Nursing 215 Q u alitative Q ua nt it at iv e M easureable I n te rp re tiv e It objective biological behavioral Its interobjective systems structures I subjective personal intentional We intersubjective cultural shared values Healing Fig 13 • 1 D, Healing and the four quadrants (I, We, It, Its). Source: Adapted with permission from Ken Wilber. Copyright © Barbara Dossey, 2007. 3312_Ch13_207-234 26/12/14 5:53 PM Page 215 person plural, but if you and I are communi- cating, then you are second person and my first person is part of this extraordinary “we.” So we represent first-, second- and third-person as: “I,” “We,” “It” and “Its.” These four quadrants show the four primary dimensions or perspectives of how we experience the world; these are represented graphically as the upper-left (UL), upper-right (UR), lower- left (LL), and lower-right (LR) quadrants. It is simply the inside and the outside of an individual and the inside and outside of the collective. It includes expanded states of consciousness where one feels a connection with the Divine and the vastness of the universe, the infinite that is be- yond words. Integral nursing considers all of these areas in our personal development and any area of practice, education, research, and health- care policy—local to global. Each quadrant, which is intricately linked and bound to each other, carries its own truths and language (Wilber, 2000b). The specifics of the quadrants are provided in Table 13-1. • Upper-left (UL). In this “I” space (subjec- tive), the world of the individual’s interior experiences can be found. These are the thoughts, emotions, memories, perceptions, immediate sensations, and states of mind (imagination, fears, feelings, beliefs, values, esteem, cognitive capacity, emotional matu- rity, moral development, and spiritual ma- turity). Integral nursing starts with “I.” (Note: When working with various cultures, it is important to remember that within many cultures, the “I” comes last or is never verbal- ized or recognized as the focus is on the “We” and relationships. However, this development of the “I” and an awareness of one’s personal value, beliefs, and ethics is critical.) 216 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm Upper left Upper right Individual interior (intentional/personal) “I” space includes self and consciousness (self-care, fears, feelings, beliefs, values, esteem, cognitive capacity, emotional maturity, moral development, spiritual matu- rity, personal communication skills, etc.) I We Collective interior (cultural/shared) “We” space includes the relationship to each other and the culture and worldview (shared understanding, shared vision, shared meaning, shared leadership and other values, integral dialogues and communication/morale, etc.) Lower left Source: Ken Wilber, Integral Psychology: Consciousness, Spirit, Psychology, Therapy (Boston: Shambhala, 2000). Table adapted with permission from Ken Wilber. Copyright © by Barbara M. Dossey, 2007. Table 13 • 1 Integral Model and Quadrants Individual exterior (behavioral/biological) “It” space that includes brain and organisms (physiology, pathophysiology [cells, mole- cules, limbic system, neurotransmitters, phys- ical sensations], biochemistry, chemistry, physics, behaviors [skill development in health, nutrition, exercise, etc.]) It Its Collective exterior (systems/structures) “Its” space includes the relation to social sys- tems and environment, organizational struc- tures and systems [in healthcare—financial and billing systems], educational systems, in- fomation technology, mechanical structures and transportation, regulatory structures [en- vironmental and governmental policies, etc.] Lower right • Subjective • Interpretive • Qualitative • Objective • Observable • Quantitative 3312_Ch13_207-234 26/12/14 5:53 PM Page 216 • Upper-right (UR). In this “It” (objective) space, the world of the individual’s exterior can be found. This includes the material body (physiology [cells, molecules, neuro- transmitters, limbic system], biochemistry, chemistry, physics), integral patient care plans, skill development (health, fitness, ex- ercise, nutrition, etc.), behaviors, leadership skills, and integral life practices and any- thing that we can touch or observe scientifi- cally in time and space. Integral nursing with our nursing colleagues and health-care team members includes the “It” of new be- haviors, integral assessment and care plans, leadership, and skills development. • Lower-left (LL). In this “We” (intersubjec- tive) space resides the interior collective of how we can come together to share our cul- tural background, stories, values, meanings, vision, language, relationships, and to form partnerships to achieve a healing mission. This can decrease our fragmentation and enhance collaborative practice and deep dialogue around things that really matter. Integral nursing is built on “We.” • Lower-right (LR). In this “Its” space (in- terobjective) the world of the collective, exterior things can be found. This includes social systems/structures, networks, organi- zational structures, and systems (including financial and billing systems in health care), information technology, regulatory struc- tures (environmental and governmental policies, etc.), any aspect of the technologi- cal environment, and the natural world. Integral nursing identifies the “Its” in the structure that can be enhanced to create more integral awareness and integral partnerships to achieve health and healing—local to global. We see that the left-hand quadrants (UL, LL) describe aspects of reality as interpretive and qualitative (see Fig. 13-1D). In contrast, the right-hand quadrants (UR, LR) describe aspects of reality as measurable and quantita- tive. When we fail to consider these subjective, intersubjective, objective, and interobjective aspects of reality, our endeavors and initiatives become fragmented and narrow, inhibiting our ability to reach meaningful outcomes and goals. The four quadrants are a result of the differences and similarities in Wilber’s inves- tigation of the many aspects of identified real- ity. The model describes the territory of our own awareness that is already present within us and an awareness of things outside of us. These quadrants help us connect the dots of the actual process to more deeply understand who we are, and how we are related to others and all things. Content Component 5: AQAL (All Quad- rants, All Levels). The fifth content component in the theory of integral nursing is the explo- ration of Wilber’s “all quadrants, all levels, all lines, all states, all types” or A-Q-A-L (pro- nounced ah-qwul), as seen in Figure 13-1E. These levels, lines, states, and types are impor- tant elements of any comprehensive map of reality. The integral model simply assists us in further articulating and connecting all areas, awareness, and depth in these four quadrants. CHAPTER 13 • Barbara Dossey’s Theory of Integral Nursing 217 Fig 13 • 1 E, Theory of integral nursing (healing, metaparadigm, patterns of knowing in nursing, four quadrants, and AQAL). Source: Adapted with permission from Ken Wilber. Copyright © Barbara Dossey, 2007. Healing Spirit Mind Body Casual Subtle Gross Me Us All of us Group Nation Global 3312_Ch13_207-234 26/12/14 5:53 PM Page 217 Briefly stated, these levels, lines, states, and types are as follows: • Levels: Levels of development that become permanent with growth and maturity (e.g., cognitive, relational, psychosocial, physical, mental, emotional, spiritual) that represent a level of increased organization or level of complexity. These levels are also referred to as waves and stages of development. Each indi- vidual possesses both the masculine and the feminine voice or energy. One is not superior to the other; they are two equivalent types at each level of consciousness and development. • Lines: Developmental areas that are known as multiple intelligences (e.g., cognitive line [awareness of what is]; interpersonal line [how I relate socially to others]; emo- tional/affective line [the full spectrum of emotions]; moral line [awareness of what should be]; needs line [Maslow’s hierarchy of needs]; aesthetics line [self-expression of art, beauty, and full meaning]; self-identity line [who am I?]; spiritual line [where “spirit” is viewed as its own line of unfold- ing, and not just as ground and highest state], and values line [what a person considers most important; studied by Clare Graves and brought forward by Don Beck, 2007, in his spiral dynamics integral, which is beyond the scope of this chapter]). • States: Temporary changing forms of aware- ness (e.g., waking, dreaming, deep sleep, altered meditative states [such as occurs in meditation, yoga, contemplative prayer, etc.]; altered states [due to mood swings, physiol- ogy 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.]. • Types: Differences in personality and masculine and feminine expressions and development (e.g., cultural creative types, personality types, enneagram). This part of the theory of integral nursing (see Fig. 13-1E) starts with healing at the center surrounded by three increasing concen- tric circles with dotted lines of the four quad- rants. This part of the integral theory moves to higher orders of complexity through personal growth, development, expanded stages of con- sciousness (permanent and actual milestones of growth and development), and evolution. These levels or stages of development can also be ex- pressed as being self-absorbed (such as a child or infant) to ethnocentric (centers on group, community, tribe, nation) to world-centric (care and concern for all peoples regardless of race or national origin, color, sex, gender, sexual orien- tation, creed, and to the global level). In the UL, the “I” space, the emphasis is on the unfolding “awareness” from body to mind to spirit. Each increasing circle includes the lower as it moves to the higher level. In the UR, the “It” space, is the external of the individual. Every state of consciousness has a felt energetic component that is expressed from the wisdom traditions as three recognized bodies: gross, subtle, and causal (Wilber, 2000b, 2005). We can think of these three bodies as the increasing capacities of a person toward higher levels of consciousness. Each level is a specific vehicle that provides the actual support for any state of awareness. The gross body is the individual physical, material, sen- sorimotor body that we experience in our daily activities. The subtle body occurs when we are not aware of the gross body of dense matter, but of a shifting to a light, energy, emotional feelings, and fluid and flowing images. Exam- ples might be in our shift during a dream, dur- ing different types of bodywork, walks in nature, or other experiences that move us to a profound state of bliss. The causal body is the body of the infinite that is beyond space and time. Causal also includes nonlocality in which minds of individuals are not separate in space and time (L. Dossey, 1989; 2013). When this is applied to consciousness, separate minds be- have as if they are linked, regardless of how far apart in space and time they may be. Nonlocal consciousness may underlie phenomena such as remote healing, intercessory prayer, telepa- thy, premonitions, as well as so-called miracles. Nonlocality also implies that the soul does not 218 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm 3312_Ch13_207-234 26/12/14 5:53 PM Page 218 die with the death of the physical body—hence, immortality forms some dimension of con- sciousness. Nonlocality can also be both upper and lower quadrant phenomena. The LL, the “We” space, is the interior col- lective dimension of individuals that come to- gether. The concentric circles from the center outward represent increasing levels of com- plexity of our relational aspect of shared cul- tural values, as this is where teamwork and the interdisciplinary and transpersonal disciplinary development occur. The inner circle represents the individual labeled as me; the second circle represents a larger group labeled us; the third circle is labeled as all of us to represent the largest group consciousness that expands to all people. These last two circles may include peo- ple but also animals, nature, and nonliving things that are important to individuals. The LR, the “Its” space, the exterior social system and structures of the collective, is rep- resented with concentric circles. An example within the inner circle might be a group of health-care professionals in a hospital clinic or department or the complex hospital system and structure. The middle circle expands in in- creased complexity to include a nation; the third concentric circle represents even greater increased complexity to the global level where the health of all humanity and the world are considered. It is also helpful to emphasize that these groupings are the physical dynamics such as the working structure of a group of health care professionals versus the relational aspect that is a LL aspect, and the physical and tech- nical structural of a hospital or a clinic. Integral nurses strive to integrate concepts and practices related to body, mind, and spirit (the all-levels) in self, culture, and nature (“all quadrants” part). The individual interior and exterior—“I” and “It”—as well as the collective interior and exterior—“We” and “Its”—must be developed, valued, and integrated into all aspects of culture and society. The AQAL in- tegral approach suggests that we consciously touch all of these areas and do so in relation to self, to others, and the natural world. Yet to be integrally informed does not mean that we have to master all of these areas; we just need to be aware of them and choose to integrate integral awareness and integral practices. Be- cause these areas are already part of our being- in-the-world and cannot be imposed from the outside (they are part of our makeup from the inside), our challenge is to identify specific areas for development and find new ways to deepen our daily integral life practices. Structure The structure of the theory of integral nursing is shown in Figure 13-1F. All content compo- nents are represented together as an overlay that creates a mandala to symbolize wholeness. Healing is placed at the center, then the meta- paradigm of nursing, the patterns of knowing, the four quadrants, and all quadrants and all levels of growth, development, and evolution. [Note: Although the patterns of knowing are su- perimposed as they are in the various quadrants, they can also fit into other quadrants.] Using the language of Ken Wilber (2000b) and Don Beck (2007) and his spiral dynamics integral, individuals move through primitive, infantile consciousness to an integrated lan- guage that is considered first-tier thinking. As they move up the spiral of growth, develop- ment, and evolution and expand their integral worldview and integral consciousness, they move into what is second-tier thinking and par- ticipation. This is a radical leap into holistic, systemic, and integral modes of consciousness. Wilber also expands to a third-tier of stages of consciousness that addresses an even deeper level of transpersonal understanding that is be- yond the scope of this chapter (Wilber, 2006). Context Context in a nursing theory is the environment in which nursing acts occur and the nature of the world of nursing. In an integral nursing environment, the nurse strives to be an inte- gralist, which means that she or he strives to be integrally informed and is challenged to fur- ther develop an integral worldview, integral life practices, and integral capacities, behaviors, and skills. The term nurse healer is used to de- scribe that a nurse is an instrument in the heal- ing process and a major part of the external CHAPTER 13 • Barbara Dossey’s Theory of Integral Nursing 219 3312_Ch13_207-234 26/12/14 5:53 PM Page 219 healing environment of a patient or family. An integral nurse values, articulates, and models the integral process and integral worldview and integral life practices and self-care. Nurses as- sist and facilitate the individual person/s (client/patient, family, and coworkers) to ac- cess their own healing process and potentials; they do not do the actual healing. An integral nurse recognizes herself or himself as a healing environment interacting with a person, family, or colleague in a being with rather than always doing to or doing for another person, and enters into a shared experience (or field of conscious- ness) that promotes healing potentials and an experience of well-being. Relationship-centered care is valued and inte- grated as a model of caregiving that is based in a vision of community where three types of rela- tionships are identified: (1) patient–practitioner relationship, (2) community–practitioner rela- tionship, and (3) practitioner–practitioner rela- tionship (Tresoli, 1994). Relationship-based care 220 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm Fig 13 • 1 F, Healing and AQAL (all quadrants, all levels). Source: Adapted with permission from Ken Wilber. Copyright © Barbara Dossey, 2007. Spirit Mind Body Casual Subtle Gross Me Us All of us Group Nation Global Environment (society) Person(s) Health Healing Nurse Q u alitative Q ua n ti ta ti ve M easu reab le In te rp re tiv e Not knowing Sociopolitical EmpiricsPersonal Aesthetics Ethics It objective biological behavioral Its interobjective systems structures I subjective personal intentional We intersubjective cultural shared values 3312_Ch13_207-234 26/12/14 5:53 PM Page 220 is also valued as it provides the map and high- lights the most direct routes to achieve the high- est levels of care and serve to patients and families (Koloroutis, 2004). Process Process in a nursing theory is the method by which the theory works. An integral healing process contains both nurse processes and pa- tient/family and health-care worker processes (individual interior and individual exterior), and collective healing processes of individuals and of systems/structures (interior and exte- rior). This is the understanding of the unitary whole person interacting in mutual process with the environment. Applications to Practice The theory of integral nursing can guide nurs- ing practice and strengthen our 21st-century nursing endeavors. It considers equally impor- tant data, meanings, and experiences from the personal interior, the collective interior, the individual exterior, and the collective exterior. Nursing and health care are fragmented. Col- laborative practice has not been realized because only portions of reality are seen as being valid within health care and society. The nursing profession asks nurses to wrap around “all of life” on so many levels with self and others that we can often feel overwhelmed. So how do we get a handle on “all of life?” The following questions always arise: How can overworked nurses and student nurses use an integral approach or apply the theory of integral nursing? How do we connect the complexity of so much information that arises in clinical prac- tice? The answer is to start right now. Remem- ber that healing, the core concept in this theory, is the innate natural phenomenon that comes from within a person and reflects the indivisible wholeness, the interconnectedness of all peo- ple, all things. The practice situation that fol- lows addresses these questions. Imagine that you are caring for a very ill pa- tient who needs to be transported to the radi- ology department for a procedure. The current transportation protocol between the unit and the radiology department lacks continuity. In this moment, shift your feelings and your inte- rior awareness (and believe it!) to “I am doing the best I can in this moment” and “I have all the time needed to take a deep breath and relax my tight chest and shoulder muscles.” This helps you connect these four perspectives as fol- lows: (1) the interior self (caring for yourself in this moment), (2) the exterior self (using a re- search-based relaxation and imagery integral practice to change your physiology), (3) the self in relationship to others (shifting your aware- ness creates another way of being with your patient and the radiology team member), and (4) the relationship to the exterior collective of systems/structures (considering how to work with the radiology team and department to im- prove a transportation procedure in the hospital). Professional burnout is high, with many nurses disheartened. Self-care is a low priority; time is not given or valued within practice set- tings to address basic self-care such as short breaks for personal needs and meals. This is worsened by short staffing and overtime. Also, we do not consistently listen to the pain and suffering that nurses experience within the pro- fession, nor do we consistently listen to the pain and suffering of the patient and family members or our colleagues (Dossey, Luck, & Schaub, 2015; McEligott, 2013). Often there is a lack of respect for each other, with verbal abuse oc- curring on many levels in the workplace. Nurse retention and a global nursing short- age are at a crisis level throughout the world (International Council of Nurses, 2004). As nurses deepen their understanding related to an integral process and integral worldview and use daily integral life practices, we will more consistently be healthy and model health and understand the complexities within healing and society. This enhances nurses’ capacities for empowerment, leadership, and acting as change agents for a healthy world. An integral worldview and approach can help each nurse and student nurse increase her or his self-awareness, as well as the awareness of how self affects others—that is the patient, family, colleagues, and the workplace and community. As the nurse discovers her or his own innate healing from within, she or he is able to model self-care and how to release CHAPTER 13 • Barbara Dossey’s Theory of Integral Nursing 221 3312_Ch13_207-234 26/12/14 5:53 PM Page 221 stress, anxiety, and fear that manifest each day in this human journey. All nursing curricula can be mapped in the integral quadrants so that students learn to think integrally about how these four perspectives create the whole (Clark 2006; Hess, 2013). Meaning of the Theory of Integral Nursing for Practice A key concept in the theory of integral nursing is meaning, which addresses that which is in- dicated, referred to, or signified (L. Dossey, 2003). Philosophical meaning is related to one’s view of reality and the symbolic connections that can be grasped by reason. Psychological meaning is related to one’s consciousness, in- tuition, and insight. Spiritual meaning is re- lated to how one deepens personal experience of a connection with the Divine, to feel a sense of oneness, belonging and feeling of connec- tion in life. In the next section, four integral nursing principles are discussed that provide further insight into how the theory of integral nursing guides nursing practice and meaning in practice. See Figure 13-1F for specifics for each principle. Integral Nursing Principle 1: Nursing Starts With “I” Integral Nursing Principle 1 recognizes the in- terior individual “I” (subjective) space. Each of us must value the importance of exploring one’s health and well-being starting with our own personal work on many levels. In this “I” space, integral self-care is valued, which means that integral reflective practices become part of and can be transformative in our developmen- tal process. This includes how each of us con- tinually addresses our own stress, burnout, suffering, and soul pain. It can assist us to understand the necessity of personal healing and self-care related to nursing as art where we develop qualities of nursing presence and inner reflection. Nurse presence is also used and is a way of approaching a person in a way that respects and honors the person’s essence; it is relating in a way that reflects a quality of “being with” and “in collaboration with.” Our own inner work also helps us to hold deeply a conscious awareness of our own roles in creating a healthy world. We recognize the importance of addressing one’s own shadow as described by Jung (1981). This is a composite of personal characteristics and potentials that have been denied expression in life and of which a person is unaware; the ego denies the characteristics because they are in conflict and incompatible with a person’s chosen conscious attitude. Mindfulness is the practice of giving atten- tion to what is happening in the present mo- ment such as our thoughts, feelings, emotions, and sensations. To cultivate the capacity of mindfulness practice, one may include mind- fulness meditation practice, centering prayer, and other reflective practices such as journal- ing, dream interpretation, art, music, or poetry that leads to an experience of nonseparateness and love; it involves developing the qualities of stillness and being present for one’s own suf- fering that will also allow for full presence when with another. In our personal process, we recognize con- scious dying where time and thought is given to contemplate one’s own death. Through a re- flective practice, one rehearses and imagines one’s final breath to practice preparing for one’s own death. The experience prepares us to not be so attached to material things nor to spend so much time thinking about the future but to live in the moment as often as we can and to live fully until death comes. We are more likely to participate with deeper compas- sion in the death process and to become more fully engaged in the death process. Death is seen as the mirror in which the entire meaning and mystery of life is reflected—the moment of liberation. Within an integral perspective, the state of transparency, the understanding that there is no separation between our prac- tice and our everyday life is recognized. This is a mature practice that is wise and empty of a separate self. Integral Nursing Principle 2: Nursing Is Built on “We” Integral Nursing Principle 2 recognizes the im- portance of the “We” (intersubjective) space. In this “We” space, nurses come together and are conscious of sharing their worldviews, beliefs, 222 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm 3312_Ch13_207-234 26/12/14 5:53 PM Page 222 priorities, and values related to working to- gether in ways to enhance integral self-care and integral health care. Deep listening, being pres- ent and focused with intention to understand what another person is expressing or not ex- pressing, is used. Bearing witness to others, the state achieved through reflective and mindful- ness practices, is also valued (Beck et al., 2011; B. M. Dossey, 2013; B. M. Dossey, Beck, & Rushton, 2013; Halifax et al., 2007). Through mindfulness one is able to achieve states of equanimity—that is, the stability of mind that allows us to be present with a good and impar- tial heart no matter how beneficial or difficult the conditions; it is being present for the suf- ferer and suffering just as it is while maintain- ing a spacious mindfulness in the midst of life’s changing conditions. Compassion is where bear- ing witness and lovingkindness manifest in the face of suffering, and it is part of our integral practice. The realization of the self and another as not being separate is experienced; it is the ability to open one’s heart and be present for all levels of suffering so that suffering may be transformed for others, as well as for the self. A useful phrase to consider is “I’m doing the best I can.” Compassionate care assists us in liv- ing as well as when being with the dying per- son, the family, and others. We can touch the roots of pain and become aware of new mean- ing in the midst of pain, chaos, loss, grief, and also in the dying process. An integral nurse considers transpersonal dimensions. This means that interactions with others move from conversations to a deeper di- alogue that goes beyond the individual ego; it includes the acknowledgment and appreciation for something greater that may be referred to as spirit, nonlocality, unity, or oneness. Transpersonal dialogues contain an integral worldview and recognize the role of spirituality that is the search for the sacred or holy that in- volves feelings, thoughts, experiences, rituals, meaning, value, direction, and purpose as valid aspects of the universe. It is a unifying force of a person with all that is—the essence of being- ness and relatedness that permeates all of life and is manifested in one’s knowing, doing, and being; it is usually, although not univer- sally, considered the interconnectedness with self, others, nature, and God/Life Force/ Absolute/Transcendent. Within nursing, health care, and society, there is much suffering (physical, mental, emo- tional, social, spiritual), moral suffering, moral distress, and soul pain. We are often called on to “be with” these difficult human experiences and to use our nursing presence. Our sense of “We” supports us to recognize the phases of suffering—“mute” suffering, “expressive” suf- fering, and “new identity” in suffering (Halifax et al., 2007). When we feel alone, as nurses, we experience mute suffering; this is an inabil- ity to articulate and communicate with others one’s own suffering. Our challenge in nursing is to more skillfully enter into the phase of “expressive” suffering, where sufferers seek lan- guage to express their frustrations and experi- ences such as in sharing stories in a group process (Levin & Reich, 2013). Outcomes of this experience often move toward new iden- tity in suffering through new meaning-making in which one makes new sense of the past, interprets new meaning in suffering, and can envision a new future. A shift in one’s con- sciousness allows for a shift in one’s capacity to be able to transform her or his suffering from causing distress to finding some new truth and meaning of it. As we create times for sharing and giving voice to our concerns, new levels of healing may happen. From an integral perspective, spiritual care is an interfaith perspective that takes into ac- count dying as a developmental and natural human process that emphasizes meaningful- ness and human and spiritual values. Religion is recognized as the codified and ritualized be- liefs, behaviors, and rituals that take place in a community of like-minded individuals in- volved in spirituality. Our challenge is to enter into deep dialogue to more fully understand religions different than our own so that we may be tolerant where there are differences. Integral action is the actual practice and process that creates the condition of trust wherein a plan of care is cocreated with the pa- tient and care can be given and received. Full attention and intention to the whole person, not merely the current presenting symptoms, illness, crisis, or tasks to be accomplished, CHAPTER 13 • Barbara Dossey’s Theory of Integral Nursing 223 3312_Ch13_207-234 26/12/14 5:53 PM Page 223 reinforce the person’s meaning and experience of community and unity. Engagement be- tween an integral nurse and a patient and the family or with colleagues is done in a respectful manner; each patient’s subjective experience about health, health beliefs, and values are ex- plored. We deeply care for others and recog- nize our own mortality and that of others. The integral nurse uses intention, the con- scious awareness of being in the present mo- ment with self or another person, to help facilitate the healing process; it is a volitional act of love. An awareness of the role of intu- ition is also recognized, which is the per- ceived knowing of events, insights, and things without a conscious use of logical, an- alytical processes; it may be informed by the senses to receive information. Integral nurses recognize love as the unconditional unity of self with others. This love then generates lovingkindness and the open, gentle, and car- ing state of mindfulness that assist one’s with nursing presence. Integral communication is a free flow of ver- bal and nonverbal interchange between and among people and pets and significant beings such as God/Life Force/Absolute/Transcen- dent. This type of sharing leads to explo- rations of meaning and ideas of mutual understanding and growth and loving kind- ness. Intuition is a sudden insight into a feel- ing, a solution, or problem in which time and actions and perceptions fit together in a uni- fied experience such as understanding about pain and suffering, or a moment in time with another. This is an aspect that may lead to recognizing and being with the pattern of not knowing. Integral Nursing Principle 3: “It” Is About Behavior and Skill Development Integral Nursing Principle 3 recognizes the importance of the individual exterior “It” (ob- jective) space. In this “It” space of the indi- vidual exterior, each person develops and integrates her or his integral self-care plan. This includes skills, behaviors, and action steps to achieve a fit body and to consider body strength training and stretching and conscious eating of healthy foods. It also includes modeling integral life skills. For the integral nurse and patient, it is also the space where the “doing to” and “doing for” occurs. However, if the patient has moved into the active dying process, the integral nurse com- bines her or his nursing presence with nursing acts to assist the patient to access personal strengths, to release fear and anxiety, and to provide comfort and safety. Most often the patient has an awareness of conscious dying and a time of sacredness and reverence in this dying transition. Integral nurses, with nursing colleagues and health-care team members, compile the data around physiological and pathophysiological assessment, nursing diagnosis, outcomes, plans of care (including medications, technical pro- cedures, monitoring, treatments, traditional and integrative practice protocols), implemen- tation, and evaluation. This is also the space that includes patient education and evaluation. Integral nurses cocreate plans of care with pa- tients, when possible combining caring–healing interventions/modalities and integral life prac- tices that can interface and enhance the success of traditional medical and surgical technology and treatment. Some common interventions are relaxation, music, imagery, massage, touch therapies, stories, poetry, healing environment, fresh air, sunlight, flowers, soothing and calm- ing pictures, pet therapy, and more. Integral Nursing Principle 4: “Its” Is Systems and Structures Integral Nursing Principle 4 recognizes the importance of the exterior collective “Its” (in- terobjective) space. In this “Its” space, integral nurses and the health-care team come together to examine their work, their priorities, use of technologies and any aspect of the technolog- ical environment, and create exterior healing environments that incorporate nature and the natural world when possible such as with out- door healing gardens, green materials inside with soothing colors, and sounds of music and nature. Integral nurses identify how they might work together as an interdisciplinary team to deliver more effective patient care and to coor- dinate care while creating external healing environments. 224 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm 3312_Ch13_207-234 26/12/14 5:53 PM Page 224 Application of the Theory of Integral Nursing in Practice, Education, Research, Health-Care Policy, Global Nursing The world is currently anchored in one of the most dramatic social shifts in health-care his- tory, and the theory of integral nursing can in- form and shape nursing practice, education, research, and policy—local to global—to achieve a healthy world. The theory of integral nursing engages us to think deeply and pur- posefully about our role as nurses as we face a changing picture of health due to globalization that knows no natural or political boundaries. Practice The theory of integral nursing was published in this author’s coauthored text in 2008 and 2013 (Dossey, Beck, & Rushton, 2008; 2013) and is currently being used in many clinical settings. The textbook clearly develops the in- tegral, integrative, and holistic processes and clinical application in traditional settings. It in- cludes guidance about the use of complemen- tary and integrative interventions. Education The theory of integral nursing can assist edu- cators to be aware of all quadrants while or- ganizing and designing curriculum, continuing education courses, health education presenta- tions, teaching guides, and protocols. In most nursing curricula, there is minimal focus on the individual subjective “I” and the collective intersubjective “We”; the emphasis is on teach- ing concepts such as physiology and patho- physiology and passing an examination or learning a new skill or procedure. Thus, the learner retains only small portions of what is taught. Before teaching any technical skills, the instructor might guide a student or patient in an integral practice such as relaxation and im- agery rehearsal of the event to encourage the student to be in the present moment. The following are examples of how the the- ory of integral nursing is being used. At Quin- nipiac University, Hamden, Connecticut, Cynthia Barrere, PhD, RN, CNS, AHN-BC, and Mary Helming, PhD, APRN, FNP-BC, AHN-BC, introduced the theory of integral nursing to their nurse educator colleagues, who use the theory in their holistic undergraduate and graduate curricula as they prepare holistic nurses for the future (Barrere, 2013). Darlene Hess, PhD, NP, AHN-BC, HWNC-BC, (Hess, 2013) used the theory of integral nurs- ing in her Brown Mountain Visions consulting practice to design an RN-to-BSN program at Northern New Mexico State (NNMC), in Espanola, New Mexico. This RN-to-BSN program prepares registered nurses to assume leadership roles as integral nurses at the bed- side, within organizations, in the community, and other areas of professional practice. Hess also uses the integral process in her private nurse coaching practice. In the Integrative Nurse Coach Certificate Program (2013), the integral perspectives and change are major components (Dossey, Luck, & Schaub, 2015). Juliann S. Perdue, DNP, RN, FNP, has adapted the theory of integral nursing into her integrative rehabilitation model (Perdue, 2011). Diane Pisanos, RNC, MS, NNP (per- sonal communication, June 15, 2012) inte- grates integral theory and process to organize her life and health coaching practice. Research A theory of integral nursing can assist nurses to consider the importance of qualitative and quantitative research (B. M. Dossey, 2008, 2013; Esbjorn-Hargens, 2006; Frisch, 2013; Quinn, 2003; Zahourek, 2013). Our chal- lenges in integral nursing are to consider the findings from both qualitative and quantita- tive data and always consider triangulation of data when appropriate. We must always value introspective, cultural, and interpretive expe- riences and expand our personal and collective capacities of consciousness as evolutionary progression toward achieving our goals. In other words, knowledge emerges from all four quadrants. Health-Care Policy A theory of integral nursing can guide us to consider many areas related to health-care pol- icy. Compelling evidence in all of the health- care professions shows that the origins of CHAPTER 13 • Barbara Dossey’s Theory of Integral Nursing 225 3312_Ch13_207-234 26/12/14 5:53 PM Page 225 health and illness cannot be understood by fo- cusing only on the physical body. Only by ex- panding the equations of health, exemplified by an integral approach or an AQAL approach to include our entire physical, mental, emo- tional, social, and spiritual dimensions and in- terrelationships can we account for a host of health events. Some of these include, for ex- ample, the correlations among poverty, poor health, and shortened life span; job dissatisfac- tion and acute myocardial infarction; social shame and severe illness; immune suppression and increased death rates during bereavement; and improved health and longevity as spiritu- ality and spiritual awareness is increased. Global Health Nursing The theory of integral nursing can assist us as we engage in global health partnerships and projects. Global health is the exploration of the value base and new relationships and agendas that emerge when health becomes an essential component and expression of global citizenship (Beck et al., 2011; B. M. Dossey, Beck, & Rushton, 2013; Gostin, 2007; Karpf , Swift, Ferguson, & Lazarus, 2008; Karph, Ferguson, & Swift, 2010); J. Kreisberg, personal commu- nication, August 25, 2011; WHO, 2007). It is an increased awareness that health is a basic human right and a global good that needs to be promoted and protected by the global commu- nity. Severe health needs exist in almost every community and nation throughout the world as previously described in the UN Millennium Goals. Thus, all nurses must raise their voices and speak about global nursing as their health and healing endeavors assist individuals to be- come healthier. As Nightingale (1892) said, “We must create a public opinion, which must drive the government instead of the government having to drive us . . . an enlightened public opinion, wise in principle, wise in detail.” 226 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm Practice Exemplar A nurse can use the theory of integral nursing in any clinical situation; it assists us in inte- grating the art and science of nursing simulta- neously with all actions/interactions. As discussed previously, healing, the core concept, can occur on many levels (physical, mental, emotional, social, spiritual). Having an inte- gral awareness and creating a space for the possibility that healing can occur allows for a unique field of experience. As nurses engage in their own healing, reflective integral prac- tices, personal development and self-care, they literally embody a special way of being with others. That is, they “walk their talk” of car- ing–healing. There is a mutual respect for self and others in each encounter as the nurse is al- ways part of the patient’s external environ- ment. Even while giving medications and performing various acute care technical skills, a nurse’s healing presence in each encounter can reflect a “being with” and “in collaboration with.” Nurses must engage in their own devel- opment and also personally experience the var- ious reflective practices (relaxation, imagery, reframing) before engaging the patient in these practices. Background J. D. is a lean, extroverted, competitive, 6’4,” 200-pound, 64-year-old global energy corpo- rate executive who travels internationally. J. D., an avid jogger, had a recent executive physical with normal stress test and blood work and was declared “a picture of good health.” His father and paternal grandfather both died of heart attacks in their 60s. He eats a Mediterranean diet when possible and drinks several glasses of wine with meals. He uses a treadmill or runs daily. J. D. has been a widower for 2 years after a tragic head-on au- tomobile accident in which his wife was killed by an intoxicated driver. He has four grown children who live in the same city and who quarrel over loopholes in their inheritance left by their mother and maternal grandmother. Two children are executives and have prob- lems with alcohol abuse; two others are hap- pily married, and each has two preschool children. 3312_Ch13_207-234 26/12/14 5:53 PM Page 226 CHAPTER 13 • Barbara Dossey’s Theory of Integral Nursing 227 Practice Exemplar cont. One Sunday, J. D. placed second in a city marathon and was disappointed he didn’t win. On finishing a morning shower on Monday morning after a restful night’s sleep before a scheduled international trip, J. D. had severe back pain. He tried stretching exercises, and the pain went away, so he related it to a back strain from the marathon. He then drove to his office and collapsed onto the steering wheel after he parked his car. A friend saw this and immediately called 911. He was taken to a nearby emergency room, where he was immediately assessed and sent for cardiac catheterization where he received a stent to open the complete occlusion of his right coro- nary artery. Later that night his cardiologist confirmed from his electrocardiogram that he had had a severe inferior myocardial infarction with cardiac irritability; a few days later, he de- veloped pericarditis secondary to the infarction and was placed on pain medication. His cardiac situation was even more com- plicated. His cardiologist informed him that he also had an 80% blockage at the bifurcation in his left anterior descending coronary artery and circumflex that was in a difficult place for a stent. Because he had excellent collateral cir- culation, he was placed on cardiac medications and told that he would be monitored over the next few months to determine whether he needed further invasive procedures or possibly open heart surgery. He was started on gradual CCU cardiac rehabilitation. J. D. was very quiet when the nurse entered the room after the cardiologist left. The nurse had a hunch that J. D. might want to talk about what he was experiencing. After a brief exchange, the nurse followed with further ex- ploration of the meaning and negative images that he conveyed. She asked him if he wanted to pursue some new ideas that might help him relax and to engage in a guided imagery to ac- cess his inner healing resources and strengths. He said that he would. This encounter took 10 minutes. After the guided imagery, the following dialogue unfolded. Nurse: In your recovery now with your heart healing, how do you experience your healing? J. D.: There is this sac around my heart; every time I take a deep breath, my breath is cut off by the pain [pericarditis]. My heart is like a broken vase. I don’t think it is healing. The pain medication is helping. Nurse: I can understand some of your frustra- tion and concern. However, some important things that are present right now show me that you are better than when you first came to the CCU. Your persistent chest pain is gone, and your heartbeats are now regular, which shows that the stent is very effective. If you focus on what is going right, you can help your heart and lift your spirits. Let me share some ideas so that you might be able to shift to some positive thoughts. J. D.: I don’t know if I can. Nurse: I would like to show you how to breathe more comfortably. Place your right hand on your upper chest and your left hand on your belly and begin to breathe with your belly. With your next breath in, through your nose, let the breath fill your belly with air. And as you exhale through your mouth, let your stomach fall back to your spine. As you focus on this way of breathing, notice how still your upper chest feels. J. D.: (After three complete breaths) This is the easiest breathing I’ve done today. Nurse: As you focused on breathing with your belly, you let go of fearing the discomfort with your breathing. Can you tell me more about the image you have of your heart as a broken vase? J. D.: I saw this crack down the front of my heart right after the doctor told me about my big arteries that have the 80% blockage. This is very scary. Nurse: (Taking a small plastic bag full of crayons out of her pocket and picking up a piece of paper) Is it possible for you to choose a few crayons and draw your heart as you just described it? J. D.: I can’t draw. Nurse: This has nothing to do with drawing, but something usually happens when you place a few marks to create an image of your words. J. D.: If you mean the image of a broken vase, I can draw that. Continued 3312_Ch13_207-234 26/12/14 5:53 PM Page 227 228 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm Practice Exemplar cont. He began to place an image on the paper. When halfway through with the drawing, he said, “I know this sounds crazy, but my father had a heart attack when he was 63. I was visit- ing my parents. Dad hadn’t been feeling well, even complained of his stomach hurting that morning. He was in the living room, and as he fell, he knocked over a large Chinese porcelain vase that broke in two pieces. I can remember so clearly running to his side. I can see that vase now, cracked in a jagged edge down the front. He made it to the hospital, but died 2 days later. You know, I think that might be where that image of a broken heart came from.” Nurse: Your story contains a lot of meaning. Remembering this image and event can be very helpful to you in your healing. What are some of the things that you are most worried about just now? J. D.: Dying young. (Tears fill his eyes) I have this funny feeling in my stomach just now. I don’t want to die. I’m too young. I have so much to contribute to life. I’ve been driving myself to excess at work. I need to learn to relax and manage my stress and change my life. Nurse: J., each day you are getting stronger. This time over the next few weeks can be a time to reflect on what are the most impor- tant things in your life. Whenever you feel discouraged, let images come to you of a beau- tiful vase that has a healed crack in it. This is exactly what your heart is doing right now. Even as we are talking, the area that has been damaged is healing. As it heals, there will be a solid scar that will be very strong, just in the same way that a vase can be mended and become strong again. New blood supplies also come into the surrounding area of your heart to help it heal. Positive images can help you heal because you send a different message from your mind to your body when you are relaxed and thinking about becoming strong and well. You help your body, mind, and spirit function at their highest level. Is it possible for you to once again draw an image of your heart as a healed vase and notice any difference in your feelings? J. D.: Thanks for this talk. With a smile, he picked up several crayons and began to draw a healing image to encour- age hope and healing. When J. D. entered the outpatient cardiac rehabilitation program, he was motivated to learn stress management skills and express his emotions. Two weeks into the program, J. D. did not appear to be his usual extroverted self. The cardiac rehabilitation nurse engaged him in conversation, and before long, he had tears in his eyes. He stated that he was very discouraged about having heart disease. He said, “It just has a grip on me.” The nurse took him into her of- fice, and they continued the dialogue. After lis- tening to his story, she asked J. D. if he would like to explore his feelings further. He nodded yes. This next session took 15 minutes. To facilitate the healing process, she thought it might be helpful to have J. D. get in touch with his images and their locations in his body. She began by saying, “If it seems right to you, close your eyes and begin to focus on your breathing just now.” She guided him in a general exercise of head-to-toe relaxation, accompanied by an audiocassette music selec- tion of sounds in nature. As his breathing pat- terns became more relaxed and deeper, indicating relaxation, she began to guide him in exploring “the grip” in his imagination. Nurse: Focus on where you experience the grip. Give it a size, ... a shape, ... a sound, ... a texture, ... a width, ... and a depth. J. D.: It’s in my chest, but not like chest pain. It’s dull, deep, and blocks my knowing what I need to think or feel about living. I can’t be- lieve that I’m using these words. Well, it’s bigger than I thought. It’s very rough, like heavy jute rope tied in a knot across my chest. It has a sound like a rope that keeps a sailboat tied to a boat dock. I’m now rocking back and forth. I don’t know why this is happening. Nurse: Stay with the feeling, and let it fill you as much as it can. If you need to change the 3312_Ch13_207-234 26/12/14 5:53 PM Page 228 CHAPTER 13 • Barbara Dossey’s Theory of Integral Nursing 229 Practice Exemplar cont. experience, all you have to do is take several deep breaths. J. D.: It’s filling me up. Where are these sounds, feelings, and sensations coming from? Nurse: They are coming from your wise, inner self, your inner healing resources. Just let yourself stay with the experience. Continue to use as many of your senses as you can to de- scribe and feel these experiences. J. D.: Nothing is happening. I’ve gone blank. Nurse: Focus again on your breath in ... and feel the breath as you let it go. ... Can you allow an image of your heart to come to you under that tight grip? J. D.: It is so small I can hardly see it. It’s all wrapped up. Nurse: In your imagination, can you introduce yourself to your heart as if you were introduc- ing yourself to a person for the first time? Ask your heart if it has a name. J. D.: It said hello, but it was with a gesture of hello, no words. Nurse: That’s fine. Just say, “Nice to meet you,” and see what the response might be. J. D.: My heart seems like an old soul, very wise. This feels very comfortable. Nurse: Ask your heart a question for which you would like an answer. Stay with this and listen for what comes. After long pause: J. D.: The answer is practice patience, that I am on the right track, that my heart disease has a message, don’t know what it is. Nurse: Just stay with your calmness and inner quiet. Notice how the grip has changed for you. There are many more answers to come for you. This is your wise self that has much to offer you. Whenever you want, you can get back to this special kind of knowing. All you have to do is take the time. When you set aside time to be quiet with your rich images, you will get more information. You might also find special music to assist you in this process. ... Your skills with this way of know- ing will increase each time you use this process ... now that whatever is right for you in this moment is unfolding, just as it should. In a few moments, I will invite you back into a wakeful state. On five, be ready to come back into the room and feel wide-awake and relaxed. One ... two ... three ... four ... eyelids lighter, taking a deep breath ... and five, back into the room, awake and alert, ready to go about your day. J. D.: Where did all that come from? I’ve never done that before. Nurse: All of these experiences are your inner healing resources that are always with you to help you recognize quality and purpose in living each day. All you have to do is take the time to remember to use them and direct your self-talk and images toward a desired out- come. If you want, I can teach and share more of these skills. J. D.: Ever since my wife died, I have had a sense of “What is the meaning of my life? what is my purpose?” Some days I feel like I have lost my soul. I go through my days doing and doing, and yes I do accomplish a lot. But deep down I am not happy. I have been asking myself the question, “What am I doing . . . or NOT doing . . . that is feeding the problems I don’t want and believing that I can find hap- piness out there?” Today with you in this ex- perience, a light switch got turned on in me. My happiness is buried inside me. I have to gain access to it again somehow. I try to fix my kids by giving them more money. I actually don’t really sit down with them. Sometimes I feel like I don’t really know anything about them. I have grandkids that I rarely see. I get frustrated with my corporation as I feel we are contributing to environmental pollution. We [the corporation] can do more about changing this. You helped me identify my needs and how I can contribute differently. I feel a new kind of ownership about my life. Evaluation and Outcomes Together the patient and the nurse evaluate the encounter and determine whether the re- laxation and imagery experiences were useful and discuss future outcomes. Such sessions frequently open up profound information and possibilities. To evaluate the session further, Continued 3312_Ch13_207-234 26/12/14 5:53 PM Page 229 230 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm Practice Exemplar cont. the nurse may again explore the subjective ef- fects of the experience with the patient. Re- laxation and imagery are integral life practices for connecting with our unlimited capabilities and capacities. The patient can experience more self-awareness, self-acceptance, self-love, and self-worth. These integral life practices can be transferred to daily life as resources for self- care. The best way to develop confidence and skill in using relaxation and imagery in a clin- ical setting is for the nurse to embody these practices in her or his own life as a part of per- sonal self-care and enrichment. Learning how to be authentic and fresh in interactions and in each moment can be en- hanced as we learn to bear witness by deep lis- tening and “simply noticing” what is going on. It is so easy to get locked into our analytical logic that we block ourselves from reaching into our hearts and moving into our intuitions or emotions. With time and practice, we give space to what might appear. Both good and negative thoughts always contain some wis- dom. After such a patient encounter, it is a time to really reflect on what happened: How did you stay focused for the patient and stay in the moment? In this kind of encounter, we can never predict what will happen. As we engage in our work, our challenge is to be aware of learning to bear witness, not trying to fix any- thing, and just exploring the moment with self and other(s). It seems that when we least ex- pect it, we might experience or access a deeper place on inner wisdom. Reflection is often how the contrast of the light and shadow, the “dark nights of the soul” are resolved. ■ Summary The theory of integral nursing addresses how we can increase our integral awareness, our wholeness and healing, and strengthen our personal and professional capacities to more fully open to the mysteries of life’s journey and the wondrous stages of self-discovery with self and others. There are many opportunities to increase our integral awareness, application, and understanding each day. Reflect on all that you do each day in your work and life—ana- lyzing, communicating, listening, exchanging, surveying, involving, synthesizing, investigat- ing, interviewing, mentoring, developing, cre- ating, researching, teaching, and creating new schemes for what is possible. Before long, you will realize how all the quadrants and realities fit together. You might find you are completely missing a quadrant, thus an important part of reality. As we address and value the individual interior and exterior, the “I” and “It,” as well as the collective interior and exterior, the “We” and “Its,” a new level of integral understanding emerges, and we may also experience more balance and harmony each day. Our time demands a new paradigm and a new language in which we take the best of what we know in the science and art of nurs- ing that includes holistic and human caring theories and modalities. With an integral ap- proach and worldview, we are in a better po- sition to share with others the depth of nurses’ knowledge, expertise, and critical-thinking ca- pacities and skills for assisting others in cre- ating health and healing. Only an attention to the heart of nursing, for “sacred” and “heart” reflect a common meaning, can we generate the vision, courage, and hope required to unite nursing in healing. This assists us as we engage in health-care reform to address the challenges in these troubled times—local to global. It is not an abstract matter of philosophy, but of survival.1 1 For additional information please go to bonus chapter content available at See Barbara Dossey’s website at to download the theory of integral nursing PowerPoint and one-page handout. 3312_Ch13_207-234 26/12/14 5:53 PM Page 230 CHAPTER 13 • Barbara Dossey’s Theory of Integral Nursing 231 References American Holistic Nurses Association and the American Nurses Association. (2007). 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Alternative Therapies in Health and Medicine, 10(6), 40–49. Zahourek, R. (2013). Holistic nursing research: Challenges and opportunities. In B. M. Dossey & L. Keegan (Eds.), Holistic nursing: A handbook for practice (6th ed., pp. 775–794). Burlington, MA: Jones and Bartlett. 3312_Ch13_207-234 26/12/14 5:53 PM Page 233 3312_Ch13_207-234 26/12/14 5:53 PM Page 234 Section IV Conceptual Models and Grand Theories in the Unitary– Transformative Paradigm 235 3312_Ch14_235-262 26/12/14 4:55 PM Page 235 236 There are three grand theories clustered in the Unitary–Transformative Paradigm. In this paradigm, the human being and environment are conceptualized as irre- ducible 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 (SUHB) is explicated by Howard Butcher and Violet Malinski. The SUHB is based on the premise that humans and environments are patterned, pandimensional energy fields in contin- uous mutual process with each other. Persons participate in their well-being, which is relative and personally defined. Several theories, research traditions, and prac- tice traditions have evolved from this conceptual system. While Parse has recently called humanbecoming a paradigm rather than a school of thought, the editors continue to situate humanbecoming within the Unitary-Transformative Paradigm. Humanbecoming is featured in Chapter 15, written by the theorist herself. Human- becoming is defined as a basic human science that has cocreated human expe- riences as its central focus. Humanbecoming portends a view that unitary human beings are expert in their own health and lives. For Parse, human beings choose meanings that reflect value priorities cocreated in transcending with the possibles. Humanbecoming has well-developed research and practice methods that guide the inquiry and practice of nurses embracing it. Newman’s theory of health as expanding consciousness (HEC) is explicated in Chapter 17 by Margaret Dexheimer Pharris. According to HEC, health is an evolving unitary pattern of the whole, including patterns of disease. Conscious- ness, or the informational capacity of the whole, is revealed in the evolving pattern. Pattern identifies the human–environmental process and is characterized by meaning. Concepts important to nursing practice include expanding conscious- ness, time, presence, resonating 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. Section IV Conceptual Models and Grand Theories in the Unitary–Transformative Paradigm 236 3312_Ch14_235-262 26/12/14 4:55 PM Page 236 Chapter 14Martha E. Rogers Science of Unitary Human Beings HOWARD KARL BUTCHER AND VIOLET M. MALINSKI Introducing the Theorist Overview of Rogers’ Science of Unitary Human Beings Applications of the Conceptual System Practice Exemplar Summary References Martha E. Rogers 237 Introducing the Theorist Martha E. Rogers, one of nursing’s foremost scientists, was a staunch advocate for nursing as a basic science from which the art of practice would emerge. A common refrain throughout 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 mas- ter’s degree in nursing from Teachers College, Columbia University, in the program developed by another nurse theorist, Hildegard Peplau. In 3312_Ch14_235-262 26/12/14 4:55 PM Page 237 1951, she left public health nursing in Phoenix to return to academia, this time earning both a master’s of public health and a doctor of sci- ence degree from Johns Hopkins University in Baltimore, Maryland. In 1954, after her graduation from Johns Hopkins, Rogers was appointed head of the Division of Nursing at New York University (NYU), beginning the second phase of her ca- reer overseeing baccalaureate, master’s, and doc- toral programs in nursing and developing the nursing science she knew was integral to the knowledge base nurses needed. During the 1960s, she successfully shifted the focus of doc- toral research from nurses and their functions to humans in mutual process with the environ- ment. She wrote three books that explicated her ideas: Educational Revolution in Nursing (1961), Reveille in Nursing (1964), and the landmark An Introduction to the Theoretical Basis of Nursing (1970). From 1963 to 1965, she edited Nursing Science, a journal that was far ahead of its time; it offered content on theory development and the emerging science of nursing, as well as re- search and issues in education and practice. Rogers died in 1994, leaving a rich legacy in her writings on nursing science, the space age, research, education, and professional and political issues in nursing. Overview of Rogers’ Science of Unitary Human Beings The historical evolution of the Science of Unitary Human Beings has been described by Malinski and Barrett (1994). This chapter presents the science in its current form and identifies work in progress to expand it further. Rogers’ Worldview Rogers (1992) articulated a new worldview in nursing, one that was commensurate with new knowledge emerging across disciplines, which rooted nursing science in “a pandimensional view of people and their world” (p. 28). Rogers (1992) described the evolution from older to newer worldviews in such shifting perspec- tives as cell theory to field theory, entropic to negentropic universe, three-dimensional to pandimensional, person–environment as di- chotomous to person–environment as integral, causation and adaptation to mutual process, dynamic equilibrium to innovative growing diversity, homeostasis to homeodynamics, waking as a basic state to waking as an evolu- tionary emergent, and closed to open systems. She pointed out that in a universe of open sys- tems, energy fields are continuously open, infinite, and integral with one another. A view of change as predictable, or even probabilistic, yields to change as diverse, creative, innovative, and unpredictable. Rogers (1994a) identified the unique focus of nursing as “the irreducible human being and its environment, both defined as energy fields” (p. 33). “Human” encompasses both Homo sapiens and Homo spatialis, the evolutionary transcendence of humankind as we voyage into space; environment encompasses outer space, the cosmos itself. Rogers was aware that the world looks very different from the vantage point of this newer view as contrasted with the older, traditional worldview. She pointed out that we are already living in a new reality, one that is “a synthesis of rapidly evolving, accelerating ways of using knowledge” (Rogers, 1994a, p. 33), even if peo- ple are not always fully aware that these shifts have occurred or are in process. She urged that nurses be visionary, looking forward and not backward and not allowing themselves to be- come “stuck” in the present, in the details of how things are now, but envision how they might be in a universe where continuous change is the only given. Rogers (1994b) cautioned that al- though traditional modalities of practice and methods of research serve a purpose, they are in- adequate for the newer worldview, which urges nurses to use the knowledge base of Rogerian nursing science creatively to develop innovative new modalities and research approaches that would promote the betterment of humankind. Postulates of Rogerian Nursing Science Rogers (1992) identified four fundamental pos- tulates that form the basis of the new reality: • Energy fields • Openness 238 SECTION IV • Conceptual Models and Grand Theories in the Unitary–Transformative Paradigm 3312_Ch14_235-262 26/12/14 4:55 PM Page 238 • Pattern • Pandimensionality (formerly called both four- dimensionality and multidimensionality) Rogers (1990) defined the energy field as “the fundamental unit of the living and the non-living,” noting that it is dynamic, infi- nite, and continuously moving (p. 7). Although Rogers did not define energy per se, Todaro- Franceschi’s (1999) wide-ranging philosophical study of the enigma of energy sheds light on a Rogerian conceptualization of energy. She highlighted the communal, transformative na- ture of energy, noting that energy is everywhere and is always changing and actualizing poten- tials. Energy transformation is the basis of all that is, both in living and dying. Rogers identified two energy fields of con- cern to nurses, which are distinct but not sepa- rate: the human field and the environmental field. The human field can be conceptualized as person, group, family, or community. The human and environmental fields are irreducible; they cannot be broken down into component parts or subsystems. For example, the unitary human is neither understood nor described as a bio–psycho–sociocultural or body–mind–spirit entity. Instead, she maintained that each field, human and environmental, is identified by pattern, defined as “the distinguishing charac- teristic of an energy field perceived as a single wave” (Rogers, 1990, p. 7). Pattern manifesta- tions and characteristics are specific to the whole, the unitary human–environment in mu- tual process. Change occurs simultaneously for human and environment. The fields are pandimensional, defined as “a non-linear domain without spatial or temporal attributes” (Rogers, 1992, p. 29). Pandimen- sional reality transcends traditional notions of space and time, which can be understood as perceived boundaries only. Examples of pandi- mensionality include phenomena commonly labeled “paranormal” that are, in Rogerian nursing science, manifestations of the chang- ing diversity of field patterning and examples of pandimensional awareness. The postulate of openness resonates throughout the preceding discussion. In an open universe, there are no boundaries other than perceptual ones. Therefore, human and environment are not separated by boundaries. The energy of each flows continuously through the other in an unbroken wave. Rogers repeat- edly emphasized that person and environment are themselves energy fields; they do not have energy fields, such as auras, surrounding them. In an open universe, there are multiple poten- tials and possibilities. People experience their world in multiple ways, evidenced by the di- verse manifestations of field patterning that continuously emerge. Rogers (1992, 1994a) described pattern as changing continuously while giving identity to each unique human–environmental field process. Although pattern is an abstraction, not something that can be observed directly, “it reveals itself through its manifestations” (Rogers, 1992, p. 29). Individual characteris- tics of a particular person are not characteris- tics of field patterning. Pattern manifestations reflect the human–environmental field mutual process as a unitary, irreducible whole. They reveal innovative diversity flowing in lower and higher frequency rhythms within the human– environmental mutual field process. Rogers identified some of these manifestations as lesser and greater diversity; longer, shorter, and seemingly continuous rhythms; slower, faster, and seemingly continuous motion; time expe- rienced as slower, faster, and timeless; prag- matic, imaginative, and visionary; and longer sleeping, longer waking, and beyond waking. Beyond waking refers to emergent experiences and perceptions such as hyperawareness, uni- tive experiences attained in meditation, precog- nition, déjà vu, intuition, tacit knowing, mystical experiences, clairvoyance, and telepathy. She explained “seems continuous” as “a wave frequency so rapid that the observer perceives it as a single, unbroken event” (Rogers, 1990, p. 10). This view of the ongoing process of change is captured in Rogers’ principles of homeodynamics. Principles of Homeodynamics Homeodynamics conveys the dynamic, ever- changing nature of life and the world. Her three principles of homeodynamics—resonancy, CHAPTER 14 • Martha E. Rogers’s Science of Unitary Human Beings 239 3312_Ch14_235-262 26/12/14 4:55 PM Page 239 helicy, and integrality—describe the nature and process of change in the human–environmental field process. Resonancy is “the continuous change from lower to higher frequency wave patterns in human and environmental fields” (Rogers, 1992, p. 31). Although she verbalized the need to delete the “from–to” language, which seems to imply linearity and directionality, Rogers never actually deleted it in print. However, it is important to remember that this process is nonlinear and nondirectional because in a pandimensional universe there is no space and no time (Phillips, 2010a). Resonancy specifies the nonlinear, continuous flow of lower and higher frequency wave patterning in the human–environmental field process, the way change occurs. Both lower and higher frequency aware- ness and experiencing are essential to the wholeness of rhythmical patterning. As Phillips (1994, p. 15) described it, “[W]e may find that growing diversity of pattern is related to a dialectic of low frequency–high frequency, similar to that of order–disorder in chaos the- ory. When the rhythmicities of lower-higher frequencies work together, they yield innova- tive, diverse patterns.” Helicy is “the continuous, innovative, un- predictable, increasing diversity of human and environmental field patterns (Rogers, 1992, p. 31). It describes the creative and diverse na- ture of ongoing change in field patterning, a “diversity of pattern that is innovative, creative, and unpredictable” (Phillips, 2010a, p. 57). Integrality is “continuous mutual human field and environmental field process” (Rogers, 1992, p. 31). It specifies the process of change within the integral human–environmental field process where person and environment are unitary, thus inseparable. Together the principles suggest that the mutual patterning process of human and environmental fields changes continuously, innovatively, and unpredictably, flowing in lower and higher frequencies. Rogers (1990, p. 9) believed that they serve as guides both to the practice of nursing and to research in the science of nursing. Theories Derived From the Science of Unitary Human Beings Rogers clearly stated her belief that multiple the- ories can be derived from the science of unitary human beings. They are specific to nursing and reflect not what nurses do but an understanding of people and our world (Rogers, 1992). Nursing education is identified by transmission of this theoretical knowledge, and nursing practice is the creative use of this knowledge. “Research is done in relation to the theories” (Rogers, 1994a, p. 34) to illuminate the nature of the human– environmental field change process and its many unpredictable potentials. Theory of Accelerating Change Rogers derived the theory of accelerating change, formerly known as the theory of ac- celerating evolution, to illustrate that the only “norm” is accelerating change. Higher fre- quency field patterns that manifest growing diversity open the door to wider ranges of ex- periences and behaviors, calling into question the very idea of “norms” as guidelines. Human and environmental field rhythms are acceler- ating. We experience faster environmental motion now than ever before. It is common for people to experience time as rapidly speeding by. People are living longer. Rather than view- ing aging as a process of decline or as “running down,” as in an entropic worldview, this theory views aging as a creative process in which field patterns show increasing diversity in such manifestations as sleeping, waking, and dreaming. “[I]n fact, as evolutionary diversity continues to accelerate, the range and variety of differences between individuals also in- crease; the more diverse field patterns evolve more rapidly than the less diverse ones” (Rogers, 1992, p. 30). The theory of accelerating change provides the basis for reconceptualizing the aging process. Rogers (1970, 1980) used the principle of helicy and the theory of accelerating change to put forward the notion that aging is a con- tinuously creative process of growing diversity of field patterning. Therefore, aging is not a process of decline or running down. Rather, 240 SECTION IV • Conceptual Models and Grand Theories in the Unitary–Transformative Paradigm 3312_Ch14_235-262 26/12/14 4:55 PM Page 240 field patterns become increasingly diverse as we age as older adults need less sleep; are more sat- isfied with personal relationships; are better able to handle their emotions; are better able to cope with stress; and have increasing crys- tallized intelligence, wisdom, and improved problem-solving abilities (Whitbourne & Whitbourne, 2011). Butcher (2003) expanded on Rogers “negentropic” view of aging in out- lining key elements for a “unitary model of aging as emerging brilliance” that includes re- placing ageist stereotypes with new positive im- ages of aging and developing policies, lifestyles, and technologies that enhance successful aging and longevity. Within a unitary view of aging, later life becomes a potential for growth, “a life imbued with splendor, meaning, accomplish- ment, active involvement, growth, adventure, wisdom, experience, compassion, glory, and brilliance” (Butcher, 2003, p. 64). Theory of Emergence of Paranormal Phenomena Another theory derived by Rogers is the emer- gence of paranormal phenomena, in which she suggests that experiences commonly labeled “paranormal” are actually manifestations of changing diversity and innovation of field pat- terning. They are pandimensional forms of awareness, examples of pandimensional reality that manifest visionary, beyond waking poten- tials. Meditation, for example, transcends tra- ditionally perceived limitations of time and space, opening the door to new and creative potentials. Therapeutic Touch provides another example of such pandimensional awareness. Both participants often share similar experi- ences during Therapeutic Touch, such as a visualization of common features that evolves spontaneously for both, a shared experience arising within the mutual process both are ex- periencing, with neither able to lay claim to it as a personal, private experience. The idea of a pandimensional or nonlinear domain provides a framework for understand- ing paranormal phenomena. A nonlinear domain unconstrained by space and time pro- vides an explanation of seemingly inexplicable events and processes. Rogers (1992) asserted that within the science of unitary human be- ings, psychic phenomena become “normal” rather than “paranormal.” Dean Radin, direc- tor of the Conscious Research Laboratory at the University of Nevada in Las Vegas, sug- gests that an understanding of nonlocal con- nections along with the relationship between awareness and quantum effects provides a framework for understanding paranormal phe- nomena (Radin, 1997). “Deep interconnect- edness” demonstrated by Bell’s Theorem embraces the interconnectedness of everything unbounded by space and time. In addition, the work of L. Dossey (1993, 1999), Nadeau and Kafatos (1999), Sheldrake (1988), and Talbot (1991) explicate the role of nonlocality in evo- lution, physics, cosmology, consciousness, paranormal phenomena, healing, and prayer. Tart (2009), in his excellent text The End of Materialism: How Evidence of the Paranormal Is Bringing Science and Spirit Together, reviews the research supporting common paranormal experiences with separate chapters on telepa- thy, clairvoyance/remote viewing, precognition, psychokinesis, psychic healing, out-of-body experiences, near-death experiences, post- mortem survival, and mystical experiences. Murphy (1992) in his highly referenced and researched text presents the evidence support- ing what he refers to as emergent extraordinary human abilities such as placebo effects, para- normal experiences, spiritual healing, medita- tive, mystical, and contemplative practices on health and healing. The relevance of these ex- periences and practices to nursing is in the number that occur in health-related contexts, and Rogers’s nursing science provides a theo- retical and scientific understanding that accounts for the occurrence of paranormal ex- periences. Within a nonlinear–nonlocal context, para- normal events are our experience of the deep nonlocal interconnections that bind the uni- verse together. Existence and knowing are locally and nonlocally linked through deep connections of awareness, intentionality, and interpretation. Pandimensionality embraces the infinite nature of the universe in all its di- mensions and includes processes of being more CHAPTER 14 • Martha E. Rogers’s Science of Unitary Human Beings 241 3312_Ch14_235-262 26/12/14 4:55 PM Page 241 aware of naturally occurring changing energy patterns. Pandimensionality also includes intentionally participating in mutual process with a nonlinear–nonlocal potential of creating new energy patterns. Distance healing, the healing power of prayer, Therapeutic Touch, out-of-body experiences, phantom pain, pre- cognition, déjà vu, intuition, tacit knowing, mystical experiences, clairvoyance, and tele- pathic experiences are a few of the energy field manifestations patients and nurses experience that can be better understood as natural events in a pandimensional universe characterized by nonlinear–nonlocal human–environmental field integrality propagated by increased awareness and intentionality. Manifestations of Field Patterning Rogers’ third theory, rhythmical correlates of change, was changed to manifestations of field patterning in unitary human beings, discussed earlier. Here Rogers suggested that evolution is an irreducible, nonlinear process characterized by increasing diversity of field patterning. She offered some manifestations of this relative di- versity, including the rhythms of motion, time experience, and sleeping–waking, encouraging others to suggest further examples. In addition to the theories that Rogers derived, a number of others have been developed by Rogerian scholars that are useful in informing Rogerian pattern–based practice and research. The first such theory to be developed was Barrett’s (1989, 2010) theory of power as knowing participation in change, described in Chapter 29. Butcher’s (1993) theory of kaleidoscoping in life’s turbulence is an example of a theory de- rived from Rogers’ science of unitary human be- ings, chaos theory (Briggs & Peat, 1989; Peat, 1991), and Csikszentmihalyi’s (1990) theory of flow. It focuses on facilitating well-being and harmony amid turbulent life events. Turbulence is a dissonant commotion in the human–envi- ronmental field characterized by chaotic and unpredictable change. Any crisis may be viewed as a turbulent event in the life process. Nurses often work closely with clients who are in a “cri- sis.” Turbulent life events are often chaotic in nature, unpredictable, and always transforma- tive. The theory of kaleidoscoping in life’s turbulence is described in more detail in the Bonus content for the chapter.1 Other theories derived from Rogers’s nurs- ing science include Reed’s (1991, 2003; see Chapter 23 in this volume) theory of self- transcendence, the theory of enfolding health- as-wholeness-and-harmony (Carboni, 1995a), Bultemeier’s (1997) theory of perceived disso- nance, the theory of enlightenment (Hills & Hanchett, 2001), Alligood and McGuire’s theory of aging (2000), Butcher’s theory of aging as emerging brilliance (2003), and Zahourek’s (2004, 2005) theory of intention- ality in healing. Applications of the Conceptual System New worldviews require new ways of thinking, sciencing, languaging